Plenty of Americans experience chest pain these days.  A clueless lame duck president is presiding over the greatest destruction of wealth in modern American history, while people lose jobs, homes, pensions, and their faith in the future.  Expect lots of people to show up in emergency rooms with scary, unremitting chest pain.

         For years the standard diagnostics for new chest pain in those without cardiac history has been to get an electrocardiogram, followed by a cardiac exercise stress test.  Not doing an EKG in such circumstances would please many an American malpractice lawyer.

         However, a recent British study of 8176 consecutive patients entering special hospital chest pain clinics has placed the standard diagnostic regimen on its head, with broad implications for what we pay for in health care.

The Power of Prognosis

         The recent, large scale British study did show chest pain patients with lots of risk factors were more likely to die or have acute heart disease over the next two and a half years.  However, 47% of such follow-up events occurred to people with fully negative tests.  Getting a Òclean bill of healthÓ was useless to half the people who later got sick.

         So you walk into a hospital with frightening chest pain. What does having that EKG additionally tell you about your future heart risk?  According to this study, nothing.  As for stress exercise testing, the added prognostic information was a little bit more than nothing.

         What did provide useful prognostic information was a detailed history and physical.  Time spent with a patient asking about risk factors and integrating the answers to the physical exam provided the best indication of future cardiac health.  The better the history, the better the prognostic accuracy.

The American Example

         Many American physicians will probably look at the British study and conclude that when facing new chest pain in a patient, you just need more tests. One retired physician friend, aged 60 and healthy, finds that on meeting a new general physician his history and physical have become vestigial.  The first matter of business is blood testing.

         Walk into a doctorÕs office and complain of chest pain and more than blood will be required from you.  Even if clear evidence appears of gastroesophageal disease or costochondritis, a 60-year-old male with chest pain ÒdeservesÓ further testing to Òmake sureÓ no cardiac disease is present.

         First up, a cardiac echocardiogram to check overall heart function.  Next comes a stress exercise EKG.  If there is Òany questionÓ of possible heart disease, and with the high false positive rates of EKG stress tests thatÕs likely, a much more expensive gated pool radioactive dye stress test will follow.  If anything shows up there, your next step is a  cardiac cath.

         I have seen this pattern performed in 25-year-old athletes with aching ribs to Òmake sureÓ no cardiac pathology was present. The cardiologists performing these studies are often under financial pressure from their Òpractice managersÓ to pay for their expensive equipment.

         What is the prognostic value of all this testing? Nobody really knows.

         In most cases, good studies of efficacy simply donÕt exist. Especially under the Bush administration, effectiveness studies have been ceded to the drug and device makers.  The recent statin study of Crestor, paid for by the manufacturer, run by a Ònoted researcherÓ slated to earn millions if his CRP test was vindicated, lead to global headlines proclaiming:  Pretty much everyone should take statins.  As pointed out in the New England Journal of Medicine, the epidemiologic biases in that study, which threw out 80% of the potential participants and created potentially huge volunteer bias, are so broad as to bring into question whether any company can impartially study its own products. By looking mainly at short term data, the FDA has pretty much made inevitable future disasters like those of vioxx and Fen-phen.

Fixing the Mess

         American medical care is based on who gets paid, in turn based on who has the most effective lobbyists.  At present we spend huge amounts on high tech testing, which in many cases doesnÕt tell you any more than a good history and physical.

         But history and physicals take time, and physicians donÕt get paid for their time Ð theyÕre paid for procedures.  So the first matter of business is to pay for what does work:  cognitive services.  Physicians and health workers who actually listen to you, ask you questions and answer yours;  Òold fashionedÓ medicine.

         The costly and difficult effectiveness studies need to be done by potentially impartial groups, like the now eviscerated government Office of Technology Assessment.   We can also partner with European governments, who want to know what works and what it costs. Then we can compare our expensive treatments with Òdull,Ó public health stuff like vaccinations, education, public bike programs, and green spaces in cities.

            LetÕs see whoÕs worth the money.

Dr. Matthew Edlund practices sleep medicine and psychiatry in Sarasota.  His new book, Designed To Last, is available online. He can be reached at 365-4308 and via his Web site at doctoredlund.com.