The Heart Healers (44 page)

“Donald, do you know what you have? It’s what we call new onset typical angina.” I explained the three characteristics of angina, and what it implied. “In a fifty-year-old man who smokes, this means you have a 95% probability of having coronary heart disease. People with recent onset angina are at significant risk of a heart attack.”

“Maybe I’m overreacting,” I said. Willie the Phillie’s face flashed before me. “But with recent onset angina you never know what will happen next. Donald, I want you to come in to my hospital … as in now.”

Donald’s jaw fell like Facebook’s opening stock price. Yet he emphatically shook his head and looked away, unwilling to make the transition from reunion reveler to invalid in a matter of seconds. “You’re right, you’re overreacting.”

The taxi pulled up and the other three passengers clambered in, urging Donald to quit dawdling on the curb. And so, in a few seconds, I faced a quandary. Over outraged protests I could demand everyone get out, send the taxi away, and involve Donald’s wife, Mort, and Mort’s wife in the decision. Confronting uncertainty, I waffled. I chose the route less challenging.

“OK, Donald, if you’re going to disagree and fly home,” I hissed, “I am calling my cardiologist friend Sanjay in Houston. I am going to ask him to see you first thing tomorrow morning, and I want you there in his office. And one other thing. Not one cigarette between now and then.”

Donald, looking pale, grim, and shaken, nodded. He squeezed into the taxi. As the taxi’s taillights disappeared. I felt a wave of guilt. I knew the safest course, and in the pressure and uncertainty of that transient moment, I had acquiesced in what I believed was a second-best solution. Now I stood silently asking myself what if the unlikely happens between now and tomorrow morning? Was Donald on the cusp of becoming a statistic?

Sanjay saw Donald on Monday. Donald had smoked nervously on the way to Sanjay’s office, and then had another episode of angina while Sanjay was examining him. He moved quickly to record Donald’s ECG during the pain. It was profoundly abnormal. Sanjay called me to say that he recommended that Donald have an immediate coronary angiogram.

The bad news came quickly. The angiogram revealed that Donald had multiple atheromas in all three major vessels of the heart. For relief of his angina Sanjay and I agreed that Donald needed bypass surgery. I knew the city’s leading bypass surgeon quite well from working on national committees together over the years, so I called him. More bad news. He was on his way out of town for the next two weeks, so the best younger member of his team would operate. I did not know the surgeon, but after talking with him, I felt he was the best alternative since I felt Donald needed urgent surgery.

I spoke to Donald that night. Dread whistled through the fiber-optic lines.

“You’ll be fine,” I reassured him. I thought he would be.

Immediately after surgery I spoke with the surgeon, who was pleased with his surgical result. A week later Donald had come through surgery without difficulty and was ready for hospital discharge. I had a feeling of deep satisfaction that my medical training had helped Donald emerge from his personal fog of war.

Then disaster struck. Donald returned to his high-stress legal practice. Soon thereafter he called to relate what he said was the most frightening moment of his life. He had walked uphill to a rental car in another city. As he opened the door he felt the onset of crushing chest pain. Unable to breathe, he collapsed onto the car seat, thinking that he was about to die. After a few minutes, however, the pain gradually abated. My first thought was that one of Donald’s vein bypass grafts had closed. The saphenous vein bypass graft closure rate was about 15% in the first year at that time; internal mammary artery (IMA) grafts almost never closed. Donald had had both types of grafts, since he needed multiple bypasses, more than is possible with the IMAs only. In such situations we attach the IMA to the left anterior descending (LAD), because as “the widow maker” it is the most important heart vessel. I called Sanjay and we quickly agreed we needed to see Donald’s blood vessels again. He needed repeat angiography. The angiogram showed that I had been only partly right; I was in the right church but the wrong pew. Donald had the misfortune to suffer a complication I have only seen once, thank God.

Unrecognized by the young surgeon at the time of the procedure, he had twisted the IMA almost 180 degrees when he attached it to the LAD. With restricted blood flow, the twisted graft had finally closed off. I called my surgeon friend. He was deeply apologetic. “We are all terribly distressed about the technical mistake that occurred in my OR,” he said. “I have to tell you that with that graft closed, we have no surgical options. We think that the amount of disease he has in his coronaries makes his prognosis pretty poor.” Donald was not a candidate for angioplasty and his surgical option had blown up in our faces.

