Heart
a Framingham calculator, a tool designed to estimate one’s risk of a heart attack within the next ten years. I
If life is a continuous struggle against the inexorable march of entropy, then the heartbeat is at the core of that conflict.
the Aztecs opened the chests of slaves with flint knives and ripped out their still-beating hearts as offerings to their idols. In Western fairy tales, witches seeking immortality consumed the hearts of innocents. In Snow White, for example, the evil queen insists the hunter cut out the girl’s heart to ensure that she is really dead. Even today, when brain death has become a widely accepted sign of demise, people continue to associate a heartbeat with viability. Families come up to me in the intensive care unit and say, “His heart is beating. How could he be dead?”
Cardiovascular deaths in America have actually declined by almost 60 percent since the mid-1960s. From 1970 to 2000, the average life span in the United States increased by six years. Two-thirds of this increase in longevity came from advances in cardiovascular treatments. (In recent years there has been decreasing life span in middle-aged whites for non-cardiovascular reasons.)
Although more than 60 percent of Americans will develop some form of cardiovascular disease in their lifetime, less than a third will die of it, so we know our treatments are effective.
There is a downside to this success, of course. Patients who once might have died of heart disease now must live with it, though often in an enervated state, a fraction of their former selves. Every year more than half a million Americans develop congestive heart failure, in which the heart weakens or stiffens to the point that it cannot properly pump blood to meet the energy demands of the body.
Ironically, as we become more adept at treating heart disease, the set of people who are ill with it is growing.
The heart was once considered the center of human action and thought—the source of courage, desire, ambition, and love. Even if those connotations are outdated, they are still deeply relevant to how we think about this organ and how it shapes our lives.
Unlike the humans who dissect them, frogs are cold-blooded.
Over the years, I have learned that the proper care of my patients depends on trying to understand (or at least recognize) their emotional states, stresses, worries, and fears. There is no other way to practice heart medicine. For even if the heart is not the seat of the emotions, it is highly responsive to them. In this sense, a record of our emotional life is written on our hearts. Fear and grief, for example, can cause profound myocardial injury. The nerves that control unconscious processes, such as the heartbeat, can sense distress and trigger a maladaptive fight-or-flight response that signals blood vessels to constrict, the heart to gallop, and blood pressure to rise, resulting in damage.
In his book The Lost Art of Healing, the cardiologist Bernard Lown describes a case from an Indian medical journal in which a prisoner is condemned to death by hanging. A physician persuades the prisoner to allow authorities to bleed him rather than hang him because death by exsanguination is relatively painless. The man is strapped to a cot and blindfolded. Then his arms and legs are scratched, leading him to believe that he is bleeding. Lown writes: Vessels filled with water were hung at each of the four bedposts and set up to drip in a basin on the floor. The water began to drip into the containers, initially fast, then progressively slowing [mimicking bleeding]. By degrees the prisoner grew weaker, a condition reinforced by the physician’s intoning in a lower and lower voice. Finally the silence was absolute as the dripping of water ceased. Although the prisoner was a healthy young man, at the completion of the experiment, when the water flow stopped, he appeared to have fainted. On examination, however, he was found to be dead, despite not having lost a single drop of blood.
in the marginPsychosomatic death
What these deaths had in common was the victims’ absolute belief that there was an external force that could cause their demise and against which they were powerless to fight. This perceived lack of control, Cannon postulated, resulted in an unmitigated physiological response in which blood vessels constricted to such a degree that blood volume acutely dropped, blood pressure plummeted, the heart acutely weakened, and massive organ damage resulted from a lack of transported oxygen.
