Controversies in Cardiology

It was with great excitement that we watched the media coverage of the 2005 European Society of Cardiology Congress in Sweden, in particular the interest that was generated around gendered aspects of cardiovascular disease and the debates over stenting, exercise and revascularisation. As social scientists interested in technology and health practice, these debates resonated with issues that have been discussed in our fields for some time, particularly questions relating to differences and inequalities in the distribution and use of medical technologies. In the wake of the recent media coverage of these controversies [1] then, we would like to raise some questions that could frame future collaborative research programmes on cardiovascular disease. We claim that it is time to develop more knowledge about (and the consequences of) the uneven distribution of technologies used in cardiology across regions and countries, and about the inequalities and differences in the ways in which these technologies can be used on different patients — in different regions or of different sex. There is a need for a discussion of cardiovascular treatments and technologies that incorporate a considered approach to the introduction and diffusion of technology, and the integration of the technology in local organizational practices [2]. This could be done by studying the technology of angioplasty. Especially in the European context, angioplasty is a treatment for one of our most serious and life threatening diseases, heart disease, the most common cause of death in the developed world. This treatment was first used clinically in 1977 [3], but in Europe, while France frequently employs the technology and has for some time, in the UK and the Nordic countries, the use of angioplasty is only taking off now, after a slow start at the beginning of the 1990s. Even within a single country, the use of the technique can vary. In Sweden, for example, some regions perform twice as many angioplasty treatments per population as others. In addition, angioplasty is now widely being used in conjunction with stents [3], a technique that shows promise in some cases, for example as an early treatment for myocardial infarction and as an alternative to highly invasive coronary artery bypass surgery, but is significantly more costly and may have other disadvantages in the long term [4]. One of the benefits of angioplasty is that it allows for a rapid decentralization, or multi-localization, of heart disease treatment. But why does this technology's adoption and use vary so much nationally and internationally? Differences in angioplasty treatment rates are not attributed to specific pathological patterns but to medical, economic and political issues [5,2]. This would suggest that the value of angioplasty as a treatment is negotiated in local practices, negotiations that are mirrored in the medical debates about its use [6,7]. These debates can be influenced by input from different types of organizations; national boards of health and welfare, county councils, medical educators and other doctors. Many patient groups, non-profit groups and for profit industry insiders have also started their own channels to spread information about the use of angioplasty to potential patients, doctors, and hospital administrators. Sometimes angioplasty is presented as a way of increasing patient safety and improving the quality of life, and as an economical alternative to bypass surgery. At other times, the actual long-term benefits are debated. This debate means that angioplasty is particularly interesting as a case study of local practices of learning, organizational decision making, and how technologies become part of everyday, embodied medical practice. We think these three areas deserve consideration. It is important to examine how information about angioplasty treatment is directed to the medical community, especially given the prevalence of angioplasty simulators at cardiovascular conferences and in hospital simulator centres. Simulators allegedly simulate clinical experience but they simultaneously introduce new methods and new technologies. They are used to train young medical students, but their presence in hospitals and at display booths outside of conference halls tends to cause a flurry of interest about the ‘new’ and ‘flashy’ simulators, which simultaneously generates interest about the techniques they simulate. As simulator technology is adopted, the techniques they simulate are also adopted. It is important to consider the relationship between technology transfer and technique transfer, and shed light on how simulator technology development impacts the medical techniques available to local populations. This would lead to a better understanding of why and how healthcare practices are changing in cardiovascular care through an understanding of the implications technology development can have for healthcare practices. To learn about the use and distribution of medical technologies, it is fruitful to examine the integration of angioplasty as a method of treatment into everyday clinical practice. Here we suggest looking at how physicians produce and maintain local theories about whether, how and when angioplasty should be used and thereby make technology into an useful tool in everyday work. It is also important to think about how angioplasty places demands upon and creates boundaries for actions in organizational life. The use of medical technologies can have repercussions on professional authority and experience, economic efficiency, patient safety and illness trajectories. When the choice to use angioplasty is made, the repercussions this decision has on these issues should be considered. This can be done by observing the details of practice in cardiovascular medicine; by examining how physicians interact with each other and with technology in clinical situations where decisions are made about angioplasty and the use of stents. Analysing the practice of decision making in the clinics approaches the very core of issues in cardiovascular care, since medical practice is decision making. How these decisions are made – in different circumstances – can tell us a lot about how medical technologies are used and distributed, and with what consequences for patients, medical staff and health care. Certainly not least, we would like to concur with those presentations that highlighted gender differences in coronary care. Issues of gender are significant, as men are much more likely to receive angioplasty and stents than women, largely because women's symptoms of heart disease and heart attack have been difficult for the medical and broader community to recognise and respond to. These inequalities raise questions about the gendered nature of biomedical and cultural understandings of the body. Given that heart disease is just as common in women as in men, yet recognised, diagnosed and treated much less frequently, the debate about adopting angioplasty therapies within general care provision is very important for women. It is imperative that issues of gender are highlighted within discussions of new technologies so that current inequalities are challenged, rather than reinforced. When discussing the use of medical techniques for the treatment of heart disease, we would like to suggest existing research that has examined issues of gender, technology and medicine [8]. The 2005 European Society of Cardiology Congress showed that the European cardiology community has much to report on how we treat our hearts. But sometimes it can be useful to gather perspectives from outside of the community, too. Our research on technology and health practice is directed at many of the same, important issues. We would like to suggest that a combined medical and social scientific effort could lead to collaborative studies that can address the issues of technology and health care in cardiology more effectively.