On Interventions.

Who is an interventionalist?

Is it only those of us that put in stents? How does my putting in a stent make me different from someone who makes a difference to the patient in any other way? I’ve often wondered the significance of calling myself an “interventional” cardiologist. Am I really making a difference to my patients or am I just feeding my ego and my wallet?

In the first two decades of the new millennium, interventional cardiology has grown in a meteoric fashion. With new devices and techniques becoming available, patients are undergoing a variety of new procedures. From reopening blood vessels to the heart, brain and limbs as well as other vital organs, to replacing heart valves, to stem cell therapy and cardiac devices, interventional cardiologists (myself included) are performing radical new procedures that could scarcely be imagined in the last century. Often, patients come back to thank me after the procedure and say: “Thank you for saving my life with the heart procedure”. In the initial days of my career, I used to believe that I was actually “saving lives” with my stents.

With age, comes wisdom.

As I followed these patients, as well as those in whom stents were deferred for a variety of reasons, I realized that human lives end for many reasons. Stents do improve symptoms but come with their own liabilities. When you traumatize the blood vessel with a balloon and a metal stent, you are causing direct injury with both short and long term consequences. Most of these consequence are trivial, some dangerous but rarely can be fatal. Stents do not change the disease process. They are palliative tools at best. They push the disease aside. They can’t prevent new disease within themselves, around their margins – either upstream or downstream. Rarely, they can clot  – often in catastrophic and fatal fashion. Keeping them open require blood thinners, which can make you bleed. Stopping blood thinners makes them more likely to clot.

Are they really that pointless?

Probably not. In patients having a heart attack, they are “life saving”. When a combination of high blood pressure, a soft cholesterol plaque and increased cardiac demand, results in injury to the inner lining of the heart’s blood vessels, the blood vessel is either partially or completely obstructed by clot, inflammatory cells and the ruptured plaque. A timely stent in this setting helps repair the blood vessel and restore blood flow – saving muscle and maybe, lives.

In contradistinction to this, putting a stent in patients with chronic blocked arteries improves flow and may reduce symptoms (assuming they are from a lack of blood flow) but do nothing to prevent heart attacks or death. They may or may not improve heart function.

A chronic blockage, is exactly that. It is “chronic”. It has been there for a long time (chronos – gr. for time). In all probability, it will be there for a long time. Even the ones that are “90%” blocked. Most times, the body will develop alternate mechanisms around the blockage. Surprising to many, having chronic blockages in the heart’s arteries does not predict an increased risk of death but may cause at-times disabling chest pain. Much like chronic arthritis. These are just as well treated with medications as they are by stents. Most studies (not conducted by device companies) show that non-stent therapy is just as effective but demands efforts by both patients and physicians with regards to followup, compliance and lifestyle modification.

Stents, therefore, are the signs of a lazy approach to a problem in treating chronic blockages by both physicians and patients. From a physician’s perspective, it gets rid of the irritating complaints about chest pain and the anxiety thereof. There is no need to worry about side effects (mostly non-lifethreatening) of medications for angina. Most patients are happy and grateful, (lifesaving and all that jazz) as well as socially  keeping up with the joneses. Patients are alleviated of their guilt of having a poor lifestyle, by throwing money at their problem and gain absolution by getting a stent and rid of symptoms. Few people spend as much time talking about changing the lifestyle, controlling blood pressure, complying with statins or stopping smoking. All “interventions” that are clearly more effective (and cost-effective) at treating symptoms and also increasing event-free survival.

My personal approach to treating angina and heart disease has undergone a paradigm shift over the last few years. Each referral for chest pain is an opportunity to intervene. Not just with stents. But to change their lifestyle. To understand why controlling their blood pressure is important. To understand what diet does to their body. To make an effort to stop smoking. Most importantly, to realize the strongest tool in the treatment of heart disease is knowledge. An educated patient is an empowered patient and usually is more conducive to healthful habits. A healthy lifestyle is the keystone for the edifice of cardiovascular health.

So, does that mean I don’t believe in stents?

Heck no! I think they are an amazing device that in the right situations are lifesaving and in others, can be life altering. Take a 55 year-old construction supervisor with chest pain. Each time he “gets winded”, his employer wonders. Each time he pops pills, people notice. He is passed for promotions and is often the first guy to be “downsized”. Thanks to the threat of losing his job from his health, he “stress-eats” and smokes.  A stent (even with low risk disease) gets the patient back on his feet. With the right education from his “interventional” physician, has him losing weight and quitting smoking. Having been through the inconvenience of heart disease, he is more compliant to medications – especially because he now understands his disease better.

So to go back to the original question, who is an interventional physician?

Anyone who “intervenes” to ensure a good outcome is an interventionalist. Stents may be part of cardiac interventions but a true cardiac interventionalist is one whose actions improve your overall cardiac health. If you can put in a stent but not change the patient’s reasons for needing a stent, you are a proceduralist.

Many would argue that in the current healthcare milieu in the US, that it is not possible to achieve the lifestyle discussion and education (a task often left to nurses and cardiac rehab teams) by physicians. Many will cite need to cover the cath lab or see more patients as an excuse. This is humbug. I run a busy practice and perform a variety of procedures. I’m frequently on call at the hospital. When I walk into that patient’s room, he/she is paying my for my time to give them my best advice, not the quickest advice or short cuts. My focus is on the outcome, not the billing. If I can spend 3 or 4 hours in a complex procedure to get a blood vessel open, I owe it to the patient to spend the 10-15 minutes in each visit to make sure that I reiterate the importance of the real cardiac interventions that save lives.

To paraphrase Charlton Heston:

“Stents don’t save lives. Smart patients and physicians with stent save lives. ”

 

Kartik Mani