November
2007 Archives:
November 12, 2007 -- 12:50pm EST
About Those Stents: Tiny Time Bombs in
Your Heart...or Not?
This morning's New York Times announces
that the drug-eluting stent has been pardoned and taken off Death
Row. In an article, titled "A
Heart Stent Gets a Reprieve From Doctors", Barnaby Feder
discusses the recent flurry of data that seems to be reversing
the year-old panic that drug-eluting stents (DES) were "tiny
time bombs in your heart". This phenomenon was dubbed the "firestorm
of the ESC" because the first major presentations, pointing
out a higher-than-reported incidence of potentially fatal late
stent thrombosis in DES, were made at the 2006 European Society
of Cardiology (ESC) meeting last September.
I reported on the misinformed flame-stoking press
coverage at the time, and specifically the news
report that started off:
"Millions of Americans could be walking
around with tiny time bombs in their hearts."
In my blog entry of exactly one year ago, titled "Eentsy
Weentsy Time Bombs -- or -- The Pen is Mightier Than the Clot",
I critiqued that report and took its author to task for scaring
the hell out of patients with incorrect information.
This morning's NYT references the same report,
attributing it to "a cable news network". In point of fact
the author, Robert Bazell, is the Emmy and Peabody awarding-winning
chief science and health correspondent for NBC, and his report appeared
on the NBC Nightly News with Brian Williams. Bazell continued his
thrust a month later in his broadcast
about the FDA stent safety panel:
"Many cardiologists have gotten carried
away with the new technology with results that could be very
dangerous for some patients."
Or..."Watch out for that cowboy in your heart!"
The point being that much of the negative and incorrect
news coverage appeared in the broadcast and mainstream media and
had a very big impact.
As I look back and read my report from
November 21, 2006, as well as the various
DES articles we posted on Angioplasty.Org, in light of the new
data presented at this year's ESC, TCT and AHA meetings, I have to
say nothing in my mind has changed. These stents work well, there
is a very small, but serious complication involved, strict adherence
to dual antiplatelet therapy is critical, patient selection is extremely
important (don't use DES in patients who won't be able to comply
with the Plavix/aspirin combo and consider using a bare metal stent
in situations that have a low risk for restenosis), and statistically
speaking, the small increase in complications from DES will be offset
by the increased restenosis seen in bare metal stents (studies have
shown that restenosis presents as a heart attack about 1/3 of the
time).
All this was known a year ago, the new registries
and studies have confirmed this knowledge.
So nothing has changed...except, oh yeah, the sales
of drug-eluting stents have slumped, down over a billion dollars
worldwide, and DES usage in the U.S. has dropped from 90+% to low
60% range. Boston Scientific and Cordis are laying people off and
the field has been in turmoil.
Except that now multiple studies, including the
oft-quoted SCAAR
Registry from Sweden, are revising the view that DES are dangerous.
It's a billion-dollar Emily
Litella gag.
So to me, the very interesting question was one
raised by Rotterdam-based Dr. Patrick Serruys, during a panel at
the TCT last month. In referring to the 2006 ESC presentations, he
asked:
"How could such a small group of studies
by a small group of people have such a big effect on the entire
field of interventional cardiology?"
I have an answer. Tune in tomorrow....
(By the way, after I sat through almost a dozen
studies presented at TCT, all showing no difference in heart attack
or death between drug-eluting stents and bare metal stents, I asked
the panel, "So would you conclude that there's no ticking time
bomb inside patients' hearts?" And distinguished cardiologist, Dr.
Sigmund Silber of Munich, replied, "No. Millions of patients
are walking around with a ticking time bomb in their hearts -- it's
called coronary artery disease!")
