Thousands of Americans get stents to treat heart disease when they aren't needed

[PAUL-E]

Too Much Angioplasty
If you've been diagnosed with a clogged artery in your heart, there's a good chance your doctor recommended angioplasty. That procedure involves first clearing out the blockage and then propping the artery open with a tiny cylindrical device called a stent.
More than one million stents are inserted in people in the U.S. to open up blocked coronary arteries every year. Yet researchers have known for nearly a decade that angioplasty usually only saves lives if done immediately after a heart attack.
Here's what you should know about when angioplasty and stents are necessary, and when they aren't.

The Old Thinking

Angioplasty, introduced in the 1980s, gained steam after its effectiveness as an emergency treatment for heart attacks became clear.
In angioplasty, also called percutaneous coronary intervention (PCI), the doctor inflates a thin balloon in the narrowed artery to crush deposits, leaving a stent in place to keep the vessel open.
When performed within hours of a heart attack to clear a blocked or nearly blocked artery, it's clear that angioplasty can be lifesaving.
“Thirty years ago, doctors made the assumption that since it could help with a heart attack, it would help with other blockages due to coronary artery disease,” says David Brown, M.D., a cardiologist and professor of medicine at the Washington University School of Medicine in St. Louis.
When You Do, and Don't, Need It

But a pivotal 2007 clinical trial of 2,287 people with stable heart disease found that having a stent implanted didn’t reduce the risk of death, a heart attack, or other major cardiovascular events when added to a patient’s drug therapy. Subsequent studies had similar results.
Yet 13 percent of nonemergency stents are still inappropriate, according to a Yale University study published online last November by JAMA.

One explanation for the continued use is that the procedure—which is relatively quick and easy—is seen as a moneymaker for doctors and hospitals, says Brown, who has written about the overuse of the procedure.
In most cases, you don’t need a stent unless you’re having a heart attack or have severe angina (chest pain) that doesn’t respond to medical therapy.
http://www.consumerreports.org/conditions-treatments/too-much-angioplasty/

I would think that clearing out the artery would be beneficial not necessarily the stent but most likely the people didn't make the right nutrition and lifestyle changes with there second chance.

 

[Vince]

