Heart scans: the triumph of profit over science

by Carolyn Thomas  ♥ @HeartSisters

This kind of ad is part of a growing marketing strategy to cash in on your fears. They’re run by for-profit hospitals, medical centres, and sometimes just non-professional entrepreneurs who park their huge mobile body imaging vans in church, community or big box store parking lots.

For example, an ad from the Heart Hospital of Austin in Texas reads:

“Find a new way to tell Dad you love him! Show your love with a HeartSaver CT Scan!”

The website Track Your Plaque warns:

“The old tests for heart disease were wrong – dead wrong. Heart scans are the most important health test you can get!”

A radio ad for the Princeton Longevity Center in Princeton, New Jersey asks:

“Does your annual physical use the latest technology to prevent heart disease before it strikes?”

And this center’s website further promises that its full-day exams – which include heart scans and usually are not covered by health insurance plans – can detect the “silent killers that are often missed in a typical physical exam or routine blood tests.”

Yet most major health agencies (like the American Heart Association, the American College of Radiology, the American Cancer Society) do not recommend routine use of heart scans in low-risk people without heart-related symptoms. 

The non-profit group Public Citizen recently sent letters to 20 U.S. hospitals and medical institutions (listed here) asking each to sever their relationships with a screening company called HealthFair because the company’s heavily promoted, community-wide cardiovascular health screening programs are “unethical and are much more likely to do harm than good.”

Here’s the problem with ignoring evidence: over time, a mix of calcium, fat, cholesterol, cellular waste and fibrin builds up in your coronary artery walls as plaque. In response to plaque build-up, cells in your artery walls can multiply and secrete additional substances that can worsen the state of those arteries. But while artery-hardening calcium MAY indicate disease is present, a heart attack actually occurs when a soft kind of unstable or “vulnerable” plaque ruptures in the coronary artery wall and causes blood to clot.

These CT heart scans, however, cannot see this dangerous soft, unstable, vulnerable plaque – only the hard stuff. And if you’re a woman with heart disease, according to a study reported in the February 2010 issue of the American Journal of Cardiology, you have far less of this hard calcified plaque than men anyway.(1)

So this kind of marketing is “a big problem” says physician Dr. Kimberly Lovett, a member of the San Diego Center for Patient Safety at the University of California, San Diego School of Medicine.

In an editorial in the Journal of the American Medical Association, Dr. Lovett suggests that inappropriate testing can lead to inappropriate treatment. She writes:

“These marketing strategies exploit patient fears and promote tests that aren’t necessary for most people.

“Direct-to-consumer cardiac testing may pose more harm than benefit.”

Dr. Lovett is one of a growing chorus of physicians calling for a crackdown on indiscriminate testing and treatment in favour of an evidence-based approach to cardiac care.

But money talks – often loudly enough to drown out evidence and the voices of experts like Dr. Lovett. 

Ads like the one at the top of this page are not unusual, according to a special report from Consumer Reports Health. As doctors and hospitals add more and more expensive high-tech gadgetry to their arsenals, all too often it’s profit, not science, driving decisions on how heart disease is detected and/or treated.

And as the Pulitzer Prize-winning newsroom ProPublica discovered, body imaging test facilities are indeed profitable for their owners. After they investigated a chain called Heart Check America in 2011, ProPublica journalists found that scans were often done without a doctor’s order, and not read by a radiologist. The chain was then not only forced to shut down its Colorado clinics but also ordered to pay $3.2 million by the Colorado Department of Public Health and Environment for conducting CT scans without state-licensed doctor referrals – at the time, the largest fine ever imposed by the radiation program division in the state’s history.

Dr. Gilbert Welch, a Dartmouth Medical School professor who studies over-diagnosis problems created by attempts at early disease detection, told ProPublica:

“Scans can result in false positives, leading to unnecessary treatments that are invasive and risky. The assumption they’d like you to make is that this could only help you. But that’s not right. It could hurt you.”

The Consumer Reports investigation revealed the following:

• People often get the wrong heart tests. Good tests detect disease and lead to effective treatments. But many heavily marketed cardiac tests don’t do that. Dr. Lovett says: “I can understand how people would think ‘what’s the harm?’ But not only is the wrong test a waste of resources, it can be downright dangerous if it leads to inappropriate treatment.”

