11 ms·

Surgery for Blocked Arteries Is Often Unwarranted, Researchers Find

168 points by ra7 7y ago

stopadvertising 7y ago
The healthcare system seems to be optimized towards extracting as much money from older people as possible. I just hope we can move the ball forward and try to make it good at healthcare instead by the time I get old.
- Merrill 7y ago
  IIRC about half of medical expenses are incurred in the last 18 months of life. That would be around $1.6 trillion annually.
  - ip26 7y ago
    Google suggests it's about 10% (for the last 12 months)
    - Gustomaximus 7y ago
      A quick google and a few articles seemed to agree E.g. "Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan" https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0174 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....
  - mgarfias 7y ago
    I’m checking out before I get there
    - ineedasername 7y ago
      You can't: As long as you live past 1.5 years, you'll always have a "last 18 months" of your life ;)
      - mgarfias 7y ago
        I meant before I get there as in before the costs to keep me alive go eat the hell up
        ineedasername 7y ago
        But how would you know? You could be a healthy 74-year old and think, "well now is the time, before I go down hill". But you could be cutting off 10 or even 20 years of life in decent health. Or you could wait until you start to get sick, but how would you know it's not just short-term? You could have a case of pneumonia but recover in a month, and again go on for another 10 years. I've seen a fair number of elderly be sick for most of a year and still come out of it: A relative recently passed at 94, but around 86 she had some serious health issues, and her fate was very uncertain. But she beat them, and had another 8 years where she took great joy in seeing multiple great-grand nieces & nephews born, swim in her pool, listen to her read them stories, etc. They were some of her happiest times, but would have never happened if she'd been trying to beat the 18-month decline.
        mgarfias 7y ago
        Because dementia runs in mom's family. Shes getting it and is aware of it, so if I get it I should be aware of it also. At some point its time to pull the plug.
  - prepend 7y ago
    That seems normal since so many people die at the end of their life. You wouldn’t expect expensive, life saving procedures to take place in the middle of people’s lives. Since many don’t succeed those costs pile up and count in your stat. But many do succeed do people’s lives are extended.
- wwweston 7y ago
  On one hand, incentives matter (reward improving care). On the other hand, incentives matter (markets are not known for keeping away from extractive practices). Reward outcomes rather than fee-for-service?
  - Gatsky 7y ago
    This is on the money, it’s all about incentives. In Australia there is a public and a private health system. In public, the surgeons are paid a salary which is the same whether they do 1000 or zero operations. In private they are paid per procedure, with zero salary. The probability of getting an operation is very different for the same condition in public and private.
    - refurb 7y ago
      If you’re paid the same whether you do surgeries or not, wouldn’t that incentivizing not doing surgeries? Less stress and less risk for the doctor.
      - Gatsky 7y ago
        No. Doctors are not bureaucrats. They have a 1 on 1 relationship with a patient and they do want to help them (this fact seems lost on many people). You don’t need to incentivize them to do the right thing, it is more that perverse incentives interfere with how things should be, for example performing pointless revascularizations.
      - ineedasername 7y ago
        Except they aren't necessarily paid more for surgery. That is a common misconception. Surgeries take time. Not just for the surgery, but the prep time before and then the aftermath. -For example, a bit of searching shows an appendectomy takes about an hour. Lets add 1/2 hour onto that for prep & cleanup. -Searching indicated about $900 to $1200 is the typical insurance payment to the surgeon. That's $600 to $800 an hour. -Based on my own insurance claims, specialist visits are reimbursed from $200-$300. Average 10 minutes per visit and that works out to $1200 to $1800 and hour. (Non specialist annual "wellness" checkup/physical was reimbursed around $180 for $1080 an hour) Certainly not all surgeries are necessarily the same, so rates may vary and there could be more or less $/hour, although the same goes for office visits. As such, doctors already are paid roughly similar, or close enough that concerns of pushing surgeries for the $$$ probably don't need to be a huge worry.
- colechristensen 7y ago
  This assumes widespread bad faith, when I think the situation is much different. The healthcare system is biased towards doing something . Patients want there to always be some action taken, and actions are found. Doing nothing seems like giving up.
  - prepend 7y ago
