What Are The Dangers of Unnecessary Cardiac and Vascular Procedures?
Lesson for Patients With Cardiovascular Disease Gleaned from Philip Roth’s Everyman
A core mission of the skeptical cardiologist has long been to prevent patients and individuals from getting unnecessary cardiovascular procedures and surgeries.
To be sure, cardiologists and cardiovascular surgeons do many life-saving procedures.
However, I have seen far too many procedures and surgeries that were done either on the wrong kind of patient or performed with little evidence that the long-term benefits outweighed the short-term risks.
At the top of the list of cardiac procedures that patients should consider with great skepticism and care are:
-Left atrial appendage occlusion (LAAO) (aka Watchman)
-Routine, screening, annual, or post-coronary stenting stress tests
-Cardiac stenting outside the setting of an acute ST-segment elevation myocardial infarction.
-Percutaneous closure of PFO following stroke.
-Percutaneous tricuspid valve repair
To help readers better understand these issues In 2022 I wrote about the numerous inappropriate cardiovascular imaging studies and procedures that were performed on the protagonist of Philip Roth’s excellent novel, Everyman.
Everyman, written in 2006, deals with death, aging, and illness in a typical Roth fashion.
To my wonder and surprise, the unnamed protagonist goes through one cardiovascular procedure after another without raising any significant questions for the physicians recommending and/or performing the procedures. Most of these operations were likely unnecessary and all of them were performed without a significant trial of medical therapy or even a minimal discussion of risks and alternatives.
Although the book was written in 2006 and there have been many changes in our understanding of optimal cardiovascular care since then there is much that Everyman (and woman) can learn from the mistakes that the protagonist, aka Everyman, made which ultimately led to his demise.
Thousands of patients to this day undergo similar unneeded risky cardiac tests and surgeries. Let's look at some of the cardiovascular myths and patient errors that are revealed in Everyman.
Everyman begins at the funeral of the protagonist who suffered a cardiac arrest at age 71 years, an event which complicated the last of many (arguably unnecessary) cardiovascular surgeries he underwent. From here the narrator chronicles Everyman's life, focusing on the events and people surrounding the major health issues he suffers as he ages.
For twenty-two years after a burst appendix complicated by life-threatening peritonitis, initially misdiagnosed as a psychiatric problem but ultimately treated with surgery, everyman experiences excellent health and lives an exemplary lifestyle.
He swims daily but one day notes that “he couldn’t finish the first lap without pulling over to the side and hanging there completely breathless.” As he ponders possible causes he finds it preposterous that he could develop severe cardiac disease because he has had a “lifelong regimen of healthful living”, free of smoking, excess drinking or obesity and full of vigorous exercise in the form of swimming.
Be Aware of False-positive EKGS
Alas, when Everyman sees the doctor the next morning “his EKG showed radical changes that indicated severe occlusion of his major arteries.”
In reality, an outpatient electrocardiogram in a patient with everyman’s presentation rarely makes a clear-cut diagnosis of severe coronary artery occlusion. His symptoms of shortness of breath on exertion relieved quickly with rest are more compatible with stable angina and this disease we now know is best evaluated as an outpatient.
Abnormalities on ECGs are frequently false-positives, thus ECGs are frequently read as showing old heart attacks in patients with totally normal hearts. This is why a screening ECG performed on someone without symptoms is a bad idea (see here.)
Emergent/Urgent Invasive Angiography Only Warranted for Acute Heart Attack
In 1989, in New York (and most of America) the typical approach to a patient with shortness of breath and an abnormal ECG was to hospitalize them and perform an invasive angiogram (aka a cardiac catheterization) to directly look at the coronary arteries.
“Before the day was out he was in a bed in the coronary care unit of a Manhattan hospital having been given an angiogram that determined that surgery was essential.”
The risks of the invasive angiogram are significant and include death, stroke, heart attack, and arterial bleeding (see here.) A better approach in 2024 is the coronary CT angiogram ( see here.)
Since 1989 it has become abundantly clear that we don’t need to rush into doing the cardiac cath unless the patient is having an active, acute heart attack.
Avoid the Rush to Cardiac Surgery
In many of the hospitals I have worked at over the last 30 years, patients like Everyman were not only rushed off for their cardiac catheterization with little discussion but as soon as the diagnostic procedure was completed they were told they needed to be rushed off to cardiac bypass surgery.
Barring evidence of an acute heart attack, it is rare that a patient's condition requires such urgency.
There are very few individuals who have the temerity to question pronouncements as they are often told this is their only choice.
Roth’s everyman never questions anything the doctors recommend to him. He never asks for a second opinion.
“The only question was should the surgery be performed immediately or the next morning.”
The next morning Everyman undergoes a 7-hour open-heart bypass operation. Upon awakening, he learns he has received five grafts and has a “long wound down the center of the chest” and “a tube down his throat that felt as though it were going to choke him to death.”
