The Tangled History of Cardiac Care
Publication Year: 2012
Published by: The Johns Hopkins University Press
Cover, Title Page, Copyright
List of Figures
When I had cancer a few years ago, I was lucky in many ways. I faced no difficult decisions. As soon as the radiologist confirmed the existence of the fist-sized tumor I had first felt near my stomach, the course was clear. The tumor had to be removed. A kind surgeon quickly obliged, and I was tumor-free in ten days. When genetic analysis revealed that the tumor was not susceptible to any chemotherapy, I was spared another decision: there ...
This book is one piece of a much larger research project, in pursuit of which I have accumulated countless debts. Robert Martensen first set me working on the problem of coronary revascularization when I was a medical student in 1993. Albert Mulley contacted me ten years later and encouraged me to pursue questions I had initially left unanswered. His insight and support have been invaluable ever since. The research, amid teaching commit-...
Introduction: An Embarrassment of Riches
John Hunter had a problem. A busy surgeon and anatomist, he had little time to care for his own health. By the time he turned 50, he suffered terribly from angina pectoris. His physician, William Heberden, described this syndrome so well that the symptoms are recognizable to any doctor or patient today: a strangling pain in the chest, often spreading down the left arm, brought on by exercise and relieved by rest. As the disease progressed, eating...
Part I: Theory and Therapy
1. The Mysteries of Heart Attacks
Every day in the United States, thousands of men and women submit to angioplasty and bypass surgery. Each technique is a marvel of cardiac science and ingenuity. Nonetheless, the treatments require patients to make a dramatic leap of faith. Look closely at the details of the bypass procedure: after an anesthetist renders the patient unconscious, the surgeon removes arteries and veins from the patient’s arms, legs, or chest and then saws open...
2. The Case for Plaque Rupture
In March 1844 sculptor Bertel Thorvaldsen attended a performance at the Royal Theatre in Copenhagen. We do not know what he thought of the show, but we do know what happened to him that night: he died suddenly at the theater. An autopsy performed at his home revealed the likely cause. As reported in the...
3. The Case against Plaque Rupture
Paris Constantinides and Meyer Friedman had great confidence that their methods had produced definitive evidence in support of the plaque rupture hypothesis. The three other groups who employed comparably rigorous techniques converged on plaque rupture as the most likely cause of heart attacks. One might expect that the results of such methodical scientific research would speak for themselves. In practice, however, this does not always happen...
4. Learning by Doing
Into the 1970s autopsy studies, animal research, and coronary angiography continued to generate results that lent support to competing theories about the cause of heart attacks. Even the basic question—was a coronary thrombosis the cause or consequence of the attack?—remained contentious. Uncertainty about this point undermined the claims of researchers who saw plaque By the end of the 1970s, however, the discord had largely disappeared, ...
5. The Plaque Rupture Consensus
A proliferation of new autopsy techniques, diagnostic technologies, and therapeutic interventions from the 1960s through the 1980s provided many new ways to study the causes of heart attacks. Methodological diversity initially perpetuated the discord that had dominated the field since the 1930s. In the 1980s, however, the diverse techniques began to converge toward a unifying theory, one that accepted the causal role of coronary thrombosis ...
6. Rupture Therapeutics
The previous chapter told a conventional intellectual history of the plaque rupture hypothesis. It traced how the idea became popular as doctors fit more and more observations into the plaque rupture framework. But there are other facets of this history. From the 1930s into the 1960s, as doctors debated the role of plaque rupture and intramural hemorrhage, the morbid pathology of myocardial infarction was largely an academic question. Doctors ...
7. Therapeutic Ruptures
The consolidation of the plaque rupture consensus demonstrates how medical practice can influence medical theory. Only when doctors began to intervene acutely during heart attacks in the 1970s did they become convinced that coronary thrombosis caused the attacks. Only with the increasing use of statins and platelet inhibitors in the 1990s did the plaque rupture hypothesis become popular. Something else can happen as well: established...