    Patients do want to do something. And the fact that doctors and surgeons and lots of other individuals in healthcare make much more money by doing something means there’s lots of inertia to action, even if it’s not the best or even useful. I think the healthcare provider incentive is a more important factor since there is such a power imbalance. I’ve had numerous elective surgical procedures recommended. When I asked for non-surgical therapies I was told there are none. When I researched I found them and found other healthcare providers. I’m pretty young and healthy so the bias for surgeons to recommend surgery seems really strong. Maybe it’s not sinister and it’s just a coincidence that a surgery costs $10-30k and physical therapy costs $1k to someone other than the person who is recommending.
  - hestipod 7y ago
    I was advised to have surgery I didn't need and it ruined my life. I will be ending it soon because of all the pain and loss and abandonment and not one of them will care or help prevent that outcome because they got paid. Nobody said "do nothing". They all advised surgery. They advised surgery multiple European doctors later said was never needed and wasn't appropriate. Every one of those doctors attacked when confronted about the outcome and necessity...called me a liar and mental and that the pain and disability was not real. They said I was just trying to get a big payday from them. Everything was about protecting their profits. From the moment I was victimized people started blaming me and trying to discredit me. Doctors, staff, their lawyers, administrators. They never admit fault and will cover each other's back. I have met many people like me...victims of this system. American hospitals and doctors operate for profits not as a public service. They don't get their big houses and fancy cars and status without that precious surgery income. It's very much about bad faith in the American Healthcare Business. People don't want to believe it and think because they haven't had their life taken from them that it's great and people like me are extreme outliers. The number THREE cause of death in America is doctors and hospitals killing people. But nobody cares until it's them. Bad faith is part and parcel with for profit anything and healthcare is one of the biggest for profit cabals on them all in America. Anyone who believes otherwise is just preserving their own income stream or sanity because they need to believe the system will be there for them. As long as "other people" are the victims then for most people it's all fine. I had a life...I had a future...I deserve to live safely and without pain...and I am denied this because they stole my health and means to earn. They made my value zero. Bad faith is their mission statement.
- tootie 7y ago
  I think that's not a valid conclusion to draw from this. The stent procedure has been considered the gold standard for quite a while and doctors have not had reason to question it until right now.
  - astura 7y ago
    They had a reason to question it, the evidence of stent overuse has been piling up for at least a decade. https://www.vox.com/science-and-health/2017/11/3/16599072/stent-chest-pain-treatment-angina-not-effective https://www.vox.com/science-and-health/2017/11/3/16599072/st...
carbocation 7y ago
Gina Kolata is a fine scientific writer, but I think that the presentation of the exclusions is a bit too brief and subtle. The main controversy being addressed is whether revascularization in stable disease has benefit. Not heart attack patients. Not people with significant left main coronary artery disease. COURAGE and this trial address that question in different ways. It is addressed in the article, but you kind of are left to draw your own conclusions: > The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery, two situations in which opening arteries with stents can be lifesaving. Instead, the patients had narrowed arteries that were discovered with exercise stress tests. This doesn't at all address the need for revasularization during a heart attack (about which there is universal agreement). It addresses whether revascularizing people not having a heart attack can be helpful.
- vo2maxer 7y ago
  The article in The Washington Post explains it better for the interested reader [1]. There is also this thread with a good discussion [2]. [1] https://www.washingtonpost.com/health/2019/11/16/embargoed-drugs-are-effective-invasive-procedures-patients-with-stable-heart-disease-major-trial-finds/ https://www.washingtonpost.com/health/2019/11/16/embargoed-d... [2] https://twitter.com/rwyeh/status/1194638074765967362?s=21 https://twitter.com/rwyeh/status/1194638074765967362?s=21
- dr_ 7y ago
  True, but that’s pretty much what I took from this article. People with vascular heart disease who have not had an acute coronary event still compromise a significant chunk of the patient population. Many of them still currently receive stents or cabg.
- Dowwie 7y ago
  What brings a cardiology fellow at Mass General to Hacker News? I think it's great that you're here and sharing insight.
  - carbocation 7y ago
Merrill 7y ago
