Heart

by Sandeep Jauhar

  No doubt we should celebrate the rise of high-tech medicine. For example, more than 90 percent of patients who present directly to hospitals that do angioplasty have door-to-balloon times today of less than ninety minutes, with a median time of approximately sixty minutes, a major improvement from only a few years ago. However, this means that the bar is continually being set higher for every new treatment.

  I believe that cardiovascular medicine in its current form, focusing on investigating minor iterations of commonly used drugs or add-on therapies or optimizing existing procedures, will increasingly produce only marginal advances in the years ahead. We will need to shift to a new paradigm, one focused on prevention—turning down the faucet rather than mopping up the floor—to continue to make the kind of progress to which patients and doctors have become accustomed. In this paradigm, psychosocial factors will need to be front and center in how we think about health problems. Despite the centuries-old association of the heart with emotions, this is still a domain that remains largely unexplored. However, today it is increasingly clear that chronic diseases like hypertension, diabetes, and heart failure are inextricably linked to the state of our neighborhoods, jobs, families, and minds.

  Heart disease, as we’ve seen, has psychological, social, and even political roots. To treat our hearts optimally will require interventions on all these fronts. This is much easier said than done, of course. Psychosocial “repair” is just as prone to unexpected consequences, difficult trade-offs, conflicting values, and diminishing returns as any medical treatment. We cannot even agree on what should be repaired. But we will have to find ways, as Peter Sterling, the neurobiologist, has put it, to “reduce the need for vigilance and to restore small satisfactions,” such as our contact with nature and with one another. For some, this will require city-planning initiatives to encourage walking or bicycling, for example, instead of more sedentary lifestyles. Others will require fortification in more social realms, such as the enhancement of public life. For still others, cardiovascular benefits will come from more individualistic pursuits, such as yoga and meditation. Whatever the case, it is increasingly clear today that the biological heart is inextricably linked to its metaphorical counterpart. To treat our hearts, we must repair our societies and minds. We must look at not only our bodies but also ourselves.

  •

  I am lying on a blanket, staring up at the stars. Though the sun set more than an hour ago, the sky is fringed with streaks of orange. The air is still and smells of citronella and bug spray. Though the party is winding down, children continue to play in a sugar-fueled frenzy, barreling down inflatable slides and running tag on the lawn. My daughter, Pia, is sitting on my chest, burrowing her head affectionately into my neck. “Are you happy?” she asks me, her warm breath tickling my skin.

  “Yes,” I reply. “Are you?”

  “Yes, Dad,” she says. “I’m happy, too.”

  As another summer winds down, my CT scan is a distant memory. It was supposed to change everything, but in the end it was a hiccup, a PVC, and my life has returned to its normal rhythm. Like when you plan a trip somewhere and you think the place will feel different, the way you see it in pictures, and then you get there and it’s the same as the place you came from: same sky, same air, same clouds. Of course, I’ve made changes. I exercise almost every day now, and I eat better, too. I spend more time with my children and with friends. I still enjoy working hard, but I am no longer so contemptuous of relaxation.

  Many factors that affect our health are out of our direct control—we cannot diminish the stress that comes with reading the newspaper, or with supporting a family in a competitive economy, or with living in a violent neighborhood—at least not without patient and collective effort. But many entail decisions, and ways of behaving, that we can master. Do you want to live a long, healthy, and prosperous life? Don’t smoke. Exercise. Eat right. But also take good care of your interpersonal relationships and the way you deal with life’s inevitable upsets and traumas. Your mind-set, your coping strategies, how you navigate challenging circumstances, your capacity to transcend distress, your capacity to love—these things, I believe, are also a matter of life and death.

