Angina Treatments Often Inappropriate

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Too often, the chronic chest pain called angina is treated inadequately. Proven treatments like aspirin and beta blocker drugs are underutilized; while others, such as chelation therapy, with little or no scientific evidence to support them are overused. For these reasons three national medical organizations have issued the first set of guidelines for the treatment of angina. It is an attempt to bring reason, not to mention a scientific basis, to the treatment of this common manifestation of heart disease which afflicts an estimated 10 million Americans. But the new guidelines leave much to be desired where they concern high-tech procedures, according to cardiologist and researcher, Thomas Graboys, MD, director of Lown Cardiovascular Center. A long-time critic of this country's excessive rate of cardiac catheterization, angioplasty, and coronary bypass surgery, Dr. Graboys, who did not participate in setting the guidelines, is interviewed at the end of this article.

Last month, the American College of Cardiology, the American Heart Association, and the American College of Physicians published their new treatment guidelines in the Journal of the American College of Cardiology and Circulation: the Journal of the American Heart Association. The audience, however, is not limited to cardiologists since most Americans with angina are treated by their primary care physicians. Several were represented on the guidelines committee which told the nation's physicians that the odds of having "an adverse cardiovascular event" are reduced by 25% when their angina patients take daily aspirin. All people with angina should receive sublingual [under the tongue] nitroglycerin, "a short-acting drug with no known long-term consequences." All beta blocker drugs (some generic names: propranolol, atenolol, metoprolol) are determined to be equally effective and are usually the preferred initial treatment. Drugs for the lowering of cholesterol and control of diabetes are advised where appropriate. "The education of patients" was singled out as a neglected area. Doctors should inform their patients about preventive measures like diet, exercise, smoking cessation, and advise them about symptoms that might signal a heart attack.

Angina occurs when there is decreased blood flow to the heart muscle, as a result of plaque-narrowed coronary arteries, hypertension, or valvular disease. The heart is temporarily deprived of oxygen and nutrients, causing intermittent pain which is usually triggered by exercise, emotional stress and/or cold weather. Discomfort in the jaw, shoulder, back, or arm are also common symptoms. The new guidelines apply only to people with stable angina, which has a predictable pattern for a prolonged period, as opposed to unstable angina characterized by symptoms that occur at rest, initially upon exertion, and are increasing in severity.

The guidelines committee advises physicians to discourage the use of vitamins E and C, acupuncture, and chelation therapy because the committee members found no scientific evidence to support their use in the treatment of angina. As for diagnostic procedures, the committee found many studies to support the continued use of the standard exercise treadmill test for people with chronic stable angina. It gave a "thumbs down" to a high-tech procedure called electron beam computed tomography, "which, despite an increase in popularity in recent years, has not been demonstrated to be clinically beneficial."

High-Tech Excesses
Too often angina inappropriately leads people to the operating room for a diagnostic procedure called coronary angiography or cardiac catheterization (CC). The blockages or constrictions that doctors see in the motion and still x-ray pictures of the coronary arteries during the course of CC are usually treated with angioplasty and/or coronary artery bypass surgery. The aim of both surgical procedures is to increase blood flow to the heart by widening the constricted arteries (angioplasty) or bypassing the constriction with grafted healthy blood vessels that have been removed from another part of the body. All three carry the risk of death, stroke, and heart attack. And three procedures have their limitations; for example, in 30-60% of people given angioplasty, the vessels will close up again within six months.

Interview with Dr. Thomas Graboys

The new guidelines are aimed at physicians, but consumers could also use some help in identifying appropriate care. For that, HealthFacts turned to Thomas Graboys, MD, director of the Lown Cardiovascular Center, Brookline, Massachusetts. Since 1980, this Harvard-affiliated Center has offered second-opinion consultations for people who have been told they should undergo one of these procedures.

HF: Dr. Graboys, in an earlier interview with HealthFacts, you said that 75% of the people who undergo angioplasty and bypass surgery have chronic stable angina and that the majority with this condition can safely delay or altogether forgo these procedures by managing their heart problems with medication and lifestyle modification. How would a person know whether he or she is receiving optimal drug treatment?

TG: It depends on the number of medications that a patient is taking. Many of the patients we see have never been on beta blockers, or nitrates, or cholesterol-lowering drugs--the most basic tenets of taking care of a patient with coronary disease. A patient comes in with symptoms and the testing starts immediately--the patient is often never even given a trial of drug therapy. Drug therapy should be tried for at least a few weeks or months, and the patient should then be retested.

HF: Then you are happy with the new guidelines?

