When I look back at the path that Cardiological Society of India (CSI) has traversed during the past 42 years of my association with it, I feel amazed at the progress that the Indian Cardiology Community has made not merely numerically but more so in the quality of the scientific content. It has been a long journey covered in a short period of time.
While the CSI was established in 1948 by some of the greats in cardiology of that era, from Calcutta, Mumbai, Delhi, Chennai, and Vellore, my association with CSI began in 1970 before I went to Philadelphia and Chicago for my cardiology training. That was the time when CSI was in its nascent stage and held its annual conferences jointly with the Association of Physicians of India along with several other speciality associations. CSI formed a small section in the entire joint API conference and I remember when I presented my first paper on the “Post Mortem Studies in Acute Infective Endocarditis”, there were hardly 100 attendees in the entire hall. Annual conference in a medical college campus or in a public hall with shamiana in an open ground was a norm. One could not dream of staying in a star hotel and invariably residential arrangements were made in circuit houses or medical college hostels. Total number of dedicated cardiologists/physicians on behalf of CSI used to be in the range of about 250–300. Out of these, only about 20% attendees were dedicated cardiologists who devoted 100% of their time to the practice of cardiology.
Those were the days when clinical cardiology was at its peak. Very few studies whether published in Indian Heart Journal or presented at the annual conference were technology-dependent since entire country had handful of cardiac catheterization laboratories. Slowly by 1980s, several institutions in the country started the DM Cardiology programs. Until then, very few institutions like Christian Medical College, Vellore, All India Institute of Medical Sciences; Maulana Azad Medical College, Delhi; G.S. Medical College, L.T. Medical College, T.N. Medical College and Grant Medical College from Mumbai; Post Graduate Institute of Medicine, Chandigarh and Medical College, Chennai had very few cardiology postgraduate seats (though because of lapse of time I might have inadvertently missed out on some institutions). Rest had to go to USA or UK to be trained as cardiologists. ECG was the only tool available. During 1970s and 80s when the cardiologists like us were trying to establish Cath Labs, there were several insurmountable government and bureaucratic challenges. Those were very trying times that many of the current generation cardiologists can’t even imagine. While the challenge of acute shortage of funds could somehow be met by the donations from philanthropists, “License Raj” to import equipment coupled with exorbitant duties and government procedures could prove to be daunting and discouraging. Nonetheless “when going gets tough, tougher gets going”. Results of their dedication and commitment to bring Indian cardiology to the International level are here to see.
Earliest cine angiographic laboratories were established in our Balabhai Nanavati Hospital, L.T.M. Medical College and Jaslok Hospital in Mumbai. Until then in other institutions, the angiographic studies were performed with rapid film changer from ELEMA SCHONENDER. While undergoing training in Cook-county Children's hospital in Chicago, I had the opportunity to watch some of the earlier studies performed on 12 mm cine angiographic films. With advanced technology, recording was switched over to 35 mm cine films. Currently, cine images are recorded on CDs. I remember once the image intensifier broke down in the cath lab and I had the opportunity of performing a small baby's cardiac catheterization studies with the help of an over-head mirror – an earlier technology of image viewing in Cath lab.
Until late 1970s, the thrust of the papers published in Indian heart journal and/or presented at CSI dealt with either rheumatic, congenital, primary myocardial disease, or hypertension. The great turning point came with the widespread establishment of cine angiographic laboratories and other diagnostic tools like echo, stress, and myocardial perfusion scanning performed all over the country. Now the focus has shifted considerably to coronary artery disease. Coronary bypass graft surgery started gaining grounds from Mumbai and Chennai in the beginning. Open economy coupled with abolishment of License Raj helped the growth of cardiology due to availability of funds, and easy import of sophisticated equipment.
