Author + information
- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions⁎ ()
- ↵⁎Address correspondence to:
Spencer B. King, III, MD, MACC, Saint Joseph's Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342
My first trip to southern India was in the early 1990s at the beginning of the stent era. The conference featured speakers from around the world talking about the advantages of the stents that were available and several that were in development. One by one, the presenters would tout the latest and greatest stent. First, a stent was referred to as the “Cadillac” of stents, then another the “Porsche,” and finally one that was the “Maserati” of stents. There was speculation that someday the Indians would make their own stent as the price for many patients was prohibitive. I was chairing the session and recalled saying that the solution might be to make a low-cost device that would be functional but not necessarily the “Maserati” of stents. I had been in Chennai traffic for 3 days and observed that a very sturdy car (the Ambassador) was not at all stylish (as Shaquille O'Neal would say) but was much better suited for the crowded streets of Chennai than those trophy cars.
As I write this in early March on my return from the India Live conference, now more than 20 years after my first visit, I have observed that the traffic in Chennai is no better, but the practical but clunky Ambassador is gone and replaced with all the models available around the world, including some Porsches and probably Maseratis. As far as I know, my entry level (Ambassador) stent was never built. But, just as the cars, all the stents in the world are now available, including ones made in India. However, instead of making a “clunker” stent, their aim is to create cutting-edge medical products not just for the India market, but to compete on the world scene. Backed by significant capital, vast human labor resources, and an exploding domestic market (i.e., increasing incidence of cardiovascular disease), they are well on their way to becoming a major player, but with major challenges.
While at the India Live conference, which was a very high-quality demonstration of advanced interventional care attended by 1,500 interventionalists, I learned several things that may have major impact on our specialty. First, through a more relaxed pathway to innovation, some of the technology advances of the future will clearly come from India. Second, with health costs out of control in many Western countries (the United States being the poster child) the ability to deliver care at a fraction of the costs in Western countries will gain increased attention. While I was there the government set a cap on the price to be paid for drug-eluting stents. Many will oppose price controls, but as long as quality devices are provided at these prices, the competing companies will have to adjust. India's epidemic of diabetes will soon make that country the diabetes capital of the world and with it the accompanying cardiovascular disease. So there is unfortunately continuing escalation of the need for medical devices. Although comparable cost effectiveness may not be achievable in richer countries, there will be important lessons to be learned from how India manages healthcare. The third thing I learned relates to acute coronary care. Treatment of myocardial infarction is an unmet need for the massive Indian population. Primary percutaneous coronary intervention (PCI) is simply unavailable to most, despite world-class facilities in many urban centers, and even in those cities with highly advanced cardiovascular facilities transportation through traffic over clogged highways creates a severe impediment. Here, there is a regional initiative using telecommunications to enable diagnostic electrocardiograms to be sent from neighborhood health centers, which are almost everywhere, to on-call cardiologists. The intention is for ST-segment elevation myocardial infarction to be addressed as a national public health problem, a lesson I believe can be used elsewhere. Of course primary PCI will not magically become available, but reperfusion therapy and a chance to triage patients will. Think of the opportunity for unique registry data and important outcomes research.
In addition to the technological demonstrations at India Live there was an emphasis on case selection with discussions of U.S. and European guidelines, the appropriate use criteria, as well as the heart team approach to decision-making regarding revascularization. I found the range of opinion as broad as I observe elsewhere. Incorporation of evidence-based guidelines into practice remains a struggle. I assured them that this is not unique and remains so in the United States as well.
Education is the number one priority in India. Much of the post-graduate education in interventional cardiology has been supported by industry with fewer restrictions than in the United States or Europe. With profit margins potentially shrinking, there may be less industry funding. The need for training in interventional cardiology will only expand as India (soon to be the largest cardiovascular disease population in the world) will surely need more highly educated interventionalists. Therefore, it is wise for the American College of Cardiology to continue to collaborate with programs, such as India Live and others, throughout the country. Interest in guidelines, training and competence documents, and continuing medical education remains very high.
Despite the impressive progress India has made over the past 20 years, the problem of providing cardiovascular care for this massive population from prevention to invasive therapy remains daunting. Medical care is highly privatized and not available to the majority of the population. The governmental efforts to address the cardiovascular epidemic will be a greater challenge than addressing infectious disease epidemics. However, I believe the challenges will produce many ideas that may be helpful to the rest of us and we should pay attention. Exchange of medical knowledge is no longer a one-way street and there is much that we can all learn from this emerging medical giant.
- American College of Cardiology Foundation