so let's go on and let's make just a few more minutes on
today's special topic and that is the unnecessary triad
here's the unnecessary triad positive stress tests means you may have blocked arteries that's not
so much the problem is the problem that about fourth to a third of these are false positives
the other bigger problem is what happened to Tim Russert about two-thirds of the people that are
going to have a heart attack or that have a heart attack don't get blockage they don't have that
much plaque yet so anyhow if you have a positive stress test you'll be probably they'll want to
take you to the cath lab for an angiogram the angiogram usually detects atherosclerotic plaque
doesn't matter if the plaque is big enough to cause a blockage if the plaque is detected
and depending on what the cardiologist thinks you may be recommended a stent or even a bypass
unfortunately you know actually I'm less concerned about unnecessary stents and unnecessary bypasses
I'm more concerned about this next statement stents and bypasses often create a false
sense of security both for the doctors and the patients so you've got a lifestyle problem you
think it's a plumbing problem only and you think I'm gonna fix it with plumbing that
doesn't work just like you can't out-supplement a lifestyle problem you can't out-stent you can't out
bypass a lifestyle problem either this progression from stress test to cardiac cath to stent is
tragically common and it's often unnecessary in terms of costs it's billions of dollars each year
if the stress test is a false positive all that stuff is for nothing cardiac cath that involves
inserting a cath long thin tube into a blood vessel in the groin or arm with the cath docs
perform diagnostic procedures like angiogram and treatments like the stent itself an angiography
combines the catheterization X-ray and dye injection radioactive dye here's the cath you see
right here they threaded it in into an area gave the injection of the dye then you get a picture
of the arteries and then you get that little error there and there showing some a smaller diameter
the assumption is well then that's about to close off and cause a heart attack that's
not how heart attacks occur let me go back to the script coronary angiography is known by
other names arteriography invasive or percutaneous angiography interventional angiography or catheter
angiography catheter cath or a cardiac cath with dye a coronary stent is a small mesh-like tube
like here you take it to one of these pinch points you thread it through you expand it in the theory
the assumption is that that will keep you from having a heart attack it's an incorrect assumption
so in the US there are about two million stents done each year again like I said
that was until COVID happened and the placement of these stents again has plummeted there's still not
good research showing how much yet that's going to take some time doctors and patients assume
stents fix the problem the science shows that it doesn't and again I'll get tons of haters you're
telling me my stent didn't work I had pain before then I don't have pain now I'm not telling you
your stent didn't work like I said before stents save lives about 10 of them the other thing I'm
telling you is I'm not telling you one thing or another I'm just reporting the science look at the
COURAGE trial the ORBITA trial the ISCHEMIA trial the COURAGE trial as you see here was
I believe that was well I'm not going to go into I mean these were like New England Journal JAMA and
Lancet level these were leading medical journal trials so the COURAGE trial reported placing
a stent and unblocked arteries failed to reduce the risk of death heart attacks or cardiovascular
events the ORBITA trial the ORBITA trial was interesting it was the one that was done in
England because American human subjects committees would not agree to putting somebody in a study
where you said you need a stent take them into the or prep them do all that stuff put them to sleep
and then not do a stent that's exactly what they did the study group got the stent the placebo
group did not get a stent and guess what those who had a stent were no better off than the ones
that didn't have a stent and this is for treating angina so again don't don't write me and tell me
that I'm crazy I'm just telling you what happened in the study I know that's very hard for a lot of
people to believe ISCHEMIA trial so you know the COURAGE trial ORBITA trial some of these others
started really making it clear that maybe the stents are not preventing heart attacks guys well
does that mean we should just go to bypass well the CABG coronary artery bypass graft that's
what a lot of people did they started going to the bypass well the ISCHEMIA trial showed that
and bypasses and bypasses no more effective than drugs for treating stable heart disease
so again you can't do plumbing to fix a lifestyle problem risks and downsides mortality rates
you know it sounds awesome and gruesome you're sticking a needle into the groin you're threading
a catheter up into the heart yes that's a problem but frankly I'm not quite so concerned about the
