Diagnosing Musharraf

A heart surgeon weighs in on Musharraf’s ticker trouble.

[dropcap]P[/dropcap]ervez Musharraf remains hospitalized at the Armed Forces Institute of Cardiology in Rawalpindi. Pakistan’s former president and Army chief has been there since Jan. 2, when he developed heart trouble en route to a special court that is to indict him for the treason of sacking some 60 judges in November 2007. Musharraf’s detour set off a news storm—with contentious political, legal, moral, and ethical issues being furiously debated—that has yet to subside.

Did Musharraf require hospitalization? According to news reports, Musharraf had to be rushed to AFIC after he developed a severe and persistent chest pain that traveled to his arm, began to sweat and feel sick. Such complaints in a 70-year-old are extremely suggestive of serious heart problems and a possible heart attack. If this description of how he felt is correct, immediate hospitalization was the right call.

In classical medical terminology, such complaints were referred to as “unstable angina pectoris” but are now included in the spectrum of “acute coronary syndrome.” At AFIC, Musharraf was admitted to a coronary-care unit and received medications to stabilize his condition. Basic tests were then done. We do not have any details of these initial tests, but we do know that these excluded the possibility of an actual acute myocardial infarction or heart attack.

Subsequent diagnostic tests were also performed. Again, we do not have any details of what tests were done, but based on the reports submitted to the court, one thing is clear: besides having general problems that many people his age have, the important finding was that he has considerable calcium deposits in the arteries of his heart.

It would seem that the one important heart test Musharraf did go through at AFIC was a CT angiogram. This is primarily an advanced x-ray that besides providing a picture of the heart arteries also yields an assessment of the amount of calcium deposited in them. The higher the calcium score, the greater are the chances of having severe blockages of the arteries.

Many of us remember that during one of his visits to the U.S., then-president Musharraf made a mysterious side trip to middle-of-nowhere Paris, Texas, where Pakistani-American cardiologist Dr. Arjumand Hashmi runs a sophisticated cardiac center. It is possible but not confirmed that at that time Musharraf at least underwent a CT angiogram. When Dr. Hashmi now states that Musharraf has serious blockages in his heart arteries, he is probably comparing the calcium scoring done at his facility many years ago with the latest AFIC results.

Based on what is known, it would appear that Musharraf does indeed have considerable blockages of his heart arteries. The extent of these blockages is, however, being debated by people who don’t know the difference between a heart artery and a vein in the heart.

The latest question being raised by these armchair heart specialists is the question of an angiography. They claim Musharraf has refused to have an angiography. As someone who has seen thousands of angiography test results over my professional lifetime, and operated on a few thousand patients based on these results, I am entirely amused by this sudden expertise developed by media personalities and lawyers who have no idea what this test is all about.

Coronary angiography is a specialized test that requires the passage of a catheter or small plastic tube through the artery in the leg or the arm into a heart artery so that a special medicine can be injected and x-ray pictures can be taken to outline artery blockages. This is an invasive procedure. And like all invasive procedures it can only be performed if the patient agrees to go through with it. Medical ethics hold that it is entirely Musharraf’s right to refuse such a procedure. (Frankly, looking at the chief prosecutor in this case, my suggestion to Musharraf as a heart doctor would be to have a coronary angiogram done as soon as possible.)

AFIC is a pretty good place to take care of the problem of heart artery blockages. But, again, it is the patient’s sole right whether he wishes to seek further care from Ajmer Sharif or Paris, Texas. If a Pakistani court or a government official denies a patient that right and there happens to be an unfortunate outcome, will that court or government official then responsible be willing to accept the charge of being accessory to homicide?

Many pundits and politicians are of the opinion that Musharraf is lying, that he was never sick and sought refuge at the Army-run AFIC to avoid indictment. As far as the lying part goes, even the interior minister Chaudhry Nisar Ali Khan has said that Musharraf’s health scare was genuine. Musharraf’s choice to opt for an Army hospital appears fairly obvious and far from sensational: as a former soldier, he obviously felt more comfortable being treated in an Army facility. After Pakistan Tehreek-e-Insaf chief Imran Khan fell off a forklift last year and required hospitalization for spine fractures, he ended up not in an orthopedic hospital but at his own hospital—a cancer hospital. This was because Khan was sure he would get the best possible care there. Patients prefer hospitals where they know the doctors involved and can expect good care, so it is entirely appropriate that Musharraf went to an Army hospital.

There is also a lot of reactive nonsense about Musharraf’s wanting to seek treatment abroad when there is “quality” medical care available in the country. Both Prime Minister Nawaz Sharif and Punjab Chief Minister Shahbaz Sharif are known to visit London every so often for “routine” medical checkups. Since politicians don’t want people to know they are sick, there’s been no disclosure about the medical details of these checkups. And, of course, we all remember when Asif Ali Zardari as president developed neurological problems thought to be heart trouble and ended up in Dubai for diagnosis and treatment. There’s also the security issue. The chances of successful treatment and survival of Patient Musharraf, Al Qaeda and the Taliban’s most-wanted man, are far brighter abroad.

Hussain is a cardiac surgeon and editor-at-large of Newsweek Pakistan. From our Feb. 8, 2014, issue.