M 32 The San Juan Daily Star

The San Juan Daily Star
November 21-23, 2014
An Incipient Threat to Our Hearts
illions of Americans are walking
around with deposits in their coronary arteries that do not obstruct blood flow to their hearts — at least,
not until a piece of the plaque ruptures and
forms a blood clot, causing a heart attack.
These plaques are signs of a condition called nonobstructive coronary artery
disease, and they are found in 10 percent
to 25 percent of patients who have a coronary angiogram, typically done for patients with symptoms like chest pain or
shortness of breath or those who flunk a
cardiac stress test.
Historically, doctors have considered the partial obstructions insignificant,
and a surprisingly large percentage of patients with them are sent home without
treatment. Often patients are given “the
good news that they don’t have a coronary
blockage,” said Dr. Thomas M. Maddox, a
cardiologist at the Veterans Affairs Eastern
Colorado Health Care System and the University of Colorado in Denver.
Sadly, the news isn’t really good.
By some estimates, the majority of heart
attacks result from these nonobstructive
lesions. Four years ago, Dr. Maddox and
his colleagues published a study of nearly
1.5 million patients with varying degrees
of coronary artery disease. Compared
with those who had major obstructions in
their coronary arteries, patients with nonobstructive lesions were less likely to be
prescribed therapy with aspirin, a statin
or other drugs to reduce their heart attack
This month, Dr. Maddox and coauthors published a study in JAMA graphically demonstrating the sometimes
devastating consequences of ignoring nonobstructive coronary disease, especially
in patients with symptoms.
The researchers gathered data on
37,674 veterans without known coronary
artery disease who underwent elective angiograms between October 2007 and September 2012 in the Veterans Affairs health
care system. Fifty-five percent were found
to have obstructive coronary disease, and
22 percent had nonobstructive disease.
The risk of having a heart attack or dying
within one year was directly related to the
extent of disease in the participant’s coronary arteries. As expected, the risk was
greatest among patients who had obstructive coronary disease, defined as a blockage equal to or greater than 70 percent in
one or more coronary arteries.
But the prognosis for patients with
nonobstructive disease was hardly benign.
Compared with those who had no evidence of coronary artery disease, or CAD,
the risk of suffering a heart attack within
just one year of the exam was doubled in
patients with nonobstructive CAD in one
artery, and more than four times greater in
those with nonobstructive disease in two
or three arteries. The death rate increased
with the extent of nonobstructive disease.
“These findings highlight the need to
recognize that nonobstructive CAD is associated with significantly increased risk
for myocardial infarction,” or heart attack,
Dr. Maddox and his colleagues concluded.
The researchers spurned the traditional distinction made between nonobstructive and obstructive CAD, and suggested that all patients with nonobstructive
disease would likely benefit from drug
treatment — although no randomized clinical trials have yet been done to support
this recommendation. (In particular, stents
have not been shown to be an effective preventive for such patients.)
“If we did an angiogram on every
adult, a significant number would be found
to have nonobstructive disease and be at
risk of a heart attack,” Dr. Maddox said
in an interview. “If an angiogram shows
a blockage of 30, 40 or 50 percent in one
or more arteries, the patient should be on
preventive therapy.”
He does not recommend routine angiograms, however, which are costly and
have risks of their own. On rare occasions,
they can cause bleeding, infection, damage to blood vessels, or an allergic reaction
to the dye used. Alternatively, patients can
choose a noninvasive test, like a coronary
calcium score or CT angiogram.
Heart disease is linked to a slew of
risk factors: smoking; being overweight,
obese or physically inactive; having high
cholesterol, high blood pressure, Type 2
diabetes or pre-diabetes; a family history
of heart disease before age 65; consuming
an unhealthy diet; and being 55 or older.
Chronic stress also has been linked to
heart disease.
Doctors usually advise patients at
risk to modify their living habits. If they
smoke, they should stop — within as little
as a year, their coronary risk can drop to
that of a nonsmoker.
Those who are overweight may be
told to cut down on fattening foods, eat
more fruits and vegetables, and to exercise more, measures that help lower body
weight and cholesterol and help control
high blood pressure and diabetes.
If high cholesterol is a problem, saturated fats like dairy and meat fat should be
reduced, and unsaturated olive or canola
oil used when fat is needed.
Some of this advice was given to
my father in 1979 after he suffered a heart
attack at age 58. He never smoked, was already active and not overweight. He modified his diet, which helped to keep him alive for 13 more years. But lacking anything
more to do to protect himself, he succumbed to a second heart attack at age 71.
Now there is proof that certain medications can ward off even a first heart
attack in people at risk. The two most commonly recommended are a daily baby aspirin and a statin.
Aspirin thins the blood, reducing
the risk that a blood clot will form in a
coronary artery. The Food and Drug Administration does not recommend daily
use to prevent a first heart attack — but
some doctors do. Possible side effects include an increased risk of gastrointestinal
A statin, though primarily prescribed to lower blood levels of artery-clogging cholesterol, turns out to have cardiac
benefits beyond slowing the formation of
new plaques in coronary arteries.
