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- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions∗ ()
- ↵∗Address correspondence to:
Dr. Spencer B. King III, Saint Joseph’s Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342.
“Incredible India” is the current marketing slogan for this vast and diverse land. The hot news I read this week while in Chennai was all about the troubled railway system and a major controversy over blocking normal highway traffic to allow VIP convoys to freely pass. There is nothing like traffic to stir emotions. On the interventional cardiology front, things were different as the emotions stirred seem to be productive and optimistic ones. A dramatic demonstration of this progress was the IndiaLIVE conference in Chennai, which has exploded in size and scope. Dr. Mathew Samuel and other pioneers of Indian cardiology have made this conference, like several around the world, a magnet for the presentation and discussion of issues of practice. I have participated in this course for a number of years and was amazed by its growth. I do not know how many thousands of physicians attended, but each room was packed to capacity. Physicians attended from over 20 countries throughout the region—from the Middle East and Africa to Southeast Asia, as well as Japan, China, Korea, Europe, and North America. Live case demonstrations from local experts and visiting authorities provided the background for lively discussions. I was impressed by our Indian colleagues’ lack of reluctance to challenge each other vigorously. Although discourse was largely polite, the spicy interchanges to some degree matched the south Indian cuisine. It reminded me of the way things once were at the annual American College of Cardiology and American Heart Association meetings many years ago. Disagreement openly and respectfully expressed can go a long way toward bringing out important teaching points about procedure performance and clinical decision making. The evidence, and lack thereof, was well understood by the presenters and audience, and informed judgment was demonstrated to not always come to the same conclusions.
What were the hot issues? Some that I observed were related to the epidemic of advanced coronary artery disease among young Indians. There is a strong belief that there are genetic predispositions amplified by dramatic lifestyle changes. This provides a substrate for significant enthusiasm about a technology with potential long-term hypothetical advantages. Bioresorbable vascular scaffolds are viewed by some here as being as good as the latest drug-eluting stents, with the promise of long-term superiority as the arteries resume somewhat normal function without a stent remaining. Is all of the evidence in? No! Is the enthusiasm high? Yes! Are there doubts expressed? Definitely yes! All of this is good. First-generation bioresorbable devices will naturally be very exciting, and the ability to deliver them in diffusely-diseased Indian patients was clearly demonstrated. The “preparation” of the artery to allow implantation of the devices is called by some the “disruption” of the artery to make it supple enough. Will this approach ultimately be benign or not? The diffuse calcified atherosclerosis, in some cases, prevented even passage of modern metal stents and required atherectomy in many cases. It was interesting to see that the decalcifying technology of orbital atherectomy is not available in India. A technology available in the United States, but not outside of the United States, is truly a unique circumstance. At least this gave me a chance to talk about something technical that they had not previously experienced. Certainly, the risks for these young patients are not going to be solved even by a stent with a perfect result. Research into secondary prevention remains essential, and application of known effective therapies should be applied to all.
Aside from the rapidly advancing cardiovascular capabilities in India, their hospitality is unsurpassed. I was honored to share the Lifetime Achievement Award with Dr. Alain Cribier, whose seminal contribution of transcatheter aortic valve implantation has been shared unselfishly and extensively across India. In my acceptance speech, I pointed out that despite having performed 250,000 percutaneous interventions and having over 600 cardiac catheterization laboratories, India is not currently where it should be in clinical research. Submissions to JACC: Cardiovascular Interventions by country shows that India, 1 of the 2 largest countries in the world, ranks number 12. I predict this will change for several reasons. The clinical activity and expertise of 3,000 interventional cardiologists in India is rapidly expanding. There is increasing interest in investigation, and organized registries are developing. Unique approaches to medical care, such as pharmacoinvasive approaches to ST-segment elevation myocardial infarction for the vast population that has no access to primary percutaneous coronary intervention, are being pioneered by colleagues in south India and could become a model for many areas of the world. Methods to perform even high-tech interventions at a fraction of the cost in Western countries should be widely studied. Developing device and pharmacological industries in India have the incentive to invest in research in the country, and they are beginning to do that. What are the limitations to expansion of research from this highly-talented pool of physicians? I was informed that lack of training in research methods has been a major defect in the educational system. Much of the expertise in research and development has been obtained abroad, but I see this now expanding in India as well. In the future, the submissions and publications of important studies from India will, I believe, far exceed its current position at number 12, and “Incredible India” will take on a new meaning.
- American College of Cardiology Foundation