In her office, Carole showed me angiograms of program participants whose coronary disease had regressed. “When people talk about the Ornish program, they usually talk about the diet,” she said. “But the social support and stress management are probably the most important pieces.” Patients were often reluctant to participate in group therapy, she said. “Some ask for a waiver. They don’t want to open up to strangers. But it almost always ends up being their favorite part.”
Ornish himself puts a great premium on the psychosocial piece of his program. He has pointed out, for example, that some patients in his original control group adopted diet and exercise plans that were almost as intense as those of the intervention group. However, their heart disease still progressed; diet and exercise alone weren’t enough to facilitate coronary plaque regression. At both one- and five-year follow-ups, stress management was more strongly correlated with reversal of coronary artery disease than exercise. “The need for connection and community often goes unfulfilled in our culture,” Ornish said in a 2015 interview. “We know that these things affect the quality of our lives, but they also affect our survival to a much larger degree than most people realize.”
Many studies have suggested that Ornish is probably right. In one example, patients who were depressed after a heart attack were four times as likely to die within six months as those who were not, irrespective of usual Framingham risk factors like high cholesterol, hypertension, obesity, and smoking. In another study, menopausal women with no history of cardiovascular disease who expressed more hopelessness on a psychological questionnaire had more carotid artery thickening and an older vascular age than matched patients who felt good about their lives.2 No doubt many of these studies are small, and of course correlation does not prove causation; it is certainly possible that stress leads to unhealthy habits—poor nutrition, less physical activity, more smoking—and this is the real reason for the increased cardiovascular risk. But as with the association of smoking with lung cancer, when so many studies show the same thing and there are mechanisms to explain a causal relationship, it seems perverse to deny that one probably exists. What Ornish and others have concluded is fully consistent with what I have learned in my two decades in medicine: that the emotional heart affects its biological counterpart in multiple mysterious ways.
Carole told me she uses “trackers” to see how well patients follow the program on the days they do not come to the center. There are trackers for diet and exercise, of course, but also ones for love and support. Patients are asked to rate “How connected am I?” on a simple numerical scale. Those who do more than one hour of stress management daily have the greatest improvement in coronary blood flow. “We run our lives at such a frenetic pace,” Carole said. “Our sympathetic nervous systems are on overdrive. But how we react to the stress is under our control.”
Unfortunately, I was not going to be able to participate in the Ornish program. Traveling to New Jersey twice a week for nearly three months wasn’t feasible, and abridged courses, Carole sadly informed me, were not yet available. She promised to send me some material so I could get started on my own. “Try to find joy in each day,” she said, walking me to the elevator. “Instead of thinking about the past or worrying about the future, focus on the present.” I told her I would do my best. Then I went down to the parking lot, got into my car, and joined the Friday evening rush toward Long Island.
* * *
Perhaps more than any other area of medicine, cardiology has been at the forefront of technological innovation and quality improvement over the past fifty years. This golden period has witnessed a barrage of life-prolonging advances, many of them discussed in this book, including implantable pacemakers and defibrillators, coronary angioplasty, coronary bypass surgery, and heart transplantation. Preventive health initiatives, such as smoking cessation and cholesterol and blood pressure reduction, have supplemented these biomedical advances. The result has been a 60 percent drop in cardiovascular mortality since 1968, the year I was born. There are few stories in twentieth-century medicine that have been as uplifting or far-reaching.
For a while it appeared that cancer would replace heart disease as the leading cause of death in the United States, but no more. The rate of decline in cardiovascular mortality has slowed significantly in the past decade. There are many reasons for this. The fall in smoking rates has leveled off. Americans have become more overweight. Diabetes cases are projected to nearly double in the next twenty-five years. But I believe there is another reason, too. Cardiology in its current form might have reached the limits of what it can do to prolong life.
This would have been heresy to pioneers like Walt Lillehei, Andreas Gruentzig, and Michel Mirowski, but today it is hard to refute. The law of diminishing returns applies to every human enterprise, and cardiovascular medicine is no different. For instance, ever since coronary thrombosis was shown to be the cause of most heart attacks, cardiologists have taken it as an article of faith that more rapid treatment of such thromboses improves patient survival. “Time is muscle,” goes the operative mantra, and the shorter the delay, the better. Yet a study of nearly 100,000 patients published in 2013 in The New England Journal of Medicine found that shorter “door-to-balloon” times—the period from a patient’s hospital presentation to inflation of a balloon to restore coronary blood flow—did not improve in-hospital survival. The median door-to-balloon time dropped to sixty-seven minutes, from eighty-three, in the period studied, but short-term death rates did not change.
