Prof. B. M. Hegde,
MD,FRCP(Lond.),FRCP(Edinb.),FRCP(Glasg.),FRCP(Dublin),FACC.
Pro Vice Chancellor,
MAHE University, Manipal-576 119. India.

“Great minds discuss ideas,
Average minds discuss events,
Small minds discuss people.”
-----------------------------Anon.

When the editor asked me to write an article on Interventional Cardiology, I attempted that with great trepidation. Being a poor clinical cardiologist, that too of the untouchable variety, (I do not have my DM) I have to be very cautious in the midst of this new tribe of powerful people. Knowing full well the ridicule that I would be exposed to, I never volunteered to do this, but was forced into it.

I still remember how an old student of mine addressed me, when he chaired a session, where I was speaking on heart failure. He took great care to avoid the prefix `cardiologist’ for me. He kept on saying, “he is a physician” and, even by mistake, did not mention the word cardiologist. Another student used to write to abuse me each time I wrote an article in this field! This was despite the fact that I have been a Visiting Professor of Cardiology at the London University since 1982 and, still continue to be so. My long training at the National Heart and Middlesex Hospitals in London, in cardiology, where I ended up as the Visiting Professor, notwithstanding. I have been twice selected for the Commonwealth Fellowship in cardiology in London. Later, I trained under Nobel Laureate Harvard cardiologist, Bernard Lown. This introduction was deemed fit, lest the new breed of interventional cardiologists should ignore even to glance at this piece!

Our education being replicative, it does not allow us to think about our learning material. If one has to learn from one’s own experience, he should be able to do a bit of introspection. We seem to believe everything that we read for our examinations, as gospel truth. Rarely do we develop the capacity to question the published knowledge. David Eddy, a former associate professor of cardiovascular surgery at the Stanford University, came to the interesting conclusion, after extensive study of the medical literature, that “eighty five per cent of what doctors do is based on soft data; only fifteen per cent is based on hard unequivocal data.” This applies to textbooks as well.

New Statesman once quoted a high school student who said:

“Sciences are learning facts from a book and not thinking for yourself,
I wanted to express my own ideas and then think for myself!”

Why do we do what we do, then? Many wise teachers have answered this million-dollar question and, I only have, herein, attempted to quote a few of them. I shall not impose my ideas on the reader at this point in time, but let him draw his own conclusions. Please remember that medical muddling is a good business. Professor Krumholz, cardiologist at the Yale, wrote in an editorial in the New England Journal of Medicine, regarding an audit of post-infarction revascularization, ”In a fee-for-service system, cardiac procedures generated billions of dollars in revenues each year. A high volume of procedures brought prestige and financial rewards for hospitals, physicians, and the vendors of medical equipment.” 1 One could easily grasp the motive behind these procedures in cardiology. If that were so in the USA, what of our corporate hospitals and others in India? There is always the profit motive in these ventures that make the employee to perform or perish. Most of us are skilled labour in this new hospital industry! The initial investments in costly cardiac equipment would, perforce, demand higher returns to pay both the staff and the banks! Young interventionists are, therefore, egged on to do more and more.

This situation brings to mind the saying of Mark Twain:

“For a man with a hammer in the hand and wanting to use it, everything here looks like a nail needing hammering.”

The above adage is shown to be true in interventional cardiology, by two landmark papers. The first one is by the Harvard group, led by Nobel Laureate Bernard Lown, in the JAMA.2 The study showed that only three per cent of the 200 patients referred to their centre for CABG by local cardiologists, scientifically needed the procedure. The rest were followed up for fifteen long years without any adverse effects. The authors advocated “stricter control at the level of an angiogram in the diagnosis of coronary disease. Angiogram is indicated only as a pre-requisite for plumbing, and should only be done after the decision to revascularise is made on the patient’s clinical condition. Done earlier, this might frighten the patient and relatives into agreeing for the procedure unnecessarily.”

Next is the advice by one of the leading professors of cardiac surgery in England, Tom Treasure, who in his paper in The Lancet, strongly pleaded for reducing cardiac angiography set ups in the UK to avoid their overuse.3 Professor Hampton, of the Nottingham University, found in one of his studies that in his area more than 47% of the angiograms were inappropriately done.4 Drs. Tu and colleagues, in Yale found, in a comparative study of Philadelphia in the US and Ontario, in Canada, that the intervention ratio, in the immediate post-infarction period in these two identical populations was 10:1. Surprisingly, at the end of the year there were almost equal numbers of those patients alive in both the places!5

Another audit of sixty thousand bypass surgeries done in the US, showed that only 14 per cent did get extra life, ranging from three months to four and a half years. A good 84% did not get any extra life or benefit!6

