Every March, about 25,000 healthcare professionals, mostly cardiovascular physicians, attend the Annual Scientific Sessions of the American College of Cardiology. Each year there is some research bombshell that is reported by the newspapers. This year, in New Orleans, a new clinical trial of over 2,000 stable heart patients with narrowed (stenotic) coronary arteries showed that angioplasty/stent procedures, used to reopen stenotic coronary arteries with tiny balloons and metal supports (stents), are no better than medical therapy for prolonging life, preventing heart attacks (myocardial infarctions), or controlling symptoms of chest pain (angina) and shortness of breath. This result came as a surprise to many doctors and patients. The New York Times (3/27/07) quoted the lead author of the trial, Dr.William Boden, a cardiologist at the University of Buffalo Medical School as saying, “When I saw the results, I was incredulous.”

The angioplasty/stent technique is invasive, but requires no surgery. There are some risks including the recent reports of rare but dangerous blood clots at the stent site. Medical therapy includes aspirin, cholesterol lowering drugs, diet, exercise, stopping smoking and control of high blood pressure.

It seems intuitive to patients and many doctors that correcting coronary stenoses with angioplasty/stents would prevent death and heart attacks, but intuition is not enough for those physicians who practice “evidence based medicine” and rely heavily on research trials to guide their clinical decisions. Many cardiologists had suspected, based on previous research, that too many angioplasty procedures were being performed.

Although this trial’s results are impressive, it is narrowly focused on stable patients and it is about prevention and symptom relief and not about treating acute or worrisome situations. Cardiologists will continue to recommend stent/angioplasty procedures for a variety of legitimate reasons, although this trial might result in fewer procedures being done in the future.

For patients who are experiencing an acute heart attack or an unstable coronary event, emergency angioplasty/stent procedures can be life saving. Time is of the essence for these patients, and a victim needs to quickly go to a hospital where these emergency procedures are offered. Both Jersey Shore and Monmouth hospitals offer emergency angioplasty/stent services.

For patients who have chronic symptoms such as chest pains or shortness of breath, the trial showed that medical therapy was, on average, just as good as invasive procedures in controlling symptoms. But sometimes the medicines are not very effective, and the invasive procedure might offer a superior alternative. In fact, there were patients in the trial who were randomized to the medical group, but they had do be switched to the invasive group because the medications weren’t working or were causing side effects.

Similarly, the angioplasty/stent procedure may be preferred by the cardiologist because of worrisome findings that might be discovered in “stable” patients during stress testing, angiography or ECG monitoring. There are a variety of such special circumstances in which angioplasty/stent intervention or even bypass surgery would be a better choice than medical therapy.

A practical matter which could influence the choice of treatment is that the patient may insist on the invasive procedure for psychological reasons, and it is not uncommon for patients and their families to pressure the cardiologist to choose the invasive option despite evidence that medical therapy would also be appropriate.

From the cardiologist’s point of view, it is easier to convince people to go the invasive route and, ironically, it is often more difficult to convince the patient to just take pills, diet and exercise. Such conservative advice may cause the patient to seek a doctor who will be more aggressive. Also, the cynic might point out that invasive cardiologists collect large fees for these procedures. Financial incentives should not influence the choice of therapies, but, in real life, they sometimes do.

A physician needs to pay attention to the results of research trials, but he cannot use those results as the only factors to consider when recommending treatment for his patient. The doctor must place research into perspective and then consider his patient as an individual and not a statistic. The really good physician will consider multiple factors including judgment, careful case analysis, experience, medical knowledge, and awareness of the patient’s preferences. He cannot fall out of his chair because the press gets excited during March Madness. He just has to apply the art and science of medicine and do what is best for his patient. That is his job.

Read "America's Best Doctors: Can you find one?", by Paul Goldfinger here