  I imagine I’ll repeat the CT scan at some point to see whether my coronary plaque has progressed. But I am not all that afraid of what I will find. I feel reassured by the knowledge that has accumulated in my field over the past century, even the past decade. We can now replace heart valves without open-heart surgery. We can inject stem cells to heal damaged heart muscle. My paternal grandfather was in his early fifties when he died. I am forty-eight as I write these words. But I am not my grandfather. I am privileged to live in an era in which the human heart has yielded to the human hand. The three-centimeter trip took millennia, starting ostensibly from the pericardium but really from a time when the heart was an almost supernatural object surrounded by taboos. Through this journey, the heart was transformed into a machine that can be manipulated and controlled. But these manipulations, as we have learned, must be complemented by attention to the emotional life that the heart, for thousands of years, was believed to contain.

  After so many years in the business, I see heart shapes everywhere: in the splash of raindrops on my windshield, in the beets I slice in my kitchen, in strawberry slivers and bitten cherries. And every morning, the drops of milk at the swirling center of my coffee cup make a spiral wave.

  I still often think of my grandfathers and of course my mother. I can picture my paternal grandfather slumping in cardiac arrest onto that stone floor in Kanpur, surrounded by his alarmed family. Or my maternal grandfather sitting in his drawing room in New Delhi on the day he died, listening to the news on the BBC while waiting for his breakfast. In the span of a few heartbeats, he was no more. Though the mechanisms of their deaths (and probably my mother’s) were the same, the outcomes were so different. One death left enduring trauma, the other two gratitude for a merciful demise. For much of my life, I feared the heart’s power, but I don’t see it as I once did. Yes, the heart can snuff out your life, but when the pressure of existence builds up, this organ, prime mover and citadel, is also a safety valve that can facilitate a quick and humane end.

  *Stress tests cannot tell if a plaque is vulnerable. Even today, no test in medicine can do so reliably.

  *Women measuring higher on the hopelessness scale had more carotid thickening, equal to the amount caused by one year of aging.

  Supplementary Reading

  INTRODUCTION: THE ENGINE OF LIFE

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  1. A SMALL HEART

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  2. PRIME MOVER

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  Pasipoularides, A. “Galen, Father of Systematic Medicine: An Essay on the Evolution of Modern Medicine and Cardiology.” International Journal of Cardiology 172 (2014): 47–58.

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  Shoja, Mohammadali M., Paul S. Agutter, Marios Loukas, Brion Benninger, Ghaffar Shokouhi, Husain Namdar, Kamyar Ghabili, Majid Khalili, and R. Shane Tubbs. “Leonardo da Vinci’s Studies of the Heart.” International Journal of Cardiology 167, no. 4 (2013): 1126–33.

  West, John B. “Marcello Malpighi and the Discovery of the Pulmonary Capillaries and Alveoli.” American Journal of Physiology—Lung, Cellular, and Molecular Physiology 304, no. 6 (2013): L383–L390.

  3. CLUTCH

  Alexi-Meskishvili, V., and W. Bottcher. “Suturing of Penetrating Wounds to the Heart in the Nineteenth Century: The Beginnings of Heart Surgery.” The Annals of Thoracic Surgery 92, no. 5 (2011): 1926–31.

  Asensio, Juan A., B. Montgomery Stewart, James Murray, Arthur H. Fox, Andres Falabella, Hugo Gomez, Adrian Ortega, Clark B. Fuller, and Morris D. Kerstein. “Penetrating Cardiac Injuries.” Surgical Clinics of North America 76, no. 4 (1996): 685–724.

  Cobb, W. Montague. “Daniel Hale Williams—Pioneer and Innovator.” Journal of the National Medical Association 36, no. 5 (1944): 158.

  Dunn, Rob. The Man Who Touched His Own Heart. New York: Little, Brown, 2015.

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  Meriwether, Louise. The Heart Man: Dr. Daniel Hale Williams. Englewood Cliffs, N.J.: Prentice-Hall, 1972.

  Werner, Orla J., Christian Sohns, Aron F. Popov, Jannik Haskamp, and Jan D. Schmitto. “Ludwig Rehn (1849–1930): The German Surgeon Who Performed the Worldwide First Successful Cardiac Operation.” Journal of Medical Biography 20, no. 1 (2012): 32–34.

  4. DYNAMO

  Goor, Daniel A. The Genius of C. Walton Lillehei and the True History of Open Heart Surgery. New York: Vantage Press, 2007.

