There may be good and bad news for people considering having coronary stents implanted as treatment for narrowed arteries.
In the past, people whose coronary arteries were narrowed by heart disease could have up to three stents implanted per year, all paid for by the National Health Insurance. Now, the insurance will provide even more coverage. The Bureau of National Health Insurance on Jan. 1 expanded its coverage plan to pay for up to four coronary stent procedures per year.
Coronary stenting is a surgical procedure used to treat patients with heart disease or a high risk of heart attack. The procedure involves the insertion of a tiny mesh tube into a narrowed coronary artery to keep the artery open.
While some cardiologists say stents can prevent a clot from blocking the artery, thereby increasing survival rates and reducing the risk of a heart attack or sudden cardiac death, others disagree.
TRUSTING YOUR DOCTOR
“Most patients assume when their cardiologist recommends surgical intervention for a partially blocked artery, there’s no alternative. Likewise, many heart patients agree to certain diagnostic tests believing the doctor wouldn’t prescribe them if there was a better way to get information about their heart’s health,” Michael Ozner, a preventive cardiologist and medical director of wellness and prevention at Baptist Health South Florida, wrote in an article titled “6 Cardiac Procedures You May Not Need,” which has been published on several health Web sites.
“In both cases, heart patients should know that certain heart surgeries and diagnostic tests may be harmful to their health,” he wrote.
In recent years, an increasing number of cardiologists have been putting more emphasis on preventive measures such as cholesterol-lowering drugs, which are not only cheaper, but also less invasive.
Andrew Lee (李應紹), associate professor and attending cardiologist at Jen Ai Hospital’s Division of Cardiology, is one of the many cardiologists in Taiwan who believe that interventional methods have been over-used and that some cardiologists recommend procedures such as coronary stents and coronary artery bypass surgery even though some patients don’t really need it.
“In many instances, stents can save lives. However, although a narrowed or blocked artery can be stretched open with a balloon catheter, sometimes it fails and the artery may close up again,” he said.
Lee said heart problems that arise from hardening of the arteries affect the entire body, but interventional methods such as stent implants and bypass surgery only solve part of the problem by fixing coronary arteries, instead of targeting the root of the problem by treating the underlying biology of the arteries.
“Bypass surgery only solves problems at the present and in the past, but what will kill you are the problems in the future,” he said. “If the only thing wrong with the patient was a blocked artery, then bypass surgery helps very little.”
“We can’t see into the future and expect that opening a blocked artery will solve all future problems. About 10 to 20 percent of the patients still die from a stroke,” he added.
Lee cited a recent study titled “Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation,” which showed that when it comes to treating heart conditions, invasive procedures did not offer more benefits than non-invasive procedures for heart patients.
LIFESTYLE CHANGE
The study, conducted from 1999 to 2004, was designed to determine if combining angioplasty and stents with medication and lifestyle changes could effectively prevent death and heart attacks.
The study involved 2,287 people at 50 centers in North America. Patients with partially blocked coronary arteries and chronic stable angina were randomly divided up into two groups. Both groups received medication and made healthy lifestyle changes, but one group had angioplasty with a bare metal stent implanted, while the other did not.
The results, published in March 2007 in the New England Journal of Medicine, showed that there was no significant difference in survival or reduced risk of heart attack between the two groups. In other words, interventional procedures were not proven to be more beneficial than conservative medical treatments such as taking medication and making lifestyle changes.
In his book The Great American Heart Hoax, Ozner wrote: “The studies on angioplasty delivered even worse news ... Unless the patient was in the midst of a heart attack, the opening of a blocked coronary artery with a balloon catheter resulted in a worse outcome compared to management through medication.”
However, this did not stop 15,000 Taiwanese who had coronary stents implanted last year. Bureau of National Health Insurance statistics showed that the health insurance fund paid out NT$576 million (US$16.5 million) for coronary stent surgery last year.
At last year’s market price of NT$27,000 for a bare-metal stent (stents that are not coated with drugs), the health insurance fund paid for 21,000 stents that were implanted into 15,000 people. This means that the average coronary surgery patient received a NT$38,400 slice of the nation’s health insurance pie.
Patients also had the option of having more expensive drug-coated stents (known to surgeons as “drug-eluting stents”) implanted, provided they paid the difference in price. Depending on the brand, a drug-coated stent could cost anywhere from NT$20,000 to NT$80,000.
OPEN WALLET SURGERY
If interventional methods require patients to open their chest as well as their wallet, with no medical evidence on their effectiveness for patients with partially blocked arteries, why have so many doctors recommended the procedure to their patients?
“The problem lies in the way the National Health Insurance [NHI] system is designed,” Lee said.
Interventional treatments are mostly covered by the health insurance, while doctors are not reimbursed for encouraging patients to exercise and eat healthy diets.
“Most heart disease patients are sold a bill of goods by a cardiology industry that has a vested interest in making sure that as many people as possible are treated with expensive surgical procedures, rather than with less costly lifestyle changes and/or medications,” Ozner wrote.
Lee agreed, saying that “much of the NHI resources are going to waste. Many doctors don’t even ask their patients about their medical history before they prescribe expensive treatments for which they will be reimbursed.”
As a result, the NHI fund, whose deficit has grown to NT$28 billion, might be paying for treatments that patients don’t actually need.
However, not all heart problems can be treated by preventive measures, said Ho Yi-lun (何奕倫), a cardiologist at the National Taiwan University Hospital.
“A coronary artery that has been narrowed by 50 to 70 percent should have a stent implanted. Only patients with arteries narrowed by less than 30 percent can benefit from [lifestyle changes such as] exercising,” he said.
The cardiologist said it was unlikely that doctors would prescribe invasive treatments based solely on whether the treatments are covered by the NHI, because “the bureau is very strict on violations.”
When it comes to serious problems such as hardening of the arteries, relying on lifestyle changes is not very effective, he said.
One thing the doctors did agree on, however, was that patients who are told they need surgery should seek a second opinion.
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