I have sometimes been called a contrarian. This can be both a positive and negative label.
The positive is that, sometimes, the contrarian view turns out to be correct. And, even when the future is unknown, the debate unsettled, a contrarian view serves to counter soft consensus thinking. In case you haven’t heard, consensus thinking is common in Medicine.
The negative is that contrarian can often be used as a pejorative: this person is a nihilist and doesn’t believe in anything.
Let me explain.
History shaped my worldview of medical evidence.
When I started in medical school, consensus held that we used anti-arrhythmic drugs in patients who had just had a heart attack. You could not speak against this practice. Yet, this consensus turned out to be deadly when studied in a randomized controlled trial. The number needed to kill patients with this practice was 29.
Then, in residency, in our outpatient clinics, consensus held that we should use hormone replacement therapy in post-menopausal women to reduce cardiac outcomes. And, this too, was found to be harmful in the Women’s Health Initiative randomized trial.
In private practice, common practice held that patients with low heart rates should have pacemakers, regardless of symptoms. We then learned that symptoms should guide pacemaker implantation—not any one number.
At next week’s ACC meeting, you will read studies about the common practice of sodium restriction in patients with heart failure. I predict you should buckle up.
I could go on and on. The point is that living through these reversals affects your prior beliefs. Proponents of new therapies, authors of observational studies, the experts, are quite skilled in framing new developments as game-changing.
But…I have this historical voice in my mind talking to me. I wonder if this new thing is similar to many of the other reversals.
The core problem we have in 2023 is that we have made so many gains that true progress is quite hard.
When we learned to stop heart attacks with emergency stents, the number of patients with heart failure plummeted. Life was extended. When we developed four classes of drugs for heart failure, the number of patients dying of heart failure also fell. It’s the same in cancer therapy. Patients who would have died in decades past now live into old age.
The cardiologist of today faces a different question then the cardiologist of the 1990s.
Today, the question is not can we do something (clip a mitral valve, ablate an arrhythmia, implant a defibrillator), but should we do it.
What is the true value of these new things?
The value is clear when a young person is having a heart attack: you get that person in the lab and open the artery. A much different question, however, comes up when a ninety-year-old patient with chronic kidney disease and dementia is winded because of a stenotic aortic valve. Of course, we can place a new valve, but should we?
Progress today is often sold as major but in reality is incremental.
A good example: this week, in the Journal of the American Medical Association, two studies show that an ultrasound catheter can deliver energy to the kidney and this reduces blood pressure by about 6 mmHg over 2 months.
The idea that a procedure could reduce BP is neat. High blood pressure is an important problem. And people hate taking medicines long term. So, renal denervation with catheters is a possible advance.
But the degree of BP-reduction (6 mmHg) from that new catheter, could easily be had with simple lifestyle changes or a generic med that costs pennies. Crucially, high blood pressure treatment is not for 2 months, or 2 years, but 20-40 years.
This device might pass muster at FDA. If it does, doctors will embrace it. Marketing forces will be huge.
Yet we won’t know its value.
So I will be quite critical of this paper, not because it is a bad paper. It is not. But because it is too early to start using this therapy. We need more data.
For this criticism, some will label me a contrarian. Mandrola doesn’t believe.
I accept this label—totally.
But be sure, when new interventions pass muster in trials, I become an early adopter.
I want to help my patients. I love things that work. The problem is that finding new things that really work is hard.
We need contrarians, now, more than ever.
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