Monday, September 07, 2009

INTERVENTIONAL CARDIOLOGY UNDER ATTACK AGAIN. NEWS FROM ESC 2009

The just concluded European Congress of Cardiology ( ESC ) 2009, brings more bad news for interventional cardiology. Back in 2006, at the ESC in Barcelona, the Interventional Cardiology world was rocked by the announcement from ESC that DES was killing patients ( the problem of late stent thrombosis ). Well, we got over that after about two years, basically with re-defining stent thrombosis and also recalculating the trial data with these new definition.
In the just concluded ESC, two papers will surely impact on Interventoonist. One was discussed in a previous blog, namely the 2 year follow-up of the SYNTAX trial, showing that after two years, PCI for left main stem was obviouly inferior to CABG, in terms of re-intervention rates and also rates of AMI.
Well, another paper presented in this ESC 2009, was a small paper by a group of German workers under Dr Rainer Hambrecht ( Kliniks Links der Wesen, Bremen, Germany ), which showed that regular exercise over 2 year period, was as good as PCI in terms of symptom relief and improvement in Myocardial Perfusion. This study, reported in Barcelona in Sept 3rd 2009, is actually a combination of two studies, one carried out, almost similarly, in 2004, but not completed, together with renewed patient enrollment by Dr Rainer and group. What is obvious, is that a regular exercise regime, is as good as PCI in patients with chronic stable angina. Something which is supported by the COURAGE trial.
What this will translate out for patient care is that in patient with stable coronary artery disease ( assymptomatic, or with just a positive stress ECG, or found incidentally by one of the many MSCT scans around the place ), can be managed by intensive medical therapy and a regular exercise program. Buying a bicycle is certainly cheaper than undergoing PCI, and obviously less rsiky too. However, it must be poited out that in the symptomatice stable CAD group, PCI will relieve chest pains in minutes and medical therapy will take longer.
It is not difficult to understand why intensive medical therapy and rugular exercise will help. It is well known that regular exercise and medical tehrapy will promote collaterisation and also ischemic preconditioning, so that after two years, there will be more collateral vessels and also the myocardial cells will become adapted and more resistant to ischemia.
When we first planned to do ad hoc angioplasty ( angioplasty done right after a coronary angiogram, at the same sitting ) it was to save cost, and we had no COURAGE trial to guide us. In fact, we were guided by the " oculo-stenotic reflex ". Simply put, you see a stenosis, that is the bad guy. You dilate and remove the stenosis ( bad guy ), you should then have done some good for your patient. How simplistic, and now we know also how wrong. Angioplasty has a risk. Even amongst the best of us, we do have the occasional mortality and morbidity. What's even worse is that ad hoc angioplasty has spawn a whole industry od " dilating for bread ". Angiograms are done for no rhythm or reason ( often pprompted by MSCT scans for completely assymptomatic patients ( MSCT is a commercialised examination for checking yoyr heart artery ). Then the see and blockage on the scan. The guy who sees the blockage, so called, will scare the life out of the ignorant patient and subject him / her to a coronary angiogram and before you know it, the blockage ( sometimes insignificant blockages ), have been dolated. All these for RM 30K for " saving your life ". Medicine has become a business.
Blogs like this is to educate the public and also some doctors, so that they will be wiser ( hopefully ) and not be so easily " conned ".

1 comment:

Sonnet said...

Thanks for this usefull reume.