32 The San Juan Daily Star November 21-23, 2014 An Incipient Threat to Our Hearts M By JANE E. BRODY illions of Americans are walking around with deposits in their coronary arteries that do not obstruct blood flow to their hearts — at least, not until a piece of the plaque ruptures and forms a blood clot, causing a heart attack. These plaques are signs of a condition called nonobstructive coronary artery disease, and they are found in 10 percent to 25 percent of patients who have a coronary angiogram, typically done for patients with symptoms like chest pain or shortness of breath or those who flunk a cardiac stress test. Historically, doctors have considered the partial obstructions insignificant, and a surprisingly large percentage of patients with them are sent home without treatment. Often patients are given “the good news that they don’t have a coronary blockage,” said Dr. Thomas M. Maddox, a cardiologist at the Veterans Aﬀairs Eastern Colorado Health Care System and the University of Colorado in Denver. Sadly, the news isn’t really good. By some estimates, the majority of heart attacks result from these nonobstructive lesions. Four years ago, Dr. Maddox and his colleagues published a study of nearly 1.5 million patients with varying degrees of coronary artery disease. Compared with those who had major obstructions in their coronary arteries, patients with nonobstructive lesions were less likely to be prescribed therapy with aspirin, a statin or other drugs to reduce their heart attack risk. This month, Dr. Maddox and coauthors published a study in JAMA graphically demonstrating the sometimes devastating consequences of ignoring nonobstructive coronary disease, especially in patients with symptoms. The researchers gathered data on 37,674 veterans without known coronary artery disease who underwent elective angiograms between October 2007 and September 2012 in the Veterans Aﬀairs health care system. Fifty-five percent were found to have obstructive coronary disease, and 22 percent had nonobstructive disease. The risk of having a heart attack or dying within one year was directly related to the extent of disease in the participant’s coronary arteries. As expected, the risk was greatest among patients who had obstructive coronary disease, defined as a blockage equal to or greater than 70 percent in one or more coronary arteries. But the prognosis for patients with nonobstructive disease was hardly benign. Compared with those who had no evidence of coronary artery disease, or CAD, the risk of suﬀering a heart attack within just one year of the exam was doubled in patients with nonobstructive CAD in one artery, and more than four times greater in those with nonobstructive disease in two or three arteries. The death rate increased with the extent of nonobstructive disease. “These findings highlight the need to recognize that nonobstructive CAD is associated with significantly increased risk for myocardial infarction,” or heart attack, Dr. Maddox and his colleagues concluded. The researchers spurned the traditional distinction made between nonobstructive and obstructive CAD, and suggested that all patients with nonobstructive disease would likely benefit from drug treatment — although no randomized clinical trials have yet been done to support this recommendation. (In particular, stents have not been shown to be an eﬀective preventive for such patients.) “If we did an angiogram on every adult, a significant number would be found to have nonobstructive disease and be at risk of a heart attack,” Dr. Maddox said in an interview. “If an angiogram shows a blockage of 30, 40 or 50 percent in one or more arteries, the patient should be on preventive therapy.” He does not recommend routine angiograms, however, which are costly and have risks of their own. On rare occasions, they can cause bleeding, infection, damage to blood vessels, or an allergic reaction to the dye used. Alternatively, patients can choose a noninvasive test, like a coronary calcium score or CT angiogram. Heart disease is linked to a slew of risk factors: smoking; being overweight, obese or physically inactive; having high cholesterol, high blood pressure, Type 2 diabetes or pre-diabetes; a family history of heart disease before age 65; consuming an unhealthy diet; and being 55 or older. Chronic stress also has been linked to heart disease. Doctors usually advise patients at risk to modify their living habits. If they smoke, they should stop — within as little as a year, their coronary risk can drop to that of a nonsmoker. Those who are overweight may be told to cut down on fattening foods, eat more fruits and vegetables, and to exercise more, measures that help lower body weight and cholesterol and help control high blood pressure and diabetes. If high cholesterol is a problem, saturated fats like dairy and meat fat should be reduced, and unsaturated olive or canola oil used when fat is needed. Some of this advice was given to my father in 1979 after he suﬀered a heart attack at age 58. He never smoked, was already active and not overweight. He modified his diet, which helped to keep him alive for 13 more years. But lacking anything more to do to protect himself, he succumbed to a second heart attack at age 71. Now there is proof that certain medications can ward oﬀ even a first heart attack in people at risk. The two most commonly recommended are a daily baby aspirin and a statin. Aspirin thins the blood, reducing the risk that a blood clot will form in a coronary artery. The Food and Drug Administration does not recommend daily use to prevent a first heart attack — but some doctors do. Possible side eﬀects include an increased risk of gastrointestinal bleeding. A statin, though primarily prescribed to lower blood levels of artery-clogging cholesterol, turns out to have cardiac benefits beyond slowing the formation of new plaques in coronary arteries. Statins sometimes reduce the