ISCHEMIA: Invasive Strategy No Better Than Meds for CV Events https://www.tctmd.com/news/ischemia-invasive-strategy-no-better-meds-cv-events https://www.tctmd.com/news/ischemia-invasive-strategy-no-bet... I haven't been able to find out what the medical alternative treatment consists of other than changing diet, losing weight, stop smoking, stop drinking, start exercising, taking statins, etc. These are, of course, all good and useful things, but I knew a man who had a quadruple bypass and refused to make any lifestyle changes. Maybe not having a bypass would have focused him on making those changes.
mgarfias 7y ago
I know TFA says for people without chest pain, but I’d be dead without angioplasty + stent.
naringas 7y ago
I think that in general surgery is often unwarranted. surgery should be the absolute last resort.
- chkaloon 7y ago
  I agree. Anything that's not emergent or immediately life saving you should think long and hard about. I had meniscus repair knee surgery in August. Now I have nerve damage that is causing pain in that lower leg. I probably would have been fine and recovered to moderate sports activity without it. My dad had knee replacement surgery at 76, and he never fully recovered from it. If it's at all elective, just say no as a default.
  - astura 7y ago
    Friend of mine went to the doctor after tearing her meniscus. Doctor said she absolutely needed surgery and it won't heal without surgery. She said "thanks but no thanks." It healed on its own.
    - viburnum 7y ago
      They tried to sell me on meniscus surgery too. I saw a PT and he fixed my knees in two weeks with a hamstring stretch (I've since learned that about half the programmers I know have tight hamstrings. It hurts your knees and makes good posture impossible).
      - mattrp 7y ago
        I’ve heard this referred to as programmers syndrome. The tight hamstrings also lead to frequent lower back pain as does the lack of movement. It takes as little as 15 minutes of sitting for your spinal discs to compress. Moving your legs restores the blood flow. Similarly sitting makes it difficult for your heart to pump blood from your feet. And if course there’s the unsightly posture as well. All of which is restored with regular stretches, yoga, etc. I’m no medical professional as I’m sure those who are can tell but these are the things I’ve learned over the years in my own experience. A lot is within our control but I also know a lot of people who have done everything possible from a dietary and exercise standpoint and still need a bypass relatively early in life. I have an in law who was a surgeon himself. He came home one day after work and his wife asks how’d it go today and he said oh not bad I ran a few tests recently and checked myself into the or for a stint. He didn’t bother to tell anyone before and might have not have said anything afterward either. We look at the medical profession largely through the lens of how our insurers and policy makers want us to view medicine. We also see anecdotal information that fools us into thinking one thing when it’s really another. Often times the most analytical minds can forget that it takes quite a bit of study and rigor to reach a valid conclusion. And at the same time we are seeing that the human body is not just one thing but billions of cells and bacteria that are as different from person to person as fingerprints are unique to the individual. What disturbs me most about these articles is that they very subtly shape the mindsets and opinions we hold to be skeptical of surgery in general and to be skeptical of surgeries late in life as luxuries of a bygone era unfit for today’s ideal lifestyle of personal discipline and pious austerity. As far as I’m concerned we haven’t yet scratched the surface of what’s possible to extend life to 100 or even 200 or beyond. And what a fantastic exploration that would be - equally as rewarding as becoming an interplanetary species. Sadly the current mindset seems to be reverting to an age where 45 was old and 55 was an ideal time to die and just think of the cost savings windfall we’d have if everyone were to agree.
throwawaysea 7y ago
Note that the article says bypass surgeries and stents are still considered life saving for heart attacks and main coronary blockages but likely unnecessary otherwise, since the outcomes for drug regimens and improved lifestyles are just as good for those other cases. Furthermore the doubt cast on drug/lifestyle regimens (they patients won’t stick to it) is also called out here as false since the drug regimen for stents can be more intensive. My additional take away is that it is good for people to maintain healthy skepticism about our medical system, its incentives, and the accuracy of our current knowledge.
- ineedasername 7y ago
  I think it's more the lifestyle choices than the medications that are the difficult things to stick with, regardless of surgery/non-surgery pathway. A few pills in the morning is nothing compared to the continuous discipline needed to stick to both an exercise regime and major diet changes.
dang 7y ago
http://archive.is/B6WME http://archive.is/B6WME
omegaworks 7y ago
