# The documentary 'the widowmaker' was interesting but felt very biased **URL:** \ **Category:** Cafe Society\ **Created:** [August 15, 2015, 3:12pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921 "2015-08-15T15:12:10Z")\ **Posts on this page:** 10\ **Page:** 1
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [August 15, 2015, 3:12pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/1 "2015-08-15T15:12:10Z")
This was a documentary about heart disease and how a test called the cornoary artery calcium scan (CAC scan) can give you a rough impression of how much plaque you have in your coronary arteries. It was very pro-CAC but also very anti-stent and claimed stents are overprescribed because they are a money maker for hospitals. Having said that, I have no idea how much was true or how much wasn’t since the bias was obvious. It also didn’t make sense how much they harped on both how cheap a CAC scan is, sub $100 (I think some places do them for $49) but then they talk about how the fact that health insurance doesn’t cover them is a massive barrier. In the days of $6000 health insurance deductibles, in what world is a scan that costs $100 every few years going to bankrupt anyone? Can’t people pay out of pocket to get a rough idea of how much plaque they have in their heart? I would pay $50 to get a good idea of how my heart is doing irrelevant of whether insurance covered it or not. I did find a study showing people with low scores had a much lower rate of death than people with high scores > **[Study Shows Value of Calcium Scan in Predicting Heart Attack and Stroke Among...](https://www.hopkinsmedicine.org/news/media/releases/study_shows_value_of_calcium_scan_in_predicting_heart_attack_and_stroke_among_those_considered_at_either_low_or_high_risk)** > > A new study shows that coronary artery calcium (CAC) screening, an assessment tool that is not currently recommended for people considered at low risk, should play a more prominent role in helping determine a person's risk for heart attack and... Does getting a stent prevent you from getting coronary bypass surgery at a later date? Are 80-95% of stents useless? I’ve read they don’t do much to prevent heart attacks or death. I thought coronary bypass surgery was also overprescribed heavily. However I"m having trouble finding the study right now. ---
**Author:** ![Dewey\_Finn](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dewey_finn/32/4222_2.png) [@Dewey\_Finn](https://boards.straightdope.com/u/Dewey_Finn)\ **Post date:** [August 15, 2015, 4:23pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/2 "2015-08-15T16:23:39Z")
> [@Wesley\_Clark](#): > > Does getting a stent prevent you from getting coronary bypass surgery at a later date? > > Are 80-95% of stents useless? I’ve read they don’t do much to prevent heart attacks or death. IANAD and have not seen this documentary, but my understanding is that a stent is implanted after a heart attack, not as a preventive measure. ---
**Author:** ![Bumbazine](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/bumbazine/32/362_2.png) [@Bumbazine](https://boards.straightdope.com/u/Bumbazine)\ **Post date:** [August 15, 2015, 5:03pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/3 "2015-08-15T17:03:03Z")
I had a stent implanted after my heart attack 10 years ago. If I didn’t have it I’d be dead, period. They do what they were designed to do. ---
**Author:** ![beowulff](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/beowulff/32/542_2.png) [@beowulff](https://boards.straightdope.com/u/beowulff)\ **Post date:** [August 15, 2015, 5:11pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/4 "2015-08-15T17:11:05Z")
One datapoint: A few years ago I went to the doctor because I was having chest pain upon exertion. I was not in what they considered a high-risk category for CAD (relatively young (49), not overweight, athletic). The doctor sent me for a Calcium Score. The test came back **ZERO**. So, the doctor started to look elsewhere, but wasn’t able to give me a reasonable diagnosis, so I went to a cardiologist, who recommend an Angiogram. This test showed a 90-90% blockage in my LDA (AKA the Widowmaker), and they took me in for immediate bypass surgery. Even before the surgery, I had looked up the statistics for the Calcium Score test, and found that it was very, very bad at detecting CAD in younger patients. ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [August 15, 2015, 5:48pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/5 "2015-08-15T17:48:11Z")
> [@Bumbazine](#): > > I had a stent implanted after my heart attack 10 years ago. > If I didn’t have it I’d be dead, period. > They do what they were designed to do. Again, that is why I’m confused. In the documentary they talk about how many people say that, but the science is not really clear on it. ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [August 15, 2015, 5:49pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/6 "2015-08-15T17:49:46Z")
