PRAISE FOR HEART
“Dr. Jauhar expertly weaves little-known tales from medical history into his own personal and professional experiences to create a richly detailed book about the human heart. Thoroughly engrossing and full of historical gems.”
Lindsey Fitzharris, author of The Butchering Art
“Cardiologist Jauhar moves beautifully between ‘dual tracks’ of ‘learning about the heart...but also what was in my heart,’... Covering enough physiology to make scientific details easily understood, Jauhar emphasizes how brave, desperate, and sometimes foolhardy experiments led to important developments, such as the heart-lung machine… Jauhar is thoughtful, self-reflective, and profoundly respectful of doctors and patients alike; readers will respond by opening their own hearts a little bit, to both grief and wonder.”
Publisher’s Weekly, starred review
“Sandeep Jauhar writes with the eye of a doctor and the heart of a poet. His latest book, Heart: A History, is a superb tribute to our most vital organ.”
Marilyn Yalom, Stanford University, author of The Amorous Heart
“In Heart: A History, Sandeep Jauhar, one of the most talented physician-writers of our era, takes us on an enlightening, uplifting journey through the major milestones and advances of heart disease—while at the same time anchoring his intimate, personal experiences.”
Eric Topol, Scripps Research Institute, author of The Patient Will See You Now
ALSO BY SANDEEP JAUHAR
Doctored
Intern
HEART
HEART
A HISTORY
SANDEEP JAUHAR
For Pia, my heart
The animating spark of the body, nurse of its life, the creative principle and harmonizing bond of the senses; the central link in the human structure … mainstay of our nature, king, governor, creator.
—Bernard Silvester, twelfth-century poet and philosopher
Contents
Prologue: CT Scan
Introduction: The Engine of Life
PART I: METAPHOR
1. A Small Heart
2. Prime Mover
PART II: MACHINE
3. Clutch
4. Dynamo
5. Pump
6. Nut
7. Stress Fractures
8. Pipes
9. Wires
10. Generator
11. Replacement Parts
PART III: MYSTERY
12. Vulnerable Heart
13. A Mother’s Heart
14. Compensatory Pause
Supplementary Reading
Acknowledgments
Index
HEART
Prologue: CT Scan
I’d been getting short of breath. When I walked up the scuffed steps to my fourth-floor office, I had to stop to rest. Sometimes, at night, I would start to wheeze as my airways congested with mucus, and I’d break into fits of cough. As a physician, I was privileged to have been a first responder on 9/11, but many of us who had been at Ground Zero were reporting respiratory problems. So I went to my friend Seth, a pulmonologist, for an evaluation. He ordered pulmonary function tests, in which I sat in a glass-walled booth and blew hard into a plastic tube. Airflow and lung volumes were normal. Seth diagnosed me with acid reflux, a common cause of chronic cough, and prescribed a daily antacid. But I persuaded him to order a CT scan of my chest. My symptoms seemed out of proportion to his benign diagnosis. I was worried that my lungs had been damaged by the smoke and dust I’d inhaled downtown.
As Seth predicted, the CT scan revealed normal lungs. However, an incidental finding caught my eye. “Coronary artery calcifications are noted,” the report offhandedly stated. Coronary calcium is a marker of atherosclerosis, hardening of the arteries. It had been reported as an incidental finding on countless CT scans of my older patients over the years, and I’d scarcely paid any attention. But now, at age forty-five, I wanted to know more. How much calcium was present, and where, exactly? A radiologist informed me that the scan I’d had did not have the resolution to answer these questions.
On my computer, I pulled up a Framingham calculator, a tool designed to estimate one’s risk of a heart attack within the next ten years. I put in my height and weight, blood pressure and cholesterol, and the fact that I am a nonsmoker and don’t have diabetes. The program spit out a ten-year risk of a heart attack of 2 percent and of any cardiovascular event (including angina and stroke) of about 7 percent. Reassuringly low. However, I also knew that for an Indian immigrant with a strong family history of heart disease, the calculation probably underestimated the true risk.
My brother, Rajiv, also a cardiologist, suggested a treadmill stress test, but I was playing tennis on weekends without any symptoms. A stress test would only detect coronary blockages greater than 70 percent, and I was pretty sure my disease was not that advanced. So I opted for a special, noninvasive CT angiogram to look into my coronaries. Every Father’s Day I received spam e-mail about this test. “Make sure Dad is not among the hundreds of thousands of men in America who appear healthy but are actually a ticking time bomb.” Strange to think that I might now be one of those men. I called Dr. Trost, the cardiac radiologist in our department, and scheduled the scan. She reassured me that I was at low risk for heart disease. “But for your peace of mind, you should probably have it,” she said.
