Re: Stenting

"David Rollo" <drollo@xxxxxxxxxx> wrote in news:1153818122.219796.280170
@s13g2000cwa.googlegroups.com:

These are very extreme views. I find it hard to reconcile what R Pierce
Butler is saying with modern cardiology practice.

For starters:
1. In my hospital I work on the basis of 2%-5% false positives or
negatives for nuclear stress tests. There are many studies reporting
over 90% sensitivity & specificity. We seem to do better than that.
It's exceedingly rare, for example, for someone with an abnormal
thallium scan to turn out not to have an anatomically-appropriate
lesion on follow-up angiography. Stress echo, when well done, is about
the same.

Then why would the OCALA hospital publish the rather damnning stats they
did. They are not the only ones that publish stats like that.


2. There is no prep for a nuclear stress test, unless it's a
Persantin / adenosine (non-exercise) version, when caffeine is excluded
for 24 hours. We don't ask people to skip breakfast. Certain
medications may need to be stopped.


IIRC my prep *** said no caffiene, nicotine, colas, high sugar content
breakfast, and more. It also said I would be at the office between 4-6
hours. There was a bunch of other things on the *** that were most
annoying. I have since thrown the *** away.


3. As far as the non-exercise, or chemical version goes: A Persantin
(dipyridamole) test sometimes makes people feel unwell because of BP
fall, but I've hardly ever had a patient complain about an adenosine
scan, and in any case symptoms from this cease within a few seconds of
stopping the infusion.


Maybe the patients are too afraid to admit that they are on the verge of a
panic attack. I remember the ride home after the first one. I was not
feeling well due to my heart pumping so hard. The heart contractions were
very strong, very noticeable, and most disturbing as I could feel each
beat.

4. Testing to exhaustion is not part of a normal diagnostic protocol.
I've only ever seen that in gung ho physical performance evaluations
("executive health checks"). Diagnostic testing is heart rate or
symptom-limited. If you test to exhaustion in asymptomatic people, then
yes, of course you will generate false-positives, and no, you don't
learn anything new. I don't know what value it has other than as a
confidence-building exercise for some people.


Then why did they do it the first time for me?

5. Clopidogrel (e.g. Plavix) for life is not standard practice after a
drug-eluting stent. One year, maybe a little longer. Some people have
recently expressed the view that it should be taken for longer periods,
but it rarely is. Side-effects from clopidogrel also have been rare in
my experience (unless you have to undergo unexpected surgery, when
there certainly are additional bleeding risks.)


Maybe I need a new cardiologist? I have a feeling that the issues may be
systemic to the way cardiology is practiced in the US. Maybe I am one of
"those" patients? In either case I have not seen of heard of anyone in the
US refuting the stats published by OCALA and others.

6. Recovery rate after CABG is prolonged in octogenarians - may take
a year before they're back to where they were - but it can be very fast
in people in their 50s and 60s. Plenty of these folk are back at work
in a month. A lot depends on how the early post-surgery period is
managed - rapid removal of the endotracheal tube (within a couple of
hours) greatly speeds up the process, and use of all-arterial grafts
(i.e. no leg veins) eliminates the mobility problems.


You don't recover overnight from having your chest split open and rib cage
spread. The pain is quite excruciating from all accounts I have read. In
addition from what I have seen and heard, you never really recover. Ask
the families of the patients. Ask them if they are really 100%.

Splitting the sternum isn't fun stuff. What is intersting is the various
hospitals that describe the CABG procedure to the patient. Depending on
who writes it it ranges from "Yoy will go in, go to sleep and wake up all
better" to some rather graphic details stating that you will be in
excruciating pain for a few to several days.

It is intersting that the loss of cognitive function likely due to "micro-
strokes" caused by surgical debris is just now coming to light and that few
docs talk about it and some don't even know about it.

I confess to being confused myself as to why the OP (dayb_) is
confused. The multiple options listed seem to be the same options that
face all of us whether we've had stents, symptoms, heart attacks, or
just plain nothing at all so far (waiting for the blow, Woody
Allen-style). I think you have to count on it that stenting (PCI) in
the elective or non-acute situation doesn't do anything but relieve
symptoms, although it's very good for that. Most heart attacks occur
from a lesion that arises acutely in a place that did not warrant a
stent 10 minutes earlier. And long-term angiogram follow-ups have shown
that if there is further deterioration, it has usually happened at
places in arteries which were not the ones that looked like they could
be stented at the time of the original angiogram. So what would be the
point of stenting moderate narrowings that are not currently causing
trouble?

David Rollo
Cardiologist, Melbourne Australia



David,

While it is likely apparant that my attitude is "not good" regarding this
and maybe I am looking at the nuclear stress testing and CABG wrong. Right
now the way I see it is as follows:

1) Avoid CABG at all costs unless you like being cognitivly impaired.
There are some that say that a surprisingly large percentage of CABG
procedures are performed unnecessarily. Recovery? You may never
"recover" as brain damage usually is permanent.

2) Stress tests are inaccurate. So much so that docs dismiss them and then
have other tests performed to determine the true extent of any disease if
there is any at all.


I wish you were here in the US. Maybe you could convince me that my views
are wrong. I am a skeptic, not a bigot. A skeptic demands to be convinced
with evidence. A bigot believes what he wants in spite of evidence.

Maybe you can answer the following. After a successful cath scan, why
would a doc want a nuclear stress test? What are the number of patients
that benefit from a stress test following a cath scan?



Pierce
.

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