Mark C Petrie Department of Cardiology, Glasgow Royal Infirmary.
Keith Oldroyd Department of Cardiology, Western Infirmary, Glasgow.
Felix Zijlstra Department of Cardiology, Academic Hospital Groningen, Groningen, The Netherlands
Corresponding author:Dr Mark C Petrie, Department of Cardiology, Western Infirmary of Glasgow, Dumbarton Road, Glasgow, G12 8QQ
E mail: mcp1n@udcf.gla.ac.uk“I’m sorry, Mr Paxman”
SMJ 2005 50(4): 149-150
In the following dialogue please imagine that you were the cardiologist who was on call on the night to which Jeremy Paxman is referring. . He has invited you to appear on “Newsnight” and has a personal inter interest in what you have to say say.. .. .
Jeremy Paxman: “Thank you for coming and indeed for looking after me recently when I had the misfortune to require your services. Could we discuss the treatments that you were able to offer me when I had my heart attack?”
You: “We gave you aspirin, a tablet to lower your cholesterol and two other drugs, called beta-blockers and angiotensin converting enzyme inhibitors. All these treatments have been shown to be beneficial after a heart attack. We looked after you in a coronary care unit where we monitored you closely. Unfortunately because you had had a tooth removed that day, we were not able to offer you treatment with a clot busting drug”.
Jeremy Paxman: “It’s a shame I couldn’t have received the clot busting drug. Why is it given?”
You: “A heart attack is caused by one of the blood vessels (arteries) that supplies the muscle of the heart blocking off. The clot busting drug aims to open up the artery. The benefits are substantial and include an improvement in the numbers of people alive following a heart attack and less damage to the pump function of the heart.”
Jeremy Paxman: “That sounds worthwhile. Are there any other ways of opening up the blocked artery?”
You: “There is a procedure called angioplasty that can open up blocked arteries. This involves a small puncture in the groin that allows access to the heart arteries. A balloon is passed down the artery and when inflated can open the artery. Often metal scaffolding, called a stent, is left in place to help keep the artery open.”
Jeremy Paxman: : “Is this as good as the clot busting treatment?”
You: “All cardiologists agree that angioplasty is to some extent better than the clot busting drug. The degree to which angioplasty is better is, however, debated. Certainly the artery can be opened up in more than ninety per cent of cases. One of the drawbacks of the clot busting treatment is people who receive it have are slightly more likely (around two per every one hundred patients treated) to have a stroke. Angioplasty certainly reduces this to around one in a hundred.”
Jeremy Paxman: “At least I didn’t suffer a stroke. You said that the clot busting drug makes people live longer after a heart attack. Is this true of angioplasty?”
You: “When the clot busting drug was first brought out it was compared to leaving the patient on tablets and was found, on average, to prolong life. Because the clot busting treatment is now standard therapy, angioplasty has been compared to the clot busting drug. This means it has to be very good to demonstrate a benefit over and above this effective therapy. Certainly a recent analysis of all the trials comparing these two treatments does suggest that angioplasty does look like it prolongs life longer than the clot busting drug. It does seem clear that patients who have had angioplasty are less likely to have subsequent heart attacks.”
Jeremy Paxman: : “To be better than the clot busting drug, which is not bad itself, sounds impressive. Are there moves to replace the clot busting treatment with angioplasty?”
You: “This has been discussed but there are not enough people around qualified to do it. It would cost a fortune to have on call rotas with the capability to do this”.
Jeremy Paxman: : “Would it be possible for relatively large areas to be covered by a hospital with sufficient expertise to allow it to become standard management. Patients could be transferred to the centres with the ability to open their blocked artery.”
You: “That idea has been looked at in Denmark. Patients were transferred from a wide area to a few centres that could open arteries. Transfer was safe and the patients transferring for angioplasty did better than those who stayed put receiving clot busting therapy.”
Jeremy Paxman: “Could that kind of set up be applied to Britain? It might not cost a fortune and with large areas covered, many more people with the expertise may not be required.”
You: “Yes, but this trial from Denmark was only presented around 18 months ago. Discussions are only beginning in the United Kingdom.”
Jeremy Paxman: “Could I summarise what I understand from what you have told me so far? When someone has a heart attack there are two ways of opening the artery. The first is the clot busting drug which is pretty good compared to nothing, but the second, angioplasty, appears to be at least as good and almost certainly better to some extent.”
You: “Yes. Almost all cardiologists if they were unlucky enough to have a heart attack would choose angioplasty over clot busting drugs.”
Jeremy Paxman: “Apologies for self-referencing but can we go back to what happened when I had my heart attack? I understand that there may be some debate as to the degree to which angioplasty is better than the clot busting drug and that offering the clot busting drug may be reasonable. But what happens when, like me, the patient is unable to undergo clot busting treatment. Do patients then have their arteries opened up by angioplasty? I cannot remember that happening to me?”
You: “No. You came in at ten o’clock in the evening. We cannot open our cardiac catheterisation laboratory after six o’clock.”
Jeremy Paxman: “That’s surprising. I thought that you were a large hospital. Do you have arrangements to transfer patients to another hospital that can open arteries?”
You: “No. Most people get by with the drugs that we gave you.”
Jeremy Paxman: “If angioplasty is almost certainly better for heart attacks than clot busting drugs then it must be a lot better than getting nothing at all? Do you think it would be a good idea to get a mechanism in place to offer angioplasty to people who cannot receive clot busting drugs? You have said that patients can be transferred for angioplasty safely and do well, even if the other hospital is quite far away. And, if this mechanism is in place, perhaps all patients with heart attacks could have this procedure once this mechanism is in place.”
You: “We are beginning to look at that. I can’t do angioplasty so it’s not really my field.”
Jeremy Paxman: “But were you not the heart specialist on call the night that I came in and therefore responsible for looking after me while I had my heart attack? If you couldn’t personally open my artery by angioplasty in the event that I couldn’t receive clot busting drugs, is it not up to you to ensure there is a mechanism in place to give me the best chance”.
You: “We’re no worse than anywhere else … . .”
Jeremy Paxman: “Again, apologies for self-referencing, but since my heart attack I have been breathless and noticed my ankles swelling. I have been told I have a condition called “heart failure”. What is this? Does it mean I might die earlier than I may have otherwise?”
You: “I’m sorry, Mr Paxman … …”
If you are a cardiologist and the above interview seems plausible, yet makes you feel a little uncomfortable, please establish a plan in case Mr Paxman arrives at your door. If you are a potential patient please contact your nearest cardiologist and ask him (or her) whether s/he has a plan if you have a heart attack and cannot receive a clot buster, day or night.