• Angioplasty is overused. Recent research suggests that many patients in non-emergency situations are rushed to angioplasty, an invasive procedure using metal stents to clear blockages in the coronary arteries, when dietary changes and exercise, plus drugs, would be just as effective and much safer. Other research shows that angioplasty is also too often used for severe blockages, when surgery to bypass the occluded arteries could provide longer-lasting benefits. See also: Cardiologists Accused of Implanting Cardiac Stents That Weren’t Needed or Did You Really Need that Coronary Stent?

• Heart disease is often misunderstood. Many patients, and even some doctors, have an outdated understanding of the best way to prevent heart attacks.

Dr. Diane Kelsall is Deputy Editor, clinical, at the Canadian Medical Association Journal, and Editor of CMAJ Open. She wrote recently about a newspaper flyer she came across for a U.S. clinic offering all kinds of discount body scans to Canadians.

“I could have everything from a heart scan for $150 or stroke scan for $60 to an ultrasound imaging of my deep leg veins ($60) to find those pesky blood clots that may be lurking. They were even offering ovarian and uterus scans for $60 (which seemed to be the going rate for most of the 11 scans) to detect masses and cysts that apparently could lead to ovarian cancer or uterine cancer. For $500, I could have all the scans and reassure myself that my arms and legs had decent blood flow and that my gallbladder was cancer- and gallstone-free.”

But the fact is, she reminds us, that there is no evidence that such scans can save lives on a population basis. Full stop. She adds:

“Not only do they not save lives, the scans may show a small lesion that we as physicians are obligated to investigate, often with those very blood tests and needle injections that the authors of this flyer reassure me are NOT part of the scans.

“And these investigations may not be limited to a simple blood test. Sometimes, much more invasive procedures, with their accompanying risks to health, are required to determine whether the lesion is or is not something we should be worried about in the long run.”

Alan Cassels is a Canadian drug policy researcher here at the University of Victoria and co-author of the book Selling Sickness. His forthcoming book is called The ABCs of Medical Screening: Looking for Sickness in 26 Wrong Places. He’s concerned that, despite the lack of clinical evidence supporting heart scans, we seem all too willing to believe all that for-profit heart scan advertising. He too cites the Consumer Reports Health study:

“The survey found nearly two-thirds of respondents who were between 40 and 60 with no history or symptoms of any form of cardiovascular disease said they would definitely have a complete battery of heart-screening tests if they were free.”

What this survey showed was that many people regularly get heart screening tests, whether it’s an EKG, an exercise stress test or an ultrasound of their carotid arteries and do so in the belief that there is no harm in over-testing.

According to Consumer Reports, 87 per cent of those surveyed completely or somewhat agreed with the statement that it was “better to have a scare that turns out to be nothing than to not get tested at all.”

What does this all mean? Alan Cassells warns:

“To me, the ‘better safe than sorry’ axiom is a strongly held belief.

“My corollary: if you are ignorant to the harms associated with heart screening, the more likely you’ll submit to it.

“Are you worried about heart disease? Then follow the lifestyle advice that most doctors and experts would give: stop smoking, get regular exercise, don’t eat too much fat and salt, manage your stress.

“Wait a minute. Isn’t that the advice they give if they find you have high levels of calcium in your coronary arteries? Why yes… it is…”

Read the rest of Alan’s report called “Welcome to the Heart Scanning Industrial Complex” published in The Tyee.

(1)  Nasir K, Gopal A, Blankstein R, et al. Noninvasive assessment of gender differences in coronary plaque composition with multidetector computed tomographic angiography. Am J Cardiol 2010; 105:453–458.

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Q:  What’s been your experience with body imaging clinics and/or heart scans?

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See also:

• Heart screening scans – or scams
• The business of prostate cancer: putting profit before patients
• The myth of osteoporosis: blowing the whistle on the “epidemic”
• Why do doctors call it “practice variation” instead of poor care?
• Cardiac society gets half of its funding from stent industry
• Angioplasty.Org – a comprehensive resource for independent information before you go to the cath lab to have a stent implanted

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