Leisure, Lifestyle & Wellness
Coronary Angiography, the Villain of the Piece
“I have said that the soul is no more than the body. And I say that the body is not more than the soul.” — Whitman in 1855
 
“Medicine is flying blind. Thousands of medical journal articles are published every month on potential new treatments and diagnostic tests. Precious few of them measure how well doctors are doing in the real world, outside of controlled trials—what they are doing right, what they are doing wrong and what they are forgetting to do entirely. No wonder our medical system wastes billions of dollars a year,” writes Mathew Herper of Forbes magazine.
 
Last week, The Outlook published a detailed article on angioplasties in our hospitals and their hazards. Most of it was about the cost of stents and their misuse and abuse. Little did the writer, or even the interview that followed, touch upon the crucial point—the coronary angiogram, the villain of the piece. 
 
I had written about it and have been doing so even before some of the leading American researchers, like Harlan Krumholz, came on the scene. The only area where angioplasty has a proven track record is immediately after (minutes after) a heart attack, if the heart attack-related coronary artery is the blocked culprit with an added clot blocking the vessel. 
 
For heart attack patients, Dr Krumholz picked ‘door to balloon time’—how fast the patient is treated upon arrival at the hospital. Hospitals that are doing badly on this measure can’t blame it on how long the ambulance took to get there. Angioplasty is done to make money by frightening patients and their relatives that there are blocks in the coronary arteries. Almost every living human being, including children, has one, two or even three vessel blocks. This was shown so elegantly in the post-mortem angiograms done on 205 American young soldiers shot dead in Vietnam and Korean wars.
 
So, almost all our angioplasties are done unnecessarily. The epicardial vessel blocks (shown to patients and relatives to frighten them) do not usually critically restrict heart muscle blood flow which takes place through collateral vessels (nature’s bypass) and the perforating coronary vessels dilation (coronary reserve) when needed in young healthy individuals. This process is well oiled in nature, called pre-conditioning, helping patients to get over the blocks. 
 
In addition, if the doctor studies the FFR (flow fraction ratio) across a block, almost 90% of the so-called critical blocks become benign and need to be left alone. No hospital, to my knowledge in India, does FFR studies, although they do all and sundry tests to collect money from patients. If one has a two-camera angiogram facility, where all the so-called blocks are simultaneously viewed from two angles at 90 degrees to each other, even the 90% block might just be only 10% block from another angle. No hospital has that facility either, as it will cut down their angioplasty indications to less than 20%! How can they show a profit to their shareholders?
 
They all follow the Wall Street greed! In essence, the only indication for angioplasty is immediately after a heart attack, if the vessel blocked is the one causing the heart attack. Exertional angina (most patients have that) is no indication for angioplasty. Medical treatment is better. Lifestyle change is the basis of all coronary artery disease treatment. Asymptomatic patients have no indication for angioplasty at all. Do understand that coronary artery blocks are not synonymous with coronary artery disease.
 
Therefore, the only way to curb angioplasties, and the attendant exorbitant costs to patients and the exchequer, is to ban routine angiograms to diagnose coronary artery disease. Way back in 1991, the Harvard group of Professor Bernard Lown had shown that a moratorium on coronary angiography alone can save patients from greedy cardiologists. 
 
A paper in Journal of the American Medical Association began a debate in the UK to cut down on cardiac centres there, to save money for the NHS and the lives for their patients. Tom Treasure, an aggressive cardiac surgeon, made a plea in The Lancet. The scientific role for angiogram is only when the patient’s clinical assessment demands either an angioplasty or bypass surgery for relief of chest pain just to know where to plumb. Legislations to control the cost of stents will not do any good to patients who are now being exploited through unnecessary angiograms for diagnosing coronary artery disease.
 
The government must legislate to have outcome audits of all such procedures; only then will we make cardiologists practise scientific cardiology, nothing else. For big corporations, the idea that ‘you can’t manage it if you can’t measure it’ is an old chestnut. General Electric, Toyota and other companies have had data-driven quality improvement efforts, for years. But medicine—supposedly a more scientific profession—has been slow to measure itself. Dr Krumholz has been one of a handful of pioneers behind the scenes pushing to do this.
 
There are many other reasons to work on banning diagnostic angiograms in asymptomatic patients faster. 
 
