Heart--A History

by Sandeep Jauhar

  In the emergency room, I was led to a curtained-off space where Rajiv, Harwinder, and my father were sitting with my mother. She lay on a gurney, a purple throw draped over her. She had on red nail polish; a bright red bindi still adorned her forehead. My father sat on a stool beside the stretcher, his arms thrown over her body, his head resting on her arm. He touched her hands, massaged her feet. Her mouth was open. He asked me if they would close it for the funeral. “She was so pretty,” he said, and then he broke down.

  Later that morning, I took Harwinder back to my parents’ house so she could prepare it for visitors. As we pulled up, the haze from a neighbor’s sprinkler refracted a colorful rainbow, a minor affront on such a solemn day. Inside the house, I managed to make it up to the landing before I was overcome. The fan was still running in my mother’s bedroom. Her shawl was hanging on her brass bed frame. The pillow she used to prop up her feet lay under her comforter. Inside the closet was the back massager I’d presented her years before, still in the box; she’d been waiting to open it. On the bedroom floor were the discarded flip tops of drug vials, gauze, and a “smart pad” for checking arrhythmias: the detritus of a futile and aborted resuscitation that the paramedics had left behind. Like both my grandfathers, my mother had succumbed to ventricular fibrillation after a sudden heart attack, though in her case it had happened during sleep. That cardiac death had hit my mother during slumber made the heart seem even more menacing.

  In the wet, flat days that followed, there was so much to do—informing friends and relatives, receiving guests, then the funeral and the cremation—there was almost no time to grieve. But once the ceremonies were over, the grief pelted me like waves from the sea, receding periodically only to wash over me once again. At the funeral of a friend’s mother two years before, a colleague had said to me, “You never really grow up until your parents die.” Now, finally, I understood what he meant. What he meant was, while your parents are alive, there is always someone who thinks of you as a child. When I was a boy, my mother used to tell me a Hindu myth about a man who had been promised the world—unlimited riches—if he would just drown his mother. At the riverbed, as he starts to submerge her in the frigid water, she implores, “Stay out of the water, son!… You’ll catch a cold.” And so it was with my mother. If our family was a body, my mother was its heart: the piece that nourishes and ensures the workings of the rest. On the morning of her funeral, as I was adjusting my tie in front of the mirror, I could almost hear her telling me to stand tall, wear a proper suit, and speak confidently. I remembered the frogs in high school, and I started to cry. I could hear my mother telling me once again, “You should do a different experiment, son. Your heart is too small for this.”

  In a way, her death was merciful, putting an end to her suffering. But it was sudden, and it left a deep hole. “This world is like that,” the proprietor of my mother’s favorite sweets shop told me when I visited her. In the prior three months, she had lost her mother-in-law, her brother-in-law, and both her parents. And though I knew many had suffered far worse tragedies than mine, the swiftness of my mother’s death gnawed at me. At times, I felt angry: angry that she had been so content to play a supporting role to my father’s, resentful of the light touch she had applied to my adult life. And, of course, I felt guilty. She’d complained of chest pains the night before she died. Should I have taken her complaint more seriously? As a cardiologist, I knew that one of every two women will develop heart disease in her lifetime, and one in three will die from it, two-thirds with unrecognized symptoms. Yet in my mother’s case, I suffered a blank. Rajiv had no patience with my second-guessing. “I don’t want to hear that you made a mistake with Mom,” he cried. “You did not, you did not, you did not! We will never know for sure what she died from. All we know is that it was a blessing.”

  In physiology, there is the concept of referred pain, when an injury to a visceral organ is felt someplace else—as, for example, when heart injury causes arm or jaw pain. And perhaps so it is with emotional pain, too. What I was really feeling was remorse for neglecting my mother in her final days. I had been preoccupied, too focused on my own interests. In her last couple of months, when she was ill and terribly lonely, she would ask me when I was going to come to visit. Then, invariably, she would tell me not to come that day; it was too cold, too hot, or too wet—always something with the weather—and she didn’t want me to get sick. After her death, it was a daily struggle trying to keep such regrets from taking hold. But the person who would have fought hardest against them would have been my mother.

