As in many other fields, emotions rule over hard scientific data in medicine too under a variety of circumstances. A glaring example is the now fashionable coronary artery bypass surgery. As stated earlier, in the USA, while some 380,000 bypass operations were done in one year (1990) compared to 18,000 operations in 1981, only 150 operations per million were carried out in the UK that year. Another related, but not so invasive, procedure, namely, balloon angioplasty, came into the scene in the late 70s with lot of fanfare. It was thought that this procedure would replace bypass surgeries to a certain extent. On the contrary, a staggering number of 285,000 angioplasties were done in the USA in 1990. In short, there has been a quantum jump in both these procedures recently — both going up in tandem. The noteworthy point is the difference in the operation rates between the UK and USA. Although the scientific reasoning has been the same in bowtie countries, doctors in the USA have done

Sevenfold more operations in one year. If we look carefully at these figures, the fact that stares us in the face is the personal monetary gain for the operating team in the USA compared to hardly any fiscal benefit to the team in the UK.

Be that as it may, let us look at the development process of the coronary artery disease — a relentless disease which has no cure as yet. Our only hope is prevention.

While it is true that fixed blocks in the large surface coronary arteries in man might result in exceptional chest pain, such’ blocks have not been shown to kill anybody. The fatal heart attacks (myocardial infarction), in which a portion of the heart muscle dies, are usually caused by near-normal looking surface arteries being blocked suddenly by a large clot. To date the mystery of how this clot gets formed has not been solved.

The critical narrowing of the aforementioned large arteries serves as a good provocation for collateral blood flow keeping the muscle viable. Prospective studies have shown even extensive blockage of all the three large vessels to be innocuous as far as death is concerned. The fears expressed by certain medical quarters that these blocked arteries can eventually cause damage to the good muscles of heart has not been borne out by facts. Nevertheless, significant damage tithe total heart has not been borne out by facts. Curiously, even disease of the left main artery (labeled ‘widow-maker’) which is supposed to kill the victim in a short time, has been shown to be absolutely safe (without operation) in a large cohort of men having these blocks who refused surgery (lucky blokes !!).

What then are the real indications for bypass surgery? There are two absolutely certain indications. The first is intractable chest pain which cannot be relieved by any medical method. Fortunately, the latter situation is exceptionally rare. The second indication is Avery poorly functioning heart (left ventricle) with a large dilation of its wall (aneurysm) whose capacity to pump blood has been severely curtailed. Whereas such patients gain good functional benefit through bypass surgery coupled with resection of the bulge,

The mortality rate of these patients with respect to the operative procedure (peril-operative mortality) is prohibitively high consequences; many surgical teams (whose prime goal is to make money) do not like operating on these patients.

Another myth created by the doctors is the hope that bypass surgery prolongs life. There are no studies available to date which have shown improved survival rates after bypass surgery, although minor benefits in longevity were shown by two small groups but only in young patients, who, in the first place, did not need surgery. Two of the milestone studies in this regard suffered from a flawed study design. In fact, bypass surgery has consistently been shown to progressively accelerate blocking of the native circulation (the patient’s own arteries).

The story of angioplasty is still worse. There has not been single large- scale, well-conducted study which has indicated this procedure to be useful at all. Even the recent RITA study did not show this procedure in a good light. The angioplasties arteries of nearly half the patients get blocked off in virtually no time atoll; in the remaining patients, these arteries get blocked off progressively. All attempts to keep these opened vessels functioning for a long time through methods such as using drugs of all kinds and resorting to various diets have come to naught. Nevertheless, there are two more ongoing studies. One of them pertaining to the use of drugs such as harden, an extract of leeches, and the other to self-administered, low-dose heparin(which ought to be ready in the near future). The hope of using the latest monoclonal antibodies against platelet-aggregating globulin, though theoretically sound, does not seem to be promising; as its cousin did not do well in heart transplant patients. Nature keeps its secrets close to its chest. A new process called fibro cellular intimae hypertrophy (FCIH) blocks these angioplasties vessels, which we have yet not understood fully. Curious are the ways of the human body!

Why then are these procedures being carried out even in thecae of innocent people who have no chest pain or any other disability related to the heart’s pumping capacity? The only one reason could be a good business proposition; the scenario is alto common and transparent.

Let us consider a typical situation. A middle aged man, coming up in life, goes for a total medical check-up. Some test shows something abnormal. He is thus goaded to get an X-rayon the heart vessels, lest potentially dangerous, but quiet, blocks in these arteries should result. Such blocks are sometimes seen even in children, as shown by the Vietnam and Korean war victims and also by the recent Los Angeles riot victims. As has-been stressed earlier, such blocks rarely kill a person. But the doctor invariably informs the innocent victim, by showing him the blocks in his heart vessels that he is sitting on a volcano which can erupt at any time and finish him off. Which person under these circumstances can refuse the ruse of total cure by bypass surgery or angioplasty? The advocate, the jury and the judge are all rolled into one person; the cardiologist. Depending on whether the cardiologist is an intervention list or not, his advice would be to go in for angioplasty or surgery. The judgment thus delivered, the hapless victim is gripped by intense fear ofsuddendeath and is relentlessly pushed on to the operating table. The relatives also join in the plea for ‘correcting the plumbing’. The diagnosing doctor and the intervention team must adopt totally different ideals and values if the situation has to change for the better.

How can we save the day? We must convince all doctors to treat on a priority basis those human beings suffering from intractable chest pain or consequent heart failure and not the so-called ‘menacing coronary angiograms’.

Angiograms should be done only after the decision to interfere has been made, depending on the patient’s actual condition and not for diagnosing coronary artery disease as a gold standard. Infect, the largest coronary artery surgical study has shown that angiograms are only needed to plan the operation and not as an algorithm of the indications for surgery. Health education of patients should take on paramount importance in order to counter the menace of proliferating bypass centers!