Issues of the Heart

Few days back, one of my senior colleagues shared an article on how deaths from heart attacks have dramatically come down in the United States. However, as I read it I know very well that only a minuscule of patients in our country who suffer a heart attack would ever undergo emergency angioplasty.

Angioplasty - that's the name given to the way they save the heart by opening the blocked artery by pushing in a catheter, inflating a tiny balloon and inserting a stent which will keep the artery wall patent. And this has to be done fast . . . very fast. 

Take the example of 2 patients whom I saw in emergency over the last couple of days at KCH. We worked fast to ensure that both the patients are referred to a higher centre. When we referred, the minimum we expected was that both the patients would be given Streptokinase to dissolve the block in their coronary artery. 

The first patient, a 38 year old mother of three with well documented anterior wall myocardial ischemia, was prescribed Aspirin, Atorvostatin and Clopidogrel and sent back home. 

The second patient was a 60 year old gentleman with typical symptoms of Myocardial Ischemia. He did not have typical features on ECG, but since the symptoms were typical, we referred him. Couple of days, the relatives came back saying that he had a heart attack with elevated enzymes. 

The guy was luckier as from the prescription, it seems that he got low dose heparin. 

There are 2 aspects. 

The first is the cost involved in treatment. The latter patient incurred a cost of 60,000 INR for treatment at the cardiac specialty centre he went to for a 3 day stay. No small amount for a middle class family, leave alone for the majority of my fellow citizens. 

The second aspect being the number of intervention cardiologists available in the country. I wonder if the total number of intervention cardiologists in the whole country is even a 4 digit number.

The third aspect is about where you'll be treated. The first patient was seen by cardiologists in a public healthcare set up. The second patient in a private tertiary cardiology care centre.

When we look at it - Yes . . . there's a lot of people dying out there or more than that getting debilitating heart damage due to ischemic heart disease, all because of high costs and non-availability of specialists. 

Well, the future looks bleak in a country which is still grappling with maternal deaths, children dying of diarrhoea and respiratory tract infections, tuberculosis and malaria. 

As for the time being the best option for us remains - 

1. Healthy eating habits

2. Good exercise

3. Control of risk factors such as diabetes and hypertension. 

From the policy, we would need to see - 

1. If thrombolysis treatment can be authorised in primary care.

2. Short courses for medicine consultants in the public health secondary care institutions to do angioplasties.

Till those happen, the 3 cardinal rules to have a healthy heart remains the best option in the country . . . 

On diseases of the heart

Recently I chanced upon an article about an interventional cardiologist in the US, who has been sent to jail for performing unnecessary coronary angioplasties.

I was sort of transported 18 years back when a senior cardiologist in town had asked my dad to undergo cardiac surgery for a problem with a cardiac valve. I had just started my graduate studies in medicine. Therefore I had the privilege of getting in touch with friends who knew cardiologists. We decided to take him to a public care facility which had a cardiology department. The doctors there just put him on anti-failure medicines and told us that dad need not undergo the surgeon’s blade as of now.

We continued to take him for his routine check-ups every year. He had his last check up couple of months back and he is still on the good old medicines. Not many medicines . . . furosemide tablets and digoxin. And, it’s eighteen years.

The first cardiologist we saw had brought my mother to tears saying that unless we did surgery there was not much hope.

Couple of months back when I was at home, one of my cousins were telling about how interventional cardiology centres were sprouting all around the state. It was quite a good investment and returns were quite assured. There were stories about targets of the number of angiographies and angioplasties being given to the interventional cardiologists being employed in such centres.

Coming back to NJH, about 3 months back, I had 2 patients who had undergone angioplasties. It is quite common for patients who have got angioplasties to have compact discs of the images of the angiogram and the procedure. However, I was surprised to find that they only had hand-drawn images of the artery blocks. I could not resist thinking on how true were the supposed artery blocks that both my patients had.

Regarding Dr. Mehmood Patel, he was convicted only because this happened in the US. The major news item today in India is about the record compensation that has been doled out for a case of medical negligence in Kolkotta.

Unnecessary medical procedures are something very rampant in the country. It starts with basic blood investigations. I’ve heard of laboratories within hospitals that have specific codes from doctors for tests which need not be done but are charged. The tests are charged, but not done and normal values of the same are recorded. Then there are investigations such as IgM/IgG for tuberculosis, serological tests done before the stipulated time (e.g. Widal test done on 1-2 day fevers), Erythrocyte Sedimentation Rate (ESR) etc. which are of no use to the patient.

There have quite a good number of uteri that are removed in the country for no reason. We’ve had news about such hysterectomies which were done under the Rashtriya Swasthya Bima Yojana. Then there are asymptomatic gall stones, tonsils, appendices etc which are operated on for no obvious reasons. And one should not forget the umpteen number of unnecessary Cesarian sections done.

News about Dr. Mehmood and Mr. Kunal Saha’s successful litigation should be a clear message for each of us in the healthcare profession to be truthful to our patients. This has far reaching implications.

On the lighter view, I remembered a anecdote . . .

‘It is common for elderly men from well to do families in my community in Kerala to unbutton the upper part of their shirt. It is usually done to show off the gold chain on the neck. That used to be during the olden days. Nowadays when they do the same . . . and it is done . . . to show off their bypass scars’ . . . However, with interventional cardiology, those days will also be gone soon.

I leave with a link to an article I read in The Hindu about Paul Dudley White, who is known as the founder of Preventive Cardiology as well the father of American Cardiology.

I’m sure that there is much more for the heart in terms of prevention of heart diseases than the sole choice of interventional cardiology.