August 19th, 2013
Look Before Leaping to Conclusions About Bush’s Stent
Ajay J Kirtane, MD, SM
In a recent video interview on TCTMD, interventional cardiologists Ajay Kirtane and Gregg Stone discuss the media reaction to the George W. Bush case and criticize the much-repeated view that Bush’s stent was neither warranted by guidelines nor medically indicated. CardioExchange invited Kirtane to further address the issue. We wondered about the impact of the Bush case on the public perception of PCI, and asked Kirtane if he was concerned whether the publicity about the case might lead to the perception that 1) asymptomatic people should have stress tests, 2) a positive stress test should lead to CT angiogram (CTA), and 3) a positive CTA should lead to PCI, with no discussion of optimal medical therapy (OMT). Here is Dr. Kirtane’s response:
In our discussion on TCTMD, Dr. Stone and I reviewed the various scenarios regarding the Bush case, but rather than jumping to a conclusion that was critical of the patient and physician, we actually tried to explore the various possibilities that could explain the care he received.
What is behind the perception coming out of this case? In my opinion it is because many (press and physicians alike) jumped upon the buzz-worthy “unnecessary” bandwagon rather than a more balanced view, such as one offered by Burt Cohen on his Stent Blog.
Even with the limited details we had, I wonder why the following message wasn’t stressed:
1) Some asymptomatic people CAN have stress tests (at their preference or if they want to vigorously exercise far more than any of the enrolled patients in COURAGE or any other studies). The guidelines are just general guidelines, and individual-based decisions can vary from them.
2) If an asymptomatic person gets a positive stress test, it is absolutely reasonable to order a CTA next (to avoid unnecessary catheterization if the stress is falsely positive or the lesions are not prognostically important). In fact this is EXACTLY one of the scenarios in which I order CTA (typically to avoid invasive cath). That is a VERY IMPORTANT point to mention rather than disparaging a good test.
3) Depending on what the CTA shows, “asymptomatic or minimally symptomatic” patients may or may not get cath/PCI with potential prognostic importance based upon the anatomy. That the CTA is noninvasive ALLOWS AND FACILITATES a discussion of OMT without the patient on the table. How do we know that this case had no discussion of OMT? There are some lesions that even ardent proponents of OMT would agree favor revascularization over OMT alone. As I said on the webcast, because this case was bound to have intense scrutiny almost proves that the anatomy/lesions were serious/dangerous and not trivial.
The plain fact is that, according to colloquial wisdom, it is convenient to think that patients don’t need testing and procedures because it’s easy to paint cardiologists and interventionalists as greedy (or technicians only) and PCI as bankrupting the health care system. That’s why the bias is always to favor doing less and why the press is quick to publish sensationalist (and perhaps even unethical) quotes like, “He is the poster child for the inappropriate use of stenting now” (Boston Herald) or, “This is American medicine at its worst” (USA Today), rather than addressing the far more interesting and disconcerting question of what dangerous disease could have been hiding within the highly active former president while manifesting only minor (or no) symptoms.
This whole area (asymptomatic stable ischemic heart disease) is very tricky and the real truth is that the screening that we do for CAD is frankly not all that good or reliable. That to me is an even bigger story than repeated stories on overuse. What bothers me is that people often discount effective treatments when the real issue is trying to find the right patients in which to use them. The literature has moved well beyond the primary endpoint of COURAGE, and that trial itself can be used to prove both arguments. We also get swept up in the public health/economic debate that is even less personalized and can at times undermine the concept of individualized care. And finally, we have potentially fraudulent cases that only hurt the field further.
Dr Ajay Kirtane say “What bothers him is that people often discount effective treatments when the real issue is trying to find the right patients in which to use them”. I think the correct approach is to find the right treatment to use in the patient.
In the first message you want to stress, at the end of the paragraph you say “The guidelines are just general guidelines, and individual-based decisions can vary from them.” You imply that they were not followed in this case. By the way I agree with you and I believe in tailored medicine. Most of the criticism are related to this point, that apparently they didn’t follow the guidelines.