So, early one morning in June, I went for the test. While I lay on the gantry outside the C-shaped scanner, a tech inserted an IV in the back of my hand. The scan would have to resolve millimeter-sized plaque in a grapefruit-sized organ moving at a velocity of 200 millimeters per second. I was given an intravenous beta-blocker to slow down my heart to reduce image blur. A nitroglycerin tablet was also placed under my tongue to dilate my chest arteries so the scan could visualize them better. After a couple of preliminary images, a nurse injected X-ray-opaque dye into my vein. “You’re going to feel warm all over,” she said as I blushed, thinking I had wet myself. The final run-through took less than a minute.
After Dr. Trost reviewed the images, she called me into the reading room. The gray-and-white pictures were up on a large monitor. White specks, radiographic grit, were in all three of my coronary vessels. The main artery feeding my heart had a 30 to 50 percent obstruction near the opening and a 50 percent blockage in the midportion. There was minor plaque in the other two arteries, too. Sitting numbly in that dark room, I felt as if I were getting a glimpse of how I was probably going to die.
Fear Heart (Courtesy of Darian Barr)
Introduction:
The Engine of Life
There is nothing shameful about a heart attack.
—Susan Sontag, Illness as Metaphor (1978)
Perhaps the most consequential event in my life occurred fifteen years before I was born. On a sweltering July day in India in 1953, my paternal grandfather died suddenly. He was only fifty-seven. The circumstances were unusual, and like most family tragedies, ours has acquired a touch of myth. Everyone agrees that in the morning on the day he died, my grandfather was bitten by a snake coiled between sacks of grain in his little shop in Kanpur. He did not see the type of serpent, but snakebite is common in India, and by all accounts my grandfather was feeling fine when he came home for lunch. My father, who was almost fourteen, was going for an interview at Kanpur Agricultural College the following day, and my grandfather had planned to accompany him. They were sitting on the stone floor, inspecting my father’s high school diploma, delighting in all the academic honors he’d received, when, midway through the meal, neighbors brought in the corpse of the shiny black cobra they claimed had bitten my grandfather. (It had been killed by a snake charmer summoned to the shop.) My grandfather took one look at it and went pale. “How can I survive this?” he said, before slumping to the floor. The nei
ghbors exhorted him to say “Ram, Ram,” a Hindu prayer, but his last words, lying on the floor, his eyes turning to glass, were “I wanted to take Prem to college.”
A government ambulance used to make rounds in the village regularly. Around 7:00 p.m., several hours after my grandfather’s collapse, it was flagged down on a routine drive. By then, rigor mortis had set in, traveling like a slow wave from my grandfather’s neck and jaw into his limbs. The paramedics immediately declared my grandfather had passed—he had no heartbeat—but the family, in denial, insisted they take him (and the snake) to a British-built hospital about five miles away. A doctor there pronounced my grandfather dead on arrival.
“It was a heart attack,” the doctor said, dispelling the family’s belief that a snake had killed their elder. My grandfather had succumbed to the most common cause of death throughout the world, sudden cardiac death after a myocardial infarction, or heart attack, perhaps triggered in his case by fright over the snakebite. With nothing to be done, and the summer heat threatening to spoil the body, my grandfather was brought back to the village and cremated the following day. Before a garlanded casket set on a pyre soaked in oil, people beat their heads in grief under a light blue sky.
Listening to family lore, I grew up with a fear of the heart as the executioner of men in the prime of their lives. Because of the heart, you could be healthy and still die; it seemed like such a cheat. The apprehension was fed by our grandmother, who came to live with us in California in the early 1980s (until she got homesick and returned to the tiny village in Kanpur where her beloved husband had died). Even thirty years after his death, she still wrapped herself in white gossamer shawls that smelled of mothballs, befitting a widow. Once, at the Los Angeles Zoo, she bowed respectfully to the snake they brought around, clasping her hands and muttering a prayer before insisting we take her home. She was a strong-willed woman who ably took over the reins of the household after her husband died. And yet, like Miss Havisham, she spent her life in mourning over one freakish, incomprehensible incident. In India, snakes symbolize infinity and timelessness, as well as misfortune and death. To the end, in her mind, it was a venomous snake that killed her husband. And in a way, in the suddenness with which a heart attack can fell a healthy and vibrant life without warning, it was.
My maternal grandfather also fell victim to sudden cardiac death, though many years later. He was an army doctor who set up a successful private practice at his home in New Delhi. On a September morning in 1997, just after his eighty-third birthday, he woke up complaining of abdominal pain, which he attributed to an excess of food and scotch the night before. After a few minutes, he bellowed a loud groan and went unconscious; just like that, he was gone. He almost certainly had had a massive heart attack, but that wasn’t what killed him. It was the ensuing arrhythmia—ventricular fibrillation, in which the heartbeat becomes chaotic—that prevented his heart from sustaining blood flow and life. When I talked to my mother about his death, she said she was sad that he died so suddenly. But she was thankful, too.
