The Heart of the Matter

"And all of a sudden he just dropped dead. He ran and everything."

My friend told me as we drank in the bar, acknowledging with sorrow and fear the death of a male coworker. It was an acceptance of the toll of heart disease in our country, particularly among two 45-year-old men. According to the Centers for Disease Control, heart disease is responsible for approximately 1 out of 4 (600,000) of all American deaths and 1 out of 3 if you include stroke.  It is the leading cause of death for both men and women. Of these deaths the majority are from coronary artery disease (385,000). There are approximately 715,000 heart attacks a year, of which approximately 190,000 occur in individuals who have had one previously.

Although death from heart disease is a great burden on our population, it has decreased dramatically over the years.

Ford and Capewell, J Am Coll Cardiol. 2007; 50 (22):2128-2132

According to a 2011 article by Ford and Capewell in the Annual Review of Public Health, approximately 44%-76% of this decline appears to be because of prevention (such as smoking cessation) and the remaining from treatment such as coronary care units and rapid cardiac catherization during an acute heart attack.

Heart disease is a particularly sobering situation for men, as it affects us more than women. What man reading this post is as fit as Neil Reid was? He played college basketball for Indiana University in 1999. He died of a heart attack at age 36. Dana Carvey, the famous Saturday Night Live alum, had coronary artery bypass surgery at age 42. James Fixx, marathon runner, died of a heart attack at age 52. Former president Bill Clinton had coronary artery bypass surgery at age 57 and then had cardiac stents placed 6 years later. Personally, I think I will suffer a heart attack some time in my own life. Hopefully, it will just be later rather than sooner (at least from my perspective).

For me, the question is not why do we have so many heart attacks, but rather why don’t they occur even more frequently? There are only three main arteries around the heart (coronary arteries), and each is about the size of a piece of spaghetti. Considering how small these precious arteries are, it’s amazing they function as well as they do. The main arteries are the left anterior descending, the left circumflex and the right coronary artery. Smaller arteries arise from these larger arteries and provide blood flow to the whole heart.



From Wiki


Many people do not understand how most heart attacks occur. Many think that cholesterol clogs up a coronary artery by causing a cholesterol plaque (similar to a clogged pipe drain), leading to a heart attack. Actually, these plaques can often be very small and not cause much occlusion of the coronary artery. A heart attack usually occurs because a plaque int he coronary artery ruptures. The body then tries to repair this rupture. Just like when you cut yourself and your body forms a scab, the body tries to repair the damage caused by the rupture of the plaque by forming a blood clot inside the blood vessel. This blood clot prevents blood from flowing in the blood vessel, and therefore a heart attack occurs immediately.

This is the reason that the first medication given to heart attack victims in the emergency room is blood thinners to help increase blood flow (usually it begins with 4 baby aspirin which the patient chews) followed by a catherization to open up the blood clot, often with a stent, followed by more blood thinners such as Plavix.

Knowing one’s risk factors can help decrease the probability of heart disease. One of the largest public health undertakings to study heart disease began in Framingham, Massachusetts in 1948. The original study involved 5209 men and women and in 1971 it enrolled another 5,124 men and women to study the risk factors for heart disease. This large epidemiological study created the Framingham Risk Score, which allows an individual or a provider to calculate a 10-year risk score for an individual. You can find such a calculator here. The main risk factors are high blood pressure, high blood cholesterol, smoking, obesity, diabetes, and physical inactivity.

One critical element is that these risk factors are additive. Such that if a person smokes, has diabetes and has hypertension, they are at a much greater risk of future heart disease than if that person only had one risk factor.

Whatever one can do to limit the totality of risk factors, the more likely there is to be a favorable benefit.

Lastly, I want to emphasize again that, if at all possible, it is better to prevent heart disease than treat it, particularly in regards to coronary artery disease. If one is having a heart attack and has a stent put in (a wire mesh device that opens the artery), it can, and often is, life-saving and can prolong one’s life. Further, if one is having “unstable angina,” or pain from coronary artery disease that is changing in duration or severity, a stent can also be live-saving.

However, many cardiac stents are not placed for acute heart attacks or unstable angina, but rather for chest pain from stable angina. That is, the pain occurs at specified time and duration, (such as walking up the fourth flight of stairs). The primary purpose of such stents is to decrease pain, NOT to prolong life or prevent another heart attack. It is critically important to understand this, because too many people feel their artery is clogged and, like a plumber, the cardiologist has put in a stent which will open the coronary artery and prevent a future heart attack and prolong life.

There was a large study called the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial in 2007 that enrolled 2,287 individuals, half of which received stents and half of which received medication for chronic stable angina. The follow-up was 4½ years. There was no statistical difference between death, nonfatal heart attack, or stroke (20% in the angioplasty group, versus 19.5% in the medical group). This is what Steve Nissen, a past president of the American College of Cardiology said about placing stents in individuals with chronic stable angina on the PBS Newshour “We know that stents do, in fact, help to relieve chest pain, but they really do not prolong life or reduce the risk of a heart attack in patients that are otherwise stable.”

This all points to the idea that coronary artery disease, like nearly all disease, is a process, not a static event. It is not treated by one pill, or one stent or one "magic bullet." Rather, try to curb the entire process by taking appropriate medications, lowering blood pressure, keeping one’s blood sugar down, and not smoking. And if you have chest pain that you think is coming from the heart, chew several baby aspirin (4 are usually given in the ER) and GET TO THE ER!