8. Fear and Unpredictability
In addition to psychological and financial motivations, another factor may have contributed to the persistence of prophylactic revascularization in the era of plaque rupture consensus: fear. Fear of heart attacks swept popular media and the medical literature in the twentieth century. This anxiety paralleled the growing focus on risk and risk factors in medicine. The idea of a “risk factor” was first formalized by Framingham Heart Study researchers in the ...
Part II: Complications
9. Surgical Ambition and Fear
On December 13, 1960, Cleveland Clinic surgeon Donald Effler wrote to a Montreal colleague, Arthur Vineberg. Effler and Vineberg, two pioneers in the new field of cardiac surgery, exchanged letters often. They shared stories of their successes and failures as they worked to develop new surgical techniques. This time Effler had bad news. He had recently operated on a fellow physician. The procedure—a valve replacement—had gone well, but ...
10. Suffering Cerebrums
Pioneering cardiac surgeons faced other problems in addition to high mortality. Surgeons’ initial wariness about operating on the heart had arisen from their fear that any manipulation of the organ would threaten the rest of the body. All tissues depend on the constant flow of oxygenated blood that the heart and lungs provide. A brief disruption that did not kill a patient might still leave other organs injured. Attention was focused on the brain, the most ...
11. Deliriogenic Personalities
Surgeons quickly learned that their concerns about the brain’s vulnerability during open-heart surgery were justified. First with the early finger-fracture techniques on rheumatic valve disease, and then with their efforts to bring heart-lung machines to fruition, physicians witnessed a devastating toll of cerebral complications. Committed to overcoming this problem, they worked to visualize the complications, gauge their severity, and eliminate...
12. The Case of the Missing Complications
After spending fifteen years refining the techniques of cardiac surgery on patients with congenital or rheumatic heart disease, cardiac surgeons in the 1970s took on a new problem: coronary artery disease. Coronary artery surgery had existed on the fringe of cardiac surgery since the 1930s, but it was overshadowed by valve surgery in the 1950s and 1960s. A few surgeons, however, had recognized the potential of a bypass procedure. With coronary...
13. Selective Inattention
On April 4, 1962, Johns Hopkins surgeon David Sabiston used a piece of saphenous vein to bypass an obstruction in the right coronary artery of a 41-year-old man. This feat might have earned him international fame: he was the first surgeon to perform what would become one of the most important operations known to surgery. Instead, the patient suffered a stroke and died on the third day after the procedure. A clot had formed where the bypass...
14. The Cerebral Complications of Coronary Artery Bypass Surgery
As surgeons succeeded in making cardiac surgery the most prominent specialty in American medicine in the 1960s, they witnessed the complications their patients suffered, from strokes and seizures to cognitive dysfunction and personality change. But despite being aware that cardiac surgery put their patients’ brains at risk, they paid little attention to cerebral complications during the early years of coronary artery bypass grafting. As bypass surgery entered ...
15. A Taxonomy of Inattention
In 1991 two of the most influential organizations devoted to heart disease, the American Heart Association and the American College of Cardiology, teamed up and released their first official guidelines about coronary artery bypass surgery. The guidelines reviewed the most accurate information then available so that physicians and patients could make the best decision possible about the procedure. They had much information to work with. Over ...
16. Competition’s Complications
Imagine a conversation that takes place a thousand times each day in this country. A cardiac surgeon recommends that a patient undergo coronary artery bypass surgery. The patient asks if there will be any complications. The clinical evidence supports a wide range of possible answers. One surgeon could say, “Yes, we have to put you on a heart-lung machine; this is an imperfect substitute for the heart and introduces the risk of stroke, cognitive ...
Conclusion: Puzzles and Prospects
Every day, all over America, ambulances whisk people with chest pain into emergency rooms. Doctors take a history, perform a physical exam, order diagnostic tests, and, when suspicion of a heart attack is high, send the patient to coronary angiography. Once the results are available, the doctor and patient can review clinical trials, practice guidelines, and other tools of evidence-based medicine. Such knowledge should enable good decisions about aspirin...
Page Count: 336
Illustrations: 25 b&w illus.
Publication Year: 2012
OCLC Number: 859687412
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