George W. Bush’s Recent Stent Surgery—Two Perspectives
by Maggie Mahar
George W. Bush’s Recent Stent Surgery—Two Perspectives
(re posted with author’s permission)
Last week, when former President George W. Bush underwent stent surgery, the procedure was declared a great success. What is surprising is that not everyone in the mainstream media applauded.
From Bloomberg News “Former President George W. Bush’s decision to allow doctors to use a stent to clear a blocked heart artery, performed absent symptoms, is reviving a national debate on the best way to treat early cardiac concerns.
“The discussions have been ongoing since 2007, when the trial known as Courage first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with chest pain. The results were confirmed two years later in a second large trial.
“The debate has centered on both the cost of stenting, which can run as high as $50,000 at some hospitals, and its side effects, which can include excess bleeding, blood clots and, rarely, death. Opponents say the overuse of procedures like stenting for unproven benefit has helped keep U.S. medical care on pace to surpass $3.1 trillion next year, according to the U.S. Centers for Medicare and Medicaid Services.
“’This is really American medicine at its worst,’” said Steven Nissen, head of cardiology at the Cleveland Clinic in Ohio . . . ‘It’s one of the reasons we spend so much on health care and we don’t get a lot for it. In this circumstance, the stent doesn’t prolong life, it doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better’” . . .
“’Stents are lifesaving when patients are in the midst of a heart attack’ added Chet Rihal, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota . . . ‘They allow immediate and sustained blood flow that help a patient recover. For those who aren’t suffering a heart attack, the benefits are less clear . . . While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks.’ A review of eight studies published last year in JAMA Internal Medicine also found no differences.
“Two large-scale clinical trials completed within the last seven years have shown that drug therapy works just as well as stents in preventing cardiac complications. (The three major U.S. heart associations changed their guidelines in 2011 in an effort to reduce excess treatment. )
[This is important. The major U.S. heart associations have absolutely no vested interest in recommending fewer procedures. When they say “Do Less,” everyone should listen–mm. ]
“In Bush’s case,” Freddy Ford, the former president’s spokesman told Bloomberg, ‘he underwent the procedure without any symptoms after a stress test during his annual physical turned up signs of an electrical abnormality on an EKG . . .
“Paul Chan, an associate professor at the Mid-America Heart Institute in Kansas City, Missouri, questioned why Bush would have undergone a stress test at all if he didn’t have symptoms. While it’s fairly common practice for doctors to put older patients through such tests even without chest pain, Chan said, there’s no evidence showing it’s beneficial. . ..
“The reality is that we don’t know if we can change the trajectory of disease in people who don’t have symptoms, are doing fine and are physically active . . . There’s no evidence treatment will help them live longer, feel better, or have fewer heart attacks.”
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The Dallas Morning News had a very different take on Bush’s operation.
From the Dallas Morning News: “Former President George W. Bush’s unexpected surgery Tuesday to clear artery blockage in his heart served as a reminder that even the fittest and most health-conscious must be watchful of cardiovascular disease.
[Translation: Even if you’re fit and healthy, you should worry. You may need surgery tomorrow.]
The Dallas paper continued: “Doctors discovered on Monday the blocked artery during Bush’s annual physical examination at the Cooper Clinic in Dallas. The famously fit 67-year-old then had a stent implanted in his heart Tuesday at Texas Health Presbyterian Hospital.
“The health scare. . . came as a surprise, given that Bush is an exercise fanatic who showed no outward symptoms of distress. . . .
“About 600,000 Americans die each year from heart disease, according to the Centers for Disease Control and Prevention . . . many people, like Bush, show none of the common symptoms, such as tightness in the chest and shortness of breath.
“The blockage typically builds up slowly over many years, causing heart disease to sometimes become a silent killer. Experts said that highlights the need for those with risk factors to get periodic screenings.
“’It’s very important for the public to understand that it’s not necessarily pain,’ [that signals a need for stenting] said Dr. Gaurav Gupta, an interventional cardiologist at Methodist Dallas Medical Center.”
