Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
4 April 2007

FOUR CHOICES

            The rage in the newspapers and on television the past week is a controversy about whether drugs work as well as angioplastic cardiac surgery.  A paper was presented at the March 2007 American Heart Association meeting in New Orleans showing that angioplastic surgery for coronary artery disease was no better than using drugs to treat the problem.  I have had no fewer than eight telephone calls and three clinic visits to the time of this dictation wanting to know why a patient had angioplasty done when they could have used medications. 

            It seems that the role of the physician must mean different things to different people.  The real truth is that a physician and a healthcare provider at your clinic perform the function of being advisors.  We advise patients about how to manage their healthcare problems.   We try to review all of the possible alternatives available and let the patient make the choice on what they want to do.  Healthcare providers have neither the authority nor the capability to make a patient do anything, but we work very hard to advise patients on how to best care for themselves.  The problem of what to do with heart problems can be very well illustrated by a gentleman who came to the clinic this week asking what he should do about his heart problem in light of the paper presented in New Orleans.

            This gentleman was 62 years of age and as far as he was concerned, he was in very good health.  His blood pressure had been high over many years time and he had balked at taking medications stating that he just felt fine.  His cholesterol was too high and he was overweight. His blood tests indicated that he was diabetic although he was “trying” to control this with diet and exercise.  In spite of whatever effort he made, he was in no way successful with this and his diabetic blood test had been abnormal for two years.  He had come to the clinic several weeks ago stating that he had chest pain after he climbed the stairs at his local establishment.  He worked on the third floor of the building and as an effort for better exercise, he decided that he was going to climb the stairs each day instead of taking the elevator.  But he noticed that by the time he got to the top of the stairs on the third floor, he was having a sensation of discomfort in his chest.  This tightness in his chest went away after he rested for several minutes.  He came to the clinic to discuss this and a stress test was done.  It demonstrated that there was an area of his heart that was not getting enough blood, very likely representing a block in one of his coronary arteries.  It was explained to him that if this block closed completely, he would have a “heart attack” in which a piece of his heart muscle would die.  If that piece of muscle was in a critical area or comprised more than 40% of his heart muscle, it would be fatal for him, too. 

            I advised him that he should see the cardiologist and have an angiogram done to see the nature of the blocks in his heart arteries and whether or not they needed specific address.              He made the appointment to see the cardiologist but now returned to me stating that he wanted to take medications instead if that was just as good as any surgery that might be done.

            So I got out a piece of paper and I wrote down his four choices.   They were as below:

            1.  Keep doing what he is already doing.  Take a chance that the heart attack won’t happen.  After all, with his characteristics there is only one chance in six that he will have a heart attack this year.  That is Russian roulette.  Why worry?  For his clinical characteristics, the likelihood that he would have a heart attack in the next five years was 60%.  I suggested that if he was a gambling man, he wouldn’t have to do anything except hope his luck holds out. 

            2.  I told him his second choice was to change his lifestyle.  His weight was excessive.  His exercise program consisted of whatever walking he did each day.  He acknowledged that he frequently forgot to take his medications and he never checked his blood pressure.  When we checked his cholesterol in the clinic it was abnormally high as was his diabetes test.  I suggested that if a lifestyle change were to be instituted, he could reverse some of the abnormalities that were in his heart arteries if he lived that long.  But going out and trying to start an exercise program after the chest pain is already occurring is a very risky business and was officially not medically advised at this time. 

            3.  He could choose to take medications on a regular basis faithfully and monitor his blood pressure and cholesterol.  Associated with this would be the necessity that he control his diet much better than he has ever done and start a supervised monitored exercise program whereby his heart performance during the exercise could be certified as safe.  If he survived the five years that are cited in the above studies done in New Orleans, his risk of having a heart attack would be better than if he had done the angioplasty at this time.  But please remember the risks don’t turn around in the first month or the first year or even the first three years.  Medication treatment alone has a worse risk than angioplasty for three years.  After that, if the person survives that long, their risk of a heart attack is much less using medications than it is having had an angioplasty. 

            4.  The fourth choice for this gentleman was to proceed to the cardiologist as I suggested, have an angiogram done and then determine whether or not any procedure is indicated.  Once the person is having significant chest pain such as this gentleman, his risk of having the heart attack goes up substantially.  The immediate benefit of having an angioplasty done and stopping the chest pain exceeds drug therapy for about three years.  Of course after the angioplasty is done and a stent is placed, medications to control blood pressure, cholesterol and diabetes are still indicated with a lifestyle change to prevent the disease process from coming back.

            In regard to cost, choice #1 of doing nothing is only expensive for those who die.  For them, there is lost income for their family and funeral expenses.  Choice #2 of a change in lifestyle is really cheap.  It is much cheaper started early in life rather than waiting for the chest pain to finally come and be forced into lifestyle changes.  This choice may not be effective once chest pain is occurring. 

            Choice #3 may cost as little as $12.00 a month depending upon effectiveness of generic medications.  It may cost as much as $100.00 to $200.00 a month if newer more effective patent protected medications are used.  Once again, this choice is much better made early in life before chest pain ever develops.

            Choice #4 gets kind of spendy at around $40,000.00 all told if an angioplasty is necessary.  Drugs and lifestyle change are much cheaper but only work predictably if started early in life before chest pain problems begin. 

            The best advice the healthcare provider can give is to take care of oneself beginning early in life.  By age 40, everyone should know their blood pressure, their cholesterol and their blood sugar.  If there are abnormalities, lifestyle change should start right away.  Unfortunately, lifestyle change has proved ineffective for the vast majority of our population who helter-skelter eat what they want and don’t worry about health.  Once chest pain has occurred, the best advice we can give is to be evaluated to determine if there are eminent problems that are going to require an angioplasty to predictively save the person in the immediate future.  But as I said above, healthcare providers are only advisors and the choices are always up to the patient.  The gentleman I mentioned above did elect to get his heart evaluated and I thought that was a very wise choice.