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More, as the wise men say, is not always better. The family of Pijush Das, a 48-year-old clerk, wanted more. So they were not happy when a heart specialist at a Calcutta government hospital prescribed medication along with a change in lifestyle after he complained of chest pain and discomfort.

Das's wife urged him to consult a doctor in a reputed heart hospital. 'The new doctor was quite alarmed. He asked me to get an angiogram and mulled over an angioplasty with stents because he feared blocks in the arteries,' he recalls. Das did not have the money for it and though his wife suggested that her wedding ornaments be mortgaged for the treatment, he decided to go back to the original doctor — who again prescribed medication.

Two years later, Das is in good health. 'The pain has disappeared. Now I know the doctor at the private hospital was trying to dupe us. I have a colleague who had a similar problem, and the doctor put in a stent. His pain recurred within a year.'

In India, where doctors are often looked upon as gods and seldom questioned, there is growing concern that cardiac patients across the country are being overtreated. Patients often go through bypass surgery, stenting (angioplasty) even if they don't need it.

'The culture of 'more is better' is a worldwide phenomenon, influenced by many factors, including poor understanding of evidence and financial incentives to do more,' says Dr Vikas Saini, a cardiologist and president of Boston's Lown Institute, which is spearheading Right Care Alliance, a healthcare movement against overtreatment. India-born Saini believes that many of the invasive treatments prescribed by doctors in India for heart treatment are 'avoidable'.

In the US and elsewhere in the West, questions are being asked about unnecessary and high-priced medical treatments for heart problems. 'Some hospitals have lost recognition or accreditation and many cardiologists have been punished for the overuse of procedures such as stents which sometimes can be harmful,' points out Dr K. Srinath Reddy, president, Public Health Foundation of India, and president, World Heart Federation.

Many interventional cardiologists — experts who practise minimally invasive, non-surgical procedures (such as angioplasty) — feel the stent (a meshed pipe inserted into a blocked artery) is the solution for all heart-related problems, rues Dr Reddy, former head, cardiology, All India Institute of Medical Sciences, New Delhi.

'Everybody knows that many cardiac procedures are unnecessary, but nobody can measure this as no statistics are available in India,' he stresses.

According to some estimates, 2.5 lakh angioplasties are done in India in a year, with the market growing at 15-20 per cent annually. In 2013, 1.2 lakh bypass graft surgeries were conducted, says Dr Kunal Sarkar, head, Medica Institute of Cardiac Sciences, Calcutta, and president-elect, Indian Association of Cardiovascular and Thoracic Surgeons. India has an annual requirement of 10-12 lakh procedures.

For several years now, there has been a debate on the benefit of stents versus bypass surgery. A heart bypass operation is an open heart surgery, in which the heart is opened up and then operated on. Most doctors and patients prefer angioplasty because it's less invasive and offers quicker relief.

'Angioplasty is a one-hour simple procedure. There is no cut or stitch and hence no fear of infection,' says Dr Praveen Chandra, head of interventional cardiology at Medanta, Gurgaon, and chairperson, National Interventional Council (NIC) of the Cardiological Society of India (CSI), a non-profit body.

But stents are not always a solution. For one, when more than two stents are put, the procedure is often more expensive than a bypass. (Bare metal stents cost Rs 15,000-30,000 while drug-eluting stents, which are coated with drugs to prevent blockage, cost up to Rs 1.3-1.5 lakh). Second, stents at times need replacement.

'Some stents are quite expensive and the total costs can far exceed the costs of the latest bypass surgical procedures. Once performed, the latter can last up to 20 years while many stents can fail within a year or two when heart blocks recur,' says Dr Tapas Raychaudhury, director, cardiac surgery, Woodlands Hospital, Calcutta.

The new angle in the debate is the growing popularity — although still in small sections — of a system that says no to both surgery and stenting. This group advocates medication with lifestyle changes.

'Many patients who've been treated with angioplasty could have been managed equally well with aggressive medical therapy. But doctors fail to consider that an option,' says Dr Prashant Joshi, cardiologist at the Indira Gandhi Government Medical College and Hospital, Nagpur, quoting a 2007 study in the New England Journal of Medicine.

Indeed, the section advocating medicine is far outweighed by the pro-stent lobby. Some doctors claim that the use of stents is on the rise also because of pressures from stent-manufacturing companies.

'Because the stent market worldwide is far bigger than the arms/weapon market, there is a lot of commercial pressure to push more and more stents,' Dr Sarkar says. 'Cardiologists also push these procedures for obvious commercial reasons.'

