He who was made a heart patient

ISLAMABAD: Faqeer Muhammad, a middle-aged laborer, felt pain. He went to a cardiologist for check-up and was diagnosed with the muscular pain; unrelated to the heart. The doctor conducted a stress test which turned out negative thus reconfirming his earlier finding.

Faqeer consulted another cardiologist for second opinion who did an angiography test. There was insignificant artery blockage which didn’t require implanting stent. The doctor nevertheless did. Unable to afford treatment cost, he sold his belongings to pay the bill. However, the issue remained unresolved.

Three months later, Faqeer went to the cardiologist he had first consulted. He was feeling pain. This was a typical heart problem, diagnosed the doctor who was unmindful of the fact that a stent had already been inserted. Upon medical investigation, it was transpired that not only an unnecessary angioplasty was done, it ended up at re-narrowing of the stent thus causing the heart pain. This necessitated yet another angioplasty for replacement of the first stent. Treatment cost was paid from the charity fund of the hospital where replacement was done.

Faqeer eventually became a heart patient which he was not when sensed the danger first due to the muscular pain. How many patients have met his fate remains anybody’s guess as there is neither any accountability of careless physicians nor any system to ensure that only qualified interventional cardiologists perform angioplasties. This reporting is part of the Implant Files, an ICIJ-led investigation into the medical device industry and regulations. Readers can share their stories here.

A Supreme Court effort to regulate cardiovascular treatment has failed to yield desired results. The court had ordered devising the qualification standards for interventional cardiologists to operate cath labs where angiography and angioplasty are carried out. An interventional cardiologist is the one who is qualified to diagnose and treat cardiovascular disease as well as congenital (present at birth) and structural heart conditions through cath lab procedures such as angioplasty and stenting.

Although there is no proper data available about the number of interventional cardiologists in Pakistan, they are estimated to be around 400, background interviews with the doctors indicate. One in three of them isn’t qualified for doing such procedures. The doctor who inserted, and medically unnecessarily, the first stent in Faqeer is among those unqualified interventional cardiologists. He is still doing procedures, unchecked.

While Faqeer was lucky to have survived. Another patient died four day after his angioplasty by the same so-called interventional cardiologist as blood clots developed due to improper procedure. The family took it as a fait accompli, not knowing the role of doctor in landing him to grave. As record of adverse events are not kept and the investigation of such occurrences is not carried out by the hospital in absence of a strong regulator, the patients are eventual casualties.

In order to preempt such malpractices, the Supreme Court had ordered the formation of rules to regulate cath labs and its operators like physicians and nursing staff. Those who can perform as interventional cardiologists were required to register at the website of Pakistan Society of Interventional Cardiologists and their names were to be displayed for public knowledge. It has not been done yet.

The criteria set for such physicians require them to be “FPSC medicine/ MRCP/ Diplomate American Board in Medicine or equivalent with at least 15 years of practical experience in interventional cardiology with at least 75 procedures per year in last 2 years.” The exemption for non-qualified to the prescribed criteria has been given till 2023 “only after which formal 2 years training/ Fellowship in Interventional cardiology will be mandatory.”

Until 2023, one time exemption has been granted to “all senior cardiologists with MBBS, with at least 25 years of active interventional cardiology practice within the country or outside,” according to the rules approved for the cardiologists who can perform angioplasty in the cath labs registered with authorities. Ironically, neither the cath labs have been registered nor the unqualified cardiologists have been stopped from operating.

A training mechanism was also been devised for those not meeting the above-mentioned criteria. “FCPS cardiology, or equivalent, with at least 3 years post fellowship adequate supervised training/ experience in interventional cardiology at CPSP recognized and PSIC registered Catheterization laboratory under the supervision of a certified interventional cardiologist. He/ she should have done at least 75 procedures/year as primary operator. Training/ experience certificate to this effect should be provided by the Catheterization laboratory director/ HOD or Head of institute,” according to the rules.

However, this proposal of training has not generated much enthusiasm due to significant resistance from those needing it the most, according to the insiders of cardiologist community. This is in addition to the lukewarm response to the idea of reporting cardiac procedures to the national cardiac registry which was intended to improve the treatment and reduce the adverse events. Meanwhile, patients are prone to fatal risks in this culture of impunity.