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M4 Dispatches
Notes from the Maryland Mensa Monthly Meeting
by The Boreal Badger (a.k.a. Thomas Weinbaum
vonWaldenthal)
How mortifying! After last month's warning about the difficulty of spelling words from Sanskrit, Pali and Tamil, I let slip by a typo in English. In the very first paragraph, "I have tries to..." should have been "I have tried to..."
Mea maxima culpa. (In mitigation, permit me to note that the letters 'S' and 'D' are adjacent on the QWERTY keyboard.)
September's speaker, who addressed a good crowd at Catonsville's Stillwater Church on the 18th, was Dr. Stephen Pollock, MD, FACC, the director of The Heart Institute at St. Joseph's Hospital in Towson. Born in Roslyn, LI, he moved here with his family at the tender age of three. He attended Gilman and then Brown, returning to Maryland to graduate from the University of Maryland's medical school in 1975, with a specialty in internal medicine in 1978. Then came two more years devoted to the study of cardiology, which saw him finally going into practice in 1980. The topic of heart disease drew his attention directly, as his father and brother both suffered from that ailment, and he himself was diagnose with heart disease at the age of 51.
About now I should disclose my own interest in the subject: I also am a heart patient. Over six years ago, while undergoing a pre-operation check-up for the removal of a benign parotid tumor, my EKG (electrocardiogram) pointed out with the word "ABNORMAL" at the top, in large red capital letters. After a radioactive stress test, I was whisked off to UMMC for a test called a cardiac catheterization in which a tube as snaked in through my femoral artery and up to my heart, and a marker chemical drizzled in so as to provide a moving picture of my beating heart and its supplying arteries. The three things that I remember most about the experience are that I was given a wonderful sedative that was like a three-martini lunch, that it calmed me enough that I could dispassionately observe that my arteries looked like an extra-terrestrial deep-sea shrimp, and that the admitting nurses were aghast that I'd driven myself there on my motorcycle.
It seems that at some unknown point in the past I'd unknowingly suffered at least one heart attack, that most of my coronary arteries were pretty much clogged up, and that the bottom 1/4 of my heart was dead scar tissue which would never beat again. Since then I've had a quadruple bypass operation at Union Memorial (by a charming and funny, but very competent, little Peruvian heart surgeon, who complained about the difficulty of reaching over my larger body), and I'm still surviving to write this column and to warn others from my unfortunate experience to watch their diet and blood pressure whenever I see them eating large helpings of fat and salt or working themselves into a state where their face turns alarmingly red or purple (with optional throbbing veins). There'll be more on this below, but for now you'll understand that the topic holds a certain personal interest for me, and that I've gone out of my way to learn more about the subject.
I used the word "unknowingly" in the previous paragraph with intent, because I was totally unaware of any heart problems. Heart disease (properly called 'coronary artery disease') is what occurs when the arteries that supply blood to the heart become clogged up. The heart is a muscle, and quite aside from the blood that it pumps that muscle requires its own oxygenated blood supply to function. Deprived of its oxygen supply, the heart tissue dies, and with it so does the person in which it resides. I never had any chest pains or twinges radiating down my left arm, nor did I have the "band around the chest" symptom that some sufferers have described. All that I've been able to dredge from my memory was a drive with a fellow M from Ottawa to New Hampshire in a cramped little Dodge, after which she told me that I looked "grey in the face." Indeed, most heart disease victims have no noticeable symptoms at all, and (as our speaker repeatedly told us) in one third of cases the first symptom is also the last. Forget those on-stage dramatic displays of clutching at the cheat or dragging down the drapes; most heart attack sufferers are dead before they hit the floor. (My own cardiologist, a fellow guitarist, informs me that the presenting symptom for my own condition is death.)