For several years, CSI and Association of Cardio Thoracic surgeons of India used to have joint annual conferences. There used to be healthy exchange of clinical and academic data between two arms of cardiovascular medicine. Dr Andreas Gruentzig and Dr Geoffrey Hartzler accepted my invitation to come to Mumbai in 1982 and 1988 respectively. We were fortunate to perform PTCA to LAD on 6th February, 1985 at Breach Candy Hospital, Mumbai in a patient who had post anterior wall myocardial infarction angina using USCI balloon and steerable wire. After 7 years or so, the patient developed inferior wall MI. It was rewarding to see that the patent LAD had supplied collaterals to the totally occluded RCA. Subsequent growth of PCI has been phenomenal. For the first time from our institution in Mumbai, we presented a paper on the angiographic studies in acute myocardial infarction setting which I consider as a landmark paper for India; after the publication of Dewood's paper on angiographic studies in AMI. This will provide the roadmap for the growth of PAMI in future. We studied and presented several papers on early pre-discharge stress test in acute infarction to risk stratify AMI.
In the late 1980s though not concerned initially with CSI, a few of us like Dr. Mathews, A.B. Mehta, Ashok Sheth, Upendra Kaul, Soma Raju, Ashok Dhar and myself and several others who were convinced about the future of coronary angioplasty met informally at Hinduja Hospital in Mumbai. The group was called PCI Registry of India. At that time, the sole purpose for meeting was to share our experiences and discuss complications which used to be in abundance because of unfriendly hardware and absence of stents. The PTCA registry ultimately became the National Interventional Council of CSI and has grown to be the main platform for interventional cardiologists of India with annual meeting attracting close to about 1000 attendees. The data and scientific content are keenly watched by international and Indian devices and pharma companies.
The science and art of interventional cardiology has percolated far and wide over the entire country with more than 1000 cardiac catheterization laboratories, several of them owned by cardiologists in tier 2 and 3 cities providing round the clock PAMI services.
The growth of cardiology has shifted to a large extent from the teaching hospitals to private hospitals run by corporates or trusts. This indeed is a great change. In the earlier era, most of the papers, presenters, and panelists in CSI meetings and publications came from the teaching hospitals. Today, I find greater representation from the private hospitals. Their contribution by no means is small. They provide state of the art facilities, efficiency, and DNB programs.
Today, at any given time, there are more than 1000 students enrolled as DM/DNB students all over the country. I have seen many of them and it is amazing how aggressive some of them are!! They have tremendous knowledge of the use of hardware like IVUS, OCT, FFR, and their competence in performing interventional procedures is no inferior to the best in the world.
Today, on an average, more than 5000 delegates attend the CSI conference which is a phenomenal growth when compared to 250 odd numbers in the earlier times.
One important change that is glaringly visible is the participation by foreign guest faculty in the CSI and NIC meetings. In the 70s their presence was sparse and the speakers attended mainly by our personal invitations since many of us had worked with them during our training abroad. Most of them traveled economy to be upgraded to business – courtesy Air India. Dr Andreas Gruentzig traveled economy!! That is what we could afford. There was no industry backing and at the same time the cardiology community was cynical with some even critical towards the success of coronary angioplasty. Nobody wanted to invest, practice and put efforts into it. Today, I see large number of foreign faculty members and still larger number waiting eagerly to be invited to our CSI and NIC meetings.
In current CSI conferences and Indian heart journal myriad of technology-dependent papers, viz. echo, TEE, myocardial perfusion scan, PET, IVUS, OCT, FFR, use of Impella, ECMO, or percutaneous cardio pulmonary bypass or now abandoned trans myocardial laser revascularization for critically ill patients are being presented. Lag period between introduction of technology in the market and its use in the patient care is less than 1 year. It seems Indian cardiologist who used to boast of good clinical sense has found a new love in technology dependent cardiology.
Any growth has certain built-in side effects. Though the number of delegates has burgeoned, the actual attendance in the scientific sessions is dismal. With industry pumping in money lavishly to garner business, the focus seems to have shifted from science to sight seeing with family and children. Speakers several times has to address empty chairs. At any given time, more number of delegates are seen in the exhibition areas than those listening to even a highly respected speaker. Science of cardiology seems to have taken a back seat. Also, the focus has drifted from holistic patient care to mere intervention. Powers that be in the CSI need to address these concerns and motivate its members to keep science above self.
“If I have seen further than others it is by standing upon the shoulders of giants”
Isaac Newton 1642–1727.
Dr Dev Pahlajani receiving CSI Lifetime Achievement Award.
Dr Gruentzig – visit to Mumbai, 1982.
Conflicts of interest
The author has none to declare.