Statins sometimes reduce the size of
existing lesions. They can suppress inflammation that contributes to plaque formation. They improve the function of cells
that line the arteries, enabling them to expand as needed.
Statins may also stabilize plaques, reducing the chance that they will rupture
and block arteries feeding the heart.
Given these benefits and the fact that
plaque rupture is the source of 95 percent
of heart attacks, Dr. Maddox said that if
he had coronary artery disease and was
stranded on a desert island, the one drug
he would want to have with him is a statin.
The San Juan Daily Star
November 21-23, 2014
That Medical Test Costs $50, or Is It $500?
hen I was growing up in Lexington, Ky., in
the late 1970s, we used to go to an all-youcan-eat buffet called Duff’s. It was the cheapest restaurant in town. My father and mother ate
for $2 apiece, my brother and I were charged $1, and
my little sister, who was 3, ate free. After my father
paid the cashier, we’d sprint over to the smorgasbord
and fill our plates. We’d fill them again and again. If
the fried chicken got cold, my father would tell us to
throw it out and get more. We gorged; we took advantage; we were wasteful — because we perceived
it as free. We’d eat so much that one of us would invariably get sick on the way home.
In many ways, Duff’s is like our health care system. Someone else appears to be paying for it, so who
cares how much it costs?
To fight this, insurers continue to raise co-payments and deductibles, making us pay more in an attempt to reduce inefficient spending. But health care
costs continue to rise. Recently, the agency that runs
Medicare said that health spending would increase
by 5.6 percent in 2014, 2 percentage points more than
last year. Health care prices in the United States dwarf
those of all other industrialized countries.
Some have advocated price controls. A better
strategy is price transparency. Patients may be shouldering more of the burden of health expenditures,
but they still don’t know what they are paying for.
Requiring patients to have more “skin in the game”
without giving them adequate price information is
like making Duff’s customers pay à la carte but not
telling them what the steak costs compared to the
chicken. Without this information, they are bound to
make bad choices.
Forcing consumers to shop blindly while requiring them to share costs is also fundamentally unfair.
Cost sharing redistributes the burden of health care
costs, particularly to low-income earners who often
have high-deductible insurance plans, but does little
to lower spending.
Price transparency, on the other hand, can remedy this. For example, in a study published last
month in JAMA, patients in a health insurance plan
were given access to a pricing website that calculated
out-of-pocket costs for various medical procedures.
The authors found that patients who used the website
(searchers) spent 14 percent less for laboratory tests
and 13 percent less for CT and M.R.I. scans than those
who did not (nonsearchers). Notably, searchers in the
study had spent more than nonsearchers before the
website went up, indicating that they were no more
frugal at baseline. Price transparency appeared to be
the factor that drove the decrease in spending.
In another recent study in the journal Health
Affairs, patients in five cities (mostly in the Midwest)
were given information about how much an M.R.I.
cost at different clinics, but were not penalized if they
chose a more expensive option. Meanwhile, patients
in nine other cities were given no such data. After
two years, the average cost of an M.R.I. fell by $95 in
those places where prices were provided but increased by $124 where they were not because of competition among different centers and more cost-conscious
Doctors, too, lack basic information about what
health care tests and procedures cost. When I was a
resident in New York City, we used to order patients’
weekend labs on Friday afternoons. Every patient on
our ward would routinely get a complete blood count
and an electrolyte panel (and additional blood tests
as needed). With 60 patients, this added up to hundreds of assays every weekend. None of us knew that
an electrolyte panel costs about $100, and no one ever
thought to ask. But most patients don’t need an electrolyte panel or complete blood count every day. With
a few drizzles of ink, we would spend thousands of
dollars with hardly a second thought. Knowing the
lab prices might have dissuaded our profligacy, but
the hospital never shared this information with us.
Today, several states are demanding greater
health care price transparency to protect patients. In
California, for example, hospitals are required to advertise their charges for the 25 most common outpatient procedures. A similar law applying to health
insurers was enacted in Massachusetts last month.
Corporations are also pushing for more openness.
The Safeway grocery chain, for instance, has provided prices for screening colonoscopies to its employees since 2009, resulting in a drop in the average
price of the procedure by nearly 20 percent because
employees, responsible for any excess charges, are
shopping around.
Of course, price data has to be paired with quality figures so patients don’t make the mistake of
equating more expensive care with better care. (In
medicine, there is usually very little correlation.) We
also have to guard against cost shifting, in which
providers cut prices on services for which rates are
available but charge more for services whose rates
are not.
We are lucky to live in an era in which consumers enjoy great power and choice. Unfortunately,
the health care industry remains a major exception.
As doctors, we strive to provide information to our
patients to help them make informed medical decisions. In today’s cost-cutting environment, it is only
fair that we provide them the data to make informed
financial decisions, too.