The writer of twice-monthly health columns is a practicing cardiologist, clinical professor at Wayne State University School of Medicine and founder of the Kahn Center for Cardiac Longevity in Bingham Farms. He is an author and has appeared on national TV, including "Dr. Oz" and "The Doctors Show."
By Dr. Joel Kahn
Do you sign the surgical consent form? The decision to pursue or decline a recommended medical or surgical procedure is one of the most difficult situations faced by patients impacting their short and long-term health.
I have discussed these decisions with thousands of patients and their families before invasive cardiac procedures like heart catheterizations and stent implants (which I am trained to do), and heart bypass and valve surgery (which heart surgeons perform).
Over 3 millions of these procedures are performed annually in the U.S., many in outpatients with no or stable symptoms. These procedures have risks of death, heart attack, stroke and other complications that can exceed 5 percent of those treated.
When powerful new scientific data become available, it is even more pressing to consider all options as practice patterns change very slowly. A $100-million study published last April randomized over 5,000 “serious” heart patients with stable angina chest pain and very abnormal stress tests to proceeding directly to heart catheterization, stents or bypass surgery versus no procedure. Men and women were studied.
The non-surgical group was treated with medications, diet, fitness and abstinence from smoking. Participants were followed for over three years. The results were stunning and showed that there were no differences between the two groups for death rates and other primary endpoints.
What can a heart patient do when faced with a recommendation for an invasive procedure? The study did not include patients in the midst of a heart attack or other emergency. There are patients, particularly those with recurrent and life-threatening symptoms being treated as in-patients in hospitals, who are in an urgent situation requiring an invasive procedure.
Difficult to Challenge
Fortunately, most heart patients are stable and are outpatients when they face a decision about a procedure. In my experience, it is very difficult for a patient and their families to challenge a recommendation for a procedure. These questions atre worth asking the medical team:
1) Are you familiar with the ISCHEMIA study and can I be treated like the conservative group?
2) Can you refer me to an intensive cardiac rehabilitation (ICR) program like Pritikin ICR (Ann Arbor) and Ornish ICR (Rochester Hills and Flint) which my insurance will pay for?
3) Can I have external counterpulsation therapy (ECP), which my insurance will pay for?
4) Can I be referred to a preventive cardiologist to pursue lifestyle changes that go even further than the ISCHEMIA study?
The value of a second opinion from a heart specialist who has no “skin in the game” cannot be overemphasized. For outpatients contemplating invasive procedures, there is usually time to schedule a second opinion.
I have performed many of these assessments and, on occasion, have even done this for hospitalized patients. Advances in cardiac care, including invasive procedures, have improved both the quality and quantity of life for many sick patients.
Nonetheless, many heart procedures are performed in patients that could have had the option to safely take medication and change their lifestyle. Some of these patients suffered tragic, avoidable complications. Whenever possible, a second opinion should be the first choice.