Fully Consensual Heart Disease Treatment


“Fully Consensual Heart Disease Treatment” When he was a surgeon at
the Cleveland Clinic, Dr. Caldwell Esselstyn published a controversial
paper in the American Journal of Cardiology. Heart bypass operations
carry significant risks, including the potential to cause further
heart damage, stroke, brain dysfunction. Angioplasty isn’t much better, also carrying
significant mortality and morbidity, and often doesn’t work, in
terms of decreasing risk of subsequent heart
attack or death. So, it seems we have
an enormous paradox. The disease that is the leading
killer of men and women in Western civilization
is largely untreated. The benefits of the invasive procedures
are at best temporary, with most patients eventually
succumbing to their disease. In cancer we call
that palliative care, where we just kind of
throw up our hands, throw in the towel and give up actually
trying to treat the disease. So why does this juggernaut of
invasive procedures persist? Well one reason is that performing
surgical interventions has the potential for
enormous financial reward. That’s considered one of the barriers to the
practice of preventive cardiology –
adequate return. Diet and lifestyle interventions
loses money for the physician. Although the practice of preventive
cardiology is not as lucrative, this article was hoping to nudge
cardiologists in that direction by appealing to less
tangible benefits. Another barrier is doctors don’t
think patients want it. Physician surveys show that doctors often
don’t even bring up diet and lifestyle options, assuming that patients
would prefer for example to be on cholesterol-lowering drugs
every day for the rest of their lives. That may be true for some, but
it’s up to the patient to decide. According to the official
AMA Code of Medical Ethics, physicians are supposed to disclose all
relevant medical information to patients. The patient’s right of self-decision
can be effectively exercised only if the patient possesses enough
information to enable an informed choice. The physician’s obligation is to present the
medical facts accurately to the patient. For example, before starting someone at moderate
risk on a cholesterol-lowering statin drug, a physician might ideally
say something like “You should know that for
folks in your situation, the number of individuals who
must be treated with a statin to prevent one death from a cardiovascular
event such as a heart attack or stroke— is generally between
60 and 100, which means that if I treated
60 people in your position, 1 might benefit
and 59 would not. As these numbers show, it is
important for you to know that most of the people who take a
statin will not benefit from doing so and, moreover, that statins
can have side effects, such as muscle pain, liver
damage, upset stomach, even in people who do not
benefit from the medication. I am giving you this information so that
you can weigh the risks and benefits of drugs versus diet and then
make an informed decision.” Yet how many physicians
have these kinds of frank and open discussions
with their patients? Non-disclosure of medical
information by doctors, that kind of paternalism is supposed
to be a thing of the past, but now physicians are supposed
to honor informed consent, unless the patient’s in a coma
or something or it’s an emergency. But too many physicians continue
to treat their patients as if…they were unconscious. At the end of this long roundtable
discussion on angioplasty and stents, the editor-in-chief of the
American Journal of Cardiology reminded the participants of an
important fact to place it all in context. Atherosclerosis is
due to high cholesterol, which is due to poor
dietary choices, and so if we all existed
on a plant-based diet, we would not have even
needed this discussion.

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