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THE TYRANNY OF PREVAILING OPINIONS |
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The
caption is borrowed from Harold Laski. The sentiment fits
the bill correctly in the field of hi-tech medicine these
days. Science is change. Life is a constant ceaseless
change until death. What is true in science today, may be
the folly of tomorrow.
For the purposes of this paper we shall confine ourselves
to the most advertised, and the most thoroughly
researched medical intervention - the revascularisation
procedures in coronary heart disease . The latter is made
out to be one of the most dreaded diseases of the elite
and the well-to-do sections of society, although
extensive data show that coronary disease has a higher
prevalence among the economically underprivileged even in
the advanced West (1).
The present day media hype regarding this disease makes
every middle aged person feel that he or she could be the
next victim of this killer. The ordinary lay articles in
newspapers and "health" magazines project this
widow-maker to be one of the leading killers of the
industrialized society. This fear psychosis is one of the
reasons why patients get heart attacks. The blood clot,
the final assault on the coronary vessel, could be
hastened by fear. The scientific fact regarding the
incidence of coronary artery disease, though, is
otherwise. Stehabens, a professor of pathology from New
Zealand, after extensive studies both in the USA and
Europe for over three years, writes in the leading
medical journal, The Lancet, that "there has not
been even 1% rise in the incidence of this disease in the
last one hundred years" (2). The apparent rise has
been due to better labeling, the ageing population, and
the awareness in society that brings people to hospitals.
The disease has been graphically described thousands of
years ago in the Ayurvedic text - Shushruta Samhita. This
disease has been reported in Egyptian mummies as also in
ancient China, even in young ladies.
Why then is there this new scare ? It is a simple
business proposition. One, and possibly the only one,
area where the doctors, hospitals and the sellers of
medical equipment, get billions of dollars in cash, in
addition to prestige, and status is the procedure which
claims to "bypass" the blocked coronary blood
vessels on the surface of the heart. The simple
"banana logic" that an open vessel is better
than a blocked vessel, gives credence to the belief that
bypassing a block in the native circulation, with the
help of a conduit, or crushing the block to open the
artery, is better than leaving the block alone. This
however, has been shown to be untrue (3). Angioplasty,
even when not complicated by restenosis, may not
substantially reduce the risk of a myocardial infarction
and prolong life. (4)
The scientific data in this direction does not seem to
have affected the peak rise, and continued increase in
the rate of revascularisation procedures, not only in the
West (5), but also in the poor countries of the
developing world. The recent findings that the x-ray
picture of a block in the vessel, has very little to do
with the final assault on the patient giving rise either
to the agonizing chest pain (angina) or a heart attack,
does not seem to register in the minds of the
perpetrators of these procedures (6).
Dr. Atillio Masseri, a great proponent of this banana
logic, has been converted lately when he wrote in The
Lancet "the final assault on the heart muscle is the
clot which blocks the vessel, and new data is strong
enough to suspect inflammation as the root cause of the
final clot" (7). I wish we knew the secrets of the
clot coming on !
If one were to critically analyze the scientific hard
data in this field, one comes across three landmark
studies. The first CASS study, published in 1983 in the
leading American journal, Circulation, was a prospective,
randomized one. The study showed that surgical
revascularisation was as effective as medical treatment
for this malady; although it claimed (not based on hard
data) that the quality of life was better for surgically
treated patients (8). A later analysis of the same data
by another leading American Cardiologist, Shahabudin
Rahimtoola, showed that the study design, especially with
reference to randomization, was flawed.
Be that as it may, we will move on to the second study
which was an audit of sixty thousand revascularisation
procedures done in the West. The original study published
in The Lancet showed that the said procedure gave the
patient on an average 4.23 months of extra life (9).
Please do not get misled. This is a statistical term.
Life and death are not in the realm of doctors. Death
does not even depend on disease. It depends on four major
events, bad luck, bad people, bad genes, and finally, on
the fact that we are human and live in a world run by
inflexible laws of Nature.
A re-analysis of the same data, reported in the Archives
of Internal Medicine, under the title " In the of
the beholder" revealed the secret of the conclusions
in the paper referred to earlier (10). Of the 60,000
procedures 84% the patients (who had no symptoms prior to
the operation) did not get any benefit in their
longevity; but 16% of those who were severely symptomatic
(they either had severe chest pain or shortness of breath
restricting their activity) got their life extended by 6
months to 4.5 years. See the irony of reporting the same
data in different ways !
