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Bed rest and other kinds of cardiac overtreatment – Heart Sisters

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Bed rest and other kinds of cardiac overtreatment – Heart Sisters

by Carolyn Thomas    @HeartSisters  

“From my earliest days in medicine, I have struggled against the prevailing model of health care” is how the pioneering cardiologist Dr. Bernard Lown sums up his long and impressive career as a rebel.

Dr. Lown is now Professor of Cardiology Emeritus at Harvard, but to me he is the physician I love to quote here on Heart Sisters – as in my blog post title, Why Aren’t More Doctors Like Dr. Bernard Lown?         .

In April of 2012, the 91-year old Dr. Lown spoke at the Avoiding Avoidable Care conference, whose lofty annual goal is “the transformation of health care culture from one focused on volume and quantity to one centered on value and quality.

Consider this excerpt from his important presentation to his colleagues:  

“From my earliest days in medicine, I have struggled against the prevailing model of health care.

“My opposition in part was provoked by the growing prevalence of overtreatment. Resorting to excessive interventions seemed to be the illegitimate child of technology in the age of market medicine.”

But Dr. Lown’s first observations of cardiac overtreatment – unlike almost all modern examples – were not related to technology at all.

“It involved keeping patients with acute heart attacks on strict bed rest for 4-6 weeks. This was a form of medieval torture. It promoted depression, bed sores, intractable constipation, phlebitis, lethal pulmonary embolism and much more.”

Worse, he added, unnecessary bed rest requirements actually made heart patients worse, increasing their risks of deadly heart rhythms and further coronary artery blockages.

Other physicians were aware of this danger, too, but they also thought they needed to protect heart attack survivors against “cardiac rupture” – considered at that time to be due to physical activity.

Current evidence-based practice means, of course, getting heart patients up and out of that bed and moving around. I was certainly told to do so while recuperating in the CCU (the intensive care unit for heart patients – coincidentally, just one of many concepts in cardiology invented by Dr. Lown!)

In fact, I was told by my CCU staff that as soon as I could demonstrate my ability to walk up and down stairs (and pee, not necessarily at the same time), I might be allowed to go home early!

Dr. Lown explained that in the early 1950s, his teacher and mentor Dr. Samuel Levine urged him to let heart patients at the Lown Clinic that he’d founded in 1947 get out of bed and recover in comfortable chairs.

This was a massive and controversial change in cardiac care, initially opposed by staff – until they witnessed the changes in their patients.

Patient improvement was striking. In fact, hospital mortality from acute myocardial infarctions (heart attacks) more than halved, depression diminished, pulmonary emboli nearly vanished, hospitalization was markedly shortened, rehabilitation and resumption of work was hastened.

“I am not aware of a single cardiovascular measure since then that improved survival of heart patients as much as this common sense change in medical management.

“One should mention, if only as a historical footnote, that there was not a scintilla of evidence supporting prolonged bed rest. While patients were harmed, doctors profited.”

He went on to include a surprising number of  popular procedures on his “overtreatment”  list of excessive interventions, most notably the pervasive rush to revascularize* (meaning to open up or replace a blocked coronary artery by implanting a coronary stent or by open heart bypass graft surgery):

Recognition that new technologies were driving overtreatment became evident with introduction of implanted pacemakers in the 1960’s. Compared to my colleagues, I was implanting only about a third as many and inactivating like numbers. Pacemakers though were small cost items compared to what soon followed.

“If more than a half century ago overtreatment was at a trickle pace, it is now at flood tide.”

His own Lown Clinic practice near Boston largely avoided that flood, preferring the evidence-based option for heart attack patients called medical management (also called OMT, Optimal Medical Therapy, typically including medications, exercise and improved dietary choices).

Dr. Lown continued:

Let me repeat: over any five-year period, we referred fewer than 30 per cent of patients with multi-vessel coronary disease for revascularization.”

Many heart patients who have been told they have “multi-vessel” heart disease (meaning two, three, four or more coronary arteries with significant blockages) cannot even imagine being told they don’t “need”  bypass surgery, yet for decades, cardiologists at the Lown Clinic have successfully treated over 2/3 of multi-vessel patients without a trip to the O.R.  Dr. Lown explained why patients almost always expect their doctors to do something:

“The bypass or the stent are definite answers to a problem; you have it done and it’s over, it’s ended.