  I wish she could have seen her funeral, witnessed the scores of friends who came from across the country. For someone who was content to cede the spotlight to her accomplished husband and children, she would have been shocked at how many came to pay their respects, not because of anything she did, but because of who she was, which is perhaps the greatest accomplishment of all.

  * * *

  The ashes remained in my father’s closet for almost two months. He couldn’t decide whether to scatter them in the holy water at Haridwar, on the banks of the Ganges River in India, or in the Atlantic off the shore of Long Island. In the end, he elected not to make the long journey. So Rajiv booked a motorboat in Freeport, and we set off on a bright morning just after Memorial Day to submerge my mother’s remains. On a table on the boat, the priest opened a suitcase and arranged the items we would need: incense, cotton balls, the urn, a few edibles. My father, dressed in brown slacks and a yellow shirt, watched quietly. He had never been particularly religious, and it was clear that for him my mother’s passing, notwithstanding this last ritual, was over. As the boat sped hard over the waves, my belly churned. I had to keep my waist in contact with the priest’s table to keep from falling over.

  The priest started off by placing a long piece of red thread on my and my brother’s heads, dangling down to our shoulders. He smeared tikkas of red paste on our brows. Next, he lit incense sticks and cotton balls soaked in oil. Rajiv and I made sixteen balls of dough, about the size of a donut hole, from flour, water, and milk and placed them on a metal plate, along with acorns, rice, and an assortment of seeds and other provisions, including holy water from Haridwar, that were supposed to sustain my mother in her journey into the afterlife. The priest unscrewed the top of the urn, and we sprinkled holy water on the plastic bag containing my mother’s remains. We then opened the bag and poured in more water and some milk, along with the items on the plate. Next, we emptied the contents of the bag into a white wicker basket. The ashes were charcoal gray; it was hard to believe that this was all that was left of the body. We placed the empty bag in the basket, too. Then we waited for the dust to settle.

  The boat slowed to a stop. As the eldest son, Rajiv was given the honor of scattering the ashes, but I wouldn’t have been able to do so anyway; by then I was feeling horribly seasick. On the deck, while the priest chanted, his bald pate glistening in the heat, Rajiv placed the wicker basket on a metal hook at the end of a long stick. Then, without ceremony or words—apart from the inscrutable Sanskrit syllables spitting out from the priest’s lips—he leaned over the side of the boat and lowered the basket into the water. It had a metal weight to help it sink. I watched it submerge like a head, ghostlike, its contents exploding into a murky cloud in the greenish water. The priest told us to clasp our hands together in prayer. No one said anything as he violently chanted. Then, when he was done, a crew member retrieved the basket with some rope and lifted it back onto the boat. We turned around to head back to shore.

  My father rode in the car with me on the way home. We were both tired, and my stomach was just beginning to settle. I put on Beethoven’s Piano Sonata no. 8, the Pathétique. I looked over at my father. He was staring ahead quietly, listening to the music. He rolled down the window, and a hot wind passed over us. He said nothing for a while; there were only the shrieks and wails of passing cars. Then he said, “We spent our whole life together. I miss her all the time.”

 
14

  Compensatory Pause

  Satisfaction cannot be stored.

  —Peter Sterling, neurobiologist

  In 1990, Dean Ornish, a cardiologist at the University of California at San Francisco, and his colleagues published the Lifestyle Heart Trial in the British journal The Lancet. In the study, forty-eight patients with moderate-to-severe coronary artery disease were randomly assigned to usual care or an “intensive lifestyle” that included a low-fat vegetarian diet, an hour of daily walking, group psychosocial support, and stress management. After a year, patients in the lifestyle group had a nearly 5 percent reduction in coronary plaque. After five years, the reduction was about 8 percent. Patients who adhered most closely to the program derived the most benefits in an almost dose-dependent relationship. Patients in the group receiving usual care, on the other hand, had an average 5 percent more coronary obstruction after one year and 28 percent after five years. They also had roughly double the rate of cardiac events, including heart attacks, coronary angioplasty, coronary artery bypass surgery, and cardiac-related deaths.

