Angioplasty unnecessary in some cases, study finds
July 5th, 2011
06:14 PM ET

Angioplasty unnecessary in some cases, study finds

Half of all procedures done to widen arteries in non-emergency situations may be unnecessary, according to a study published in the Journal of the American Medical Association on Tuesday.

A percutaneous coronary intervention, also called PCI or angioplasty, is a procedure to widen a blocked or partially blocked artery. It’s often performed on patients suffering a heart attack, or an acute attack of angina. It’s also done on some patients with non-acute heart disease – partial blockages of one or more coronary arteries.

Researchers from several major heart centers analyzed more than half a million PCIs performed in the years 2009 and 2010, at more than a thousand hospitals. Of those done in acute situations, nearly all – more than 98% – were deemed “appropriate,” according to the study.  However, many PCIs in non-emergency situations were not recommended under guidelines developed by a leading group of heart experts.  Among non-acute cases, 50% were deemed “appropriate,” 38% “uncertain” and 12% “inappropriate,” according to the study.  Most of the inappropriate procedures were done on patients with low-risk heart conditions.

Dr. Hani Jneid, an assistant professor of medicine and interventional cardiologist at Baylor College of Medicine, who was not part of the study, says the results probably underestimate the actual number of inappropriate procedures. That’s because the criteria don’t take into account patients with conditions like cancer or advanced kidney disease, that make them poor candidates for angioplasty.  “You could hurt patients, for example by pushing them into dialysis,” Jneid says.

Researchers also found that some hospitals are far more likely than others to do unneeded PCIs. Jneid calls this “troubling” and says it suggests that some patients are being pushed into procedures for the financial benefit of doctors or hospitals. “You hate to say that, but it’s a possibility.”

In the study, 71% of patients who had “inappropriate” PCIs were privately insured, which means they were better able to pay the cost of the procedure, which can run up to several thousand dollars. Among patients who underwent “appropriate” PCIs, 65% were privately insured.

Reducing the number of unneeded PCIs would not only save hundreds of millions if not billions of dollars, but would help patients avoid potentially serious side effects, including blood clots and post-operative bleeding.

Jneid says patients whose condition is stable should understand that a PCI is not likely to prolong their life. However, he says they may benefit by having less chest pain and a generally better quality of life. 

soundoff (64 Responses)
  1. fiskenmann

    Interesting. I wonder if those patients on the 'inappropriate' result list were contacted that they were inappropriately charged for the procedure! I know that I am still paying through the rear for mine.

    July 5, 2011 at 22:46 | Report abuse | Reply
    • Steve MD

      Some indications for cath
      Are "need to know" with some cardiologists. Of course there are other treatments for angina but given the opportunity to revascularize which will potentially save myocardium in the future for the pt the cath is highly desirable and formmany life saving when it comes to relief of anginal symptoms. It is people like yourself who
      Make the comment of about the cost who
      Would be the first to sue your cardiologist If you had a big fat MI because your cardiologist decided to treat your 95% McDonald/pizza hut stenotic lesions with medical therapy alone because your angina was not appropriate to cath.

      July 5, 2011 at 23:11 | Report abuse |
    • fiskenmann

      Well, Steve, the self proclaimed MD who thinks that everyone who has angio is a junk food smoker, I'm sure there is a quoto that hospitals need to meet to prosper just like law inforcement and speeding tickets. If it weren't for us sinners, you saints would be out of business!!!

      July 5, 2011 at 23:31 | Report abuse |
    • Son of a Doc

      I had PTCA (Percutaneous Transluminal Coronary Angioplasty as they called it then in 2001) at 44 years of age. I was 90% occluded in the RCA and 70% in the first diagonal off the LAD.

      I had been in acute angina for the week proceeding the procedure, denying it the whole time . . . all the while smoking cigarettes and sucking down ribs at a Super Bowl party, calling myself a wuss for feeling weak during step aerobics classes . . . but deep down inside, I knew what was going on, having learned these facts and symptoms in dinner conversations with my parents, a cardio and thoracic vascular surgeon and a surgical nurse about the classic precursor signs of the onset of an MI: a tightening of the chest (especially in reaction to introduced tobacco smoke, I found out), shortness of breath, radiating pain (in my case, templar) . . .