In the short time that he had returned to work, Donald had not lost weight. He was not going to slow down. With the surgery option eliminated, our only option was prevention. Donald’s survival was going to be dependent on changing his diet, starting an exercise program, losing weight, stopping smoking, and medication to drastically reduce his bad LDL. It seemed that Donald had not taken good health practices seriously over his first fifty years. With Donald’s history, Sanjay and I were not optimistic that we would be able to prevent a future heart attack.

As Donald’s medical brain trust gloomily viewed his future, we did not realize that when he had the edifying experience of impending doom in his rental car Donald had undergone a foxhole conversion. He stopped smoking. He changed to a healthy diet. He lost thirty pounds in weight and maintained it. And, he initiated a daily exercise program.

*   *   *

WE STARTED WITH
diet. But how in the world are you to sort out useful facts from the often-conflicting cacophony of advice on diet? The good news is that in 2002, someone did the work for us. At the Harvard School of Public Health scientists Drs. Frank Hu and Walter Willett analyzed data from 147 studies of the influence of diet on heart disease. Their conclusions are unequivocal: “Compelling evidence from metabolic studies and clinical trials in the past several decades indicates that at least three dietary strategies are effective in preventing coronary heart disease: substitute non-hydrogenated unsaturated fats for saturated and trans fats; increase consumption of omega-3 fatty acids from fish, fish oil supplements, or plant sources; and consume a diet high in fruits, vegetables, nuts, and whole grains and low in refined grain products.”

But they also tell us what is not known: “simply lowering the percentage of energy from total fat in the diet is unlikely to improve lipid profile or reduce CHD incidence.” In simple terms, the long-revered low fat diet is not going to do much to your cholesterol or reduce your risk for CAD. And finally they tell us what remains controversial: “Many issues remain unsettled, including the optimal amounts of monounsaturated and polyunsaturated fats, the optimal balance between omega-3 and omega-6 polyunsaturated fats, the amount and sources of protein, and the effects of individual phytochemicals, antioxidant vitamins, and minerals.” In case you feel yourself fading back into confusion, they offer this broad conclusion: “Substantial evidence indicates that diets using non-hydrogenated unsaturated fats as the predominant form of dietary fat, whole grains as the main form of carbohydrates, an abundance of fruits and vegetables, and adequate omega-3 fatty acids can offer significant protection against CHD. Such diets, together with regular physical activity, avoidance of smoking, and maintenance of a healthy body weight, may prevent the majority of cardiovascular disease in Western populations.”

How much does poor diet influence the appearance of CAD? In 2012, a twenty-two-year follow-up study of 42,000 men analyzed one component of diet, soda consumption. The impact is startling. As Dr. Frank Hu of the Harvard School of Public Health summarized, “Even a moderate amount of sugary beverage consumption—we are talking about one can of soda every day—is associated with a significant 20% increased risk of heart disease.” According to a July 2012 Gallup poll, however, nearly half of U.S. adults, 48%, report drinking at least one glass of soda per day, with soda drinkers averaging 2.6 glasses daily. So independent of your opinion of New York mayor Michael Bloomberg’s quixotic ban on sale of soft drinks greater than sixteen ounces in retail food establishments, his heart and his thinking are in the right place, if preventing early death from CAD is a societal goal.

But really, how important is diet? A landmark 2012 study that analyzed data from forty countries suggests it is very important. In patients with known CAD a heart-healthy diet—rich in fruits, vegetables, nuts, whole grains, and fish—was associated with a reduced risk of cardiovascular death by 35%, second heart attack by 14%, stroke by 19%, and congestive heart failure by 28%, compared with those eating the poorest diet. While the study surely will not end the diet debates, it will have an impact on cardiologists’ practice. Dr. Robert Eckel of the University of Colorado, who was not involved in the study, commented: “This is the kind of evidence we need; it’s incredibly encouraging. I’ve been in the clinic today and I can’t tell you how many times I’ve emphasized a heart-healthy diet to patients.”

Why are these diet elements good or bad in relationship to what we know about atheroma formation and plaque rupture? Fish, fruits, nuts, and tea are good, most likely because they are high in antioxidants like omega-3s and a long list of other less well-known potent antioxidants. Antioxidants are important because they are anti-inflammatory. Inflammation plays a role in plaque formation and is the predominant force in plaque rupture. I agree with my friend Dr. David Agus, author of the bestseller
The End of Illness,
that individual diet supplements have not been shown to decrease CAD. The fiber in leafy vegetables is good, most likely because it accelerates intestinal transport and decreases intestinal absorption of unhealthy foods. The bad elements are trans fats, which are fats that are solid at room temperature, like lard, butter, and margarine. Milk fat and animal fat is bad. These dietary components are bad predominantly because they elevate blood cholesterol, increase its oxidation, and increase the expression of inflammatory substances. Simple carbohydrates like glucose (sugar) and fructose (sugar derived from corn) are bad because they predispose to increased fat storage, and ultimately to diabetes. Since bakery goods are high in trans fats, and soft drinks are high in sugar, these foods are particularly poor dietary choices.

