Overdiagnosis and Overtreatment

A recent report published in the Journal of the Royal Society of Medicine by three cardiologists, including my friend Dr Aseem Malholtra, has presented a stunning exposé around creating diseases out of non-diseases.

I am a strong advocate for appropriate screening for common diseases but the main problem here is over interpreting the results and, just as worrying, excessive investigation of incidental findings. This report has detailed the fact that in the United Kingdom alone, cardiovascular disease accounts for more than 10% of all in-patient episodes for men with spending disease just under £7 billion in the period 2012/2013 which accounted for around 6% of the total NHS budget.

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The report highlighted the problems with the excessive prescription of cardiac medications along with over investigation and unnecessary medical procedures such as coronary stenting. Interestingly, a review performed in New York State a few years ago by an independent body reviewing coronary angiography (a dye study of the coronary arteries looking for significant blockages) suggested that around 65% of the coronary angiograms performed in that state of America were unnecessary.

Coronary stenting, which is where a small hollow metal tube is placed in a blockage in a coronary artery, is a highly effective treatment for acute coronary syndromes, such as heart attack. There is a disturbing, cynical phrase known as the “oculo-dilatory” reflex, which is basically where an interventional cardiologist sees a blockage on an angiogram in a person with stable or no symptoms and routinely stents the blockage, regardless of whether it was proven to be causing the person any problems.

The reports also covered recent publicity in the media around screening for and treating coronary artery disease and in particular mentioned a movie, “The Widowmaker”. There was also a rather disturbing comment describing coronary calcium scoring as an invalidated screening tool in an asymptomatic population. This is where I am at odds with the authors. The appropriate use of coronary calcium scoring in asymptomatic people can prevent the excessive prescription of statin drugs to people where the drugs are unnecessary. In the November edition of the Journal of the American College of Cardiology, a study was published where 5000 people were screened for ten years, over the age of 50. 77% of the people in the trial fitted the US criteria to be on a statin. Half of the 77% had a zero coronary calcium score & their heart attack rate was so low that the conclusion of the trial was that statins were unnecessary in that population. There have been thousands of patients screened with coronary calcium score showing clearly that this is the most predictive test for coronary artery disease and in my opinion should be used in the asymptomatic population. It is my suggestion that all males over 50 and all females over 60 have coronary calcium scoring. If they have zero or low scores, they should be reassured. Lifestyle practices should be reinforced for all people.

The true non-disease here is that of hypercholesterolaemia. I see so many people on a weekly basis saying to me, “Doctor, I’ve got cholesterol and my doctor wants me to take a statin”. We’ve all got cholesterol and if we didn’t we’d be dead. The real question here is whether the particular cholesterol issue for that patient is spilling into the walls of their arteries causing the build-up of fat, inflammatory tissue and calcium and thus increasing the risk for heart attack over the next 5 to 10 years. The coronary calcium score is easily the best way to determine this risk and is certainly not in any way invalidated.

The real concern here is how any of this information is used and misused by the medical profession. I am completely against the use of intravenous CT Coronary Angiography as a screening tool for heart disease. This is completely invalidated with no science to support its use. Often people have this test performed and are told they have serious blockages in their arteries requiring a coronary angiogram and stenting. This, in my view, is where the unworried, well become the worried, unwell and become over investigated and over-treated.

The simple algorithm I use in my practice is based around age, risk factor profile which includes a review of the entire lipid or fat profile, hypertension, cigarette smoking, all aspects of metabolic syndrome and family history, along with the appropriate use of coronary calcium scoring, the variety of important blood markers and stressed echocardiography only for people who are in the highest risk category.

This allows me to reassure people that they do not need chronic drug therapy if they are low-risk but I may be able to prevent significant coronary events for those at high-risk.

I believe it is vital for us to have the debate about over-investigation, over-diagnosis and over-treatment but let’s not “throw out the baby with the bathwater”.