Thus, the human heart became an obsession for me, in no small part because of my family history. As a boy, I used to lie in bed and monitor the thudding in my own chest. I’d lie on my side, head in hand, and listen to the squirting pulse in my ears. I’d adjust the speed of the ceiling fan to synchronize with my heartbeat, in thrall to the two competing oscillators, so grateful that mine never took a rest.* I was fascinated by the heart’s dichotomous nature: muscular, constantly toiling, and yet so vulnerable at the same time. Years later, when I became a heart-failure specialist, I reproduced this preoccupation in my children. When my son, Mohan, was small, we used to watch a PBS special on heart disease, in which a man having a heart attack develops cardiac arrest. In the back of an ambulance, he is shocked back to life with defibrillator paddles, his body violently jerking with the electrical discharge. Mohan would stare at the scene spellbound, often rewinding the tape, until I’d insist we turn it off, fearful of the impact on his developing mind. We’d watch it again the next day.
•
This book is about what the heart is, how it has been handled by medicine, and how we can most wisely live with—as well as by—our hearts in the future. The heart’s vital importance to our self-understanding is no accident. If the heart is the last major organ to stop working, it is also the first to develop—starting to beat approximately three weeks into fetal life, even before there is blood to pump. From birth until death, it beats nearly three billion times. The amount of work it performs is mind-boggling. Each heartbeat generates enough force to circulate blood through approximately 100,000 miles of vessels. The amount of blood that passes through an average adult heart in a week could fill a backyard swimming pool. But the life that it sustains can quickly be taken away. When the heart stops, death is instantaneous. If life is a continuous struggle against the inexorable march of entropy, then the heartbeat is at the core of that conflict. By purveying energy to our cells, it counteracts our tendency toward dissipation and disarray.
More than anything, the heart wants to beat; this purpose is built into its very structure. Heart cells grown in a petri dish start to contract spontaneously, seeking out other cells (through electrical connections called gap junctions) to synchronize in their rhythmic dance. In this sense, cardiac cells—and the organ they create—are social entities. The heart can continue to beat for days, even weeks, after an animal has died. In a laboratory, the French Nobel laureate Alexis Carrel showed that properly nourished chick heart tissue cultured on a medium of blood plasma and water will pulsate for months and can remain alive for more than twenty years, much longer than the normal life span of its host. This is a unique property of the heart. The brain and other vital organs cannot function without a beating heart, but a beating heart does not depend on a functioning brain, at least not in the short term. Moreover, the heart doesn’t just pump blood to other organs; it pumps blood to itself. We cannot see our own eyes. We must struggle to use our minds to change our way of thinking. But the heart is different. In a sense, and unlike any other organ, the heart is self-sustaining.
Of all the connections of the heart—to emotions, to thought—the link between the heartbeat and life is perhaps the strongest. We associate the heart with life because, like life itself, the heart is dynamic. From second to second, and on a macroscopic scale, the heart is the only organ that discernibly moves. Through its murmurings, it speaks to us; through its synchronized contractions, it broadcasts an electrical signal several thousand times more powerful than any other in the body. Over the centuries, disparate cultures have viewed the heart as the source of a life-giving force that was to be culled or harvested. In ancient Egypt, the heart was the only organ that was left in the body during mummification because it was believed to play a central role in the rebirth of an individual after death.* In a scene often depicted in Egyptian mythology, the heart of a deceased person is weighed on a scale balanced by a feather or statuette representing truth and divine law. If the heart balanced evenly, it was considered pure and returned to its owner. But if it proved laden with sin, it was devoured by a monstrous chimera, and the deceased was banished to the underworld. Three thousand years later, in elaborate hilltop ceremonies, 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?”
The sanguine dance must eventually come to an end. Cardiovascular disease claims 18 million lives—nearly one-third of all deaths—across the globe each year. Since 1910, heart disease has been the number one killer in the United States. Today 62 million Americans (
and more than 400 million worldwide, including 7 million in the UK) suffer from heart disease.
The second most common cause of death in America—and the most common in the UK, where heart disease is the second—is cancer, but heart disease and cancer could hardly be more different. In cancer, cells divide madly, migrate wildly, invade mercilessly, in a sort of hard-charging pollution of the body. Heart disease is different: cleaner, stricter, less ambiguous, more comprehensible. Cancer patients, Susan Sontag wrote, are stained and fragmented. Cardiac patients, she said, often stand tall, seemingly healthy, like my grandfather, until they die.
The numbers could be even worse. Cardiovascular deaths in America and Britain have declined significantly since the mid-1960s, by over 50 percent and almost 60 percent respectively. 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. The twentieth century will go down in history as one in which the great scourge of cardiovascular disease finally began to come under control.
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. Heart failure is now the number one reason patients over sixty-five years old are hospitalized, and most patients still die within five years of diagnosis. Ironically, as we become more adept at treating heart disease, the set of people who are ill with it is growing.
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