30 Stents In A Single Day
December 5, 2010
Doctor Faces Suits Over Cardiac Stents

By GARDINER HARRIS

Word quickly reached top executives at Abbott Laboratories that a Baltimore cardiologist, Dr. Mark Midei, had inserted 30 of the company's cardiac stents in a single day in August 2008, “which is the biggest day I remember hearing about,” an executive wrote in a celebratory e-mail.
Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home, according to a report being released Monday by the Senate. The dinner was just a small part of the millions in salary and perks showered on Dr. Midei for putting more stents in more patients than almost any other cardiologist in Baltimore.
The Senate Finance Committee, which oversees Medicare, started investigating Dr. Midei in February after a series of articles in The Baltimore Sun said that Dr. Midei at St. Joseph Medical Center, in Towson, Md., had inserted stents in patients who did not need them, reaping high reimbursements from Medicare and private insurance.
The senators solicited 10,000 documents from Abbott and St. Joseph. Their report, provided in advance to The New York Times, concludes that Dr. Midei “may have implanted 585 stents which were medically unnecessary” from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for those procedures.
The report also describes the close relationship between Dr. Midei and Abbott Labs, which paid consulting fees to the cardiologist after he left the hospital. “The serious allegations lodged against Dr. Midei regarding the medically unnecessary implantation of cardiac stents did not appear to deter Abbott's interest in assisting him,” the report states.
The case has turned into a legal quagmire for Dr. Midei and St. Joseph, which have been sued by hundreds of patients who claim they received unnecessary implants. Some doctors say the case has revealed a level of inappropriate care that is more common than most patients know.
“What was going on in Baltimore is going on right now in every city in America,” said Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic, who said he routinely treats patients who have been given multiple unneeded stents. “We're spending a fortune as a country on procedures that people don't need.”
Dr. Midei's lawyer, Stephen L. Snyder, said that his client's treatment of his patients was entirely appropriate and that Dr. Midei, who has recently practiced medicine at the Prince Salman Heart Center in Saudi Arabia, would be exonerated.
“This is all trumped up to hide the hospital's criminal conduct,” said Mr. Snyder, who filed a $60 million lawsuit against St. Joseph on Dr. Midei's behalf accusing the hospital of damaging Dr. Midei's reputation by making false claims about his care. (The hospital responded that the assessments of Dr. Midei's care were done by independent experts.)
Last month, St. Joseph agreed to pay a $22 million fine to settle charges that it paid illegal kickbacks to Dr. Midei's medical practice, MidAtlantic Cardiovascular Associates, in exchange for patient referrals; the hospital did not admit wrongdoing. St. Joseph said in a statement Friday that it now conducts monthly random reviews of stent cases “to assure such a situation cannot occur again.”
As for Abbott Labs, a spokesman wrote in an e-mail that its affiliation with Dr. Midei ended early this year. “Dr. Midei has been a highly regarded physician in his field, with whom Abbott had consulted in the past,” said the spokesman, Jonathan Hamilton. “We have no further comment at this time.”
The case has had wide repercussions. Over the past year, St. Joseph has told hundreds of Dr. Midei's patients that they did not need the expensive and potentially dangerous stents that the doctor inserted because their arteries were not as obstructed as he had claimed. Now, state health officials are investigating other local cardiologists who inserted a suspiciously high number of stents, which are tiny wire mesh devices inserted to prop open clogged arteries in the heart.
After reports about the Midei case and the wider state investigation, the number of stent procedures performed at St. Joseph and other area hospitals plunged, raising doubts about the appropriateness of much of the region's cardiac care.
A landmark 2007 study published in The New England Journal of Medicine showed that many patients given stents would fare just as well without them. Dr. Christopher J. White, president-elect of the Society for Cardiovascular Angiography and Interventions, said that inappropriate stenting was a problem, but a rare one. The federal Medicare program spent $3.5 billion last year on stent procedures.
Prosecutors, malpractice lawyers and state medical boards are only now waking up to the issue. The Texas Medical Board last month accused a widely known cardiologist in Austin of inserting unnecessary stents. In September, federal prosecutors accused a cardiologist in Salisbury, Md., of performing unnecessary stent surgeries, and last year a Louisiana doctor was sentenced to 10 years in prison for inserting unneeded stents.
J. Stephen Simms, a Baltimore lawyer who successfully pursued a federal whistle-blower lawsuit involving kickbacks for coronary procedures, said such cases were “the flavor of the month right now” with federal prosecutors.
Jay Miller, another Baltimore lawyer, said he was devoting his entire practice to unnecessary stent cases. “And I don't think this is limited to just a few Maryland hospitals,” Mr. Miller said.
But far from questioning cardiologists who perform an unusually high number of stent procedures, many hospital executives celebrate these doctors because of the revenue they bring, which can be more than $10,000 per procedure.
“Hospital patients expect their care to be based on medical need, not profits,” said Senator Max Baucus, Democrat of Montana and chairman of the Finance Committee. “Even more disconcerting is that this could be a sign of a larger national trend of wasteful medical device use.”
Dr. Midei's fall was as rapid as it was dramatic. In a June deposition for a lawsuit against him, he said: “I didn't know what hit me. I was bewildered by what had happened.”
He had been one of the most sought-after clinicians in his region. Trained at Johns Hopkins University, he was a co-founder of MidAtlantic, a practice with dozens of cardiologists that controlled much of the cardiac business in Baltimore's private hospitals. Dr. Midei was one of the practice's stars. When MidAtlantic negotiated a $25 million merger with Union Hospital in 2007, the deal was contingent on his continued employment.
St. Joseph was so concerned about losing Dr. Midei's business that the hospital offered a $1.2 million salary if he would leave MidAtlantic and join the hospital's staff. When Dr. Midei agreed, the merger with Union collapsed, MidAtlantic sued, and the practice's former chief executive vowed in a deposition to “spend the rest of my life trying to destroy him personally and professionally.”
In the June deposition, Dr. Midei estimated that in 2005 — before research revealed that many stents were unnecessary — he performed about 800 stent procedures. Instead of dropping in subsequent years, however, the number of stents Dr. Midei inserted rose to as many as 1,200 annually, he estimated. In a 2007 internal document, Abbott Laboratories ranked Dr. Midei's use of stents behind only five other cardiologists in the Northeast, including those at hospitals four and five times St. Joseph's size.
That sort of increase in volume was an obvious red flag, said Dr. William E. Boden, clinical chief of the division of cardiovascular medicine at the University of Buffalo and an author of the 2007 stent study. “For him to have this brisk increase over those years is really unusual,” Dr. Boden said.
In stable patients, stents should be used only if X-rays show that most of the artery is blocked, and the patient has symptoms like frequent chest pain. Stent procedures can, in rare cases, cause bleeding, stroke or a heart attack. Once a stent is placed, it can result in a life-threatening clot that emerges weeks to months later. Stent patients must spend a year or more taking blood-thinning medications, which have their own risks.
In April 2009, a patient of Dr. Midei's who was also a St. Joseph employee complained that he had received an unneeded stent and that many other patients had as well. The hospital engaged a panel of experts who reviewed 1,878 cases from January 2007 to May 2009 and found that 585 patients might have received unnecessary stents.
When asked to review the cases himself, Dr. Midei found far less blockage than he had initially, according to the Maryland Board of Physicians. The hospital suspended his privileges and eventually sent letters to all 585 patients. Hundreds of lawsuits against Dr. Midei and St. Joseph followed, including from patients treated well before January 2007.
Abbott responded to the controversy by hiring Dr. Midei as a consultant. “It's the right thing to do because he helped us so many times over the years,” an Abbott executive wrote in a January e-mail cited in the Senate report.
The company sent Dr. Midei to Japan, but news of the controversy made his duties impossible, and he flew home. After one particularly critical story in The Baltimore Sun, David C. Pacitti, an Abbott executive, wrote in an e-mail, “Someone needs to take this writer out and kick his ass!”
Edward Chaid, 68, a semiretired general contractor from Timonium, Md., is among those who have sued. Five years ago, Mr. Chaid decided to get his first physical examination in decades. Just to be safe, his doctor sent him for a cardiac stress test at MidAtlantic, which revealed a small “squiggle” of concern, Mr. Chaid said. He was sent to Dr. Midei to get his arteries X-rayed, and he emerged from the procedure with two stents.
“Dr. Midei said: ‘You sure are lucky. You had 90 percent blockage.' And the nurse said, ‘Oh yeah, you were blocked in your widow-maker.' And I said: ‘Thank God. I guess I'm really lucky you got it when you did,' ” Mr. Chaid said in an interview.
Five years later, another doctor concluded that Mr. Chaid's blockage had been minimal. “I was really shocked,” Mr. Chaid said. “I'm from a generation where doctors are thought very highly of.”
But Mr. Snyder, Dr. Midei's lawyer, said that his client's care had been entirely appropriate, that doctors often interpret X-rays differently and that St. Joseph was using him as a scapegoat. A Web site created by friends of Dr. Midei lists dozens of testimonials like this one: “Plain and simple, Dr. Midei saved my life.”