> [@beowulff](#): > > One datapoint: > A few years ago I went to the doctor because I was having chest pain upon exertion. I was not in what they considered a high-risk category for CAD (relatively young (49), not overweight, athletic). The doctor sent me for a Calcium Score. > The test came back **ZERO**. > So, the doctor started to look elsewhere, but wasn’t able to give me a reasonable diagnosis, so I went to a cardiologist, who recommend an Angiogram. This test showed a 90-90% blockage in my LDA (AKA the Widowmaker), and they took me in for immediate bypass surgery. > > Even before the surgery, I had looked up the statistics for the Calcium Score test, and found that it was very, very bad at detecting CAD in younger patients. What counts as younger? is it sub 55? That is interesting that you got a 0 in the CAD but an angiogram showed a 90% blockage in the LDA. How does atherosclerosis that doesn’t show up on a CAC scan work? Is it possible the people doing the scan missed it, or did the blockages not have calcium? ---
**Author:** ![beowulff](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/beowulff/32/542_2.png) [@beowulff](https://boards.straightdope.com/u/beowulff)\ **Post date:** [August 15, 2015, 5:54pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/7 "2015-08-15T17:54:15Z")
> [@Wesley\_Clark](#): > > What counts as younger? is it sub 55? > > That is interesting that you got a 0 in the CAD but an angiogram showed a 90% blockage in the LDA. > > How does atherosclerosis that doesn’t show up on a CAC scan work? Is it possible the people doing the scan missed it, or did the blockages not have calcium? I think “younger” is relative - it depends on when the subject started to get CAD. The reason the scan missed it is because “young” plaque deposits haven’t had time to calcify. I don’t know how long that takes, but it’s probably a decade or more. The other issue with this test is the huge number of “irrelevant positives” it returns for some people. It’s not uncommon to get scores in the _hundreds_ - and still not have any symptoms. What are you going to do with that information? ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [August 15, 2015, 7:20pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/8 "2015-08-15T19:20:28Z")
Not a cardiologist but do know how to access[the guidelines](http://www.sciencedirect.com/science/article/pii/S0735109713060312) created by panels of expert cardiologists. The place they view for it to be of some potential use is if risk stratification by traditional methods results in an “intermediate risk” … if traditional risk stratification results are clearly “low” or “high” it is clearly not advised. If a risk-based treatment decision is uncertain after formal risk estimation then CAC is a “IIb” recommendation: that is a “Procedure/treatment MAY BE CONSIDERED” level,; the next one down is “not helpful” and the next up “IT IS REASONABLE to perform”. So performing a CAC may be considered (but is not necessarily considered reasonable to perform) if it is unclear by more tradition formal risk assessment scoring whether someone should be on statins (or whatever) or not, as it might modify the risk assessment in one direction or the other. In that context a CAC ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity would move the individual up to the higher level and below those would move one down to the lower one. Likewise family history, high sensitivty CRP, and ankle-branchial index, can be optionally considered. Here’s how [the AHA review the various assessments of it in plain English](http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_437479.pdf): > [@](#): > > … there is insufficient evidence that widespread screening of asymptomatic adults is clinically appropriate … there is insufficient evidence of the incremental value of carotid IMT and cost-effectiveness beyond that available from standard risk assessments. The ability to improve overall patient outcomes is not established. … AHA does not support the routine use of CAC scanning or carotid ultrasonography beyond the limited benefit for individuals at intermediate-risk for CHD. … Note: these are as applicable to using the test to _screen_ populations; not as a diagnostic tool. **beowulff** ’s circumstance was not screening; it was using the test as part diagnosis for chest pain and then the degree of suspicion should have been based on the complete clinical picture, not only formal risk assessment but when did the pain occur and what was it like, etc… Maybe one of the adult docs will be able to comment more about stents than I can. But maybe you should get this moved to IMHO? ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [August 16, 2015, 4:22am UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/9 "2015-08-16T04:22:26Z")
FWIW [this](http://interventions.onlinejacc.org/article.aspx?articleid=1862037) about at least stents vs coronary artery bypass grafts (CABG). Note: neither compared with the option of no procedure done at all. Meta-analysis published in 2014. > [@](#): > > Objectives This study sought to compare the efficacy of coronary artery bypass graft surgery (CABG) to that of percutaneous coronary intervention (PCI) with first-generation drug-eluting stents among patients with multivessel disease (MVD), unprotected left main (LM) disease, and single-vessel proximal left anterior descending (LAD) disease. … > > … Our results suggest that in patients with MVD, CABG reduces mortality, MI, and repeat revascularization, but increases the risk of stroke when compared with first-generation DES. In patients with LM disease, CABG was associated with a reduced risk of revascularization, with an increased risk of stroke, and no significant differences in death or