"The highest form of ignorance is to reject something you know nothing about,” Wayne W. Dyer, PhD, author and speaker once said. In medicine especially, this quote may hit the nail on the head, particularly for the patient.
This week, I interviewed three physicians about the proper treatment for stable coronary artery disease (CAD), after an eight-study meta-analysis showed that stenting did not reduce the risk of death, MI or angina when compared with optimal medical therapy (OMT) in the stable CAD population.
For years, controversy has stemmed from this topic. Is OMT or PCI best for the stable CAD population? While David L. Brown, MD, told me that these results should come as no surprise, as they confirm what has been written in guidelines, still a large gap remains in terms of how many of these patients are being first treated with OMT.
William E. Boden, MD, said that this battle has been raging since the results of the COURAGE trial were released in 2007. Interventionalists came out swinging against the study’s credibility, after COURAGE showed no added benefits of adding PCI to OMT when compared with OMT alone.
While evidence shows that OMT may be best for this patient population, Boden said that the message continues to be disregarded in clinical practice and by the lay public. To that end, Boden said that educating patients is imperative. He added that the public needs to have questions answered about PCI from an “unbiased source” and said that it would be difficult for a stable CAD patient to question a physician's suggestion of PCI when they are uneducated about the risks and benefits.
Similarly, data in the Journal of General Internal Medicine recently showed that elective PCI patients are often uninformed and uninvolved in treatment decisions. In fact, only 10 percent of the 593 Medicare patients surveyed said that their cardiologist gave them options to seriously consider, and 16 percent said they were asked about their treatment preference.
Additionally, in the area of electrophysiology, patients may also be ill-informed particularly when it comes to deactivation of their cardiac devices at the end of life. Nathan Goldstein, MD, when speaking about the management of device patients at the end of life, said education is key. However, currently this seems not be a top priority for these patients who may eventually be painfully shocked by devices.
Goldstein referenced a study that found that only 10 percent of hospices had a policy that addressed deactivation, meaning patients may not be fully educated on the topic. He and others urged that conversations must take place with the patient at device implantation, to understand the patient's goals of treatment, especially if a device begins to deliver painful shocks toward the end of life.
For more on this topic, stay tuned for our May cover story on managing device patients, post-implantation. To sign up for a free subscription to the magazine, go here.
On these topics of others please feel free to contact me.
Cardiovascular Business, associate editor