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Discussion in 'The Okie Corral' started by Mr981, Nov 16, 2019.
This so called study I’d label under junk science.
The last bullet item on any report will be a discussion of the need for additional study and a request for additional funding. No study is ever the definitive and final study on the topic.
Medical industry is no different than other industries in that if you have a problem, or a question, follow the money.
This is not the first trial that has shown similar results. One of the earlier major trials, the "COURAGE" trial back in the early 2010's and a few subsequent meta-analysis have shown similar trends - meaning that for stable, chronic coronary artery disease, revascularization (meaning stents) do not offer overall mortality benefits compared with combined aggressive dietary, medication, and lifestyle modifications.
The problem is how to define stable, chronic coronary artery disease. Randomized clinical trials can often cherry pick their study participants through their "exclusionary criteria" (or what we call the a priori criteria. This is why academicians debate on how a particular study can be generalized to the population at large.
Bottom line is, this is nothing new - we have known for the past 10 years or so that revascularizations in patients with stable coronary artery diseases (and "stable angina") do not offer mortality benefits over aggressive medical management and lifestyle modifications. Revascularization, however, may improve symptoms (reduce episodes of stable angina) more quickly and easily. The problem is, in order to define stable coronary artery disease, you often need an actual cardiac catherization to determine the exact percentage of blockage of a particular coronary artery.
And, no amount of medication is going to save you during an acute heart attack - an acute heart attack (including acute coronary syndromes, unstable angina... etc) still require timely revascularization to save your life.
Thanks for posting!
At my annual check-in with my cardiologist, about the only question of substance was whether I was still taking a statin. It seems my HMO puts a lot of faith in statins.
Truth be told, my bouts of angina have decreased to about zero over the last 10 years. I started on statins about the time the patent on Lipitor ran out (Nov 30, 2011). My interventional cardiologist was very excited that mere mortals could now afford the medication.
Still on the green side of the grass!
Link updated at 2200 hrs today; the Washington Post added an article on this subject this afternoon.
From what I've read of it, this was considered a large study and was highly anticipated.
Years of smoking, overeating, and frolicking with wild women would put anyone in the hospital
As a Pathology Prof. once quipped during a lecture on atherosclerosis, “and if you don’t do any of those things you may not live to be 100, but it will certainly feel like it”.
That never ending search for additional funding is an easy source or avenue for biased study results.
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What do these doctors not understand?
I want to smoke cigars, drink, and eat bacon fried in bacon fat dipped in bacon gravy every day and all I ask is that they fix me. God.
Maybe them socialized doctors are smarter. I just want someone to tell me what I want to hear, how hard is that to understand?
My wife hit the ER in our local hospital and immediately got sent by ambulance to St. Patrick's and the International Heart Institute. (IHI)
She was gray-colored and hardly breathing.
A "Douggie Howzer" type of teenaged cardiac specialist doctor stented her and she walked outta the hospital the next day after an overnight observation.
She had a second incident a year later and that was because she didn't like the side effects of the Statin.
Now she takes her statin every day as prescribed and I just bought her a new harness with Conchos on it (she likes Conchos) and she's up to tilling two acres a day again.
For a while there she slowed 'way down and could only plow 1/4 acre or less.
So pharmaceutical companies are pushing studies, and probably writing criteria, that prove that their products are equal to or better than a physical approach. I like the idea, but if I'm laying on a bed in an ED being told I have 98% blockage of a coronary artery, I think I prefer a trip to the Cath Lab or Interventional Radiology to a trip to the pharmacy.
I don't know how much will change. There is an internal pacer type device that stimulates a nerve to suppress hunger. In studies it proved equivalent to gastric bypass, but very few insurance companies cover it. Then there is the duodenal stent that all but eliminates diabetes symptoms, but insurance companies won't pay for it. I work with a guy who had gastric bypass surgery for diabetes because the insurance company wouldn't pay for the duodenal stent. The stent is minimally invasive where gastric bypass not only opens the patient up, it radically insults the digestive tract.