There are several plausible explanations for this result. Perhaps heart attack patients who are healthier and at low risk for death are already getting expeditious treatment, and those who are at higher risk are experiencing the most delays. Perhaps the follow-up time in the study was too short, and if we waited a bit longer, a survival benefit would be seen. Or perhaps there is another reason. Mortality after a heart attack has already dropped tenfold, from 30 percent to 3 percent, since Mason Sones invented coronary angiography in 1958. Can the tweaking or speeding up of existing procedures possibly yield any significant additional benefit?
There are other examples of such diminishing returns. In my specialty, heart failure, medications such as beta-blockers and ACE inhibitors have profoundly improved survival since their advent in the mid-1980s. Yet recent studies of newer agents—endothelin blockers, vasopressin antagonists—have shown little benefit. Today patients’ Framingham risk factors, such as hypertension and high cholesterol, are better controlled. It is getting harder to improve on existing successes.
No doubt we should celebrate the rise of high-tech medicine. For example, more than 90 percent of patients who present directly to hospitals that do angioplasty have door-to-balloon times today of less than ninety minutes, with a median time of approximately sixty minutes, a major improvement from only a few years ago. However, this means that the bar is continually being set higher for every new treatment.
I believe that cardiovascular medicine in its current form, focusing on investigating minor iterations of commonly used drugs or add-on therapies or optimizing existing procedures, will increasingly produce only marginal advances in the years ahead. We will need to shift to a new paradigm, one focused on prevention—turning down the faucet rather than mopping up the floor—to continue to make the kind of progress to which patients and doctors have become accustomed. In this paradigm, psychosocial factors will need to be front and center in how we think about health problems. Despite the centuries-old association of the heart with emotions, this is still a domain that remains largely unexplored. However, today it is increasingly clear that chronic diseases like hypertension, diabetes, and heart failure are inextricably linked to the state of our neighborhoods, jobs, families, and minds.
Heart disease, as we’ve seen, has psychological, social, and even political roots. To treat our hearts optimally will require interventions on all these fronts. This is much easier said than done, of course. Psychosocial “repair” is just as prone to unexpec
ted consequences, difficult trade-offs, conflicting values, and diminishing returns as any medical treatment. We cannot even agree on what should be repaired. But we will have to find ways, as Peter Sterling, the neurobiologist, has put it, to “reduce the need for vigilance and to restore small satisfactions,” such as our contact with nature and with one another. For some, this will require city-planning initiatives to encourage walking or bicycling, for example, instead of more sedentary lifestyles. Others will require fortification in more social realms, such as the enhancement of public life. For still others, cardiovascular benefits will come from more individualistic pursuits, such as yoga and meditation. Whatever the case, it is increasingly clear today that the biological heart is inextricably linked to its metaphorical counterpart. To treat our hearts, we must repair our societies and minds. We must look at not only our bodies but also ourselves.
* * *
I am lying on a blanket, staring up at the stars. Though the sun set more than an hour ago, the sky is fringed with streaks of orange. The air is still and smells of citronella and bug spray. Though the party is winding down, children continue to play in a sugar-fueled frenzy, barreling down inflatable slides and running tag on the lawn. My daughter, Pia, is sitting on my chest, burrowing her head affectionately into my neck. “Are you happy?” she asks me, her warm breath tickling my skin.
“Yes,” I reply. “Are you?”
“Yes, Dad,” she says. “I’m happy, too.”
As another summer winds down, my CT scan is a distant memory. It was supposed to change everything, but in the end it was a hiccup, a PVC, and my life has returned to its normal rhythm. Like when you plan a trip somewhere and you think the place will feel different, the way you see it in pictures, and then you get there and it’s the same as the place you came from: same sky, same air, same clouds. Of course, I’ve made changes. I exercise almost every day now, and I eat better, too. I spend more time with my children and with friends. I still enjoy working hard, but I am no longer so contemptuous of relaxation.
Many factors that affect our health are out of our direct control—we cannot diminish the stress that comes with reading the newspaper, or with supporting a family in a competitive economy, or with living in a violent neighborhood—at least not without patient and collective effort. But many entail decisions, and ways of behaving, that we can master. 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 imagine I’ll repeat the CT scan at some point to see whether my coronary plaque has progressed. But I am not all that afraid of what I will find. I feel reassured by the knowledge that has accumulated in my field over the past century, even the past decade. We can now replace heart valves without open-heart surgery. We can inject stem cells to heal damaged heart muscle. My paternal grandfather was in his early fifties when he died. I am forty-eight as I write these words. But I am not my grandfather. 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. Through this journey, the heart was transformed into a machine that can be manipulated and controlled. But these manipulations, as we have learned, must be complemented by attention to the emotional life that the heart, for thousands of years, was believed to contain.