  Lillehei, C. W. “The Birth of Open Heart Surgery: Then the Golden Years.” Cardiovascular Surgery 2, no. 3 (1994): 308–17.

  Lillehei, C. W., M. Cohen, H. E. Warden, N. R. Ziegler, and R. L. Varco. “The Results of Direct Vision Closure of Ventricular Septal Defects in Eight Patients by Means of Controlled Cross-circulation.” Surgery, Gynecology, and Obstetrics 101 (1955): 446.

  Miller, G. Wayne. King of Hearts: The True Story of the Maverick Who Pioneered Open Heart Surgery. New York: Crown, 2000.

  Rosenberg, J. C., and C. W. Lillehei. “The Emergence of Cardiac Surgery.” Lancet 80 (1960): 201–14.

  5. PUMP

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  Castillo, Javier G., and George Silvay. “John H. Gibbon Jr. and the 60th Anniversary of the First Successful Heart-Lung Machine.” Journal of Cardiothoracic and Vascular Anesthesia 27, no. 2 (2013): 203–207.

  Cohn, Lawrence H. “Fifty Years of Open-Heart Surgery.” Circulation 1007 (2003): 2168–70.

  Gibbon, John H., Jr. “Development of the Artificial Heart and Lung Extracorporeal Blood Circuit.” JAMA 206, no. 9 (1968): 1983–86.

  ——. “The Early Development of an Extracorporeal Circulation with an Artificial Heart and Lung.” Transactions of the American Society for Artificial Internal Organs 13, no. 1 (1967): 77–79.

  ——. “The Gestation and Birth of an Idea.” Philadelphia Medicine 13 (1963): 913–16.

  Shumacker, Harris B., Jr. The Evolution of Cardiac Surgery. Bloomington: Indiana University Press, 1992.

  ——. John Heysham Gibbon, Jr., 1903–1973: A Biographical Memoir. Washington, D.C.: National Academy of Sciences, 1982.

  Stoney, William S. “Evolution of Cardiopulmonary Bypass.” Circulation 119, no. 21 (2009): 2844–53.

  6. NUT

  Altman, Lawrence K. Who Goes First? The Story of Self-Experimentation in Medicine. New York: Random House, 1987.

  Forssmann, Werner. Experiments on Myself. New York: St. Martin’s Press, 1974.

  Forssmann-Falck, Renate. “Werner Forssmann: A Pioneer of Cardiology.” American Journal of Cardiology 79, no. 5 (1997): 651–60.

  7. STRESS FRACTURES

  Friedman, Meyer, and Ray H. Rosenman. Type A Behavior and Your Heart. New York: Alfred A. Knopf, 1974.

  Kannel, William B. “Contribution of the Framingham Study to Preventive Cardiology.” Journal of the American College of Cardiology 15, no. 1 (1990): 206–11.

  Kannel, William B., Thomas R. Dawber, Abraham Kagan, Nicholas Revotskie, and Joseph Stokes. “Factors of Risk in the Development of Coronary Heart Disease—Six-Year Follow-Up Experience: The Framingham Study.” Annals of Internal Medicine 55, no. 1 (1961): 33–50.

  Kannel, William B., Tavia Gordon, and Melvin J. Schwartz. “Systolic Versus Diastolic Blood Pressure and Risk of Coronary Heart Disease: The Framingham Study.” American Journal of Cardiology 27, no. 4 (1971): 335–46.

  Kaplan, J. R., S. B. Manuck, T. B. Clarkson, F. M. Lusso, D. M. Taub, and E. W. Miller. “Social Stress and Atherosclerosis in Normocholesterolemic Monkeys.” Science 220, no. 4598 (1983): 733–35.

  Kriegbaum, Margit, Ulla Christensen, Per Kragh Andersen, Merete Osler, and Rikke Lund. “Does the Association Between Broken Partnership and First Time Myocardial Infarction Vary with Time After Break-Up?” International Journal of Epidemiology 42, no. 6 (2013): 1811–19.

