Cardiologists overstate benefits of coronary intervention for stable angina

By Will Boggs MD

Cardiologists tend to overstate the benefits of percutaneous coronary intervention (PCI), and patients make decisions based on what cardiologists tell them.

Although PCI may improve angina symptoms faster than optimal medical therapy, evidence suggests that it does not reduce the risk of death or heart attack (MI) for patients with stable coronary artery disease (CAD). But patients with stable CAD think PCI will lower their risk of death and MI.

Three reports in the August 25th JAMA Internal Medicine online edition explore why and how this might be happening.

In the first study, Dr. Sarah L. Goff from Tufts University School of Medicine, Springfield, Massachusetts and her team evaluated the content of conversations between 20 cardiologists and 40 patients with stable CAD about angiograms and PCI.

In only two of the encounters, cardiologists told patients that PCI could improve their angina symptoms but would not reduce their risk of MI or death.

In five encounters, the benefits of PCI were explicitly overstated, and in a number of encounters the cardiologists implicitly overstated the benefits of angiography and PCI.

Cardiologists discussed the risks of the procedure in only a limited way, and no cardiologist mentioned the possibility of kidney failure as a risk.

In 30 encounters, cardiologists took the lead in the decision making process in ways that could discourage participation of the patient.

"When patients with chronic stable angina are advised to undergo cardiac catheterization and possible stent placement, they should ask what factors specific to their health history the cardiologist considered before recommending the procedure, what the risks of the procedure are, what the benefit is likely to be, what research the risks and benefits presented were derived from, what medications they will need to take after a stent is placed, what the alternative options are for them," Dr. Goff told Reuters Health by email. "If they do not understand what the cardiologist says at any point in the decision process, they should feel comfortable asking for clarification."

"I think it is very important to know that this study is not intended to be critical of cardiologists," Dr. Goff cautioned. "We could not, with this study design, assess patient understanding and it is quite possible in the few transcripts we analyzed where the cardiologists made the benefits quite clear that the patients still believed having a stent placed would prevent an MI and/or death."

"Because this was a qualitative study, it is important to know that this is hypothesis generating, not hypothesis testing," Dr. Goff said. "As a physician myself, conducting this study made me think more carefully about how well I understand a patient's goals and preferences for care, how well I explain risks and benefits to patients, and how I assess their understanding of what I have explained. I hope other physicians might reflect on the same. How would I be evaluated if my patient sessions were recorded?"

The Society for Cardiovascular Angiography and Interventions lists five things physicians and patients should question: http://bit.ly/1nuFIYz.

In another study, Dr. Michael B. Rothberg from Cleveland Clinic, Cleveland, Ohio and his colleagues analyzed how the presentation of the potential benefits and risks of PCI and optimal medical therapy influences patients' beliefs or decision making.

The researchers had volunteers read one of three descriptions of the risks and benefits of PCI for patients with stable angina. One description had no information about the effects of PCI on heart attack risk; one description said that PCI will not reduce the risk for MI; and one description explained why PCI does not reduce the risk for MI.

Compared with the other two groups, participants who received no information about the relationship between PCI and heart attack risk were most likely to believe that PCI prevents heart attack, were most likely to choose PCI, and were least likely to agree to medical therapy.

"We were not surprised to find that in the absence of information, most people assumed that PCI would prevent a heart attack," Dr. Rothberg told Reuters Health by email. "We were surprised that even after they were told that PCI would not prevent a heart attack, more than 30% continued to believe it would. We were even more surprised to find that many people falsely remembered the physician saying that PCI would prevent a heart attack, even though he never said that, and in some cases said the opposite."

"Physicians need to be very explicit about the benefits that a patient can expect, as well as making it clear that for patients with stable ischemic heart disease this procedure will not prevent a heart attack or make them live longer," Dr. Rothberg said. "In addition, these mistaken beliefs are so common that physicians need to be sure that patients understand what has been explained to them. One way to do this is using a technique called 'teach back,' where the physicians asks the patient to explain what he or she understands to be sure it is correct."

Finally, in a third study, Dr. Steven M. Bradley from Veterans Affairs Eastern Colorado HealthCare System, Denver, Colorado and colleagues used records from the National Cardiovascular Data Registry to show that performance of coronary angiography in patients without angina symptoms was associated with higher rates of inappropriate PCI and lower rates of PCI.

"Future studies need to define the aspects of care delivery that lead to optimal patient selection for coronary angiography and PCI," Dr. Bradley told Reuters Health by email. "This may include greater patient involvement in the decision process and application of the Appropriate Use Criteria in measurement, reporting, and clinical decision support of high-quality patient selection for coronary angiography and PCI."

"Our findings suggest broad variation in the quality of patient selection for diagnostic coronary angiography," Dr. Bradley said. "Furthermore, proper patient selection processes that occur prior to the cardiac cath lab have implications for the optimal use of both coronary angiography and PCI."

SOURCES: http://bit.ly/1mJDNzw, http://bit.ly/1tN5Q4Z, and http://bit.ly/1lsvuge

JAMA Intern Med 2014.

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