[In other words, you shouldn’t wait for “symptoms” before scheduling surgery.
Forget about ‘listening” to your body. The folks who run the testing facilities will tell you what you need to do. Just go for the screenings—as often as possible–and they’ll let you know when you should sign up for the procedure.]
The Dallas Morning News concludes:
“Hundreds of thousands of Americans receive stents each year. And the relatively simple procedure can have a lasting impact: experts said that fewer than 10 percent of patients with stents see re-blockage in the first year.
[Great. What happens to that 10 percent? And what happens after the first year?]
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The Dallas Morning News story is based on the notion that more care is always better care. This late twentieth-century view of medicine assumes that you can never be too careful. Even if you feel healthy, you should go for screening. Your doctor may be able to find something.
TIME, like the Dallas Morning News (and many other publications) stuck with the traditional script, hailing the procedure as one of the mircales of modern medicine:
“Doctors discovered the blockage during Bush’s routine physical, and recommended a stent to keep the artery open.
“That advice has become increasingly popular in recent years to treat chest pain and angina, thanks to advances in stent technology and the fact that the hour-long procedure is less invasive than bypass surgery . . . the devices are also being recommended in more patients like Bush, who show early signs of heart blockages . . . “:
A Changing Medical Culture?
By contrast, Bloomberg expressed a growing awareness that over-testing may lead to over-diagnosis—and over-treatment. (For background on how stenting has been overused in recent years, see this HealthBeat post
Health care reform aims is to squeeze some of the waste out of our health care system by reducing overtreatment. But that will require a change in our medical culture: both physicians and patients must begin to realize that, as California governor Jerry Brown tried to tell us back in 1974: “Less is more.”
For years, Americans have resisted this idea. Until very recently we tended to think that “Plenty” is never enough. Whether we were talking about the size of a restaurant meal, a McMansion or a car, “More” was always better
But in the past decade attitudes have been changing –and nowhere is this cultural change more important than in medicine.
Five years ago, if a former president underwent heart surgery that appeared successful, I very much doubt that we would have read anything like the Bloomberg story in the mainstream media.
But today, more and more doctors have been speaking out about the excesses. And some in the media are printing their objections. Regarding Bush’s operation, USA Today quoted Nissen, saying that “Bush ‘got the classical thing that happens to VIP patients, when they get so-called executive physicals and they get a lot of tests that aren’t indicated.’”
Meanwhile CNN reported that a 2006 medical examination revealed that Bush had no signs of hypertension or other modifiable risk factors and that he had a “low” to “very low” coronary artery disease risk profile.
This reflects a critical change in how some reporters cover medical care. Healthcare reform is beginning to open minds. Rather than simply interviewing the doctors who treated former president Bush, the Bloomberg reporter sought second opinions from leading medical experts. Not only that, he assumed that his readers would be interested in what skeptics had to say. (Ten years ago, I can imagine an editor saying: “Our readers don’t want to hear this.”)
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– See more at: http://www.healthbeatblog.com/2013/08/george-w-bushs-recent-stent-surgery-two-perspectives/#more-2294
This tells us everything except the thing that we need to know.
I had been doing a combination of walking and running. Then an EKG and the followup angiogram showed that I had a 90 to 95 percent blockage of my right coronary artery. Four months before, I had visited the emergency twice but they never found what had caused the problems. Looking back, the symptoms not unlike those of heart attacks.
Before I got the 2 stents the cardiologist cleared me to go back to walking but he refused to clear me to go back to running. After the 2 stents were installed, only a 50% obstruction remained. Six months after the 2 stents were installed, I went back to a combination of walking and running. After eight years of regular strenuous aerobic exercise, another angiogram picture looked like the one done immediately after the stents were installed.
So what was the amount of the obstruction in Bush’s artery?
I was told that installing stents during a heart attack is much more dangerous. Do we really want to wait in cases like mine? Or is this penny wise and pound foolish.