“Knowledge,” said Karl Popper “advances NOT by repeating known facts, but by refuting false dogmas.” One cannot agree more. Modern medicine abounds in dogmas: many of them have not been scientifically audited.  Science is change. Every single hypothesis is true until refuted by new knowledge. Knowledge today, in the medical field, is replaced by information, resulting in doctors relying only on information and not wisdom. The so-called evidence-based medicine really is evidence burdened.
 
Medical muddling seems to be a profitable business. New tests, new devices and new drugs pour into this arena on an unprecedented scale.
 
It is time to audit all the technologies used in patient-care, just as we have placebo-controlled trials for drugs before releasing them for human use. Even in the case of drugs, in some rare instances, release of drugs for patient use before they are audited by such trials had resulted in major damage resulting in their withdrawal from the market. It stands to reason that we should debate the issue of auditing untested technologies like angiograms that get into the arena of patient-care.
 
Starting with some of the audits just completed, we could move on to other areas. Many of the unmeasured physiological effects of in-dwelling catheters come to mind first. The Swan-Ganz catheter was introduced without appropriate validating studies to compare with identical groups without the catheter. This catheter, by itself, could be an adverse factor for many critically ill patients. ( Spodick DH, ‘Uncritical critical care’, British Medical Journal, The Swan-Ganz catheter. 1999; 115: 857-858)
 
In an observational study by AF Connors and colleagues showed that in critically ill patients, after adjusting for selection bias, the catheter was associated with increased mortality and increased utilisation of resources.
 
Extrapolating another study done in Worcester, ED Robin estimated that around 15,000 unnecessary deaths could have occurred in 1984 alone and his paper goes on to estimate a total of nearly 100,000 excess deaths in the US since 1975 due to the catheter. Following these studies, there was a justifiable demand for a moratorium on the use of the catheter until further prospective controlled studies cleared the mist. Understandably, strong opinions were expressed against the demand for a moratorium, but the opinion, unfortunately, ignored some of the very valid data in the field.
 
Coronary artery surgery is the next popular surgical procedure crying for proper audit. There was a demand for audit in this area way back in the early 1970s. Indeed, all new surgical procedures are better audited by controlled studies before being routinely performed in practice There was hardly any substantial change in this area even as recently as 1997. (Hegde BM, “Coronary Artery Revascularisation - Time for reappraisal” Proceedings of the  Royal College of Physicians Edinburgh, 1997) 
 
More recently, an audit showed ethically unacceptable results of overuse of both bypass and angioplasty in the immediate post myocardial infarction scenario. (“Use of cardiac procedures and outcomes in elderly patients in the US and Canada”, New England Journal of Medicine, 1997: 336; 1500-5.)
 
Writing a very balanced editorial in the same issue, Harlan Krumholz from Yale laments: “In a fee-for-service system, cardiac procedures generated billions of dollars in revenues each year. A high volume of procedures brought prestige and financial rewards to hospitals, physicians and the vendors of medical equipment.”

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COMMENTS

S.S.A.Zaidi

1 month ago

A very good article. An eye opener.
We need drs like Dr Hegde a professional with high sense of rectitude. Long live Dr Hedge.

KARTAR SAINANI

2 months ago

An excellent article giving the truth and showing how the medical profession has lost it's ethics due greed . Hats off to Dr Hegde for his excellent articles in Moneylife.

Merchant M S

2 months ago

Thank you Sir, for the article. All the misunderstanding have been cleared. Now it all depends on the clinical status of the patient, we can't allow patient to die. Almost always patient relatives blame doctor for unnecessary angioplasty and go straight to the courts if the patient dies.

Jigna Shah

2 months ago

My hubby did angioplasty twice with in 1 month bcoz of 95 blockage . 1st tym he had minor attack. So with in 1 hour angiography doctor did not soon angioplasty bcoz 1 blockage 95% he had. After 1 month again little pain was dr so did angiography didn't wait for attack. Again 95% blockage above stend. So soon again did angioplasty. So was it necessary? V r still in shock how it was happened ?

Nutan Shah

2 months ago

Very informative and alarming facts about the cause and care .
I would appreciate , your reply to query posted by Mr R D Mehta , because alarm bell is rung with not individual who suffers but by the near and dear ones due to their sheer love and affection and thus one is compelled to drag in and accept the process and advise.

It is the same medicines that I have been taking for almost 10 years and even after the plasty under taken so at times I wonder and lead to believe , it is not medicine but the creator of human being and body that rules us and all that is destine , it happens , no matter what precautions you take.