Finally, in 2013 came a randomized trial that may end the debate about what diet is best, at least among cardiologists. The five-year trial compared the Mediterranean diet (fish, vegetables, fruit, nuts, extra virgin olive oil, red wine in moderation) compared to a low fat diet, conducted in people who had no known cardiovascular disease but were at high CV risk. The Mediterranean diet had a 30% lower rate of heart attack, stroke, and cardiovascular death even though they were not required to reduce their caloric intake. If you are not on this diet, consider it. It is precisely my own diet. I drink red wine because it is high in potent antioxidants. Red wine, however, has a U-shaped curve relative to risk. Excessive wine raises blood pressure and adds abdominal fat. Sixty years after Minnesota nutritionist Ancel Keys’s studies initiated the low fat craze for preventing heart disease, this diet itself may have breathed its last. I was pleased to see Donald order grilled salmon, a salad, and red wine at our most recent dinner a few months ago, although I secretly wished he had left a little more of the Cabernet for me.

*   *   *

THE SECOND STEP
in Donald’s lifestyle modification is exercise. It should be yours as well, if you want to prevent CAD. Exercise improves the level of both good and bad cholesterol, lowers blood pressure, diminishes inflammation, and promotes weight loss. In diabetics, it favorably affects insulin utilization. In addition, exercise improves oxygen utilization by muscles, allowing individuals with compromised cardiac function to perform a wider range of daily activities. In contrast sedentary lifestyle is one of the American Heart Association’s five risk factors for CAD, along with abnormal lipids, hypertension, obesity, and smoking. Physical inactivity is a worldwide problem. In a 2012 Harvard Medical School investigators found that global mortality attributable to physical inactivity is similar to cigarette smoking (more than 5.3 million deaths per year vs. 5 million deaths per year). Worldwide, a sedentary lifestyle was associated with a 16% increase in the risk of CAD and a 20% increased risk of diabetes mortality, along with increased risk of breast and colon cancer death. In the United States, 250,000 deaths annually are attributed to sedentary lifestyle.

Donald, of course, wanted to know the minimum of amount of exercise necessary to maintain good health. So here it is from the Surgeon General: “Every American should participate in thirty minutes or more of moderate intensity activity on most, and preferably all, days of the week.” This level of activity is any exercise equivalent to brisk walking (three to four miles per hour), cycling, yard work, or swimming. This amount of activity is equivalent to 600 to 1,200 calories per week. Less than this amount is considered sedentary. A modicum of good news: you do not have to do your thirty minutes of penance all at once, you just have to do it. Donald agreed to hit the minimum target. The Surgeon General also notes that “Less than one third of adults meet the minimal recommendation for exercise. The combination of excess caloric intake and decreased exercise is responsible for the worldwide obesity epidemic.”

If you are willing to run, that’s good. But there are some facts you probably do not know about running that you should. Running is a special case of exercise. The greatest reduction in CAD mortality occurs when an individual moves from sedentary to becoming moderately active. Less is gained in moving from moderately active to very active. A recent report from the Aerobics Center Longitudinal Study, which includes 52,000 men and women with no known CAD, reveals a stunningly unanticipated outcome. A quarter of the group used running as a form of exercise. During fifteen years of follow-up 2,984 participants died. Runners had a 19% lower mortality rate than nonrunners. No surprise there. The fascinating and unexpected outcome was that people who ran ten to fifteen miles weekly had a whopping 27% reduction in death rate whereas running more than twenty-five miles per week had only a 5% reduction. Similar differences were found between people who ran six to seven miles compared to eight or more miles per hour, and running two to five days per week vs. six to seven days per week. So the benefits of running are best achieved with moderate levels rather than at greater distances, running speed, and frequency. At high levels of running, the relationship between mortality and running trends back toward less benefit. Running, like red wine, has a U-shaped curve relative to risk. As investigator Dr. Carl Lavie wryly observed, “The fact that it reached its plateau at such a low level is surprising, as is the fact that it didn’t level off but actually went the other way. We never had a point where runners did worse than non-runners, but really, if you put it in almost a joking way, it showed that if you ran enough you got yourself back to the level of a couch potato. You lost the survival advantage.”