size of existing lesions. They can suppress inflammation that contributes to plaque formation. They improve the function of cells that line the arteries, enabling them to expand as needed. Statins may also stabilize plaques, reducing the chance that they will rupture and block arteries feeding the heart. Given these benefits and the fact that plaque rupture is the source of 95 percent of heart attacks, Dr. Maddox said that if he had coronary artery disease and was stranded on a desert island, the one drug he would want to have with him is a statin. The San Juan Daily Star November 21-23, 2014 33 HEALTH That Medical Test Costs $50, or Is It $500? By SANDEEP JAUHAR, M.D. W hen I was growing up in Lexington, Ky., in the late 1970s, we used to go to an all-youcan-eat buﬀet called Duﬀ’s. It was the cheapest restaurant in town. My father and mother ate for $2 apiece, my brother and I were charged $1, and my little sister, who was 3, ate free. After my father paid the cashier, we’d sprint over to the smorgasbord and fill our plates. We’d fill them again and again. If the fried chicken got cold, my father would tell us to throw it out and get more. We gorged; we took advantage; we were wasteful — because we perceived it as free. We’d eat so much that one of us would invariably get sick on the way home. In many ways, Duﬀ’s is like our health care system. Someone else appears to be paying for it, so who cares how much it costs? To fight this, insurers continue to raise co-payments and deductibles, making us pay more in an attempt to reduce ineﬃcient spending. But health care costs continue to rise. Recently, the agency that runs Medicare said that health spending would increase by 5.6 percent in 2014, 2 percentage points more than last year. Health care prices in the United States dwarf those of all other industrialized countries. Some have advocated price controls. A better strategy is price transparency. Patients may be shouldering more of the burden of health expenditures, but they still don’t know what they are paying for. Requiring patients to have more “skin in the game” without giving them adequate price information is like making Duﬀ’s customers pay à la carte but not telling them what the steak costs compared to the chicken. Without this information, they are bound to make bad choices. Forcing consumers to shop blindly while requiring them to share costs is also fundamentally unfair. Cost sharing redistributes the burden of health care costs, particularly to low-income earners who often have high-deductible insurance plans, but does little to lower spending. Price transparency, on the other hand, can remedy this. For example, in a study published last month in JAMA, patients in a health insurance plan were given access to a pricing website that calculated out-of-pocket costs for various medical procedures. The authors found that patients who used the website (searchers) spent 14 percent less for laboratory tests and 13 percent less for CT and M.R.I. scans than those who did not (nonsearchers). Notably, searchers in the study had spent more than nonsearchers before the website went up, indicating that they were no more frugal at baseline. Price transparency appeared to be the factor that drove the decrease in spending. In another recent study in the journal Health Aﬀairs, patients in five cities (mostly in the Midwest) were given information about how much an M.R.I. cost at diﬀerent clinics, but were not penalized if they chose a more expensive option. Meanwhile, patients in nine other cities were given no such data. After two years, the average cost of an M.R.I. fell by $95 in those places where prices were provided but increased by $124 where they were not because of competition among diﬀerent centers and more cost-conscious shopping. Doctors, too, lack basic information about what health care tests and procedures cost. When I was a resident in New York City, we used to order patients’ weekend labs on Friday afternoons. Every patient on our ward would routinely get a complete blood count and an electrolyte panel (and additional blood tests as needed). With 60 patients, this added up to hundreds of assays every weekend. None of us knew that an electrolyte panel costs about $100, and no one ever thought to ask. But most patients don’t need an electrolyte panel or complete blood count every day. With a few drizzles of ink, we would spend thousands of dollars with hardly a second thought. Knowing the lab prices might have dissuaded our profligacy, but the hospital never shared this information with us. Today, several states are demanding greater health care price transparency to protect patients. In California, for example, hospitals are required to advertise their charges for the 25 most common outpatient procedures. A similar law applying to health insurers was enacted in Massachusetts last month. Corporations are also pushing for more openness. The Safeway grocery chain, for instance, has provided prices for screening colonoscopies to its employees since 2009, resulting in a drop in the average price of the procedure by nearly 20 percent because employees, responsible for any excess charges, are shopping around. Of course, price data has to be paired with quality figures so patients don’t make the mistake of equating more expensive care with better care. (In medicine, there is usually very little correlation.) We also have to guard against cost shifting, in which providers cut prices on services for which rates are available but charge more for services whose rates are not. We are lucky to live in an era in which consumers enjoy great power and choice. Unfortunately, the health care industry remains a major exception. As doctors, we strive to provide information to our patients to help them make informed medical decisions. In today’s cost-cutting environment, it is only fair that we provide them the data to make informed financial decisions, too.