> The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery NYT's anti-Sanders bias is evident, crude and largely irrelevant to the point the author is trying to make. Why even include his name in this article without mentioning his Medicare for All plan that would help 27.5 million[1] uninsured people get the access to healthcare they need. Why mention his name and not mention the 45,000 preventable deaths every year that occur due to lack of insurance[2]? At least make the minimum effort and connect how this evidence should factor into how we approach care and control costs under a universal system. 1. https://www.wsj.com/articles/number-of-americans-without-insurance-shows-first-increase-since2008-11568128381 https://www.wsj.com/articles/number-of-americans-without-ins... 2. https://news.harvard.edu/gazette/story/2009/09/new-study-finds-45000-deaths-annually-linked-to-lack-of-health-coverage/ https://news.harvard.edu/gazette/story/2009/09/new-study-fin...
anonu 7y ago
I remember an interesting anecdote (maybe from a Malcolm Gladwell book or freakonomics) that on days when there were big heart conferences, deaths from cardiac related causes dropped. The implication was that cardiac doctors are all at these conferences so they can't order invasive procedures which their patients may not need. When all you have is a hammer, everything looks like a nail. Edit: the original study https://www.ahajournals.org/doi/10.1161/JAHA.117.008230 https://www.ahajournals.org/doi/10.1161/JAHA.117.008230
- TylerE 7y ago
  That's lying with statistics. What matters isn't the daily death rate, but life expectancy. If a procedure has a 10% chance of killing you, and a 90% chance of extending your life by 30%, it's a net win.
  - Retric 7y ago
    That doesn’t always mean you should have the surgery any time soon. Suppose that surgery can be put off for 10 years without any loss of effectiveness or short term risk of death. Now you’re going to wait even if it’s eventually a good idea. Some people that either have the surgery or waited are killed off by other issues, making the waiting group have a higher expected life expectancy overall. That’s just one example where seemingly useful treatments are less useful than initially assumed.
    - raverbashing 7y ago
      Or 10 years later the surgery is seen as less or more effective, or a better version of it is developed.
  - perl4ever 7y ago
    "If a procedure has a 10% chance of killing you, and a 90% chance of extending your life by 30%, it's a net win." I think it obviously depends on the specific probabilities and your current life expectancy, not to mention whether you are risk averse when it comes to the possiblity of immediate death. For me, based on actuarial tables, I should expect to live for 36 years more. So the net expected gain with your example numbers is (0.9 * 10.8) - (0.1 * 36) = 6.1 years more. So that's a net benefit of ~17%, at a significant risk of dying right now. If it was normal to like that kind of deal, why would we buy insurance? Also, there's something fishy about the problem statement in the first place, because a successful operation doesn't extend your life by 30%, unless nothing else was going to kill you before your originally anticipated lifespan.
viburnum 7y ago
All surgery is risky, especially for old people. The stent thing seems a lot like the spinal fusion scam.
- tootie 7y ago
  The stent procedure is so popular because it's a very simple procedure. The stent can be threaded through an arm vein and inflated near the blockage. Recovery is minimal.
wrkronmiller 7y ago
Not to distract too much from the main takeaways, but I found this tangent very strange: > The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery, In context it sounds like the author is basically saying this study has nothing to do with a politician. Okay, so why bring it up?
- pmiller2 7y ago
  Because Sen. Sanders had the exact surgery the article is talking about.
  - wrkronmiller 7y ago
    Ah, okay, that makes a lot more sense now.
droithomme 7y ago
Stenting costs an average of $25,000 per patient; bypass surgery costs an average of $45,000 in the United States. The nation could save more than $775 million a year by not giving stents to the 31,000 patients who get the devices even though they have no chest pain.
- Tharkun 7y ago
  How much are the drugs? Probably not free. And they may have to be taken for the rest of the patient's life. That could add up.
vincentlee 7y ago
who cares? dont eat shit, dont die. its like the exact opposite of eat shit and die
Medicalidiot 7y ago
Alteplase is vastly inferior to stents according to current algorithms. Unless there's a novel approach the revascularition that has occured in the past month I didn't hear about, I'm skeptical that this isn't some type of p hacking. I can't read the article because it's behind a paywall.
- mrestko 7y ago
  That's not what the study it's about. If you can't be bothered or are not able to read the article, why would you feel compelled to comment?
WheelsAtLarge 7y ago
This is good news but my first thought was that it takes discipline to change a lifetime of bad habits. Are people really going to change their lives and adopt a new way of living and eating? I dought that it will happen. I suspect that surgery is still the best option for most people.
known 7y ago
"I want to go when I want. It is tasteless to prolong life artificially; I have done my share, it is time to go. I will do it elegantly" --Einstein

