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July 2011 Archives:


July 9, 2011 -- 7:05pm PDT

Are Stents Beings Overused? How Much and Where?
Paul S. Chan, MD, MScDr. Paul Chan sat down with me recently to talk about the study published this week in JAMA that he served as lead author on. The article, "Appropriateness of Percutaneous Coronary Intervention." has generated hundreds of news reports about "unnecessary stenting", "overuse of angioplasty", etc.

In my exclusive interview with Dr. Chan, we talked about the real meaning of this study, what it was meant to do (benchmark the use of PCI in the U.S.) and how it's being (mis) interpreted by the press (I'll be discussing this aspect in a subsequent post).

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Dr. Chan also discusses the field of cardiology, its self-reflection, shown in studies like this one, and also some ways in which clinical cardiologists, referring physicians and...patients(!)...need to be brought into the decision-making process. Also, a fact which I haven't seen discussed much in the press: the NCDR is sending member hospitals quarterly reports of inappropriate procedures, mapped to the Appropriate Use Criteria, so they can look at their rates and improve upon them in very specific ways.

Read the entire interview here .

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July 6, 2011 -- 11:30pm PDT

A Perspective on the Appropriate Use of Angioplasty and Stents
Ralph Brindis, MD, MPH, FACCDr. Ralph Brindis is the Immediate Past President of the American College of Cardiology and helmed the National Cardiovascular Data Registry (NCDR) since its inception in 1997 -- this is the registry that was the source for the data analyzed and reported in yesterday's JAMA study, "Appropriateness of Percutaneous Coronary Intervention."

In my exclusive interview with Dr. Brindis, I talked with him about the study, his feeling about what it showed, both the positive findings and what he calls "opportunities for improvement." While there was almost 100% adherence to guidelines for acute angioplasties (which made up 71% of the total angioplasties performed) the study also pinpointed the fact that PCIs for non-acute patients had a higher rate of "inappropriates", as defined by the ACC/SCAI Appropriateness Criteria -- and that this rate varied widely from hospital to hospital. This means that those hospitals with higher than average "inappropriate" PCIs needed to look at their cases, their decision-making process and work to bring it closer to the norm.

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The crazy thing about much of the news reporting about the publication of this study in JAMA is the implication that an "investigative team uncovered previously unreported data" and exposed the fact that "up to half of angioplasties performed may not be beneficial."

The fact is that none of this data would exist if it were not for the ACC, SCAI and physicians like Dr. Brindis, who is a co-author of the JAMA study. And the point of the study was specifically to take a "look-see" at how PCIs were being done in the U.S. and that look showed only 4% of all PCIs could be classified as "inappropriate". Most importantly, the study showed precisely where the inappropriates were happening, and opened up a discussion about how to reduce that number and improve the use of angioplasty.

Speaking of inappropriate, I'll be discussing the inaccurate reporting of this study by most of the mainstream media in an upcoming post, but for now, read over our interview with Dr. Brindis. (We'll be posting a companion piece, talking to the study's lead author, Dr. Paul Chan, tomorrow.)

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July 5, 2011 -- 4:15pm PDT

Angioplasty and Stents Inappropriate Only 4% of the Time
Are Stents Appropriate?A major study of a half-million angioplasties, published today1 in the Journal of the American Medical Association (JAMA), refutes two major myths about angioplasty and stent use in the United States: myth #1, that angioplasty is vastly overused and unnecessary in most cases; and myth #2, that most angioplasty is used in stable patients and therefore has little or no benefit over drugs in reducing death or heart attacks.

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Titled "Appropriateness of Percutaneous Coronary Intervention", this paper is the first comprehensive look at how closely interventional cardiologists in the U.S. are adhering to the practice guidelines for PCI (angioplasty and stenting) most recently published by the professional cardiology and surgical societies in January 2009.

So...cut to the results! Of the 500,154 procedures studied, only 20,731 (4.1%) were deemed "inappropriate". And more than two-thirds of the procedures were done in patients who were having a heart attack or who were unstable and at an extremely high risk for having an acute event.

"Great work," Dr. Ralph Brindis, immediate past-President of the American College of Cardiology, told me. He continued:

"What's so fascinating about this study is the good news: that in general we're pretty appropriate. An important point is that 71% of all angioplasty is performed for either STEMI, NSTEMI or for acute coronary syndrome (ACS) or unstable angina.... So this is actually in contradistinction from the first page of the COURAGE Trial in the New England Journal which implied that maybe 70% or more of angioplasty is for stable angina in the United States...and that simply is not true! Well over 70% of all angioplasty in the United States is for acute syndromes.

Actually Dr. Brindis was being generous. The COURAGE Trial put the prevalence of angioplasty in stable patients at 85% when it is actually at 29% -- the exact opposite!

So, who cares? What does this matter to patients? Isn't this just another internal dispute in the medical community? Actually, not! The take-home message from this study is of vast importance to patients. Angioplasty, when performed during an acute episode (71% of the time) can save your life. If you think you are having a heart attack, get to a hospital that performs angioplasty ASAP. Angioplasty can stop a heart attack in its tracks!

Angioplasty.Org will be reporting in more detail about this study, and will also be posting exclusive interviews with Dr. Paul Chan, lead author of the JAMA study, Dr. Ralph Brindis, immediate past-President of the ACC and guiding light for the NCDR registry, and Dr. Gregory Dehmer, former President of the SCAI and co-author of the Appropriateness Criteria.

But take the following incorrect and distorted "dreadlines" from today's news with a grain of salt -- unless, of course, you have high blood pressure:

"Heart Procedure to Clear Arteries May Be Misused 12% of Time, Study Finds" -- Bloomberg News

"Angioplasty unnecessary in some cases, study finds" -- CNN

"Study Finds Too Many Elective Stent Procedures" -- MedPageToday

"Many US heart stents inappropriate: study" -- Reuters

And stay tuned to Angioplasty.Org.

1 Appropriateness of Percutaneous Coronary Intervention ; JAMA. 2011;306(1):53-61.doi:10.1001/jama.2011.916

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