February 2009
Archives:
February 17, 2009 -- 5:00pm EST
Medpedia -- OMG!!!
So
yet another web-based health site was launched today, with great
fanfare in the New
York Times, CNET and
other news outlets.
According to Medpedia's founder:
[James] Currier is aiming to build the
most complete database of information from medical professionals
and combine it with forums for consumers and patients to share
treatment stories, raise questions and directly engage with
the physicians editing Medpedia’s content.
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Since the New York Times featured a screen shot
of a page titled "Coronary Artery Angioplasty", I felt
it was fair game to critique the information on the
angioplasty page and its sister page on "Cardiac
Stents".
Cutting to the chase, I am far from impressed.
In fact, I read these two pages and my reaction, as per the title
of this posting, was OMG!!! If the information contained in these
two entries is any indication of the accuracy of the rest of Medpedia,
I would definitely advise patients to go elsewhere.
The entries on angioplasty and stents are
riddled with outdated and blatantly incorrect information about
interventional treatments for coronary artery disease. I am truly
surprised, given the sources that Mr. Currier cites in his statement
to the New York Times:
Mr. Currier said Harvard Medical School,
the National Health Service in England, the Centers for Disease
Control and Prevention, and the School of Public Health at
the University of California, Berkeley, are among the medical
organizations that have donated more than 7,000 pages of content
to Medpedia. Some institutions, including the N.H.S., the American
Heart Association and the University of Michigan Medical School,
will encourage staff and faculty members to contribute to Medpedia.
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It sounds impressive, to be sure, but here is just
a sampling of the misinformation (with corrections) on the topic
of angioplasty and stents:
Medpedia states: "A heart attack occurs
when blood flow through a coronary artery is completely blocked.
Sometimes the accumulation of plaque causes the blood vessel to
burst and a blood clot to form on the vessel surface." Bizarre
to say the least. Arteries bursting?? This is not even close to
a description of a heart attack.
In describing an angioplasty, Medpedia states: "The
doctor passes a long, thin, flexible tube (the catheter) through
the sheath, over the guide wire, and up to the heart. The catheter
is moved to the blockage, and the guide wire is removed." Perhaps
this may be seen as wonkish, but the guide wire is NEVER
removed during the procedure. It is the "rail" over which
all catheters are advanced. It is only removed when the procedure
is over and the patient is judged stable.
In describing "cardiac stents", Medpedia
states: "The meshwork of stents is usually made of metal,
but sometimes a fabric is used. Fabric stents, also called stent
grafts, are used in large arteries." Well...except that
(1) "fabric stents" actually contain metal and (2) they
have nothing whatsoever to do with coronary artery disease or cardiac
stents -- stent grafts are used, sometimes, to treat a triple A --
Abdominal Aortic Aneurysm -- this is an unrelated medical issue which
has nothing to do with blocked coronary arteries.
Medpedia states that: "In about 20% of
cardiac stent placements, the artery narrows again within six months
of the angioplasty." Correction: with drug-eluting stents
(DES), the numbers for restenosis are in the single digits. This
is not news -- DES were introduced in the U.S. five years ago!
Medpedia states that: "Treatment with
radiation can also limit this growth [restenosis]. For this procedure,
a doctor places a wire where the stent is placed. The wire releases
radiation and stops cells around the stent from growing and blocking
the artery. This procedure, involving intracoronary radiation,
is known as brachytherapy." Unfortunately for Medpedia,
not only has brachytherapy not
been proven useful, but both companies making brachytherapy
equipment ceased manufacturing several years ago.
And I could go on, but I'll end with this...Medpedia
states that "Metal stents preclude patients from having
a magnetic resonance imaging (MRI) test within the first few months
following the procedure." Except that the FDA approved
both the Cypher and Taxus DES for immediate MRI FIVE YEARS AGO! In
fact on Angioplasty.Org, we have a Patient
Forum Topic just answering questions about this issue. Correction
-- it is perfectly safe to have an MRI immediately following stent
placement.
As a rough estimate, it would seem that much of
the information about interventional medicine on Medpedia is five
years old.
Angioplasty.Org has
been online since 1997, has thousands
of patient postings, and reports the most current news about
stents, angioplasty and interventional medicine. Considering the
quality of the information about this area that I've seen on Medpedia,
I would not call it Web 2.0 -- rather Web minus 1.25.
February 11, 2009 -- 12:25pm EST
Taking Cost-Effectiveness to Heart
The current economic environment is forcing
many issues into sharper focus. Cost-effective medical therapy
is one and it presents the Obama administration with a major challenge,
as Alicia Mundy reports in
Monday's Wall Street Journal:
The drug and medical-device industries
are mobilizing to gut a provision in the stimulus bill that
would spend $1.1 billion on research comparing medical treatments,
portraying it as the first step to government rationing....
The administration hopes to expand coverage while limiting
use of treatments that don't work well.... The House version
of the stimulus package sent shudders through the drug and
medical-device industry. In a staff report describing the bill,
the House said treatments found to be less effective and in
some cases more expensive "will no longer be prescribed."
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I'm all for expanding medical coverage: it's dis-heartening
(sorry!) how many patients write into our Forum,
unable to afford critical medications like Plavix because
they've lost their insurance -- some have stopped taking it; some
have had heart attacks as a result. So to expand coverage to more
people, the money is going to have to come from somewhere.
But my immediate reaction to hearing that government
might be "comparing medical treatments" to determine which
are "effective" is not so much the "I'm not going
to let bureaucrats tell me what I can and can't do" stance,
as it is the fact that, at least in the field of the treatment of
heart disease, there are so many unresolved questions within the
medical specialties themselves. And each new study or trial often
(not always) adds new and confounding information. I mean we still
aren't sure how long Plavix needs to be taken post stenting. Should
we use bare-metal or drug-eluting stents, when and in whom -- or
no stents at all because the Fractional
Flow Reserve is above 80? CT Angiogram or not? Or should we reverse
the historical trend and put interventions on the shelf, a la COURAGE,
and stay with medical therapy only for most?
