Drive-by angioplasty

Don had an angioplasty 6 months ago. When asked about the symptoms that prompted him to go to the hospital, he explained:

"I remember feeling really tired for about a week before I went. I'd read that fatigue can sometimes be a sign of heart disease. But then I had some trouble breathing. You know, like not being able to get a deep breath."

"My wife and I were planning on going on vacation. So I wanted to be certain something wasn't going on in my heart. That's when my wife insisted that she take me to the hospital.

"I kind of remember going there and arriving in the emergency room, but then I don't remember anything. Next thing I know, I'm waking up in a hospital bed. My wife and kids were there, looking all concerned. They said that I just got two stents and that the doctor just barely saved my life."

Happy story, happy ending? Not quite.

I reviewed the angiograms made during Don's hospital stay. They did, indeed, show some plaque, but not anywhere close to the amount necessary to account for symptoms like fatigue or breathlessness. For symptoms like this to occur without physical exertion, say, at your desk or relaxing at home, a critical >90% blockage would be required.

The worst "blockage" Don had was 50% at most. The leap was made to connect his relatively vague symptoms with these "blockages," leading to the implantation of two stents.

This is not as uncommon as you think. Yes, the practice of cardiology can be a life of acute procedures, urgent situations, and crises. Unfortunately, some people with questionable need for these procedures also get swept up in the wave. Sometimes it's due simply to the doctor's need to do "something," nervous family waiting in the wings. Sometiems it's intellectual laziness: putting in two stents seems to satisfy many patients' needs to have something "fixed," even when symptoms like fatigue could be due to anemia, sleep deprivation, a thyroid disorder, or any other myriad conditions that require a diagnostic effort (otherwise known as thinking). And sometimes it's simply done with financial motives, since angiplasty and related procedures pay well.

I call this "drive-by angioplasty," the impulsive, poorly considered coronary procedure that really should never have happened. How often does this happen? What percentage of heart procedures fall into this category? There are no clear-cut estimates. There are crude attempts by independent agencies that have put the number of unnecessary heart catheterizations up to 20% of the total number performed. The proportion of angioplasty procedures, stents, etc. that are not necessary is a tougher number to pinpoint, given the uncertainties surrounding the indications for these procedures, physician judgment that factors into the decision-making process, and the fact that many decisions are made on a qualitative basis, not precise quantification.

In real life, I would put the proportion of flagrant drive-by procedures at no more than 10%. However, that is 10% of an enormous number. The annual cardiovascular healthcare bill is $400 billion. 10% of that is $40 billion--an unimaginable sum. It also adds up to tens of thousands of people per year needlessly subjected to procedures. Consider that 10,000 heart procedures were performed today alone.

Should we push for legislation to control how and when heart procedures are performed? I don't think so. Despite my criticisms of the status quo in heart care, I still favor the freedom and rapid development of a free-market approach. However, you as a healthcare consumer need to be armed with information. You don't go to the car dealer unarmed with information on prices and comparative performance of the car you want. You should do the same with health. Information is your weapon, your defense against becoming the victim of the next drive-by heart procedure.

Comments (7) -

  • Anonymous

    1/27/2008 11:49:00 AM |

    You've mentioned before about the medical communities bias toward procedural medicine. If hospitals were to change their position and embrace a preventive bias for heart disease treatment, (early detection, and then addressing with appropriate supplements, drugs, and diet.) any ideas on how much savings for the nation could be had?

  • Dr. Davis

    1/27/2008 2:00:00 PM |

    Our analysis suggests $634 million per 100,000 people would be saved if they were to engage in a simple program of prevention using heart scans.

    Our analysis and rationale can be found at

  • Rich

    1/27/2008 10:01:00 PM |

    Dr. Davis: I fully agree that legislation is not the answer to this unfortunate practice. I favor freedom for physicians, and an informed public. Government regulation can and will ruin the practice of health care and incentives for new medical techniques and approaches. For those who think the government can be helpful, take a look at Medicare.

  • Anonymous

    1/27/2008 11:02:00 PM |

    I had a “drive-by” angioplasty done in 1999 and a “drive-by” angiogram done in 2000 by the same cardiologist. He told me that I had 90% blockage on one of my main arteries after he performed the first angioplasty. Few years later, a neurologist told me that I actually suffered from panic attacks, not heart attacks. I always wonder how an experienced cardiologist could mistake a panic attack as a heart attack, not once but twice.

  • Dr. Davis

    1/28/2008 1:43:00 PM |

    "To a man with a hammer, everything looks like a nail."

    It holds true in medicine, unfortunately. Especially when each swing of the hammer pays thousands of dollars.

  • Warren

    1/29/2008 2:32:00 PM |

    I have often thought that one underlying force that drives this phenomenon might be the fear of lawsuits.  Being a lawyer, I hate to bash the legal profession, but I know that once the person is on the cath table and any blockage is found that some interventional cardiologist somewhere might choose to stent, some doctors may feel the need to practice defensive medicine.  Even before they get to the cath table this is probably an influence.  In other words, say this patient died of a heart attack soon after this hospital visit (which as we all know, could happen even if the symptoms were unrelated to his plaque burden).  If the hospital had not done the procedure (especially since they have an entire crew of people sitting around all day long just waiting to do these), it's possible that some other intervention-oriented cardiologist might be found who would testify that the standard of care these days is to do the angiogram, and that had this been done, it's quite possible, even likely, that the blockage could have been opened up and death avoided.  (Even though we know that this is speculative and depends on how close to this visit the heart attack occurs, as far as the likelihood that this might be a life-saving procedure.)  The further out the heart attack occurs, the less compelling the causation argument.  But I gotta believe that there is defensive medicine being practiced in some of these situations.  And the trouble is, it's the very state of the treatment attitude that contributes to this result, i.e., the fact that unexpected heart attacks are as common as they are, and the proliferation and ready availability of cath labs, so that they are viewed as routinely available.

  • Dr. Davis

    1/29/2008 2:59:00 PM |

    Hi, Warren-

    Yes. I agree absolutely.

    In fact, I believe this is exceptionally common. So common that it's become acceptable standard of care.

    Often the appearance of doing something is better than the appeareance of doing nothing, regardless of how ineffective the treatment is.