In the US nearly one million people a year die from heart disease, so it's something well worth learning about. First of all, it's not only couch-potato types who die of heart disease; some of its more athletic victims were Johnny Unitas, Tim Russert and Jim Fisk.) Secondly, it's not only a disease of men: men and women over the age of 50 are equally likely to have some heart disease. In the lethality stakes, it easily beats out the more publicized killers, too. Colon cancer is only the number six killer, and breast cancer the number five.
So what causes the clogging that kills? In a minority of cases, a blood clot in some relatively large vein breaks loose and travels to the heart, where it lodges in a smaller-diameter artery and blocks it, but in the vast majority of cases the coronary arteries are gradually obstructed by deposits of cholesterol plaque, effectively reducing the inner diameter if the blood vessel and hence its ability to transport blood. Those of you who remember your high school physics will recall that only a certain flow of liquid can go through a given opening; trying to force more through will only increase the pressure, not the flow. As the heart tries to pump harder to make up for the deficit, blood pressure increases, the heart is further stressed and the blood vessels can either form bubbles called aneurisms, or if the fatty deposits have hardened the artery too much for it to stretch the blood vessel even pop like overinflated rubber-balloon animals. Needless to say, these are situations one wishes to avoid.
And what's this fatty plaque made of? Well, it's (mostly) made of cholesterol. High school science again: fats, oils and fatty acids are collectively known as 'lipids'. (Where one attended high school determines whether one pronounces it with a long or short 'I'.) Cholesterol is a fascinating compound, which has many roles in the body's biochemistry. (For instance, testosterone is made from it.) Cholesterol comes in two forms, low-density lipoprotein (LDL for those who have difficulty with polysyllabic words) and high-density lipoprotein (DL, ditto). It's the former that forms the arterial plaque, and so the two types are often referred to as 'bad' and 'good' cholesterol, respectively.
The 'good' cholesterol is actually good for the heart, so one wishes to increase it while decreasing the 'bad' cholesterol. Simply put, 'bad' cholesterol can be reduced by avoiding food with saturated fats and trans-fats, such as coconuts, avocados, most cooking oils, butter and cheeses, while 'good' cholesterol can be raised with exercise, canola (rapeseed) oil, olive oil, almonds, very dark chocolate and Vitamin B in the form of nicotinic acid. (There are also medications that can affect cholesterol, about which more later.) However, one's diet is not the only source of cholesterol; it is also produced by the body (notably in the liver) and the production rate seems to be at least partly controlled by genetic factors (remember Dr. Pollock's male relatives, supra?), so diet alone can be only of partial benefit.
Now, after you've been scared enough, I should note that not everyone with heart disease dies of it. There are a lot of other things, some with dauntingly long names, which can go wrong with the human body before HD can have a fatal effect. There are also traffic accidents, drowning, electrocutions, cuts, falls and (in Baltimore and DC) the deadly effects of lead poisoning, either slowly due to a childhood of chewing paint chips or rapidly due to interrupting some lead's trajectory on the streets after dark. As most HD sufferers have no symptoms, they won't be inconvenienced if they fall prey to one of those other problems before they suffer a fatal heart attack.
Nonetheless, on wouldn't wish to depend upon a violent death for avoiding a heart attack, so there are courses of action open to those who wish to give themselves a better chance. Dr. Pollock has seen stunning advances in his field since his student days, and we should all be glad for them. (I know I'm thankful for them!) I think most of my readers will remember Dr. Christian Barnard's pioneering heart transplant, and most will recall that the first coronary bypass surgery took place in 1981 (when I was just entering the workforce). Bypass surgery uses bits of veins from a patient's legs to reroute the heart's blood supply around their blockage(s). Also, there are small balloons and tubes called 'stents' which can be placed inside a clogged artery to widen it and/or reinforce it.
Those are surgical procedures. There re also medical interventions that can be effective: that is to say, treatment with medicines. There are a number of drugs that have been developed to treat HD, all of which can have side effects:
Statins are used to inhibit the formation of cholesterol; the dosage must strike a balance between 'enough' and too much, because some cholesterol is still necessary. Not too long ago, it used to be thought that LDL should be reduced to below 130 (in the units used in this country), but now the aim is to get it below 70. One takes this latest figure with a grain of salt (a substance which one should avoid) because it has greatly increased the potential market for stations. These drugs can have a damaging effect on the liver, so periodic blood tests are needed to watch for problems.
