January 2009
Archives:
January 30, 2009 -- 9:50am EST
Wrist Angioplasty Gaining Acceptance in
U.S.
Over
the past year, the
transradial approach, doing angioplasty and inserting coronary
stents using the wrist as the access site, has gotten significant
attention. Peer-reviewed studies and presentations at meetings
have consistently shown decreased bleeding complications, increased
patient comfort and safety, and lower cost.
A big question is why it isn't used more
in the U.S. -- in Europe, Asia and South America it's done far
more often (40-50% as opposed to 2%) than the "standard" femoral
approach which uses an artery in the groin.
One answer is training and interest. Traditionally
cardiologists aren't trained to do radial procedures during their
fellowships. Another is the perception that certain complex interventional
procedures are more difficult to do via the wrist.
But this may be changing. Yesterday Dr.
John Coppola of St. Vincent's Hospital in New York held one
of his radial courses -- and it did not need to be promoted,
because it was filled to capacity even before being announced.
Terumo Interventional, which makes equipment specifically for
the radial technique, told me that all the training courses in
the U.S. that they are involved in currently have a waiting list
-- this certainly was not the case only a year ago.
This past fall major meetings like TCT and
ISET have been featuring symposia
on the radial technique, and a recent article, "Radial-access
PCI safe and successful in high-risk patients and complex lesions",
published on theheart.org, generated far more online comments from
cardiologists than the average story. And a
recent study of 600,000 patients, published in JACC Interventions,
showed a sharp uptick in radial procedures in the last quarter
of 2007. (More current data is not yet available.) And the popular
press has been reporting more as well: the CBS "Early Show" recently
did a
two-minute segment, with Dr. Howard Cohen sitting on a park
bench showing catheters to host Julie Chen!
So all of these movements are showing a gain for
the wrist approach in the U.S.
One big reason, of course, is that results
show lower bleeding complications, and lower mortality with the
wrist approach: a safer approach to both angioplasty and diagnostic
cardiac catheterization.
Support for these views can be found in the many
peer-reviewed journal articles listed in the Reference
and Bibliography section of Angioplasty.Org's Radial
Access Center (now in its second year). But one
such study, published in JACC back in 2005, recently was brought
to my attention.
A Stanford
study of 3,500 consecutive patients undergoing angioplasty
showed the incidence of retroperitoneal hematoma (RPH) at 0.74%.
This is a very serious complication, where bleeding occurs at the
femoral access site, but backwards into the large abdominal space
in the body. It's often not recognized until well after the procedure
and it can be very dangerous, resulting in serious blood loss,
increasing morbidity and mortality. This means 1 in 135 patients
will suffer this complication. And it was significantly more common
in women.
The radial approach virtually eliminates this complication.
Stay tuned....
January 28, 2009 -- 10:25am EST
Plavix Safety Update
Monday's
post about the FDA
statement on the safety of Plavix (clopidogrel) when used in
conjunction with proton pump inhibitors (PPI) such as Prilosec,
Prevacid, Protonix, Nexium, etc., made reference to a joint statement
by the American College of Cardiology Foundation, American Heart
Association and the American College of Gastroenterology.
So here is a link to the paper, titled: "ACCF/ACG/AHA
2008 Expert Consensus Document on Reducing the Gastrointestinal
Risks of Antiplatelet Therapy and NSAID Use".
The summary states:
In appropriate patients oral antiplatelet
therapy decreases ischemic risks, but this therapy may increase
bleeding complications. Of the major bleeding that occurs,
the largest proportion is due to GI hemorrhage. Concomitant
use of NSAIDs further raises the risk of GI bleeding. Gastroprotection
strategies consist of use of PPIs in patients at high risk
of GI bleeding and eradication of H. pylori in patients with
a history of ulcers. Communication between cardiologists, gastroenterologists,
and primary care physicians is critical to weigh the ischemic
and bleeding risks in an individual patient who needs antiplatelet
therapy but who is at risk for or develops significant GI bleeding.
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January 26, 2009 -- 2:30pm EST
Plavix, Prilosec, Prevacid, Protonix --
Do I Hear a Nexium?
Gimme a "P"! Or more precisely,
a PPI (Proton Pump Inhibitor). And to add a few more initials,
gimme an FDA, which today issued an "Early
Communication about an Ongoing Safety Review of clopidogrel bisulfate
(marketed as Plavix)".