in the marginPathology of psychosomatic deaths
For instance, in 1957, Curt Richter, a scientist at Johns Hopkins, described experiments on wild rats in which the animals were dunked in a glass jar filled with water and sprayed by a narrow jet that precluded the animals from floating—in essence, waterboarding them. Wild rats are fierce, suspicious animals that react very negatively to any form of restraint. Not surprisingly, most rats rapidly drowned within minutes (though a few amazingly were able to swim for eighty or more hours before drowning). When Richter measured the heartbeat of the drowning rats by means of electrodes inserted under the skin, he discovered to his surprise that the rate was not rapid, as would be expected from sympathetic overactivity. “Contrary to our expectations, the EKG records indicated that the rats succumbing promptly died with a slowing of the heart rate rather than with an acceleration,” Richter wrote, suggesting parasympathetic activation. Moreover, drugs that increased parasympathetic activity accelerated these deaths; drugs that blocked this activity prevented them. Therefore, Richter concluded that the rats died as the result of parasympathetic, not sympathetic, overactivation. “The situation of these rats scarcely seems one demanding fight or flight—it is rather one of hopelessness; whether they are restrained in the hand or confined in the swimming jar, the rats are in a situation against which they have no defense.” Richter further noted that teaching the rats that their situation…
I remembered what our anatomy professor had told us: if we ever had to push a needle through the chest wall, the right ventricle is the first structure we would hit.
Daniel Williams, a showboating surgeon who made up in boldness and technical prowess what he lacked in humility.
“Dr. Williams took the boldest and most thorough-going step possible [to] combat this irrational fear. He threw open the doors of his operating room once a week to the public and said in effect, ‘Come watch us work, observe conditions and see for yourselves that there is nothing to be afraid of.’”
Williams was getting ready to close the chest when he noticed the knife had traveled deeper, puncturing the pericardium with a hole about one-tenth of an inch in diameter. With little time to mull over his options, he asked for more catgut and needle and stitched the pericardial wound closed, carefully timing the movement of his needle with the beating heart in a sort of surgical tango. He noted that there was also a small wound in the thin-walled right ventricle—in the heart muscle itself—but it had formed a dark clot on its surface and was no longer bleeding. Williams decided to leave it alone.
In that essentially pre-antiseptic era, the Grim Reaper appeared more often bearing a thermometer than a scythe.
in the marginNice sentence
Rehn wrote a detailed account of his operation in a surgical journal. His wording was careful, even a bit defensive. Scarcely a decade earlier the great Billroth had proclaimed that “the surgeon who would attempt to suture a wound of the heart should lose the respect of his colleagues.” Perhaps feeling the weight of history bearing down on him, Rehn wrote, “I was forced to operate. There was no other option open to me, with the patient lying before me, bleeding to death.”
“Lemme tell you something. There’s one of these doctors in Atlanta that’s taken a knife and cut the human heart—the human heart,” he repeated, leaning forward, “out of a man’s chest and held it in his hand,” and he held his hand out, palm up, as if it were slightly weighted with the human heart ... “[and] he don’t know no more about it than you or me.”—Flannery O’Connor, “The Life You Save May Be Your Own”
Setting down his plate, Shah asked me, a first-year fellow, if I wanted to come along and watch. But there was no time to lose. Outside, my breath smoked vaporously in the frigid air.
in the marginGood transition by implied dialoue
When he did, incredibly the heart began to shrink as blood, life’s fluid, was diverted into the plastic-and-metal apparatus. The heart nevertheless continued to beat, though weakly and more slowly. Much of my life I’d lived with the fear that the heart could stop at any moment and one’s life would be extinguished. And here it was, shrinking like a balloon with a small leak. It sent shivers through me. Never had the boundary between life and death seemed so thin.
Though the need was great, Lillehei’s proposal to use one human as living circuitry for another was shocking, to some even immoral: the first operation in human history that had the potential to kill two people.
We are in large part recompensed for the long and difficult hours by seeing the most miraculous change in the children and in witnessing the joy and relief of the parents when they see their children running about happily and without effort like other children.—Lord Brock, cardiac surgeon, Guy’s Hospital, London
Toward the end of his first year at Jefferson Medical College in Philadelphia, John Heysham Gibbon Jr. considered quitting medicine to become a writer, a passion he’d nurtured since his college years at Princeton. His father, a pragmatist, advised him to obtain his medical degree, telling him (in advice that sounds very familiar) that he would not “write worse for having it.” So Gibbon persevered and received his MD three years later, in 1927.
An early heart-lung machine, circa 1954 (Courtesy of Walter P. Reuther Library, Archives of Labor and Urban Affairs, Wayne State University)
Alas, the field would have to wait until 1960, when the first successful human coronary artery bypass operation was performed by Dr. Michael Rohman in the Bronx.