      My cardiologist demanded a stress test before he would relase me to go skiing that Friday. I wne in Thursday. The nurse and the tech hooked me up. I was literally 10 steps into the test when the tech asked, "Are you alright?/ Can you go on?" My reply was, "Hell, if I'm going to go into cardiac arrest, it might as well be in a cardiologist's office . . . Warm up the paddles!" The stunned nurse and tech let me go on for about 10 seconds then stated firmly, "Ok, you need to stop know. We have all the data we need."

      When the Doc came in, his first words were, "Son, you are clogged up like a bad drain pipe. Not going to be any skiing for you this weekend." I tried to wiggle out of it, saying I would bring nitro pills, that I would stay on the bunny slopes and the lodge making new lady friends at the bar . . . He said that he might have allowed the first excemption, but the latter he was afraid would lead to "strenuous activity that might leave me come and gone" . . .

      So I waited until the following Tuesday. He invaded, unblocked, stented, and everyone had a good time. After a day of recovery, I felt 20 years younger and began exercising 2, 4, even 8 hours a day (I was unemployed) . . .

      As such, I have seen first hand the efficacy and life changing effects of this procedure. To me it was not anyone's quota nor inappropriate. It saved my life.

      Sounds like to me that you are just jealous of those medical people who dedicate their lives to helping people they don't eveen know oftentimes at the expense of their own personal relationships then want to be fairly compensated for thier service. Next time you need a medical practioner, I suggest you hire a plumber for your vascular system, and an electrician for your neuro system, and a car mechanic for you skelatal issues . . . not that any of them are gougers either, bright boy . . . but at least they will charge you less . . . which you will see if you live . . .

      July 6, 2011 at 00:07 | Report abuse |
    • fiskenmann

      Of course these are the type of responses expected from 'MD's', sons, wives and daughters of 'MD's' and their pets and servants. So much for the 'appropriate' cases but we're talking about those who were victims of the mighty dollar!

      July 6, 2011 at 00:23 | Report abuse |
    • DerekM117

      Do us MDs and our "pets and servants" and just take care of yourself when you get sick. You can do just as well, right?

      July 6, 2011 at 01:04 | Report abuse |
    • fiskenmann

      In a lot of cases, a patient can take care of themselves. Now if you want to talk about medication abuse, look no further than the abuse upon the elderly.

      July 6, 2011 at 01:15 | Report abuse |
    • Jesus

      I know a Doc who told me around November that he had to get a number of these done before Christmas so he could fly the family for a two week Aruba vacation. Hid comment was, "they're like chicken soup, they can't hurt and may help".

      July 6, 2011 at 07:35 | Report abuse |
    • surgeon

      Almost every surgeon will tell you that those stents don't work well after several years whether that be in the leg (PAD) or heart (CAD). They get clogged and then make bypass harder. Most medical students know this as well. What frustrates me is that the cardiologist should not be treating ordinary angina with these stents. That should be reserved for emergencies.

      I would actually argue that it is fraud and lacking in informed consent. They often tell the patients that they will just clean up the "pipes." What they don't do is provide the risks, benefits, and alternative therapies (CABG aka a bypass).

      July 6, 2011 at 08:53 | Report abuse |
    • Karen

      I can tell you after many years in a cath lab as a nurse that I have seen 20 percent blockages stented because the doctor wanted to.

      July 6, 2011 at 08:56 | Report abuse |
    • Dan

      A friend of mine who works in nuclear medicine said that hospitals just like any other business are in the business of separating your money from you. Every possible test that the insurance co will pay for is run(your co-pay and deductible included) to maximize their revenue. Many medical treatments are often based on profit potential and not in the best interests of the patient.

      July 6, 2011 at 09:29 | Report abuse |
  2. Smee

    Doctors ordering unnecessary and costly procedures? Surely you jest!

    July 5, 2011 at 22:55 | Report abuse | Reply
    • DRJ

      I hate these studies they put Drs in a fix.
      What if you don't recommend it and someone drops dead? Do you think the family will think twice before suing?