Over the last 30 years on numerous occasions, I have stopped this mad, frenzied rush to the OR recommended by doctors (both invasive cardiologists and cardiac surgeons) who insisted that my patients needed coronary bypass surgery.
Coronary bypass surgery is preferred over medical therapy in some situations (most clearly >50% stenosis of the left main coronary) but in 2024 we know that the majority of patients with severely blocked coronaries can be treated successfully with aggressive medical therapy.**
Think Twice Before Having Other Vascular Procedures: Medical Treatment Is Advancing and Very Effective
In 1998, when Everyman was 65 years old his high blood pressure “would not respond to changes in medications.” and the doctors “determined that he had an obstruction of the renal artery.” Again, without any discussion of risk or benefits he underwent angiography of the renal artery, and “the problem was solved with the insertion of a stent that was transported on a catheter maneuvered up through a puncture in the femoral artery and through the artery to the occlusion.”
Until large randomized trials of this renal artery stunting procedure were performed in the early 2000s, there was enthusiasm for it as a treatment for difficult-to-control hypertension.
By 2014 several large trials had shown no benefit of renal stenting over optimal medical therapy in mortality, BP control, or kidney function.
More Unnecessary Coronary Procedures
Everyman goes on to have surgery (a carotid endarterectomy or CEA) on an obstruction in his left carotid the next year.
The year after his carotid artery surgery, Everyman “had an angiogram in which the doctor discovered that he’d had a silent heart attack on the posterior wall because of an obstructed graft.” Given that Everyman mentions no symptoms related to this and given the previous inappropriately aggressive test and procedure ordering of his doctors, I can only presume that this repeat invasive angiogram was done because of an abnormal stress test.
Cardiology guidelines now recommend against the routine performance of stress tests following stenting or bypass procedures which I have discussed in detail here. This practice was the norm 20 years ago and persists to this day. A major concern with these routine tests is downstream testing like invasive angiograms which follow false positive results.
When inappropriate invasive angiograms are performed, coronary blockages are often found and stents are frequently placed that don’t reduce the risk of heart attack or help symptoms. Sure enough, Everyman has a stent implanted in his LAD coronary artery, one which was not involved with the posterior wall of the heart at all.
The next year he gets another coronary stent, this time in a bypass graft. A year later he gets 3 more coronary stents. Again, no symptoms were mentioned, and no benefit was obtained, other than to the pocketbook of the stenting doctor and the catheter companies and to the expanding coffers of the hospitals complicit.
The Coup de Grâce
I have written in detail about carotid surgery and whether Everyman's death during his second CEA could have been prevented.
Spoiler alert: the surgery was unnecessary.
Given modern medical cardiac preventive therapies if we choose wisely the procedures we undergo I feel we can forego growing pale and spectre-thin for far longer than Everyman did.
Noninvasively Yours,
-ACP
*(Succinct analysis here
**This is a common misconception and on a daily basis, hundreds of individuals needlessly die suddenly because they feel invincible. A healthy lifestyle improves your odds bu many who have inherited powerful risk factors, cannot overcome the cardiovascular cards they have been dealt.
For those at high risk due to family history of heart disease proactive diagnosis of subclinical disease using advanced biomarkers and imaging is warranted.
Once subclinical atherosclerosis is identified (by a test such as a coronary artery calcium scan) or markedly abnormal lipoproteins are noted, the inherited silent premature build-up of atherosclerotic plaque can be halted by the remarkable therapeutic tools available to preventive cardiology thereby preventing the need for stents, bypass surgeries and other vascular procedures.
***If you are interested in a deep dive and discussion on the benefits of and indications for coronary artery bypass surgery I recommend this recent Substack:
by John Mandrola, who has become the best cardiologist in the world at critically analyzing cardiac studies and procedures and summarizing their importance (at This Week in Cardiology.)
I've worked with many great PCPs over my career and I can tell you would be fantastic to work with. . But I've also worked with many who are very much wedded to the old paradigm of CAD and who were very much complicit in the freight train to the cath lab mind set. At one health center I worked it was not uncommon for the PCPs to directly contact a cardiologist who only did caths/stents, i.e. he didn't do cardiology consults, didn't manage cardiology patients post stent or pre-stent, just did any cath that any doctor wanted done. Frequently, if the PCP wanted a cath done and the cardiologist felt it wasn't warranted , that cardiologist would not get any more referrals. On top of that, if any lesion was found it got a stent, somewhat irrespective of the severity and without any requirement of ischemic testing, FFR, etc.
Many PCPs view the stable CAD patient as a "hot potato" and only feel comfortable once the coronary anatomy is outlined by an invasive angiogram and a stent implanted.
What they don't realize is that the patient has been converted from stable CAD to an unstable situation with that stent.
Very well done exploration of therapeutic cardiovascular misguidance. These reviews are an invaluable roadmap to providers who know these assertions to be true but who need the evidence based corroboration. Great job!