I agree with Dr Gregg Stone there are few absolutes, we don’t now anything about this particular case and they are entitled to the benefit of the doubt. Without a doubt a controversial case.
Some people argue this is a case of VIP Medicine. Do we have VIP physician as well? If a regular physician don’t follow the guidelines he is in trouble, but not everyone not every time.
Well said, Ajay. It’s very difficult to comment much further on President Bush’s case, without a lot more detail. At a minimum, one would suspect that several physicians were brought in to consult and one would hope that the patient was reasonably well-informed about the potential risks and benefits of his treatment.
Ajay. Right on and thanks for the shout-out. I completely agree and think that the real issue here is the diagnostic pathway and how the right patients get the right treatment, whether they are symptomatic, asymptomatic, stable or urgent. And CT angiography may have an important and under-utilized role in this determination, as you point out. I polled four CT experts immediately after the news of Bush’s stent came out and will be reporting on that soon on my blog.
Part of the reason this received such “bad press” is that it was George Bush that had the procedure done. Not exactly a media darling. Would have been a much different story if it was, for example, someone like Stephen Speilberg. I didn’t even hear a discussion of what symptoms, if any, Clinton had before his CABG or PCI procedures. He may well have had symptoms – but there was not a public discussion as there is with Mr Bush!
Secondly, the press/media have never favored physicians when there is an avenue not to do so…thus I think it is exactly what I expected to hear when the announcement was made that the former president had the procedure. Leopards do not change their spots!
Allow me to pose a hypothetical case which combines some of the nuances of the discussion above:
GB is a 66 yo male who is evaluated on “routine annual examination”. He is entirely asymptomatic and in fact “is known as a strenuous exercise enthusiast who runs and rides mountain bikes regularly”. He has no significant cardiac risk factors. He undergoes “routine stress testing” which reveals an area of possible inferior wall ischemia vs diaphragmatic artifact. He exercised for 12 minutes. A CCTA is performed and shows a small, non-dominant RCA and the remaining coronary arteries are free of disease. The calcium score is 0. The EF is 60%.
My questions I pose are these:
1. Does one proceed with a cardiac catheterization?
2. Does one provide reassurance and recommend continued exercise?
3. Does it matter if the patient is a former president or not?
Of course one could go on and on asking what ifs. The possible scenarios are mind-boggling. Most if not all of us writing or reading here know any of the specifics of the President’s case, hence we need to be careful in our positive or negative criticism. However, on the surface, from what has been made available to us, I think there are indeed some questions that are legitimate to ask. It’s not unfair to question what transpired, especially in the new environment of concern about inappropriate revascularizations.
The lengthy justification provided NO EVIDENCE to support the choice made. There must have been considerable anxiety on the part of Bush’S MD’s that if -God forbid- Bush would have suffered a massive MI or death that they would be blamed for inadequate care. The rationale offered after the initial non-invasive tests did not seem to justify further action. And the angiogram did not demonstrate Left Main or LAD disease.
This appears to be yet another case of CYA, therapeutic overkill (and cost overrun).
And YES, this attitude does raise the cost Americans pay for health care.
I think that the most important part of Bush’s case is the false sense of security most physicians have when caring for a very fit, physically active patient. Although exercise and fitness reduces the risk of coronary artery disease, it does not eliminate it. Furthermore, I think it is rediculous for any of us to criticize on the care President Bush received as none of us were there and none of us know the exact circumstances.
There is no doubt that inappropriate stress imaging is performed very frequently and stents are placed in asymptomatic patients very frequently. Without the details of the president’s circumstance, I am hard pressed to criticize his physicians however it does provide an appropriate venue to discuss inappropriate and wasteful medicine.