Well Jim:
As one open heart surgery dude with cholesterol at 118 and appropriate weight during my heart attack (felt like I had a mild chest cold) would suggest, the stent procedure was probably unnecessary. More directly and to answer your question, yes they should wait and treat the blockage with other methods first. We do not know what Bush’s percent of blockage was; but, it did not sound like he was in distress (which we do not know either). Stents are problematic and will not extend your life one day if they are not needed to clear an artery for blood supply.
To get into rehab I went through a stress test to make sure I could stand the physical exercise even though I am a backpacker, runner, kayaker, snowshoer and generally all around great guy. 🙂 I was the healthiest guy in the ER that day; but it did not matter, I was going to die without the operation. My heart was fluttering.
The discharge write-up described me as a “63 year old gentleman” which caused my sons and daughter to laugh and wonder if they confused me with someone else. I laughed too . . .
“over-testing may lead to over-diagnosis—and over-treatment.”
Often when conservatives point out that medical malpractice litigiousness is a factor in international health cost comparisons, liberals point out studies that point out (factually correct) that tort costs are a very small component of overall medical spending and that there don’t exist enough savings there to bring US spend down in line with other developed nations (also factually correct). But those statements by liberals tend to ignore the indirect cost of torts, which leads to the practice of defensive CYA medicine as represented in the quote above.
m.jed:
There is no survey to suggest such a finding and if we use the GAO study, it suggests the opposite with regard to defensive medicine. Even this finding is limited as it was not thorough enough. I am not sure what you mean by indirect costs.
Right, but CYA medicine still doesn’t show much cost, rejecting your point.
John:
The issue here is not defensive medicine which in this particular case is expensive and as high as $50,000 for the procedure. In this case, it was probably uncalled for as the old Pres was not exhibiting any signs of heart stress and could have been treated with heart meds as a preventative measure. Stent application in instances other than heart distress will not improve or extend your life one bit which leads me to a conclusion:
This is not defensive medicine and it is a costly and unnecessary procedure in this case.
The real driver of US health care costs is the profit motive. Health insurers scream blue murder at being limited to 20% profit. Doctors who own treatment facilities prescribe to cover the costs of their summer homes and art collections. Hospitals merge to fight insurers and preserve their own 20% plus profit margins.
It’s not even the doctors or drug makers. The big take is big capital. If you own a hospital, an insurance franchise, or a piece of medical equipment, you expect to make 20% or higher profits. If you don’t you squeal like a stuck pig until the government bails you out. Then, you squeal like a stuck pig about the government.
No wonder everything costs twice as much here. Malpractice insurance is a red herring.
run75441, you said, “We do not know what Bush’s percent of blockage was; but, it did not sound like he was in distress (which we do not know either). ”
My cholesterol was under control and I was a little underweight by the published tables. Before the EKG found the electrical problem, I was doing 2 miles in 19 minutes with no signs of a heart problem. I was doing it every other day! But 2 weeks later an angiogram found a 90-95% blockage. I would have thought that was impossible. In my case, the sequence was bad EKG, Stress test confirming poor blood supply to a part of the heart, and Angiogram confirming a large blockage to a coronary artery feeding a large part of the heart.
Given my experience I don’t believe the standard of care should be that the patient must be having cardiac distress before a stent is installed. (ie chest pain, shortness of breath, achy jaw) If we do that we will see an increasing number of people arriving at the Emergency Room as a Dead On Arrival. And more patients dying in the process of having a stent installed during a heart attack which I was told was much more dangerous.
I agree that our health care system is too expensive and that there is some overuse. The problem is getting at the problems areas while continuing reasonable care. Perhaps the standard should include the percentage of blockage and area of the heart which would be compromised if a fragment of a plaque dislodged and resulted in a 100% block of the artery. If it doesn’t already.
We should be careful with these standards of care because once they have been defined, doctors are graded on compliance, and some doctors will slavishly abide by them. (Bad personal experience)
Anyway perhaps the most significant problem with stents is the wildly varying cost of identical procedures!
I saw a similar problem when some researchers were arguing that we should stop doing PSA tests because of the possibility of false positives. And the over reaction of some doctors and their patients. For years we have heard that early detection is key in the treatment of cancer. Given that, in my opinion we should continue to do the inexpensive PSA tests but educate doctors and patients as to what the test actually means and the dangers of over reaction.
