Is there too much heart stent surgery in China？

　　"If you want to be rich, get involved." Different people will have different interpretations of this sentence.

　　Medical students may regard it as a popular guide, cardiovascular patients may regard it as the touchstone of doctors’ character, and medical experts and the media public may smell the signal of overtreatment.

　　A few days ago, the doctoral student of the First Affiliated Hospital of Suzhou University reported that Yang Xiangjun, the tutor, had installed the bracket in disorder and took back the buckle. The discussion about cardiac stent is hot again.

　　"The cost is more than 200 yuan, and the profits are 30,000 to 40,000 yuan." Is the heart stent really a cash cow for doctors? Are people’s concerns about the abuse of cardiac stents justified?

　　Stent surgery has gone far beyond the scope of simple medical technology.

　　In May, 2005, Lin Hao, a native of Ningbo, was unwell, and once even had difficulty walking normally. Lin Hao went to three hospitals for examination, but failed to find out the cause.

　　Later, during the cardiovascular examination in the First Hospital of Ningbo, the doctor told him that you had come to the right place. One of Lin Hao’s coronary arteries was blocked seriously, and another one was also blocked. The doctor suggested that a heart stent should be installed immediately to ensure normal blood supply.

　　Cardiac stent, also known as coronary stent, is a commonly used medical instrument in cardiac interventional surgery. This 1-3 cm hollow and retractable catheter can open the hardened and narrow coronary artery and keep the blood flow perfusion of the heart muscle.

　　It has been 35 years since the first case of cardiac stent intervention in China. In the past 35 years, stents have developed from the first generation of metal to the third generation of bioabsorbable, percutaneous coronary intervention (PCI)— — The number of stent surgery, commonly known as stent surgery, has soared.

　　According to the data reported by the National Health and Health Commission on the network of percutaneous coronary intervention (PCI) (including the data reported directly by the network and the data from military hospitals), in recent years, the proportion of patients with ST-segment elevation myocardial infarction (STEMI) undergoing direct PCI has obviously increased, with a total of 55,833 cases, accounting for 38.9%. Surgical indications and instruments are reasonable, and the mortality rate of interventional therapy is stable at a low level, which was 0.21% in 2016.

　　ST-segment elevation myocardial infarction (STEMI) refers to a kind of acute myocardial infarction with typical ischemic chest pain lasting for more than 20 minutes, the concentration of serum myocardial necrosis markers increased and dynamically evolved, and the electrocardiogram has typical ST-segment elevation. It is mainly due to acute occlusive thrombosis induced by coronary plaque injury, and direct PCI is recommended for acute patients within 12 hours of onset.

　　Lin Hao had an operation three days after he was hospitalized. At that time, she and her wife chose imported stents among domestic stents and imported stents. Finally, it cost nearly 30 thousand yuan, and a stent was installed in her coronary artery.

　　However, to the delight of the old couple Lin Hao, they did not operate on the chest, but only on the thigh, and only a band-aid was put on the wound after the operation. She was discharged from the hospital less than ten days after the operation. Some of her patients at the same time put three or four stents at a time. This made her feel that her illness was not so serious.

　　However, within three years after installing the stent, Lin Hao still felt chest pain from time to time. Every time she goes to see a doctor for this reason, the doctor will let her stay in hospital for two or three days. In these three years, almost every year, she has to stay in the hospital once or twice for this.

　　"In the final analysis, this thing is not something that belongs to people. It will still have some influence in the heart." Although more and more people are doing heart stent surgery, Lin Hao still feels that putting this foreign thing into the human body, even the progress of medicine, is still worrying.

　　Lin Hao’s idea also represents the views of many people. "You have to take medicine for life after heart stent surgery", "Blood vessels may be blocked after heart stent surgery", "Heart stents are useless, and doctors put them in order to take kickbacks", "XX’s family put more than a dozen stents, but they still can’t be saved. If they don’t put stents, they can live longer" … … These unclear discussions are often regarded as common sense in daily life, and also become some "knowledge" advocated by the media.

　　In fact, the average number of stent implantation in China is 1.5. At the 21st National Forum on Interventional Cardiology (CCIF) on April 21st, 2018, Huo Yong, director of the Cardiovascular Department and Heart Center of Peking University First Hospital, said that in 2017, the mortality rate of interventional therapy for coronary heart disease in mainland China remained stable at a low level in recent years, and the number of stent implantation remained stable at around 1.5, indicating that the indications and instruments for interventional therapy were reasonable. (Including data reported directly by the network, data added after verification by provincial quality control centers and data of military hospitals).

