I didn't understand all the terms used in this article, but I did understand what was being said overall and it's a little scarey.
PCI = angioplasty with or without stenting (I think)
CAD= coronary artery disease
Gut feelings may trump evidence-based medicine when choosing PCI to treat stable CAD
August 16, 2007
San Francisco, CA - Gut instincts may sometimes trump evidence-based medicine when it comes to performing PCI in patients with stable coronary artery disease (CAD), a new study suggests. Cardiologists asked hypothetically about their motives for choosing PCI even in patients who might do just as well or better with medical therapy acknowledged that PCI instinctively seemed a better choice or that past experiences or anticipated regret sometimes guided their decision.
"The apparent gulf between evidence and practice appears to be motivated primarily by emotional and psychological factors," Dr Grace A Lin (University of California, San Francisco [UCSF]) and colleagues write in the August 13/17, 2007 issue of Archives of Internal Medicine.
To heartwire, study senior author Dr Rita F Redberg (UCSF) emphasized that physicians in the focus groups defended their choices despite agreeing on a lack of evidence to support them. "We did try to point out during the focus sessions that PCI was an invasive therapy and there could be complications secondary to invasive therapy. And people still told us that they would feel much worse about a heart attack or sudden death that could have been prevented than a complication of a PCI, even though there are no data that they actually would be preventing a heart attack or sudden death by doing PCI."
Emotional decision-making
Lin and colleagues conducted three focus groups with a total of 20 interventional and noninterventional cardiologists who were asked to discuss three hypothetical case scenarios and describe what course of action they would take. One case involved a 45-year old asymptomatic man with a history of MI and a high calcium score; the second hypothetical case was a 55-year old female smoker with sharp pain in the chest occurring primarily in the evenings and not associated with exercise; the third, a 60-year-old man with no chest pain or shortness of breath who tires early.
Despite reviewing evidence that showed that an invasive approach was not warranted in any of the hypothetical cases, the focus groups generally agreed in all cases that they would send the patient for PCI. Some cardiologists justified their decision by saying that an open artery is always preferable and that they wanted to deliver the best possible therapy, which in their minds is PCI. Others told anecdotes of past patients who had not gotten PCI who went on to have MIs or die suddenly and said that this influenced their subsequent decision-making. Assuaging patient anxiety, particularly if the patient self-referred after obtaining a coronary calcium score, was another driving factor, as was the occulostenotic reflex.
"Once a lesion considered significant was identified, the consensus about current practice was to proceed, in most situations, with PCI at the same time," the authors note. Additional explanations for choosing PCI included medicolegal concerns and technological advancements such as electron-beam computed tomography (EBCT) and CT angiography that persuaded cardiologists to refer for or perform angiography and PCI.
The study authors conducted their study before the results of COURAGE came out in March. According to Redberg, there is a heightened awareness about the lack of benefit of PCI in stable CAD patients in the wake of the COURAGE trial, "but even before COURAGE came out, people really knew that there never had been a study that found a benefit of PCI over medical therapy, and we do report that data in our paper. . . . But COURAGE got a lot of publicity and certainly may have changed the way people think about medical therapy vs PCI for stable CAD."
But Redberg also thinks physicians fail to recognize when they themselves are not basing decisions on evidence, preferring to think that it is others who are acting inappropriately. "I think we have to have some sort of understanding or recognition that there is more than evidence that drives practice. I think most people feel that they practice according to the best evidence, but even when we tried to be quite clear that there is just no evidence to support what people are telling us they would do, I don't think anyone changed their minds. They still felt doing an intervention would be better than not doing one."
Selective evidence-based medicine
An accompanying editorial by Dr Mauro Moscucci (University of Michigan, Ann Arbor) points out that PCI is not without its risks: "Inappropriate procedures will put patients who are unlikely to benefit from the procedure at substantial risk of fatal and nonfatal complications," he writes. As such, Lin et al's work is a "sobering first documentation that the practice of medicine pertaining to PCI might be far from evidence based."
Moscucci's views are echoed by Dr William Boden (Buffalo General Hospital, NY), co-primary investigator for the COURAGE trial, who commented on Lin et al's paper for heartwire.
"This just reinforces that there is an apparent disconnect between clinical knowledge and the belief about the benefits of PCI," Boden said. "The benefits of angioplasty in STEMI patients have created a belief that because the procedure is identical to that which is undertaken electively in stable patients, the benefit that accrues in the acute patients will likewise accrue in the chronic patients, and that has become the conventional wisdom."
Boden worries that a study like Lin et al's will "fly below the radar" of most cardiologists, who should, in fact, use this kind of qualitative research to pause and rethink their own decision-making. "Belief systems trump evidence," he said. "We continue to see example after example of how we really don't practice evidence-based medicine in this country. I like to refer to this as either selective evidence-based medicine or feel-good evidence-based medicine. We love studies that reinforce our preconceived belief systems and we go out of our way to tout their virtues. By contrast, when studies like OAT, ICTUS, or COURAGE come out, everybody is quick to criticize them and is very reluctant to incorporate them into their clinical practice approaches."
Boden continued: "We have this peculiar brand of evidence-based medicine in the US, which is that we embrace studies that reinforce our belief systems and disdain, denigrate, go out of our way to bad-mouth studies that collide with our existing belief systems."