The basic concern is that some recent studies
have questioned whether the effectiveness of Plavix may be compromised
by a group of drugs known as Proton Pump Inhibitors (PPI). Presented
as an abstract at the AHA in November, a
major study by Medco, the nation's leading pharmacy benefit manager,
looked at almost 17,000 patient benefit records and found a 74% increase
in heart attacks in patients taking both Plavix and PPIs together.
These include the drugs in my title, plus a few more. (Compounding
the concern is that Prilosec is also available over-the-counter.)
PPIs are often prescribed for patients who are taking Plavix, because
Plavix, especially when taken with aspirin, can cause upset stomach
and gastric bleeding and these PPIs are effective in reducing those
adverse reactions.
The problem is that PPIs may also inhibit the enzyme
that activates clopidogrel. While some studies have shown this to
be true, others have not. Also, this is not the first time that Proton
Pump Inhibitors have come under review by the FDA. In August 2007,
the FDA started
a review, based on some small studies showing an increase in
heart problems. But the clopidogrel connection was not involved there.
One of the problems is that all drug eluting stent
patients are required to take aspirin and clopidogrel for a year,
at least. Stopping prematurely can lead to stent thrombosis (blood
clots in the stent) and heart attack or death. So, if a drug is found
to inhibit Plavix, it could be dangerous.
However, the
CREDO study, also presented at this year's AHA, found that
there was no interaction, that patients taking PPIs showed an
increase in cardiovascular events at one-year whether the patient
was on Plavix or not. And that Plavix had a beneficial effect
in reducing cardiovascular events whether the patient was taking
PPIs or not.
Confused?
The conflicting results between these two major
studies prompted the AHA, ACC and American College of Gastroenterology
to issue a statement to patients not change their medications without
consulting their clinician. The SCAI also issued a similar statement,
and concluded by stating:
"SCAI is eager for the findings of ongoing
studies, including the large, randomized study COGENT-1, which
is expected to clarify the possible interactions between clopidogrel
and PPIs."
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Unfortunately, Cogentus Pharmaceuticals, the company
sponsoring the COGENT-1 trial announced on Thursday that it is filing
for bankruptcy and that the trial was being terminated.
Still confused?
Wait....other recent studies have also shown
various genetic markers which indicate not all patients process
Plavix efficiently -- this is not news to those who have been discussing "Plavix
resistance" in some patients for some time.
So many questions about a drug that every stent
patient must take!
In today's notice, the FDA recommends:
- Healthcare providers should continue to
prescribe and patients should continue to take clopidogrel
as directed, because clopidogrel has demonstrated benefits
in preventing blood clots that could lead to a heart attack
or stroke.
- Healthcare providers should re-evaluate
the need for starting or continuing treatment with a PPI,
including Prilosec OTC, in patients taking clopidogrel.
- Patients taking clopidogrel should consult
with their healthcare provider if they are currently taking
or considering taking a PPI, including Prilosec OTC
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January 25, 2009 -- 5:30pm EST
Medtronic Seeks Runners -- Stents Included
Medtronic
(NYSE: MDT) recently announced that
it is looking for runners from around the world who have benefited
from medical technology to participate in the company's 4th Annual
Medtronic Global Heroes program. The photo to the left is of Alberto
Salazar, a world-renown marathon champion. He is Medtronic's
honorary captain for the program. Salazar is 50 and in 2007 collapsed
from sudden cardiac arrest. He was revived via CPR and had an implantable
cardioverter-defibrillator (ICD) to treat arrhythmia. He continues
to train runners and had three participating in last summer's Olympics
in Beijing. He is "committed to spreading the word about running
and living safely with a chronic health condition."
I am always amazed at the number of people who
continue their athletic activities after having a device implanted
(most could outrun me with no difficulty -- but that's another story...).
Our Forum Topic, "Exercise,
Sport, Physical Activity After Stent", has the stories of
scores of stent and heart patients who continue to run, ride horses,
etc. (By the way, I confirmed with Medtronic that patients who have
coronary stents are eligible for the competition
-- as long as there is no concurrent untreated coronary disease.
Individuals with abdominal aortic stent grafts are not eligible.)
More from Medtronic's press
release:
Known as The Most Beautiful Urban Marathon
in America™, the Medtronic Twin Cities Marathon is a three-day
weekend celebration of fitness that includes the Medtronic
TC Family Events and TC 5K, the Medtronic TC 10 Mile, and the
marathon.
