Coronary Artery Disease: Back to Basics

If you’ve ever had a heart attack or recurring angina, chances are you’ve either had or been recommended to have an angioplasty (or, as it’s now called, percutaneous coronary intervention—or PCI). This procedure involves inflating a balloon on the tip of a catheter inserted into a narrowed artery. Performed more than a million times a year, angioplasty is the standard of care for patients who have had a heart attack. It is also a popular therapy for many who are suffering with angina and for asymptomatic patients with blockages in the coronary arteries. But there’s a problem. Contrary to popular belief, angioplasty does not prevent heart attacks or save lives.

Studies Show Harm

Conventional wisdom dictates that angioplasty is best done within 12 hours after a heart attack, but at least a third of patients are not treated within that time frame. Nevertheless, “late” angioplasty is routinely performed on the assumption that it provides benefit. Well, it doesn’t. A large, multi-center study published in theNew England Journal of Medicine revealed that when angioplasty was done three to 28 days after a heart attack, it failed to reduce the occurrence of death, repeat heart attacks, or heart failure. Even worse, during four years of follow-up there were more heart attacks in the group that had angioplasty, compared to those treated conservatively with drugs. Another major drawback of angioplasty is restenosis, or closing up of the opened artery. To counter this, a tiny metal “scaffold” called a stent is usually placed in the artery to keep it propped open. But even stents can become blocked with scar tissue over time, so most are coated with drugs to reduce this risk. While this may sound like a good idea, three new studies show that it’s anything but. Although drug-coated stents may decrease restenosis, they interfere with the creation of collateral circulation that naturally bypasses blocked arteries, increase risk of potentially fatal blood clots—and more than double the risk of heart attack or death!

Even the FDA Warns of Risks

The FDA recently convened an expert panel to look at the safety of drug-eluting stents, and they concluded that these stents are safe and effective only when used as originally approved: in patients with one blocked artery and no significant heart damage. Well over half of all drug-eluting stents are implanted in patients who do not meet these criteria. The panel warned physicians to be more discriminatingand judicious in their use of these stents, stating that, in many patients, they increase risk of blood clots, heart attacks, and death from heart disease. Cardiologists are not likely to pay much attention to this. I predict that business will continue as usual, but the hundreds of thousands of stent recipients will be forced to take Plavix, a drug that helps prevent blood clots, for the rest of their lives—at a cost of $1,400 a year. That’s great news for stent and drug manufacturers, but it’s bad news for you.

“Cures” Worse Than the Disease

It’s very difficult for me to even read these studies, much less comment on them as if they were newsworthy. It’s like additional evidence that the earth is round. Angioplasty, bypass, and other invasive heart procedures not only do not, but cannot, prevent heart attacks or prolong lives in the vast majority of patients who have them.Way back in 1983—long before angioplasty became the revenue-generating darling of cardiology—the Coronary Artery Surgery Study (CASS) was published. This definitive clinical trial was expected to confirm the benefits of bypass surgery in patients with significant heart disease. Instead, CASS showed that bypass was a bust. Rates of heart attack and death from heart disease were no lower in patients who had surgery than they were in a similar group of patients treated without surgery. The death rate in the patients who didn’t have bypass surgery was a surprisingly low 1.6 percent per year. The chance that any surgery will improve upon a death rate this low is virtually nil. It boils down to one indisputable fact: You cannot save the life of someone who is not going to die.

This Study Is Relevant Today

The findings from this study are as relevant today as they were 24 years ago. At the time of the CASS trials, the death rate of patients 65 and older hospitalized for bypass was 11 percent. While the in-hospital death rate for bypass has dropped to 2.2 percent (this includes all age groups; it’s higher for older people), the annual mortality rate for patients with heart disease treated with noninvasive methods has fallen below 1 percent—meaning you’re still more than twice as likely to die from the surgery as you are from the disease. I’ve said for more than 10 years that a middle school math student could take these figures and determine that the current use of invasive heart procedures is fraud. When you weigh the certain pain and cost of surgery against the slim chance of benefit, it’s an easy call. Yet today, bypass, angioplasty, and other “lifesaving” heart procedures continue to be foisted upon more and more folks who don’t need them. The most recent trial comparing medical therapy versus angioplasty in patients with stable coronary disease is the COURAGE trial published on april this year in the New England Journal of Medicine. In this trial angioplasty did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when compared to medical therapy.

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