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Angioplasty and stent placement continue to be frequently performed for patients with non-emergency coronary artery disease, despite clear evidence that it provides minimal beneﬁt. For example, it does not prevent heart attacks or death, yet as many as 9 out of 10 patients mistakenly believed that the procedure would reduce their chances of having a heart attack. But at the same time, the cardiologists weren’t stupid. Those who referred them for the stent and those who performed the procedure didn’t believe that. Okay, then why were they doing it? Focus groups of cardiologists have documented a chasm between knowledge and behavior. While aware of the evidence to the contrary, they recommend and perform PCI (angioplasty and stents), because they somehow believe that it helps in some ill-deﬁned way. “[P]hysicians tended to justify a non-evidence-based approach (“I know the data shows there is no benefit, but”) by focusing on [how easy it is to do the procedure] and belief that an open artery was better” even if it didn’t actually affect outcomes, all the while minimizing the risks. I mean the procedure only kills 1 in 150. So, here some are blaming the patients for not listening, but maybe it’s the physicians who are the ones ignoring the evidence.
Or maybe physicians have too poor a grasp of the relevant statistics to adequately inform the patient? Regardless, what we’ve got here is a failure to communicate. So, tools have been developed. For example, a sample informed consent document that lays out the potential benefits and risks, even laying out how many procedures your doctors have done and your out-of-pocket costs. Note there are a lot of blanks to be filled in, though. What are some concrete numbers?
The Mayo Clinic came up with some prototype decision-making tools. In terms of benefits, will having a stent placed in my heart prevent heart attacks or death? No, stents will not lower the risk of heart attack or death, but a week later those getting stents report they feel better at least, though a year later even the symptomatic-relief benefit appears to disappear. Okay, so there appeared to be this temporary-relief-in-chest-pain benefit. What about the risks?
During the stent procedure, out of 100 people, two will have bleeding or damage to a blood vessel, and one will have a tad more serious complication such as heart attack, stroke, or death. And then, after that, during the first year after the stent, three will have a bleeding event because of the blood thinners you have to take because you have this foreign material in your heart, but that doesn’t always work, and so two will have their stent clog off leading to a heart attack.
What does the world’s #1 stent manufacturer have to say for itself? They acknowledge the evidence shows stents don’t make people live longer, but living longer is overrated. Look, if all we cared about was living longer, entire disciplines of medicine would disappear. Why go to the dentist? Of course, the difference is that 80 percent of people don’t believe that getting a cavity filled is going to save their life, like they mistakenly do for stents, and there isn’t a one in a hundred chance you won’t make it out of the dentist chair.
The stent companies actively misinform with ads like this. “Open your heart and your life.” “Life wide open.” “Freedom begins here.” Their TV ad mentioned a few side effects. Turns out they missed a few, but more importantly, they’re giving the false impression that stents are more than just expensive, risky band aids for temporary symptom relief. But what’s wrong with symptom relief? Look at those smiling faces. Even if the benefits are only symptomatic and don’t last long, if people think that outweighs the risk, what’s the problem?
What if I told you that even the symptom relief may just be an elaborate placebo effect, and you could get the same relief from a fake surgery; so, there really weren’t any benefits at all? We’ll see what the science says next.
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