Up to 25 runners will be selected to receive
a paid entry for themselves and a guest to the Medtronic
Twin Cities Marathon or the Medtronic TC 10 Mile and a travel
package that includes airfare for the Global Hero and guest
to the Twin Cities. The 28th Annual Medtronic Twin Cities
Marathon weekend will take place Oct. 2-4, 2009.
The deadline for applications
is March 31, 2009.
In addition to providing race entries and
travel expenses, the Medtronic Foundation will donate $1,000
to a select non-profit patient organization that educates
and supports people who live with the Global Hero’s medical
condition. To qualify as a Global Hero, runners must currently
be using a medical device therapy to treat the following
disease categories: heart disease, diabetes, chronic pain,
spinal disorders, or neurological, gastroenterology and urological
disorders. Eligible medical devices include any pacemaker
or implantable cardioverter defibrillator (ICD), any spinal
device, any neurological device, any insulin pump, or any
heart valve. All runners with eligible medical devices are
welcome to apply with no restriction on manufacturer.
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To apply or recommend someone to be a 2009 Medtronic
Global Hero, visit medtronic.com/globalheroes.
Good luck!
January 21, 2009 -- 12:20pm EST
XIENCE V™ Stent Takes the Lead
In sharp
contrast to the current gloomy picture in the healthcare sector,
Abbott (NYSE: ABT) reported this morning that its 4th quarter
2008 global sales rose 10.1% over 2007, and that the company's
XIENCE V drug-eluting stent was a significant contributor to
the bottom line. The company stated: |
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Worldwide medical products sales increased
15.6 percent; with 58.9 percent growth in global vascular sales
driven by the continued success of the XIENCE V™ drug-eluting
stent (DES), which became the market-leading DES in the U.S.
during the fourth quarter.
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The XIENCE V was
approved by the FDA in July and is part of the new generation
of stent technology, which I characterized last May as "DES
2.0", composed not just of new stent technologies, like
XIENCE V and Medtronic's Endeavor, but a new way of looking at
the process of stenting: when is it beneficial?, how to do it better?,
how to verify proper placement?, etc.
Interestingly enough, another company involved
in DES 2.0 is Volcano.
The company doesn't make stents, but innovates in imaging technologies
like IVUS, OCT and Volcano also has been reporting
double-digit growth, recently reporting a boost in sales of
its FFR functional measurement products, due in great part to the
striking results from the FAME trial. It seems that FFR (or Fractional
Flow Reserve) is becoming a hot property in its own right --
St. Jude Medical just acquired Radi Systems, the other manufacturer
of FFR devices.
And more innovations will be coming: Abbott and
others are working on biodegradable stents that will completely disappear
when their work is done, Cardiac CT has made significant advances
in lowering the radiation dose without compromising image quality
and, in the near future, may be incorporating the ability to perform
perfusion measurement, currently the territory of the nuclear stress
test.
Clearly the word for the future in healthcare is cost-effectiveness (well,
okay, it's a hyphenated word...). But new technologies are going
to have to prove that they can reduce costs AND benefit patient care.
Of course, any advance in patient care will have the effect of reducing
costs down the road (less repeat procedures, less care needed for
chronic conditions, etc.).
Whether innovation is enough to turn the economic
tide, at least in the device industry, is yet to be seen, but these
recent figures certainly are good news.
January 19, 2009 -- 7:20pm EST
When Less is More: Stents, That Is
So many news reports about the recent FAME
study in the New England Journal of Medicine drive
home a message that is not exactly correct. The "Stents May
Be Overused" headline is misleading. And here's why.
Yes, the FAME study did show that when FFR (Fractional
Flow Reserve) was used routinely to measure whether or not a coronary
lesion was ischemic, less stents were implanted per patient,
and the resulting decrease in major cardiac events was significant.
But stenting, as an important therapy, was never
called into question. The patient population for the FAME study consisted
of patients with multivessel disease -- and 94% of these patients
had stents implanted. Yes, that's 94%! It's just that the number
of stents per patient was lower, on the average:
two stents instead of three.
In
fact Nico Pijls, the co-principal investigator for FAME, told Angioplasty.Org
that, rather than reduce the total number of stents used, the use
of FFR could easily expand the patient population that could benefit
by stents. For example, patients with multiple blockages might only
have only 2 that are measured as ischemic, and thus would be candidates
for stenting, rather than surgery.