Beta blockers are used to lower blood pressure by limiting the heart rate, acting much like the governor on a steam engine. Since blood pressure is needed for other bodily functions, such as the turgor of erectile tissue. Also, they can cause fluid retention and drowsiness. Dosage must be adjusted to the individual with some care.
Aspirin (acetyl salicylic acid) acts a blood thinner, and reduces the load on the heart. It's easier to pump liquid than sludge. The side effects can include stomach trouble and easy bleeding, both internal and external. Increasing the dosage beyond 1/2 a standard tablet doesn't seem to lead to any improvement in outcome. This is one of the most cost-effective treatments available.
Diuretics cause the body to expel excess interstitial water, so that fluid doesn't collect around the heart to cause congestive heart failure, which used to be called 'dropsy'. Since statins cause fluid retention, these drugs are usually indicated for those using statins. Diuretics can deplete the potassium level in the nervous system, leading to fatigue and mental fuzziness. Even without statins, this is a very cost-effective treatment.
Potassium chloride (KCl) supplements can be taken to replace the potassium lost to diuretics. Like aspirin, this medication can cause stomach irritation, and so both ought to be taken with food.
ACE inhibitors can actually mop up excess cholesterol while it's still floating around in the blood stream, before it settles in the arteries.
Tissue Plasminogen Activator (TPA) is a clot-busting drug that can save lives if administered during a heart attack, but seldom is the patient fortunate enough to have a supply on hand, as well as a qualified person to administer it.
Plavix has a blood thinning component, as well as other effects, but is now only indicated for the first year after surgery or an attack. People I know who have used it have complained of cognitive impairment and/or memory impairment, and there have been reported cases of inter-cranial bleeding.
New drugs are constantly being developed, such as Atacand and Zetia, but one must always watch for those which a profit-driven health care system can promote for financial rather than medical reasons. Some recent (and well-advertised) drugs have been withdrawn because they were unsafe, but others because they were just attempts to bypass the time limits on patent protection, adding no value over less-expensive generic preparations.
(Another note about distorting financial incentives: After my cardiac catheterization test, the attending surgeon wanted to schedule me for a heart transplant. I rejected the treatment because I figured that the lifestyle restrictions would be unacceptable, and opted instead for bypass surgery. It was only later that I learned that in order to retain its certification for heart transplant surgery a practice had to perform a minimum number of such operations per year. I certainly hope that the doctor's decision wasn't influenced by the need to make his numbers, but I'm glad that I decided not to go that route. I've already lived longer --and better-- than most transplant patients, and without the need for anti-rejection drugs.)
There are also other, non-medical ways to reduce risk. These include diet and exercise, and the avoidance of behavior that raises the blood pressure, such as drinking caffeine or alcohol, smoking, and ingesting excess sugars.
Let's get back to our speaker. He cited the now famous Framingham study, noting that only 20% of HD sufferers had any symptoms before a heart attack, and so it's useful to have tests that can look for problems. Since a bypass cast $30,000 back in 1982, and angioplasty around $10,000 (I'm willing to bet that the cost hasn't gone down. Any takers?), it makes sense to try to avoid un-needed surgery by using less expensive tests. A simple stress test (around 80% accurate) costs around $100, and a radioactive stress test (around 90% accurate) about $1,000. There's a new (and relatively inexpensive) test that spots plaque buildup by the calcium concentration in the surrounding vessel tissue, and the speaker recommended it. Of course this would mean some income for clinics such as his, and would also lead to more people being treated for HD (since so many are likely to unwittingly develop it), but that's certainly better than dying unexpectedly. Trust me, it's greatly preferable to spot these things while they can be treated medically, rather than (like me) becoming a Ginsu commercial. |
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