Are veterans and the VA any more “crusty” than others?

Like many University physicians, we also work at a United States Veterans Affairs (VA) medical center, where one encounters a patient population that appears in many ways different from the patients at a typical private practice. Compared with nonveterans, they are overwhelmingly older males, and are more likely to report having “fair” or “poor” health, two or more chronic medical conditions, serious psychological distress, and past or active tobacco and alcohol abuse [1]. Whether it is due to their prior service or a perceived need to be strong, it is our experience that veterans have a tendency to minimize anginal symptoms, trying to “tough it out,” and are less likely to present for timely revascularization. Sixty-eight percent of veterans admitted to VA facilities with acute myocardial infarction (MI) present >12 h after symptom onset, compared with 18% of Medicare patients [2]. These patients are more likely to have irreversible myocardial damage and less likely to undergo reperfusion. Based on their baseline risk factors and delays in presenting after MI, one might suspect that veterans might have a higher prevalence of both severe coronary artery disease (CAD) and chronic total occlusions (CTO) compared to other patient groups of similar age and gender. To explore this question Jeroudi et al. performed a retrospective analysis of 1,699 patients undergoing angiography at the Dallas VA Medical Center over a 2 year period. They found in their cohort that 20% of patients had no CAD, 20% had CAD and prior coronary artery bypass surgery (CABG), and 60% had CAD without prior CABG. CTOs were found in 89% of patients with prior CABG, and 31% of patients with CAD without prior CABG. Patients with CTOs were more likely to have had a prior MI, congestive heart failure, diabetes, stroke, and left ventricular dysfunction. Is there any difference between veterans and nonveterans with regards to CTOs? This report demonstrates that a significant proportion of VA patients with CAD have CTOs, but the rate of 31% is surprisingly no higher than that seen in most studies of other CAD populations (see [3], Table 3). The rate of CTOs in CABG patients is much higher than without CABG, reflecting the acceleration of native-vessel atherosclerosis in bypassed vessels. Overall, veterans may be no more likely to have CTOs than the general CAD population, but one has to keep in mind that they may be more likely to have CAD in the first place. Obstructive coronary disease is more frequently found in angiograms of veterans (80% vs. 61%), either indicating a higher prevalence of disease, or perhaps more appropriate utilization of diagnostic cardiac catheterization [4]. How are CTOs managed at this VA? Perhaps the most notable aspect of the report by Jeroudi et al. was that percutaneous coronary intervention (PCI) was performed in 30% of patients with CTOs without prior CABG, and 15% with prior CABG with very high (70–80%) success rates. This demonstrates a high level of expertise and boldness that has not typically been associated with the VA, which as a system is known for aggressive application of optimal medical therapy and the generation of the COURAGE study. That a center of excellence in advanced CTO-PCI can develop within a larger medical system specializing in preventative care is testament to the strengths and flexibility of the VA healthcare system, as well as to its ability to attract and retain dedicated and sophisticated interventionalists. What is changing at the VA? Despite recent negative press about the VA regarding outpatient waiting times and falsification of scheduling data, the VA performs better than non-VA service providers on processes of care and intermediate outcome measures (such as blood pressure and lipid control) [5]. Veterans are more likely to report having health insurance and higher satisfaction with their care compared with nonveterans. It is also uplifting that the VA has recognized its shortcomings and with the support of the nation has