The documentary, The Widowmaker (available on Netflix streaming) should definitely be watched by everyone.
It presents some great information on dying suddenly from heart attacks in an entertaining way.
It makes two important points: coronary stents don’t prevent heart attacks and coronary scans can identify advanced coronary artery disease before heart attacks happen.
I am in total agreement with these two points and have made them several times in previous posts (here and here).
The film is a work of advocacy, however, and twists the truth to prove its underlying theory: that greedy doctors and hospitals are choosing to “push” expensive coronary stents that do no good until you are having a heart attack. Also, that doctors and hospitals are also somehow suppressing the use of coronary calcium scans, which could prevent millions of heart attacks and deaths.
Creating black and white heroes and villains in documentaries makes for riveting entertainment, but often at the cost of sacrificing the truth.
Let’s look at the villains that The Widowmaker presents.
First up is Julio Palmatz. Dr. Palmatz is a vascular radiologist who invented, along with Dr. Shatz, one of the three primary stents that ultimately gained widespread clinical usage. The Widowmaker implies that Palmatz was THE stent developer, and follows Julio as he revisits the garage in Texas where he developed prototypes for the slotted tube stent.
At this point in the movie, it would be understandable if you thought Julio was going to be one of the heroes. He seems very personable as he describes the inspiration for his stent design and points out the area in the garage where his work bench stood.
However, the documentary wants, ultimately, to portray Palmatz as greedy, unconcerned about patient welfare, and in the pocket of wealthy investors.
He has done well financially because the patent on his coronary stent was eventually sold to Johnson and Johnson for millions (and he is interviewed on the grounds of his Napa Valley vineyard).
A recent scholarly analysis of the process of the development of stents differs with this portrayal of Palmatz:
“We found that the first coronary artery stents emerged from three teams: Julio Palmaz and Richard Schatz, Cesare Gianturco and Gary Roubin, and Ulrich Sigwart. First, these individual physician-inventors saw the need for coronary artery stents in their clinical practice. In response, they developed prototypes with the support of academic medical centers leading to early validation studies. Larger companies entered afterwards with engineering support. Patents became paramount once the technology diffused. The case of coronary stents suggests that innovation policy should focus on supporting early physician-inventors at academic centers.”
Although stents ultimately have become over-utilized, they represent a tremendous invention and contribution to cardiac care.
In the setting of acute heart attacks, stents are clearly life saving and thousands of patients have had their clinical angina or claudication greatly relieved when stents are utilized appropriately for blocked coronary and peripheral arteries.
Consequently, Palmatz and many of the other interventional cardiologists who developed and performed early studies on coronary stents are widely considered heroes by the vast majority of knowledgeable cardiologists.
There is no evidence that they have colluded with industry to inappropriately promote stents or to suppress utilization of methods for early diagnosis and prevention of coronary artery disease.
The documentary then switches to characterizing the world of cardiology after stents were approved by the FDA in the early 90s.
There clearly was (and is) an irrational exuberance about stents and some of this sprang from excellent reimbursement for doing the procedures.
The focus moves to Mt. Sinai Hospital in Manhattan, and arguably the busiest interventional cardiologist in the world, Samir Sharmin.
The movie implies that Mt. Sinai was going broke until it began performing lots of catheterization and stent procedures. Sharmin who does over 1500 interventions per year and apparently earns over 3 million dollars per year is interviewed and filmed performing a stent procedure.
The average viewer likely gathers from the context of the interview with Sharmin, that he is only doing these procedures to make money.
At various points during the movie, Dr. Steven Nissen, past president of the American College of Cardiology, is interviewed and referred to as “America’s top cardiologist.”
In my opinion, Nissen has been an outstanding, independent voice of reason in the world of cardiology. During the interview, he makes the very valid points that coronary calcium scans have not been embraced for routine usage because there are no outcomes data.
At one point he says, “I don’t like medical cults” in reference to those who support more widespread coronary calcium scans.
The movie leaves the uninformed viewer thinking that Nissen is part of a cabal blocking coronary calcium scans, perhaps due to his connections with industry or an inappropriate resentment of the “calcium club” pushing the scans.
Nothing could be further from the truth. I think Nissen is one of the few prominent cardiologists who are not subject to major bias of one type or another and I strongly respect his opinions.