In the larger interest of common man, I suggest and earnestly request you to guide one and all what actions should be initiated while such symptoms of angina or breathless ness are felt while walking or working.

On the whole , I compliment you for such excellent factual study put up for alerting one and all.

Nutan Shah

2 months ago

Very informative and alarming facts about the cause and care .
I would appreciate , your reply to query posted by Mr R D Mehta , because alarm bell is rung with not individual who suffers but by the near and dear ones due to their sheer love and affection and thus one is compelled to drag in and accept the process and advise.

It is the same medicines that I have been taking for almost 10 years and even after the plasty under taken so at times I wonder and lead to believe , it is not medicine but the creator of human being and body that rules us and all that is destine , it happens , no matter what precautions you take.

In the larger interest of common man, I suggest and earnestly request you to guide one and all what actions should be initiated while such symptoms of angina or breathless ness are felt while walking or working.

On the whole , I compliment you for such excellent factual study put up for alerting one and all.

Ramesh Poapt

2 months ago

GREAT! SIR...

RAJENDRA DALPATRAM MEHTA

2 months ago

I appreciate the article. You are right in pointing at the greedy hospitals. However, if patient has a real problem like angina pain or so, what should he do? Surely he cannot wait for the heart attack to strike. Please advise.

Trump Promised to Resign From His Companies — But There’s No Record He’s Done So

At a news conference last week, now-President Donald Trump said he and his daughter, Ivanka, had signed paperwork relinquishing control of all Trump-branded companies. Next to him were stacks of papers in manila envelopes — documents he said transferred "complete and total control" of his businesses to his two sons and another longtime employee.

 

Sheri Dillon, the Trump attorney who presented the plan, said that Trump "has relinquished leadership and management of the Trump Organization." Everything would be placed in a family trust by Jan. 20, she said.

 

That hasn't happened.

 

To transfer ownership of his biggest companies, Trump has to file a long list of documents in Florida, Delaware and New York. We asked officials in each of those states whether they have received the paperwork. As of 3:15 p.m. today, the officials said they have not.

 

Trump and his associates "are not doing what they said they would do," said Richard Painter, the chief ethics lawyer for President George W. Bush. "And even that was completely inadequate."

 

ProPublica's questions to the transition team were referred to an outside public relations firm, Hiltzik Strategies, which declined to comment. The president's team did not allow reporters to view documents, which they said were legal records separating Trump from his eponymous business empire. Dillon's law firm, Morgan Lewis, has not released the records and they declined further comment, saying it doesn't comment on client issues.

 

ProPublica looked at more than a dozen of Trump's largest companies, which are registered or incorporated in three states. Officials in New York and Delaware said documents are logged as soon as they are received. In Florida, officials told us there is typically a day or two before documents are logged into the system.

 

Here is what we found:

  • Business filings for Trump Organization LLC, Trump's primary holding company, had not been changed, according to New York's Department of State. Wollman Rink Operations LLC, which runs the Wollman Rink in Central Park through an agreement with New York City, hasn't been updated either. Trump is listed as the sole authorized representative of the company. 
  • Ivanka Trump is still listed as the authorized officer on records for two entities related to the Old Post Office in Washington, D.C., which the Trump family bought and turned into a hotel. No changes have been filed for either of the companies, which are registered in Delaware.
  • Documents on The Donald J. Trump Foundation, which Trump has said he would dissolve, haven't been updated. The charitable foundation has been in a swirl of controversy over its collection and disbursement of funds and an active investigation by New York's attorney general. (The foundation cannot legally dissolve until the investigation is complete, but the New York Attorney General's office told ProPublica that Trump can resign as an officer at any time.)
  • In Delaware, where the majority of Trump's businesses are registered, state officials told ProPublica that no amendments have been filed for four businesses tied to the Old Post Office and that the most recent filings for two businesses related to the Trump National Golf Club in Washington, D.C., were made more than a year ago.
  • In Florida, no changes have been made for years to three key Trump businesses operating there: the Trump International Golf Club in Palm Beach, the Mar-A-Lago Club, and DJT Holdings, which has controlling interest in most of Trump's golf courses in the U.S. and abroad, according to the state's Division of Corporations.

 

Even if Trump hands over his companies to a new trust, the plan fails to solve many of his bigger business conflicts, experts say. Terms of the trust that would insulate the president from the Trump Organization haven't been made public. Trump's decision not to divest his assets has also been heavily criticized by several former White House attorneys and ethics chiefs.