He characterized the FAME results as a refinement
of stenting, and that they actually may expand the use of the procedure
as well.
You can read Angioplasty.Org's exclusive interview
with Dr. Pijls here.
January 18, 2009 -- 11:30am EST
Glad to be of Service!
In response to my
recent post about Jane Brody's misleading
article in the New York Times, an article that one might see
as upsetting to a stent patient, reader BC (not me) writes in:
Thank you!, Thank you! I was one of those
misled by what I had read in the popular press (additional
articles aside from Ms. Brody’s latest) and was feeling
awful on both counts: that I had had the stents put in and
that I had to keep taking those awful meds with their associated
awful side effects.
You really put me at ease,
Which lowers my blood pressure,
Which puts me at lower risk for another “coronary event.”
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The reader, by the way, had a heart attack a year-and-a-half
ago, and two bare-metal stents inserted in a very critical artery
to prevent "another coronary event". He also made lifestyle
changes and feels better today than he has in years. He also continues
reading the New York Times.
January 17, 2009 -- 7:30pm EST
FAME: "Back to the Future"
The leading story about stents this past
week has been the publication of the FAME study and how a new St.
Jude Medical device that measures blood pressures inside the artery
can reduce the number of unnecessary angioplasty and stent procedures.
Well...it's not a new device; it's definitely not
a new concept; and St. Jude doesn't exactly get the credit for it
either, since their chief role was to acquire
the company that created the product. But it is an important
study!
First off, read Angioplasty.Org's article
on the FAME study, which clarifies some of this; then read my
exclusive interview with the FAME study's co-principal investigator,
Dr. Nico Pijls.
OK.
Now, let's get in the time machine and return to the genesis of coronary
angioplasty. It's 1977 and Andreas Gruentzig has fashioned a balloon
catheter to open a blockage in a patient's coronary artery. The balloon,
which he is holding in the picture to the left, not only can open
a blockage in a coronary artery but, oddly enough, also has the capability
of measuring the blood flow or pressure at the proximal and distal
ends of the stenosis (a.k.a. "blockage"). If the blockage
is significant, the two pressures are widely divergent, demonstrating
that there is a diminished blood flow through this arterial segment.
These "pressure gradients" would be displayed on the monitor
behind him, if there were an actual procedure going on.
Gruentzig continually monitored the pressure gradient
during procedures and, when the distal and proximal pressures were
similar, due to the dilatation or expanding of the balloon and compression
of the plaque, he judged the procedure finished. Optimal dilatation
of the stenosis had been achieved! Gruentzig was also very conservative
regarding the ability of angioplasty to achieve a result. He called
dilatation "a controlled injury" of the artery and was
adamant that the decision to intervene needed to be made with great
care and understanding of the downsides of the procedure.
In these early days, the measurement of pressures
required a separate lumen, which made the balloons were pretty wide
and unable to get into narrow arterial spaces. Then Dr. John Simpson
invented a much thinner balloon catheter: he got into the narrow
spaces, but he sacrificed the ability to measure pressures. Gruentzig
was not entirely comfortable with this "advance". But unfortunately
he died in a plane crash in 1985, and well....
Fast-forward to the 21st century. For two decades,
angioplasty has been done without monitoring the procedure with pressure
gradients. Decisions were made primarily by eye (a.k.a. the oculo-stenotic
reflex): there's a narrowing there; let's put in a stent.
Now, thanks to Dr. Nico Pijls and others, cardiologists
can measure pressures with a guide wire, using Doppler sensors et
al. We are now able to measure gradients and make intelligent, data-based
decisions about whether or not to dilate a blockage.
The results? Well, don't intervene on a lesion/blockage
that is not significant. It may do more harm than good. Gruentzig
would have said the same. And now the FAME study reaffirms what he
already knew, but which has been forgotten through the years.
Back to the Future!
January 15, 2009 -- 8:10pm EST
Thank You, Associated Press, for the Too
Many Stents Headline
You see -- I made a bet. When I interviewed
Dr. Nico Pijls on Monday (he is the co-principal investigator
of the FAME study) I predicted that on Wednesday and Thursday,
after the embargo for the publication of his FAME study in the
New England Journal of Medicine was lifted, we would see headlines
(or, as I now call them, "dreadlines") invoking the
mantra that "too many stents are being used", "angioplasty
doesn't work", etc.