For the record, I have refused recommended medical procedures. (Note the plural.)
If I may, Jim’s statement: Before the EKG found the electrical problem, I was doing 2 miles in 19 minutes with no signs of a heart problem.
offers an example of why this discussion is so difficult. If there were no signs of a heart problem before the EKG, then the EKG would not have found a problem.
The question then becomes, is the EKG and then angiogram finding of clinical significance. In Jim’s case, considering he had no overall functional deficit, as offered in his statement one could argue it was not.
This is what Bloomburg’s article is noting, and the Dallas Morning News is arguing Jim’s position.
In my area of practice, consider that as we age, the detection of a disc protrusion with no symptoms rises to 65% by age 65. It is the same for the infamous rotator cuff tear. So, does the doctor really know if what was seen on the film is the actual cause of your pain and dysfunction? The answer can be yes, if the doctor truly spent the time during the history and physical. Frankly, it’s a big “if”. That is because there are many moments in the process of making a diagnosis when one can easily convince them self that they got what they need to make the prescription.
Thus, you get a patient treated for 3 years with a dx of post concussion headache with out the doctors (yes, plural) considering a possible neck injury. That the concussion was do to falling down a full flight of stairs and being knocked out just never led to the obvious question: What else could or would have been injured in such a fall. It was assumed the bump on the head explained everything and thus there was no impetus to even question their conclusion and resultant approach to care for the patient.
Just one example this year in a 29 year and going career.
The problem with health care is globally the same. It is the way medicine is practiced and the way it is practiced is simply the result of the frailty of our human nature. Very little in the ACA addresses the weakness because the weakness has not been identified existing. Instead the problem with health care is considered as a logistics problem.
Daniel Becker wrote: “offers an example of why this discussion is so difficult. If there were no signs of a heart problem before the EKG, then the EKG would not have found a problem.”
The EKG was done as a pre operative test. Neither I nor my doctor were aware of any heart problem before that EKG! The scary part of this discussion is that a blockage can get so dramatically large without discovery.
As to the clinical significance of the angiogram, it showed a 90 to 95% blockage. If we choose to leave those dramatic blockages then we will be leaving people to an early death.
I had an aunt who developed angina in 1959. This was before stents and before coronary bypass surgery. She was given “heart pills” and sent home. (Pills probably for the pain.) Two years later she went to sleep and didn’t wake up. Her treatment was very inexpensive.
If we want to save more money on blocked arteries then we should also concentrate on patient rehabilitation. If the patient does not change his diet and does not do vigorous exercise then the patient who received stents will need bypass surgery within 5 to 10 years. (experience of a family member)
In your example I hear you saying that the practice of medicine is somewhat imperfect and that needs to be taken into account when setting the standards of care. That makes sense to me.
This discussion is difficult and it is bound to be so. We have been rationing medical care based on ability to pay. Now we are discussing rationing medical care based on need and/or benefit. This discussion will require a lot of trust.
The EKG was done as a pre operative test. Neither I nor my doctor were aware of any heart problem before that EKG! The scary part of this discussion is that a blockage can get so dramatically large without discovery.
Yes, scary as the patient, but as the doctor/researcher interesting. Again the question becomes what is truly clinically significant. The literature is suggesting, as often happens that such accepted medical understanding and treatment that a single blockage is not as life threatening as originally thought. Which then leads to the question of how to set up a double blind study to find out. The best that can be done currently is going back and comparing outcomes of those who choose the stent vs those who choose drugs. But this implies the potential for selection bias, though minimal given enough time and large numbers.
Lastly is the issue of percentages. Nothing in the practice of medicine is effective 100% of the time for 100% of the human race. So what do you do with those who don’t fall on the side of the positive responses? And the entire sector of health care is beginning to acknowledge that there has been a publishing bias regarding research such that only half the knowledge is being presented. This is because there is a predominate practice of only publishing positive results. Even neutral results are not making it into the published literature bases.