Are Elective Heart Stents the “Botox” of Cardiology: New Data on Blood Flow and Big Fraud
You would hope that when a cardiologist recommends placing a permanent mesh device called a heart stent into a patient’s artery the indications are genuine and the procedure is genuinely needed. Therefore, when websites like those of Joseph Mercola, DO, a family practice doctor who thrives on controversy,questions if heart stents are a scam, it might be easy to dismiss the question as fearmongering from someone who profits from conspiracy theories.
My street cred is a bit different. I performed my first heart angioplasty (PTCA) in 1986 in training at the prestigious University of Texas Southwestern Medical Center, completed an advanced angioplasty fellowship with the late Geoffrey Hartzler, MD, a world leader in the field, and performed thousands of invasive heart procedures, PTCA, and heart stent implantations at respected medical centers. I maintain board certification in Interventional Cardiology. Furthermore, I have been qualified as a medical expert on the field of heart stents in several dozen states. Therefore, the question of whether there are unnecessary heart stents being implanted, some with coding or indications that may be fraudulent and dangerous, is one I can address. Do the headlines and websites that suggest abusive and excessive heart stent placements have credibility? Do cardiologists even scare people into excessive procedures as has been claimed? Indeed, cardiologists have been investigated and prosecuted for placing unnecessary stents or altering records in terms of the indications for heart stents so the question is not without some basis in the court of law.
As background, there is clearly a benefit for the placement of emergency heart stents in hospitalized patients experiencing a major heart attack (ST elevation myocardial infarction or STE MI) major heart attack as well as many patients with a non-ST elevation MI (nonSTEMI). The guidelines developed to regulate the use of heart stents support this practice as do I. The controversy and criticism is pointed to outpatient and elective procedures not qualifying as STEMI or nonSTEMI indications. Over a decade ago a large studycalled the COURAGE trial evaluated over 2,200 patients with stable heart disease. The use of heart stents early in the therapy of these patients did not reduce the risk of MI, death, or other cardiovascular events. More recently a widely publicized trial could not verify benefits of heart stents in patients with stable heart symptoms. Guidelines have advised against elective heart stents except for patients with angina symptoms refractory to “optimal medical therapy. Even more patients with no symptoms at all may get them too.
Recently I read someone call elective heart stents the ‘botox” of cardiology or purely cosmetic procedures. Is this true? A new study reports data suggesting that cardiologists and hospitals are “gaming” attempts at oversight and use of appropriateness criteria that may limit heart stents by using codes that are not appropriate and may be illegal. The authors examined the frequency in patients scheduled for outpatient and elective hearts stents under a code of “unstable angina”, a rather vague term that avoids scrutiny and implies urgency. They found that after appropriate use criteria (AUC) where published in 2009 the number of outpatient procedures coded in this manner increased significantly. For example, in the state of New York the rise was from 0.6 to 8.3% and in my state of Michigan it increased from 2.4 to 6.5%. This was not a shift of patients from inpatient to outpatient centers as the number of inpatient procedures coded in this manner did not drop.
In an accompanying editorial titled “Gaming, Upcoding, Fraud”, cardiologists from the Washington University School of Medicine wrote that “in the absence of a better explanation, it seems that upcoding to unstable angina is being used to circumvent the guideline-mandated trial of medical therapy prior to PCI (heart stents) and thereby justify inappropriate PCI (heart stents) in stable angina patients”. They went on to indicate that this practice “violates patient autonomy, puts patients at risk of procedural complications and, at worse, may cross the threshold into criminal activity”. These comments were inclusive of both cardiologists and hospital administrations.
In reality, the policing of heart stent procedures, and many other medical activities, often has put the “wolf in charge of the hen house”. Cardiologists with a reputation for abusing the system by placing unneeded stents are rarely reprimanded even if they are well known to dozens of trainees, nurses, and fellow physicians. Some hospitals are instituting new policies of mandatory review in certain patient groups shown not to be ideal for heart stents like diabetic patients with multivessel disease.
In terms of patient being scheduled for elective and outpatient heart procedures after a stress test or for chest pain, I would recommend that:
1) If at all possible, seek a second opinion, preferably from a cardiologist that does not perform invasive procedures. This may be particularly valuable if the second opinion comes from a cardiologist trained in preventive methods.
2) Explore the COURAGE trial and other data regarding Optimal Medical Therapy.
3) Investigate data on the reversal of heart disease with lifestyle measures pioneered by Nathan Pritikin, Dean Ornish, MD, and Caldwell Esselstyn, MD. The first two of these programs (Pritikin and Ornish) have approval from Medicare and other insurers for payment for Intensive Cardiac Rehabilitation therapies without heart stents if chronic stable angina is present. Dr. Esselstyn sees patients at the Cleveland Clinic. I and other cardiologists, like Robert Ostfield, MD at the Montefiore Medical Center in the Bronx, Kim Williams, MD and colleagues at Rush University, and Baxter Montgomery, MD in Houston, regularly see patients referred for heart stents and even heart bypass surgeries that do not need these procedures and are appropriately guided to lifestyle medicine therapies.