 

[PAUL-E]

It's all about the $$$$ not always about the patient, seem like when any big company regardless of field messes up instead of doing the right thing they lie higher expensive layers and try to get out of it, it's sad but true trust me I know they go for that OJ justice.

 

[Vince]

Cardiac Stents Being Overused
A new study gives fresh evidence that many people with clogged heart arteries are being overtreated with stents, and that a simple blood-flow test might help prevent unnecessary care. Fewer deaths, heart attacks and repeat procedures occurred when doctors implanted fewer of these tiny artery props, using the blood-flow test to decide when they were truly needed, the study found.
Results were published in Thursday's New England Journal of Medicine.
Several reports in recent years have suggested that stents and artery-opening angioplasty procedures were being overused in non-emergency cases, often without giving medicine alone a chance to work. Concern about stent complications also has made doctors more cautious about elective angioplasty.
"It's really raised a lot of question about when is it appropriate," said Dr. Robert Harrington, director of the Duke Clinical Research Institute, who had no role in the new study.
The finding that blood-flow testing may help guide these decisions "adds another parameter for us to consider," he said.
The test has been around for some years but is used in only about 10 percent of angioplasties now, several heart specialists said.
More than 1 million angioplasties are done in the United States each year, and about half are the type in this study — non-emergency cases involving people with narrowings in two or more major heart arteries.
The study was done in the United States and Europe, and involved 1,005 people who were having chest pain because of reduced blood flow to the heart or were recovering from a mild heart attack. All were scheduled to have angioplasty based on the usual test — an X-ray called an angiogram, in which a dye is injected so doctors can see artery narrowings.
Half of the study participants had their narrowed areas treated with angioplasty and stents, as indicated by angiograms alone.
The rest were given a blood-flow test. Doctors place a wire in the artery and measure pressure in front of and beyond the narrowing. This tells whether the narrowing is keeping a big amount of blood from getting through to the heart. In this group, only narrowings that significantly impeded blood flow were treated with angioplasties and stents.
Results: people given the blood-flow test received on average, roughly two stents versus roughly three for the others.
A year later, only 13 percent of them had died, suffered a heart attack or needed further artery treatment, versus 18 percent of those treated on the basis of angiograms alone. Rates of chest pain at one year were similar.
Between 5 and 10 percent of those given the blood-flow test were able to skip angioplasty and stents altogether, and were prescribed medicines instead, he said.
Copyright AP