“But that ain’t so. A patient still has coronary disease, still has risk factors, and the lifestyle that brought the patient to the doctor in the first place will bring that patient to the doctor a second and third time.”

As Dr. Lown told his audience, the Lown Clinic’s management of coronary artery blockages was also individually tailored. For example:

  • “We rigorously treated risk factors.
  • “We encouraged optimism.
  • “We addressed social and family problems.
  • “We discussed significant psychosocial stresses.
  • “We minimized shuttling patients to other specialists.
  •  “Our doctors spent much time listening, thereby fostering trust and adherence to prescribed lifestyle changes.

In short, as Dr. Lown said:

“We did much for the patient and as little as possible to the patient.

In his presentation, Dr. Lown also addressed the commonly heard fear of malpractice lawsuits as a significant reason for doctors resorting to overtreatment:

“The Lown Group, with its minimalist approach, should have been deluged with malpractice suits.

“After all, we deviated from community norms. We did not adhere to the standard of practice prevailing nationwide. Yet during the past 40 years, we have not had a single malpractice suit for denying a patient with coronary artery disease a revascularization procedure*.”

Yet he also acknowledged to his colleagues that this attitude is “a tiny minority voice” compared to the direction modern cardiology has clearly chosen instead.

I’m not a physician, but it does seem clear to me that cardiologists whose livelihoods depend on implanting coronary stents, and surgeons whose livelihoods depend on performing surgery are unlikely to be receptive to Dr. Lown’s suggestions that their specialties may not be required in many cases. The famous medical journal The Lancet bluntly blamed this scenario on a “broken system”, adding:

“We have a hospital-centred sickness system driven by financial incentives.”

And if you’re a person who has just been told you have a blocked artery in your heart, you’re also likely to agree with the cardiologist who tells you that one of your treatment options is to open up that blocked artery. So much can depend on how the alternative options – especially both risks and benefits – are presented during what is almost always an overwhelming and frightening time for patients.

This weekend in Philadelphia, the American Heart Association’s annual conference is underway, with 18,000 cardiologists and other healthcare professionals attending  from around the globe, all awaiting the much-anticipated results yesterday of a new study called ISCHEMIA. This research looked at what kinds of cardiac interventions are most likely to improve patient outcomes – and which ones are not.

I’ll be reporting on (and translating into a patient-friendly, jargon-free version of) the key surprising results of that  coverage for you next Sunday.

Meanwhile. . .

Q: What are your impressions of Dr. Lown’s ‘less is more’ philosophy?

Definitions:

  • *cardiac rupture: an area of the muscular wall of the heart that weakens and ruptures, usually because of a heart attack
  • *revascularize: to restore blood flow to a body part or organ that has suffered a blocked blood vessel, spasm or injury that has reduced the blood flow
  • *stent: An implantable device made of expandable, metal mesh that is placed (by using a balloon catheter) at the site of a narrowing coronary artery during an angioplasty procedure. The stent is then expanded when the balloon fills, the balloon is removed, and the stent is left in place to help keep the artery open.
  • *ischemia: an inadequate blood supply to an organ or part of the body, especially the heart muscle
  • *OMT: Optimal Medical Therapy –  a list of recommended treatments for patients who have had a heart attack, typically aspirin and aggressive cholesterol and blood pressure control; considered a proven option for people with coronary artery disease, with or without an invasive revascularizing procedure
  • *arrhythmia:  a condition in which the heart beats with an irregular or abnormal rhythm

See also:

Dr. Bernard Lown’s biography

The Lown Conversation (a charming blog about medicine written a few years ago by Dr. Lown and his granddaughter, Melanie Lown)

Why Aren’t More Doctors Like Dr. Bernard Lown? (includes full transcript of his 2012 presentation)

A Cardiologist’s Advice on How to Use this “Wonder Drug(Dr. Lown taught me everything I wasn’t taught before hospital discharge about how to take my nitroglycerin

Did You Really Need That Coronary Stent?

When Doctors Use Words That Hurt

Squishing, Burning and Implanting Your Heart Troubles Away

Say What? Do Patients Really Hear What Doctors Tell Them?

What Prevents Heart Disease “Better Than Any Drug”?



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