Getting Over the Siege Mentality
Spencer B. King, III, MD, Editor-in-Chief, JACC: Cardiovascular Interventions*
"Interventional cardiology is under attack." I hear this phrase frequently from my colleagues and those in the industries that develop and market much of the technology we use. I think we should get over the mindset that we are victims, not because it is completely untrue, but because it is unproductive. What is the evidence that there are those who oppose interventional cardiology?
The volume of interventional cardiology cases has stopped increasing in the U.S. overall, and many laboratories have seen their case volumes going down. Case load for peripheral vascular and structural heart disease cases has not followed this path but the bread-and-butter of interventional cardiology (i.e., coronary stenting) has. Some studies have suggested that coronary stenting is unnecessary, and medical therapy only is as good or better. Guidelines and appropriateness documents continue to be updated and revised, but there is an impression that they may not reflect the outcomes of the most current interventional methods and may not contain the latest evidence.
In responding to the perception that our subspecialty is under siege, we sometimes react in less than productive ways. The story of coronary intervention is a very compelling one and should be well understood by physicians, patients, and payers, and if we hold to the evidence and build on it with appropriate investigation, it will continue to be.
We must not get trapped into the argument that interventions are "superior to medical or surgical therapies." This generalization is no more correct than the inverse or the incorrect assumption that aspirin and statins are appropriate for the entire population because of statistical significance driven by the subpopulations that really need them.
Why have stent volumes moderated? There are perhaps several reasons: - 1 The market was oversold. That is, the use of stenting in the U.S. was twice that of other developed countries, and the growth from this level was unsustainable.
- 2 Drug-eluting stenting has resulted in less restenosis, less repeat procedures, and therefore fewer stents.
- 3 Referring physicians and patients were persuaded that stenting did not "fix" the problem and prevent events.
- 4 The largely unjustified fear that stenting is associated with a significant increase in arterial thrombosis was prevalent.
- 5 Increasing appreciation of the potential to stabilize coronary atherosclerosis with appropriately targeted medical therapies is a reality for many patients.
Whereas some of these are reasonable and some are in need of clarification and education, there is no need for interventionalists to become defensive.
The positive aspects of the coronary interventional story need emphasis. - 1 Acute myocardial infarction is best treated with stenting, period. The guidelines attempt to reflect evidence of how this can be accomplished through primary percutaneous coronary intervention when available and transfer percutaneous coronary intervention when it can be streamlined.
- 2 Angina due to obstructive epicardial coronary artery disease and documented ischemia is most effectively treated with stenting, when technically feasible. The FAME trial, which studied the predictive value of fractional flow reserve, and other evidence should not be viewed as a reason to avoid physiological assessment of ischemic but rather as documentation of the effectiveness of coronary intervention to eliminate ischemia.
Which defensive arguments are not selling? - 1 The "oculostenotic" assertion that since there is a lesion it may get worse.
- 2 The "vulnerable plaque" may be lurking and, therefore, stenting is needed even for nonobstructive lesions. Yes, methods of predicting sites of arterial thrombosis leading to acute myocardial infarction and frequently death should receive great attention, but we do not currently have proof that these can be predicted, or if they are, what therapy can prevent the catastrophic event.
- 3 Stenting will provide improved longevity compared with other therapeutic methods. We simply do not have the studies to establish that, although our improving techniques certainly seem to be pointing toward more parity with surgical methods.
As with any confrontation we should recognize the enemy. In this case, it is the destructive disease of coronary atherosclerosis. In order to fight any battle all resources need to be brought to bear. In war, the ground, air, and sea forces may be needed to defeat an enemy. In the case of our enemy, medical therapy, interventional methods, and surgery all play vital roles. In the near future, more and more revascularization cases will be performed as hybrid procedures taking advantage of arterial grafting and stenting (which may eventually prove superior to vein grafting). Effective methods to stabilize coronary disease are here and need to be applied in a more focused personalized way. However, relief of ischemia will always be achieved most effectively by restoring the plumbing.
We should not fear "comparative effectiveness research" but insist that studies be designed to evaluate those patients who actually have the need for the therapies tested. The contribution of interventional cardiovascular medicine makes a compelling story. We have no need to be defensive.
* Address for correspondence to: Spencer B. King III, MD, Editor-in-Chief, JACC: Cardiovascular Interventions, Saint Joseph's Heart and Vascular Institute, 5665 Peachtree Dunwoody Road, NE, Atlanta, Georgia 30342 (Email: sbking{at}sjha.org).
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