Heart
Catheterizations – Are They Helpful? It
was reported this week that the number of coronary angiograms has dropped 25 % over
the past six years. The drop is believed
to be due to a 2007 report that the procedure doesn’t prolong life or decrease
the risk of a stroke or heart attack in patients who don’t have symptoms of an
impending heart attack.

The Clinical Outcomes Utilizing Revascularization and
Aggressive Drug Evaluation (COURAGE) trial began enrolling participants in
1999. The results were published in 2007
(Boden WE et al, Optimal medical therapy
with or without PCI for stable coronary disease, N Engl J Med. 2007 Apr
12;356(15):1503-16).

Heart catheterization with ballooning and stenting can be life-saving
if someone is experiencing the symptoms of a heart attack or if they are
experiencing crescendo angina (chest pain due to inadequate blood flow to the
heart muscle that is occurring with less and less exertion or stress). The COURAGE study found, however, that the
procedure doesn’t decrease the likelihood of a future heart attack, stroke, or
death in people with stable coronary artery disease.

Given what is known about the lack of benefit I would never
consent to undergoing a heart catheterization procedure if I didn’t have any
symptoms suggestive of heart disease. I
wouldn’t allow a cardiologist to perform the procedure if I had angina that was
predictable in nature and wasn’t significantly limiting my activities. I would only agree to the procedure if I
suspected I was having a heart attack or if I was having angina attacks that
were being triggered more easily or were increasing in frequency or
severity.

The reason is simple.
All medical procedures have an element of risk. That risk shouldn’t be accepted unless the
procedure is likely to improve the outcome of a medical condition. Several years ago I was asked to review the
medical record of someone who had died following a "routine” heart
catheterization. The study had shown
normal coronary arteries. Unfortunately,
the catheter bruised the lining of one of the arteries causing bleeding. The resulting clot blocked the artery and
caused a major heart attack from which the individual did not recover, even
though a second procedure was tried.

The risk of dying from an arteriogram is low, but that’s no
consolation to the family who has lost a loved one. Statistics don’t apply to individuals; the
incidence of death for that individual turned out to be 100 %.