Choosing a treatment for heart disease

CAD is mainly caused by risk factors like diabetes mellitus, hypertension, smoking, dyslipidemia and genetic factors. Though effective control of these risk factors can reduce the incidence of CAD, 50 per cent of the deaths and myocardial infractions (heart attack) occur without any risk factors/symptoms.

So early detection and effective treatment of this disease is of paramount importance to reduce the mortality, long-term medication and sufferings, financial loss and loss of working days. Treatment of CAD includes early and effective removal of blocks and reestablishing the blood flow to the heart.

Bypass surgery
There are different modes of treatments to remove the block inside the coronaries, namely, coronary artery bypass grafts (CABG) or bypass Surgery, Angioplasty with stenting (Percutaneous transluminal coronary angioplasty or PCTA) and medical management.

CABG means the blocks are bypassed and blood flow is reestablished using different blood conduits namely arteries or leg veins. This is a major surgery and a team of doctors and para-medical personnel are needed to perform this operation.

Though it is performed at many centres in India, well experienced team can produce good results for the patients. Though patient requires a longer recovery period, its long term results are excellent.

Angioplasty
Coronary angioplasty is a very effective way of removing blocks without surgery and the patient can resume work within one or two days.

This procedure is simple in the sense it does not involve anaesthesia, ICU stay or pain for the patient. Though it looks very attractive for the patient and relatives it is not always true.  If the patient suffers from multiple blocks, diabetes and if his heart is weak, angioplasty may not be effective and he may end up having to undergo surgery later.

Medical management was the only way to manage the CAD till 1980s. Though block cannot be by passed/flow cannot be reestablished with this, symptoms can be significantly reduced using a variety of medicines.

It is true that no medicine is available to remove the block till this day. But it can prevent progression of blocks.

To chooses between CABG and PTCA there are various factors that need to be considered – number of blocks, diabetes, Left ventricular (LV) function (Heart pumping status), financial status of the patient, health insurance, surgical back up, mental status and the doctor who is mobilising for the procedure.

It is not possible for the patient to make the correct decision. It is the cardiologist who is the decision maker. As angioplasty is performed by cardiologist and surgery by surgeon, many cardiologists have a tendency to prefer angioplasty over surgery. Most cardiologists take decisions for the patients on the basis of the American Heart Association guidelines. But this may not be always suited for Indian conditions.

In India most of the patients most patients do not have health insurance coverage.
Sometimes the cardiologist’s decision may be biased. The long-term implication of a wrong decision includes sudden death, heart failure, permanent disability and heavy financial liability. It has virtually become fashionable for those who can patients who can afford to go in for angioplasty for multiple blocks. This can cause more serious problems if the case selection is wrong.

Multiple stenting
 Tertiary centre with most experienced team of doctors is the key to success. Multiple stenting can cause huge cost to the patient especially if drug coated stents are used. Most patients in India are not able to afford huge cost. Even if they manage to mobilise fund for the procedure, the recurring expenditure incurred due to repeat revascularisation (most common complication of multiple stenting) is almost prohibitive. So we have to strongly consider the financial background of the patient while taking a decision for our patient.

It is myth that surgery is of high risk and angioplasty is simple and safe. Though scientifically PTCA can produce almost equal results like CABG, repeat revascularisation is the major disadvantage of PTCA. So in case of multiple blocks surgery may be the preferred mode of revascularisation.

To help doctors take appropriate decisions to treat a CAD patient, we need a national policy and guidelines from the Indian Cardiological Society. And, the public should be made aware of the necessity of health insurance, considering the huge expense involved in treating various cardiac problems.

Dr Yusuf A Kumble
MD, DM (AIIMS). Associate Professor and Interventional Cardiologist, KMC Hospital, Mangalore