Preventing Commercial Exploitation Of Bypass Operation & Angioplasty

Even as an angiography shows blockages, it does not mean that a bypass operation or angioplasty is needed, says Dr (Col) Kulwant Sharma

A Joint Task Force (JTF) 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 the world over to formulate these guidelines. The purpose was to help doctors reach at correct conclusions while working out the best possible approach for the given patient.

In addition, it was also aimed at exercising 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 into 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 a three-month trial must be given to the patient with conservative (non-surgical and 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 if no improvement is observed or in case further deterioration is noted, then the classification of indication automatically upgrades to ‘Class I’.

In case the class of indication works out to be ‘Class III’, then the given treatment or surgery is ‘contraindicated’ ie forbidden, unless performed under exceptional circumstances, which the treating physician/cardiologist/cardiac surgeon has to specify. In the US, Canada and Europe, it is an obligatory 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 to the patient against a receipt. This certificate must be included along with the set of medical documents in the hospital. 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 instance, a patient who has been detected with severe blockages in his angiogram (70 per cent or more at one or more places), he should fulfill the following criteria to be classified as ‘Class I’ indication for bypass or angioplasty:

• His/her angina should be so severe that it interferes with his daily routine. This 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. Otherwise, throughout the day he does not experience angina, then this is not a ‘Class I’ candidate (remember: not every chest pain is angina). A pain is 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, II, III and IV, as described by the New York Heart Association (NYHA) and this classification is accepted worldwide.
• Similarly, goes the severity of his breathlessness vis-à-vis the nature of his occupation/life style. Breathlessness (called ‘dyspnoea’ in medical parlance) too is divided into four classes by the NYHA.
• Echocardiography should reveal left ventricular ejection fraction (LVEF) to be equal to or less than 35 per cent (normal is between 50-70 per cent).
• Coronary angiography should reveal any of the following three:

a) Left main coronary artery (LMCA) disease, measuring more than 50 per cent.

b) Left main equivalent (LME) disease (both the branches of left main trunk ie LAD and LCx are involved to an extent of 70 per cent or more and that too only where the ‘proximal segment’ ie 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 per cent or more end up as Class II (a) or (b) or as Class III.

In a nutshell, just because an angiography shows blockages, it does not mean that a bypass operation or angioplasty is necessary. 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 oxidised 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 per cent or more on angiography develop, a lot of collateral circulation is deemed to have developed which neutralises the strangulating effect of them. But as age advances, angiogenesis and collateral channel development keep going slow and the process of blockage formation keeps speeding up as risk factors keep adding up over the years. Risk factors can be 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.

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. This, like arthritis, might bother once in a while, but should not shorten the life or significantly change its quality. All those people whose angiography shows blockages at one or more places, which are 70 per cent or more, doctors should not rush headlong into bypass operation or angioplasty for them. Doctors should evaluate on the touchstone of the JTF of AHA/ACC/ESC, which have been painstakingly formulated and followed worldwide.

Conclusion

Visible blockages on angiography create panic and the healthcare industry tries to help by removing or bypassing these blockages. But fact in the absence of scientific knowledge, people tend to get scared of shadows and real threats lurking in the background are glossed over. Hence, both doctors and the patients should take care to avoid bypass and angioplasty without sufficient reason and blockages.

The writer is a Consulting Cardiologist with Neovask Heartcare Centre, Delhi.
E-mail: neovask@hotmail.com