The Sky is Not Falling, It’s the Limit

August 3, 2016 | James Hansen, DO

Right now is a great time to be an interventional cardiologist. The face value of this statement is low, filled with trite optimism and an intolerable sense of idealism. Some senior operators would certainly disagree. To ask them, a career in interventionalism is self-inflicted destitution. I am of the opposite persuasion, and not just because I feel like being contradictory.

It is true that rates of cardiac catheterization have fallen. We are, as we have always been, threatened with the prospect of declining reimbursement [PDF].  At this point, surgical revascularization continues to offer better long term outcomes at the cost of higher up front mortality. In diabetics, the LIMA graft still reigns supreme. Thanks to the national decline of smoking and the advent of statins, the incidence of obstructive coronary disease is lower. The COURAGE trial has shown that in selected patients, revascularization of stable obstructive coronary disease does not improve outcomes.

However, innovation continues to allow us to push the envelope of what was once possible. Thomas Edison was once asked about his 100+ failed attempts to create a working light bulb.  He famously replied that he had not failed; he simply discovered 100 ways to not make a light bulb.  The third generation of vascular scaffolds is in the market, building upon our previous successes and failures. At this point, the LIMA graft is the only graft that provides surgical revascularization with any superiority. As the population continues to age, older patients will make poorer surgical candidates, making the percutaneous revascularization the more desired approach. Bioabsorbable stents, while still relatively rudimentary and bulky, offer an unparalleled opportunity to revascularize, ultimately with no residual evidence. Innovation has not been more clearly displayed than in the juvenile field of structural heart disease and transcatheter aortic valve replacement. This success is already paving the way for the much more complicated mitral valve.

There will be setbacks. There will be complications. There will be the unforeseen, and thus not accounted for.

Cardiology is the most evidence-based field of medicine in the modern era. This evidence-base is sometimes met with criticism and the suggestion that we cannot provide a randomized controlled trial for every possible condition. This is true. We must extrapolate our results, sometimes liberally. But this also means that interventional cardiologists have the largest foundation on which to draw. The next idea, the next technique, the next ‘eureka’ is around the corner, germinating in someone brave enough to question the status quo. The best days are the ones where one question is answered, but generates another ten.

Today is a great day to be an interventional cardiologist, not because we’ve figured it out, but because we are still figuring it out and helping our patients with innovation in real time. I have no doubt that, in time, many of our other clinical dilemmas will also yield their secrets. We haven’t failed; we have just discovered 100 different ways to treat heart disease

This article was authored by James Hansen, DO, a Fellow in Training (FIT) at Lahey Medical Center.