In cardiac care, the mantra is fast becoming circumstance, circumstance, circumstance.
Fear of heart problems is justified since heart disease remains America's No. 1 killer, but patients with stable or no significant symptoms too often are rushed into invasive tests and treatments unnecessarily and without having all the facts, according to an investigation by Consumer Reports.
The magazine's September edition reports that direct-to-consumer advertising can lead people to get the wrong tests, which can prove ineffective, costly and even harmful to them if it leads to inappropriate treatment.
It also found that angioplasty, an invasive procedure that's used to identify and clear blockages in the coronary arteries, is too often a first line of defense for people who don't have symptoms such as worsening chest pain or shortness of breath. In such nonemergency cases, patients should be given a chance to change their diet and exercise habits and start medication, all of which could address the problem just as well and more safely than going straight for an angioplasty, Consumer Reports said.
The financial incentives around angioplasty, a potentially lifesaving procedure when used during heart attacks and certain kinds of angina, can induce doctors to overuse the procedure on patients whose conditions haven't proven to benefit from it.
"Angioplasty is a great procedure in several circumstances, and we need to do more of it and do it better," said Dr. John Santa, director of Consumer Reports' Health Ratings Center in Yonkers, N.Y. Â "It's not a great procedure in several other circumstances and we should be doing less of it."
"The key is symptoms," he said. "If patients are having heart-attack symptoms or having more and more chest pain, angioplasty is a good procedure to do. If they're not having chest pain or if it's stable - not increasing in frequency or severity - they should be careful about a recommendation to have angioplasty.
"Our concern is it can be easier and more profitable" for doctors to recommend angioplasty than to wait or pass on it, he said.
The invasive procedure is big business. About 600,000 angioplasties are performed every year in the U.S. at a cost of more than $12 billion, according to a study in the July 6 issue of the Journal of the American Medical Association (JAMA).
Part of the problem is that when patients undergo angiography, they're sedated and exposed to X-rays while doctors look for blockages. If some are found, doctors can quickly move on to angioplasty, where a balloon is typically inflated and a stent is placed to open the blockage. But sometimes nonemergency patients don't know their options - such as having a stress test to determine whether they're even candidates for angioplasty - before they're rushed into a scenario where they may find it hard to say no to an angioplasty while they're already on the operating table, Santa said.
"Some cardiologists aren't doing as much as they should to give them the time they need, explain all the options and not doing angioplasty when there may be alternatives that are safer and just as effective," he said.
The good news is that angioplasty is used appropriately about 99 percent of the time when patients suffer an acute medical emergency, the JAMA authors found after examining data of 500,000 angioplasties.
But when it came to nonemergency cases, the verdict was split. Only half of angioplasties performed on patients not experiencing an immediate health crisis were deemed appropriate compared with 12 percent that were classified as inappropriate. About 38 percent were considered uncertain. The hospitals in the study varied widely as to what portion of their volume was classified as inappropriate. Rates ranged from 6 percent to nearly 17 percent of their nonacute procedures.
Two years ago, an article in the New Yorker magazine painted a portrait of a kind of medical Wild West taking root in parts of the country, especially in cardiac care. The piece set off alarm bells among policymakers and captured the attention of President Obama after it compared two relatively similar Texas towns and found one, McAllen, had drastically higher per-person health-care costs than nearby El Paso. An aggressive, entrepreneurial culture among doctors and heavily marketed elective tests were prime drivers, wrote the author, Dr. Atul Gawande, a Harvard cancer surgeon.
There's been more recent general awareness of the overuse issue with invasive cardiac procedures, said Dr. Gordon Tomaselli, president of the American Heart Association and a cardiologist at Johns Hopkins University in Baltimore. He doesn't deny that overuse still happens, but he said imaging tests that don't require catheterization - such as CT scans that measure calcium deposits - are likely overdone as well.
"There's probably more overuse of the less invasive tests, which were until recently very well reimbursed," Tomaselli said.
Meanwhile, in cases where there's no medical emergency and angioplasty is being considered, it's good to slow down and weigh all the options, he said.
"With elective coronary angiography and angioplasty, it's best to sit down and figure out whether or not the specific areas of blockage in the angiogram are the ones causing the actual symptoms from the stress test before going in and doing definitive treatment."
Patients should keep in mind that preventing risk factors for heart disease by not smoking, eating a healthy diet and getting physical activity, among other things, is always preferable to treating heart disease, Tomaselli said.
Angioplasty is a good means of preventing heart attacks in some patients but it isn't a cure-all, he said. "It relieves symptoms very well but it does not prolong life."
Said Tomaselli: "The message shouldn't be that these tests are absolutely no good. These tests are good, but they have to be used in the right circumstances."