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Broken Hearts

If you're a heart patient, how do you know which treatment you need?

Donald Drake, the Philadelphia Inquirer's former medical writer, found himself researching this question -- not for the newspaper, but for himself. The result was Drake's series of stories for the Inquirer on his search for the right treatment. In 1999, when he was 65 years old, Drake underwent angioplasty, a procedure in which a tiny balloon-tipped catheter is inserted into a coronary artery to clear blockages.

But that was after he spent months scouring the medical literature and consulting a number of specialists in an effort to sort out his options. Among them were the more invasive options of bypass surgery (cracking open the chest and attaching healthy blood vessels from another part of the body to detour diseased coronary arteries) and "keyhole" surgery (installing replacement vessels through small incisions, without opening the chest).

Drake found that it's not unusual for two knowledgeable and experienced cardiac specialists to recommend two entirely different procedures because each is convinced he or she has found the best one. Drake also discovered that the flurry of recent advances in heart care makes the right decision a moving target for consumers who are trying to weigh the pros and cons of treatments, some of which remain unproven.

The advances have resulted in treatments that include prescribing a slew of cholesterol-lowering drugs and other heart medications, propping open clogged coronary arteries with tiny mesh scaffolds called stents (the procedure performed on Vice President Dick Cheney), keyhole surgery, and operating on beating hearts without the aid of a heart-lung machine.

Even specialists find it difficult to keep up with the rapid pace of cardiac developments, Drake says. In addition, some fail to consider whether a given treatment will meet a particular patient's quality-of-life expectations. Perhaps more disturbing is that many patients accept whatever procedure their specialist recommends without question.

Arming yourself with facts

Unlike those patients, however, Drake made up his own mind. He concluded that because he wasn't a competitive sportsman who required being symptom-free, he wasn't willing to undergo the added risk of a bypass, even though some surgeons had urged him to undergo a bypass instead of angioplasty.

The inconsistency Drake discovered in his quest for better health is a hallmark of the heart-treatment establishment, not a fluke, studies show. The bottom line: It's important to tap all available resources, look closely at the consensus of opinion, and apply smart strategies to make sure you get the most appropriate cardiac care.

The personal stakes are obvious. But no less serious are the implications for our nation's health.

Twenty six percent of all deaths in the United States are related to cardiovascular disease, making it the biggest killer of both men and women. The number of cardiovascular surgeries increased 484 percent from 1979 to 2005. Doctors conducted 1.3 million procedures to remove coronary artery obstructions in 2005. And in that same year, hospitals performed approximately 469,000 bypass surgeries - up from 300,000 in 2001.

For a better sense of modern heart care, consider a study by University of Maryland investigators. They compared their own heart-treatment appropriateness scores with treatment guidelines from the American College of Cardiology/American Heart Association and RAND, the think tank in Santa Monica, California. The differences of opinion were telling.

The investigators, who were cardiologists, concluded that angioplasty was necessary for 54 percent of the 153 patients in the study. But the ACC/AHA and RAND guidelines called for angioplasty in 19 percent and 27 percent of the patients, respectively.

The investigators also concluded that bypass was inappropriate for 46 percent of the patients. But according to the ACC/AHA and RAND guidelines, bypass was out of the question for 17 percent and 42 percent, respectively. These numbers show that people using the same guidelines can disagree and that science alone doesn't always have the right answer for each individual patient.

Other researchers have long known that the frequency of certain heart procedures varies by region. The reasons range from the availability of, rather than the true need for, cardiac expertise and facilities, to a mindset that Dr. Andrew Ziskind, a cardiologist at the University of Washington, describes this way: "If you've got a stapler on your desk and no Scotch tape, you're going to use staples. It's so easy, so accessible, that it becomes part of the scheme."

Getting a balanced view

A Harvard University and University of Toronto study found that elderly Americans, among a study group of 224,258 people, were five times more likely to receive angioplasty or bypass surgery than were elderly Canadians, in a group of 9,444. Yet, after either procedure, the Americans were just as likely as the Canadians to die within one year.

"People are actually choosing less surgery than doctors are prescribing if they're educated and get a balanced view," says Dr. John Wennberg, director of the Center for the Evaluative Clinical Sciences at Dartmouth Medical School in Hanover, New Hampshire. "They often don't even know they have an option."

The importance of gathering multiple opinions about treatment choices struck home for Richard Warner, then 67, who had a heart attack in London. Physicians there told him he needed a bypass. So did a surgeon in Fredericksburg, Virginia, where he teaches history at Mary Washington College.

Yet a number of tests he underwent in Fredericksburg indicated he was recovering remarkably well. On the recommendation of his cardiologist, Warner eschewed surgery and instead went on a strict vegetarian diet for a while and took beta blockers, the blood thinner Coumadin, and a cholesterol-lowering drug. Today, he feels great.