A recent report by the cost audit branch of the ministry of corporate affairs referred to a nexus among hospitals, cardiologists and stent suppliers. 'There appears to be (such a) nexus... as private hospitals charge different rates for the same DES (drug-eluting stents),' the report said.

Dr Saini goes a step forward, zeroing in on 'money changing hands' in India for referrals between doctors, or between doctors and hospitals. 'This is so common that it is not considered unusual, though it should be a source of shame. This adds to a tendency to treat medicine as just another business, and to do more to patients.'

In private hospitals, doctors often have 'targets' to meet — they are given a figure (of operations, stents, tests, etc.) by hospital administrators which they have to meet. A doctor, who doesn't wish to be named, says that a top Delhi hospital circulated a monthly list showing how much 'business' each doctor had managed to generate. 'This, in a way, served as a warning to 'under-performing' doctors,' he says.

But there is also no denying that stents are a vital part of heart care. Doctors point out that coronary artery disease (CAD) manifests itself in a more complicated form in India than in the West, and is often more severe in Indians. 'Indians are more predisposed to CAD,' says Dr Shuvanan Roy, a senior cardiologist at Fortis Hospital, Calcutta.

Because CAD is an unpredictable disease, cardiologists can overestimate the risk and go for overtreatment, argues Dr Suvro Banerjee, an interventional cardiologist at Apollo Gleneagles Hospital, Calcutta. 'There are unscrupulous practitioners but not more than 10 per cent,' he holds.

Often, it is the patient who — worried about the limitations of mere medicinal therapy — demands that a stent be put. Take the case of Prem Lal, a 55-year-old accountant with a private firm in Calcutta. He had gone for a routine check-up when it was found that he had a block in one of his cardiac vessels. The cardiologist he consulted attributed his slight pain and short breathlessness on physical exertion to this problem. When the doctor said it could eventually lead to a heart attack, Lal decided to undergo an angioplasty to remove the block. But a section of doctors believes that Lal, who was healthy and non-diabetic, could have handled his heart problem with medicines and lifestyle modification.

The problem, the experts say, is the lack of relevant guidelines that doctors and patients can follow. 'The uncertainty and confusion persist because we do not have our own therapeutic guidelines,' stresses Dr Chandra Mohan Gulhati, editor, Monthly Index of Medical Specialities.

Right now, Indian cardiologists follow guidelines meant for American and European heart patients. 'In the US and Europe, it is mandatory for heart specialists to log in each and every datum of a particular procedure,' Dr Banerjee says. 'But the problem in India is that we don't have our own data.'

Some tentative steps, however, are being taken. Doctors are being urged to fill in the required data online, says former CSI president Dr P.K. Deb. 'We have also initiated moves to create specific guidelines for Indians with technical help from the European Society of Cardiology. But it will be three or four years before we come up with anything comprehensive.'

The NIC too is in the process of putting checks and balances in place. 'All hospitals must have a committee to look into the appropriateness of each (angioplasty) procedure before it is carried out,' Dr Chandra says.

Meanwhile, the Lown Institute seeks to bring together clinicians and patients to 'organise a new way of seeing and doing things'. It recently set up an international group with doctors from six countries, including India, and hopes to work with any individuals and groups in India who want to collaborate on this.

'We want to restore the art of healing by doing as much as possible for the patient and as little as possible to the patient,' he says. 'There is so much work to do!'

HEART PRESCRIPTIONS

Angioplasty

Ideal for those who suffer

» acute heart attack

» unexpected chest pain

» persistent symptoms despite medical care

» narrowing of the arteries

Limitations

Symptoms may recur within six months (one out of 10 cases), often because the arteries have narrowed again.

Bypass surgery

Meant for those with

» stable angina but have persistent symptoms

» arterial narrowing in several vessels, especially the left main coronary artery

» poor blood pumping in the left ventricle

» those who have had a heart attack and if their blood vessels cannot be widened with angioplasty

» diabetes

Limitations

Longer recovery time and a higher complication rate. But minimally invasive bypasses involving Y-graft (a Y-connection between two arteries) hasten recovery.

Optimal medical therapy

This, with common medication such as ACE inhibitors and beta-blockers, is recommended for people who have

» chronic chest pain

» high blood pressure

» abnormal heart rhythms

Limitations

OMT doesn't work for cases involving acute heart attacks, blocks in multiple vessels or heart attack patients who are diabetic.