Doctors Fail to Explain Risks of Angioplasty

Percutaneous coronary intervention (PCI) is a procedure to expand arteries and improve blood flow to the heart. Commonly known as angioplasty, it’s performed on more than 1 million people a year in the U.S. According to a new report in JAMA Internal Medicine, a lot of them are receiving insufficient information from their doctors about the intervention.

The National Institutes of Health says that serious complications from angioplasty are rare, but they can happen no matter how skilled the doctor is. There’s no excuse for a medical provider not to explain all the risks and benefits of a suggested procedure to someone who’s not having an emergency or in a life-threatening situation.

A story from Reuters summarized the JAMA report. Admittedly, the study was small. Researchers analyzed recordings of 59 conversations between cardiologists and patients about the wisdom of having the procedure to address their angina. That’s chest pain that often flares after exercise or a stressful situation, and often can be managed with rest or medication.

Of the nearly 60 doctor-patient discussions, only two covered all the points people needed to make a fully informed decision.

PCI occurs after an angiogram, in which a small tube, or catheter, is inserted into a big artery (usually in the groin) and threaded to coronary arteries. Dye is injected to render the blockage visible on an X-ray.

The “balloon” angioplasty follows. A tiny deflated balloon is threaded through catheter to the site of the blockage. The surgeon inflates the balloon to open the artery, often followed by the placement of a stent, or tiny piece of wire mesh, to ensure the vessel remains open. As the balloon inflates to compress the plaque, the stent expands to the artery wall.

Some stents are coated with medication that’s continuously released into the artery to help prevent scar tissue from blocking the artery.

PCI is recommended not only to reduce angina, but to reduce the risk of heart attack. But not everybody benefits, and as with all invasive procedures, it has a risk of infection, damage to blood vessels or rupturing an artery, which would require open-heart surgery to repair.

So, “Having a PCI if you don’t really need one is not something an informed patient would do,” Floyd Fowler, Jr., told Reuters. He’s a senior scientific advisor at the Informed Medical Decisions Foundation, and wasn’t involved in the study. If someone doesn’t have enough information about the advantages and harms of a procedure as well as about alternative treatments that might be more appropriate to try first, patients might overestimate the benefits of angioplasty, he said.

The doctors in the JAMA study discussed alternative treatments in only 1 in 4 patient conversations. They were even less likely to confirm that patients understood the information they did offer, and to explain the pros and cons of different stents that might be used during surgery.

Most of the physicians recommended the procedure, which is no surprise to anyone familiar with the fee-for-service business model, or the propensity of providers who have skills and equipment to want to use them even when more conservative (and safer) measures might be appropriate. When doctors did advise a PCI, most patients agreed.

“In the rare instances when doctors didn’t express an opinion or recommended against the procedure,” Reuters said, “patients always listened.”

“Patients should be asking if the treatment will affect how long they live or prevent an event like a heart attack,” Dr. Grace Lin told Reuters. An internist at the University of San Francisco Medical Center, she was co-author of an editorial accompanying the study. “Patients should consider asking for a second opinion if they feel like they haven’t been given all the information they need in order to feel comfortable making a decision.”

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