MI. Available data were insufficient to draw meaningful conclusions regarding the relative efficacies of CABG and PCI with DES in patients with single-vessel proximal LAD disease. … > > … These findings support the use of CABG in patients with MVD, particularly among those with complex or severe disease. > > Evidence for the optimal treatment of LM disease is less clear. … > > … Our study had insufficient power to draw clinically directive conclusions for patients with single-vessel proximal LAD disease. … Although these findings suggest PCI may be comparable to CABG in patients with proximal LAD disease, statistically inconclusive results highlight the need to rely on additional clinical considerations to aid in procedural choice. … > > … There is suggestive evidence that first- and second-generation stents may have differential efficacy profiles, which in turn could affect the optimal procedural choice between CABG and PCI with DES. … Stents compared to “standard medical care” and no procedure is discussed in [this 2012 NYT article](http://www.nytimes.com/2012/02/28/health/stents-show-no-extra-benefits-for-coronary-artery-disease.html), at least for stable coronary artery disease. > [@](#): > > The researchers reviewed eight randomized trials comparing P.C.I. with standard medical care. Combining data from all the studies, the researchers found that prescribing beta blockers, ACE inhibitors, statins and daily aspirin — now standard for treatment of stable coronary artery disease — was just as effective as stent implantation for prevention of chest pain, heart attack, the need for a future P.C.I. and death. > > More than half of patients with stable coronary artery disease are now implanted with stents without even trying drug treatment, Dr. Brown said. The reason, he believes, is financial. … [The actual article.](http://archinte.jamanetwork.com/article.aspx?articleid=1108733) Note drug eluting stents made a small fraction of all stents used. But in [this 2014 meta-analysis](http://archinte.jamanetwork.com/article.aspx?articleid=1783047) of those with stable CAD and documented, objective findings of myocardial ischemia, drug-eluting stents were more common. And stents added initially to medical therapy (MT) resulted in > [@](#): > > no significant reduction in mortality, nonfatal MI, unplanned revascularization, or angina compared with MT alone This paragraph in the latter cite is potentially pertinent to the limited value of the calcium artery scan (CAC) score. > [@](#): > > Although it remains unclear how myocardial ischemia confers increased mortality risk, our results in combination with those of prior research suggest that myocardial ischemia may be more of a marker for atherosclerotic burden, with the increased propensity of future events being mediated by the volume of atherosclerotic plaques at risk of becoming unstable, rupturing, and inciting thrombosis and MI rather than by progressive fibroatherosclerotic coronary disease. In support of this concept, patients with myocardial ischemia have a greater atherosclerotic plaque burden as measured by calcium score than those without ischemia.36 This concept is also consistent with the 25-year-old observation that the vast majority of plaques responsible for acute MI emanate from stenoses of less than 70% by angiography prior to the acute event.37 Thus, the lesions that are responsible for most cases of MI and subsequent death are not severe enough to induce ischemia on stress testing, and the lesions responsible for causing ischemia do not tend to rupture. Since intervening on a marker of an outcome that is not in the causal pathway of the subsequent adverse clinical events would not be expected to reduce those events, it should not be surprising that prior clinical trials14,17 and meta-analyses33,38- 40 consistently demonstrate that PCI fails to reduce death or MI in patients with stable CAD who are concomitantly aggressively treated with contemporary medical therapy for secondary prevention. Let me try to parse that out. It is especially pertinent to **beowulff** ’s circumstance and comment. Old established lesions, those that cause high CAC scores, cause myocardial ischemia, but tend to _not_ be the ones that rupture and cause new MIs. Stenting those narrow areas apparently does little good. It’s the newer lesions, which have not yet calcified, and which are more likely to not be so narrowed, that are more likely to rupture and cause MI and death. It seems to me that the current guideline giving at most a weak optional nod to CAC to help further stratify intermediate risk individuals is reasonable. FWIW. I’d still be interested in what one of our adult-side docs’ take on this stuff is. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [August 16, 2015, 3:04pm UTC](https://boards.straightdope.com/t/the-documentary-the-widowmaker-was-interesting-but-felt-very-biased/727921/10 "2015-08-16T15:04:14Z")
Sorry to multi-post but [this editorial](http://amaprod.silverchaircdn.com/data/Journals/INTEMED/929736/ien130011.pdf.gif) may be of interest to our op. I am sure that each case should be an individualized decision but it sure does seem like often stents are done when optimized medical therapy alone would work better, and often instead of that more effective and less risky approach, and that when a procedure is needed CABG is more often the better choice.