"You've got to choose your doctors carefully, don't you?" he says with a hint of self-satisfaction. The strategy worked for Warner, but it won't necessarily lead to better health for other heart patients. Doctors caution that for some people in similar circumstances, surgery might be necessary.Gathering a range of opinion is just one way consumers are likely to get the most appropriate cardiac care.

Making choices

Here are some other strategies:

  • Find an advocate. Heart patient Andre Pilevsky of Summit, New Jersey, credits his sister, a medical resident at the University of Pennsylvania at the time, for making sure he received proper treatment in good hands. The lesson he learned: Advocates on your behalf are worth more than you can imagine.
  • Learn about evidence-based medicine, that is, the practice of administering treatments that have proven their effectiveness. You can read study results in medical journals or, by consulting the National Library of Medicine's MEDLINE/PubMed, summaries of these results.
  • Understand your treatment plan, advises the University of Washington's Dr. Ziskind, including the types and amounts of medications your doctor prescribes. Raise a red flag when something seems amiss.
  • Ask if your hospital participates in the National Cardiovascular Data Registry, which reflects national, real-life practice outcomes in heart care.
  • Be skeptical but not so skeptical that you are closed to the possibility that surgery may be the best option for you. Heart treatment guidelines such as those from the American College of Cardiology and the American Heart Association are "medicine by committee," cautions Dr. Robert Vogel, director of clinical vascular biology at the University of Maryland-Baltimore. "Almost none of these have been subjected to prospective [clinical] trials."

Though these guidelines are geared to medical professionals, many experts believe they can be broadly instructive for consumers, too. The American College of Cardiology posts its guidelines on the Web.

The group recommends that you steer toward institutions and specialists that perform a high volume of the treatment you're considering, because more experience means greater likelihood of success. But don't rely only on mortality statistics for individual hospitals. The sickest heart patients often are transferred to top-notch facilities, where they die as a result of their severe illness, not poor care, explains Dr. David Baran, director of heart failure and transplant research at Newark Beth Israel Medical Center in New Jersey.

Many specialty organizations publish the number of procedures their professional members should perform each year to maintain their competency, says Dr. Raymond Gibbons, a cardiologist and director of the Nuclear Cardiology Laboratory at the Mayo Clinic in Rochester, Minnesota.

Another tip from the doctors' organization: Arrive at the specialist visit with written questions regarding your heart-care concerns and needs. You're more likely to leave with solid answers. And don't be afraid to ask questions and to keep asking if you don't get a satisfactory answer the first time. "How many times did you perform this kind of surgery last year?" and "Are you board-certified in your subspecialty?" are entirely appropriate, says Gibbons. "Physicians who are well trained generally don't mind those kinds of questions," Gibbons says. "When somebody asks me that, I'm happy to tell them exactly where I came from, where I trained, what my credentials are. I have nothing to hide."

References

Heart disease and stroke statistics, Dallas, TX. American Heart Association.

Hall, M. et al. National hospital discharge survey. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Advance Data No. 332.

Ziskind, A. et al. Assessing the appropriateness of coronary revascularization: the University of Maryland Revascularization Appropriateness Score (RAS) and its comparison to RAND expert panel ratings and American College of Cardiology/American Heart Association guidelines with regard to assigned appropriateness rating and ability to predict outcome. Clinical Cardiology. Vol. 22(2):67-76.

Interview with Dr. Andrew Ziskind, cardiologist, University of Washington

Pashos, C.L. et al. Use of cardiac procedures and outcomes in elderly patients with myocardial infarction in the United States and Canada. New England Journal of Medicine. Vol.336(21): 1500-1505.

Interview with Dr. John Wennberg, director, Center for the Evaluative Clinical Sciences, Dartmouth Medical School

Interview with Richard Warner, heart patient

Interview with Andre Pilevsky, heart patient

Interview with Dr. Robert Vogel, director of clinical vascular biology, University of Maryland-Baltimore

Eagle, K. et al. ACC/AHA guidelines for coronary artery bypass graft surgery: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 100:1464-1480.

Interview with Dr. David Baran, director of heart failure and transplant research, Newark Beth Israel Medical Center

Interview with Dr. Raymond Gibbons, director, Nuclear Cardiology Laboratory, Mayo Clinic

American Heart Association. Cardiovascular Disease Statistics. http://www.americanheart.org/presenter.jhtml?identifier=4478

American Heart Association. Open-Heart Surgery Statistics. http://www.americanheart.org/presenter.jhtml?identifier=4674

American Heart Association. Heart Disease and Stroke Statistics. 2007 Update At-A-Glance.

American Heart Association. Statistics Committee and Stroke Statistics Sub-Committee. Heart Disease and Stroke Statistics Circulation. 2008; 117. http://www.circ.ahajournals.org/cgi/content/full/117/4/e25

Eagle K, et al. ACC/AHA 2004 Guideline Update for CABGS: Summary Article. Circulation, Vol. 110: 168-1176.

Centers for Disease Control. Leading Causes of Death. Final Data for 2006. http://www.cdc.gov/nchs/fastats/lcod.htm

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