The Voice in the Ear -- Burt's Blog
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November 2007 Archives:

November 8 » Headline Writers Play "Telephone"
Thoughts on the dreadlines about Cardiac Computed Tomography (CTA) and radiation.

November 6 » The Super X-Ray
What do Cardiac CT and Boris Karloff have in common?

 

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!")

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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.

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November 6, 2007 -- 9:48 EST

The Super X-Ray
Invisible RayOn 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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