　　"Now medical insurance is very strict with the management of hospital consumables, and it is not allowed to implant multiple stents at one time." Zhang Li (a pseudonym), deputy chief physician of the Department of Cardiology, a 3A hospital in Northeast China, said. She admits that cardiac stent surgery is more determined by subjective factors, and the guidelines only explain when stent surgery is more beneficial, not specific. As long as it doesn’t violate the general principle, there won’t be much problem.

　　Li Heping (a pseudonym), chief physician of cardiac surgery in a 3A hospital in Beijing, pointed out that starting from June 15th this year, Beijing will further cancel the addition of all consumables after canceling the drug addition. Even from the most secular point of view, from the hospital level, the economic benefits of stent placement no longer exist, and there is no reason for hospitals and departments to encourage patients to undergo stent surgery.

　　"A doctor who wants to make money from a patient has done it once or twice and will soon be looked down upon and eliminated." Li Heping said that when the chief physician makes a decision, he should also be supervised by the attending physician and the resident doctor. "Can you give up all these people who support you for economic benefits?"

　　However, Hu Dayi, a famous cardiovascular expert, clearly pointed out that introducing third-party supervision is an important means to develop the industry and protect the doctor-patient relationship from the perspective of social and industry development. Hu Dayi appealed that the stent itself is a good technology, but its use has gone far beyond the scope of pure medical technology, and it has been derived into an industry that may generate huge economic benefits.

　　His biggest worry comes from the current use of stents, and hospitals are both referees and athletes. Hu Dayi pointed out that in the discussion on the overuse of stents, it was insisted that there was no data displayed by over-users of stents in China. "There are very few patients with stable angina pectoris in China, and at the same time, it is acknowledged that the proportion of ST-segment elevation myocardial infarction with the most positive stent benefit is very small, and most stent patients are marked as unstable angina pectoris or ACS."

　　"Who is reviewing the data and how to verify the data? False data is more terrible and harmful than no data. " Hu Dayi pointed out that the data were reported by doctors in all units, which is the key to the problem. He called for a fair, open and transparent mechanism to control the use of stents.

　　Is the heart stent abused?

　　Li Heping told the reporter of China Youth Daily and Zhongqing Online that when discussing whether to abuse stents, we can first think from two angles: First, whether stents should be placed instead. In this case, if the doctor induces the patient to place it, it is abuse. Second, placement that does not fully conform to the guidelines can also be called abuse. Li Heping believes that the latter is a more common situation. "There should be no doctor who will put a stent in a blood vessel without problems."

　　Hu Dayi has expressed concern about the risks of stents and pacemakers. He pointed out that doctors put unwanted metal foreign bodies in patients’ blood vessels and bodies, and sometimes their condition has not been alleviated, but it has also increased additional risks, such as the risk of bleeding caused by the need for "double anti-platelet therapy" for stents, the risk of infection caused by pacemakers, and even the risk of sepsis. Hu Dayi is worried that excessive medical treatment will harm patients and further worsen the relationship between doctors and patients.

　　Under what circumstances will cardiac stents be abused? Hu Dayi once expressed his views, mainly in several aspects.

　　One is to do coronary CT after over-physical examination. For some patients with plaque but no clinical symptoms found by CT, there is no assessment of myocardial ischemia, direct coronary angiography or even intracoronary ultrasound. As long as the final stenosis is greater than or equal to or even less than 70%, put the stent. In addition, many patients with stable angina pectoris are labeled as unstable diagnosis and treatment, and these patients are often placed with multiple stents.

　　Li Heping once saw a patient with 13 stents in his heart. However, these stents were not put on at one time, but after 5-10 years and several operations, they were placed one after another.

　　Zhang Li explained that in practice, a single stent can solve the problem, but there are cases where two or more stents are implanted in order to be "perfect".

　　"Stents are mainly used to improve blood supply and relieve patients’ symptoms. For example, there are many coronary lesions in a patient, but the most serious one may be only one. A single stent can be treated, but other lesions may not look good after implantation, and stent connection may be re-implanted. " Zhang Li said that coronary arteries were connected with stents, and most of them could not put more than a dozen stents. This situation was basically caused by stent stenosis and continued implantation.

　　Hu Dayi also mentioned a situation, that is, the patient’s main coronary artery supplying myocardium — — There are many lesions in the left main artery and multiple blood vessels, and bypass surgery should have been performed, and stents were also placed.

　　Li Heping and China Youth Daily and Zhongqing Online reporter confirmed this statement. He said that some patients have a very serious degree of coronary heart disease, for example, all three vessels have a stenosis of more than 75%, or are complicated with diabetes. At this time, according to the stent guidelines, cardiologists should not place stents, but should hand them over to cardiac surgery for bypass surgery.