The movie also attempts to portray the editor of Circulation, a major cardiology journal supported by the American Heart Association as inappropriately withdrawing a paper that would have endorsed coronary calcium scanning. It’s not possible to really tell what the truth is about this withdrawal, but this is a very minor episode in the history of coronary calcium scanning.
Ultimately, The Widowmaker fails its audience in presenting the truth because it desperately wants to convince us that there is a connection between the promotion of coronary stents and the failure of coronary calcium scans to be accepted by guidelines and covered by insurance.
There is no such connection. Many interventional cardiologists are enthusiastic promoters of prevention and aggressive use of coronary calcium scans. I have seen no evidence of greedy interventionists trying to suppress coronary scans.
In Part II of this analysis, I will take a look at the “heroes” of The Widowmaker, the inventors and promoters of coronary calcium scans, and we will see if they are truly heroic.
23 thoughts on “The Widowmaker Documentary: A Need For Heroes and Villains Detracts From The Truth”
Hello Doctor Anthony,
My Father passed away from a heart attach at age 49.
I am 59. I had a stent put in in 2007 and a multi CABG in October of 2017. I do not smoke or drink. I eat well but I am overweight. Since the CABG I have been on a therapeutic dose of K2 and D3 (360 and 4000) for just over 6 months under my own care. I recently convinced my Cardiologist to get a Calcium scan done (a little late in the game). I got a score of 3387. This is not a typo. I am back to work for 8 months now, I feel good and I am in good physical condition. My Cardiologist matter of fact gave me the results. He knows I feel good. His recommendation was to put me on Repatha. Should I not be monitored more closely with additional calcium scans to ensure this is not an upward trend or should I stop working and be preparing my funeral.
Regards, Kevin
Kevin,
Not a good idea to do a calcium scan on patient post CABG. It’s pretty much meaningless. You are super high risk and should be on high intensity statin plus/minus repatha. Don’t prepare for your funeral the high calcium score is a given. Maximize exercise, follow my dietary plans, maintain ideal body weight, minimize stress, maximize sleep and take aspirin, high intensity statin plus; minus repatha.
Hi Dr. Anthony,
If I do not monitor further build up of calcium in my heart area from a CAC (now I have a base line) how will I know if I am slowing or stopping calcium build up. I also understand that there is soft plaque under the calcium (80/20, soft/calcium). I am still losing weight.
Regards, Kevin
I’m almost 72 and overall good physical condition. Never smoked. Father and grandfather died at 57 and 47 from heart attacks sue to their lifestyle. I do have high cholesterol. Heard about calcium scan but sure my internist would not recommend. Should I pursue calcium scan just to get an idea on the level of calcium I have…..might could help my internist care for me?
If I were seeing you as my patient I would definitely recommend a calcium scan to you
Hi Steve, I wonder if you are taking any medication to lower your cholesterol? What is your cholesterol level without any medication? Thanks a lot
Hello Dr. Anthony,
You wrote a calcium score of >10 in a 68 year old would qualify.
Not sure what the >10 means. I see scoring ranging from 0-400 and above. Can you please explain, Doc, about the >10. Thanks, Doc.
Calcium score can be anywhere from zero to several thousand.
So a score of 5 would be 10.
Should I, a 68 year old man, take a low dose aspirin 3x a week because his renowned cardiologist recommended it saying “At your age it is guaranteed you have plaque build up.” Taking Statin 10mg. He said the calcium score would not change his mind on his treatment. On vegan diet my ldl becomes very low. On other diets not so much change. Any thoughts? Going for a calcium test soon.
You can read my general approach to aspirin here (https://theskepticalcardiologist.com/2014/05/09/should-i-take-aspirin-to-prevent-stroke-or-heart-attack/). I prefer to use a guided approach: only take it if there is evidence of significant atherosclerotic plaque. Recent studies emphasize the risks of aspirin and the need to be more selective in its use. A calcium score >10 in a 68 year old would qualify.
Thanks, doc! Will take the test and see.
I’ve always been motivated. You name it. By any “standard” measure I’m as healthy as not to worry.
I decided to get a CAC very recently ’cause of my father’s death at 75, and was gobstoppered to get an Agatston total of 1,609.
One thousand six hundred and nine.
So, since I’m an “older person” at 71, what’s the “value” of this number?
