Getting to the heart of cardiology


  • Letters
  • Sunday, 16 Nov 2003

A recent letter to the editor painting ‘a cynical and unflattering ’ picture of doctorsregarding their management of coronary heart disease patients in Malaysia hasprovoked a response from a prominent consultant cardiologist,DR DAVID K.L.QUEK. 

Although it is clear that the writer has some in-depth knowledge regarding several aspects of the modern therapy of coronary artery disease, especially those related to angioplasty, stents, coated stents and coronary bypass surgery, his assumptions on how heart specialists deal with this evolving science, on the other hand, are extremely contentious.  

To scurrilously impugn that cardiologists as a whole are misleading the public by preferring one option of treatment (i.e. angioplasty with stents) or even intentionally under-treating patients, for the sake of profit is mischievous and uncalled for. Let me try and clarify the issues raised. 

First, balloon angioplasty is now some 25 years old, having been developed by a pioneering Swiss doctor, Dr Andreas Gruentzig, in 1977. On the other hand, coronary artery bypass surgery really took off in the early 1960s, making it some 40-odd years old.  

The early angioplasty results on very carefully selected cases showed tremendous promise and created a buzz around the world. That cholesterol plaques can be squashed away to clean up a bunged-up blood vessel became the exciting must-do technique for many inspired doctors, in this case, cardiologists.  

With the derring-do of pioneering specialists, a wider spectrum of more difficult cases was attempted with mixed but overall favourable results. Importantly, the safety of the procedure was firmly established under well-trained hands. 

But, it soon became apparent that balloon angioplasties had some deficiencies, chief among which was the tendency to further damage the heart artery lining (inherent in the technique itself), as well as to flatten and fracture the cholesterol plaque, which sometimes flake off the wall and close-up the blood vessel instead. This so-called sub-acute or acute closure due to the shifting of the plaque makes the procedure somewhat riskier than it should be. Earlier attempts to correct this include prolonged balloon inflation to try and tag the flaked-off plaque back against the arterial wall, or to scrape off excessive debris with some mechanical devices. 

Further, there is another potential problem of early or later re-growth of reactive scar tissue which tends to re-narrow (re-stenosis) the blood vessel at the site where it was balloon-dilated. This was shown to take place in up to 40% to 50% of the time, making the procedure of plain old balloon angioplasty less successful than we hoped it would be. 

We still do not fully comprehend why this takes place but we do know that different individuals react differently, with few predictable features – some people develop bad scars when injured (e.g. skin cuts or operation scars-keloids) while others very little.  

Nevertheless, most treated patients (in excess of 70% to 90%) report very satisfying relief of symptoms with many becoming able to reduce their medications to a minimum. 

Over the past 20 years or so, this technique has clearly improved the lives of many people, providing most with an excellent quality of life with much reduced symptoms. Importantly, there were not more people dying due to this “new” procedure, when compared with simply giving medications, or for that matter when compared to those who elected for bypass surgery. 

Because the success was so well-received it is no surprise that cardiologists have mustered their considerable interests into translating this initial gain into a uniformly practised procedure which can now be performed with minimal risk after some careful training and peer-structured apprenticeship. 

But yes, it is true that some one-third or so may suffer a recurrence of their symptoms, some of which are due to the problem of re-stenosis, but also some from the natural progress of the heart disease itself. Such is the nature of coronary artery disease and the atherosclerotic process (cholesterol furring up of heart blood vessels).  

We now know that tackling the heart artery lesion itself is insufficient. We have to treat the entire process by targeting all the risk factors such as high blood cholesterol (especially the “bad” cholesterol known as LDL), high blood pressure, diabetes mellitus, and cigarette smoking. 

Other newer risk factors (such as high homocysteine level, C-reactive protein) have now been identified in our never-ending quest to combat this deadly disease, which can never really be cured, but perhaps attenuated and made more bearable. Importantly, with new advances we know we can also extend and improve quality of life. 

Thus, in tandem with this insight of treating the whole patient, cardiologists strove to overcome these technical problems as well as re-stenosis. To be sure, many of these newfangled techniques have now fallen by the wayside – these include laser therapy, scraping or cutting devices (atherectomy), and various suppressive drugs.  

Then came the ingenious development of thin metallic scaffoldings known as stents. These tiny laser-cut wire meshes (which look like metal coils) help prop up, widen and maintain the balloon-dilated blood vessel, keeping it as widely open as possible. Indeed, with scrupulous research, early stents were shown to halve the incidence of re-narrowing or re-stenosis. Even then, we discovered that our human body still manages to mount a scarring reaction against the stainless steel mesh (the stent), and negate whatever good early results we have achieved. 