If doctors can't agree on the best therapies, how
can government agencies do so?
Where
some insight can be found is in The
Editor's Page of the current JACC Cardiovascular Interventions. Dr.
Spencer B. King, III, a pioneer of coronary angioplasty, discusses
the opportunity for medicine in this era of "danger". One
thought stood out for me:
Science and technology have been at the
heart of interventional cardiovascular medicine and must also
drive medical intervention. Through clinical research, we have
created an extensive evidence base that is currently being
enforced through various mechanisms, but does one-size evidence
fit all? It would be ludicrous to put a stent in every patient
with angina without clear evidence of what the treatment was
to accomplish. On the other hand...the suggestion that everyone
with an abnormal C-reactive protein needs massive statin therapy
is the one-size-fits-all concept that, along with direct-to-consumer
advertising, drives medical costs. Medicine must be personalized
in order to be effective and cost-effective...the era of "every
therapy for everyone" is over. The opportunity for medicine
is to harness the power of technology, medical informatics,
genetics and personalized prevention, and therapy for the best
outcome for our patients.
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Personalized medicine. It's a concept that's been
bandied about for a while now, but with new and exciting developments
in decoding genetic markers, along with the hard work of physician
teams and medical societies who have been authoring Appropriateness
Criteria, the idea is being recognized as critical: a variety of
available therapies is needed to treat a variety of individuals and
physicians need to use the most current data to triage the right
patients to the right therapy.
Headlines in the popular press that proclaim "medical
therapy trumps stents" or "CT scans are useless and costly" are
meaningless, unless applied to specific patients with specific individual
clinical situations. Stents or statins can be great for the right
patient; not so much so for the wrong one.
So, as someone who has never been able to walk
into Macy's and just buy a suit off-the-rack, I sincerely hope the
push towards cost-effectiveness does not put much stock in the concept
of one-size-fits-all medicine.
February 6, 2009 -- 5:30pm EST
Vote for Radial!
This
week's poll on theheart.org is about the transradial (wrist) approach
to catheterization and angioplasty. The question is "Should
radial access become the default choice for PCI?" (scroll
down to access the item.)
We, at Angioplasty.Org,
have been bringing this technique of catheter-based interventions
to the forefront and now, theheart.org (part of WebMD) has taken
up the question.
The current voting is 47% to 53%, slightly
favoring femoral -- but this almost 50/50 vote is interesting,
since currently in the United States, only 3% of PCIs are done
radially. If you favor the radial approach, let your voice be heard!
February 5, 2009 -- 5:00pm EST
CT Heart Scans, Radiation and the Media
A
new study, published
yesterday in JAMA, describes a wide variation in the
measured radiation exposure from CT angiograms, depending on which
of 50 centers did the scans, what methods were used and, to some
extent, which scanner was used. This report predictably resulted
in "glowing" headlines about CT angiograms -- and not
the good kind of glowing.... Here's a sampling:
However, the point of this study was not
to show that CT scans of the heart have suddenly been found to
be dangerous! In fact, the doses recorded at the high end were
what was considered "normal" less than a year ago (e.g. NY
Times, June 29, 2008). Strikingly, as the accompanying
editorial by Dr. Alfred Einstein states:
"The estimated overall median effective
dose for CTA...was 12 mSv, somewhat less than the value reported
in several earlier studies using 64-slice scanners."
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What is actually real important news,
for both medical professionals and patients, is
that, using dose reduction strategies, CT angiograms of excellent
quality were done with exposures of only 2.1 mSv, approximately
what New York City residents are exposed to annually, just from
walking around. That's why I titled Angioplasty.Org's coverage, "CT
Scans of the Heart Can Be Done with Low Radiation Dose." That's
news!
And
the implications for patients and professionals are profound. If
you are a patient, says Dr. Michael Poon, past president of the SCCT,
ask the imaging center where you have been sent for a CT angiogram, "'What
method are you using to lower the dose?' And if they don't
know what you're talking about, I would say, 'See you later!'"
For imaging professionals, the PROTECTION
I study in JAMA has a clear message: learn the latest dose reduction
strategies and work with your equipment vendor to implement them.
With radiation at these low levels, CT angiography may mount a
challenge to the most often-prescribed nuclear stress test, which
carries radiation doses from 12-21 mSv. Of course, you never read
headlines such as "Nuclear Stress Test Zaps Patients" because
it's been around so long.
Ever since multislice CT scanners became
available in 2002-2003, industry and the imaging profession have
been working on ways to reduce the radiation exposure. The PROTECTION
I study in JAMA shows some positive results, but since 2007, when
that data was collected, technology has advanced significantly
-- enough so that Dr. Tony DeFrance, for example, regularly performs
320-slice scans with Toshiba's AquilionOne scanner at 1 or 2 mSv.
Likewise, physicians such as Dr. Michael Poon are using GE Lightspeed
units, and getting in similar ranges. Philips and Siemens have
also developed low dose strategies.
As evidenced at the start of this post, whenever
a study about CT angiography is published, the popular press jumps
on the story with accompanying "dreadlines", doing a
disservice to the technology, those who practice it, and certainly
to patients.
A shining, and unfortunately rare, exception
to this recent spate of news stories, was Dr. Nancy Snyderman,
Chief Medical Correspondent for NBC News, who discussed her own
CT heart scan with Matt Lauer on yesterday's "Today Show" (video
below).
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