Surgery, The Ultimate Placebo by Ian Harris

Author:Ian Harris
Language: eng
Format: epub
Publisher: New South
Published: 2016-02-09T05:00:00+00:00

CORONARY STENTING

The idea behind ‘revascularising’ coronary arteries is very appealing: ‘My blood vessels were blocked and the doctor unblocked them.’ Like so many things addressed in this book, this sounds good and seems hard to argue with, unless you look at it scientifically and ask the right questions.

The debate between the cardiothoracic surgeons (on the side of coronary artery bypass grafts or CAGs, in which blood vessels from elsewhere, like leg veins, are used to bypass obstructed arteries in the heart) and the interventional cardiologists (on the side of angioplasty/ stenting, in which tubes are placed inside the blocked heart arteries to open them back up) continues. There are dozens of clinical studies comparing these two treatments for heart disease. Everybody wants to know which one is best, but I am more interested in whether either of them is better than not doing them.

The best evidence tells us that there is no difference between these two methods when it comes to the chance of dying, and not much difference for anything else, except that you are more likely to need another ‘revascularisation’ with stenting. That would only be important, however, if revascularisation was important in the first place. The fact that the stents block up a lot more than the CAGs didn’t seem to affect the comparison that much. Even the newer, more expensive drug-eluting stents (which contain drugs to reduce later blockages) don’t confer any advantage over the old ones when it comes to keeping you alive or preventing a future heart attack, and yet they are much less likely to block up within the first year. If the blockage is the problem in the first place, why doesn’t it matter if your revascularisation blocks up or not?

As a pragmatist, if I had a blocked artery I would like to know if revascularising my blocked blood vessels actually changes my chance of dying. I could spend some time explaining how my heart has compensated for the blocked vessel, as witnessed by my continued existence, or I could ask why the high blockage rates in these stents don’t actually seem to confer any disadvantage, but that is just stacking biological explanations up against opposing explanations, a theoretical game that can go on forever. The arguments about what treatment is best and how it works distract us from asking the most important question: ‘Am I less likely to die if I have this procedure, compared to if I don’t?’

So what is the evidence? For ‘stable’ heart disease (not an acute heart attack), the largest and best known study comparing stenting to not doing a stent showed no advantage to stenting in any of the outcomes measured: mortality, heart attack or hospitalisation. And the most recent review of this topic came to the same conclusion.

Even for ‘acute coronary syndrome’ (like a heart attack), a review of the randomised trials shows that there is no significant advantage in overall survival over five years for patients having routine invasive angiography/ stenting.

There are differences in many other things, but not the big one – the chance of dying.

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