Friday, August 8, 2008

How To Prevent Commercial Exploitation Of Bypass Operation & Angioplasty.

A Joint Task Force has been set up by the American College of Cardiology, American Heart Association and European Society of Cardiology (ACC/AHA/ESC), to frame guidelines for carrying out various treatments, procedures and surgeries related to heart. This expert committee has studied the published research data from world over to formulate these guidelines. Purpose of this is not only to help doctors to reach at correct conclusions while working out the best possible approach for the given patient but also to exercise restraint on commercial exploitation of certain types of treatment modalities especially Bypass Operation and Angioplasty with Stent. These guidelines are upgraded from time to time, in keeping with the newer research data coming in.
Depending upon the strength of available scientific evidence (class A, B, C or D), various severities of each disease have been classified into Class I, Class II (a & b) and Class III of indications. Detailed descriptions have been given as to the various parameters pertaining to Clinical Examination (severity of Angina, severity of breathlessness etc), lab test reports, echocardiography report and Coronary Angiography findings and accordingly all patients are meant to be clubbed in to various classes of indications. In case the level of indication is Class I, immediate Bypass Operation or Angioplasty must be performed without any delay. But in case the level of Indication is II (a) or II (b), at least three months trial must be given to the patient with conservative (non-surgical & non-invasive) treatments, whichever are available at the time. After three months, the patient is meant to be re-evaluated and in case improvement is observed in his condition, the same line of treatment is recommended to be carried on. But in case no improvement is observed or in case further deterioration is noted, then the classification of indication automatically gets upgraded to “Class I”. In case the class of indication works out to be “Class III”, then the given treatment or surgery is “Contraindicated” i.e. forbidden, unless performed under exceptional circumstances, which the treating physician/ cardiologist / cardiac surgeon has to specify.
In USA, Canada and Europe, it is an obligatory/mandatory requirement that before a patient can be taken up for Bypass Operation or for Angioplasty, the treating Cardiologist must issue a “Class I Indication” certificate. In our country, such a legal stipulation has not come into force as yet, for whatever reason/s but conscientious physicians and cardiologists and alert public can take advantage of these guidelines to put brakes on misuse of these two commercially lucrative kinds of treatments.
Even lay people can make a rough evaluation based upon these guidelines: for a patient who has been detected to be having severe blockages in his angiogram (70% or more at one or more places), he should fulfill the following criteria to be classified as “Class I” indication for Bypass or Angioplasty:
1. His/her angina should be so severe that it interferes with his daily routine. Which means that an office worker on a desk job gets an attack of angina only when he runs up a hill or a flight of stairs but otherwise throughout the day he does not experience angina is NOT a “Class I” candidate (remember: every chest pain is not angina. A pain gets labeled as “Angina” only when specific abnormalities have been demonstrated in ECG, which can be a resting ECG, transtelephonic ECG or a continuous monitored ECG for 24 hours which is called “Holter ECG Monitor”). Various severities of Angina have been classified into Class I, Class II, Class III and Class IV, as described by the New York Heart Association (NYHA) and this classification is accepted world-over.
2. Similarly goes the severity of his breathlessness vis-à-vis the nature of his occupation/ life style. Breathlessness (called “dyspnoea” in medical parlance) too has been divided into four classes by the NYHA.
3. Echocardiography should reveal “Left Ventricular Ejection Fraction” (LVEF) to be equal to or less than 50% [II (b)] or less than 35% [II (a)] (normal LVEF is between 50% and 70%).
4. Coronary Angiography should reveal any of the following three:
a. Left Main Coronary Artery (LMCA) disease, measuring more than 50%.
b. Left Main Equivalent (LME) disease (both the branches of Left Main trunk i.e. LAD and LCx are involved to an extent of 70% or more and that too only where the “proximal segment” i.e. the segment before their first branch is given off, is involved.
c. Triple Vessel Disease (TVD), where LAD, LCx and RCA all three are involved and that too only the “proximal segments”. Mid segment or terminal segment lesions (blockages), even when showing up as 70% or more end up as Class II (a) or (b) or as Class III.
In nutshell, just because an Angiogrpahy shows blockages, it does not mean that a Bypass Operation or Angioplasty is a must. The process leading to blockage formation is not a disease process at all. It is nature’s protective mechanism wherein the lining of our arteries (called “endothelium”) has been equipped to pick up toxic particles, including “oxidized LDL” particles of cholesterol to render then harmless. If this protective mechanism were not there, our life spans would have been drastically cut down! The process of this blockage formation starts right at birth (even before birth, in fact!) and it takes many decades for the blockages to show up on angiography. As the blockages keep forming, new arteries keep growing in us all the time (called “Angiogenesis”) leading to formation of “Collateral Circulation”. Therefore, essentially blockage formation is not a curse: it is in fact a blessing! By the time severe blockage showing up as 70% or more on angiography develop, a lot of Collateral Circulation is deemed to have developed which neutralizes the strangulating effect of them. But as the age advances, angiogenesis and collateral channel development keep slowing down and the process of blockage formation keeps speeding up as risk factors keep adding up over the years: risk factors like high blood pressure, diabetes, cholesterol, obesity, smoking, pollution etc. It is only when the blood supply to the heart starts getting choked and symptoms in the form angina and breathlessness start appearing and only when pumping action of the heart starts becoming weak (shown by weakness of movement on echocardiography called “hypokinesia” and reduced “ejection fraction”) that Bypass Operation or Angioplasty are called for, not as such.
Alternatives to bypass surgery or angioplasty with modern drugs and other management techniques have changed the natural history of coronary artery disease. Like so many other diseases of the past that were considered lethal and are now considered benign because we have effective treatments, it is time to downgrade coronary artery disease from the lethal disease it once was, to a relatively benign disorder which, like arthritis, which might bother you once in a while, but should not shorten your life or significantly change it’s quality.
All those people whose angiography shows blockages at one or more places, which are 70% or more, should not rush headlong into Bypass Operation or Angioplasty. They should insist on being evaluated on the touchstone of the Joint Task Force (JTF) of AHA/ACC/ESC, which have been painstakingly formulated for your benefit by people who are treated like demigods in the field of Cardiology all over the world. If advised Bypass or Angioplasty, they should do self evaluation as per details given above or should at least insist on demanding a certificate from their Cardiologist to the effect that they fit in with the “Class I” level of indication as per the JTF guidelines. Wording of the suggested certificate is given as under:

