During what seemed to have been a routine annual exam last month, former president George W. Bush was taken from the clinic and rushed to a nearby tertiary care hospital, where he had a cardiac scan and an urgent PCI (percutaneous coronary intervention, or angioplasty) which included insertion of a coronary artery stent. At the time, his spokesman stated that Mr. Bush had no symptoms, and his general fitness was obviously excellent, given his well-publicized biking excursion of 60-+ miles. Moreover, a complete medical report in 2006 gave him an excellent rating for overall cardiovascular health.
What was learned over the ensuing days was that the patient (yes, that patient) had been undergoing a cardiac stress test and EKG changes (the exact nature of which have remained private) developed leading to the heart scan and PCI/stent.
How did all this transpire, and did he get the best treatment, or was it an overdose of precaution? What does his experience teach us, if anything?
On bmj.com today, Dr. Aseem Malhotra, a cardiologist at the Royal Free Hospital in London, argues that stenting offers no more benefit than drugs for treating stable coronary artery disease - and asks was George W. Bush aware of the potential harms? The article is part of The BMJ s Too Much Medicine campaign to help tackle the threat to health and the waste of money caused by unnecessary care.
The first question, especially given the hypothetical expressed in Dr. Malhotra s introduction as noted above, is: Did Mr. Bush have stable coronary artery disease? If he had no symptoms, he could not have had stable CAD, the hallmark of which is angina typical chest pain that occurs on exertion or during other predictable stressors and disappears after a short time of rest or with medication. Unstable angina develops when chest pain does not disappear, or becomes more frequent for no reason, or does not respond to usually-effective remedies, such as sub-lingual nitroglycerine. He had nothing of this sort. So why did he have the progenitor test, the stress-test, which propelled him into the system?
It seems likely that he had it because he got what he thought to be VIP care. However, too much of a good thing may not be. Numerous studies, dating back to classics such as 2007 s COURAGE study (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) and 2012 s JAMA meta-analysis have shown that, in patients with chronic, stable angina, PCI and stenting of partially blocked coronary arteries does not improve angina management nor prolong life nor prevent heart attack or stroke, as compared to optimal medical therapy: drugs and lifestyle changes. In fact, last year a group of medical societies, including the American College of Cardiology, coalesced to promote the concept of Choosing Wisely, whose goal is to educate both patients and physicians about how to avoid overused medical tests. Here s what they said about routine heart studies:
- Don t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
- Don t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
A group of Harvard Medical School cardiologists summed up the approach to performing PCI in patients with minimal or stable CAD:
There are only two reasons for undergoing any treatment: to feel better or to live longer. If you aren t having chest pain or other symptoms, angioplasty to open a narrowed artery can t make you feel any better. And the results of COURAGE and other studies show it won t help you live any longer.
ACSH s Dr. Gilbert Ross summarized the G.W. Bush situation thusly: Mr. Bush did not, apparently, have any reason to undergo a cardiac stress test, other than his doctors flawed reasoning to do everything possible to protect his health (my words). But did they? Would Mr. Bush have continued to do perfectly well in his active life if he had taken a pass on that stress test, and just continued to have regular check-ups focusing on real problems with a minimum of preventive screenings ? I believe so, and this will hopefully be a lesson for Americans who want to leave no stone unturned, whatever the cost in dollars, or in unintended consequences.