　　Zhang Li also confirmed with China Youth Daily and Zhongqing Online reporter that this phenomenon is not uncommon. "Sometimes we refer patients to higher-level hospitals and should have bypass surgery. When we come back, we find that we still have stent surgery."

　　Why did the patient who should have thoracotomy and bypass surgery finally choose stent surgery? Li Heping and Zhang Li found that the reason is not single.

　　Li Heping told the reporter of China Youth Daily and Zhongqing Online that there are more than 700 hospitals capable of performing cardiac surgery in China, and half of them have less than 50 operations per year. Therefore, not all patients are qualified for heart bypass surgery in local hospitals.

　　In addition to the factors of medical level, patients also participate in decision-making during surgery. Li Heping also mentioned that at present, the relevant standards require that the degree of coronary artery stenosis is above 75% before stent placement. However, some patients with stenosis of more than 60% also choose to place stents. This may be because patients and doctors think that the disease will develop to more than 75%.

　　Li Heping said frankly that for a considerable number of patients, thoracotomy sounds more horrible, and more people choose minimally invasive surgery to reduce the risk of surgery and the cost of recovery. Some patients hold the traditional concept that major surgery hurts their vitality and prefer not to use a knife to treat diseases. But for these patients, the effect of stent is even less. When the disease develops to a certain extent, the opportunity of bypass surgery may have been lost.

　　But medical judgment is never the only criterion for decision-making. Before the operation, there will be a conversation. As long as one of the patients and their families disagrees, the operation will not be carried out. Zhang Li said that in addition to these reasons, considering the problems after bypass surgery, there is no good treatment for the bridge blood vessels at present, which is also a factor for doctors and patients to consider.

　　Heart stent is not enough, medical resources need to sink.

　　"From the doctor’s point of view, (we) all feel that the strength of the heart stent is not enough." Li Heping learned that there are more than 50,000 cases of bypass surgery in China every year, and this number exceeds 300,000 in the United States. He pointed out that there will be a similar comparison from the PCI perspective.

　　But the whole is not enough, does it mean that there is no abuse? Li Heping pointed out that the limited resources do not rule out the possibility of being used for ineffective treatment.

　　On June 19th, 2016, China Guidelines for Percutaneous Coronary Intervention (2016) was released during Shenyang Northeast Cardiovascular Forum. This guide was led by Han Yaling, a famous cardiovascular expert and academician of China Academy of Engineering, and completed by an expert group composed of 113 top experts in cardiovascular field in China.

　　This guideline suggests that for patients with stable coronary heart disease (SCAD), the degree of coronary artery stenosis should be taken as the basis for decision-making whether to intervene. Stenosis ≥ 90% can directly intervene; When the stenosis is less than 90%, there should be evidence of ischemia or FFR≤ 0.8 of the lesions were intervened.

　　Li Heping found from relevant academic articles several years ago that the proportion of absolute compliance with the guidelines in stent surgery in the United States is not particularly high. When explaining this data, the article also takes into account that the doctor’s medical judgment does not play a decisive role in the decision-making process of whether to perform surgery or not.

　　What makes many doctors more worried is that the inaccurate argument about the abuse of cardiac stents is too prevalent and will affect patients who really need it.

　　There used to be a common saying in society that at present, half of the heart stents can be dispensed with. This statement, which does not come from the survey and is not supported by data, has also become a "proof" for Suzhou doctoral students to report their tutors and cause public concern.

　　"If a patient with acute myocardial infarction is sent to a hospital where stents can be placed well, he refuses to put stents, which is a great loss for the patient." Li Heping is worried about this statement.

　　A clinical doctor in cardiovascular medicine and a cardiologist in a third-class hospital in Beijing refused the interview for the same reason. She believes that the data of the Health and Health Commission has clearly proved that the current stent surgery is by no means an abuse, but a deficiency. Too much discussion on this issue will lead to the opposition of the "nonsense faction", which is not good for real patients.

　　Huo Yong pointed out at the 21st CCIF that the number of cases of interventional therapy for vascular diseases is still significantly concentrated in big cities and hospitals, and graded quality control is imperative.

　　"For patients with acute myocardial infarction, the best treatment is to place stents within 6 hours. From this perspective, our stents are far from enough. " Li Heping has just participated in a study on the in-hospital mortality rate of cardiovascular diseases in China. He found from the data that the mortality rate in different regions is very different. And this is also a problem that is difficult to be solved quickly at present.

　　"National Health Commission is also doing quality control of disease treatment. Going down one level is to find some key indicators to evaluate each hospital in a targeted manner, give some intervention and training, and improve the medical level from the ability level." Li Heping said.

　　China Youth Daily Zhongqing Online Reporter Li Chenhe Intern Sun Ji Source: China Youth Daily