November 8, 2007 -- 11:14 EST
Headline Writers Play "Telephone"
I've tagged these in past
columns as "Dreadlines" -- an over-amplification
of a news item (i.e. a distortion, as in old
school "Heavy Metal"). But when you add misinformed
medical reporting to the "anything for a thrill" MO
of the headline writers at Fox News, you get things like this:
Super
X-Ray Drawing Controversy for
Super-Dose of Radiation
It's the game of "Telephone" -- you whisper
a message in the next person's ear and by the end of the line...well,
you get the idea.
That's exactly what happened to the study which
I discussed in Tuesday's
post. The CorE 64 trial, presented at the AHA this week, proved
the extremely high accuracy of Multislice CT in ruling out coronary
artery disease. To be sexy, AP dubbed it a "Super X-Ray".
But in the story was a completely inaccurate line that the CT radiation
dose was 10 times higher than a standard angiogram. I disputed this
in my post, and yesterday an expert in the field, Dr. Michael Poon,
President of the Society
for Cardiovascular CT, confirmed to me that major studies have
shown the radiation dose from CT to be 1-2 times that of a standard
angiogram, and certainly the same as, if not less than, the dose
from a nuclear stress test.
But facts shouldn't get in the way of selling papers
(or, in the case of Fox News, selling...um, what is it that they're
selling anyway?) So what started out on Monday as the scientific
presentation of a very successful randomized clinical trial of Multislice
CT, turned within 24 hours into the totally fear-mongering headline
above -- which is great on Halloween, but not so much when people's
healthcare is concerned.
November 6, 2007 -- 9:48 EST
The Super X-Ray
On
Halloween night, Turner Classic Movies ran a Karloff-a-thon and
I got to see a favorite sci-fi flick from my nerdy 8th grade years: "The
Invisible Ray" -- a cautionary tale in which an unknown
ray, emanating from a meteor that crashed in Africa long ago, was
able to melt and destroy rocks and statues, yet also cure blindness
and countless other diseases -- all, of course, at the expense
of making Boris Karloff glow in the dark and instantly kill anyone
he touches ("Pushing
Daisies" anyone?).
So it was with amazement that, when I logged onto
the news yesterday, I saw headlines everywhere proclaiming a medical
breakthrough: the "Super
X-Ray".
We had just posted an article about the results
of the CorE 64 study, presented at the annual American Heart Association
Scientific Sessions in Orlando by the investigators at Johns Hopkins.
The goal was to compare the diagnostic accuracy of 64-slice CT angiography
with the current "gold standard" of invasive cardiac catheterization
in the detection of coronary artery disease. The results were excellent
-- you can read more about the study in our article, "64-Slice
CT Heart Scan Gets High Marks As Test for Blocked Arteries."
It quickly became clear that all the articles about
the "Super X-Ray" were in fact about the CorE 64 study.
In fact, most of the articles were feeds from the AP
article by Marilynn Marchione.
I've discussed with cardiologists from the Society
of Cardiovascular Computed Tomography the fact that this technology,
which has been around for a few years now, needed a name. Sometimes
it's called Multislice
CT (CT stands for "computed tomography") or Multidetector
CT or Cardiac CT or CT Angiography, CTA and so on. And there are
generations from 16-slice to the current 64-slice and coming soon
at your neighborhood imaging center, the 256-slice scanner.
But now the retail press has taken care of that:
presenting the "Super X-Ray". I'll take two, please.
By the way, I'll be writing more on this subject
-- because there are some serious inaccuracies in the AP article,
for example, stating that Multislice CT scans "deliver 10
times more radiation to the patient than a standard angiogram".
(Who wouldn't glow after one of those?) There are a number of studies
that show the range of radiation doses to be anywhere from the same
to about twice as much, depending on who does the study, what equipment
is used and whether newer techniques such as gating and phasing are
used (significantly reducing the radiation dose).
Even at its high end, the radiation exposure from
CTA is similar or less than what the patient gets in a typical nuclear
stress test -- a widely-used test that many imaging specialists
feel will be replaced by CTA.
For more, and more accurate information and interviews
with experts about this and other imaging technologies, visit Angioplasty.Org's
Imaging Center.
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