How to Avoid the Unnecessary Cardiovascular Operations of Philip Roth’s ‘Everyman’

Earlier this year, the skeptical cardiologist wrote about the cardiovascular misadventures of the lead character in Philip Roth’s novel every man.

I originally planned this as a single blog post, but very quickly realized that there are more important points to addressing cardiovascular disease than could be contained in a 1,000 word post.

After Roth’s Jedermann is taken to the hospital to have an invasive coronary angiography, which he probably didn’t need, he is then rushed to have a coronary bypass surgery, which he probably didn’t need. In 1998, at the age of 65, he underwent renal artery stenting for high blood pressure, which is now considered doubtful.

The first unnecessary carotid surgery

A year after his renal artery stent, he had a left carotid artery (CEA) endarterectomy, which he described as “surgery for another major obstruction, this one in his left carotid artery, one of the two main arteries that extend from the aorta to the base. describes the skull and supplies blood to the brain, and if it remains clogged it could cause a stroke or even sudden death.

He describes the procedure in detail: “The incision was made in the neck, then the artery supplying the brain was pinched off to stop the flow of blood. Then it was slit open and the plaque that was causing the blockage scraped out and removed.”

He is told “there was nothing out of the ordinary from a medical point of view, or so he was led to believe by the sympathetic surgeon, who assured him that a carotid artery endarterectomy was a standard vascular surgical procedure and he would internally be back at his easel for a day or two.” days.”

A lot has changed since Everyman got his CEA in 1999. My practice in the 1990’s was to strongly consider referral of my patients with asymptomatic carotid obstructions >70% for CEA, but as medical management of atherosclerosis progressed, studies since 2010 began showing minimal benefit in stroke reduction for CEA.

In 2022, I will rarely see a patient being sent for CEA who has not had a stroke or transient ischemic attack.

A recent UK publication states: “The role of CEA in asymptomatic patients has been a source of considerable controversy, with some countries performing large numbers of CEA procedures in asymptomatic patients (e.g. the United States and Italy) while CEAs are not performed in Germany for asymptomatic patients in Denmark. Furthermore, the latest stroke guidelines now advise against performing CEA on asymptomatic patients in Australia.”

This paper found a 63 percent reduction in CEA performed in England in asymptomatic patients between 2011 and 2017.

The Choosing Wisely project aims to identify low-value procedures and CEA in asymptomatic individuals with carotid stenosis >50% was in the top 5 for Australian/New Zealand Choosing Wisely neurology procedures. The recommendation: “Do not routinely recommend surgery for a narrowed carotid artery (>50% stenosis) that has not caused symptoms.”

Everyone is asymptomatic. He had no symptoms from the obstruction in his carotid artery. There is no mention of stroke symptoms in the book and it must be assumed that everyone, like thousands of Americans, is undeservingly receiving an annual carotid ultrasound, the non-invasive test that allows identification of asymptomatic plaque build-up.

It is important to note that many guidelines mention that CEA is only useful in the asymptomatic patient if the preoperative risks of stroke, death, and myocardial infarction are less than 3%.

Therefore, in order for a patient or referring physician to make an informed decision, they would need to know the surgical outcomes for the surgeon performing the procedure. In the real world, almost nobody has this data.

The reason surgery for carotid blockages appears to be less helpful over the past 2 decades is similar to why coronary artery stenting and bypass surgery are less helpful: improved medical control of atherosclerosis with lipid-lowering therapy, blood pressure control, and lifestyle changes , including cigarette smoking cessation.

Unfortunately, we have no idea what medical therapy eachman received. Given that statins were widely used in the mid ’90s and given his history of coronary artery bypass surgery, he should have taken the strongest available.

More unnecessary coronary procedures

The year after his carotid artery surgery, Everyman had “an angiogram in which the doctor stated he had suffered a silent posterior wall heart attack because of an occluded graft”. Given the fact that nobody reports any related symptoms, and given their physicians’ previous unduly aggressive testing and procedural orders, I can only assume that this repeated invasive angiography was performed as a result of an abnormal stress test.

Cardiac guidelines now discourage routine exercise testing after stenting or bypass procedures, which I have discussed extensively here. This practice was the norm 20 years ago and continues to this day. A major problem with these routine tests are downstream tests, such as invasive angiograms, that follow false positive results.

When inappropriate invasive angiograms are performed, coronary blockages are often found and stents are often placed, which do not reduce the risk of heart attack or relieve symptoms. Sure enough, everyone has a stent implanted in their left anterior descending coronary artery, one that didn’t communicate with the back wall of the heart at all.

The next year he gets another coronary stent, this time in a bypass graft. A year later he gets three more coronary stents. Again, no symptoms were mentioned, no benefit achieved, except for the stenting doctor’s wallet.

A final carotid ultrasound followed by fatal carotid surgery

As we reach page 156 of this 182-page novella, Roth writes, “The next time he went to the hospital for the annual checkup of his carotid arteries, the ultrasound showed that the second carotid artery was now seriously blocked and required surgery.”

As suspected, one of Everyman’s doctors has ordered a routine annual carotid ultrasound. Significant asymptomatic carotid stenosis is often identified in screening studies prior to coronary artery bypass graft (CABG) surgery. There are no good randomized studies on the management of such cases. Some carotid stenoses are treated concurrently with CABG, others are treated sequentially and to a lesser extent, such as Jedermann’s stenosis, medically.

Outside the United States, international organizations are fairly unanimous in condemning the routine screening of asymptomatic patients with carotid ultrasound.

So, yes, everyone got into the cycle of repetitive annual low-value carotid screening, and it eventually caught up with them.

Everyone would like general anesthesia “to make the procedure more bearable than the first operation under local anaesthetic”.

Roth writes: “He went under feeling far from lost, far from doomed, eager to be fulfilled once more, yet he never woke up. cardiac arrest. He was no longer, free of being, stepping into nowhere without even knowing it. Just like he feared from the start.”

Everyone’s destiny is not unique. How can today’s patients avoid or minimize this merry-go-round of cardiovascular testing, invasive procedures, and potentially fatal surgeries?

lesson for patients

• Refuse low-quality screenings like routine annual EKGs or carotid ultrasounds
• Strongly consider getting a second opinion if you are recommended for invasive vascular or major surgery, especially if you are symptom free
• Ask your doctor why they order imaging tests; How will the results change his treatment?
• Keep in mind that just because it seems logical to mechanically remove localized blockages in the arteries to our head or brain, the process of atherosclerosis that caused these blockages is diffuse and the optimal approach is most often a systemic medical one

Anthony C. Pearson, MD, is a noninvasive cardiologist and professor of medicine at St. Louis University School of Medicine. He blogs about nutrition, heart testing, quackery, and other skeptical stuff at The Skeptical Cardiologist, where a version of this post first appeared.