August 19th, 2013
Look Before Leaping to Conclusions About Bush’s Stent
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.