1 in 7 Angioplasties Are Unneeded

One out of every seven patients having a non-emergency angioplasty to clear a clogged artery in the heart didn't meet criteria for needing the procedure, according to a new study from New York. And based on guidelines, it was uncertain whether the stent-inserting surgery was appropriate in another one-half of patients. "Patients need to be aware that they are sometimes being referred for something that they don't need, and they can get by with a less invasive option, which is taking medicines," said Edward Hannan, the lead author of the study from the University at Albany. During an angioplasty, doctors use a balloon to open up a narrowed artery and insert a wire scaffold called a stent to keep the artery propped open. Stent procedures have exploded in popularity in recent years — and several studies have raised concerns about overuse. The American Heart Association, the American College of Cardiology, and other professional organizations have published guidelines to help doctors determine whether patients are good candidates for the procedure — based on their symptoms and heart test results, for example. For patients with severe chest pain or who have recently had a heart attack, the procedure is nearly always recommended. But for people without such an urgent need, medications such as blood thinners and statins can sometimes be a better approach. Hannan said angioplasty procedures cost around $12,000 to $15,000, compared to medications, which can be several hundred dollars per year. Many patients who have a heart procedure also take medications. To see how well doctors are sticking to the AHA and ACC guidelines, Hannan and his colleagues gathered data from 58 hospitals in New York State. Among more than 24,000 patients who had an angioplasty in late 2009 and 2010, 36 percent met the criteria for being appropriate candidates. Nearly half of the patients fell into the uncertain category — in which there isn't good evidence to say whether medications or a stent would be the better option. And the researchers deemed 14 percent of patients inappropriate for the procedure, they reported in the Journal of the American College of Cardiology. In other words, based on these patients' symptoms and heart test results, it didn't appear that inserting a stent would improve their quality of life or help them live longer, said Dr. John Spertus, a professor at the University of Missouri in Kansas City, who helped write the appropriateness criteria. The new study didn't determine why patients sometimes had the procedure when they didn't need it. Spertus said it's possible some are asking to get a stent. "We use an analogy of a clogged pipe. One would feel that if you opened up the clog, the flow would be better. But studies show it doesn't make (patients) live longer, and without symptoms, it won't make them feel better," said Spertus, who was not involved in the study. Hannon said cardiologists likely play a role in overuse. The same physician who is doing a probe to determine the extent of heart disease is also the one who would clear the artery, so "that person is referring (the patient) to himself," he said. Angioplasty is also a relatively easy procedure to complete once patients have had those heart exams. "In an ideal world, you might argue that those patients should get the diagnostic procedure, then come off the table, and be given a trial of medications. If the medications fail to alleviate symptoms, then come back and get the procedure," Spertus told Reuters Health. "But that just isn't done." Hannan said there is a need for more research on the situations in which patients benefit from angioplasty versus medications, given how many patients were on the fence in terms of whether they would gain from the procedure. The professional societies "are very careful to say you shouldn't deny (angioplasty) when the patient is uncertain. On the other hand, from the standpoint of cost consciousness, these patients have not been proven to do better with (angioplasty) than with medical therapy." He said the New York Department of Health is contacting hospitals and doctors who appear to be overusing angioplasty "so they can be wary of not doing this in the future."