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Heart disease sometimes erupts as a full-blown emergency with sudden, crushing chest pain. That’s when immediate intervention to restore blood flow to the heart can be lifesaving.
But in many situations, the path to aggressive care moves faster than called for, which can lead to overtreatment, worse outcomes and complications, says William Boden, a professor of medicine at the Boston University School of Medicine. When treating heart disease, he says, “there are many clinical instances when less is more.”
Boden and other experts suggest that when it’s not an emergency, consumers take time to do research so they can make informed decisions. That involves talking with doctors about such things as whether an expensive imaging test is needed and which hospital to choose for open-heart surgery.
And if you feel rushed into making a decision, “ask for a second opinion,” Boden says.
Here are the key questions to ask along the way:
The heart disease treatment odyssey often starts on a treadmill in a doctor’s office, as part of an exercise stress test. That test can be essential if you have symptoms that indicate heart disease, such as chest pain while exercising, or if you’re at high risk of a heart attack.
But some doctors include exercise stress tests as part of routine checkups, or as a safety check in people before certain surgeries.
Experts we spoke with said that’s generally not a good idea, in part because for people without heart disease symptoms, the test is often more likely to reveal a harmless abnormality than to identify a real problem.
So if you feel fine and are at low risk, ask why a stress test is necessary, says Marvin M. Lipman, Consumer Reports’ chief medical adviser. “If you don’t get a satisfactory answer, politely decline it or ask for a second opinion,” he says.
If you undergo a stress test and it has abnormal or uncertain results, your doctor will probably refer you to a catheterization laboratory for more tests. That’s where the cascade of procedures often speeds up.
In that lab, a physician first performs coronary angiography, which involves threading a thin tube into an artery and injecting a dye so that narrowing shows up on an X-ray.
But patients are sometimes asked to sign a consent form that allows doctors to immediately remove the blockage (with a procedure called angioplasty) if they see restricted blood flow.
That’s not usually necessary, Boden says. “What should happen is hitting the pause button and having a thoughtful, transparent discussion of all the treatment options,” he says.
In angioplasty, a doctor inflates a thin balloon in an artery to widen it, leaving a stent in place to prop the blood vessel open. It can be lifesaving when performed within hours of a heart attack.
But in other circumstances, lifestyle changes plus medications to control blood pressure and cholesterol and prevent clots is at least as effective and usually safer. For instance, a study of 200 people with chest pain, published in the Lancet in 2017, found that those who had stents implanted did no better than those who received a sham surgery.
One explanation for the continued overuse of angioplasty is that it is seen as a moneymaker for doctors and hospitals, says David Brown, a cardiologist at the Washington University School of Medicine in St. Louis.
So if you’re scheduled for angiography, talk with your doctor about what to do if that test finds worrisome but not immediately dangerous signs of harm.
It often makes sense to try two to three months of lifestyle changes and drugs first, and turn to angioplasty and stents only if those measures don’t ease your symptoms enough.
In some people, heart disease is so serious that medication, even combined with angioplasty, may not be enough. In that case, you probably need open-heart surgery, often to bypass blood flow around coronary artery blockages or correct a malfunctioning heart valve.
Although both problems are serious, they’re not always emergencies, says Steven Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic Foundation. People should be wary of doctors who do an angiogram in a non-emergency “and then say, ‘We can do your bypass tomorrow,’ ” Nissen cautions.
Instead, your doctor can often stabilize your condition with drugs, giving you time to consider options. Although that’s not something many people think of doing, Nissen says they should. “People will often do a better job comparison shopping with a car they might buy than the heart program they go to.”
Unfortunately, finding that information is harder than it is for cars. But Consumer Reports now has updated open-heart surgery ratings of more than 500 hospitals nationwide. These are published in partnership with the Society of Thoracic Surgeons (STS), which collects data directly from hospitals on key measures such as mortality and complication rates.
Which hospital you choose matters. Of the hospitals in our ratings, only about 100 appear in our chart of best heart hospitals.
Choosing the right surgeon is also important. Although information about specific surgeons is tricky to find, Consumer Reports, working with STS, reports heart-surgery outcomes for groups of surgeons who practice together. Those ratings are available at CR.org/heartsurgeons.
If the surgical group you’re considering is not listed, ask the surgeon how well he or she performs on the STS measures. If the surgeon can’t share that information — or won’t — we suggest that you keep looking.
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