I refer to the letter Reveal mortality rates following angioplasty, bypasses by Dr Mohamed Ebrahim Sulaiman where he requests that mortality results in our hospitals be revealed following the death of a civil servant who recently underwent bypass surgery.

I am afraid results of this nature from the Ministry of Health may fall in the domain of the Official Secrets Act and to obtain these statistics from a private center may necessitate a court order.

However, I note that Dr Ebrahim has quoted the MASS II study as a reference for non-invasive therapy (presumably medical therapy) as an alternative to surgical interventions in coronary heart disease.

His frustration with procedure-related mortality may be understandable but I am afraid he has taken the results of the MASS II study out of context.

Coronary artery disease is an anatomical disease meaning you have chest pain or breathlessness as a result of a surgical blockage or blockages of the coronary arteries.

These blockages can be discrete or diffuse and may affect single or multiple arteries of the heart. On occasion, especially, in younger patients these arteries may go into spasm and temporarily mimic a blockage.

These blockages in general are due to the condition called atherosclerosis. How do you overcome anatomical blockages?

Prior to the development of bypass surgery by Ren Favaloro in 1967 at the Cleveland Clinic, the mainstay of management has been medical treatment. However after the development of imaging techniques involving coronary angiography by Dotter, Sones, Seldinger and Melvin Judkins in the 1950s and 60's, the anatomy of the coronary arteries and any blockages could be clearly delineated, offering patients a surgical option to overcome these blockages by the myocardial revascularization techniques developed by Favaloro.

However not all patients would be suitable for bypass surgery. Patients generally must be in good condition to undergo surgery and co-existing diseases like diabetes etc could be a contraindication for surgery but most importantly the blockages themselves should be discrete and the "run-off" meaning the caliber of the arteries after the blockages should be wide enough to be able to take a new vessel.

Sept 16, 1977

Lumen that are too small run the risk of being blocked early. All these decisions as to which patient is suitable for surgery or medical therapy is usually discussed by a group of surgeons, cardiologists, anesthetists, dieticians, nurses etc at a meeting called the cardiac catheterization laboratory conference where all the angiography films of patients are brought together.

But almost everything changed on Sept 16, 1977 when Andreas Gruentzig at the University Hospital, Zurich performed a technique called "percutaneous transluminal coronary angioplasty" (PTCA) to the left coronary artery of 38-year old Adolph Bachman, an insurance salesman who had recurrent chest pain and a positive stress test.

Gruentzig presented his results to disbelieving cardiologists at the American Heart Association meeting the same year. In the subsequent three years, Gruentzig performed coronary angioplasties in 169 patients with nearly 90 percent of these individuals still alive ten years later.

But balloon angioplasties had the risk of abrupt vessel closure which occurred in approximately 1% of cases, often necessitating emergency bypass surgery.

This was overcome when Sigwart reported the first implantation of an intracoronary stent in March 1986.

With the evolution of PTCA and stenting, a new modality in overcoming the anatomical blockages in coronary artery disease other then medical therapy and bypass surgery came into being.

This modality is currently known as percutaneous coronary interventions. (PCI).

Two developments

Today a combination of medical therapy, bypass surgery and PCI has become the mainstay in the treatment of coronary artery disease. But who gets which modality has become blurred as a result of two developments.

1. Many patients presenting suddenly with chest pain especially to private centers are told that they have blockages when a diagnostic angiogram is carried out and are sometimes "advised" or "coerced" into proceeding to PCI to save costs and to avoid complications as a result of these blockages later. Many patients generally trust their doctors and agree to the procedure. The danger here lies in the fact that the coronary angiography images are the privy of the doctor, his cath-lab staff and the unsuspecting patient. The films do not make it to the cath-lab conference.

This practice, rightly or wrongly, may safe the patient money and discomfort of a second angiogram if indeed PCI needs to be carried out but also exposes the patient to the danger of not having a second opinion where lesions could be more amenably treated either medically or with bypass surgery.

In lay terms this means there is a danger that a patient could only have a 30% block of his arteries but instead of advising him for medical therapy, he may be plastied and stented which can translate into an astronomical bill.

2. A significant number of patients present to emergency units with chest pains and it has now become the practice in many centers in the US and UK to offer PPCI- primary percutaneous balloon angioplasty. The key phrase is "Time is myocardium". Basically what it means is a blocked artery can result in dead heart muscles if not treated quickly enough and dead heart muscle unfortunately cannot regenerate.

The American Heart Association and American College of Cardiologists have deemed that to prevent myocardial death, "door to balloon" times meaning the moment a patient hits the emergency room door to the time he undergoes PCI should be less then 90 minutes. Again there is no way angiography films will have the benefit of an audit at the cath-lab conference and patients will generally have to submit to the best judgment of their doctor.

But PPCI has become established practice in many emergency and trauma units and indeed has saved many lives. Studies have shown that PCI restores blood flow to the heart better than clot-dissolving therapy when PCI is performed quickly at hospitals with experienced staff. However, PCI programs are available at only 25 percent of acute-care hospitals in the United States. Physicians at hospitals without PCI facilities can initiate treatment on site with clot-dissolving therapy or transfer patients to hospitals that have PCI facilities.

Elizabeth Bradley from the Division of Health Policy and Administration, Yale University School of Medicine performed an analysis published on Feb 21, 2006 saying that successful hospitals who achieve this 90-minute target generally have certain qualities and these include:

- Setting the explicit goal of reducing door-to-balloon times.
- Active senior-administrator support.
- Innovative protocols to identify delays and reduce them.
- Flexible standardized protocols.
- Driven, respected individual clinical leaders
- Interdisciplinary teams committed to the goal.
- A no-blame culture in the organization
- Organization is resilient to challenges or setbacks.

Many clinical trials including COURAGE, GUSTO, PRISM and CAPTURE have shown that various combinations of medical therapy, PCI and or bypass surgery have indeed proven to be immensely beneficial in reestablishing coronary blood flow which lends a better quality of life to a significant number of patients depending on the type of coronary syndrome the patient has, ranging from unstable angina to an outright heart attack although no one trial has shown that one combination is better then the other conclusively.

Bypass grafting better

Medical therapy discusses aspirin, clopidogrel, warfarin, nitrates, heparin, streptokinase, t-PA and its variants, calcium blockers, ACE inhibitors, angiotensin blockers, beta blockers and statins.

There are trials such as ASTEROID and METEOR involving the newer statins that show that there could be long-term regression of atherosclerosis, the disease process responsible for the blockages, which may reduce the need for surgical interventions in the future but there is currently no substitute for clot-dissolving therapy, PCI or surgery for acute blockages.

The MASS II trial is a randomized controlled clinical trial of three therapeutic strategies for coronary artery disease.

The study comprised 611 patients randomly assigned to undergo bypass surgery, PCI or medical therapy.

Treatment comparisons showed no difference between PCI and medical therapy although bypass surgery had a significant protective effect compared with medical therapy.

It demonstrated that although medical therapy reduced the need for PCI, bypass grafting was superior to medical therapy for eliminating anginal symptoms.

And all three modalities yielded relatively low cardiac related deaths. Controversy generally arises when there is a debate as to which modality needs to be individualized to a specific patient.

In the local setting, unless it is an absolute emergency and in the absence of a cath-lab conference, this can only be overcome if the patient seeks a second opinion.

AHMAD SOBRI is the pseudonym for surgeon who has served in both the public and private sectors. He is currently preparing to migrate.