CDU

CHICAGO — Associations that target specific diseases are usually optimistic. They have to be. They put themselves on the forefront of conquering the disease they target. They have to be, because they need to raise money to continue the fight. They have to be, to avoid despair.

And the showcases for their optimism are their annual conferences.

That has clearly been the case with the annual Scientific Sessions of the American Heart Association (AHA; Dallas) — lots of upbeat reports and public initiatives launched, last year, for instance, the "wear red" effort and an increased focus on heart disease in women; in all years, the rollout of studies indicating advances in therapeutics that treat this No. 1 killer, supporting the feeling that this thing can be conquered.

But the year 2006 AHA Scientific Sessions appeared to be somewhat different, somewhat less optimistic, somehow a bit more toned down.

The reason?

The reason we think is that — as in the most recent balloting in the U.S. — reality breaks through. And in the case of cardiovascular therapy, reality is pointing ever more clearly to the fact that technology doesn't save lives, technology can only put off man's final endpoint.

The more subdued tone was struck in one of the first presentations at the AHA meeting by its president, Raymond Gibbons, who appeared to put "the cat on the roof" (one of my favorite uncle's phrases implying imminent failure, with the next announcement that the cat is deceased, the result of an ugly fall).

Gibbons did this with what appeared to be a clear effort to reduce expectations. Specifically, he emphasized the difficulties that the AHA faces in reaching its rather daunting goal of reducing heart disease by 25% by 2010, that message a possible semaphore indicating the unreachable reality of that goal.

Gibbons called for major overhaul of the U.S. healthcare system and suggested the need for broad national healthcare coverage — not what you usually hear from top drawer medical types (and my uncle, a GP, wouldn't have been, since he constantly prophesied the horrors of "socialized medicine" in the U.S.).

Gibbons expectation-reducing message was followed by various market-reducing messages during the conference.

Among the most important was a debate focusing on the increasing concerns about drug-eluting stents (DES) vs. bare-metal stents (BMS), with one study underlining what we had heard from a group of cardiovascular surgeons more than two years ago.

The study indicated that yes, DES had demonstrated early-term reduction of restenosis, but the restenosis effect is only delayed. The study found that restenosis following DES use was low early on but then was equivalent to BMS over three years.

(The thrombosis issue with DES, of course, is still shaking out, but a late-November report out of the prestigious Cleveland Clinic will certainly put an even brighter beam on this and probably depress a DES market already trending down.)

Overall, the take-away would seem to be the standard wisdom that the short-term, manufacturer-sponsored trials should be looked at with considerable skepticism.

Still another report is likely one that caused some concern among the interventionalists at the meeting — that after three days following severe heart attack the outcomes for the angioplasty/stenting strategy fail to produce significantly better results than bypass.

And there was still one more study that drew our attention and — if considered in a broad psychological context — should dampen the optimism of those who consider technology a sort of ultimate answer in healthcare. The study reported that a large majority of those implanted with defibrillators, but very clearly declining in their health status and nearing death, refuse to have their ICDs turned off, even though these devices may continue to provide unuseful shocks and add to the discomfort of dying, often the worst attribute of this end experience.

We can't help but extrapolate from this — to say that human beings in a technologically sophisticated environment probably have expectations for med-tech that are much too high.

The healthcare industry, of course, promotes this. More and better technology fits the Western world scenarios of continuing improvement via technology and higher profits, with those profits often translating to more R&D, more technology.

One AHA conference with lowered expectations won't change this, but we can only hope that clinicians will do the right thing and attempt to put a slight brake on their patients' faith in the healing powers of technology.