danger associated with that as I've said before I'm concerned about the false positive the false
negative the false assurances that people get from having these procedures done 800 to 2,500 deaths
occur annually from angiography and attributed to the angiography and I don't think that all of
those should be attributed I mean because you're not going in there unless you have high risk
already by definition now as I've said we get a lot of people that go in there that really don't
have high risk they just had a false positive test and again we send a strong message to the people
that don't go in there you don't have risk but anyhow a lot of high risk people do end up getting
into this process some cardiologists think caths are risk-free they're not actually a friend of
mine used to run a cardiac cath lab he walked in one night and one of the cardiologists was doing a
cath on the other cardiologist just so they could see what it was like these cost about 20,000 a
piece and again all I'm saying is let's look at the science let's look at the evidence and let's
figure out is this a plumbing problem or is it a lifestyle problem there's radiation risk once you
start adding angiography to these activities the combination of a nuclear stress test
angiogram and then stent placement that together is one of the absolute highest
exposures to radiation and that's okay if you're really saving a life but what if 90% of them are
not the assumption that the stress test coronary angiogram and stents root is the best way to
detect and treat heart disease is killing and disabling more people than i think maybe in the
modern world at least chris thinks that i think he's very close to right I will tell you this this
problem is killing more people than anything in the modern world and it's disabling heart attack
stroke heart attacks number one causes death stroke is the number one cause of disability
and in the UK some reports recently said that dementia had overtaken both of those as the number
one cause of death and disability bottom line it's all associated with this one problem burning the
inside of our arteries eighty percent of that happens with prediabetes and we're not testing
for that we're subjecting people to this instead so yes you can make a strong case that this is
one of the worst things that's happening in terms of health in our population the stress tests cath
labs angiograms and stents are overused and you have to admit some of it's for financial reasons
if you don't believe that read some of the stuff from Atul Gawande a-t-u-l-g-a-w-a-n-d-e there was
a book James you may remember it you did about 10 years ago it started from a New York Times article
about overuse of medical technology and seeing the patient as a cash register they looked at that in
a town called McAllen texas it became a big big deal in terms of helping us make health care cost
containment policy for the country not going to go down that bunny hole but however these procedures
can be life-saving when done during a heart attack remember that if you're having an event you need
to be in the hands of a good interventional cardiologist if he or she needs to do a stent
for heaven's sake do that your life will depend on it but if they're saying you've got a clog
there think twice before you do that we want to emphasize there's a more effective approach for
those who have time on their sides that's why we must concern ourselves with evidence-based
medicine again look at what's actually happening we need to avoid non-contributory procedures like
nuclear stress testing coronary angiogram stents bypass grafts unless indicated or if the patient
is asymptomatic or is symptomatic I talked with the doc yesterday he's in the Long Island area
it's Dr. Dave you look him up on Facebook we did a video he'll post soon and I'll have him on the
channel soon he's a preventive cardiologist working with a bunch of interventional guys
and I've challenged him on some of this he said look I found your channel I'm the one
that I know exactly your position on these things and yes these things are overused but think about
a couple of things number one don't forget that stents can save lives in the right moment exactly
right the other thing he said and I brought it up in the book what do you do if a patient
comes in and they said Doc I'm going to have a heart attack like my Uncle Joe I know you can
fix that what are you going to do this is not just a doctor problem it's a patient problem as well
continue to get great feedback regarding the webinars and here's why you know on the
Internet when you hear a webinar you expect for somebody to try to sell you something we're not
doing that we're trying to tell you something people are coming in with their labs from Quest
inflammation panel OGTT insulin survey response and then they're finding out do
I have inflammation do I have insulin resistance and where does that fit in terms of other folks
we're getting ready to start one for CIMT as well so again people are really
excited about finding out their own status looking forward to seeing you there thanks