Could this be the pill approach Obama suggested OUR grandmothers take?
I don’t buy it. Definitely before there are issues sure, but a 100% occlusion of the LAD or RCA, diet ain’t do ****.
Damn son, you married a horse?
Wondering what he is talking about too but is ugly enough to get away with it.
Most cardiologists believe regular tap water should be fortified with statin and beta blocker.
When you are in the ER with acute chest pain, elevated troponin, and EKG changes consistent with an acute MI - you are going to the cath lab to get revascularized with stents. The study does not change this. At that point, you do not have "stable angina" nor "chronic stable coronary artery disease."
What the study is addressing is chronic stable CAD. And this is where the pendulum is swinging. For a couple of decades, the pendulum was in the direction of stenting everything we can find (and a few cardiologists actually went to prison for this for cath'ing and stenting patients who did not need them)… now, over the past 10 years, we are finding that stents on chronic stable patients do not really improve mortality. And stentings are not without their own risks. So a more conservative non-invasive approach is where the pendulum is swinging now.
Yes, acute critical occlusion of proximal LAD, RCA, or the left main will still earn you a trip to the cath lab for stents, and probably CABG if it's the left main or acute 100% occlusion where we cannot pass the guidewire to stent you. Nothing in the literature is changing that.
And newly diagnosed left heart failure will still earn you a trip to the cath lab for ischemic eval.
However, CTO of distal LAD, or one of the OM's, diagonals, with adequate collaterals are probably reasonable to treat with aggressive medical managements nowadays - statin, beta blockers, nitrates, ACEI, antiplatelets, ranolazine, quit smoking/cocaine/meth, exercise... etc.
And, if maximal medical therapy and lifestyle modification are not resolving your stable angina and you want symptom relief, then stenting is probably still reasonable as a symptom relieving measure, understanding that stenting in these cases probably offers no overall mortality benefits and does not decrease MACE. Again, this study does not change this approach.
This new study is basically confirming what we've suspected/known all along from the original COURAGE trial a decade ago. It addresses some of the criticisms on the generalizability of the COURAGE trial.
*edit to clarify some of the acronyms - was in a hurry this morning.
LAD - Left Anterior Descending (the major coronary artery feeding the main chamber of your heart, the "widow maker.")
RCA - Right Coronary Artery - the main feeding artery to your right ventricle and the bottom of your heart.
CABG - Coronary Artery Bypass Graft (open heart surgery)
CTO - Chronic Total Occlusion - when a coronary artery is CTO, there are usual collateral flows that develop to go around it. This is to distinguish from acute occlusion of a coronary artery which causes an acute heart attack.
OM - Obtuse Marginal (branches of coronary arteries)
Diagonals - also branches of coronary arteries.
MACE - Major Adverse Cardiac Events - acute heart attacks, heart failures, life-threatening arrhythmias, strokes, sudden cardiac deaths.
Point is, acute blockages and heart attacks are still treated with stents and open heart surgery - nothing has changed. What we are realizing over the past 10 years is that in chronic stable blockages causing stable chest pain, stenting is no better than medical management when it comes to mortality or major cardiac events down the road. Keep in mind that stenting is not without its risks. Coronary artery rupture during stenting is a known complication (and often results in deaths). And after stents, you will need to be on "Duel Antiplatelet Therapy" ("DAPT") for at least 12 months, up to 30 months - using two different anti-platelet meds to "thin" your blood - putting you at significantly increased risk for bleeding.
If a person needs a stint or a bypass, they better get it. Eating a stalk of celery and running around the tennis courts is not a realistic alternative to miracle of medical science surgical techniques!
Nope. Glad you're still here.
Everyone's different. If you're one of the people for whom the device was designed to offer an optimal (lifetime?) solution, nothing to complain about. Keep on keeping on.
Now, if you were some who'd ended up having several of them inserted over time (like someone I spoke to), it might make you wonder about simultaneous options and treatment plans for the individual.