HCR -- Stable Angina

By John Ballard

Here is the NIH link.

Stable angina is chest pain or discomfort that often occurs with activity or stress.

Angina is a type of chest discomfort caused by poor blood flow through the blood vessels (coronary vessels) of the heart muscle (myocardium).

Causes Your heart muscle is working all the time, so it needs a constant supply of oxygen. This oxygen is provided by the coronary arteries, which carry blood. When the heart muscle has to work harder, it needs more oxygen.

Symptoms of angina occur when the coronary arteries are narrowed or blocked by hardening of the arteries (atherosclerosis), or by a blood clot. The most common cause of angina is coronary heart disease (CHD).

Angina pectoris is the medical term for this type of chest pain.
Stable angina is less serious than unstable angina, but it can be very painful or uncomfortable.

So what's the big deal?
The big deal, as usual, is money -- yours or that of the insurance company going to the doctors. 
I will connect the dots for dull-witted readers.
The more it costs the insurance company the more rates go up.
And for Medicare beneficiaries, the more it costs the more you (if you are still working), your children and grandchildren will be paying in taxes. 
Got it?
Good.

Now read this.

Why do cardiologists often pass up safe, low-tech treatments for chest pain?  By David Brown

Can American doctors say �No� to an aggressive and high-tech treatment they�re used to providing even when it turns out a less heroic and cheaper one works just as well?

~~~~~~~~~~~~~~~~~~~

At issue is how to treat about 500,000 Americans who each year develop �stable angina,� which is chest pain that occurs in predictable fashion and is caused by blockages in the heart�s coronary arteries. There are two common treatment approaches. One is angioplasty with stenting, in which a catheter is threaded into the narrowed artery, which is then propped open with a tube made of metal mesh. The other is medication and changes to lifestyle.

In many people�s minds, this issue is settled. The answer came in a $33.5 million clinical trial called COURAGE, whose results were announced five years ago.

In that experiment, 2,300 people with stable angina were given �optimal medical therapy� consisting of aspirin, beta blockers and statin drugs, along with help losing weight, quitting smoking and keeping blood pressure under control. Half were also randomly assigned to get angioplasty and stenting. (The varieties of the procedure are known collectively as �percutaneous coronary intervention,� or PCI.)

After nearly five years, the rate of heart attack and death in the two groups was essentially the same: 18.5 percent in those getting only medical therapy and 19 percent in those who also got stents. The only difference between the groups was that people getting stents were slightly more likely to be angina-free (66 percent vs. 58 percent after one year).

~~~~~~~~~~~~~~~~~~~

The Obama health-care law � if it survives this year�s election and Supreme Court review � has many incentives aimed at making doctors do a better and more economical job.

Physicians may get more money if they adhere to guidelines (unless there�s a good reason not to). Medical organizations may get a �bundled payment� for a patient�s care, giving them reason to try cheaper, equally good therapies first. Quality ratings � and the status that comes with them � may be linked to following �best practices.�

The federal government also now officially sponsors the emerging field of �comparative effectiveness� research, which is built on the assumption that doctors can, and should, change their practices based on evidence and also what patients actually want.

It seems clear, though, that it will take more than incentives and new studies to make lessons like the one taught by COURAGE stick. It will require changing minds.

So how much is on the table?

A PCI procedure costs about $17,000. More than 500,000 are done each year in this country. Medicare pays for about 350,000 a year; this treatment alone accounts for at least 10 percent of Medicare�s total spending growth since the mid-1990s.

COURAGE sent shock waves through the cardiology community. There were immediately efforts to refine or discredit it. Some commentators said it was old news, citing previous smaller studies that showed the same thing. Others pointed to subgroups of patients (women, people with severely limited coronary blood flow) that seemed to do better with the more aggressive treatment.

But the message has remained clear: Cardiologists are jumping to angioplasty and stenting too quickly in lots of patients.

Ten percent of Medicare's spending growth over a decade is not chicken feed.

More details at the link. Read it and make a mental note for future reference. Should you or someone you know be diagnosed with stable angina, you are now better informed.