Dear Editor,
MY fellow alumnus of the University of Guyana, now residing in the UK, Dr Mark Devonish, has recently advanced some very apposite points about cardiologists and the practice of cardiology in Guyana. His expressed goal is “patient information!”
I will now provide, apropos, patient and personal information for Mark and the general public.

Background
In 2004/2005, the Government of Guyana (taxpayers) spent 500,000 USD – half a million US dollars – to send 10 Guyanese patients overseas for cardiac treatment. This averaged 50,000 USD per patient. For a country such as ours, this was an unsustainable situation. This lead to the birth of the Caribbean Heart Institute (CHI) in 2006, which is a public/private partnership with the Government of Guyana and the Board of Directors of CHI. The cost of treatment has been continuously revised to its current position, where we can now provide care for 100 patients instead of 10 patients (2004/2005) for the same cost. CHI provides the cheapest bypass surgery in the Caribbean, since there are no fees charged by the cardiac surgeon or the perfusionists. We are also the cheapest for coronary angiograms, angioplasty and coronary stent implantation. For general information, a coronary angiogram is the procedure to take pictures of the arteries of the heart to find blockages. Angioplasty is when we stretch the blockage with a balloon to open it, and stent implantation involves putting in a mesh-like tube to keep the artery open. The prevalence of heart disease in Guyana is almost at epidemic levels. I have had patients as young as 28 with heart attacks and as of recent, there has been a surge in males in their mid 30s coming in with massive heart attacks. While the disease may have been seen in only the older population previously, we are now experiencing more severe heart disease in the under-50 age group too frequently. Unfortunately, too many patients think that their symptoms are related to “gas” or something non-cardiac. By the time they reach hospital, they would have been three to four days without appropriate treatment. Misinformation can scare patients, undermine trust and cause more delays, which result in dire consequences, including death.

Practice Privileges
A long time ago I decided to live and practise in Guyana and the Caribbean.Consequently,I did not pursue residence in North America and the UK, even though I have done advanced studies in Canada and the USA. In Canada, I trained at the University of Toronto in Adult Cardiology and Interventional Cardiology and then moved to Boston, USA at Tufts University for Clinical Cardiac Electrophysiology.  I live and practise in the Caribbean and I am fully qualified to do so in the fields of Adult Cardiology, Interventional Cardiology and Cardiac Electrophysiology. Guyana and the Caribbean need its own citizens to develop its systems and I am proud to be a part of this pioneering brigade. Since returning to Guyana, I have been able to provide care to patients not only in Guyana, but also to those in Trinidad, Jamaica,The Bahamas, Tortola, St. Lucia, Grenada, Antigua, Suriname, St. Vincent, Barbados and The Cayman Islands.

Surgical Back-up
Dr Devonish observes that Coronary Angiograms and other Coronary Interventions should have a back-up team of surgeons around.
In resource-rich communities abroad, this is feasible. In Guyana, there is a paucity of personnel and equipment to facilitate this on every occasion.
We are forced to work with limited capabilities until government /private entities can provide them.

With our “oil-rich” economy on the horizon, we will be able to match overseas standards.
There are three (3) cardiac catheterization facilities in Guyana and my work is mainly done at two of these. A single surgery team in the city is sufficient back-up. We do have a visiting cardiac surgery team every month from New York that provide heart surgery for those needing it. Without early angiograms and angioplasty, people will suffer unnecessarily. I am good at it, my team is good at it and our patients survive now, when previously they had no options. The written guidelines for cardiology do not consider cardiac care in the developing (Third) world; therefore, we have to blaze our own paths, adjust according to our needs and resources. Careful patient selection, improved techniques and team growth minimises complications and adverse outcomes. We have never had a complication which required surgical rescue.

Statistics
I will provide some of our results for your consideration. In July 2017, I presented data of our programme in Trinidad at the Caribbean Cardiac Society meeting, which showed that before implementing the new treatment protocols, there was a 28% rate of death for heart attack patients and an average of 8.8 days of hospital stay. After implementing the new protocols which include angiograms, angioplasty and stenting, there was a drop in death to 2.4 % and hospital stay was reduced to 4.6 days. This represents a 10-fold reduction in death rates and halving of hospital stay. If one considers that it costs USD $2000-$6000 per day to treat a hospitalised cardiac patient, this translates to savings of $USD 8000 – $24000 per patient.

The following represents data for the first six months of 2018, pro-rated for the entire 2018.
My team and I have had approximately 8500 patient visits for clinics, admissions and inpatient consultations over one year for the two facilities I cover. Out of this, there are 382 angiograms (4.5%) and 270 Angioplasty with Stenting (3.2%). This represents a very small percentage of cardiac patients receiving invasive care. There are many more patients who should have the benefit of an Angiogram with proper Revascularization (Stent or Bypass Surgery), but for various reasons, they are unable to get this level of care. Most of the complex and difficult cases are planned to occur when the surgical team is on ground or arriving. Angiogram and angioplasty with stenting are not the first choice of investigation and treatment. Several non-invasive methods are available and utilised to manage patients before any invasive procedures are done. These would include ECG, Echocardiograms, Stress Testing, Ambulatory blood pressure monitoring, Holter Monitoring and Sleep studies.
Clinical audits of outcomes are mainly done by the Libin Cardiovascular Institute, University of Calgary, who also assisted in development of treatment protocols, training, research and infrastructural development specific for our needs and resources. Additionally, real-time consultations are done with colleagues in Trinidad when necessary. Pre-surgical assessments are done by the surgical team based in New York. My results are comparable to regional and international standards, because I was properly trained by world-class teachers, professors and proctors.

Since returning to Guyana I was able to do the first implantation of an Intracardiac Defibrillator, first cardiac resynchronisation device, first implantable loop recorder, first pacemaker lead extractions, first radiofrequency ablation for atrioventricular node re-entrant tachycardia, first ablation for Wolff-Parkinson-White Syndrome and first ablation for concealed retrograde accessory pathway. As the head of Cardiology, I was instrumental in opening the first Cardiac ICU in the public sector (GPHC) and also the Cardiac ICU at Woodlands Hospital. I have established protocols for the treatment of heart attacks (Acute coronary syndrome), heart failure and cardiac arrhythmias based on our resources. I lead the initiative to ensure that every patient admitted to GPHC with a heart attack can have free angiogram and stenting without delay, once they meet clinical criteria. I have competent, young, dedicated and enthusiastic healthcare professionals who make up my teams, working with the singular goal of improving healthcare in Guyana.

Challenges
Obviously, there is much room to grow and improve our national healthcare delivery systems. Patient and care-giver education is critical in prevention, early detection and intervention to manage cardiovascular health. It is also true that cost is a major determining factor in seeking and providing healthcare. For this reason, I am a strong supporter for a National Health Insurance initiative to be developed in Guyana. This is what we should be debating, instead of petty personal grouses. Every citizen should have the right to the highest quality of care available without fear of discrimination, loss of dignity or bankruptcy regardless of gender, social status, financial means, ethnicity, sexual orientation, political affiliation or any other criteria used to divide us. For this to occur, we would need every Guyanese and many non-Guyanese on board.
Until that goal is achieved, there would be much discussion, some heated and contentious, but hopefully we would find consensus to benefit all Guyanese.

Regards

Dr Mahendra Carpen, MBBS DM FACP FESC FACC
(Interventional Cardiologist and Cardiac Electrophysiologist)