Cardiologists often affiliate with coronary calcium imaging facilities for the purpose of using a positive calcium score as a justification for a nuclear stress test. My hospital offers coronary calcium for a fraction of the cost of a non-contrast chest CT even though it is a more difficult procedure and requires increased interpretation. They know that the coronary calcium will generate nuclear stress tests which will drive big revenue.
The literature is clear regarding the appropriate use of stents. The only circumstance that makes sense based on Courage, Rita II, and Fame II is to use stents to abort STEMI and severe angina refractory to medical management period! The level of inappropriate nuclear stress imaging and inappropriate revascularization going on in this country is criminal. Perhaps when not for profit hospitals start losing their not for profit status and get fines, the practice will slow down.
I agree with everyone, but remain concerned that many people who have asymptomatic coronary disease have serious consequences; who was that famous middle aged marathon runner who dropped dead of an MI about 10 or 15 years ago? But data speaks louder than anecdote; for example I found this:
“50 apparently healthy men with angiographically proven CAD and asymptomatic exercise-induced ST depression have been followed prospectively for 15 years in the Oslo Ischemia Study. Fourteen men died. The initial presenting clinical event in these 14 men was chest pain in 4 (30%)–but in only 1 case was it recognized as typical angina–silent myocardial infarction in 5 (35%) and sudden death in 5 (35%). Thirty-six men survived, with 19 developing symptoms. Overall, chest pain was the first clinical event in 22 of the total of 33 men with symptoms (66%), whereas myocardial infarction occurred in 6 (18%) and sudden death in 5 (16%).” [Thaulow E, et al; Initial clinical presentation of cardiac disease in asymptomatic men with silent myocardial ischemia and angiographically documented coronary artery disease (the Oslo Ischemia Study). Am J Cardiol. 1993;72:629-633]
Myocardial infarction and sudden death can be the presenting symptom in CAD. The issue is quite serious; granted optimal medical therapy has gotten quite good in the last couple decades and can prevent many of these events, but frankly I would rather be a vigorous middle aged recreational athlete than a statistic in an epidemiological study.
Jeff- Jim Fixx was the marathoner you were thinking of.
As is well known president Bush is an avid mountain bike cyclist. I would hate to think he wad way out in the back 40 when he had an ischemic episode leafing to VF. We don’t know much about this case but would assume he had an appropriate ischemic workup that lead to this course of therapy. As noted im Foxx as an active marathoner may well have benefited from this type of pre-emptive approach had it been available then.
The main problem is not the particular case of president George W. Bush. I think the debate between OMT vs PCI will continue. The real issue is the overwhelming therapeutic misconception the general public has about PCI, 80 to 90% of the patients are convinced that after PCI they will have less MI and lower risk of death even after you explain them the facts of OMT vs PCI. Many physicians think this particular case has the potential to prolong this misconception. A lot of people know the benefits of PCI and only few know the benefits of OMT and even think it’s a lie, and this has to change.
I have read in past posts that if you have an asymtomatic CAD patient who is an avid athlete is better to perform a PCI to avoid sudden death and MI, because exercise does not eliminate the risk of CAD, but PCI neither and there are documented cases of late stent thrombosis after exercise.
Vigorous exercise as a triggering mechanism for late stent thrombosis: A description of three cases. Bastiaan Zwart*1, et al. Platelets Vol. 21: 72-76 (Volume publication date: 2010)
Late peripheral stent thrombosis due to stent fracture, vigorous exercise and hyporesponsiveness to clopidogrel. Linnemann B, et al. VASA 2012 Mar; 41(2):136-44.
Late stent thrombosis associated with heavy exercise. Simsek Z, Arslan S, Gundogdu F. Tex Heart Inst J 2009; 36(2):154-7.
There are a few absolutes. It is very important to keep the patients informed about this debate, in the end we will meet in the middle. The future is prevention.
What is a higher risk, a late stent thrombosis. With exercise, or a vulnerable plaque that ruptures with exercise. Nothing is a perfect answer. Each case. Must. be individualized.