Chances are, heart disease is going to get you. It’s eternally America’s number one killer, estimated to cause about 600,000 deaths a year.
If you want to get a better grasp on your likeliest executioner, don’t miss this fascinating piece, titled “A Cardiac Conundrum,” in the latest Harvard Magazine. It features Dr. David Jones, a Harvard professor of the culture of medicine, and his recent book, “Broken Hearts: The Tangled History of Cardiac Care.”
Jones discusses the shaky evidence base for many of the most common heart disease treatments, from bypass surgery to angioplasty and stents.
…“Patients are wildly enthusiastic about these treatments,” he says. “There’ve been focus groups with prospective patients who have stunningly exaggerated expectations of efficacy. Some believed that angioplasty would extend their life expectancy by 10 years! Angioplasty can save the lives of heart-attack patients. But for patients with stable coronary disease, who comprise a large share of angioplasty patients? It has not been shown to extend life expectancy by a day, let alone 10 years—and it’s done a million times a year in this country.” Jones adds wryly, “If anyone does come up with a treatment that can extend anyone’s life expectancy by 10 years, let me know where I can invest.”
“The gap between what patients and doctors expect from these procedures, and the benefit that they actually provide, shows the profound impact of a certain kind of mechanical logic in medicine,” he explains. “Even though doctors value randomized clinical trials and evidence-based medicine, they are powerfully influenced by ideas about how diseases and treatments work. If doctors think a treatment should work, they come to believe that it does work, even when the clinical evidence isn’t there.”
And another key passage:
Jones argues that the predominant explanation of what causes heart attacks—-obstructions in the coronary vessels that need to be cleared—-is primarily to blame, because it leads to an erroneous emphasis on the highly visible plaques looming on angiogram screens. In fact, these plaques are not heart attacks-in-waiting; smaller, often invisible lesions in the heart vessels are now understood to cause most heart attacks. The problem isn’t so much that bypass surgery or angioplasty or stents aren’t working, Jones explains, but that in some cases, the interventions target the wrong lesions. “Instead of trying to stent every possible lesion, we need to realize that there are certain risks—-small plaques—-and that we cannot manage them all with stents or bypass. We need interventions, especially lifestyle changes or medications, that address the causes of atherosclerosis, and not just the largest plaques. And we need to accept that there are some large plaques that might not need intervention. What we really need to do, if we want to change the way we make decisions about these procedures, is to change both the culture among physicians and the culture among patients so that they accept a slight increase in risk tolerance.”
How lovely it would be if you could have French Fries every night and count on stents and surgery to save you. But Jones — and this in-depth piece by Alice Park — explain clearly why that isn’t so.