Dr. Pijls hoped this wasn't the case, but I was
pretty confident that it would be. However, yesterday I became a
bit concerned, because most of the popular press seemed to report
this results of this trial fairly accurately -- that is, until the
Associated Press article came out.
"Fewer
clogged arteries may need stent treatment" is the AP's
dreadline, and that kind of sets up the article. I mean if I had
a clogged artery, I would want it opened. Of course, the FAME trial
in no way suggests that a "clogged artery" should not
be stented. The FAME study is about arteries that show up as having
a blockage, but they are not significant blockages. Any artery
that is "clogged", should be opened.
But these are symantics, and the AP is interested
in...well here's the opening sentence: "A new study gives fresh
evidence that many people with clogged heart arteries are being overtreated
with stents". Overtreated -- once again implying that there
are cardiologists who can't wait to stick a stent in your artery.
The study results also were reported by KABC in
Los Angeles thus: Study:
Stents could be harmful.
For a rational explication of the FAME study results,
check out our exclusive
interview with Dr. Pijls.
But I welcome the AP article, because now I won
my bet.
January 13, 2009 -- 4:45pm EST
Dreadlines About Stents Revisited
My last
entry was about the January 1 article in the New England
Journal of Medicine which took health care journalists to
task for glossing over facts, for not presenting a truthful picture
of complex issues, etc., etc., etc. This is a concept I have written
about extensively, even critiquing
the critique in NEJM. It's a phenomenon I have dubbed, "Dreadlines" --
where a news article wants to grab your attention, so it invokes
serious illness or death as a journalistic strategy.
So only days after the NEJM article, the New
York Times published a piece by esteemed health reporter Jane
Brody, titled "More
Isn’t Always Better in Coronary Care". And in case
you were wondering where this article was headed, you might just
take the lead sentence:
"Ira’s story is a classic example of invasive
cardiology run amok."
Amok, as defined by the American Heritage
Dictionary:
"In a frenzy to do violence or kill;
in or into a jumbled or confused state; in or into an uncontrolled
state or a state of extreme activity; crazed with murderous frenzy."
Yow! Got the image? Hordes of out-of-control invasive
cardiologists running around, crazed and sticking stents into patients'
arteries with neither rhyme nor reason: killer cardiologists!!
If Ms. Brody was not envisioning such a dramatic
picture, perhaps she should have used a more accurate term -- however,
her article certainly delivers the message that angioplasty, stenting
and interventional cardiology in general are being grossly over-used: an
assumption that is not only untrue, but dangerous!!
Dangerous? How can a mere article in the "newspaper
of record" be dangerous? Is the pen mightier than the catheter?
Is there such a thing as a "killer journalist"?
My answer is "yes". And here is why.
Two years ago, the CHARISMA study was presented at the American College
of Cardiology. The study's take-home message was that aspirin plus
Plavix did not add benefit, and that in a subset of patients, it
slightly increased heart attacks and mortality. But the study had
nothing to do with stent patients. If you had a stent, it was critical
that you continued to take both aspirin and Plavix. I wrote about
this extensively and issued a warning to stent patients "Don't
Stop Taking Your Meds". But patients read the popular press
headlines (or rather the "dreadlines") which totally misreported
the study and stated: "Plavix plus aspirin may be a risky combination", "Plavix
with aspirin is deadly for some", and so on. And patients did
stop taking their meds. And in the next couple of weeks, patients
with stents wound up having heart attacks. I know this to be true,
verified by cardiologists I have spoken to.
So reading (or seeing) the news can cause heart
attacks!
That being said, I would also like to state that
nowhere in Jane Brody's brief 800-word story is the issue of emergency
angioplasty mentioned. Ms. Brody and the popular press have been
delivering the message for quite a while now that angioplasty and
stents are overused and that you should do everything you can to
avoid them.
There's only one catch: if you are having a heart
attack, you need to get to a cath lab ASAP so that a balloon can
open up your blocked artery and prevent your heart muscle from dying.
90 minutes is what you should aim for. This is not hype; this is
fact: backed up by multiple studies over the past two decades.
Angioplasty saves heart muscle.
But the retail press would have you believe otherwise.
