The PCI dispute, PCI | PCI in Northern Norway

Opinions This is a debate post. The post expresses the writer’s views.

In a post, senior doctors Kjellmo, Bjørnstad and Hovland at Nordlandssykehuset Bodø write that I have previously worked at the Department of Heart Medicine at UNN and UiT. This is correct. The doctors in Bodø think this should have been mentioned in my chronicle as a possible conflict of interest. I should probably mention that. But in that case I also have other competence challenges.

Very unvarnished from Bønaa

Because I have not only worked at the University Hospital in Tromsø. For several years I worked at Nordlandssykehuset Bodø and Sandnessjøen hospital. I have had practice at Lofoten Hospital and Rana Hospital, and I have worked as a municipal doctor in Lurøy, Værøy and Røst, and in Lyngen. I am from Helgel and have roots in Finnmark. In other words, I have many interests in the PCI matter. These interests are based on belonging to the region, experience from the health service, and a desire for Northern Norway to have a good cardiac medical treatment offer that is equal to the rest of the country.

I am afraid this is in danger, when Nordlandssykehuset would rather be professionally managed from Oslo than from Tromsø. In practice, it is a farewell to the idea of a joint North Norwegian university hospital.

This is an important reason why I have taken the floor in the debate about PCI in Bodø.

Another strong motive for saying something in this matter is based on my work as a researcher and doctor and experience with PCI treatment of heart attack patients for many years.

When PCI became introduced over 25 years ago, many believed that PCI was the solution for far more patients than is the case. This applies both in the acute treatment of heart attacks and in the treatment of chronic complaints (angina pectoris).

According to In the European guidelines for the treatment of severe myocardial infarction, a goal when choosing PCI is that the blocked coronary artery should be opened within 90 minutes. Since it takes time from the time the patient arrives at the hospital to the opening of the vein, these guidelines mean that PCI is recommended if the travel time to the PCI hospital is less than 60 minutes. But when you compare patients who are treated with PCI according to the guidelines with those who get drugs, it turns out that those who get drugs do as well, or better, than those who get treated with PCI.

A Norwegian study of 4,000 patients from the Eastland area who had major heart attacks, showed that mortality in the first 8 years after a heart attack was 28 percent lower among those who received drugs at home or in the ambulance compared to those who were treated with PCI at Ullevål Hospital. A study from central Norway found no difference in 30-day mortality between the drug group and the PCI group.

A research paper based on data from the Norwegian Myocardial Infarction Register published in 2021 showed an equally good effect on death and the risk of a new heart attack or stroke when comparing those who received drugs with those who were treated with PCI in accordance with the guidelines. Patients who were treated with PCI after the recommended time, on the other hand, had a higher risk than those who received drugs.

The most important reason to the good results with drugs, is that the patients who are treated at home or in the ambulance, have the vein opened much earlier than those who have the vein opened after being transported to a hospital where PCI is performed. When the vein is opened earlier, the damage to the heart muscle is reduced. This is probably the explanation for the fact that it now turns out that drugs cause less risk of serious pump failure (cardiogenic shock) and heart failure than PCI.

That was why with sadness and disbelief I read a news article in Avisa Nordland on 18.4.24 with the headline: “Full agreement: – We should not accept being treated as second-class patients”. From the article it appears that the county council in Nordland has made a unanimous decision to fully support continued PCI in Bodø after being briefed on the drug method and the PCI method by a senior physician at Nordland Hospital Bodø. One of the politicians stated: “We should not find ourselves being treated as second-rate patients when serious and acute illness threatens”.

I understand the decision well, given the conditions the county politicians were presented with. It’s just that the drug method is not a second-rate treatment. Medicines given early have at least as good an effect as PCI.

That is correct, as has been pointed out in this debate, that not all patients can be treated with drugs, and that drugs do not work for everyone. But PCI does not give a good result in all patients either. Sometimes you have to spend a long time opening the vein, sometimes you only manage to open it a little, and sometimes the vein closes again because the equipment used to do PCI causes the blood clot to loosen and leads to new clogging of the heart vein.