168 points by ra7 7y ago

The healthcare system seems to be optimized towards extracting as much money from older people as possible. I just hope we can move the ball forward and try to make it good at healthcare instead by the time I get old.

Merrill 7y ago
IIRC about half of medical expenses are incurred in the last 18 months of life. That would be around $1.6 trillion annually.
- ip26 7y ago
  Google suggests it's about 10% (for the last 12 months)
  - Gustomaximus 7y ago
    A quick google and a few articles seemed to agree E.g. "Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan" https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0174 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....
- mgarfias 7y ago
  I’m checking out before I get there
  - ineedasername 7y ago
    You can't: As long as you live past 1.5 years, you'll always have a "last 18 months" of your life ;)
    - mgarfias 7y ago
      I meant before I get there as in before the costs to keep me alive go eat the hell up
      - ineedasername 7y ago
        But how would you know? You could be a healthy 74-year old and think, "well now is the time, before I go down hill". But you could be cutting off 10 or even 20 years of life in decent health. Or you could wait until you start to get sick, but how would you know it's not just short-term? You could have a case of pneumonia but recover in a month, and again go on for another 10 years. I've seen a fair number of elderly be sick for most of a year and still come out of it: A relative recently passed at 94, but around 86 she had some serious health issues, and her fate was very uncertain. But she beat them, and had another 8 years where she took great joy in seeing multiple great-grand nieces & nephews born, swim in her pool, listen to her read them stories, etc. They were some of her happiest times, but would have never happened if she'd been trying to beat the 18-month decline.
        mgarfias 7y ago
        Because dementia runs in mom's family. Shes getting it and is aware of it, so if I get it I should be aware of it also. At some point its time to pull the plug.
- prepend 7y ago
  That seems normal since so many people die at the end of their life. You wouldn’t expect expensive, life saving procedures to take place in the middle of people’s lives. Since many don’t succeed those costs pile up and count in your stat. But many do succeed do people’s lives are extended.
wwweston 7y ago
On one hand, incentives matter (reward improving care). On the other hand, incentives matter (markets are not known for keeping away from extractive practices). Reward outcomes rather than fee-for-service?
- Gatsky 7y ago
  This is on the money, it’s all about incentives. In Australia there is a public and a private health system. In public, the surgeons are paid a salary which is the same whether they do 1000 or zero operations. In private they are paid per procedure, with zero salary. The probability of getting an operation is very different for the same condition in public and private.
  - refurb 7y ago
    If you’re paid the same whether you do surgeries or not, wouldn’t that incentivizing not doing surgeries? Less stress and less risk for the doctor.
    - Gatsky 7y ago
      No. Doctors are not bureaucrats. They have a 1 on 1 relationship with a patient and they do want to help them (this fact seems lost on many people). You don’t need to incentivize them to do the right thing, it is more that perverse incentives interfere with how things should be, for example performing pointless revascularizations.
    - ineedasername 7y ago
      Except they aren't necessarily paid more for surgery. That is a common misconception. Surgeries take time. Not just for the surgery, but the prep time before and then the aftermath. -For example, a bit of searching shows an appendectomy takes about an hour. Lets add 1/2 hour onto that for prep & cleanup. -Searching indicated about $900 to $1200 is the typical insurance payment to the surgeon. That's $600 to $800 an hour. -Based on my own insurance claims, specialist visits are reimbursed from $200-$300. Average 10 minutes per visit and that works out to $1200 to $1800 and hour. (Non specialist annual "wellness" checkup/physical was reimbursed around $180 for $1080 an hour) Certainly not all surgeries are necessarily the same, so rates may vary and there could be more or less $/hour, although the same goes for office visits. As such, doctors already are paid roughly similar, or close enough that concerns of pushing surgeries for the $$$ probably don't need to be a huge worry.
colechristensen 7y ago
This assumes widespread bad faith, when I think the situation is much different. The healthcare system is biased towards doing something . Patients want there to always be some action taken, and actions are found. Doing nothing seems like giving up.
- prepend 7y ago
  Patients do want to do something. And the fact that doctors and surgeons and lots of other individuals in healthcare make much more money by doing something means there’s lots of inertia to action, even if it’s not the best or even useful. I think the healthcare provider incentive is a more important factor since there is such a power imbalance. I’ve had numerous elective surgical procedures recommended. When I asked for non-surgical therapies I was told there are none. When I researched I found them and found other healthcare providers. I’m pretty young and healthy so the bias for surgeons to recommend surgery seems really strong. Maybe it’s not sinister and it’s just a coincidence that a surgery costs $10-30k and physical therapy costs $1k to someone other than the person who is recommending.
- hestipod 7y ago
  I was advised to have surgery I didn't need and it ruined my life. I will be ending it soon because of all the pain and loss and abandonment and not one of them will care or help prevent that outcome because they got paid. Nobody said "do nothing". They all advised surgery. They advised surgery multiple European doctors later said was never needed and wasn't appropriate. Every one of those doctors attacked when confronted about the outcome and necessity...called me a liar and mental and that the pain and disability was not real. They said I was just trying to get a big payday from them. Everything was about protecting their profits. From the moment I was victimized people started blaming me and trying to discredit me. Doctors, staff, their lawyers, administrators. They never admit fault and will cover each other's back. I have met many people like me...victims of this system. American hospitals and doctors operate for profits not as a public service. They don't get their big houses and fancy cars and status without that precious surgery income. It's very much about bad faith in the American Healthcare Business. People don't want to believe it and think because they haven't had their life taken from them that it's great and people like me are extreme outliers. The number THREE cause of death in America is doctors and hospitals killing people. But nobody cares until it's them. Bad faith is part and parcel with for profit anything and healthcare is one of the biggest for profit cabals on them all in America. Anyone who believes otherwise is just preserving their own income stream or sanity because they need to believe the system will be there for them. As long as "other people" are the victims then for most people it's all fine. I had a life...I had a future...I deserve to live safely and without pain...and I am denied this because they stole my health and means to earn. They made my value zero. Bad faith is their mission statement.
tootie 7y ago
I think that's not a valid conclusion to draw from this. The stent procedure has been considered the gold standard for quite a while and doctors have not had reason to question it until right now.
- astura 7y ago
  They had a reason to question it, the evidence of stent overuse has been piling up for at least a decade. https://www.vox.com/science-and-health/2017/11/3/16599072/stent-chest-pain-treatment-angina-not-effective https://www.vox.com/science-and-health/2017/11/3/16599072/st...

