The question being asked is whether Mian Sahib is really sick or is he fine as the proverbial fiddle. The answer, of course, is that he is suffering from a few rather serious medical conditions but evidently at this time these problems are under control.

Here I must say that as a physician I do not wish that anybody I know to have Mian Sahib’s medical problems.

That said, when Mian Sahib left Pakistan for London for ‘life-saving’ treatment, I had said in these columns that whatever ails him can be treated in Pakistan but no physician in his or her right mind would take on that responsibility.

At that time, many of those clamouring for his departure kept insisting that he needed to go to London immediately if he was to live for even another week.

One of the things I have learned over the last fifty years is that predicting impending death even for the very sick patients is a fraught experience. And that reminds me of an old story that I heard or read many years ago about a king and a fortune-teller.

There was once a very famous fortune-teller and his fame reached the royal court. The king asked the fortune-teller to visit the court and foretell the future of the people in the court. After going around among the courtiers, it was the king’s turn. The fortune-teller drew detailed astrological maps and pondered over them for a long time.

Finally, the fortune-teller said to the king, my lord I have bad news. You will die a violent death within a year. When the king heard this, he became very sad and dejected. The grand vizier sitting next to the king saw how sad the king had become so he decided to do something about it. He asked the fortune-teller, what do your calculations tell you about yourself?

To this the fortune teller replied, my calculations tell me that I will die in my old age from natural causes. On hearing this the vizier got up, took out his sword and chopped the fortune teller’s head off, thus proving the fortune-teller ‘dead’ wrong and making his king happy at the same time. Smart man the vizier and that was why he was the ‘grand’ vizier.

So the long and short of it all is that even the seemingly very sick can get better but what should be remembered is that getting better does not mean that they are cured. Mian Sahib is still a pretty sick man and bad things could happen to him.

So what exactly is wrong with Mian Sahib? The most important problem is his heart disease. The first time we heard about Mian Sahib’s heart problems was when he went to London for a ‘routine’ procedure on his heart for an irregular heartbeat. The procedure is called a radio-frequency ablation (RFA) where a wire is pushed into the heart and then warmed up to ‘ablate’ (destroy) the area from where the irregular heartbeat is arising.

Unfortunately, the routine procedure turned into a near disaster as the wire poked a hole in the heart, producing dangerous bleeding around the heart. A heart surgeon was luckily found in time to open Mian Sahib’s chest and repair the hole in the heart and stop the bleeding.

Mian Sahib had made quite a few trips to London for ‘routine’ check-ups which now seem to have included a few stent insertions into blocked heart arteries. That then is the second heart problem that he has and it is called ‘coronary artery disease’ or blockages of heart arteries.

Blockages of heart arteries can lead to heart attacks and even after all the development in heart medicine, heart attacks are still one of the commonest cause of death in most countries, including Pakistan.

So what exactly is wrong with Mian Sahib? The most important problem is his heart disease. The first time we heard about Mian Sahib’s heart problems was when he went to London for a ‘routine’ procedure on his heart.

The specialists that treat heart artery blockages are surgeons that perform heart artery bypass operations and medical doctors that use wires passed through the skin to carry out angioplasty and insert stents to keep the heart arteries open and prevent heart attacks.

There is much confusion among the public about what exactly medical cardiologists do and what heart surgeons do. Let me be exact. Surgeons should be referred as ‘chest cutters’ who cut the chest open to perform operations. Medical cardiologists that use wires and catheters to perform stents and angioplasty are essentially ‘wire pushers’ and should be called that.

Coming back to Mian Sahib, he has had multiple stents put into his heart arteries to keep them open. There is a problem with stents. They tend to close down. It is important to put it in perspective. The heart arteries getting these stents are about the size of the ‘lead’ in a lead pencil. The surprising thing is not that the stents close down but rather that so many of them stay open for years or even decades.

When stents stop working the choice then is often to perform a surgical bypass operation by a ‘chest cutter’ where a patient’s own veins and or arteries are used to ‘bypass’ blockages in heart arteries. As a heart surgeon I always told my patients before performing a bypass operation that I can change the pipes but I cannot change the water.

Fortunately, today we have a plethora of medicines that can actually change the water. Still, even under the most ideal circumstances all stents as well as all surgical bypasses will not stay open and clearly that has happened in Mian Sahib’s case. All the news about impending heart attacks during his incarceration suggest that.

The other medical problem Mian Sahib has is a high blood sugar or what is known as Type 2 diabetes. This we know because when Mian Sahib was receiving steroid medicines for his low platelets, his blood sugar kept going up. Diabetes in adults is easily treated with pills and injectable medicines but is a problem for patients like Mian Sahib. Diabetes even if well treated increases the chance of coronary artery blockages.

The third medical problem that was loudly proclaimed was kidney failure. I don’t think that Mian Sahib has failing kidneys but I can say that his kidney function is not normal any longer. Cardiac procedures, including angiography and stents as well as emergency heart operation after the RFA as well as the formal bypass operation, are all cumulatively damaging to the kidneys.

The major reason in my opinion why Mian Sahib has not had an angiogram procedure to see the status of his heart arteries is that all his physicians are worried about producing kidney failure. Acute or sudden kidney shut down in patients like these can often be fatal.

Finally, about those pesky platelets. Mian Sahib was definitely on at least two or more medicines to make his platelets dysfunctional to keep his stents and bypasses open. And his low platelet count was probably due to these medicines. And it was his low platelet count that in my opinion washed out the blocked stents and bypasses in his heart and is why he is doing so well now

The writer has served as professor and chairman at Department of Cardiac Surgery, King Edward Medical University.