Congratulations to Dr. Topol for coming up front and raising pertinent questions about this astonishing case. This patient represents the complete lack of good sense and ... in medical practice. Interestingly, no information was given regarding what "maximal" medical treatment of angina (was it really ischemic angina?) was provided to this patient and what kind of functional tests were done to assess the presence, site and amount of myocardial ischemia. Just two simple questions: did JACC publish this terrible medical practice as an alert or as waggery of what physicians can do in the real world? And, who ended up paying the bill?  

How could this be happening?  Whatever lines existed appear to all have been crossed in this case.  There is no way this patient had 28 unstable presentations.  I'll say it:  the economic interests of the physician were the real driving factor here, not the patient's well-being.  I've always felt physicians were the best and only way to ultimately control health care costs; this is just another example where this may not be true.  This doesn't even begin to address the subtle incentives for every borderline case.  $1000 for each cath/PCI vs. $75 for each adjustment in meds?  We need to have our keys taken away.  Nothing will change until the economic incentives change.  

Dear Dr. Topol

Congratulations for your "courage" to come foward and denounce the attonishing increse in the use of coronary stents. Our group of the Heart Institute of the Federal University of Rio de Janeiro and the National School of Public Health has been publishing in the last few years data from the brazilian national health service and have found a one year mortlity of 6,7% of patients who had stents implanted. I few that these patients who had the procedure performed were transformed from low risk patients (one and two vessel disease) in high risk patients, approaching the one year mortality of patients with left main trunk disease.

We have even seen patiens who had "prophylatic stents" implanted, that is, patients with arteries with less than 50% obstruction who had stents implanted. No additional comments.

We should all unite to stop this. In my forty five years of medical practice I have never seen a procedure utilized in such a large scale and in so many patients withouth appropriate indications.

Nelson A. de Souza e Silva, MD, FACC

Full Professor, Faculdade de Medicina da Universidade Federal do Rio de Janeiro.

Director - Instituto do Coração/UFRJ

Thank you Dr Topol for sharing this information. This could only happen in the US! Financial incentives have destroyed physician's common and clincal sense. It would be interesting to see the final angiogram with 67 stents in situ! What is needed is 'back to basics' philosophy i.e. use clinical judgement, be sensible and treat the patient with commons sense and don't be greedy.

The case report says the patient was treated with maximum medical therapy. Unfortunately, that information is not published to know if the therapy was maximal or not. Too often, beta blocker doses are often low in patient with known CAD. IF the pulse and blood pressure can tolerate titration and non-cardiac effects are tolerable, there is no reason to keep the dose low. In a retrospective study of the dose of beta blockers post MI, we found that the dose of atenolol or metoprolol was about 50% of the doses used in clinical trials on average and only 15% of the patients reached either 100 mg of atenolol or 200 mg of metoprolol daily. In reviewing the patients getting lower doses, 65% had no documented reason for maintaining a low dose for 12 months including notes about side effects. The blood pressure and pulse of this group was not low in this group. (Am J Health-Syst Pharm. 2003; 60:2471-4). Similarly, there is no information regarding any of the specific therapy that should be given to this patient. Without information regarding the therapy, the dose of medications and whether the patient was adherent to therapy or not makes justification of continuing to place stents very difficult to determine. This seems like a great example of why the fee-for-service model (they will come and we will build it) is no longer viable.

The amazing thing to me when I read the JACC case report was the assertion that all stents were placed to alleviate symptoms.  Color me skeptical.

im 35 had 2 open heart operations ,and a recent heart attack,,,its a heredatory dissorder and im physically fit and healthy,,im now living with my secong mechanical valve and my warfrin levels are all ver the place as my body is resistant to warfrin,,,its so bad that i require about 5 blood tests a week constantly adjust my medication and currentlyon 16mil,my surgeon has told me i will not survive another operation because of the complexity of my case,,so do i not deserve another chance on my 3r op,,,1 stent 20 stents who cares,,,1 operation 2operations,,3operations,,,we should just do our best,,,all of us were all human living on the same planet,,,where has thegood old care gone from the health systems,,,,,mat disley from australia,,,,

Thanks for the comments here. It turns out this case report has led to a considerable discussion in China  http://www.thepreparedminds.com/archives/2615

Dr. Topol, it is not a question of the need to ration needed care, it is a question of how to eliminate the use of expensive, useless care.