TG: The guidelines are sufficiently loose to allow a cardiologist tremendous latitude for the use of cardiac catheterization (CC). Once you undergo CC, then the next step invariably is angioplasty or bypass surgery. This is a very common scenario: During a CC, a person [is found to have a] discrete narrowing of one vessel and then is urged to have angioplasty [while still on the operating table], even though the patient has few or no symptoms. The point of undergoing a procedure is to feel better. How can you make someone feel better when they had no symptoms?

HF: But people think they're going to have a heart attack any minute once they are told blockages are present.

TG: The public thinks this is a plumbing problem--much of this has been promulgated by the press. It's much easier to write about some new technique or new technology than it is to write about taking a pill which doesn't sell newspapers. If it were a plumbing problem, then it would be clear that all heart attacks occur, or all people dying suddenly do so because they have critical narrowing of a vessel. But in many patients, what we call the "culprit vessel" is the one thats the least narrowed. When we look back [at the CC results after a heart attack] the "culprit vessel" was the one that was only 30% narrowed, not the one that was 90% narrowed. Even though you would intuit that it would be the latter not the former.

HF: Give a common example of someone headed for an unnecessary procedure.

TG: An individual with no heart symptoms goes for a checkup and is told to undergo an exercise stress test. He "fails" the stress test and is urged to undergo a CC. During the CC, he is found to have underlying heart disease, or "silent ischemia," which is possibly indicative of impaired blood flow to the heart. The patient is then urged to undergo bypass surgery. The problem with this advice is the risks of the operation [e.g., the death rate from bypass surgery ranges from 1.2% to 7%] may well have exceeded those presented by silent ischemia. People in this situation should ask their doctors: What is so terribly wrong [with me] to compel an operation that comes with the risk of dying or having a heart attack or a stroke? That's not to say there isn't the occasional patient free of symptom who by virtue of a significant problem on an exercise test is truly at high risk. The decision is not black and white; it requires the judgment of the physician.

HF: This example and the earlier one illustrate why you advise people to get a second opinion before undergoing the CC, which itself has a small risk of death, heart attack, and stroke. How should people go about getting a second opinion?

TG: Go to another cardiologist who is not in the same group or at the same hospital as the first cardiologist [who recommended a procedure].

HF: The new guidelines seem to be largely aimed at family physicians and internists. According to the guidelines committee, most people with angina are treated by their primary care physicians. From your point of view, as someone who is sought out for a second opinion, are primary care physicians providing less than optimal treatment for chronic stable angina?

TG: No. The big problem is the primary care doctors send their patients to a cardiologist who then recommends a procedure. The primary care doctors feel intimidated--worried theyll be sued if the patient has a heart attack.

HF: Isn't there a difference in cardiologists--interventional and non-interventional?

TG: Yes, if the cardiologist is hospital-based, then he or she is probably an interventional cardiologist. If office-based, then he or she is probably non-interventional, but this can differ depending upon the city. There are too many cardiologists in this country; and too many who dont know how to use medicines.

HF: Bypass surgery stands out as the surgical procedure subjected to the most randomized controlled clinical trials. The operation has a clear value to people with left-main artery disease and triple-vessel disease. But we've known for years that half of all bypass operations are either unnecessary or questionable, yet the rate continues to increase, along with the rate of angioplasty. Why don't published studies create the expected changes in the way doctors practice?

TG: Economics "drive the train" in the provision of medical care [bypass surgerys five-year costs were $57,000, angioplastys were $54,000(*)]. You wouldn't expect the rate of these procedures to go down, not when hospitals are scrambling for their fiscal survival--now more than ever. In the greater Boston area, we have a blood bath going on with many smaller, community hospitals wanting to open CC labs and do bypass surgery. They're claiming that there is a need for it; that's a lot of baloney. The last thing we need is more CC labs. We need more doctors trained to use medications to bring down cholesterol and to treat with aspirin and with beta blockers, which only a minority of patients are currently getting.

(*) The cost comparison is given in five-year terms because about 30% of people initially treated by angioplasty eventually have bypass surgery. The initial cost of angioplasty ranged $21,000-$32,000. These costs come from a study conducted by Mark A. Hlatky and colleagues (New England Journal of Medicine, 1/9/97).

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Well, this article is really a true story for most of the heart patients out there. physicians are not considering any medicines for lowering cholesterol or improving blood flow to the heart. Instead they just tell the patients to go to the operating room for angioplasty and then bypass. I think second opinion with another cardiologist of another group is really needed to make sure that angioplasty or bypass is really needed.