In 1967, René Favaloro performed the world’s first coronary bypass surgery at the Cleveland Clinic using veins from the leg to bypass the coronary obstructions, the standard technique still in use.
Shah never called me to tell me what happened, but the next day I heard from my parents that the patient never made it out of the OR. His blood pressure continued to drop, despite the balloon pump and intravenous medications, and around seven that morning, nearly seven hours after we’d arrived at the hospital, he died, another victim of endocarditis, Osler’s great killer. It was an important lesson for me at that early stage in my career. No matter the extraordinary progress that has been made in heart surgery over the past century, the heart remains a vulnerable organ. Despite our best efforts, cardiac patients still die.
One paper found that nearly one in five heart attacks present with sudden death as the first and only symptom, a discovery that ratified the tremendous fear that millions of Americans were living with. By the early 1960s, a definitive association had also been made between cigarette smoking and heart disease. (Smokers in previous studies hadn’t lived long enough to draw definitive conclusions.) This led to the first surgeon general’s report detailing the health hazards of smoking.
In 1966, the United States became the first country to require warning labels on cigarette packages. Four years later, primarily because of Framingham, President Nixon signed legislation banning cigarette ads on television and radio, one of the great public health triumphs of the second half of the twentieth century.
Compared with whites, South Asians have more multivessel coronary artery disease and are more likely to have a more dangerous anterior location of a myocardial infarction. South Asians will soon make up over half of the world’s cardiac patients.
in the marginWhy?
For example, consider heart disease in Japanese immigrants. Coronary artery disease is relatively rare in Japan. However, its rate is almost double in Japanese immigrants who settle in Hawaii and triple in those who settle in the mainland United States.
In the early 1970s, Sir Michael Marmot and his colleagues at the UC Berkeley School of Public Health studied nearly four thousand middle-aged Japanese men living in the San Francisco Bay Area. They found that immigrants who stayed true to their Japanese roots (as evidenced in surveys by their ability to read Japanese, the frequency with which they spoke Japanese, the frequency with which they had Japanese co-workers, and so on) had a much lower prevalence of heart disease, even when they matched Americans in terms of serum cholesterol and blood pressure, than immigrants who were more integrated into their new culture.
In small preindustrial communities, he writes, people tend to know and trust one another. Generosity is rewarded; cheating tends to be punished. When this milieu is disrupted, as in migration or urbanization, there is often an increased need for vigilance. People get estranged from their neighbors. Communities become diverse and more mistrustful. Physical and social isolation often results. Add in poverty, fragmented families, and joblessness, and you get extremely stress-prone populations. The chronic arousal triggers release of hormones, such as adrenaline and cortisol, that tighten blood vessels and cause retention of salt. These in turn lead to long-term changes like arterial wall thickening and stiffening that increase the blood pressure that the body tries to maintain.
Socially stressed laboratory monkeys also develop more heart disease than matched controls. In another study in Science, male monkeys that had stranger monkeys introduced into their cages, often in the presence of an estrogen-laden female monkey, resulting in fights for dominance and less social huddling, developed more coronary artery disease than a control group of monkeys that was not stressed, even though cholesterol levels, blood pressure, blood sugar, and body weight were similar between the two groups.
“I told them, if it’s pericarditis, give me more medication,” he told me later. “Means, do whatever it takes to make the pain go away.”
Gruentzig meticulously pursued his vision. He forged collaborations on steerable catheters with American manufacturers, including the company that would eventually become the multibillion-dollar conglomerate Boston Scientific.
Gruentzig never got a chance to witness this revolution. He and his second wife, a medical resident, died on October 27, 1985, when the private plane he was piloting crashed in a storm in rural Georgia. He was forty-six years old. That year was a tragic one for interventional cardiology. Smoking caught up with the field’s heroes. Mason Sones died of metastatic lung cancer; Charles Dotter, ironically, of complications of coronary bypass surgery.
It is now widely accepted that spiral wave reentry underlies most abnormally fast heart rhythms, including ventricular fibrillation, the most common cause of cardiovascular death in the Western world.
An American dies of cardiovascular disease (including stroke and heart failure) every thirty-three seconds, accounting for about one in four deaths nationwide, and the terminal event in most of those deaths is ventricular fibrillation. Purveyor of life, the heart is also its Grim Reaper.
