Angioplasty: Ending Inappropriate Use

Angioplasty and stenting may be overused

Angioplasty and stenting continue to be used in stable coronary artery disease (i.e. not in the middle of a heart attack), even though large randomized controlled trials have shown that they add no significant survival benefit. Angioplasty and stenting are exceedingly expensive and carry risks (including heart attack and stroke) to the patient.

Heart stent

The COURAGE study reported in 2007 that angioplasty and inserting stents, or PCI (percutaneous coronary intervention), provided temporary relief from angina, but did not result in fewer deaths, myocardial infarction or cardiovascular events than medication and lifestyle changes. The OAT clinical study indicated that for high-risk patients with total occlusion of the infarct-related artery, PCI conducted after the myocardial event did not reduce the risk of death, re-infarction or heart failure.

The data were a shock to many cardiologists, who saw symptomatic relief in patients and have been performing angioplasties and inserting stents in a good-faith effort to help improve quality of life.

Despite this information and the changes to professional medical society guidelines, a 2011 study reported no decline in the use of PCI. A number of media outlet covered the news, raising awareness among the public and questioning the continued reliance on procedures that were not shown to be effective.

Surely by now – years after additional research and attention to the issue – the use of angioplasty and stenting has decreased. But unfortunately that is not the case and it may be a matter of money. Recent cut backs on healthcare revenue are being blamed for the overuse of stents – doctors make much more money through the $30,000 stent procedure than to spend time with the patient discussing the alternative: medication and lifestyle changes. In fact, in 2013 the Joint Commission and the American Medical Association Physician Consortium for Performance Improvement cited elective PCI on patients with stable coronary artery disease as one of the most overused medical procedures.

Some patients and doctors may also think that PCI helps to solve the “plumbing” problem of a blocked artery, but inflammation is a contributing factor and most ruptures occur at mild lesions. Misconceptions about the relationship between cardiovascular disease and narrowed arteries – with most patients erroneously expecting that a stent will reduce the chance of a future heart attack – may also be at the root of the overuse of the procedure. As many as a million patients in the US may have been given stents they don’t need in the last decade and unnecessary stents cost upwards of $2.4 billion a year to our healthcare system.

To raise awareness of this issue, Parsemus Foundation supports publication of articles analyzing and discussing peer-reviewed studies on appropriate and inappropriate use of angioplasty and stenting. Our goal is to prevent patients and loved ones from facing unnecessary risks and in some cases debilitating medical expenses, without a clear expected benefit. Most patients undergo angioplasty because they believe it may save their life; if that is not the case, then they (and their doctors) deserve to know the full picture.

Media coverage:

2011
OAT Trial Had Little Impact on Clinical Practice, Forbes
Doctors Overuse Heart Treatment, Despite Guidelines, Reuters
Guidelines Don’t Curb Unnecessary Treatment for Heart Attack Patients, Bloomberg
Adherence to Angioplasty/Stent Guidelines Lacking: Study, U.S. News & World Report
Heart Stents Still Overused, Despite Guidelines: Study, Huffington Post

2013
Heart stents still overused, experts say, New York Times
Dollars and Stents: Docs Profit by Overusing Angioplasty, NewsMax
Deaths Linked to Cardiac Stents Rise as Overuse Seen, Bloomberg
The Good, the Bad and the Ugly: Stents in the News, Forbes

A few relevant background studies:

Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. (2007) N Engl J Med. 356:1503-1516. Free full text
CONCLUSIONS: As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.

Lin GA, Dudley RA, Redberg RF.(2007). Cardiologists’ use of percutaneous coronary interventions for stable coronary artery disease. Arch Intern Med.167(15):1604-9.
CONCLUSIONS: The widespread application of PCI in stable coronary artery disease for indications unsupported by evidence may reflect discordance between cardiologists’ clinical knowledge and their beliefs about the benefits of PCI. Nonclinical factors appear to have substantial influence on physician decision making. Future studies should focus on the development of methods to help providers more fully incorporate clinical evidence into their medical decision making.

Lin GA, Dudley RA, Redberg RF (2008). Why physicians favor use of percutaneous coronary intervention to medical therapy: a focus group study. J Gen Intern Med.23(9):1458-63. Free full text
CONCLUSIONS: The widespread use of PCI in patients with stable coronary artery disease–despite evidence of little benefit in outcomes over medical therapy–may in part be due to psychological and emotional factors leading to a cascade effect wherein testing leads inevitably to PCI. Determining how to help physicians better incorporate evidence-based medicine into decision-making has important implications for patient outcomes and the optimal use of new technologies.

Lin GA, Dudley RA, Lucas FL, Malenka DJ, Vittinghoff E, Redberg RF. (2008) Frequency of stress testing to document ischemia prior to elective percutaneous coronary intervention. JAMA. 300(15):1765-73. Free full text
CONCLUSIONS: The majority of Medicare patients with stable coronary artery disease do not have documentation of ischemia by noninvasive testing prior to elective PCI.

Siontis GC1, Tatsioni A, Katritsis DG, Ioannidis JP.(2009) Persistent reservations against contradicted percutaneous coronary intervention indications: citation content analysis. Am Heart J.157(4):695-701.
CONCLUSIONS: Despite strong randomized evidence, a fraction of the literature, mostly corresponded by interventional cardiologists, continues to raise reservations about recently contradicted indications of PCI.