Broken Hearts: The Tangled History of Cardiac Care

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 1950s and the 1960s, as they attempted to explain the distribution of heart disease. Their work broadened our sense of who is “at risk” of heart disease, from an initial focus on elite white men, to all men, and now to any person— worldwide—who strays from an ideal of perfect diet and behavior. Risk factors have since become ubiquitous considerations throughout medicine.1 Fear, however, has a different character than caution based on risk assessment. It has had a more visceral impact on how doctors and patients have thought about and treated heart disease. Fear of heart attack and sudden death spread quickly as heart disease gained the public’s attention in the 1920s and 1930s. Few diseases had a similar abilchapter eight Fear and Unpredictability Fear and Unpredictability 103 ity to strike down previously healthy men and women in their prime. Medical textbooks made this clear. A 1928 edition of A Text-Book of Medicine by American Authors observed that “sudden death is always a danger, and cannot be anticipated.” A 1950 text noted, “There is perhaps no other disorder in which a patient, apparently progressing favorably, is so likely to die unexpectedly.” The frequent lack of prior angina was especially troubling: “A particularly distressing aspect of this disease is the frequency with which it suddenly strikes young men, between 35 and 55 years of age, without prior warning.” Even now the first sign that anything is wrong might be the last. Peter Libby’s 1998 review of the pathophysiology of atherosclerosis captured this well: a “dramatic acute clinical event, such as myocardial infarction or cerebrovascular accident, may be the first manifestation of atherosclerosis.”2 Widespread advertisements accentuate the fear. The billions of dollars spent marketing statins and platelet inhibitors fuel the sense that we are all at risk and that we all ought to take the medicine. Something similar happens with bypass surgery and angioplasty, even though they are not marketed as aggressively . Intensive media coverage of celebrities in need of bypass surgery— David Letterman in 2000, Bill Clinton in 2004, Regis Philbin in 2007, Larry King in 2010—contributes to the pervasive fear and the willingness of people to submit to dramatic medical interventions.3 Doctors feel this fear with particular acuity. Throughout the twentieth century , they saw themselves as the group most at risk of the ravages of coronary artery disease. In his 1910 account of angina pectoris, William Osler described it as the “morbus medicorum,” literally the disease of doctors. James Herrick featured a physician in his early case reports about coronary thrombosis. Experts had little trouble explaining doctors’ peculiar risk. When two statisticians from the Metropolitan Life Insurance Company characterized the mortality of physicians in 1947, they were not surprised by the high prevalence of coronary artery disease. They cited the “special activities and burdens” of doctors: “Their call to service at any time, their constant guard against varied infections and their need for mental alertness all may well impose strains that are felt in few other callings.” By mid-century the fear was well established. Two New York physicians even called coronary disease “an occupational hazard of the medical profession.”4 The prevalence, or the perceived prevalence, of heart disease among physicians motivated a particular kind of therapeutic imperative. Physicians desperately wanted better therapies for a disease that so many of them suffered 104 Theory and Therapy from, but they worried that this desperation colored how they thought about promisingnewtherapies.EugeneBraunwald,perhapsthemostinfluentialcardiologist of the late twentieth century, warned his colleagues in 1971 against excessive enthusiasm for bypass surgery, explaining that “members of the medical profession, themselves subject to the ravages of coronary arteriosclerosis in disproportionately high numbers, are often in the vanguard of those having faith in the efficacy of each newly reported therapeutic maneuver.”5 Fear could color judgment. The traditional model of atherosclerosis as a disease of progressive obstruction had particular appeal in this world of pervasive fear. Yes, some people were struck out of the blue and...