If practice standards were followed for stable patients, especially findings realized from the March 2007 COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), patients would be informed that medical therapy is just as good as angioplasty or stent to relieve their angina, and that a PCI will not reduce their risk of heart attacks or death.
I asked Chan this week why so many cardiologists are doing procedures that aren't based on necessity criteria, especially in light of COURAGE and the recent federal probe of thousands of procedures in Florida and three other states.
"While there's about 20 or 25 indications for when a PCI is inappropriate, the major driver as to why a procedure would be labeled inappropriate is that a patient didn't have symptoms to begin with," he says. "They were asymptomatic. They never had chest pain or anything that would be considered similar to angina, and for whatever reason they wound up getting a heart catheterization."
He adds, "more than half of the patients who were inappropriate didn't have symptoms at all."
What is going on?
The urge to screen for heart disease
Chan, who practices at the Saint Luke's Mid America Heart and Vascular Institute in Kansas City, MO, replies that today "there's a greater emphasis on prevention within the cardiovascular community, kind of what is mimicked in mammography and colon cancer screening. We're trying to prevent heart disease from happening to begin with."
And many of these inappropriate procedures are being done, he says, "by well-intentioned physicians, not realizing they were not going to benefit these patients."