I have discussed these decisions with thousands of patients and their families before invasive cardiac procedures like heart catheterizations and stent implants (which I am trained to do) and heart bypass and valve surgery (which my colleagues, heart surgeons, perform). There are over 3 millions of these procedures performed annually in the USA alone, many in outpatients with no or stable symptoms. These procedures have risks of death, heart attack, stroke and other complications that can exceed 5% of those treated.
When powerful new scientific data become available, it is even more pressing to consider all options as practice patterns change very slowly.
In April 2020 The ISCHEMIA Study (costing over $100 million) was published. The study randomized over 5,000 “serious” heart patients with stable angina chest pain and very abnormal stress tests to proceeding directly to heart catheterization, stents or bypass surgery versus NO procedure. The study involved both men and women. The non-surgical group was treated with medications, diet, fitness and abstinence from smoking. Participants were followed for over 3 years. The results were stunning and showed that there were NO differences between the 2 groups for death rates and other end primary endpoints.
What can a heart patient do when faced with a recommendation for an invasive procedure?
The ISCHEMIA study did not include patients in the midst of a heart attack or true medical emergencies. There are patients, particularly those with recurrent and life-threatening symptoms being treated as in-patients in hospitals, who are in an urgent situation requiring an invasive procedure. Fortunately, most heart patients are stable and are outpatients when they are faced with making a decision about a procedure. In my experience, it is very difficult for a patient and their families to challenge a recommendation for a procedure. A list of questions to ask may be of help. Here are some questions worth asking the medical team:
1) Are you familiar with The ISCHEMIA study and can I be treated like the conservative group?
2) Can you refer me to an intensive cardiac rehabilitation (ICR) program like Pritikin ICR and Ornish ICR which my insurance will pay for?
3) Can I have external counterpulsation therapy (ECP) which my insurance will pay for?
4) Can I be referred to a preventive cardiologist to pursue lifestyle changes that go even further than The ISCHEMIA study?
The value of a 2nd opinion from a heart specialist who has no “skin in the game” cannot be overemphasized. For outpatients contemplating invasive procedures, there is usually time to schedule a 2nd opinion. I have performed many of these assessments and, on occasion, have even done this for hospitalized patients.
Advances in cardiac care, including invasive procedures, have improved both the quality and quantity of life for many sick patients. Nonetheless, many heart procedures are performed in patients that could have had the option to safely take medication and change their lifestyle. Some of these patients suffered tragic complications that could have been avoided.
Whenever possible, a 2nd opinion should be the 1st choice.
