There are cheaper tertiary centre tests for ischaemic heart disease

Dear Editor,

Please allow me to respond to the letter titled, `CHI provides affordable cardiac care for Guyanese, new treatment protocols have seen 10-fold drop in death rates and halving of hospital stay’. I would humbly ask that my letter receive the same prominence as Dr. Carpen’s letter.

I do wish to highlight some inaccuracies and an omission in Dr. Carpen’s response which purposely ignored some pertinent questions I asked. Questions, which answered will serve to inform the Guyanese public.

Let me start with the inaccuracies.

“In 2004/2005 the Government of Guyana (Taxpayers) spent $500,000 USD – half million US dollars – to send 10 Guyanese patients overseas for cardiac treatment. This averaged $50,000 USD per patient”.

What conditions did these patients have? Were they kids with congenital heart disease which required complex heart surgery?  Clearly my letter was on coronary angiograms and stents so I would assume that’s what Dr. Carpen is alluding to.

I’ve done my research. In 2007,   a coronary angiogram and stents cost approximately $8000 US in the UK. That is $42,000 US less than what Guyana allegedly paid. Let’s do some maths. Say doctor’s consultation fees were $1000 US, flight and accommodation $10,000 US. Hospital stay is generally about 48 hrs at $1000 US/day. Let’s say the patients had money to splurge so overstay their time for five days. The total cost which is a massive overestimation would be $24,000 US. Definitely not $50,000 US. Readers, don’t take my word. Research it yourselves. Do your own maths.

“The prevalence of heart disease in Guyana is almost at epidemic levels. I have had patients as young as 28 with heart attacks and as of recent there has been a surge in males in their mid 30s coming in with massive heart attacks. While the disease may have been seen in only the older population previously, we are now experiencing more severe heart disease in the under-50.”

That’s unlikely. The evidence is that young patients do have chest pain but the vast majority are benign. Occasionally, the young patient may have chest pain as a result of inflammation of the heart muscle or covering skin of the heart or blood clot on the lung. This may cause markers in the blood of heart attacks to be elevated but they are not heart attacks. Very, very rarely, young patients can have a heart attack but in those patients it is likely that they have some structural heart disease or inherited blood conditions predisposing them to premature heart attacks. That’s extremely rare. Dr. Carpen, is this medically inaccurate information?

Fact is that ischaemic heart disease (IHD) is a condition of developed countries since they have more access to fast fatty foods, smoking, obesity and associating type 2 diabetes and sedentary lifestyles. People rarely walk or cycle to work in America or Canada. In Guyana many people walk or cycle to work. The average Guyanese cannot afford to buy fast fatty foods daily. Dr. Carpen if you had said that the mortality rates for heart attacks in Guyana is higher compared to Western Society, I would agree. But this is not because of an epidemic. It is a result of poorer healthcare in Guyana and other developing countries. Guyana and the rest of the Caribbean have similar patient demographics so why only in Guyana IHD is at epidemic levels? Why not the rest of the Caribbean or South America? Dr. Carpen is this medically inaccurate information?

Recently a Minister of Government presented at the CHI with chest pain. She was advised that she needed a coronary angiogram and stenting. Because of her Ministerial privileges she was medivaced to America where she was told she does not, reassured and sent back Guyana to deal with the stresses of Dr. Carpen’s “my country” Parliament. The question is how many such patients are receiving this inaccurate diagnosis at CHI?

Also, it was only recently a friend of mine in Guyana forwarded his sister’s ECG. She is in her mid-thirties. She visited the doctor just for a routine checkup. No cardiac risk factors. No chest pain. Had an ECG done and was told she needs tests to exclude a ‘heart attack’. I reviewed the ECG. There was nothing concerning. I advised him that she does not have IHD. In premenopausal women, serious manifestations of coronary disease, such as MI and sudden death, are relatively rare. Beyond the menopause, the incidence and severity of coronary disease increases abruptly. That’s the kind of misinformation young patients are being fed in Guyana, creating the epidemic of cardiac neurosis being mistaken as heart attacks.

“Dr. Devonish observes that Coronary Angiograms and other Coronary Interventions should have a backup team of Surgeons around. The written guidelines for cardiology do not consider cardiac care in the developing (Third) world”

Dr Madhu Singh of the Balwant Singh’s Hospital does not agree with you Dr. Carpen. She had this to say on the 5th September in the Stabroek News about their cardiology service, “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!”.

Dr Carpen said: “Before implementing the new treatment protocols, there was a 28 percent rate of death for heart attack patients and an average of 8.8 days of hospital stay. After implementing the new protocols which include angiograms, angioplasty and stenting, there was a drop in death to 2.4 percent and hospital stay was reduced to 4.6 days. This represents a 10-fold reduction in death rates”.

Percentage in statistics do not mean a thing without absolute numbers Dr. Carpen.

“Several non-invasive methods are available and utilized to manage patients before any invasive procedures are done. These would include ECG, Echocardiograms, Stress Testing, Ambulatory blood pressure monitoring, Holter Monitoring and Sleep studies”.

ECG and echocardiogram? Soon the Chinese will be offering ECG services on the streets of Manhattan. The new series 3 Apple watches can do ECGs. ECG services are as pervasive as pot holes in Guyana. The ECG is not primarily a tertiary centre investigation. It’s a basic test. Also echocardiogram is another basic investigation. Even when I was in medical school echocardiograms were being done at GPHC. They are basically ultrasound scans of the heart. The kind of ultrasounds that pregnant women have.

Stress testing? Be a bit more precise. They are many forms of stress testing. If you are alluding to exercise tolerance test (ETT), then I should inform you that the evidence shows that they do very poorly in diagnosis IHD, especially in female patients, therefore it is no longer recommended.

Ambulatory blood pressure (ABP) for diagnosing IHD? ABP is used in diagnosing hypertension in patients with suspected ‘white coat syndrome’ among other blood pressure related conditions. It has no role in diagnosing IHD.

Holter monitoring? This is a form of ambulatory ECG. This is not routinely used in diagnosing IHD. It is more useful to diagnose suspected cardiac arrhythmias or transient loss of consciousness.

Sleep studies? Sleep studies have no role in diagnosing IHD. Sleep studies are done by respiratory physicians to diagnose obstructive sleep apnea (OSA). Patients with OSA do have an increased risk of IHD but sleep studies do not diagnose IHD.

So what does CHI have for investigating IHD? Frankly only angiograms. Angiograms are costly. The other cheaper tertiary centre tests: CT coronary angiograms, cardiac MRI, stress echo, myoperfusion scans etc are apparently being ignored.

Now I will look at an omission.

“A long time ago I decided to live and practice in Guyana and the Caribbean and consequently did not pursue residence in North America and the UK even though I have done advanced studies in Canada and the USA”.

Dr. Carpen what you did in America and Canada were fellowships. Fellowships are for trainees who have completed their specialist training but wish to consolidate their skills and knowledge.

In closing I would say to the readers. Do not take my words as gospel. Don’t take the word of any doctor as gospel. Do your research. Not medical journals that will use difficult to understand medical language but a google search. Question your doctor.

Yours faithfully,

Dr. Mark Devonish MBBS MSc MRCP(UK) FRCP(Edin)

Consultant Acute Medicine

Nottingham University Hospital