CORONARY INTERNATIONAL SYMPOSIUM
Lugano, June 15th, 2000
I am delighted to open this Coronary International Symposium
organised by the Cardiocentro Ticino.
This institution has given our population the opportunity to
undergo "at home" cardiological interventions 23 years after the first
coronary angioplasty was performed.
It is also a great pleasure for me to open this meeting because
some pioneers of those techniques are present here today as speakers and
discussants. Professor Bernhard Meier has worked closely with Andreas Gruentzig,
who performed the first world coronary angioplasty at Zurich University Hospital
on September 16th, 1977. Professor Meier followed Gruentzig when he moved to
Atlanta, Georgia, where unfortunately the latter died in a plane crash during a
tornado on his way back home on October 1985.
It is perhaps interesting to note that one of the first patients
to undergo surgical intervention by Gruentzig was an 84 year old diabetic and
obese rabbi living in Lugano, who suffered from severe angina pectoris and of an
incipient gangrene of his left big toe. The procedure was successful and the
amputation was avoided.
The first coronary stent was implanted in Toulouse, France in
1986 and a year later a first report of 24 coronary stents implanted in 19
patients was published in the New England Journal of Medicine. The
article's author, Professor Ulrich Sigwart, is also present at this symposium.
Those first results have made this new technique, that offers a useful way to
prevent occlusions and restenosis after angioplasty, known worldwide. Thus, the
Swiss "imprinting" in interventional cardiology is a major achievement
that cannot be disregarded.
It is also for this reason that
Switzerland holds a leading position in Europe in the use of angioplasty per
head of population, following with Belgium, Iceland and France the German
leader.
But the use of angioplasty is also closely related to the per
capita health costs, as showed by this slide, meaning that the amount of
resources devoted to the health sector is probably the best way to predict the
use of this medical technology.
Nevertheless, this does not necessarily mean that high PTCA
rates in a population lead to low rates of ischemic heart disease mortality. In
fact we all know that cardiovascular disease is multifactorial, and that habits
and lifestyles could have a powerful influence on the disease aetiology.
As shown by this slide, you will find the lowest levels of
ischemic mortality in Southern European countries without any correlation with
PTCA rates. The well-known "French and Latin paradox" suggests that
drinking wine and following the Mediterranean diet seem to be effective ways to
avoid cardiovascular events. Moreover, they definitely are more enjoyable ways
to keep death at bay than to undergo coronary angioplasty or by-pass graft
surgery.
Professor Meier, in an introductory lecture given at the annual
conference of the Swiss Cardiology Society in Lausanne in 1997, stated that
"further growth of PTCA can be predicted unless political measures, such as
rationing or drastic cuts in reimbursement" are taken.
The Lancet, in a recent look on the future, predicts a move
to fewer surgical interventions and more catheter-based ones.
In every society resources are, by definition, limited and
undoubtedly our future will be characterised by the so-called "tragic
choices" resulting from the impossibility to fit all health technology
innovations into the universal health care system.
A rational use of technology or a rational prescription and
consumption of services mean that medical goods should not only be of high
"technical" quality, but also that prescriptions have to be above all appropriate.
Appropriateness is the difficult gold standard to reach by consensus to keep
rationing at bay; patients, as consumers, can never give a valid judgement on
the effectiveness and adequacy of the health care "market". Patients,
as you all know, tend to accept every service proposed in a non-critical way;
patients tend to accept those services not only because they hope to maximise
benefits, but also in order to minimise "regret". Consequently you
have the full responsibility to provide ex-ante an adequate level of
relevant information to your patients.
Information on effectiveness, adequacy, risks, adverse events
and possible alternatives in order to allow them to enhance the integration of
such "technical" information with their individual expectations and
values. Only in doing so will we reach a really informed patient choice.
Finally, I believe that the leading question physicians should
ask themselves before they make a decision should be: "Would I be willing,
in the same situation, to accept this treatment?"
I thank you very much for your kind attention.
Patrizia Pesenti