Broken Hearts: The Tangled History of Cardiac Care by David S. Jones (review)

What causes a heart attack, and how best to prevent it? How has our understanding and treatment of heart disease changed over time? Clinician-historian David Jones, the A. Bernard Ackerman Professor of the Culture of Medicine at Harvard University, exposes the lack of consensus within the medical community about the cause of heart attacks and the ambiguity surrounding the efficacy and safety of related treatments in the twentieth century. Drawing from archival sources and the medical literature, the author traces the shifting medical theory surrounding coronary artery disease and competing treatments of coronary artery bypass surgery and coronary angioplasty that subsequently arose. Readers will certainly learn much about medical changes in cardiac care; however, Broken Hearts is really about the complexity of medical decision-making. According to Jones, patients and physicians are burdened by too many choices, all fraught with limitations and uncertainty, reflecting our enthusiasm, fear, and hopes in combating disease (pp. 16, 19).

Broken Hearts is divided into two parts: “Theory and Therapy” and “Complications.” In part 1, Jones explores how no one unifying theory about the cause of heart attacks emerged until new autopsy techniques, diagnostic technologies, and therapeutic interventions from the 1960s to the ’80s enabled scientists and clinicians to demonstrate the causal role of coronary thrombosis and plaque rupture (p. 71). The plaque rupture model had been proposed and criticized for decades, but by the 1980s, a consensus emerged as a result of numerous exchanges of knowledge from the bench to the bedside and back to the bench (p. 73). Clinicians embraced the new imaging and diagnostic technologies, such as angioscopy, to see inside living arteries, as well as the new lipid-lowering medications like Lipitor and Plavix to reduce high cholesterol in their patients. Empowered “to do something,” clinicians demonstrated “therapeutic enthusiasm,” which, Jones suggests, worked to influence medical theory and solidified acceptance of the plaque rupture model (p. 86). The common plumbing metaphor for coronary artery disease also shaped acceptance of bypass surgery and angiography to remove or reduce obstruction before the rupture (p. 88). There existed an intuitive appeal to these interventionist treatments for many patients and practitioners. In one interesting chapter, Jones explores the fear of heart attacks and the “rupture” imagery that further contributed to the dominance of the plaque rupture model. All this worked to bolster claims of therapeutic efficacy, to which Jones advocates skepticism, setting up part 2 of the book.

In the second half of the book, Jones continues the theme of uncertainty by examining the complications arising out of the “therapeutic imperative” of the clinicians. According to Jones, clinicians were aware though inattentive to the problems that cardiac surgery often induced on the patient’s brain. The ability to perform open-heart surgery in the 1950s excited surgeons with new corrective procedures, in which the benefits were deemed to outweigh the prevalence of the cerebral complications of bypass surgery. Open-heart surgery necessitated the use of heart–lung bypass machines to reroute the patients’ blood around these organs (allowing surgeons to operate within a bloodless field), but problems of air bubbles to the brain, damage to blood proteins, and changes in blood pressure often occurred as a result of the bypass technology (p. 139). Some research studies noted these complications, but the problem more or less “fell through many cracks” (p. 169). Coinciding with this was the rise of angioplasty as a competitive therapy, with its suggested lower complications. Medical debate ensued into the 1990s about which was the better therapy for coronary artery disease: medications, angioplasty, or bypass surgery? (pp. 190–91). Jones argues that the lingering uncertainty, as well as an imbalance of medical knowledge—more was known about the efficacy than the complications of each treatment—left both patients and practitioners in practical dilemmas.

This book will appeal to a wide audience interested in the history of coronary artery disease, its treatment options, and medical decision-making. For those...