Thus, the further development of the drug-eluting (coated onto the metal) stents (also known as DES), which became the new standard to forestall the problem of re-stenosis. These drug-coated stents once again halve the incidence of re-stenosis (this when compared with the uncoated stents). 

It is unfortunate that such research and development (R&D) in these new technologies has come with a price. It is true that the coated stents are very expensive, and when used multi-ply to totally correct several narrowed heart arteries, can make this procedure even more expensive than the usual bypass surgery. 

However, with the recent release of another DES, the resultant competition has caused a price fall of around one-third. In time after recovering from such R&D outlays, we are confident that these stents will become even more affordable. 

As we all know, medical advances have been stupendous in the past two to three decades, with angioplasty, stents and newer modalities paving the way of so-called keyhole surgeries. We know that mini-surgical techniques will be the way of the future. 

Contrary to established thinking about procedures such as coronary bypass surgery which has been a benchmark saviour procedure of its time from the 1960s to 1990s, it must be recognised that it is nevertheless a very traumatic mode of therapy. It will continue to be used but for increasingly difficult and selective patients where the angioplasty procedure is too hazardous or patently inadvisable. 

The fact that most of our nations’ leaders have had bypass surgeries successfully is testimony that this procedure will not become obsolete. 

But given the choice, many patients have voted with their feet by running towards a less intrusive, less painful experience – sometimes against sound medical advice, preferring to dodge perceived pain and suffering and even tempting death in the hope of avoiding bypass surgery – sometimes with catastrophic results. But patients themselves choose, wisely or otherwise. 

Statistics perhaps show best, what the trend is like. In the US, yearly some 600,000 bypass surgeries were performed in the 1970s, but this has now tailed off to around 200,000 per year. In order to stem the decline in popularity of the bypass surgery, the cardiothoracic surgeons themselves have been forced to re-orientate their paradigm towards smaller, more keyhole approaches with beating heart, mid-CAB or even robotic procedures to try and make the procedure less intimidating, less traumatic. 

By contrast, in the US, from less than a handful of cases in 1977, angioplasty procedures have now reached some 900,000 to a million annually. 

In Malaysia, angioplasty procedures now number some 8,000 to 9,000 cases per year, with the bulk of these being performed at government-subsidised institutions such as Institut Jantung Negara, University Hospital, Penang Heart Centre in Penang Hospital, Kuching Heart Centre, in Sarawak General Hospital, and Johor Baru Sultan Aminah Hospital. The rest (about one-third) are distributed in the many private medical facilities in the Klang Valley, Penang, Ipoh, Malacca and Johor Baru and Kota Kinabalu.  

To say that private specialists are overdoing these procedures is patently wrong. Most of the government-subsidised facilities do not have a fee-for-service payment which could not therefore be the driving force for this increasing preference for angioplasty procedures. 

To insult the dignity and propriety of cardiologists and their intentions is to seriously undermine the entire system of doctor-patient relationship.  

That there might be some among the doctors who could be tempted to do more for the sake of money is probably not altogether unheard of. We cannot and do not condone such practices, but sooner or later I believe the public will become the wiser, vis-à-vis these practitioners. 

We have instituted stringent medical audits to help reduce such irregularities. This is the moral hazard that most of us doctors face daily, in the fee-for-service model of our private healthcare system. However, to tar-brush the entire profession of cardiologists as mercenary is uncalled for and unfair.  

As I have already pointed out, more of such angioplasties are performed in government-sponsored institutions than in private practice. Clearly, there must be merit for such a slant in preference – and most of our patients make their own choices. 

Indeed, it is more often than not that many patients seek second or third opinions for their heart problems, before settling on an option, because any affair of the heart is frequently a life-or-death matter!  

I believe that most doctors have the patient’s paramount interest at heart – although not every patient feels the same way. 

Ultimately, patients make the choice. We can help enlighten some of them towards the right course, but most decisions by our patients are already made, more from hearsay and word of mouth from friends and relatives than from doctors. 

We can all help by providing clearer and less unambiguous information, and guide our patients towards their own destiny and choice, always with their own interests as paramount.  

I believe that doctors are made of better stuff, at least for most of us. Patients can be rest assured that they are almost always offered the best choices for treatment, but choices which increasingly they would have to make for themselves as informed partners in healthcare management. 

 

o Dr David Quek is president of the Asean Federation of Cardiology 

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