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 !

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