Angioplasty Not for All Heart Patients... But Do They Know?


Dr. Harlan Krumholz, a Yale cardiologist and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, has been studying the perception gap for more than a decade. In 2000, he led a study that examined patients' perceptions about elective angioplasty , which found that "the majority of patients" had unrealistic expectations about long-term benefits. This year, he co-authored an article in the Journal of the American Medical Association that proposed addressing this ongoing problem with detailed informed consent documents that spell out details of angioplasty's potential benefits and risks, other medical approaches, the health care team's experience and the costs of the procedure, doctor's fee and required medications.

Patients May Overestimate Angioplasty's Benefit

Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic in Ohio, goes even further. He says the communication role "is best played by a 'gatekeeper,' a primary care physician or general cardiologist that doesn't perform the procedure. When the interventional practitioner who performs the procedure explains the benefits, there is a natural tendency to overstate the benefits. In the words of Mark Twain, 'to a man with a hammer, everything looks like a nail.'"

Other cardiologists contacted by ABC News agreed that the current informed consent procedures can fail.

"Often patients do not absorb all of the information, even when great care is given to discuss the procedure and its expected outcome," said Dr. David Faxon, chief of cardiology at Brigham and Women's Hospital in Boston. "In my view, it is best done in two settings with the physician describing the procedure, its indications, expected outcomes and risks and benefits followed by the same person or another -- often a nurse -- following up to discuss it again to be sure the patient and family understand it and to answer any questions."

When it comes specifically to angioplasty, Dr. Kirk Garratt, director of clinical research of interventional cardiovascular research at Lenox Hill Hospital in New York, says he understands why patients may overestimate potential benefits. "To a layperson, it seems sensible that getting rid of a severe blockage should provide some protection against heart attack. I've had pointed conversations with certain patients over the years, and even when I've gone over things carefully and honestly, some patients simply can't shake the belief that getting rid of a plaque won't prevent a heart attack. It doesn't make sense to them."

Many patients "want to believe that [angioplasty] is life-saving so badly that no consent process would change their minds."

Dr. James N. Slater, an interventional cardiologist at NYU Langone Medical Center in Manhattan, has been there. "Most patients -- including myself in that role -- in my experience tend to overestimate the value of most medical procedures if for no other reason than they are hoping for the best." Stable angina patients often sign consent forms "immediately prior to the procedure and often are nervous and anxious. This coupled with the fact they are given sedation during angioplasty makes it difficult for them to recall what exactly they were told. After such a heroic effort on the part of the patient, maybe it is only natural that they think that Father Time may have been defeated once again."

Surgery Still Best for Some Heart Patients

Dr. Raymond Gibbons, a professor of medicine at the Mayo Clinic in Rochester, Minn., advocates a health system that encourages and reimburses doctors for taking the time to make the decision with the patient. He says some cardiologists may oversell angioplasty because of financial incentives "to grow the business," because angioplasties make money for the hospital and the doctor. But, he says, the problem "is not bad doctors. We have a bad system."

Finally, cardiac surgeons weighing in on the Baystate study had yet another perspective about how angioplasty is presented to patients. Dr. Thoralf Sundt, vice chair of surgery at the Mayo Clinic, noted that in some cases, "the benefits of surgery have been under-played and the benefits of angioplasty overplayed." He added, "Understandably, part of the issue is that no patient really wants surgery."

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