Number of percutaneous coronary interventions being done seems too high

Dear Editor,

After doing a little research I discovered an article published in both the Kaieteur News and the Stabroek News in May 2016. The name of the article is “Balwant Singh Hospital says offering 24-hr cardiac care, full time cardiologist”. Dr. Madhu Singh, the Balwant Singh Hospital (BSH) Administrator stated that the hospital performs upwards of 40 percutaneous coronary interventions (PCI) per month. Dr. Madhu Singh also said and I will quote verbatim ,“Our Centre is the only one in Guyana to offer a 24 hours service provided by a full time Cardiologist, who is backed up by a full time Cardiac Surgical Team. This is the international standard of care and safety and is a requirement for cardiac centres to function safely and be licensed. If, any centre does not have a cardiac surgeon’s support, they are taking a huge risk with their patient’s lives!”. This is the exact concern I have about the Caribbean Heart Institute not having a cardiothoracic surgeon.

Anyway, that’s not the reason I writing today. My reason for writing is to educate the Guyanese public and hopefully those in authority so that they can stop unnecessary interventions.

First let’s do some maths. The 2018 census indicates Guyana has a population of 782,225. I’ll round that off to 800,000. Guyana has a very young population with an average age of 26.2 years. About 20% (160,000) of the population is above 50 years. Coronary heart disease is generally a condition of the above 50’s. I will have to use anecdotal evidence here. When I worked in Guyana from 2000- 2002, approximately 20% (32,000) of the patients would be admitted with chest pain. Don’t think this has changed by much. Only a small percentage would actually have Coronary Artery Disease (CAD). Let’s say for argument sake that 10%  (3200) have CAD. Approximate 45% of the Guyana’s population live below the poverty line, just able to provide three meals a day and many days go hungry. The average annual income in Guyana is $4000US. A PCI cost between $1000-$6000 US much more than a year’s wage. Let’s assume that of the 55% above the poverty line 25% (800) can afford to pay for PCI. Let’s assume that all 800 hundred of these patients decide to have the PCI in Guyana, including our politicians. No one goes to America. No one goes to Trinidad. It is obvious we would not have 800 such patients every year. It is also obvious that this is a general overestimation. Eight hundred patients to be shared between CHI and BSH.

According to the CHI cardiologist they are doing upwards of 600 PCI/ year. According to the BSH Administrator they are doing upward of 480 PCI/year. That would work out to be 1080 PCI/year being done in Guyana. From a maximum of 800 patients available, how can they be doing over 1000 PCI every year? Clearly the numbers do not add up. Where are the CHI and BSH getting these additional patients from? Maybe foreigners are leaving their countries to have PCI at our world class centres. Something doesn’t add up.

My opinion. It is either both the CHI and BSH are doing PCI on patients who may not need them or Guyanese patients have become a walking time bomb of coronary artery disease. If that’s the case some serious lifestyle modifications are required or they will be dropping dead like flies in the streets.

Editor, PCI is the last option in terms of testing for CAD. PCI has lots of risk. Sticking wires into someone’s heart can result in death. As a result other non-invasive, ‘harmless’ investigations are recommended. Some of these investigations are stress echo, cardiac myoperfusion scan, cardiac MRI and CT coronary angiogram etc. To identify which test is best suited for a patient different scoring systems are used to determine the likelihood of CAD. Because of space limitations I cannot go into detail about them or outline the evidence underpinning their use. Suffice to say that the vast majority of the patients would not require a PCI as a first line investigation. They may require the non-invasive and ‘harmless’ test alluded to earlier. The reason is obvious. If the doctor can clinch the diagnosis with a less dangerous test then that is clearly better for the patient. Using the very dangerous PCI as first line and the only option goes against this reasoning.

I challenge both the CHI and BSH to do a clinical audit on all PCI they have done and are doing. From that audit, publicly provide information on how many PCI  they are doing adjusted for population and how does this compare with international standards?  How many of those PCI turn out to be positive (significant CAD requiring PCI or Coronary artery bypass grafting (CABG) and how do they compare to international standards? Finally, I would also challenge both the CHI and BSH to explain to the poor Guyanese public why they are only emphasising PCI that is very risky while ignoring less invasive and dangerous tests as per international recommendations that can clinch the diagnosis?

Yours faithfully,

Dr. Mark Devonish  

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