One would be surprised that there are quite a few small and medium studies, published even in good journals, which extol the virtues of bypass and angioplasty, although no large controlled study has ever shown that. How do the smaller studies show good results?7 If one wants to get any clue to this disparity, one has to overstand the subject and not just understand it, as we do. Many of these studies are funded by vested interests. A recent meta analysis showed how these studies could be engineered. In a mile stone paper in the April 1999 issue of the JAMA, Drs. Campbell and colleagues at the Harvard, showed how research related gifts is a common and important form of research support. The title of the paper makes interesting reading: “Looking a gift horse in the mouth-corporate gifts supporting Life Science Research!”8

Even in other areas of drug intervention the story is no different. Cardiogenic shock is the leading cause of death among people admitted with myocardial infarction, and it remains the same even today as it was 35 years ago. Reperfusion treatments including thrombolysis seem to have made no impact on the incidence of cardiogenic shock, which occurs in about 5-15% of patients with heart attack. Very aggressive reperfusion may have helped to improve short-term survival only.9

Whereas ACE inhibitors did help patients after a heart attack associated with clinical evidence of heart failure in the AIRE study, the same did not hold well in the TRACE study when ACE inhibitors were given de novo routinely. Nature must have been trying to help the ventricle after a heart attack by remodelling. The latter is assisted by the ACE system. Only when Nature fails and the victim suffers the ill effects by way of heart failure, do ACE inhibitors help a great deal. If given in the beginning ACE inhibitors might hasten the onset of heart failure by impeding the process of useful remodelling! Only symptomatic patients were helped.10, 11

Even in a study of diabetics on insulin therapy, symptomatic patients alone got benefit in their quality of life. The asymptomatic ones did not get any benefit! 12

In the MRC study of mild-moderate hypertension, it was shown that to save one patient from stroke in the long run nearly 850 patients needed unnecessary treatment for years on end.13 Even the recent HOT study gave us a warning! While the vigorously treated group did have its BP recording brought down to the ideal range, death rate did go up in that group14; an instance of the euboxic philosophy of modern western medicine, viz.: the case-sheet of the patient must have all the parameters within the normal range. It matters very little if the patient dies in the bargain, as long as all the boxes in the case sheet are correctly marked-euboxic death.15

We could, instead, try and keep a patient alive, with the boxes still slightly skewed, a stage I would like to call as dysboxic life. Long term follow up of two cohorts of Finnish men, one vigorously intervened and the other left to tend for itself as and when needed, showed that the intervened group had much higher cardiovascular and total death compared to the usual care group! Most of the anti-arrhythmic drugs did, at the end of the day, result in higher deaths in the treated group compared to the controls in the CAST study. 16

Epidemics of vascular diseases are being predicted daily to scare the public and get them to the screening centres in large numbers. Stehaben’ s extensive studies did not show any real increase in the incidence of vascular diseases in the last one hundred years.17 It is now known that routine screening, in certain situations, might even endanger the patients’ lives, if one cares to read the editorial Screening could be dangerous to your health in The Lancet! 18 Do epidemiologists cause epidemics? is an editorial in the BMJ, giving timely warning to our interventionists.19 Unfortunately, screening healthy populations makes very good business sense. While there could be a few million sick at a given point in time, there would be billions who could be detected to have occult pathologies of dubious future significance, when routinely screened. Many might even get worse after labeling! The industry would, of course, opt for the latter. Executive check-ups are a very good fishing net to have bigger catches.

Diagnostic tests are another area where we overdo testing in a big way. While good clinical sense could get most accurate diagnoses in the majority, routine tests like stress test and echocardiograms could throw up false positives in a big way. Rudimentary knowledge of statistics would tell us that the disease-based statistics applied to the vast healthy populations should, per force, bring about large numbers of false positives.

Whereas the specificity and sensitivity of the stress test depends, to a great extent, on the prevalence of the coronary disease in the population, we predict the unpredictable by looking at the ST-T changes in the electrocardiogram, even without having any clue about the prevalence of the disease in our population! 20 Cardiac neurosis has gone up exponentially in recent years after these tests were introduced, more so because these tests are done and interpreted, in many cases, by centres with inadequate experience.21

It is our bounden duty to do our best for the suffering humanity as doctors, but when it comes to professing to help the apparently healthy, through the screening procedures in society; we are on a very wet wicket, indeed. Come to think of it, one of the many meanings of the word intervene, is to go in between with malice! My only fond hope is that our divine interventionists do not aim at that.

