( By Dr. Natoobhai J.Shah & Dr. Sailesh N. Shah )

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It is essential to have adequate information about the modern trends in the diagnosis and management of painfully prevalent coronary heart disease also in our country. In fact, we have reported long back that the incidence of this annoying disease is present more in our young Indians. It afflicts them even in their late twenties and early thirties. An attempt is made here to present the factual knowledge in a simple language. IN last 25 years, cardiology is rapidly evolving to give a better diagnosis and treatment for heart diseases. There are rapid advances in the diagnostic techniques, pharmacological drug treatment, interventions with stents, balloons, laser etc. , and surgical By-pass options. All are aimed to give better relief than was possible in the past.

The authors have tried to provide basic information in a balanced manner. It is purposely authored by two cardiologists rather than one with the express purpose of providing the balanced views. The junior author is involved in U.S.A. with newer invasive or interventional techniques for several years. The influx of advances can have a favourable impact on better health. This positive achievement however, need not be carried rather too far.

The exaggerated claims from aggressive marketing by pharmaceutical firms and medical instrument makers with their commercial interest should not be lost sight of. This can only be checked by the indepth knowledge and wisdomof our medical men. The medical community can put a proper check on the exaggerated claims by the seller.

The practice of the modern cardiology in our country would also call for some Prudence. IN the modern commercial world, one has to bear with the exaggerated claims and propaganda. Irrespective of the financial status of the patient, the treating doctor has to be discerning. The over application of a particular approach can give no better results and would not be justifiable. The limitations and possible harm from the procedure must be recognized. The Risk : Benefit and the Cost : Benefit ratio must be taken into account.

We do not have insurance companies to foot the bill of the expenses. The possible emotional trauma on the family and views or beliefs of the patient should be respected. The " quality improvement in life " can have a different connotation in our Indian Cultural context. Apart from emotional ties he can also receive some help from the support system of relatives, friends, neighbours and even servants. The " Quality of Life " is thus lived with a different background philosophy. After all with the progress that we have made, the medical science cannot claim perfection.

The data based on statistics cannot be extrapolated to the biological class of human beings where each individual can be different in his body functions, in his response to diseases, and tolerance to drugs and procedures. Our progressive medical science has still a lot of lacunae left in full knowledge. The great physician of this century, Sir William Osler, had said that the greater the ignorance, the greater is the dogmatism. Medicine abounds in dogmas and the public may be fed with these half truths. To justify half truths, the figures of statistics are reeled off sometimes too often. Medicine is an ever changing science and it cannot have linear graphs as in Physics or in Mathematics. A proper decision making would require the better part of both science and art of medicine by the treating doctor.

In this small book we have tried to give some idea about the coronary arteries, the way they can get into diseased state, the possible symptoms to suspect the diagnosis and then confirm with the help of an electro-cardiogram and other diagnostic tools. Each diagnostic instrumental method is mentioned in brief. Their value and limitations are also emphasized. The modern concept of treatment of heart attacks - medical, interventional and surgical is covered. The " Risk Factors " and how to take care of these for prevention of the diseases are discussed in appropriate manner. The detailed principles of the right type of food is given at length in end chapters with due emphasis on our Indian Diet - both vegetarian and Non-vegetarian. The last chapter is covered in the form of questions and answers. They include usual questions asked by the patient community. We have tried to answer them. All along the treatise, we have attempted to emphasize on certain points rather repeatedly for better understanding of the disorder in the living human being.

The approach to treatment in spite of being modern, has to be for an individual patient. Seeing only the blocks and the degree of blocks need not necessarily create a panicky situation for immediate invasive actions. The Interventional treatment is not to be claimed as " cure all " device for the blocks. Some patients , no doubt, can be given good relief. It cannot be said as a good cure of the disease. The chances of good relief should be properly assessed. One has also to realize that each Invasive procedure has its own risks however small. It would include mortality, morbidity, other complications, along with its rate of relapse. It may be worthwhile to quote statistics in medicine but not use it for making judgement. Before having the Invasive options, all things including patientís body defence forces should be considered. The coronary artery disease course is surprisingly unpredictable. The division between " high risk " and "low risk " amongst patients has a wide gray zone. A patient can suddenly die with minimal disease, while a patient with severe or multiple blocks can live for a number of years challenging or mocking at our medical ignorance. In fact to give a uniformly serious prognosis or outlook in a patient with severe or multiple blocks is like going against the basic tenets of our biological science. The other factors involving the blood cells, its clotting mechanisms, artery spasms, behaviour of natural collaterals are also vital players and can be equally responsible. They are no less players. The fearful terms used such as "blocks with a hanging sword "or a patient " sitting on a volcano " are unscientific and would need to be condemned. Softer explanations and approach analysis for a possible option would be more human. As of today, our medical science is still imperfect. With great appreciations of our medical advances, our limitations should also be accepted in all humility.

Some of the excerpts given below are for a clearer understanding of the different faces of coronary atherosclerosis. They are taken from the " American College Cardiology Current Journal Review " of June and November 1996. The vulnerable plaques being soft are more likely to give a future heart attack because they are more susceptible to crack or rupture. This is irrespective of the degree of blockage.

"There is no relation between the degree of stenosis (blockage) and the characteristics of vulnerability. A vulnerable plaque (atheroma) may cause no stenosis or quite high grade stenosis. IN the average patient, there are far more plaques that are vulnerable but are not causing visible on angiography. "

"What we really need to know about the patientís coronary arteries is not the degree of stenosis but the number of vulnerable plaques that the patient has. The trouble is we donít have a way of doing it at the moment but in future the test by magnetic resonance imaging may be able to do this. "

"It is clear that what we look at the results of the information we get in the cardiac catheterization laboratories, we are really dealing with very crude information about a very complex subject. The angiogram tells us you absolutely nothing about the plaque composition or plaque activity. We need other tools. "

According to the committee, " Although some practitioners routinely perform Angiography and P.T.C.A. during the days after AMI in virtually all patients. " , the committee says, " The available data suggest that such a management strategy does not salvage myocardium nor reduce the incidence of reinfarction or death. "

Through out this book, we have tried to bring out certain facts which may be interesting even for the Family Physicians. They often have to bear the responsibility of advising the patients appropriate line of approach. The doctorís advice given with equipoise can be really helpful to the patient in the long run.

During the preparation of this book, we got very active help from two of our cardiologist colleagues to whom we are grateful. Dr. Dhiren R. Shah, M.D., D.M., the Cardiologist at Bhatia General Hospital of Mumbai was kind enough to review references of all relevant recent data and provide intelligent discussions. Dr. Prafulla Kelkar, M.D., D.M., D.N.B., is the Associate Profession of Medicine at the academic and prestigious cardiology department of K.E.M. Hospital, Mumbai. He is active in Interventional Cardiology. We had a healthy updated talk with consensus of view on his subject. Mr. John DíSouza, our personal secretary has done a lot of hard and sincere work. He is full of enthusiasm and his energy is well motivated. He is cut out for higher and bigger successes in life. Shri Krishna Kumar Bhaiya, Shri Baldev, Giriraj and Manmohan and his closely knit family members of Saroj Printers and publishers have encouraged us a lot and are responsible for initiating us to write a book on this important subject specifically for the readers of our country.

Dr. Natoobhai J. Shah
Dr. Sailesh N. Shah

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