Doctor X is a 50-year-old physician whom I met at a musical event several years ago. He was alone at the time; his wife had elected not to accompany him to the New York City venue—a prestigious and by-invitation-only event held annually. I remember this minor fact because I am not a music lover, but I am married to one. (Love means that you have to be willing to compromise.)
Two years later at the same event, Dr X, by now my good friend and occasional companion, took me aside and told me that his wife of many years had abruptly terminated their marriage. He was accompanied by a younger woman who was a music lover, and (to my great pleasure) a math whiz. It didn’t hurt that she was bright, very attractive, and a fine conversationalist. We all got along splendidly, and I looked forward to our annual rite of passage.
When I saw Dr X the next year, he took me aside to tell me the following story, which offers a useful look into some important medical issues. His tale went like this . . .
Dr X was entirely asymptomatic and could walk more than 5 or 6 miles for recreation without any sign of breathlessness or excessive fatigue. In short, he was a worried, well, middle-aged physician who was experiencing considerable anxiety about his health.
He consulted a radiologist and asked for a chest film to rule out cancer. The radiologist suggested that a CT scan would be more accurate and would show some lesions that an x-ray film might miss. Price was the only drawback. Dr X decided to proceed; he had decent health insurance and wanted reassurance so he could stop worrying.
A while after the CT scan, the radiologist asked Dr X to return to discuss the findings. Dr X worried some more. When he got to the radiologist’s office, he was told that the scans were normal and that there were no signs of cancer. Dr X was relieved, a great weight lifted . . .
Then the radiologist coughed and said:
“However, there are a few calcified areas in your coronary arteries. I suggest that you see a cardiologist I know. I will make the appointment for you and send him your films.”
The cardiologist had Dr X perform an exercise treadmill test; the findings were “borderline.” Dr X did not perform a 6-minute walking test (more on this later), which would have provided a low-cost alternative for prognostic information.
The cardiologist performed a very brief history and physical examination and did not note any significant abnormalities. There were no diagonal ear slits, xanthelasmas of the eyelids, or carotid bruits.
The cardiologist then suggested a standard (he used the term “routine”) angiogram to evaluate the coronary atherosclerosis. The cardiologist was aware that Dr X was asymptomatic and that he had excellent exercise tolerance.
Shortly after the angiogram was completed, the cardiologist told Dr X that he would require an angioplasty; 3 stents were subsequently placed.
What did Dr X gain from the surgery? He had been given the classic answer: “You’ll feel better.”
You might ask—as I did when I heard this story—“how can you feel better when you have no symptoms or exercise intolerance in the first place?”
What clinical lessons does this saga offer?
There are numerous studies of the results of invasive versus aggressive ideal medical therapy in patients without a history of an MI within the previous 3 hours. The AVERT1 and the TIME2 studies both failed to demonstrate a mortality benefit in appropriately chosen patients treated with an invasive or an aggressive medical regimen. There were variations in the profiles of the subjects chosen in both studies that add some uncertainty to the study conclusions.
A later paper presented a strong case for medical therapy for patients with chronic stable angina.3 Dr X had never had a single angina episode and his exercise tolerance would most likely have exceeded that of the subjects in the previous 2 studies.
The development of sophisticated testing and imaging modalities has enabled physicians to identify coronary artery lesions in asymptomatic patients. Despite this ability, however, studies have failed to demonstrate a mortality benefit from intervention therapy.1-3
Americans undergo about 1 million angioplasties a year. Prices vary . . . in some community hospitals in Florida, for example, the costs approach $50,000 per patient.
In our rapidly expanding health care system, which expends over 2 trillion dollars a year, some of this may no longer be a justifiable expense.
Yet the concern over reducing the overuse of invasive cardiac procedures is not entirely focused on a cost-benefit analysis.
In fact, there are studies that demonstrate a very real potential for significant cognitive impairment in patients who undergo coronary artery bypass grafting or coronary angioplasty and stenting. In an article published 5 years ago, the question was raised, “Does the Brain Have to Pay for the Heart’s Procedures?”4 More than 10 references were cited, each of which provided strong evidence that previous publications would have answered the query in the affirmative.
As for Dr X . . . he was asymptomatic after his angioplasty. Yet even for patients who have some angina, newer drugs, including ranolazine (Ranexa), may provide an important addition to the practicing physicians’ armamentarium and may be a welcome addition to standard anti-anginal therapy.3 In a 2008 article published in Lancet, evidence for the effectiveness of ranolazine for chronic stable angina was described and affirmed.5
The vast majority of anti-anginal drugs are now generic; they cost a tiny fraction relative to the price of invasive cardiac procedures in parts of the country where the percentage of elderly patients with health care coverage is high.
The take-home message
Coronary atherosclerotic lesions, in and of themselves, do not require an ocular-stenosis-catheterization reflex.
Many patients can have a quick and simple test for their cardiovascular disease event risk with the simple 6-minute walk test. Details are published in the August 2012 issue of the Archives of Internal Medicine.6 I urge you to read this short and informative article.
A negative test result (ie, the ability to walk more than 550 or so meters within a 6-minute frame work) provides data that suggests relatively low risk, even in patients with known coronary heart disease.
By using this simple test, you will be doing your patients a service—and it will be much more cost-effective than the cardiologist Dr X consulted.
Patients with multiple cardiovascular disease risk factors, including high blood pressure, high lipid levels, inactivity, a family history, diabetes mellitus, the metabolic syndrome, insulin resistance, and obesity, require various doses and combinations of statin drugs, antihypertensives, ACE inhibitors, calcium channel blockers, and β-blockers, as well as an aggressive dietary program and exercise adherence and a realistic appraisal of methods to reduce personal stress.
All of these options will improve the outlook for your patients who resemble Dr X in one or more details. In addition, if your patient has some angina that is not already well controlled, consider trying ranolazine, which has been demonstrated to reduce the incidence of angina in medically treated patients with CHD.5
Your patient may not need an invasive procedure if you try most or all of the suggestions listed above. Good luck in your efforts.
1. Pitt B, Waters D, Brown WV, et al; AVERT investigators. Aggressive lipid-lowering therapy compared with angioplasty in stable coronary disease. Atorvastatin(Drug information on atorvastatin) versus Revascularization Treatment Investigators. N Engl J Med. 1999;341:70-76.
2. TIME Investigators. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet. 2001;358:951-957.
3. Nash DT. The case for medical treatment in chronic coronary artery disease. Arch Intern Med. 2005;166:2587-2589.
4. Nash DT. Does the brain have to pay for the heart's procedures? 2007. http://www.consultantlive.com/display/article/10162/37704.
5. Nash DT, Nash SD. Ranolazine for chronic stable angina. Lancet. 2008;372:1335-1341.
6. Beatty AL, Schiller NB, Whooley MA. Six-minute walk test as a prognostic tool in stable coronary heart disease. Arch Intern Med. 2012;172:1096-1102.