COMMENTARY

John Mandrola's Top 10 (er, 11) Cardiology Stories of 2013

John M. Mandrola, MD

Disclosures

December 20, 2013

In This Article

Transparency, End-of-Life Care, and TACT

7. The Sunshine Act

Cardiology is a drug- and device-intensive field. Collaboration with industry is necessary. Skillful use of stents, ICDs, ablation, and pharmaceutical agents has enhanced and saved the lives of millions of patients. Yet, there is clear evidence of overuse and misuse of expensive technology. Look no further than studies that show huge geographic practice variation,[6] which I wrote about here.

The 2013 Sunshine Act has changed the landscape of cardiology education and influence. The upside of transparency is that knowing the financial relationships of investigators is an important part of judging science. Perhaps more important, though, is the possibility that the Sunshine Act will help remove those with financial relationships from guideline writing. Given the influence of guidelines, it's important that writers be free of conflicts.

The potential downsides of too much Sunshine are noteworthy. After being interviewed in the Wall Street Journal this August,[7] I wrote the following on my blog:

Doctors are a conservative lot. Concern over perception will surely decrease physicians' interactions with industry, both the useful and not so useful ones. The effect on physician education might suffer. Though the Ben Goldacres of the world rightly emphasize bias when industry entwines itself with medical education, I can attest to have learned a lot from industry-sponsored programs. And this too: one thing that happens when industry sponsors a learning session is that doctors come to it. They talk; they share cases; they come together face-to-face. Such interactions are critical. Will the disappearance of sponsored sessions decrease the amount of face-to-face learning?

We shall soon learn whether all this sunshine enhances health or causes burns.

8. Compassionate Care of the Elderly

Cardiologists are programmed to see death as the enemy. This is a very good thing when treating diseases like STEMI. But a side effect of improving life-prolonging interventions is that patients live long enough to develop other problems. Cardiologists are increasingly asked to treat the elderly and the frail. And this is a challenge because in these patients, treating death as if it's avoidable is perilous. Delaying death is not the same as prolonging life. Treating a disease is not the same as treating a person.

It's possible that 2013 will be the year in which things changed for the better in the care of the elderly. And if it is, we will have Katy Butler, an author and investigative journalist, to thank. Ms. Butler's 2013 book, Knocking on Heaven's Door, poignantly chronicles the difficulties that both her parents struggled with as they approached the end of life.[8] In both cases, suffering occurred because of disconnect with cardiologists who behaved as if death were optional.

Writing in the Wall Street Journal this September, Ms. Butler describes her mother's decision to forego aggressive intervention for valvular heart disease.[9] Despite being cared for in one of the nation's elite heart hospitals, Mrs. Butler's mother was forced to fight hard for her right to self-determination. Perhaps she mustered the strength to fight for a good death because of the lessons she learned as a caregiver for her chronically ill husband, whose death was tragically prolonged at the hands of paternalistic cardiologists. In Ms. Butler's father's case, which she describes in this award-winning New York Times Magazineessay, cardiologists implanted an unnecessary pacemaker and then refused to deactivate it, against the family's wishes.[10]

As the American College of Cardiology begins an awareness campaign for aortic stenosis, and transcutaneous approaches to valvular disease begin their long road to clinical utility, no topic could be timelier than compassionate patient-centered care for the elderly. 2013 is the year that the oath of Maimonides -- "Oh, God, Thou has appointed me to watch over the life and death of Thy creatures" -- becomes even more relevant to cardiologists, the guardians of technology.

9. Chelation Therapy

Nothing has become more virtuous in the practice of medicine than clinical evidence. We have set out the rules: The scientific method will determine the best treatments for our patients. One group gets treatment A and the other treatment B. Then we measure outcomes -- the simpler the better. These are the rules of the game; they can't be changed when we don't like how the game turns.

The TACT investigators have followed the rules. They compared 322 diabetic patients with coronary heart disease who were treated with chelation vs 311 similarly matched patients treated with placebo infusions.[11] The primary endpoint, a composite of death, MI, stroke, revascularization, and hospitalization for angina, occurred in 80 of 322 (25%) treated with chelation and 117 (38%) on placebo. That's an absolute -- not relative -- reduction of 13%, and an astounding NNT of 7. For comparison, statin drugs for primary prevention, or NOAC drugs vs warfarin in patients with AF, have NNTs greater than 100.

What makes chelation in diabetics a top story of the year is more than just the data. By the authors' own account, these findings need to be replicated. What's really big here is the voracity of opposition from the establishment. I re-read what I said in my opinion piece from November. I'm sticking to it: "It would be a huge mistake to dismiss this science because chelation does not conform to preconceived notions or because it is practiced outside the mainstream of medicine. Let's not forget about the patients with this terrible disease. It's not as if we have good treatments for them."

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