 

There is no reason to believe that this person is any healthier after this amount of revascularization that he or she would have been with appropriate medical management.  I would be interested if appropriate medical management including niacin and omega-3 fatty acids had been used.

 

I object to depriving a 90 year old of an effective intervention if that 90 year old is likely to recover from the intervention and have a good quality of life.  My great grandmother had her gall bladder removed at age 90 which at that time was a major surgery.  She enjoyed another 22 years of quality life after the procedure.  

 

If we limit our care to the procedures that will make people better, we will not need to consider rationing of health care.  How much do stress tests help?  What percentage of coronary stents really improve either quality or quantity of care.  Is Crestor treatment based on HS-CRP really sane?  And then there is back surgery! 

I am a 44 year old African-American male.  I was a healthcare professional for 17 years until I could no longer continue.  Currently I have 32 coronary stents and have had 3 CAB's over the last 10 years.  I had my first lipid xanthoma removed from my tendon when I was 7 years old.  Between 22 and 32 I had 21 sugeries to remove those nasty lipid xanthomas from literally ALL of my tendons.  I didn't receive my first stent until I was 29 years old.  The  familial hypercholesterolemia that I was diagnosed with at 26 is killing me.  I have taken many, many drugs.  I have even had LDL Apheresis.  The blockages are painful and horribly frightening to me and my family.  What choice do I have besides stenting?  I have had 3 heart attacks this year alone with kidney failure during the last M.I. this past November 2010.  My choices seem to be limited.  If my cardiologists (I have been through 4 of them) do not stent me then I will die a painful death.  I don't wish or relish that choice.

 ...still stenting...

Chattanooga, Tennessee

This is all very, very good news if you are the manufacturer of stents.

As the New York Times reports, stents are big business, with powerful manufacturers like Johnson & Johnson and Boston Scientific selling over $3 billion worth of stents last year. They have invested heavily in expanding the use of these stents; stents have become more popular as rates for the more invasive CABG have dropped. According to the Times:

“The specialists who are most likely to diagnose coronary artery disease are in many cases also the doctors who implant stents. Cardiac surgeons have seen their annual incomes dwindle to an average $425,000 down from $1.02 million in 1990, after adjusting for inflation. Meanwhile, the average income of an interventional cardiologist has risen to $550,000 from an inflation-adjusted $392,000 in 1990.”

Consider the cases of Drs. Midei (not yet charged) and Patel (convicted and sentenced to a 10 year prison term) who are the stent-happy cardiologists in Maryland and Louisiana respectively -  until health care fraud accusations stopped them.

As a heart attack survivor who sports a shiny new stainless steel stent in my LAD, however, I'm guessing that few if any of you docs responding to Dr. Topol's example have personally experienced a cardiac event yourselves. This particular patient is 56 - not 90 - so who among you would throw up your hands with a patient this young and happily shuffle them off to hospice?

There is what I call a "hierarchy of heart disease". I think I invented this term, but all heart attack survivors I know recognize its completely unofficial validity. More at HEART SISTERS - "The Seven Levels In The Hierarchy of Heart Disease" at: http://myheartsisters.org/2010/07/21/hierarchy-of-heart-disease/    This patient would definitely win the stent sweepstakes in Level #4!

PS  to Dr. Blanchet: are you saying that your great grandmother who had surgery at age 90 and lived another 22 years died at the age of 112?  Wow!

 

 

If the choice is 67 stents or die then I'd pick the 67 stents. Heck I'd pick the 167 stents.