General (retired) Pervez Musharraf was admitted to the Armed Forces Institute of Cardiology (AFIC), Rawalpindi last week. The former military dictator was en route to the Islamabad High Court (IHC) under instructions from that honorable court to appear immediately when, he ostensibly felt unwell, and was rushed to the AFIC.
Myriad political, legal and medical questions have emerged since that quite dramatic development which was televised live. General Musharraf remains in the AFIC's intensive and/or cardiac care unit and has sought exemption from court appearances.
Apparently, he is seeking to go abroad for medical treatment. The IHC on the other hand ordered, and has now received, a medical report prepared by the doctors treating General Musharraf at the AFIC. A copy of the four-page medical report has appeared and is being discussed in the Pakistani media.
Without any prejudice to the patient confidentiality issues, which are for the IHC to decide upon in this particular case, we briefly review here the medical document that is in the public domain now.
According to the report dated January 6, 2014, the 70-year-old general was brought to the emergency department at AFIC with complaints of uneasiness in the chest, sweating and discomfort in the left arm.
He did not seem to have what could be termed a typical or classic angina pectoris (chest pain). His vital signs, including blood pressure and pulse, the latter though on a slower side, were fairly stable. His physical examination of the cardiovascular and respiratory systems, as well as an Electrocardiogram (ECG) has been reported as normal in the report. General Musharraf's echocardiogram reveals no valvular heart disease or deficits in the pump function of the heart.
The medical report, signed by the Commandant and Director of the AFIC, Major General S M Imran Majeed literally rambles about a slew of medical conditions that General Musharraf presumably has, but none of which (except his borderline hyperlipidemia, personal history of smoking and family history of heart disease) have any bearing whatsoever on the principal diagnostic concern i.e. the coronary artery disease.
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Quite perplexingly, after mentioning an initial working diagnosis of what is called an acute coronary syndrome, the AFIC report goes on a wild goose chase. It omits the most important and relevant piece of information i.e. the diagnosis, as it relates to the patient's presenting symptoms. The report is all over the place and reads like what passes for a routine physical examination and tests of an important person.
According to the medical report, an initial diagnosis of Acute Coronary Syndrome (ACS) was made and the treatment started accordingly. An ACS is an all-encompassing term that includes three medical conditions viz. Acute ST-segment Elevation Myocardial Infarction (STEMI), Non-ST-segment Elevation Myocardial Infarction (NSTEMI) and the Unstable Angina (USA).
As the report reveals a normal Electrocardiogram (ECG), one can safely assume that General Musharraf did not suffer from a STEMI. There is no mention of any abnormal bio-markers of cardiac injury (enzymes detected by laboratory testing) which effectively rules out an NSTEMI as well.
In plain words and going by his doctors' report, General Musharraf did not suffer a rip-roaring or even a mild heart attack on January 2, 2014. The only working cardiac diagnosis, which may be left, if one is still suspecting an ACS, would be an unstable angina.
Apparently, the general's chest 'uneasiness' has settled. So in medical terminology, the angina symptoms, if that were the case, too have resolved.
The general's physicians opted for a Computerized Tomographic (CT) Angiogram for him instead of the more definitive and conventional invasive coronary angiography for accurately evaluating and defining his coronary artery anatomy and any pathology (abnormality) therein.
Under appropriate conditions, a conventional angiography (also called a Left Heart Catheterization) is the gold standard test in a similar situation. This suggests that the treating team's clinical suspicion for angina was probably low.
If the patient had typical symptoms, the clinical suspicion was high and there were risk factors, the conventional - and clinically prudent - route to take would have been an imminent invasive coronary angiography with possible ad hoc or staged percutaneous or surgical revascularization as warranted by the coronary anatomy.
This is a routine procedure commonly done at a high volume center such as the AFIC. Indeed, while the report concludes by recommending the conventional angiography, yet that test has not been conducted or even scheduled.
The report mentions another diagnostic test called the Coronary CT angiography that was done but apparently definition of the coronary arteries' lumen was obscured by heavy calcification, which is known a technical limitation of this procedure.
According to the American Heart Association Guidelines, such testing might be undertaken for low or intermediate risk patients. In clinical practice, we almost never use the CT angiography even as a diagnostic step in severe acute illness.
It is surprising that the next logical step in the treatment algorithm i.e. traditional coronary angiography has not been undertaken while the patient is still under cardiac care at a facility which perhaps does umpteen such procedures a day.
If the patient was having continued symptoms, a reasonable clinician following the stand of cardiac care, would have conducted the conventional angiography off the bat and decided upon and/or instituted definitive interventional or surgical treatment if indicated.
Alternatively, if the patient is stable and he and his doctors have opted for medical therapy, a discharge and follow up care plan should have featured in the said report.
Quite ironically, General Musharraf's medical team has been conducting tests such as MRI of his spine and knee and ultrasound of his prostate. In acute care medicine, it is customary to put such non-essential testing and treatments on hold and complete them, preferably in an out patient setting, once the principal diagnostic and treatment issues have been addressed.
Ordering spine MRIs and prostate ultrasound for someone admitted with chest discomfort is at least a sheer waste of resources, and at worst, is just bad medicine which conflates issues and may delay diagnosing a potentially sinister condition.
One wonders if the idea is to nail the actual diagnosis or to make things fuzzy for those, including the judges, who are relying on this report for clarity.
The AFIC is the preeminent Pakistani facility treating an array of cardiovascular diseases on a daily basis. The coronary angiography, percutaneous interventions such as stenting procedures and the Coronary Artery Bypass Grafting (CABG) surgery are done routinely at this premier institute.
The AFIC has served the general public as well as the servicemen from JCOs to the Joint Chiefs with pride.
There is nothing, prima facie, in General Pervez Musharraf's medical report to suggest that the highly capable doctors at the AFIC cannot handle his rather straightforward and uncomplicated condition.
Dr. Mohammad Taqi is a medical specialist, a Fellow of American College of Physicians and a regular columnist for the Daily Times, Pakistan. He can be reached at mazdaki@me.com or via twitter @mazdaki. Dr. Arshad Rehan is an Interventional Cardiologist and a Fellow of American College of Cardiologists. He can be reached at a.rehan@me.com or via twitter @spaelanay) By Drs.