PCI = angioplasty with or without stenting (I think)
CAD= coronary artery disease
Gut feelings may trump evidence-based medicine when choosing PCI to treat stable CAD
August 16, 2007
San Francisco, CA - Gut instincts may sometimes trump evidence-based medicine when it comes to performing PCI in patients with stable coronary artery disease (CAD), a new study suggests. Cardiologists asked hypothetically about their motives for choosing PCI even in patients who might do just as well or better with medical therapy acknowledged that PCI instinctively seemed a better choice or that past experiences or anticipated regret sometimes guided their decision.
"The apparent gulf between evidence and practice appears to be motivated primarily by emotional and psychological factors," Dr Grace A Lin (University of California, San Francisco [UCSF]) and colleagues write in the August 13/17, 2007 issue of Archives of Internal Medicine.
To heartwire, study senior author Dr Rita F Redberg (UCSF) emphasized that physicians in the focus groups defended their choices despite agreeing on a lack of evidence to support them. "We did try to point out during the focus sessions that PCI was an invasive therapy and there could be complications secondary to invasive therapy. And people still told us that they would feel much worse about a heart attack or sudden death that could have been prevented than a complication of a PCI, even though there are no data that they actually would be preventing a heart attack or sudden death by doing PCI."
Emotional decision-making
Lin and colleagues conducted three focus groups with a total of 20 interventional and noninterventional cardiologists who were asked to discuss three hypothetical case scenarios and describe what course of action they would take. One case involved a 45-year old asymptomatic man with a history of MI and a high calcium score; the second hypothetical case was a 55-year old female smoker with sharp pain in the chest occurring primarily in the evenings and not associated with exercise; the third, a 60-year-old man with no chest pain or shortness of breath who tires early.
Despite reviewing evidence that showed that an invasive approach was not warranted in any of the hypothetical cases, the focus groups generally agreed in all cases that they would send the patient for PCI. Some cardiologists justified their decision by saying that an open artery is always preferable and that they wanted to deliver the best possible therapy, which in their minds is PCI. Others told anecdotes of past patients who had not gotten PCI who went on to have MIs or die suddenly and said that this influenced their subsequent decision-making. Assuaging patient anxiety, particularly if the patient self-referred after obtaining a coronary calcium score, was another driving factor, as was the occulostenotic reflex.
"Once a lesion considered significant was identified, the consensus about current practice was to proceed, in most situations, with PCI at the same time," the authors note. Additional explanations for choosing PCI included medicolegal concerns and technological advancements such as electron-beam computed tomography (EBCT) and CT angiography that persuaded cardiologists to refer for or perform angiography and PCI.
The study authors conducted their study before the results of COURAGE came out in March. According to Redberg, there is a heightened awareness about the lack of benefit of PCI in stable CAD patients in the wake of the COURAGE trial, "but even before COURAGE came out, people really knew that there never had been a study that found a benefit of PCI over medical therapy, and we do report that data in our paper. . . . But COURAGE got a lot of publicity and certainly may have changed the way people think about medical therapy vs PCI for stable CAD."
But Redberg also thinks physicians fail to recognize when they themselves are not basing decisions on evidence, preferring to think that it is others who are acting inappropriately. "I think we have to have some sort of understanding or recognition that there is more than evidence that drives practice. I think most people feel that they practice according to the best evidence, but even when we tried to be quite clear that there is just no evidence to support what people are telling us they would do, I don't think anyone changed their minds. They still felt doing an intervention would be better than not doing one."
Selective evidence-based medicine
An accompanying editorial by Dr Mauro Moscucci (University of Michigan, Ann Arbor) points out that PCI is not without its risks: "Inappropriate procedures will put patients who are unlikely to benefit from the procedure at substantial risk of fatal and nonfatal complications," he writes. As such, Lin et al's work is a "sobering first documentation that the practice of medicine pertaining to PCI might be far from evidence based."
Moscucci's views are echoed by Dr William Boden (Buffalo General Hospital, NY), co-primary investigator for the COURAGE trial, who commented on Lin et al's paper for heartwire.
"This just reinforces that there is an apparent disconnect between clinical knowledge and the belief about the benefits of PCI," Boden said. "The benefits of angioplasty in STEMI patients have created a belief that because the procedure is identical to that which is undertaken electively in stable patients, the benefit that accrues in the acute patients will likewise accrue in the chronic patients, and that has become the conventional wisdom."
Boden worries that a study like Lin et al's will "fly below the radar" of most cardiologists, who should, in fact, use this kind of qualitative research to pause and rethink their own decision-making. "Belief systems trump evidence," he said. "We continue to see example after example of how we really don't practice evidence-based medicine in this country. I like to refer to this as either selective evidence-based medicine or feel-good evidence-based medicine. We love studies that reinforce our preconceived belief systems and we go out of our way to tout their virtues. By contrast, when studies like OAT, ICTUS, or COURAGE come out, everybody is quick to criticize them and is very reluctant to incorporate them into their clinical practice approaches."
Boden continued: "We have this peculiar brand of evidence-based medicine in the US, which is that we embrace studies that reinforce our belief systems and disdain, denigrate, go out of our way to bad-mouth studies that collide with our existing belief systems."