carbocation 7y ago

Gina Kolata is a fine scientific writer, but I think that the presentation of the exclusions is a bit too brief and subtle. The main controversy being addressed is whether revascularization in stable disease has benefit. Not heart attack patients. Not people with significant left main coronary artery disease. COURAGE and this trial address that question in different ways. It is addressed in the article, but you kind of are left to draw your own conclusions: > The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery, two situations in which opening arteries with stents can be lifesaving. Instead, the patients had narrowed arteries that were discovered with exercise stress tests. This doesn't at all address the need for revasularization during a heart attack (about which there is universal agreement). It addresses whether revascularizing people not having a heart attack can be helpful.

vo2maxer 7y ago
The article in The Washington Post explains it better for the interested reader [1]. There is also this thread with a good discussion [2]. [1] https://www.washingtonpost.com/health/2019/11/16/embargoed-drugs-are-effective-invasive-procedures-patients-with-stable-heart-disease-major-trial-finds/ https://www.washingtonpost.com/health/2019/11/16/embargoed-d... [2] https://twitter.com/rwyeh/status/1194638074765967362?s=21 https://twitter.com/rwyeh/status/1194638074765967362?s=21
dr_ 7y ago
True, but that’s pretty much what I took from this article. People with vascular heart disease who have not had an acute coronary event still compromise a significant chunk of the patient population. Many of them still currently receive stents or cabg.
Dowwie 7y ago
What brings a cardiology fellow at Mass General to Hacker News? I think it's great that you're here and sharing insight.
- carbocation 7y ago

Merrill 7y ago

ISCHEMIA: Invasive Strategy No Better Than Meds for CV Events https://www.tctmd.com/news/ischemia-invasive-strategy-no-better-meds-cv-events https://www.tctmd.com/news/ischemia-invasive-strategy-no-bet... I haven't been able to find out what the medical alternative treatment consists of other than changing diet, losing weight, stop smoking, stop drinking, start exercising, taking statins, etc. These are, of course, all good and useful things, but I knew a man who had a quadruple bypass and refused to make any lifestyle changes. Maybe not having a bypass would have focused him on making those changes.