One might ask: if all this were true, it should have been talk-of-the-town by now but nobody, not even most of the doctors seem to be knowing about it! Reason is corporatization/ commercialization of the medical profession. Nowadays, the healthcare industry looks upon you all as ‘clients’ rather than as ‘patients’ and tries to fulfill your ‘felt needs’ or ‘perceived needs’ rather than professionally assessed ‘altruistic/true needs’. Visible blockages on Angiography create fear/panic in you and the industry tries to help you by removing or bypassing these blockages. The fact that blockages are dangerous not because of their physical bulk, but because of their propensity to burst/rupture is quitely ignored. In the absence of scientific knowledge, people tend to get scared of shadows and real threats lurking in the background are glossed over. One ploy the industry uses to keep the people quiet and not babble about inconvenient things like JTF and “Indication Class” and such like things is to create very large and posh buildings which are very impressive looking. The aim is to subdue you into bovine submission and discourage you from asking inconvenient questions. Healthcare industry has created such an environment that words like “Angioplasty” or “Bypass Surgery” are spoken with slick ease even by illiterate people. Normally such words should be like tongue twisters and quite a mouthful for lay people; esp. non-english speaking population. Why can’t the same people pronounce “Joint Task Force”, “American College of Cardiology”, “American Heart Association”, “Left Ventricular Ejection Fraction”, “hypokinesia”, “Angiogenesis” and “Collateral Circulation” with the same consummate ease? Least we can do is to try-it is never too late, not even more than half a century after having gained freedom (or is it just “so called freedom”?).

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