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Heart Check-up

August 13th, 2015

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Heart Check-up

Recently there has been news about new technologies for detecting and curing heart diseases. While the news is good to hear, it can be confusing for both the people, doctors in general or even cardiologists. The abundance of choices leave all of us dazed which one to go for.

It is not difficult to determine the best option but let’s be clear that every technology has its own risks, and not detecting and not curing is pretty risky too!

Therefore, before making a decision, new technologies must be thoroughly studied and it should be decided whether the invasiveness of such technology would make the condition worse than not checking at all. If it poses that many risks, sometimes it is better to do nothing about it.

Still, by doing nothing (nobody likes pain anyway), the risk is still there. We have to find an alternative to treat that problem sooner or later. Let’s see what the options are and which one would be good for which case.

Accuracy is the main point.   Before going to have any test or investigation the patient should also ask the doctor about the pain level, the convenience and whether the health insurance covers such method. Most health insurance (including the current government coverage) does not stay up to date with the technologies since these newbies are usually expensive. The advantages over the old ones might not even be worth the additional cost to the insurance and government, but then again, we can’t really put a price tag on life, can we?

There are a few checkpoints to determine whether the new option is better than the old one. Look at the percentage of recovery, comfort level, and whether it prevents recurring of the illness.

The risk of death is there, big or small. You should study the risk of death, heart failure, paralysis and so on. These could happen in the process of any test as well as heart disease itself.

Let me give you an example. If you have myocardial ischemia (or narrowed artery), the options of  test you have, from low risk to high risk, are electrocardiogram (EKG), echocardiogram (ECHO), treadmill, stress test, cardiac MRI, Multislices Detector CT scan (MDCT) and Catheterization Coronary Angiography. The last two options involve injection of dye or contrast media.

However, speaking of accuracy, the order would change. From the least accurate is EKG, ECHO, treadmill test, MDCT, Cardiac MRI and the most accurate is Catheterization Coronary Angiography.

As for treatment options myocardial  ischemia (lacking blood supply to the heart), risk wise, the lowest risk would be exercising, using medication, Enhanced External Counterpulsation (EECP), balloon angioplasty with stenting, and the highest risk would be an operation. But then again, the risk of all these would be less risky than doing nothing.

Benefit wise, from least effective to most, is medication, EECP, and balloon angioplasty with stenting. However, coated stents today can be as effective as bypass surgery, with some slight differences in terms of effects.

However, these examples are based on reports from hundred thousands of  patients. Each patient is different and it’s a case-by-case consideration. One disease can have many ways to treat. One man’s meat is another’s poison, so what works for other people might not work for you. Two doctors treating two patients with the exact same illness does not mean the patients will end up the same way: one could die and the other could survive.  This is why you need to practice art in a science of medicine.

I had a patient in his 60’s who came to see me because he felt tight in the middle of his chest while he was walking to his car after a meal. This happened twice, and each time the tightness would last about 5-15 minutes. First he thought it was just peptic ulcer, but it didn’t get better after taking anti-ulcer medication.

I could determine right away (or maybe I am the most accurate method? Just kidding!) that he had angina or myocardial ischemia from narrowed artery. The patient was mortified when he heard the word Catheterization Coronary Angiography. I sent him to have a 64-slice or MDCT scan first and it was found that three of his arteries were narrowed. Balloon angioplasty and stent placement should be enough to treat this, so I explained the pros and cons of this option, and the risk of not treating at all. After that, I asked him what he decided to do.

Patient: Can I have a second opinion first?
Me: From whom? Your family thinks this option is good.
Patient: I want to consult another doctor… see what he says.
Me: Oh, of course! That’s a good idea. Two heads are better than one.
Wife: No, doctor. He’s just scared. He wants to see a fortuneteller for a good date to have this surgery!
Me: If that’s the case, do you need my date of birth too? But hey, the other day I went to see my fortuneteller and he said all my work would be a big success this week, but not next week. So, you know… (As in, you know I’m making that up?)

With that sentence, he agreed to the balloon procedure right away. After the procedure, we found that he had diabetes and his cholesterol level was high, so I gave him additional suggestions (which are in fact, as important as any treatment available). Otherwise he was totally fine.  He could walk on a treadmill for 30 minutes everyday within 2 weeks after the surgery.  So the fortune I made up was pretty accurate, after all!

Prof Nithi Mahanonda is consultant cardiologist and interventionist, Perfect Heart Institute.

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