  Ornish’s study was roundly criticized. It tested a small cohort, reviewers said, hardly representative of the general population. Only half the patients who were invited actually participated, suggesting possible selection bias. Also, virtually none of the patients were on statins or other cholesterol-lowering drugs, so the effect of intensive lifestyle modification on modern, well-treated heart patients was anyone’s guess. Moreover, a study published in 2013 in The New England Journal of Medicine showed that patients who consume a Mediterranean diet rich in olive oil, fruits and vegetables, fish, and nuts had a roughly 30 percent lower risk of cardiac events, including heart attacks and death, than patients advised to follow a low-fat diet, albeit one less extreme than Ornish’s.

  Nevertheless, Ornish believed in his results and scaled up his program, eventually offering it at twenty-five hospitals and clinics across the country. He persuaded Medicare to pay for it as a kind of “intensive cardiac rehabilitation.” The Ornish plan today consists of two four-hour sessions per week for nine weeks, each comprising an hour-long nutrition class, an hour of exercise, an hour of group support facilitated by a social worker, and an hour of yoga and meditation.

  I’d heard Ornish speak about the benefits of his program, so one Friday afternoon in early fall I drove out to the Chambers Center for Well Being in Morristown, New Jersey, the closest Ornish center to where I live, to learn more. I went for a selfish reason. I’d recently learned the results of my CT scan.

  When Dr. Trost showed me my coronary blockages, I can’t say I was surprised. I’d worried so much about heart disease my whole life that the result seemed almost fated. The disease was still relatively mild, but I knew that most ruptures of coronary plaque—and therefore most heart attacks—occur at places of mild, not severe, narrowing. Mild plaque tends to be softer, thinner, more fat-laden, and possibly more prone to rupture and thrombosis than more advanced plaque.1 So I found myself in a clinical catch-22, with a disease too small to fix yet too large to ignore. Why had it developed? Was it the few cigarettes I’d smoked in college? Too many pastries and marital spats? Or was the disease programmed into me? Whatever the reason, my future suddenly seemed intolerably unpredictable. I had a peculiar feeling that I wanted to speed up my life to witness the important moments before I ran out of time.

  EKG showing a premature ventricular contraction

  For years, ever since medical school, I’ve had premature ventricular contractions, a mostly benign condition in which my heart flutters or does a sort of flip-flop when an extra, unexpected beat comes in. Most PVCs are followed by a “compensatory pause,” when the next heartbeat is delayed so the heart can get back in step with its normal rhythm. During the compensatory pause, the ventricles fill with blood for a bit longer than usual, so the first beat after a premature one is unusually strong, a thud in the chest to announce the heart’s rhythm has gone back to the way it was. As I lay in my den after my scan, listening to the crickets outside, it occurred to me that my scan was like a PVC, an interruption of the normal sequence of things. Was I going to let things go back to the way they were? Or was I going to do a reset?

  Over the following days, I underwent more tests. An echocardiogram showed that my heart’s chambers and valves were functioning normally. A carotid ultrasound revealed no plaque in the arteries that feed the brain. However, a blood test did show that my level of lipoprotein(a), a cholesterol-carrying molecule, was elevated. A high serum concentration of lipoprotein(a) is associated with more than double the normal risk of developing coronary artery disease or stroke.