      July 6, 2011 at 00:22 | Report abuse |
    • kieran

      I'm a Physician – I see 'Unecessary Procedures" done by Physicians and hospitals for financial gain EVERY day. Practicising evidenced based medicine is an anethma in the US. Its all about the $$. Knee surgery is another absurd cash cow that is largely unecessary.

      July 6, 2011 at 04:02 | Report abuse |
    • Jesus

      I am good friends with an ortho Doc. Contrary to what two other Docs told me, he said that knee replacement surgery had more downside for me than upside. That was 5 years ago. My knee has deteriorated, but not so significantly that I can't live with it. I am approaching 70 and do certain conservative exercises to strengthen the muscles around the knee. My guess is that my bad knee will accompany me to my death, but without surgery.

      July 6, 2011 at 07:40 | Report abuse |
  3. doctor bill

    now why would a doctor do an unnecessary and expensive procedure? its not like they benefit from it or anything. oh wait.. they do! doctors can pretty do any procedure that could possibly pertain to the patients condition. thats how they make money so why are people shocked to find this out? ignorance in america..

    July 5, 2011 at 23:15 | Report abuse | Reply
    • Jesus

      If we didn't have a "for profit" healthcare system, this abuse would significantly be reduced.

      July 6, 2011 at 07:41 | Report abuse |
  4. lotslove

    my dad had a heart attack and never received any medical treatment. he would have had this procedure if he had gone to the emergency room. he went to a walk in clinic two days after and was referred to a cardiologist- has never had anything but stress tests. he's 74 and doing great and very happy to have not had inappropriate surgery

    July 5, 2011 at 23:32 | Report abuse | Reply
    • Smee

      Does he put nachos in his nose?

      July 5, 2011 at 23:57 | Report abuse |
  5. David B.

    Even worse is the huge number of unnecessary coronary bypass operations. That makes the angioplasty business look like small potatoes.

    July 6, 2011 at 00:18 | Report abuse | Reply
  6. DRJ

    Or unnessesary visits to eye dr for Glaucoma. Recommended tome interval is 12 months but eye Drs want to "check" eye pressure every 3-4 months! Now that's a big B S

    July 6, 2011 at 00:25 | Report abuse | Reply
  7. bill

    I'm sorry, I just read the JAMA article, available online. The conclusions of the article and the nethods are not what was described above. The conclusion was that 11% in the nonacute setting were inappropriate, not up to 50%. 38% were uncertain, and that has to do with the appropriateness criteria. However, that is very different from saying up to 50% were unecessary. Anyone with even a basic understanding of statistics knows that these are two very different statements. I wonder if the writer of the above article even read the research or just skimmed the abstract. I also wonder what his medical training is. I don't know about you, but I prefer my medical advice coming from a physician, and not a journalist.

    As far as the financial reimbursement for a physician, the fee for an angioplasty has been cut so much over the years, that it is no longer "profitable" to perform them. The reimbursement is so low now that it does not cover the cost of medical liability, office staff overhead in regards to paperwork and reimbursement, and physician time.

    As far as privately insured, there is perhaps another reason as well. Following an angioplasty, the patient needs to be discharged on Plavix or Effient. If they cannot afford this medication, and it is expensive, and the patient does not take it, the stent may thrombose, and that would lead to a heart attack, 50% of the time which is fatal. So once again, a different reason all together.

    It would seem to me that this is a complex issue and discussion is good. However, CNN, NBC, ABC et al should not be the final say.

    July 6, 2011 at 00:35 | Report abuse | Reply
    • MT

      You should re-read the article above. It says that 12% of the non-acute were considered inappropriate, not 50%, like you said. You have it backwards.

      July 6, 2011 at 02:13 | Report abuse |
    • Mike

      The very first sentence smacks of sensationalism. Half of all angioplasties performed may be unecessary. That is not what the research conclusion is. The research conclusion is 11% are inappropriate. Far different. There is no arguing for stable angina based on Courage trial medical therapy is first line. But we also know 1/3 of patients in that trial despite very aggressive medical therapy needed a stent within one year.

