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Monday, April 9th 2007

Reconsider Cardiothoracic Surgery

The trashing of stents, those little things which caused so much angst for the cardiothoracic surgeons, continues. Freakonomics (h/t Kevin, MD via OnThePharm) predicts stenting will be looked upon as a failed experiment in coming years.

By the time any of my class is approaching the end of a general surgery residency all of these things will probably have come to pass and be obvious. But for anyone currently in a surgical residency maybe CT surgery deserves another look.

Despite that advice, I have some trouble with the post and the BMJ editorial which Freakonomics is commenting on. From the BMJ,

It’s easy to feel contempt for deluded practitioners of the past who advocated bloodletting and tonsillectomies for all. Easy, that is, until one considers emerging evidence that coronary stenting and postmenopausal hormone replacement therapy may well be the contemporary equivalents of those now discredited practices.

Now that the dangers of hormonal treatments have been revealed
, we are left with a paucity of effective treatment alternatives. A few that have modest evidence of benefit include clonidine, some selective serotonoin and noradrenaline reuptake inhibitors, gabapentin and Vitamin E.

Emphasis is my own. But the BMJ’s editorial is being published on the heels of this.

The latest analysis of combined data from two parts of the study data has however found no increased risk of heart attack for women in their fifties who were taking HRT and even a slight reduction in the risk, and for women between 50 and 60 taking HRT the overall risk of death from any cause was reduced.

The new findings suggest that HRT use in women aged 50 to under 60, when most women experience the menopause, does not increase the risk of heart disease.

Even I, a second year medical student, was having it beaten into my head that the WHI was flawed before this new meta-analysis was published.

The new findings are mixed, to be sure. But still, with them I’m not sure the label this editorial pushes on HRT is deserved. Indeed, it may show the same type of leap of judgment that the editorial basically condemns. The author may be playing the “expectations game,” seeing as the health profession had such high hopes for HRT initially. But the majority, the vast majority, of women don’t take hormones out of some naive desire to protect themselves from cardiovascular risks but to alleviate the symptoms of menopause. And in the women most likely to have those symptoms, by age, HRT reduces them and probably does such without an increased risk to the heart.

Almost all the observable trends from the analysis failed to rise to the level of statistical significance. What the study found, even if the findings weren’t significant, was that younger women actually had a decreased risk of heart disease while older women had an increased risk. Younger women had decreased total mortality. All women on HRT had an increased risk of stroke.

In anycase, back to the point. Stents definitely have their problems. Problems more established than hormone replacement therapy. And while I might not banish them to the realm of antiquated therapies within the next ten years, like the BMJ article (equating them to bloodletting? yikes), I do think their use will decrease – even as new stenting technologies emerge. Which is why when combined with a potential shortfall in the number of CT surgeons in the next decade or so, a cardiothoracic surgery fellowship (something I was very interested in coming into medical school) should look way more attractive than it currently does to medical students. The past few years there have been fewer applicants than positions. I think in 2005 thoracic surgery residencies had like a 60% fill rate.

But, in part because of the shaky future of interventional methods of dealing with CAD, medical students and surgery residents probably should be considering CT surgery. And programs should stay their hand in rolling back the number of positions.

Looks like the author of OnThePharm, a pharmacist, is looking to head to medical school. Always an excellent choice. :)

I wish him luck but, considering how far ahead of the curve he probably is, I doubt he needs much of it.