In the fall of 1960, Greatbatch and Chardack licensed their implantable pacemaker to a small Minneapolis company called Medtronic, which had been started by Earl Bakken, an electrical engineer who worked with Lillehei.
A couple of weeks later, I saw Jack in the clinic. He was wearing his bowler and a vintage blazer, looking even more stylish than usual. He said he was feeling better. There was more color in his face. He had gained some weight, too. He had given up his magnets, which he could no longer apply to his body because they interfered with his defibrillator. (This was probably the reason he had resisted the device for so long, I realized.) I inspected the implantation site. It was red but dry and intact. There were small bandages covering the incision. “The visiting nurse suggested more diuretic to treat the swelling in my legs,” Jack said, hopping onto the exam table. “What do you think?” I couldn’t help but smile. I had been recommending this for months. “I think that would be a good idea, Jack,” I said. He reminded me that before he left the hospital, he’d agreed to increase fosinopril, one of his heart medications. “But sometimes it makes me dizzy,” he said. “Would it be all right if I cut the dose in half?” I started to laugh. Jack, once my most noncompliant patient, had become a convert to modern cardiology. To think that all it took was to bring him back from the dead.
Many diseases have a common, final pathway. For heart disease, that final pathway is heart failure. In the most common form, the heart’s contractions weaken because of damage—heart attacks, chemical, viral—resulting in a drop in blood flow and blood pressure. Because blood pressure determines oxygen delivery to vital organs, the body does all it can to keep the pressure up. Hormones are released that signal the heart to beat faster and the kidneys to retain water to increase blood volume (and therefore blood pressure). These hormones are a temporary fix, however. Cardiac output and blood pressure often do return to normal levels, but at a great cost. The body becomes congested as fluid accumulates and leaks into tissues. As patients become weaker and malnourished, protein levels also drop, keeping even less fluid inside the veins. Soon, water is everywhere, filling up soft tissues in the legs, abdomen, and lungs.
in the marginPhysiology
Continuous blood flow is antithetical to the way that humans, pulsatile beings, evolved. Though continuous flow can keep us alive, it alters our physiology in idiosyncratic and unpredictable ways.
We passed by a patient on a ventilator and dialysis machine; she’d had a large myocardial infarction and was now being supported by ventricular assist devices on both sides of her heart. The multiple consoles surrounded her like a pack of animals. “After so many years of study, I’ve concluded that the best thing we can do for most of our patients is to give them medicine,”
a Hindu myth about a man who had been promised the world—unlimited riches—if he would just drown his mother. At the riverbed, as he starts to submerge her in the frigid water, she implores, “Stay out of the water, son!... You’ll catch a cold.”
If our family was a body, my mother was its heart: the piece that nourishes and ensures the workings of the rest. On the morning of her funeral, as I was adjusting my tie in front of the mirror, I could almost hear her telling me to stand tall, wear a proper suit, and speak confidently. I remembered the frogs in high school, and I started to cry. I could hear my mother telling me once again, “You should do a different experiment, son. Your heart is too small for this.”
I wish she could have seen her funeral, witnessed the scores of friends who came from across the country. For someone who was content to cede the spotlight to her accomplished husband and children, she would have been shocked at how many came to pay their respects, not because of anything she did, but because of who she was, which is perhaps the greatest accomplishment of all.
Do you want to live a long, healthy, and prosperous life? Don’t smoke. Exercise. Eat right. But also take good care of your interpersonal relationships and the way you deal with life’s inevitable upsets and traumas. Your mind-set, your coping strategies, how you navigate challenging circumstances, your capacity to transcend distress, your capacity to love—these things, I believe, are also a matter of life and death.
I am privileged to live in an era in which the human heart has yielded to the human hand. The three-centimeter trip took millennia, starting ostensibly from the pericardium but really from a time when the heart was an almost supernatural object surrounded by taboos.
Though the mechanisms of their deaths (and probably my mother’s) were the same, the outcomes were so different. One death left enduring trauma, the other two gratitude for a merciful demise. For much of my life, I feared the heart’s power, but I don’t see it as I once did. Yes, the heart can snuff out your life, but when the pressure of existence builds up, this organ, prime mover and citadel, is also a safety valve that can facilitate a quick and humane end.