      And when did chest pain not become a reason to treat? If we are only talking symptoms then let's eliminate knee replacement, cataract, most back surgeries etc. These are not life threatening conditions and having invalid blind people is less strain on the Medicare dollar. However I suspect most of you would prefer to be able to see and walk. So again I ask when did quality of life not become important?

      July 6, 2011 at 08:43 | Report abuse |
  8. WF

    I'm a doctor. This is a problem, particularly at private hospitals. Both the hospital and pharmaceutical companies pressure physicians to err on the side of intervention when a more conservative route is what you would send your dad for. A trial of medical therapy should be given prior to PCI. The fee for service model (among other things) should be scrapped, as it promotes inappropriate behavior. To be clear, this article is referring only to stable angina...Not the acute heart attack (ACS), where PCI is clearly beneficial.

    July 6, 2011 at 00:35 | Report abuse | Reply
  9. Cathhead

    In the 25+ years of cathlab work, all in major hospitals performing all aspects of cardiac care, there have certainly been noticable dents in respectible presentation of necessity for treatment; both by physicians, drug/device manufacturers, hospital administrations wanting to be on the cutting edge, and personnel like myself that inappropriately induce the culture of need on the masses of uninformed patients who rely on us to be truthful and forthcoming in their time of need. This culture is owned by all of the above involved, and driven by reimbursement levels set through the DRG applied by Medicare/medicaid. If one is having an acute/STEMI situatuion, thats one thing-you need intervention and you need it now (time means heart muscle-dead meat don't beat). Otherwise, inform yourself and get a second, even a third opinion regarding your condition. A cath is for the most part easier or as easy on the body and soul as a dentist visit, the recovery time runs a little longer. So lets not run down a potentially life saving procedure en masse without looking closely at the numbers as all abstracts can be manipulated to fulfill one's need and are regularly done so. Keywords: Be informed.

    July 6, 2011 at 01:34 | Report abuse | Reply
  10. HAP

    The criteria may be debatable, but no doubt more caths are done than absolutely necessary, when viewed retrospectively. And is is also true the cornerstone of therapy for CAD is diet and exercise, regardless of the need for more invasive treatments, such as PCI and CABG. However, the reality is only a minority of patients will successfully follow the strict medical regimes as is seen in Dr. Ornish's studies. There are risks to any treatment, both to the health of the patient as well as liability. A physician makes the best judgements they can in the setting of incomplete information. If the outcome were known beforehand, such decisions would be easy. However the retrospective nature of the study is not true to the clinical decision making setting. What the question comes down to is a patient, would you gamble on the criteria being correct, or would you prefer your cardiologist to err on the side of treatment? At what point are you comfortable not being treated? If there is only a 50% chance you need a stent? 20%? 2%?

    As a disclaimer, I'm a physician, but not a cardiologist and don't do cardiac angio or stents. I do tell of diet and exercise to my patients, and it echos in the void, so to speak, and thereby have no great confidence such treatment plans are followed to any great extent.

    July 6, 2011 at 01:45 | Report abuse | Reply
    • Brenda

      Don't forget the fact if they miss one single person who has a subsequent heart attack the lawyers swoop in for the kill. Its tort reform we need.

      July 6, 2011 at 01:57 | Report abuse |
  11. Brenda

    Until you can force TORT REFORM through congress you will always have over utilization. Why?? Because if you miss something as a doctor your life is ruined by a lawyer. Yes that's right, every cardiologist knows someone who was sued because they didn't cath someone then that person had a heart attack a month later....and out come the lawyers...all lined up to sue for 2 million (of which, by the way, the person "injured" gets very little).

    July 6, 2011 at 01:53 | Report abuse | Reply
  12. Brenda

    Why do doctors order so many lab tests...because if they miss anything, no matter how small, a lawyer destroys their family, their medical practice, and their ability to have reasonable medical insurance. Its the lawyers fault we have over utilization. That is why people with pneumonia get 2 or 3 x-rays. its because 1 in 100 "pneumonias" is actually lung cancer and if the family doctor misses it, they are unemployable/uninsurable after the lawyer gets done with their wallet biopsy. The lawyers have destroyed this country.

