Is New Technology the Best Cure for Coronary Artery Disease?

New Technology the Best Cure?

Treatment of Heart Disease

CABG, PCI and Aortic Valve Replacement

Scope of the Problem of Heart Disease

Ethnic Group

Socioeconomic Factors

Biochemical Factors

Escalating costs associated with new technology for coronary artery disease

CABG cost discussion

Primary Coronary Intervention

Post-AMI author angioplasty

Reservations on cost comparisons

Who controls the patient?

Rising costs to patients

Quality of life

Conclusions for CABG and PCI

Aortic valve replacement

Current method of treatment: Surgery or Valvuloplasty

Percutaneous Aortic Valve Replacement

Subapical valve replacement

Patient benefit

Costs and benefits for aortic valve replacement

Conclusion

Annotated Bibliography

References

Bibliography: Note -- these are additional articles which I included, which you may wish to delete.

Introduction

Heart disease is the number one cause of death worldwide. Its incidence has grown due to a number of factors: increasing obesity, aging of the population, and better diagnostic techniques which can establish heart disease as the true cause of death. Heart disease's prevalence in morbidity and mortality, particularly in first-world nations, has resulted in the development of a series of methods to palliate and, in some cases, reduce or eliminate the causes of heart disease.

This paper will explore those methods which have been developed, and their effectiveness in treating heart disease. It will start with an analysis of the types of heart disease, their increases in incidents and some of the proximate causes. It will then deal with technologies which have been developed or perfected to deal with heart disease in two areas: revascularization using PCI, or percutaneous coronary intervention, and CABG, or coronary artery bypass graft surgery. It will then analyze development in aortic valve treatment, including aortic Valvuloplasty, aortic valve replacement surgery, and the newly-emerging minimally-invasive approaches to aortic valve replacement, both surgical and percutaneous.

This author posits that, despite fairly dramatic reductions in heart attack systems and a slight decrease in heart-related deaths in the United States and other first-world countries, the application of technology has had mixed results. This is particularly true when judged against the costs (time of specialists and health care staff) and resources (from capital equipment and medical facilities to medical devices and pharmaceuticals) which have been applied.

The paper finds that cardiac revascularization has added significant costs to the overall healthcare system while providing no benefit in reduced patient mortality, with the exception of primary PCI post-AMI, where PCI offers clear advantages over alternative drug treatments. The main benefit of PCI or CABG has been in morbidity and quality of patient life. There is a clear suggestion in the articles reviewed that the physicians themselves have promoted PCI to the cost of the health care system, and the fact that many diagnosticians can then easily move to a therapeutic operation during the same procedure may provide too big a temptation to add costs to the system.

On the other hand, the author argues that aortic valve replacement surgery may be an area where both patient outcomes and cost to the healthcare system are more in balance. Although the evidence is early on the value of new, minimally invasive techniques, there is clear evidence that costs can be reduced, and that a large number of 'no option' patients can avail themselves of these new technologies. Many of these patients face imminent mortality today in the absence of such new technologies.

This paper will conclude with some recommendations based on reflections within the cardiology and general medical community about the right application of medical diagnosis and therapy for the treatment of heart disease. It will also suggest which areas have been more effective in treating heart and vascular disease, and which may be, at the margins, reaching a point of diminishing health returns in regards to morbidity and mortality.

Scope of the Problem of Heart Disease

Heart disease is the number one cause of death in developed countries. When combined with related circulatory illnesses, such as peripheral vascular disease and stroke, heart disease significantly greater in incidence of death than any other illness. Heart disease both causes and is correlated with other conditions, in particular diabetes, obesity, depression and lack of exercise. Other major contributors to heart disease include types of food eaten, stress, and the aging of the population.

This last 'cause' reveals that heart disease afflicts the aged more than any other population subgroup; as humanity has made progress in combating diseases which claimed lives at an earlier age, such as bacterial infectious disease, heart disease has emerged in the resultant older populations. Finally, an improvement in diagnostic accuracy through additional cardiac markers, such as Troponin, BNP, echocardiography, stress thallium tests and other modalities, have made diagnosis more accurate and more likely to be performed; i.e. The more diagnosis improves, and the more it is applied, the more cases of heart disease will be identified.

There is an additional additive effect which, ironically, is related to our ability to better treat patients after a heart attack. The concept of the 'golden hour,' or 'minutes mean (heart) muscle' has been inculcated in many industrialized countries, to the extent that emergency crews, emergency rooms and cardiac intensive care stations have been alerted to the need to respond quickly with effective therapy to a suspected AMI. This has led to significant improvements in patient mortality rates post-AMI, but has also led to more patients with heart disease living longer with chronic issues. This has therefore led some patients to continue down the path of cardiac insufficiency for a longer time than would previously have been the case.

The incidence of heart disease varies widely from one country to another and from one ethnic group to another. The United States, for example, has a rate of diagnosis that is three times higher than the average European country. Within the U.S. there are significant differences in the overall rate of heart disease:

Ethnic Group

The highest incidence of heart and circulatory disease is amongst the Pima Indians of the deserts of Arizona. Their rates of obesity, diabetes and heart disease are four times higher than the average American. When all other factors are taken into account, the genetic component is a major causative factor for heart disease.

Blacks and Hispanics have a significantly higher rate of heart disease as well. As with all analyses of causative factors, there is a close correlation between obesity, lack of exercise and Type-2 diabetes in these ethnic groups as well. This could indicate that, because these ethnic groups are more susceptible to these confounding factors, they are therefore more prone to heart and circulatory disease.

Those of South Asian (Indian, Pakistani) and Middle Eastern ethnicity tend to have higher rates of heart disease.

Socioeconomic Factors

Those who are poorer, more depressed and/or older tend to have a higher rate of heart disease than other population subgroups in the U.S.

The rates of heart disease amongst those who are on Medicaid have been shown to be higher than the general population. In addition, there is a greater likelihood that Medicaid patients are less likely to have prophylactic drug treatment (beta blockers, statins, other drugs), as well as less likely to have CABG or PCI.

Biochemical Factors

High cholesterol is associated with higher rates of heart disease, but it is only one of several factors which have been implicated in heart problems. Higher levels of C - reactive protein and Homocysteine have been directly tied to higher rates of heart disease. Both are also associated with inflammation and stress, and both are more common in people who are obese and/or engage in relatively little exercise.

Type-2 diabetes is growing at near-epidemic proportions in the United States, to the point that even 6% of children and teens are estimated to have it at present (this was an almost unknown diagnosis 25 years ago). The mechanisms of Type-2 diabetes are too complex to enter in detail in this paper, but the primary causes are obesity and lack of exercise, which leads to the production of insulin in various places within the body (the omentum, the adrenal glands, the ovaries in women in the case of ovarian cysts, and elsewhere). Type-2 diabetes is typified by an extreme overproduction of insulin and a non-response by cells throughout the body. As a result, high and variable circulating glucose levels are not met by an increase in cellular metabolism, and the effects of uncontrolled or poorly-controlled glucose levels can exhibit the same effects on subjects as with Type-1 diabetic patients who have poor glucose control with insulin injections.

Continued insulin resistance creates the groundwork for Type-2 diabetes, with subsequent circulatory effects, such as thickening of the arteries in the heart and elsewhere throughout the body. When diabetic characteristics are added to other comorbidities which contribute to heart disease risk factors, there is an increasing concern that children and young adults are setting the stage for increases in heart disease rates in future decades.

Escalating costs associated with new technology for coronary artery disease

The question of escalating costs of cardiac and…