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November 2004 Archives
A Tale of Two Cities If you research "who did the first one", you'll find duplicate claims: Lenox Hill Hospital in New York (see last paragraph) claims the first; but so does St. Mary's Medical Center in San Francisco (see entry under 1978). The fact is that Simon Stertzer at Lenox Hill and Richard Myler in San Francisco both performed their first cath lab angioplasties on the same day in March 1978.
And me, I'm just looking for "the next Best Western"....
What Flavor Stent Would You Like? Anecdotal, but indicative of what I've been hearing from many doctors. More and more patients want to know exactly what's being put into their bodies and why, and have a say in the decision. As Michael L. Marin, MD, interim chair of vascular surgery at Mt. Sinai in NYC, told me:
Are You Experienced?
Almost half of the cardiologists in NY did only one stent the entire year?? This did not sound right to me. As I've written, the AHA/ACC guidelines recommend that operators do a minimum of 75 procedures annually. So This was a very odd statistic -- New York is not exactly a rural state! So I checked out the source of the article's data at the Center for Medical Consumers. There were the numbers, aggregated from New York State government sources. But it still didn't seem right to me, so I plumbed the depths and listed out physicians by name, and then saw that high volume operators I know, like Gregg Stone and Gary Roubin, both in New York City, were credited with less than 200 cases. According to the State data, Gary Roubin of Lenox Hill Hospital did only 126 stents in 2002 . Yeah! Maybe with his eyes closed. I've worked with Gary on live demonstration courses, and he is fast! We'd barely have our cameras focused and he'd already be done. The fact is, most of these high volume docs do 3 or 4 or more a day -- so the NYS data can't be accurate. Furthermore, I checked out a few of the "one-time" guys and found that many aren't even interventional cardiologists. My guess is they were Fellows or residents who signed off on the case records as part of their clerical duties, and thus their physicians' license numbers were entered into the database; thus they were credited with "doing" the case. So methinks the hospitals of New York are a bit more experienced than the official State data shows. Having statewide reporting is a great idea, but not if it's inaccurate. Proud of my investigative prowess, I quote the subtitle of the U.S. News article, "You can find what you need -- if you stay focused".
More About Emergency Angioplasty
Having a heart attack? Tell the ambulance to take you to a hospital that performs angioplasty!
We All Need Somebody to Lean On I cringed and hoped that this exceptional cardiologist was indeed the exception -- of course, we all know that the idea of post-procedure support is extremely important. But sometimes I wonder. At Angioplasty.Org, we get emails from patients all over the world, asking our advice on what they should do now that they have been ballooned and/or stented -- how much and often can they run, lift, have sex? We've got information on our site about post-procedural care, and I usually write back telling patients that I'm not a doctor, I just play one on the internet -- and I tell them they really need to ask their physician these questions because every patient's situation is different and post-procedure recommendations must be tailored for the individual. But I'm always amazed that a person can go through an expensive and serious procedure like an angioplasty and walk out of the hospital with a brief "Now watch what you eat!" and "Try to stop smoking!" and "Good luck!". Not long ago, I stood at a patient's bedside. The patient was about to have a stent implanted -- her second. During the pre-angioplasty prep session, the nurse asked the patient if she'd stopped smoking. "Oh sure", the patient replied. "For how long?", the nurse continued. The patient restated that she wasn't smoking now -- she's in the hospital! The nurse smiled and persisted, "I know you're not smoking now, but when did you have your last cigarette?" "Yesterday," the patient meekly confessed. Changing one's ways is not easy. But what's clear is that patients need re-training, not just a short lecture. More and more hospitals are helping in this area -- the good cardiology practices involve their patients in follow-up. But more needs to be done. Coronary artery disease -- or more accurately, atherosclerosis in the coronary arteries, because the same disease also occurs in the kidney, leg and neck arteries (I'll talk more about this in another post) -- is a chronic disease. While angioplasties and stents can provide an immediate mechanical fix, the disease is biologic and patients can do a lot to reduce the risk factors of recurrence. Disease management (see our free workshop offer from Stanford's Patient Education Center) is crucial to patients' recovery -- so I hope when patients walk out the hospital door, they walk out with the "support" they need and deserve.
So Much for Breaking News The HeartCenterOnline coverage fails to mention two crucial facts from the JAMA study: (1) for emergency angioplasty patients (those in the midst of having a heart attack and being treated with balloons/stents) there was no difference in mortality; and (2) where hospitals practiced greater than 50 cases/year, there was virtually no difference in mortality among all patients. So here's the thing: it's well known that practice makes perfect. The AHA/ACC Guidelines for performing angioplasty state that cardiologists should perform at least 75 procedures a year. Less than that (and for hospitals that perform a total of < 200 a year) should only be done "in a region that is underserved because of geography". That's why hospitals without surgical backup started performing emergency angioplasties in the first place! To save the lives of victims in geographically underserved areas where an open heart surgical team might not exist. And save lives they do! The JAMA study expresses concern, and rightly so, that these smaller low volume hospitals are expanding angioplasty beyond this emergency application. But the misreporting in HeartCenterOnline does a disservice to heart-attack victims and to the growing movement of local hospitals that are trying to provide life-saving emergency angioplasty. Sure, if you have time, go somewhere where they do angioplasty a lot! But if you're having a heart attack, you may not be able to "go the distance" to a big center. The important thing is to get as quickly as possible to any hospital that performs emergency angioplasty! |
Myler
had actually done several somewhat experimental angioplasties
with Andreas Gruentzig in San Francisco the previous year, but
they were done during bypass operations, to see if the technology
worked. Both Myler and Stertzer had learned the procedure from
Gruentzig, a German angiologist living in Zurich, and they knew
each other and communicated regularly. (The photo shows, clockwise
from the left, Gruentzig, Stertzer and Myler.) Gruentzig did
the first PTCA in Switzerland in September 1977. Somehow six
months later, both Stertzer and Myler found suitable patients
to do on the same day. They did not, they've told me, coordinate
the events. And there has been the thought that they weren't
done exactly on the same day. Nevertheless, Myler subsequently
invited Stertzer to come to San Francisco ("flowers in the
hair" not necessary -- this was the 80's). He did (I did,
too) and they joined forces to teach a whole generation of cardiologists
how to do angioplasty.