Change comes slowly, but recognizing change happens in an instant. If you want to see how much we’ve come to take for granted in cardiac care, look no further than the reaction to the sudden death last summer of journalist Tim Russert.
Shock that Russert, who collapsed and died of a sudden heart attack, had been taken “so young” echoed throughout the news media and TV-viewing public. He was so healthy, so vital — how could this have happened? We forget that it used to happen all the time, that 58-year-old men dropping dead in their tracks was once just one of those sorrowful things about middle age, and surprised very few people.
But things change, and things have changed dramatically in the realm of heart disease, across the spectrum of its prevention and care. However, it is still the leading cause of death in the United States, according to the Centers for Disease Control and Prevention. Adults today know that exercise isn’t something one leaves behind after college intramurals (though whether they heed that advisory is another matter). Cholesterol drugs are the most prescribed in the nation.
And, while obesity remains a stubborn problem, smokers are more marginalized every year.
And that’s just the prevention side, all of which can make a cardiologist such as Dr. Douglas Weaver very optimistic.
“The death rate from heart disease has dropped 25 percent in 15 years alone, [and] 40 percent in the last 30 years,” says Weaver, chief of cardiology for Henry Ford Health System in Detroit. A few major advances have made that happen, coupled with a constellation of smaller ones that, taken together, add up to a revolution in how doctors prevent and treat heart disease. Although it remains a major cause of premature death in this country, a diagnosis of coronary disease, or even a heart attack, is simply not the event it once was. The advances fall into three general areas.
“It’s true that the message is out there, and people are more cognizant, but I tell patients all the time that despite all the advances in technology, nothing cures this disease,” says Thomas LaLonde, chief of cardiology at St. John Hospital in Detroit. “That’s why primary prevention is extremely important, and secondary prevention even more so.”
By primary prevention, LaLonde means minimizing risk factors — keeping weight under control, getting regular exercise, avoiding smoking. And secondary prevention is for those with one or more risk factors, including diabetes, but most important, high cholesterol.
To LaLonde, “statin drugs are the biggest advances in medicine since penicillin and aspirin.” Statins — the class of cholesterol-lowering drugs that includes Lipitor, Zocor, Crestor, and others — have allowed millions to reduce their chances of developing blockages in their coronary blood vessels. Diet and exercise can keep cholesterol levels low, but some have a family history that predisposes them to high numbers. It’s those who are most helped by statin drugs.
Weaver joins the chorus on cholesterol-lowering drugs, saying, “Side effects of statins are so uncommon, and the benefit is so huge, it’s really made an amazing difference” in heading off heart disease before it gets established.
Weaver is 60 and LaLonde, 51. Both have lived through most of the changes that transformed their field, and both point to advances in the last 15 years as the real game-changers. That’s when angioplasty and stents came into wide use, the “percutaneous” (minimally invasive, non-surgical) procedure and devices that allowed people to be treated for heart disease before they suffered a major cardiac event.
Better diagnostic techniques, includ-ing stress tests and, most recently, the 64-slice CT angiogram, are identifying potential heart patients months or years before they suffer any chest pain. This is nothing less than revolutionary, to reopen blood vessels edging toward closing while the heart is still relatively healthy. So-called “sub-clinical” patients will respond better to treatment and recover faster, particularly when they don’t have to undergo surgical procedures in the process.
“We’re starting to send people home the same day they’ve had [angioplasty],” LaLonde says. “The restrictions [on activity] aren’t for the heart procedure but for the groin puncture [where the catheter is introduced].”
Angioplasty helps those who have heart attacks, as well. In recent years, the American College of Cardiology (ACC) has embarked on a major initiative aimed at cutting “door-to-balloon time,” the interval between when a patient is diagnosed with an ongoing heart attack and when the blockages are cleared with angioplasty. Using the mantra “time is muscle,” the ACC combined study and education to identify practices that could reduce the time to under 90 minutes.
Some parts of it are quite expensive, LaLonde says, identifying the portable electrocardiogram (ECG) units carried on ambulances, which transmit data back to hospitals via cellular links, as one big-ticket part of the process. Others are a matter of streamlining processes to get catheterization labs ready and on-call personnel scrambled to perform the procedure. But the results have been clear:
“In almost every case where EMS can get an ECG, transmit it to the [emergency room], get an interpretation and activate the lab and team, we’re able to get our response time under 90 minutes and, in some cases, under 50 minutes,” he says. The result is fewer patients who have to undergo invasive bypass surgery, with its two- to three-month recovery time.
Gone are the days when recovery from a heart attack meant taking it easy. Contemporary cardiac rehab is most often undergone in a gym, working up a sweat on exercise equipment. The heart is a muscle, after all, and muscles need to be worked.
Surprisingly, there’s never been a large study of the effect of exercise in cardiac rehab patients (although one is under way now), Weaver says. But both he and LaLonde are convinced of its benefits. Patients who exercise after a heart attack control their weight better, are less likely to smoke, and have fewer cases of sudden death. LaLonde also likes rehab’s psychological effects. “It’s a mental thing,” he says. “Patients feel they can get back to normal activity faster,” and it’s the ideal environment for education and counseling.
But even with all these advances, Weaver says coronary care has many more frontiers ahead of it. The nation’s obesity rates remain a problem, especially as they contribute to Type II diabetes, a major contributing factor for heart disease. The number of children suffering from the disease worries public-health observers. Diabetes and untreated hypertension lead to congestive heart failure, an overall weakening of the muscle, which is much more difficult to treat. Researchers now are working with stem cells and implantable pacemakers as promising treatments for the condition.
LaLonde also mentions “vulnerable plaque,” ruptures within plaque deposits that can lead to catastrophic cardiac events, believed to be the type that killed Russert. He hopes that, within the next five years, doctors will be better able to identify these deposits early and treat them.
For now, the best treatment remains prevention, something no one has to tell Darryl Price, a 52-year-old retired Detroiter who suffered his second heart attack in July. He’d already had one angioplasty, and became complacent about taking his medication: Plavix and hypertension drugs. After mowing the lawn one day, he started sweating profusely and suffered massive chest pain. A neighbor called EMS, and all the miracles of modern cardiology were summoned to save him, including the cellular-transmitted ECG. His door-to-balloon time was a new hospital record: 22 minutes. But Price learned all that technology won’t help him if he doesn’t do his part.
“I wasn’t completely unconscious,” he says of the angioplasty. “Lying on that table and seeing your heart stop is something else.”
There’s nothing like fear as a motivator. He won’t be skipping his medication anymore, he says. “That’s first and foremost.”
Derringer is a Grosse Pointe Woods-based freelancer. E-mail: email@example.com.