 

"What are the terms of the trust? Who is going to be the ethics monitor and what standards will he or she abide by?" said Norman Eisen, who served as the White House chief ethics lawyer under President Obama. "There are 1,000 unanswered questions."

 

DJT Holdings Managing Member LLC Mar a Lago Club, L L C OPO Hotel Manager LLC OPO Hotel Manager Member Corp The Donald J Trump Foundation, Inc Trump International Golf Club, L C Wollman Rink Operations LLC

 

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for their newsletter.

 

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COMMENTS

Kushal Kumar

2 months ago

The news of a scam of financial nature involving IDBI officers also is worrisome for the nation. There could surface many more in time to come. Closely relevant to the said news , readers may like to know this Vedic astrology writer’s alerts for more care and strategy in article “ 2017 – an opportune year for India with major worrisome concerns in February-March and August-September” ( Also known as “ Probable Predictions in relation to India in coming year 2017”) issued widely to Indian news media last year in October and November 2016. It was opined that first three months of year 2017 from January to March could be termed as one basket from the angle of similarity of planetary influences , while February –March could likely present major worrisome concerns. Financial or trading scams in places such as Delhi , Mumbai and the like could be in the news. Some political leaders or officials comparable to them may probably face some consequence of wrong-doing allegedly done in past. It seems the financial-trading scam allegedly involving IDBI top ranking officials highlighted in the news points to accuracy of the alert prediction of this writer.
The news of a scam of financial nature involving IDBI officers also is worrisome for the nation. There could surface many more in time to come. Closely relevant to the said news , readers may like to know this Vedic astrology writer’s alerts for more care and strategy in article “ 2017 – an opportune year for India with major worrisome concerns in February-March and August-September” ( Also known as “ Probable Predictions in relation to India in coming year 2017”) issued widely to Indian news media last year in October and November 2016. It was opined that first three months of year 2017 from January to March could be termed as one basket from the angle of similarity of planetary influences , while February –March could likely present major worrisome concerns. Financial or trading scams in places such as Delhi , Mumbai and the like could be in the news. Some political leaders or officials comparable to them may probably face some consequence of wrong-doing allegedly done in past. It seems the financial-trading scam allegedly involving IDBI top ranking officials highlighted in the news points to accuracy of the alert prediction of this writer.


November IIP 'false positive', doesn't reflect reality: Crisil
Descibing the official data on the index of industrial production (IIP) for November 2016, during which demonetisation was announced, as a "false positive", Crisil Research has said that the latest IIP figures do not reflect the true condition of the Indian manufacturing sector.
 
Belying popular expectations, India's factory output, as measured by the IIP released earlier this month, rose 5.7 per cent in November, the first month of the government's demonetisation drive. Index of Industrial Production in October had declined by 1.81 per cent, while there was a 3.4 per cent slide in the corresponding month of last year.
 
"The index of industrial production grew by 5.7 per cent on-year in November, on account of a weak base. Going by the production trend in some sectors such as auto, next month's (December) IIP growth data may be more indicative of the impact of demonetisation," said a note by Crisil, a subsidiary of American ratings agency Standard & Poor's.
 
"The IIP base year has not been updated," said Crisil Chief Economist D.K. Joshi.
 
He explained "false positive" as a term used in data analysis.
 
"The term implies that the growth rate indicated is too high. It was expected to be in the negative zone as November was the first month to have captured the impact of demonetisation," Joshi said. 
 
"IIP had fallen by 1.8 per cent in October. In November it suddenly shoots up, and so we say it is not a true reflection of the condition of manufacturing," he said.
 
"Such month-to-month the data is too volatile, it cannot be used to make long-term projections," he added.
 
Besides, the cumulative growth of the country's factory output for the April-November period at 0.4 per cent, was much lower compared to the cumulative growth of 3.8 per cent during the corresponding period of the last fiscal. 
 
Prime Minister Narendra Modi had on November 8 announced demonetisation of Rs 500 and Rs 1,000 currency notes, saying the move was aimed against black money, counterfeit currency and terror financing. The unprecedented measure set off a massive cash crunch, while citizens were given till December 30 to deposit the old notes in the banks.
 
Disclaimer: Information, facts or opinions expressed in this news article are presented as sourced from IANS and do not reflect views of Moneylife and hence Moneylife is not responsible or liable for the same. As a source and news provider, IANS is responsible for accuracy, completeness, suitability and validity of any information in this article.

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