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He opens with the following story: section read “Ironic that a plumber came to us to help him remove a clog.” The ad referred to doctors in the cardiac catheterization laboratory as “one kind of pipe specialist,” and noted that the patient in the ad returned to work “just 2 days after having his own pipes cleaned out.” Although the image of coronary arteries as kitchen pipes clogged with fat is simple, familiar, and evocative, it is also wrong [emphasis mine]. Rothberg goes on to explain that for patients with stable disease, local interventions can only relieve symptoms; they do not prevent future myocardial infarctions.
To be clear, at least 12 randomized trials conducted between 19, involving more than 5,000 patients, have found no reduction in myocardial infarction attributable to angioplasty in any of its forms.
Only in advanced disease, and after significant plaque accumulation, does the lumen narrow.
Michael Rothberg wrote a fantastic article on the misconception of the “clogged pipe” model of atherosclerosis.
As atherosclerosis progressed, they found that plaque continued to accumulate in the vessel wall until the lesion occupied approximately 40% of the area within the EEM. These findings have since been confirmed by intravascular ultrasound (IVUS).
Due to the complex remodeling that occurs in the earlier stages of atherosclerosis, coronary angiography, which only visualizes the lumen, tends to the degree of atherosclerosis.And yet, despite this overwhelming evidence, the plumbing model, complete with blockages that can be fixed, continues to be used to explain stable coronary disease to patients, who understandably assume that angioplasty or stents will prevent heart attacks—which they patently do not.The root of the problem, in my view at least, is that we as doctors—and by extension, our patients and media—spend too much time looking at images like these (angiograms of coronary arteries complete with “clogged pipes”): And not enough time looking at images like these (the histological, i.e., pathology, sections of coronary arteries): But who can blame us, I mean, angiograms are cool!I know, I know, I said I was going to limit things to one post per year, but the last one doesn’t really count and while the year isn’t even half over I’m willing to predict nothing will inspire me more to write a post in the next 6 months than Allan Sniderman’s recent editorial piece in JAMA Cardiology. Before I get into this post I want to lay a few things out.There was a day when the only thing I argued about was who the greatest boxer of all time was. 1937-42 Henry Armstrong.) Today, however, I find myself arguing about so many things—some of them actually important—from why symptomatic women should receive hormone replacement therapy after menopause (and, by extension, why the Women’s Health Initiative tells us so, if you know how to read it) to why monotherapy with T4 for hypothyroidism is a recipe for disaster for most patients.By the time that happens, eleven other pathologic things have already happened and you’ve missed the opportunity for the most impactful intervention to prevent the cascade of events from occurring at all.