After so many years in the business, I see heart shapes everywhere: in the splash of raindrops on my windshield, in the beets I slice in my kitchen, in strawberry slivers and bitten cherries. And every morning, the drops of milk at the swirling center of my coffee cup make a spiral wave.
I still often think of my grandfathers and of course my mother. I can picture my paternal grandfather slumping in cardiac arrest onto that stone floor in Kanpur, surrounded by his alarmed family. Or my maternal grandfather sitting in his drawing room in New Delhi on the day he died, listening to the news on the BBC while waiting for his breakfast. In the span of a few heartbeats, he was no more. 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.
Notes
Introduction: The Engine of Life
1. Nineteenth-century scientists used a rotating wheel driven by a motor and synchronized to the cardiac cycle to detect small variations in the heart’s rhythm.
2. The kidneys were also left behind, probably because their location in the body made removal difficult. One can almost hear the words of the recently departed Egyptian, bowed in submission, written on the papyrus: “O my heart which I had upon earth, do not rise up against me as a witness … Do not speak against me concerning what I have done.” Through the Middle Ages, the hearts of kings and princes were still often buried separately, and as recently as 1989 the queen of Hungary chose to have her heart interred in a monastery in Switzerland where her husband’s heart also lay.
2. Prime Mover
1. Unlike the cells of lesser organs such as the liver, heart cells do not regenerate in large amounts. When they die, they are gobbled up by cells called macrophages and replaced by scar tissue.
2. The importance of turbulent flow for closing the aortic valve, an idea originated by Leonardo, has been confirmed only in the past decade.
3. In his later years, Harvey reportedly said to a friend, “You know very well the storm my previous research caused. It is often better to grow wise in private at home, than to publish what you have amassed with infinite labor, to stir up storms that may rob you of peace and quiet for the rest of your days.”
4. Capillaries were discovered three decades later, in 1661, when Marcello Malpighi looked at sections of frog lung under a microscope. Malpighi referred to frogs as the “microscope of nature” because they allowed him to see structures that were not visible in larger animals. Nature is accustomed, he wrote, “to undertake its great works only after a series of attempts at lower levels, and to outline in imperfect animals the plan of perfect animals.” He added, “For the unloosing of these knots I have destroyed almost the whole race of frogs.”
5. Through experiments, Harvey proved that when the pulmonary artery is ligated and the right ventricle is injected with water, no fluid crosses the septum into the left ventricle.
6. Harvey’s analogies extended to the body politic. He wrote to King Charles I in the preface to De motu cordis, “What I have here written of the motions of the heart I am the more emboldened to present to your Majesty, according to the custom of the present age, because almost all things human are done after human examples, and many things in a King are after the pattern of the heart. The knowledge of his heart, therefore, will not be useless to a Prince, as embracing a kind of Divine example of his functions—and it has still been usual with men to compare small things with great. Here, at all events, best of Princes, placed as you are on the pinnacle of human affairs, you may at once contemplate the prime mover in the body of man, and the emblem of your own sovereign power.”
3. Clutch
1. Tamponade is a last-drop phenomenon: a small amount of extra fluid in the pericardium can cause the blood pressure to plummet. Fortunately, it is also a first-drop phenomenon: extracting even a small amount of fluid can restore blood flow and life.
2. There are reports of sporadic attempts on the battlefield, which were likely uns
uccessful. Henry Dalton, a little-known St. Louis surgeon, is often credited with the first suture of the pericardium of a stabbing victim in 1891, but his achievement was not widely reported.
3. In 1868, Georg Fischer analyzed 452 cases of heart wounds and found the survival rate to be only 10 percent.
4. Dynamo
1. Hypothermia was also tried as a treatment for metastatic cancer, leukemia, schizophrenia, and drug addiction, with discouraging results.
5. Pump
1. Edward Churchill himself said in 1934, “Although our enthusiasm is somewhat dampened by a series of ten failures, we shall continue to recommend the Trendelenburg operation under favorable circumstances.”
2. The first successful pulmonary embolectomy in America took place at the Peter Bent Brigham Hospital in Boston on January 14, 1958, well after the invention of the heart-lung machine.
3. The clotting problem was solved with the use of heparin, a blood-thinning protein discovered by Jay McLean, a medical student at Johns Hopkins, in the brains of salamanders. (The substance was initially called cephalin.) In the 1920s, animal experiments confirmed that heparin was an effective anticoagulant.
6. Nut
1. Forssmann told the journalist Lawrence Altman that this story, which Forssmann himself publicized, was apocryphal.
Heart--A History Page 22