Broken Hearts: The Tangled History of Cardiac Care

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, speaking, or even “any disturbance of the mind” brought on an episode. Heberden warned that the prognosis was poor in such cases: “For, if no accidents intervene, but the disease go on to its height, the patients all suddenly fall down, and perish almost immediately.”1 Hunter had an especially difficult time. Irascible and quarrelsome, he was quick to anger, which then triggered his symptoms. As he frequently complained, “My life is in the hands of any rascal who chose to annoy and tease me.”2 Living in London in the 1790s, Hunter had few options. He suspected that the problem arose from his heart, for when he performed autopsies on people who had suffered angina, he sometimes found their coronary arteries ossified. But Heberden had little to offer Hunter, only quiet, warmth, and “spirituous introduction An Embarrassment of Riches 2 Introduction liquors” during attacks, and opium at bedtime to prevent them. The mainstays of eighteenth-century medical practice—bleeding, purging, and vomiting— appeared “to be improper.” Hunter’s fear of rascals proved to be warranted. Aroused to a “tumult of his passion” at a confrontational board meeting at St. George’s Hospital in 1793, he collapsed and died.3 Patients today have many more options. Consider the case of former president Bill Clinton. As described by the New York Times, Clinton was “a cigarsmoking workaholic whose family history of heart disease and passion for junk food had set him up for a heart attack in the near future.” When he developed chest pain and shortness of breath in September 2004, he went to Northern Westchester Hospital. Initial tests were reassuring. However, when he went to Westchester County Medical Center the next morning for a followup test—a coronary angiography—the cardiologists discovered “potentially life-threatening accumulations of plaque in the arteries.” With four arteries more than 90 percent obstructed, Clinton was at “the edge of the cliff in coronary terms.”4 Three days later, surgeons at New York–Presbyterian Hospital put Clinton on a heart-lung machine for 73 minutes and performed a quadruple bypass of his coronary arteries. Clinton’s treatment did not end with surgery. He began an aggressive medication regimen that included aspirin, a statin, a beta blocker, and an angiotensin-converting enzyme inhibitor. He disciplined his diet and exercised more. In February 2010, while hard at work on the recovery effort after the Port-au-Prince earthquake, he developed recurrent symptoms. When angiography revealed that one of his bypass grafts had become obstructed, an interventional cardiologist performed balloon angioplasty and placed two stents in his coronary arteries. Clinton scarcely interrupted his busy schedule for the procedure.5 His doctors hoped that their efforts would prevent, or at least postpone, a heart attack. Even though Clinton’s treatment received unusual attention, it exemplifies what has become a routine part of modern health care. Coronary artery disease , a rare curiosity in Hunter’s England, is now the leading cause of death in the United States and worldwide. People who have angina or even heart attacks have a cornucopia of options for medical care—perhaps too many options . Hunter and Heberden had to rely on clinical histories and autopsies, but doctors now offer patients an escalating series of diagnostic tests, from the familiar electrocardiograms to stress tests, CT scans, radioisotope perfusion studies, coronary angiography (still the gold standard), intravascular ultra- An Embarrassment of Riches 3 sound with near-infrared spectroscopy, and many others. With a diagnosis in hand, patients have to decide among an amazing diversity of preventive and therapeutic strategies, from yoga and diets to aspirin, statins, angioplasty, bypass surgery, and perhaps even gene therapy some day. Hunter had to focus only on avoiding rascals; patients today struggle to choose the right treatment. Although patients and doctors benefit from the many achievements of scientific research and therapeutic innovation, they do not always know how to use them well. Decision making frustrates patients, doctors, and other caregivers in many...