mgarfias 7y ago

I know TFA says for people without chest pain, but I’d be dead without angioplasty + stent.

naringas 7y ago

I think that in general surgery is often unwarranted. surgery should be the absolute last resort.

chkaloon 7y ago
I agree. Anything that's not emergent or immediately life saving you should think long and hard about. I had meniscus repair knee surgery in August. Now I have nerve damage that is causing pain in that lower leg. I probably would have been fine and recovered to moderate sports activity without it. My dad had knee replacement surgery at 76, and he never fully recovered from it. If it's at all elective, just say no as a default.
- astura 7y ago
  Friend of mine went to the doctor after tearing her meniscus. Doctor said she absolutely needed surgery and it won't heal without surgery. She said "thanks but no thanks." It healed on its own.
  - viburnum 7y ago
    They tried to sell me on meniscus surgery too. I saw a PT and he fixed my knees in two weeks with a hamstring stretch (I've since learned that about half the programmers I know have tight hamstrings. It hurts your knees and makes good posture impossible).
    - mattrp 7y ago
      I’ve heard this referred to as programmers syndrome. The tight hamstrings also lead to frequent lower back pain as does the lack of movement. It takes as little as 15 minutes of sitting for your spinal discs to compress. Moving your legs restores the blood flow. Similarly sitting makes it difficult for your heart to pump blood from your feet. And if course there’s the unsightly posture as well. All of which is restored with regular stretches, yoga, etc. I’m no medical professional as I’m sure those who are can tell but these are the things I’ve learned over the years in my own experience. A lot is within our control but I also know a lot of people who have done everything possible from a dietary and exercise standpoint and still need a bypass relatively early in life. I have an in law who was a surgeon himself. He came home one day after work and his wife asks how’d it go today and he said oh not bad I ran a few tests recently and checked myself into the or for a stint. He didn’t bother to tell anyone before and might have not have said anything afterward either. We look at the medical profession largely through the lens of how our insurers and policy makers want us to view medicine. We also see anecdotal information that fools us into thinking one thing when it’s really another. Often times the most analytical minds can forget that it takes quite a bit of study and rigor to reach a valid conclusion. And at the same time we are seeing that the human body is not just one thing but billions of cells and bacteria that are as different from person to person as fingerprints are unique to the individual. What disturbs me most about these articles is that they very subtly shape the mindsets and opinions we hold to be skeptical of surgery in general and to be skeptical of surgeries late in life as luxuries of a bygone era unfit for today’s ideal lifestyle of personal discipline and pious austerity. As far as I’m concerned we haven’t yet scratched the surface of what’s possible to extend life to 100 or even 200 or beyond. And what a fantastic exploration that would be - equally as rewarding as becoming an interplanetary species. Sadly the current mindset seems to be reverting to an age where 45 was old and 55 was an ideal time to die and just think of the cost savings windfall we’d have if everyone were to agree.

throwawaysea 7y ago

Note that the article says bypass surgeries and stents are still considered life saving for heart attacks and main coronary blockages but likely unnecessary otherwise, since the outcomes for drug regimens and improved lifestyles are just as good for those other cases. Furthermore the doubt cast on drug/lifestyle regimens (they patients won’t stick to it) is also called out here as false since the drug regimen for stents can be more intensive. My additional take away is that it is good for people to maintain healthy skepticism about our medical system, its incentives, and the accuracy of our current knowledge.

ineedasername 7y ago
I think it's more the lifestyle choices than the medications that are the difficult things to stick with, regardless of surgery/non-surgery pathway. A few pills in the morning is nothing compared to the continuous discipline needed to stick to both an exercise regime and major diet changes.

dang 7y ago

http://archive.is/B6WME http://archive.is/B6WME

omegaworks 7y ago

> The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery NYT's anti-Sanders bias is evident, crude and largely irrelevant to the point the author is trying to make. Why even include his name in this article without mentioning his Medicare for All plan that would help 27.5 million[1] uninsured people get the access to healthcare they need. Why mention his name and not mention the 45,000 preventable deaths every year that occur due to lack of insurance[2]? At least make the minimum effort and connect how this evidence should factor into how we approach care and control costs under a universal system. 1. https://www.wsj.com/articles/number-of-americans-without-insurance-shows-first-increase-since2008-11568128381 https://www.wsj.com/articles/number-of-americans-without-ins... 2. https://news.harvard.edu/gazette/story/2009/09/new-study-finds-45000-deaths-annually-linked-to-lack-of-health-coverage/ https://news.harvard.edu/gazette/story/2009/09/new-study-fin...