  Mahmood, Syed S., Daniel Levy, Ramachandran S. Vasan, and Thomas J. Wang. “The Framingham Heart Study and the Epidemiology of Cardiovascular Disease: A Historical Perspective.” Lancet 383, no. 9921 (2014): 999–1008.

  Marmot, Michael G. “Health in an Unequal World.” Lancet 368, no. 9952 (2006): 2081–94.

  Marmot, Michael G., and S. Leonard Syme. “Acculturation and Coronary Heart Disease in Japanese-Americans.” American Journal of Epidemiology 104, no. 3 (1976): 225–47.

  Nerem, Robert M., Murina J. Levesque, and J. Fredrick Cornhill. “Social Environment as a Factor in Diet-Induced Atherosclerosis.” Science 208, no. 4451 (1980): 1475–76.

  Oldfield, Benjamin J., and David S. Jones. “Languages of the Heart: The Biomedical and the Metaphorical in American Fiction.” Perspectives in Biology and Medicine 57, no. 3 (2014): 424–42.

  Oppenheimer, Gerald M. “Becoming the Framingham Study, 1947–1950.” American Journal of Public Health 95, no. 4 (2005): 602–10.

  Ramsay, Michael A. E. “John Snow, MD: Anaesthetist to the Queen of England and Pioneer Epidemiologist.” Baylor University Medical Center Proceedings 19, no. 1 (2006): 24.

  Sterling, Peter. “Principles of Allostasis: Optimal Design, Predictive Regulation, Pathophysiology, and Rational Therapeutics.” In Allostasis, Homeostasis, and the Costs of Physiological Adaptation, edited by Jay Schulkin. New York: Cambridge University Press, 2004.

  Worth, Robert M., Hiroo Kato, George G. Rhoads, Abraham
Kagan, and Sherman Leonard Syme. “Epidemiologic Studies of Coronary Heart Disease and Stroke in Japanese Men Living in Japan, Hawaii, and California: Mortality.” American Journal of Epidemiology 102, no. 6 (1975): 481–90.

  8. PIPES

  Monagan, David, and David O. Williams. Journey into the Heart: A Tale of Pioneering Doctors and Their Race to Transform Cardiovascular Medicine. New York: Gotham, 2007.

  Mueller, Richard L., and Timothy A. Sanborn. “The History of Interventional Cardiology: Cardiac Catheterization, Angioplasty, and Related Interventions.” American Heart Journal 129, no. 1 (1995): 146–72.

  Payne, Misty M. “Charles Theodore Dotter: The Father of Invention.” Texas Heart Institute 28, no. 1 (2001): 28.

  Rösch, Josef, Frederick S. Keller, and John A. Kaufman. “The Birth, Early Years, and Future of Interventional Radiology.” Journal of Vascular and Interventional Radiology 14, no. 7 (2003): 841–53.

  Sheldon, William C. “F. Mason Sones, Jr.—Stormy Petrel of Cardiology.” Clinical Cardiology 17, no. 7 (1994): 405–407.

  9. WIRES

  Davidenko, Jorge M., Arcady V. Pertsov, Remy Salomonsz, William Baxter, and José Jalife. “Stationary and Drifting Spiral Waves of Excitation in Isolated Cardiac Muscle.” Nature 355, no. 6358 (1992): 349–51.

  De Silva, Regis A. “George Ralph Mines, Ventricular Fibrillation, and the Discovery of the Vulnerable Period.” Journal of the American College of Cardiology 29, no. 6 (1997): 1397–402.

  Garfinkel, Alan, Peng-Sheng Chen, Donald O. Walter, Hrayr S. Karagueuzian, Boris Kogan, Steven J. Evans, Mikhail Karpoukhin, Chun Hwang, Takumi Uchida, Masamichi Gotoh, Obi Nwasokwa, Philip Sager, and James N. Weiss. “Quasiperiodicity and Chaos in Cardiac Fibrillation.” Journal of Clinical Investigation 99, no. 2 (1997): 305–14.