The original CASS study population had 150 patients, who
were told to get immediate surgery done as they were told
to be sitting on a volcano, which might kill them any
minute, refused voluntarily to have surgery done, and
opted instead to have medical treatment. They have been
reviewed after 10 years, those with one and two vessel
disease were all alive at the end of that period and
those with the left main equivalent disease did better
than their peers in society without any disease of the
coronary arteries with lower attrition rate for their age(11)
!
The third landmark study was recently published in the
New England Journal of Medicine. This study compared
similar populations in Philadelphia and Ontario for the
same time slot. The study confined itself to the new
craze for emergency revascularisations immediately after
a patient gets a heart attack (within 30 days) (11). From
the business point of view this is a better proposition
because you have an ideal situation with an unlucky
patient in distress who could easily be converted to your
point of view, to agree to undergo the procedure!
Whereas there was a phenomenal difference in the
intervention rate of revascularisation procedures between
USA and Canada of 10 : 1, the mortality at the end of one
year was equal in both countries. (12) Writing an
editorial comment on the article was the professor of
cardiology in Yale University, Dr. Krumholz. "In a
fee-for-service system the one procedure that brings in
billion of dollars of money, fame and prestige with
status, for hospitals, doctors and sellers of medical
equipment is this revacularisation. That is the reason
why we promote revascularisation" (13).
There are many small studies extolling the virtues of
bypass. But the fact, to date, is very clear. The hard
data support the following:
- Bypass is only
Palliative.
- Must be reserved for
the poor victims of intractable chest pain and/or
extensive damage to the heart muscle. (Shortness
of breath) - the extreme situations.
- Prevention of
coronary disease must be our aim.
- For patients who do
not benefit by maximum and adequate medical
management and life style changes, and still have
intolerable pain or inability to do their daily
routine work, bypass is a boon.
The tyranny of the
prevailing opinion that any block in the x-ray picture of
the coronary arteries needs a bypass is a menace to the
innocent victim of this scourge. Medical leaders must
wake up and act conscientiously; as otherwise we will all
be hypocrites swearing by the Hippocratic Oath.
Long Live Mankind on this planet. We have been here for
well over 9,00,000 years in 50,000 generations. If
mankind were to depend only on revascularisation
procedures for survival, we should have been extinct like
the dinosaurs long long ago. Do our patients live inspite
of us ? (14) Time has come, Walrus said " to talk of
many things" of "Cabbages (CABGs) and
Kings". How true !
Bibliography:
- 1. Hegde BM., The
management of coronary artery disease: A time for
reappraisal. Proc. R. Coll. Physicians Edinb.
1995;25:421-424.
- 2. Stehbens WE. An
appraisal of epidemic rise of coronary heart
disease and its decline. Lancet
1987;1:606-610.
- Danchin N. Is
revascularisation for tight stenosis necessary?
Lancet 1993; 342: 224-5.
- Libby. P. Ganz P. Restenosis
Revisited. NEJM 1997; 337:418-419.
- Treasure T. US
doubts about angiography . Lancet
1993;341:154.
- Graboys TB, Biegelsen
B, Lampert S, et at. Ten year follow up of
CASS patients. Circulation 1990;82:1629-1646.
- Maseri A:
Inflammation, atherosclerosis & IHD events.
NEJM. 1997;336: 1014-1015.
- CASS Principal
Investigators. CABG survival data.
Circulation 1983;68:939-50.
- Yusuf S. Zucks D,
Peduzzil et al. Effect of CABG survival:
overview 10 year Results. Lancet
1994;344:563-570.
- Hox JE, Naylor C.D. In
the eye of the beholder. Arch. Intn. Med
1995;155:2277-80.
- Heub W, Bellotti G,
Ramirez J, et al. 2-8 year survival rates in
patients who refused coronary surgery.
Am J Cardiol 1989;63:155-159.
- Tu N. Pashos C.L.,
Nayor C.D. et al. Use of Cardiac procedures
& outcomes in elderly patients with MI
in USA & Canada. N Engl J. 1997:
336;1500-1505.
- Krumholz HM. Cardiac
procedures, outcomes, & accountability
NEJM 1997: 336:1522-23
- Hegde BM. The
first law of Thermodynamics. JIMA
1997;95:161-162.
[index]
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