As Dr. Gregory Dehmer, former president of the SCAI, told me a few
days ago:
"Right
after the COURAGE Trial was published, and this is not the fault
of the investigators of the COURAGE Trial -- it's the fault of
the way the media rolled the story out -- because I remember
watching the 5 O' Clock national news and the headline was "Angioplasty
Doesn't Work".
So the next week I'm back in good old Texas
and I get called in for an acute MI and there's a cardiology
fellow trying to convince the patient in the Emergency Room that
'you're having a heart attack and this [angioplasty] is what
we need to do' -- and the patient is like 'But I saw the news
and they say it doesn't work.'"
"It doesn't work". Thank you Jane Brody.
Her article goes into more detail about the types of plaque that
cause heart attacks, etc. and it leaves you with the sense that doctors
don't really know what they're talking about. But her article depends
almost entirely on the observations of one single physician: Dr.
Michael Ozner, author of the book, "The Great American Heart
Hoax". His idea, that more resources should be put into prevention,
is completely correct. But his statement that:
“Interventional cardiology is doing cosmetic
surgery on the coronary arteries, making them look pretty, but
it’s not treating the underlying biology of these arteries.”
is misleading. It is true that interventional cardiology
is not treating the underlying biology of the arteries, but it is
possibly preventing an acute event in those arteries -- one that
just might save your life or, at least, save your heart muscle. There
have been many recent studies that have proven this to be true. Yet
Brody's article quotes decade-old studies to make her point -- a
point which is, in fact, misleading at best.
January 1, 2009 -- 8:40pm EST
New England Journal Criticizes CBS News
on Transradial Angioplasty Report
As
Editor-in-Chief of the most popular public website devoted to
interventional cardiology, I approached Susan Dentzer's article, Communicating
Medical News — Pitfalls of Health Care Journalism,
published in today's issue of the New England Journal of
Medicine, with great interest. I unfortunately was a bit
disappointed, specifically with her criticism of a September
24, 2008 CBS News segment about transradial angioplasty.
A leading thesis of the article is that journalists
need to be aware that their reports can influence the behavior
of clinicians and patients -- and on that point we agree completely.
After all, one of the significant tasks that Angioplasty.Org has
taken on over the years has been to correct misleading news stories
about the field of interventional cardiology. Recent important
examples include the flawed coverage of both the CHARISMA and COURAGE trials.
We also are very aware that many patients
and healthcare professionals respond to these "retail press" stories
by going to search engines to delve further. For example, traffic
on Angioplasty.Org spikes every time a major story about stents
or angioplasty hits the newswires.
Moreover, we agree with Ms. Dentzer that
the popular press often will characterize the results of a study
incorrectly, in order to concoct what we have dubbed a "dreadline".
And these scare headlines have consequences. Cardiologists we have
interviewed confirm that in March of 2006 some stent patients stopped
taking Plavix and aspirin together, based on faulty headlines about
the CHARISMA trial, and subsequently suffered heart attacks. There
is a definite danger in misreporting -- and for that we applaud
Ms. Dentzer's article.
But in her article, she cites a recent 105-second
TV segment about the transradial approach to angioplasty that aired
on CBS's "Early Show" and she takes it to task for incorrect
reporting. Since we host the major online source of information in
the U.S. about the transradial approach, and since we feature an
interview with Dr. Howard Cohen, the subject of the CBS News piece,
and since we are also aware that CBS News logged onto our site in
the week preceding their report to research the issue, we must take
issue with the New England Journal critique of this piece.
We, in fact, were impressed with the accuracy of
the reporting by interviewer Julie Chen. Moreover, since I featured
the CBS report in this blog, I feel obligated to defend my choice.
Ms. Dentzer critiques:
First, the interviewer incorrectly described
all angioplasty as "the opening of blocked arteries through
the wrist."
But she is misreading the inflection that reporter
Julie Chen used in introducing the piece. The transcripts reads:
This morning...in our special series "Heart
Watch": Angioplasty...which is the opening of blocked arteries...through...the
WRIST! Joining us is cardiologist Dr. Howard Cohen.
Ms. Chen was very specifically drawing attention
to the fact that the wrist approach was not the norm for angioplasties --
which was the entire point of this very short piece. Her second question
to Dr. Cohen clarifies this:
...only 1 out of 100 angioplasties performed
in this country is done this way and it's better. Why so few?
Other criticisms that the NEJM article levels at
CBS is that, although Dr. Cohen states the wrist approach is cheaper,
he is not given time to "to cite the study on which his assertions
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