And opening of chronically clogged arteries with PCI may be associated with significant risk of complications. The success story gets in the papers, not the complications.

The point here is that drugs are not second-rate treatment and that PCI does not solve all problems in heart attacks and chronic coronary artery disease.

It was important for me to give the politicians in Nordland a more balanced view of what is available from scientifically based knowledge about PCI.

The third reason why I took the floor in the debate was that I became aware that several debate posts incorrectly used data from the heart attack register as support for PCI in Bodø.

A post in North Norwegian Debate on 22.4.24 bears the title “The patients’ hearts become losers against the professors’ publications”. The title gives the impression that professors care about publications and not about patients. This is an outrageous suggestion because it helps to cast doubt on the honesty of researchers. The post was written by SP politician Siv Mossleth, who is a member of the Health and Care Committee at the Storting. She writes that “for the sake of the patients, the PCI service in Bodø must not be cut, but expanded to be open 24/7”. The post contains two figures which allegedly support her claim.

The one figure is from the Heart Attack Register and shows that the proportion of patients with less severe heart attacks who have been examined with a coronary X-ray within 72 hours has increased slightly more at Helgeland Hospital than the national average. But the increase started 5 years before PCI in Bodø was started and of course cannot be taken as income for PCI in Bodø.

In addition, publishes Mossleth in his post a figure from a research article which is based on data from the heart attack register where several employees at the heart attack register are co-authors. Mossleth has published the figure without asking permission. But the most important point here is that the article concludes that more patients with severe heart attacks should be treated with drugs, and that fewer should receive PCI. So no support for PCI in Bodø. On the contrary.

Both the announcement that PCI is second-rate treatment and Mossleth’s post are examples where, in my opinion, scientifically based knowledge is delegitimized and professional assessments are called into question.

The fourth reason reason for me to take the floor in the debate is that the excess mortality from heart attacks at Nordlandssykehuset, which was reported by the heart attack register, is, in my opinion, under-communicated by the expert group and in the debate after the expert group presented its report. Excess mortality became the elephant in the room that no one talked about.

Kjellmo, Bjørnstad and Hovland writes that there is a risk that random variation affects the results if you compare changes from year to year. Precisely for this reason, we calculated mortality over a period of almost 3 ½ years before and just as long after the start of PCI in Bodø. During this period, mortality increased by 33% at Nordlandsykehuset, while mortality decreased by 12% in the rest of Helse Nord. The figures in the heart attack register’s report to the expert committee are correct and contain all heart attacks in the region without an upper age limit of 85, as the register uses when preparing quality indicators.

As head of the heart attack register, I have a responsibility to ensure that data from the register is used correctly. That is why I also spoke out in the media in 2017 about incorrect use of the register’s data ahead of the decision to create a PCI offer in Bodø.

Both then and now, I speak as a private individual and not on behalf of the register. I should have drawn attention to this and I apologize for that.

My main concern is that Helse Nord must use professional assessments as the basis for its decision as to whether PCI should still be carried out in Bodø.

Conducts PCI business in Bodø for better health for the northern Norwegian population? I do not think so.

Will it help the cardiac medical professional community in the region? No. I think quite the contrary. Two smaller units that cannot cooperate mean a weakening of the cardiac medical treatment offer in Northern Norway.

Should Nordlandssykehuset be professionally managed from Oslo and not from Tromsø in the PCI case? No. Because in that case, you start on a journey where the clock is turned back to the 1960s, before the Storting decided to establish a comprehensive university in the region.

Kaare Harald Bønaa is a senior physician in invasive cardiology at St Olav Hospital, professor emeritus in cardiovascular diseases, and head of the Norwegian myocardial infarction registry.

Previous chronicles from Bønaa: