July 2011
Archives:
July 9, 2011
-- 7:05pm PDT
Are Stents Beings Overused? How Much and
Where?
Dr.
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).
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 .
July
6, 2011 -- 11:30pm PDT
A Perspective on the Appropriate
Use of Angioplasty and Stents
Dr.
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.
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.)
July 5, 2011
-- 4:15pm PDT
Angioplasty
and Stents Inappropriate Only 4% of the Time
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.
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
|