Heartfelt with Dr Melissa Walton-ShirleyView all posts »
No mortality benefit with stents in stable angina: Not news, not the point, and what's "stable"?Feb 29, 2012 09:21 EST
Patient A: Bill has a known 80% LAD lesion, 70% circ, and 40% RCA and declined a PCI at the time of a cath a few months back, opting to try medical therapy. The cath was performed because of a nine-minute Bruce protocol with mild LAD ischemia on a nuclear. He just couldn't live without knowing if his arteries were blocked or not. Bill likes to walk, play golf, and loves to try to have sex with his wife. His medications include aspirin, a statin, and a beta blocker. His bisoprolol was recently increased to 7.5 mg bid because of recent angina when his golf cart broke down and he had to walk back to the clubhouse. He's complained of moderate erectile dysfunction (ED) and fatigue since his initial diagnosis. His cardiologist just wrote a referral to a genitourinary test for a testosterone level and an ED workup, as he explains to him that he's likely out of shape and needs to condition more. He is scheduled for an eight-week follow-up. "Let me know if you have any more difficulties," the cardiologist says, "and I can see you sooner." The patient thinks as he's putting on his coat, "I thought that's what I just did." One year later, he feels about the same, still having trouble occasionally with chest pain and in the bedroom. Five years later, he is cardiac-event free, but he is now seeing his family doctor for depression. He retired early because he just doesn't feel well and no longer goes out with his friends.
Patient B: Tom has a 90% LAD lesion, 50% circ, and a 50% RCA. He initially saw a cardiologist because he can't play tennis without moderate substernal chest pain but has very good exercise tolerance, completing 10 minutes on a Bruce protocol and a "less-than-hyperdynamic response in the anterior wall." He opts to undergo a PCI to the LAD. Three weeks later, he comes back and says, "I'm having no chest pain, but I'm short of breath a little when I play tennis, and I'm having some difficulty with fatigue." The cardiologist looks at his medication regimen and says, "You know, you had no demonstrable ischemia in anything but the LAD distribution, you are having no angina, so let's taper off your beta blocker and see how you feel. Be sure to stay on your aspirin, statin, and carry some nitro. By the way, let's go over the Mediterranean diet and then see me in a few weeks." A month later, he reports he won his tennis match yesterday, he and his wife are scheduled for a cruise in eight weeks, and he's never felt better. Five years later, he's cardiac-event free and feels great.
Point 1: Patients don't just see cardiologists because they don't want to die. They actually see us because they want to "live" and live well. Medication side effects, the cost of medications, the ability to do activities without having to consider a stopping point that may produce chest pain are all part of the formula of what it takes to be a "heart patient." Whether or not a PCI is the appropriate course of action for our patient will have to be decided in the exam room on a case-by-case basis. It cannot and will not ever be legislated. As for reimbursement, we are obligated to do what is right for the patient, no matter the reimbursement issues that we may face. We swore an oath to do that despite any economic reimbursement or medical-legal issue. When the issues of patient comfort and safety are our first consideration, there is no other argument that counts.
Point 2: What exactly is "stable" angina? It is generally defined as predictable cardiovascular symptoms of shortness of breath or discomfort located somewhere between the belly button and the ear lobes, chest, arms, or upper back when one exerts oneself. Despite this fairly classic definition, the diagnoses of stable angina and, more concerning, the diagnosis of unstable angina are often missed. How is one to approach large territories of silent ischemia? What about those patients who have their gallbladder out for severe rest pain only to discover they had a 90% LAD lesion now completely relieved with a PCI? What about the young patient I saw once with excellent exercise tolerance who had an esophagogastroduodenoscopy with a diagnosis of an ulcer but called me one night after we accidentally met at a meeting. He just wanted to talk to me about his ongoing pain of six months' duration. When I cathed him, his LAD was hanging on by a hair with haziness and what appeared to be an ulcerated plaque. He was obese, and his glucose challenge in the hospital registered a blood sugar of around 300. He had no clue that he was literally a ticking time bomb, and neither did the other two physicians that saw him. You couldn't hold a gun to my head and make me say he had a stable situation. His symptoms were moderate, but in nondiabetics, the same pain might have been severe enough to warrant the "acceptable label" of "unstable," which would have generated a referral for cath a few months earlier.
Randomized prospective trials, adequately powered have given us great insight into the question "to cath or not to cath," but when it comes down to it, the variables in our patients are so highly complex, so thoroughly affected by genetics, environment, diet, undiagnosed diabetes, first- or secondhand smoke exposure, activity levels, and job expectations that every patient should be labeled as "guilty" of having progressive angina until proven otherwise. Add to this the great danger that lies in the patient's interpretation of their symptoms and then their physician's interpretation of their symptom complex, it is no wonder that patients can still get into trouble. Despite all the data, we can still rely only upon common sense and a high index of suspicion to help us navigate a course for our patients. Whether we discuss old news, new news, or no news, and whether or not our actions lower our patient's mortality, isn't all we owe them in the long run.
Living well is important, not just living.