by Ganesan Karthikeyan and Balram Bhargava

In India, we enjoy great respect and autonomy as physicians. The public,for the most part, trusts and dutifully follows our advice. A good example of this is the near universal acceptance of Covid vaccines in our country, compared to the distrust and hesitancy seen even in rich countries. Therefore, for our part, it behoves us as physicians to continue to provide the best science-based advice, that is untainted by personal preferences, beliefs, or prejudices.
So, it is with deep consternation that we note Dr Devi Shetty (How Fit You Are Isn’t A Matter Of How Fit You Feel, TOI, April 7, shorturl. at/hkvR4) urging normal people to get screened using “sophisticated” tests such as CT scans. Failing to do so, he warns, could cause people to drop dead due to “sudden cardiac arrest”. Such warnings lack scientific basis and are instead premised on halftruths and fanciful leaps of faith. While many of the assertions made in the column deserve scientific rebuttal, in the interests of space, we shall focus on a few

Should everyone get a CT angiography done?
For the vast majority of people, who do not have any symptoms of heart disease, the answer is an emphatic NO. The CT scan is one of the tests reserved for people with chest pain or other symptoms of heart disease. There is no scientific basis for subjecting normal peopleto CT scans to screen for “silent” disease, and therefore no scientific body in the world recommends this.
While it is true that CT scans detect disease in the coronary arteries, there are two main reasons why CT scans are not used for screening people without symptoms. First, it is possible to estimate the risk of future cardiac events based on readily available information such as the person’s age, smoking status, cholesterol levels, presence of high blood pressure, diabetes, and a family history of heart disease. It istherefore recommended that normal people undergo periodic screening for the above conditions. A CT angiogram is NOT needed to estimate risk.
Second, performing a CT scan on individuals without symptoms can lead to unnecessary anxiety, and worse, trigger a cascade of further testing, which may sometimes lead to unnecessary invasive procedures such as angiography and angioplasty. There is no evidence that such procedures are beneficial in this population, and instead needlessly expose a very large number of people to the harms (not to mention the costs) associated with such procedures.
There is now good scientific evidence indicating that even in patients who have symptoms (such as exertional chest pain) due to blockages in the heart vessels, it is best to start treatment with medicines at the outset. Performing angioplasty or surgery as the first step does not reduce the risk of having a future heart attack or dying. These invasive options need to be considered, only if symptoms are not relieved with medicines.

Should you get a CT scan done before you start exercising?We are amused by the refusal to accept someone as fit before first seeing a CT scan, even if that person is used to climbing “Mount Everest twice in a month”! People who regularly exercise have greater cardiovascular fitness levels and are at a lower risk of having a heart attack, or dying suddenly, than people who do not. Unless such a person has developed symptoms, all that is required is blood pressure measurement, and routine blood tests for sugar and cholesterol. A CT scan is most definitely not needed.
Much the same applies to less active individuals too. If you intend to start exercising, the most prudent approach would be to begin slowly, and gradually intensify to a goal of about 45 minutes a day. Quite obviously, you shouldn’t consider scaling Mount Everest right away! If at any stage you feel discomfort or have symptoms during activity, you should of course consult your doctor. Getting blood pressure, cholesterol and sugar checked are recommended for all adults irrespective of whether they wish to embark on an exercise programme or not.
Finally, we completely concur with the statement that the foundation of healthcare should be based on preventive health. And this involves regular exercise, avoidance of smoking, detecting, and treating high blood pressure, high cholesterol, and diabetes. Based on current scientific knowledge, the indiscriminate performance of echocardiogram and CT scans should not be part of any preventive health programmes. On another note, as a professional group, physicians must refrain from dispensing health advice through opinion pieces and TV shows, particularly when it is at variance with evidence-based norms of practice.

Drs Karthikeyan and Bhargava are cardiologists at the All India Institute of Medical Sciences, New Delhi. Views are personal

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This piece appeared as an editorial opinion in the print edition of The Times of India.

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