
Surgery for Blocked Arteries Is Often Unwarranted, Researchers Find - ra7
https://www.nytimes.com/2019/11/16/health/heart-disease-stents-bypass.html
======
carbocation
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.

~~~
Dowwie
What brings a cardiology fellow at Mass General to Hacker News? I think it's
great that you're here and sharing insight.

~~~
carbocation
I've been on Hacker News longer than I've been at MGH ;)

Thanks for your kind words.

------
anonu
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
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.

~~~
tomjakubowski
Suppose you've just had a newborn. The doctor offers to perform surgery on
your child which 10% of the time kills them, and 90% of the time extends their
life expectancy 30%. Do you agree?

~~~
TylerE
Absolutely.

~~~
tomjakubowski
I don't think so. All else equal, a 75 year old is more likely to drop dead
tomorrow than a 25 year old (or healthy newborn) is, so the 10% death
probability is less of a problem for them. Moreover, the years at the end of
one's life are not quite the same as years of youth.

~~~
TylerE
That's exactly why this is an _easier_ question for a newborn... the 30% is on
their _entire_ life and not their remaining years. Like, if the upside is
living to 80 instead of 50, that's easier than it being the difference between
living 5 months and 6 months.

~~~
cgriswald
Sure, but that 10% chance for a newborn represents basically their _entire
life_ while for a 50 year old it’s a life mostly already lived.

------
wrkronmiller
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
Because Sen. Sanders had the exact surgery the article is talking about.

~~~
wrkronmiller
Ah, okay, that makes a lot more sense now.

------
throwawaysea
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
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.

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

------
dang
[http://archive.is/B6WME](http://archive.is/B6WME)

------
Merrill
ISCHEMIA: Invasive Strategy No Better Than Meds for CV Events

[https://www.tctmd.com/news/ischemia-invasive-strategy-no-
bet...](https://www.tctmd.com/news/ischemia-invasive-strategy-no-better-meds-
cv-events)

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.

------
WheelsAtLarge
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.

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

~~~
tootie
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.

------
droithomme
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
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.

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

~~~
chkaloon
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
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
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).

~~~
pbhjpbhj
Any chance you could link more info about that hamstring stretch?

~~~
viburnum
Sure! Okay, so it’s not exactly a hamstring stretch, but it fixed the problem
that kept me sedentary which in turn caused my hamstrings to get super tight.
I’m sorry I don’t know the name of it so I’ll have to describe it (google
failed me). Stand with one leg straight on a low stool or a stair step. Lean
forward, pushing down very hard on your leg with both hands on your leg above
the kneecap. I did this on each leg for a minute every hour or so.

The idea is to increase the range of motion in the leg. I gained a huge amount
in just a few weeks, something like 15 degrees worth. From there I was able to
walk and stand without pain (it felt so good that took up running just because
I could!). When I’ve been sick or less active I can feel the tightness coming
back and it only takes a few stretches to get back to normal again. The PT who
helped me was trained in Mackenzie technique. I guess their idea is to give
people focused stretches and exercises instead of the insane, unachievable
workouts that PTs often prescribe.

------
known
"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

------
Medicalidiot
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
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?

------
stopadvertising
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.

~~~
colechristensen
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.

~~~
hestipod
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.

~~~
ip26
_I will be ending it soon_

 _I had a life...I had a future_

Yes, but now you have a _cause_.

Ever thought about attending law school? Or some other related course of
action? You can stand up for the other people like you. You could be for them,
what wasn't there for you.

~~~
hestipod
I am not just playing emo and choosing not to go on because life is a drag. I
have lost everything and everyone and live in severe pain and just existing
takes all my energy. I have tried over and over again to work enough to have
some sort of life but my body fails and that takes the mind with it. I was
denied social assistance. Abandoned by family. Nothing has gone right since
this was done to me. While I would love to help others again as I once did...I
cannot manage myself and there is not sufficient help here. I want out of this
country back to the only place I have ever really enjoyed living in Europe but
I have not been able to realize that either. The last thing I have the energy
for is something like law school. I'd need a lot more of Maslow's lower rungs
secured before I could attempt something like that and I'd never be able to do
it on a normal schedule. I am old and broken and on a thread. I have reached
my mental coping limit after many years of pain and decline and abandonment.I
need consistent help and stability in a healthy environment to survive. That
has been denied and I have had nothing but the opposite. So there will be no
survival.

~~~
ip26
I believe you, and I'm sorry. As a young father, it's hard to imagine how your
family could abandon you. Yet of course they did, all the same. I offered
purpose, as purpose is sustaining for some. But you are of course right-
Maslow, after all, knew what he was talking about. I would help if I knew how.
I hope you do not give up- there are people who care, even if finding them is
difficult.

