Overuse of angioplasty has made national headlines this past year, with the Department of Justice and the Senate Finance Committee investigating incidences in which hospitals subjected hundreds of patients to needless angioplasty procedures.

But recent research suggests that the problem is not isolated to a few overzealous practitioners. Only half of procedures that used angioplasty to open narrowed arteries in nonemergency situations were clearly appropriate, according to a study of almost 500,000 cases published in July 2011 in the Journal of the American Medical Association. The researchers also uncovered wide variation among hospitals; the rate of clearly inappropriate angioplasty procedures varied from less than 6 percent at some to greater than 16 percent at others.

Equally disturbing, a third of patients in another large study were not discharged with the right drugs. And without the necessary drugs to control risk factors such as high cholesterol and hypertension, heart disease can be expected to progress.

Some hospitals have become such angioplasty factories that the procedure is used even when surgery to bypass the occluded artery would be better. Many patients who would have had bypass surgery a decade ago now undergo angioplasty instead, according to a recent study that tracked the rate of procedures at U.S. hospitals between 2001 and 2008.

"Sometimes patients have so many stents that bypass surgery becomes impossible," says Fred Edwards, M.D., medical director of the department of cardiothoracic surgery at the University of Florida in Jacksonville and director of the Society of Thoracic Surgeons Research Center. "That's called a full metal jacket."

One factor leading to the overuse of angioplasty is that the same doctors who perform the procedure often also act as gatekeepers for the patient's cardiac care. For example, patients often sign a consent form for angioplasty before going in for angiography, the definitive test for blocked arteries. Then, if the angiogram reveals blockages, the interventional cardiologist can recommend clearing them while the patient is still on the table.

Convenient? Sure. But necessary? Usually not. In nonemergenices, "you have time to consult with a heart surgeon and even your primary-care doctor to discuss the options and arrive at the treatment strategy that's best for you," Boden says.

Most patients and doctors overestimate the benefits of angioplasty procedure, suggests a September 2010 survey of 153 patients and their physicians at a Massachusetts medical center. Just 63 percent of physicians knew that except in emergencies, angioplasties only ease symptoms. And even those who were up to date apparently often didn't inform their patients: 88 percent of patients who consented to the procedure mistakenly believed it would reduce their risk of having a heart attack.

No doubt the financial incentive to tackle heart disease with a $10,000 procedure before running a simple test or prescribing inexpensive generic medication also plays a role. In a study of more than 23,000 Medicare claims, more than half of patients had angioplasty without first undergoing standard testing to prove it was necessary. And the rate of those procedures has increased 300 percent over the last decade and are a huge drain on increasingly limited resources, accounting for at least 10 percent of increased Medicare spending since the mid-1990s.

It's likely that the high rate of angioplasties is egged on at least in part by industry. The U.S. Senate investigation of cardiologist Mark Midei, M.D., of Towson, Md., who allegedly performed hundreds of the procedures inappropriately, revealed that he had been wined and dined and given consulting fees by stent maker Abbott Laboratories.

While Midei might be an extreme example, industry invests heavily in the cardiology community. More than half of the almost 500 authors of major cardiovascular clinical-practice guidelines published from 2004 to 2008 had financial relationships with commercial entities, according to a March 2011 report in the Archives of Internal Medicine. And groups such as the Society for Cardiac Angiography and Interventions (SCAI) and the Heart Rhythm Society get financial support from drug and device makers.

Christopher White, M.D., SCAI chairman for cardiovascular diseases at the John Ochsner Heart and Vascular Institute in New Orleans, La., says his organization accepts money from industry but sets firm boundaries, too. "Without a relationship with industry, there's no opportunity for innovation," White says. "However, we make no excuses for people who mismanage that relationship. When my society finds out about it, we kick them out."