Tue, Jan 13, 2009 - Page 16 News List

When treating heart conditions, sometimes less is more

Invasive coronary treatments are big business for hospitals and cardiologists, but mounting evidence suggests that few patients actually need these costly and sometimes risky procedures

By Jane E. Brody  /  NY TIMES NEWS SERVICE , NEW YORK

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Ira’s story is a classic example of invasive cardiology run amok. Ira, of Hewlett, New York, was 53 when he had an exercise stress test as part of an insurance policy application. Though he lasted the full 12 minutes on the treadmill with no chest pain, an abnormality on the EKG led to an angiogram, which prompted the cardiologist to suggest that a coronary artery narrowed by atherosclerosis be widened by balloon angioplasty, with a wire-mesh tube called a stent inserted to keep the artery open.

The goal, he was told, was to prevent a clot from blocking the artery and causing a heart attack or sudden cardiac death.

Wanting to avoid an invasive procedure, Ira decided to pursue a less drastic course of dieting, weight loss and cholesterol-lowering medication. But three years later, the specter of a stent arose again. An abnormal reading on a pre-surgical EKG led to another angiogram, which indicated that the original narrowing had worsened. Cowed by the stature of the cardiologist, Ira finally agreed to have not one but three coronary arteries treated with angioplasty and drug-coated stents, making him one of about a million Americans who last year underwent angioplasties, most of whom had stents inserted.

For patients in the throes of a heart attack and those with crippling chest pain from even minor exertion, angioplasty and stents can be lifesaving, says Michael Ozner, a Miami cardiologist and the author of The Great American Heart Hoax. But, Ozner said in an interview, such “unstable” patients represent only a minority of those undergoing these costly and sometimes risky procedures.

Most stent patients are healthy like Ira, who was experiencing no chest pain or cardiac symptoms of any sort. Yet Ira was afraid not to follow the doctor’s advice, despite the fact that no study has shown that these procedures in otherwise healthy patients can reduce the risk of heart attacks, crippling angina or sudden cardiac death. “We’ve extended the indications for surgical angioplasty and stent placement without any data to support the procedures in the vast majority of patients — stable patients with blockages in their arteries,” Ozner said.

What the studies do show, Ozner said, is that putting stents in such patients is no more protective than following a heart-healthy lifestyle and taking medication and, if necessary, nutritional supplements to reduce cardiac risk. The studies have also shown that stents sometimes make matters worse by increasing the chance that a dangerous clot will form in a coronary artery, as noted in 2006 by an advisory panel to the US Food and Drug Administration.

Ozner, medical director of the Cardiovascular Prevention Institute of South Florida, is one of many prevention-oriented cardiologists vocal about the overuse of “interventional cardiology,” a specialty involving invasive coronary treatments that have become lucrative for the hospitals and doctors who perform them.

Even some interventional cardiologists have expressed concern about the many patients without symptoms who are treated surgically. “The only justification for these procedures is to prolong life or improve the quality of life,” said David Brown, an interventional cardiologist and chief of cardiology at Stony Brook University Medical Center, “and there are plenty of patients undergoing them who fit into neither category.”

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