That said, I must hasten to add that many of the interventions, like bypass surgery, are a real boon to the badly suffering patients with coronary disease. Where angina is intractable, and/or the left ventricular function is really depressed, bypass surgery gives great relief to the victim, making life worth living. We should not deify ourselves by saying that these interventions, which are purely palliative, are going to keep man alive here forever and would avoid sudden death etc. Let me remind the reader of the warning given by Bernard Shaw in his book Doctor’s Dilemma saying: “ do not try to live for ever, you will certainly not succeed.” In fact, the incidence of sudden death is not altered by bypass surgery.2 The prolongation of life is only a mirage.6 Symptom relief and better quality of life are certainly the blessings.

In conclusion, I have presented here data from the same “authentic” sources that one gets all other data about the other side of the coin in modern medicine. I am not trying to say that we should be therapeutic nihilists. My only plea is that we, as a profession, should let the gullible public know the real truth, to let them be equal partners in their own management. The “paternalistic” attitude in medicine is not good; which has taken medicine to the market place. Market forces have made medicine prohibitively expensive. In addition, market forces equate us with the other traders, exposing us to the ravages of consumerism. “Never make money in the sick room” was one of the Hippocratic aphorisms.

Dr. Glenn J.R.Whitman, chief surgeon at the University of Maryland Medical Centre, explains that the complications of bypass surgery are multiplied by the time taken on the bypass machine. He goes on to say: “ having your blood pass through a plastic tube during surgery is not good for you. God didn’t make our blood go through a pump outside of us.” 22

I would request you to contemplate on what I have written and then draw your own conclusions. You could go back and do what you want to do. Science, in every sphere, is dying slowly because of specialization. New science of fractals and chaos looks at the dynamic human being as a whole, and as a part of this macrocosm. That is the future of science, including our medical science.23 In this era of exciting scopes and interventions we should never lose sight of the art of medicine.

“ Art “ is best defined by Henry Edward Thoreau as “that which makes the man’s day.” The art of medicine is that which makes the patients’ day. The intervention might be divine; but its aim should be to make the patient feel better at the end of the day! Medicine revolves round anxiety- patient anxiety of disability and death, and the doctor anxiety of doing more and more. Doctors, including interventionists, should try and allay these anxieties and not add to it. Long live medicine which aims to “cure rarely, comfort mostly, but console always.” Let us try to do most good to most people most of the time. The old meaning of science that: “Science is what scientists do”, originally written in Dutch as “Wotenchap is wot wotenchoppen doen,” has been proved wrong by the new meaning of science, what with its Sanskrit root “skei”, meaning to “cut into” everything you observe!24, 25.

“We do not see things as they are,
We see them as we are.”
------------------------Nin Anais.

Acknowledgement:
I am beholden to Dr. Dayananda Pai, Ph.D., and our Chief Librarian, for his help.

REFERENCES:

1) Krumholz HM. Cardiac Procedures, outcomes, and accountability. N. Engl.J.Med 1997; 336; 1522-23.
2) Graboys TB, Biegelson B, Lampwert S, Blatt CM, & Lown B. Second Opinion trial of Coronary angiography. JAMA 1992; 268: 2537-2540.
3) Treasure T. US doubts about angiography. Lancet 1993; 341: 154.
4) Gray D, Hampton JR, Bernstein S et. al. Audit of coronary arteriography and bypass Lancet 1990; 335; 1317-1320.
5) Tu JV, Pashos CL, Naylor DC et. al. Use of cardiac procedures and their outcome in elderly patients in US and Canada. N. Engl.J.Med 1997; 336:1500-1505.
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8) Campbell EG, Louis KS, Blumenthal D. looking a gift horse in the mouth. JAMA 1999; 279: 995-999.
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15) Davidoff F. Who has seen a blood sugar? Book. 1998. American College of Physicians.
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17) Stehabens WJ. An appraisal of the epidemic rise of coronary artery disease and its decline. Lancet 1987;I: 606-611.
18) Stewart-Brown S, Farmer A. Screening could seriously damage your health. BMJ 1997; 314: 533.
19) Editorial. Do epidemiologists cause epidemics? Lancet 1993; 341: 993-994
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21) Hegde BM. The unrest cure. Jr.Assoc.Physi.India. 1997; 47: 730-731.
22) Richard O’Mara. Heart Surgery: Does off-pump beat the pump. Indian Express, March 13th 1999.
23) Hegde BM. Chaos- a new concept in science. Jr. Assoc. Physi. India 1996; 44: 167-68.
24) Hegde BM. The science of medicine. Ibid. 1998; 46: 896-97.
25) Pickering WG. Does medical treatment mean patient benefit? Lancet 1996;347: 379-80.