Slowing Down the Rush to Open Heart Surgery
Sometimes, heart disease erupts as a full-blown emergency with sudden, crushing chest pain. That’s when immediate intervention to restore blood flow to the heart can be lifesaving.
But in many situations, the path to aggressive care moves faster than called for, which can lead to overtreatment as well as worse outcomes and complications, says William Boden, M.D. a professor of medicine at the Boston University School of Medicine. When it comes to treating heart disease, Boden says, “there are many clinical instances when less is more.â€
Boden and other experts suggest that when it’s not an emergency, you slow down and do more research so that you can make smart decisions. That involves talking with your doctors about everything from whether you really need an expensive imaging test or invasive procedure to which hospital to choose if you do need open heart surgery.
And if you feel rushed into making a decision, “ask for a second opinion,†Boden says.
Here are the key questions to ask along the way:
More on Heart Health
Do I Really Need That Test?
The heart disease treatment odyssey often starts on a treadmill in a doctor’s office, as part of an exercise stress test. That test can be essential if you have symptoms that indicate heart disease, such as chest pain while exercising, or if you’re at high risk of a heart attack.
But some doctors include exercise stress tests as part of routine checkups, or as a safety check in people heading to certain surgeries.
Experts we spoke with said that’s generally not a good idea, in part because for people without symptoms of heart disease the test is often more likely to reveal a harmless abnormality than identify a real problem.
So if you feel fine and are at low risk, before you agree to a stress test ask why it’s necessary, says Marvin M. Lipman, M.D. Consumer Reports’ chief medical adviser. “If you don’t get a satisfactory answer, politely decline it or ask for a second opinion,†he says.
Are Drugs or Stents Better?
If you do undergo a stress test and it has abnormal or uncertain results, your doctor will probably refer you to a “cath lab,†or catheterization laboratory, for more tests. And that’s where the cascade of procedures often speeds up.
In that lab, a physician first performs coronary angiography, which involves threading a thin tube into an artery and injecting a dye so that narrowing shows up on an X-ray.
But patients are sometimes asked to sign a consent form that allows doctors, if they see restricted blood flow, to immediately perform a procedure called angioplasty to remove the blockage.
That’s not usually necessary, Boden says. “What should happen is hitting the pause button and having a thoughtful, transparent discussion of all the treatment options,†he says.
Performing an angioplasty involves a doctor inflating a thin balloon in the artery to widen it at the blockage, leaving a stent in place to prop the blood vessel open. It can be lifesaving when performed within hours of a heart attack.
But in other circumstances, lifestyle changes plus drugs to control blood pressure and cholesterol levels and prevent clots is at least as effective and usually safer. A 2016 review in JAMA Internal Medicine found that approach could cut the number of angioplasties by 80 percent.
One explanation for the continued overuse of angioplasty is that it is seen as a moneymaker for doctors and hospitals, says David Brown, M.D. a cardiologist at the Washington University School of Medicine in St. Louis.
Obviously, that’s not a good enough reason to have it. Instead, if you’re scheduled for angiography, talk with your doctor about what to do if that test finds worrisome—but not immediately dangerous—signs of harm.
It often makes sense to try two to three months of lifestyle changes and drugs first, and turn to angioplasty and stents only if those measures don’t ease your symptoms enough.
Hospital Ratings: Find Top Hospitals for Heart Surgery
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WORSE THAN EXPECTED AS EXPECTED BETTER THAN EXPECTED
Data come from The Society for Thoracic Surgeons. For details go How We Rate Hospitals.
Which Hospital to Choose?
In some cases, heart disease is so serious that drugs, even when combined with angioplasty, may not be enough. In that case you probably need open heart surgery, often to either bypass blood flow around blockages in your coronary arteries or to correct a malfunctioning heart valve.
Though both problems are serious, they’re not always emergencies, says Steven Nissen, M.D. chairman of the department of cardiovascular medicine at the Cleveland Clinic Foundation. Patients should be wary of doctors who do an angiogram in a nonemergency “and then say, ‘We can do your bypass tomorrow,’ †Nissen cautions.
Instead, your doctor can often stabilize your condition with drugs, giving you time to consider options. Though that’s not something many people think of doing, Nissen says they should. “People will often do a better job comparison shopping with a car they might buy than the heart program they go to.â€
Unfortunately, finding that information is harder than it is for cars. But Consumer Reports now has updated ratings of almost 500 hospitals nationwide on how they perform on open heart surgery, including coronary bypass surgery and aortic valve replacement.
The ratings are published in partnership with the Society of Thoracic Surgeons (STS), which collects data directly from hospitals on several key measures, including actual mortality and complication rates.
Most other hospital ratings rely instead on billing records that hospitals submit to insurers, which tend to be less accurate, says David Shahian, M.D. a professor at Harvard Medical School who also oversees the STS data registry, quality measurement, and public reporting efforts.
In addition, STS holds hospitals to high standards, Shahian says. “So even those whose STS score is ‘as expected,’ or average, typically provide high-quality care, and those that earn our highest rating are truly outstanding.â€
Hospitals share their data voluntarily. “Low-scoring hospitals deserve credit for having the courage to report,†he says. “They’re demonstrating their commitment to transparency and improvement.â€
Which hospital you choose matters. Of the hospitals in our ratings, only about 70 appear in our chart of best heart hospitals that appear at the end of this report. (Note that Cleveland Clinic does not appear in the chart; though it earns a top score for valve replacement, it could not be rated on bypass surgery due to incomplete data.)
Choosing the right surgeon is also important. Though information about specific surgeons is even trickier to find, Consumer Reports, working with STS, does report outcomes on heart surgery for groups of surgeons who practice together. Those ratings are available at CR.org/heartsurgeons.
If the surgical group you’re considering is not listed, ask the surgeon about how well it performs on the STS measures. If the surgeon can’t share that information—or won’t—we suggest you keep looking.
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