What is a successful angioplasty?

Against my instincts I got stuck into Lord Winston’s Superdoctors programme on BBC 1 tonight (28/08/08).

Lord Winston comes across as a nice man and watching him with grieving parents, it is obvious that he took the time to go to the ‘bedside manner’ lectures at medical school.

Lord Robert is, of course an infertility expert and not a heart specialist, and it shows. He made the statement that angioplasty is 90% successful. I suspect that he, like most people,assumes that if an operation is 90% successful it means that 90% of people are better off. But that is not what 90% success means in angioplasty terms.

What Professor Winston was talking about was the immediate post operative result and it is certainly true that at the end of 90% of angioplasty procedures the patient is still alive and has a nice looking section of artery where there was previously a narrowing. In other words patients can be confident that their cardiologist will be satisfied with his handiwork 90% of the time. Unfortunately, it tells us nothing about whether the patient is better or worse off. But we do have evidence from large trials.

The recent COURAGE trial that compared angioplasty with good medical treatment in stable angina showed that angioplasty didn’t prevent heart attacks and the minimal improvement in symptoms and quality of life didn’t last. The RITA-2 trial published a decade earlier showed the same result so no-one should be surprised that angioplasty isn’t very successful at treating stable angina compared to good medical treatment. To be clear, the situation is different in heart attacks where research shows that angioplasty does seem to help patients if it is done quickly enough.

Lord Winston made a point of mentioning the importance of the placebo effect. This is where patients feel better even if they receive a dummy treatment. He emphasised the need for studies to make sure the benefits of operations were not simply the placebo effect. It is therefore surprising that he failed to mention that the minimal and temporary benefits of angioplasty could easily be a placebo effect. I guess that the cardiologists he spoke to were too embarrassed to tell him that we have never conducted a placebo controlled study of angioplasty.

Few people know about this but I think they should. When I used to do angioplasty I told patients so they could make an informed decision whether to take the risk or not. I was always struck by how few patients were willing to have angioplasty once they knew these facts.

Fear and Loathing

Several people, who share my views about the misuse of fear to control behaviour in cardiac patients, emailed me about the British Heart Foundation’s (BHF) most recent campaign; “Watch your own heart attack” www.2minutes.org.uk
It is worth a look - if you don’t have angina and you don't believe the next breath could be your last. The short film is a natural progression of the earlier “doubt kills” poster campaign, in which a patient experiencing chest pain is graphically represented with a flesh-coloured belt crushing his chest. These are powerful interventions. On the face of it a campaign to raise people’s awareness of the presenting features of a heart attack makes sense. The vivid, highly professional portrayal of a patient having a heart attack is designed to be remembered and acted on and it is likely that many people will seek advice earlier because of the campaign. This could save lives.

So far so good, but what about the potential downside of such campaigns? Many patients have told me that they found the “doubt kills” campaign made them and their families more anxious. I recall a patient who described how he suddenly went into a panic when he saw the “doubt kills” poster on the way into hospital with a suspected heart attack. The sudden surge in adrenaline undoubtedly put him at greater risk and damaged more heart muscle. In other words the BHF “doubt kills” campaign, that was designed to reduce risk, had the opposite effect in that patient.

In my last blog I described how fear seems to dominate the lives of many angina sufferers and how professionals sometimes inadvertently make matters worse. Accidentally terrorising angina sufferers and their families is unfortunate. An expensively funded campaign that deliberately attempts to frighten patients and their families seems wrong. Anti-drinking, anti-smoking and anti-drugs campaigns that have used fear and disgust to discourage harmful behaviours are different because aside from the risks of glorifying the activities they seek to discourage, significant downsides are unlikely.

Unfortunately, as far as I know, the BHF is not planning to evaluate the potentially negative aspects of its campaign.

I'd be interested in your view.

Angina

For the past 12 years I have worked exclusively with patients with a condition known as refractory angina. This is when angina stops patients enjoying life to the full and orthodox cardiology has run out of answers.

In my experience fear and confusion dominates the problem. Most patients and their families believe that the heart is progressively damaged with each episode of angina. Nearly all people think that the fatty cholesterol deposit (atheroma) on the inner lining of the arteries that supply the heart (coronary arteries) gradually worsen until they inevitably block the vessel altogether and this causes a heart attack. Most people know that exercise is recommended but worry that they will cause themselves harm if they overdo it. It is hardly surprising that many patients and their families live in constant fear when they have been told by their consultant, "nothing can be done" and "take things easy."

When we set up the UK's first specialist clinic for refractory angina we knew that we had to use a different approach simply because the conventional or orthodox medical model had failed. With no resources and little spare time for this new venture, we had to keep things simple. We realised that patients had a vast experience of the orthodox model and they could help us develop a better approach tailored to their needs. Putting patients at ease and simply listening to refractory angina sufferers taught us that while most were grateful that the system had "kept them alive" they were generally not impressed with the after sales service. Frightening images and ideas are commonly introduced in follow up clinics or by the bedside by professionals who appear unaware of the damaging effects of a careless explanation of a complex issue. Patients commonly recall hearing phrases such as: "there is nothing more that can be done"; "you are a walking time bomb"; " you are living on a knife-edge"; "the next one will be the last."

The aim of this blog is to share my experiences of the sort of things that really make a difference to patients' lives. Knowing that angina does no harm to the heart and that the heart is actually slightly better off after an episode than it was before, is a good place to start.

The question that nearly always follows this relevation is, "why do they do all those heart operations then?" The answer is not simple.

Some, but by no means all operations are "life-saving." By far the commonest heart procedure is angioplasty and stent, where a ballon with an etched metal tube wrapped around it is inflated at the narrowing. The ballon expands the metal tube (stent) which then acts like internal scaffolding. Intuitively this should prevent heart attacks but several trials have looked at whether angioplasty reduces heart attacks or death and it doesn't except when it is performed during a heart attack. Even then it is not clear that stents are any better at reducing the size of the heart attack than simply clearing the blockage with a simple balloon. The majority of angioplasty procedures are not "life-saving" and yet the vast majority of patients I have spoken to had previously agreed to undergo angioplasty and stent precisely because they believed that it would be more risky not to have the procedure. Bypass surgery really does appear to save lives but only in very special circumstances when there are narrowings right at the beginning of the heart's own arteries. If you are offered a cardiac procedure it is worth asking the straight question, "Will this make me live longer and if not what are the alternatives?"

Another good question is, "how long is it likely to last?" It is generally understood that angina returns in about a third of men and abut half of women within three years after a bypass. It is also important to know that the operation itself can leave a painful scar that is sometimes worse than the original angina. Angioplasty (excepting emergency situations) as I have already discussed is not a life-saving treatment and is only partially successful in eradicating symptoms. Obviously some patients experience dramatic improvements but overall the benefits are small and transient.

It is generally accepted that one of the most effective and safest interventions is education as part of a comprehensive rehabilitation process. However, consistent with our experience, the European Society of Cardiology, the American Heart Association and the NHS's Healthcare Commission have acknowledged, this critically important aspect of care is often neglected. Unfortunately, patient and carer education (as opposed to giving information) is time consuming and requires communication skills that are not yet part of the standard training requirement for cardiologists.

I will try to post regular updates on general issues that might be of relevence to you. I will not be answering individual queries.

www.angina.org