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