anonu 7y ago

I remember an interesting anecdote (maybe from a Malcolm Gladwell book or freakonomics) that on days when there were big heart conferences, deaths from cardiac related causes dropped. The implication was that cardiac doctors are all at these conferences so they can't order invasive procedures which their patients may not need. When all you have is a hammer, everything looks like a nail. Edit: the original study https://www.ahajournals.org/doi/10.1161/JAHA.117.008230 https://www.ahajournals.org/doi/10.1161/JAHA.117.008230

TylerE 7y ago
That's lying with statistics. What matters isn't the daily death rate, but life expectancy. If a procedure has a 10% chance of killing you, and a 90% chance of extending your life by 30%, it's a net win.
- Retric 7y ago
  That doesn’t always mean you should have the surgery any time soon. Suppose that surgery can be put off for 10 years without any loss of effectiveness or short term risk of death. Now you’re going to wait even if it’s eventually a good idea. Some people that either have the surgery or waited are killed off by other issues, making the waiting group have a higher expected life expectancy overall. That’s just one example where seemingly useful treatments are less useful than initially assumed.
  - raverbashing 7y ago
    Or 10 years later the surgery is seen as less or more effective, or a better version of it is developed.
- perl4ever 7y ago
  "If a procedure has a 10% chance of killing you, and a 90% chance of extending your life by 30%, it's a net win." I think it obviously depends on the specific probabilities and your current life expectancy, not to mention whether you are risk averse when it comes to the possiblity of immediate death. For me, based on actuarial tables, I should expect to live for 36 years more. So the net expected gain with your example numbers is (0.9 * 10.8) - (0.1 * 36) = 6.1 years more. So that's a net benefit of ~17%, at a significant risk of dying right now. If it was normal to like that kind of deal, why would we buy insurance? Also, there's something fishy about the problem statement in the first place, because a successful operation doesn't extend your life by 30%, unless nothing else was going to kill you before your originally anticipated lifespan.

viburnum 7y ago

All surgery is risky, especially for old people. The stent thing seems a lot like the spinal fusion scam.

tootie 7y ago
The stent procedure is so popular because it's a very simple procedure. The stent can be threaded through an arm vein and inflated near the blockage. Recovery is minimal.

wrkronmiller 7y ago

Not to distract too much from the main takeaways, but I found this tangent very strange: > The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery, In context it sounds like the author is basically saying this study has nothing to do with a politician. Okay, so why bring it up?

pmiller2 7y ago
Because Sen. Sanders had the exact surgery the article is talking about.
- wrkronmiller 7y ago
  Ah, okay, that makes a lot more sense now.

droithomme 7y ago

Stenting costs an average of $25,000 per patient; bypass surgery costs an average of $45,000 in the United States. The nation could save more than $775 million a year by not giving stents to the 31,000 patients who get the devices even though they have no chest pain.

Tharkun 7y ago
How much are the drugs? Probably not free. And they may have to be taken for the rest of the patient's life. That could add up.

vincentlee 7y ago

who cares? dont eat shit, dont die. its like the exact opposite of eat shit and die

Medicalidiot 7y ago

Alteplase is vastly inferior to stents according to current algorithms. Unless there's a novel approach the revascularition that has occured in the past month I didn't hear about, I'm skeptical that this isn't some type of p hacking. I can't read the article because it's behind a paywall.

mrestko 7y ago
That's not what the study it's about. If you can't be bothered or are not able to read the article, why would you feel compelled to comment?

WheelsAtLarge 7y ago

This is good news but my first thought was that it takes discipline to change a lifetime of bad habits. Are people really going to change their lives and adopt a new way of living and eating? I dought that it will happen. I suspect that surgery is still the best option for most people.

known 7y ago

"I want to go when I want. It is tasteless to prolong life artificially; I have done my share, it is time to go. I will do it elegantly" --Einstein