I’m told that there MUST be calcified plaque. Is this so? Another cause?
What does one do with (presumably) genetics like this?
What business does Medicine have in NOT screening for CAC?
How can insurance NOT pay for this? ($90 out of my pocket. Cheap.)
In a different world I might have had this done a few decades earlier.
If you can reduce progression of this to less than 15% per annum you’ll do fine. That’s what stats show. The standard treatment would be proper low carb diet etc. Were I you (I’m a retired doctor) I’d find an expert on this whole business. Most of my colleagues wouldn’t have a clue.
Your case exemplifies the limitations of using standard risk factors to predict risk of atherosclerosis.
At age 71, your score puts you in the top quintile for CAC in a very high risk category.
You definitely have lots of calcified plaque throughout your coronary arteries.
One has to counter your inherited abnormal predisposition to atherosclerosis by starting a statin drug.
See my latest post for discussion on insurance coverage of CAC.
There is a truth about this. It is this. Almost nothing will persuade someone to give up cigarettes, but people who’ve had a heart attack will do so much more readily than those who haven’t. That’s because a heart attack is a serious marker. Similarly, having a nasty CAC scan can act as a marker for action for people. They can see the scans and it can be explained to them. They are pretty likely to take what action can be recommended to them. Stopping smoking if they do, altering their diets to a low carb no-junk high fat diet and possibly taking statins, aspirin etc. Exercising if they don’t etc. Do such measures have an effect? Clinical trials say they do.
Have I had a CAC? (I thought long and hard about it. I’m a 65y old retired doctor who has been overweight until 3 years ago but always exercised a lot). Yes. Score zero. I don’t worry about continuing to exercise and I’m on the right diet.
I’ve a friend who’s a chemical engineer with a biochem background. He’s brilliant on data analysis. That’s his forte. He says that no screening test comes close to this in its predictive abilities. Framingham Score etc., LDL-P, Ratios etc., are all over-ruled by it. I thought the film was good but maybe over-dramatic, but that’s the way things are done nowadays. It is a disgrace in this day and age that stents are being routinely inserted into people whom they manifestly don’t help. I’m all for them when they do. What harm can they do? Well, screwing up a subsequent CABG op for one.
Very good points! The high calcium score serves as a great motivator for those patients who are otherwise not motivated and are open to being motivated. Similarly, if I can identify a large plaque growing in the carotid artery of an asymptomatic patient I can usually get them to take a statin and aspirin and start some exercise program.
Congratulations on your zero score!
The calcium score is more powerful than cholesterol measure because it is actually measuring atherosclerosis in the arteries! And that is what we are treating/trying to regress /etc.
There are many untruths in The Widowmaker. The statement that you cannot bypass a stented artery (only made by the non-doctor physicist) is one of the more blatant ones.
I just watched the Widowmaker and found it very interesting. Calcium scans seem to be very useful.One thinks that it should be a required test for older people.
The value of calcium scans actually goes down in “older people”. Right now, I’m defining older people as over age 70 but that will likely increase as I approach that age :). All men over age 70 have significant amounts of calcium in their coronaries. And if you’ve had procedures like stents or bypass surgery the scan is useless.
The greatest benefit is in intermediate risk patients under age 70.
I was hoping for acknowledgement my comment below.
Meantime: Mightn’t High CAC indicate problematic Matrix GLA Protein?
Matrix GLA Protein has not hit my radar screen.
Matrix GLA Protein: ??
http://www.ncbi.nlm.nih.gov/pubmed/23375872
http://www.ncbi.nlm.nih.gov/pubmed/22819559
http://www.ncbi.nlm.nih.gov/pubmed/25987667
http://www.ncbi.nlm.nih.gov/pubmed/24210635
http://www.ncbi.nlm.nih.gov/pubmed/16612082
Now matrix GLA protein has hit my radar screen 🙂
I would agree with this summary of The role of vitamin K in soft-tissue calcification.(Adv Nutr. 2012 Mar 1;3(2):166-73. doi: 10.3945/an.111.001628)
“More studies, both in healthy subjects and in patients at risk of vascular calcification, are required before conclusions can be drawn.”
Very preliminary data in this area on its role in cardiovascular risk
OK.
Thanks for your attention to this… and your patience.