    July 6, 2011 at 01:56 | Report abuse | Reply
  13. Janet

    tell me about it! I had one done and almost died on the table when my artery reopened... then two weeks or more with a hematoma the size of a watermelon (or bigger) and the pain that goes with it- all that and my "coronary artery disease" wasn't as bad as they thought, or enough to get a stent. Never again!

    July 6, 2011 at 03:06 | Report abuse | Reply
  14. Judith

    I would say that almost all of those 12% of uneeded procedures were done to relieve pain and if you have suffered chronic pain due to a heart condition you are darn well pleased that they did the procedure. The alternative is to leave it and like me you will probably end up having to have all or part of your aorta replaced.

    July 6, 2011 at 04:32 | Report abuse | Reply
  15. Butters

    the data in this thread suggests it's likely more rewarding to be a vet than to take care of piggies like yourselves – drs hating on drs and 5 times over restating the obvious? are you guys the phd variety? or the optometrists?

    July 6, 2011 at 06:37 | Report abuse | Reply
  16. Watchful Eye

    The decision by J&J to get out of the stent business solely because it is no longer as profitable as it once was speaks to the issue. PCI and stents have been over utilized for a long time. Please perform the same study for years in which hospitals and companies made billions from PCI and coronary stents, only to find the patients undergoing cardiac bypass surgery within months of those costly procedures. Would the patients have been better served by going directly to surgery?

    July 6, 2011 at 06:40 | Report abuse | Reply
  17. clarke

    This is not a big surprise here. Doing sleep studies is another one., want is ever in, they all get on the band wagon. It is pretty sad. It is all for the money and then someone gets paid to do a study. Everyone one gets a piece of the pie.

    July 6, 2011 at 07:38 | Report abuse | Reply
  18. asgardshill

    All I know is, my cardiologist told me that I would curl up my toes and die from an MI within 6 months if I didn't have two stents put into my coronary arteries immediately – this was 3 years ago. Then they couldn't put in either of the darned things because the blockage was too pronounced to shove them in there. So, 3 years later, with the help of my friends isosorbide mononitrate and sublingual nitroglycerin, I work at a physical job full-time, walk 3 miles a day, and lift weights. If this is death, I'll have more please.

    July 6, 2011 at 09:51 | Report abuse | Reply
  19. truth be told

    The truth is that the public has been brainwashed by the medical profession. It nauseates me to hear cardiologists and nurses telling patients that they will "fix" the artery with angioplasty, often even before they know if a narrowing exists. There is generally little or no discussion about other treatment options, what the risks are not only of the procedure but of the commitment to two platelet inhibitors long term, and there is almost never a discussion about long term risk of radiation. It is high time the media caught up to this story and keeps the public aware of the facts. As a practising cardiologist, I strongly recommend unbiased second opinions from cardiologists who do not stand to gain financially before undergoing elective angioplasty, and do not get talked into "while we're there we may as well fix it" if you have stable symptoms. Unless you are in the middle of a heart attack there is no urgency to the situation, and there is always time to consider your options.

    July 6, 2011 at 09:51 | Report abuse | Reply
  20. geoz

    Educating doctors costs them too much. And then everybody wants to take a gouge at the sick. But if we made health care universal, supposedly THAT would be bad. No one wants to compare the two scenarios, they just want to scream socialism and keep their piece of the pie.

    July 6, 2011 at 09:52 | Report abuse | Reply
  21. Fuzzycop

    Wow! It's rare to see a person from the medical industry say something like this, but it's also good to see someone admit it!

    (Jneid calls this “troubling” and says it suggests that some patients are being pushed into procedures for the financial benefit of doctors or hospitals. “You hate to say that, but it’s a possibility.”)

    July 6, 2011 at 10:04 | Report abuse | Reply
    • Fuzzycop

      It confirms what we've all known for a long time.

      July 6, 2011 at 10:04 | Report abuse |
  22. victorcamp

    Though the study's recommendations apply to non-emergency procedures, angioplasty might have saved me from 10 years of "heartburn', and the hundreds of meds I took for it. The last bout of heartburn I had was the morning of December 29, 2005, when I stopped in at an emergency room to seek relief. For the third time in two weeks it had been accompanied by "weak" arms that felt like dangling strands of spaghetti. When I described these symptoms to the woman behind the counter, I've never seen I group of people move so fast!
    Within seconds, I was on a table in back, with wires attached. A blood test quickly showed it was a heart attack. Totally unsuspected by me, the third in two weeks!
    The angiogram done the next morning showed three strong lines converging, but never meeting. I still have the picture. They did an angioplasty at the same time, and the resulting picture shows all three completing their connection.
    I haven't had heartburn since.

    July 6, 2011 at 10:09 | Report abuse | Reply
  23. stanley glauser

    I am a 20 year to the day survivor of open heart 5 way by pass.....I have read all of the above comments and if you have never experienced either one,where do you come off by stating your uncivilized and baseless opinion.I have had up to 15 interventions also..........Thank G-d for all of the doctors along the way...............Why because I am here to resond in living color ...........Instead of 6 feet under.......................

    July 6, 2011 at 10:20 | Report abuse | Reply
  24. CrystenJ

    I've read a great deal lately, on the benefits of CoQ10, on improvement of heart conditions. Everything I've read indicates this coenzyme is absolutely necessary in proper cell function, especially in the heart muscle. We apparently lose up to half of the naturally occurring CoQ10 in our bodies by age 50. It has no adverse side effects or known level of toxicity. It's been recommended to cardiac patients for years and it also increases metabolism and helps your body burn fat more effectively. In other words, it can only help and it can't hurt! I don't have heart issues yet but I've had two friends in their mid-40's drop dead of heart attacks in the last couple of years. I want to do anything I can to prevent that from happening to me!

    July 6, 2011 at 11:45 | Report abuse | Reply
  25. Maria O

    I work in the healthcare system and really, read all you want, but the big picture is, you still have to weigh the pros and cons. Unfortunately, when you're in the middle of the situation, you tend to be subjective, so you trust the "experts", in this case, the surgeon and the physician. My mother-in-law had angioplasty, was told that she was doing fine and was sent home. My sister-in-law found her face down by the bathroom door, apparently of a cardiac arrest. She was off the nicotine for over 20 years and except for her diabetes caused by a punctured pancreas caused by a previous injury, she was given a clean bill of health for someone at age 74. At least, until she was told that her angina attacks will go away with the stents. The irony of it, we found out years later the hospital was apparently under investigation for unnecessary angioplasty procedures. Go figure.

    July 6, 2011 at 16:13 | Report abuse | Reply
  26. palpitation

    In May of this year I had 2 PCTA's, and 3 days in the hospital. The hospital bill was $115,234.27 and worth every cent.

    July 6, 2011 at 18:37 | Report abuse | Reply
  27. Charles MD

    This stuff goes on all the time, I've seen it up close myself.
    Read "The Great American Heart Hoax" by Michael Ozner MD
    Actually diet trumps stenting.
    Stenting stable CAD does not prevent a heart attack or prolong life.
    We are dealing with a food borne illness.

    July 6, 2011 at 21:40 | Report abuse | Reply
  28. Patti, RN

    I really want to caution those that post these articles and the general public. If you read the complete article that the above is based on, it states 11.6% of stent in stable patients were deemed inappropriate.At most hospitals every stent placed is evaluated by specific criteria to determine the correct treatment. The problem with broad statements is the genral public though educated are not given the whole picture. I have worked in the area where stents are placed over 20 years.Recently a well-educated gentleman came to our hospital in the midst of a life-threatening heart attack. He did not want a stent placed because he had read that they were not effective. He insisted to wait for his wife to come to make the decision though the MD told him he could die and every minute the heart muscle does not get oxygen( due to a bloked artery),death of that muscle can occur. As we often say. time is muscle.

    July 7, 2011 at 14:19 | Report abuse | Reply
  29. Carlos Rodriguez-Fierro MD

    It is appalling to imaging that a doctor will put a patient at risk of death of kidney failure to make a buck. As an intervention Cardiologist we need to do whats best for our patients at all times. We have tools to identify high risk patients. Not all blockages need PCI. I am afraid some are playing a numbers game. Hospitals need to set up protective guidelines to protect patients.

    July 9, 2011 at 08:44 | Report abuse | Reply
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    August 27, 2011 at 10:49 | Report abuse | Reply
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