  Lipoprotein(a) could partially explain the extraordinarily high rates of heart disease and cardiovascular death among South Asians, but there are other factors. South Asians seem to have smaller coronary arteries than other ethnic groups, which may result in more turbulent blood flow and wall stress that can initiate atherosclerosis. South Asian blood may also contain smaller and denser cholesterol particles that are more prone to causing arterial hardening. The adoption of a “Western” lifestyle—high calories, low exercise—hasn’t helped either, possibly activating so-called thrifty genes that create abdominal fat, thus increasing the risk of insulin resistance and diabetes. (These genes might have been advantageous in times of famine, but they are a problem in a world of abundance.) Social and cultural factors undoubtedly play a role, too. This was certainly true of my mother. The culture in which she was brought up discouraged adults from taking time for themselves, away from the responsibilities of job, home, and children, to exercise. Moreover, like many of her Indian friends, my mother believed in fate, that her future—and future health—were preordained. Saddled by this fatalistic philosophy, she never believed that one could change the natural course of one’s life.

  But I did not want my CT scan to be my fate. I wanted to make changes to try to stabilize—or possibly even reverse—the damage. But what sorts of changes were needed? I was already leading a pretty healthy life. I was taking a cholesterol-lowering statin prophylactically. The changes, I realized, were going to have to be more fundamental.

  I called my friend Anand, a television producer and a yogi, who suggested getting together one evening after work at the Hindu temple in Flushing. It was a warm midsummer evening when we met. The temple is in a middle-class neighborhood of single-family homes partitioned by rusty chain-link fences. A sign out front reminded patrons, “Do not break coconut here.” When I arrived, a prayer ceremony was just ending. A man clad in a white dhoti was clanging a bell and fervently chanting, “Shanti, shanti, shanti…” I spotted Anand, a paunchy, middle-aged fellow, wearing beige kurta pajamas and with a streak of red powder on his forehead. Head bowed, he moved purposefully from one garlanded statue to the next, kneeling at each to murmur a few words. When he was finished, he came over and shook my hand. Then we went downstairs to the canteen, where we ordered dosas and sweet lassi and sat down at a cafeteria-style table to wait for our food.

  I felt as if I should explain why I had called him, but Anand seemed to require no explanation. He sat contentedly, taking in the busy room. After some polite chitchat, I told him about my scan. Brow furrowed, he listened carefully in the manner of a psychoanalyst.

  “I have always found you take things very seriously,” Anand finally said. In his mind, my scan results no doubt were related to this. “Learn to get out of your mind.”

  I laughed. “And how does one do that?”

  His face turned serious. “Yoga, meditation, a walk in the park, whatever works. When you are doing it, you think it is a waste of time, but it is the most valuable time because it is helping you manage the whole day.”

  I’d tried yoga a few times. After Sonia and I were married, we’d ventured down to a drab studio in Tribeca, where a mala-necklaced old woman made us stand in painful poses while we focused on a spot on a pitted wall. I did feel more relaxed afterward (probably acute respiratory alkalosis brought on by deep breathi
ng, I’d hypothesized), but I hadn’t kept up with the practice.

  Anand advised returning to it. “Look at this scan as a blessing,” he said encouragingly. “It will help you find ways to become more composed. Your mind, your thoughts, are not your owner, but they are behaving as your owner. Go beyond mind. That is the only place you are truly free.”

  * * *

  And so I found myself in Morristown, New Jersey. The Ornish facility was in a large office complex just off a densely wooded road. The giant oak trees were already dropping their leaves into colorful piles. Carole, the nurse practitioner who runs the program, met me at the front desk when I arrived. “We’ve had quite a few young Indian men call us,” she’d told me when we spoke on the phone.

  The sessions were over for the day, so Carole gave me a tour of the facility: the kitchen, with its polished stovetops, where participants spend an hour together having a vegetarian lunch; the gym, supervised by two nurse practitioners and an exercise physiologist, where a few stalwarts were still running on treadmills; and the stress management room, where chairs were arranged in a circle and yoga mats were still on the floor. Carole told me her father was seventy when he was diagnosed with heart disease. He’d been having pains in his shoulder, and though a stress test was normal, a coronary angiogram revealed triple-vessel disease that was so advanced, surgery or angioplasty was no longer an option. “He was living on threads,” she said. With no treatment alternatives, her father tried the Ornish program. He followed it for two months before dying suddenly of an arrhythmia. Despite this morbid introduction, Carole had been working in Ornish-style preventive cardiology ever since.