Why is the idea of improving our heart health so unattractive to us?
The problem with cardiovascular disease is that it’s not sexy.
Upon first hearing this, it seems obvious, right? What could be sexy about bad cholesterol, hypertension or angina pectoris?
But let’s take a moment to define sexy. We’ll use Merriam-Webster’s secondary definition: “sexy – adjective – generally attractive or interesting.”
After three highly esteemed cardiologists at three highly esteemed Chicago hospitals used the term “unsexy” to describe cardiovascular disease (CVD), it became clear that they meant that curing heart disease is not generally attractive or interesting to think about, talk about, or do, as, say, curing breast cancer. This remains true despite the fact that five times as many women (200,000) died in 2011 from heart attacks alone than died from breast cancer.
Cancer—really, any cancer—is sexy by comparison to CVD.
Cancer victimizes people. Whether or not a person develops cancer is mostly out of his or her control (the exception being lung cancers, roughly 90 percent of which are caused by smoking, according to the Centers for Disease Control and Prevention). We’re constantly hearing about newer, more state-of-the art, cancer-battling medicines and technologies, most of which are generally attractive or interesting.
Now, consider heart health: Dr. Robert D. Simari, a cardiologist at the Mayo Clinic, stakes the future of CVD prevention on providing exercise, activity and weight management strategies at the community level. Heightening the public’s awareness of the importance of self-reliance on managing cardiac risk factors is equally important.
“Although relatively mundane and not very sexy, these are the kinds of things that will change the face of our cardiovascular risk long term,” says Simari. “It’s a lot more exciting to talk about space-age therapies, but, in the broadest sense, for communities, those are the kinds of things [self-reliance] we really need.”
The truth is, your average American can play a huge role in heading off hypertension (high blood pressure) or preventing a heart attack through simple, unsexy things like diet and exercise. When it comes to heart disease—genetic predispositions not withstanding—there’s a certain amount of personal responsibility and hard work involved that we as Americans have a hard time embracing and accepting.
Like it or not, the future of heart health in this country depends on whether your average American citizen heeds the advice of cardiologists and starts accepting that responsibility.
Battle of the Sexes
Perhaps the most exciting, encouraging, and yes, sexy, breakthrough in modern heart health is the long-overdue debunking of CVD as a man’s disease. Because the following is true—more women than men die of heart disease each year.
According to WomenHeart: The National Coalition for Women with Heart Disease, CVD is the leading cause of death among American women. Currently, CVD kills one out of every three. A 2011 study published in Circulation, the journal of the American Heart Association (AHA), found that, in 2007, CVD claimed more women’s lives than “cancer, chronic lower respiratory disease, Alzheimer disease and accidents combined.”
Dr. Marla A. Mendelson, medical director for the program for women’s cardiovascular health at Northwestern Memorial Hospital’s (NMH) Bluhm Cardiovascular Institute, cited a 1991 study in the New England Journal of Medicine that examined differences in how hospitals in Maryland and Massachusetts treated men and women who complained of chest pains. The study showed that men in Massachusetts’ hospitals were 28 percent more likely to receive an angiogram and 45 percent more likely to undergo revascularization, a surgery to improve blood flow, than women.
“Simply put,” explains Mendelson, “the women were sent home with antacids, and the men were kept in the hospital.” Though the situation for women’s heart health has improved, we’re still seeing some of the same trends today. Carla Wills, an African American woman, suffered a heart attack in September 2008, when she was only 38 years old. Although, she believes she suffered three within one week.
One Saturday, as Wills was driving home from a friend’s house in downtown Chicago, she experienced a pressure—not pain—on her chest, right arm and under her chin, followed by a hot sensation all over. “I just went home and took some Alka-Seltzer,” says Wills. “I laid down, woke up, and I was fine.”
The feeling came back stronger the following Wednesday when Wills was at her job at the United States Department of Labor, Employment and Training Administration. After taking an Alka-Seltzer, she went to the nurse’s station at work and relayed her symptoms. The nurse took her vitals and told Wills that although the kinds of symptoms she was having were typical of a heart attack, she was too young to be having one.
In fact, Wills had experienced comparable, though far milder, chest pains as young as age 26, three months after the birth of her youngest child. She had sought medical attention, after which doctors had given her an electrocardiogram (EKG), though it yielded inconclusive results at the time.
Now, years later, Wills asked her nurse to hook her up to the EKG machine that was in the room. The nurse said no. Instead, she instructed Wills to lie down for a few minutes. Eventually, the pressure dissipated, and Wills returned to work. Later that day, Wills relayed her symptoms to a friend. He urged her to pack an overnight bag and took her to an urgent care center in the suburbs. Her description sounded all too familiar to her friend, who had experienced similar symptoms before. It turned out that he had also had a heart attack before and spent the night in the hospital as a result.
At the urgent care, the doctors performed an EKG, a test that measures how fast the heart is beating, whether its rhythm is steady or irregular, and the strength of the electrical signals as they pass through each part of the heart. Following a quick evaluation, a doctor put Wills in the back waiting room. She waited for an hour but received no word from a nurse or doctor. Frustrated, she went home.
Later, concerned and curious, Wills called her primary care physician, who informed her that she might have gastric reflux disease and prescribed some medication for it. “I didn’t rush to the hospital at that time because I don’t like running to doctors,” Wills says. “I never have. I don’t want to sit in the emergency room for hours. “When I called in sick for work that Thursday, my colleague told me, ‘Be careful. I don’t know if this was a heart attack or not, Carla, but my wife died of a heart attack. No [medical professional] would listen to her.’”
On Friday, Wills saw a hospital cardiologist. He informed her that she didn’t have a lot of the risk factors for a heart attack, told her to come back in two weeks for a stress test and sent her home. That Sunday, the same symptoms came back with a vengeance. Wills called her primary care physician; she told Wills to go to the emergency room immediately. As Wills’ friend rushed her to the hospital—the same hospital that had scheduled her for a stress test in two weeks—she felt like she couldn’t breathe, like someone was squeezing in her whole chest.
A hospital nurse performed another EKG. She then led Wills to a hospital room and told her to lie down. Five minutes later, six health care professionals surrounded Wills. They informed her that she was having a heart attack. It turned out that one of her arteries had 100 percent blockage.
“I started to weep. It wasn’t from the heart attack; it was just that I finally knew something was wrong…. I wept because I finally felt like I wasn’t crazy,” Wills says.
The doctors performed an emergency balloon angioplasty. A surgeon guided a catheter up through an artery in Wills’ thigh into the left atrium artery of her heart. The surgeon then inflated and deflated a balloon, repeatedly, at the site of the blockage, expanding the artery until normal blood flow had been restored. Finally, four stents were installed in the coronary artery to ensure that it stayed expanded and allowed for blood flow.
Now, four years later, Wills says, “I’m telling you, after that experience, I see why women die from cardiac arrest. I probably wouldn’t have believed that before, but I see why it’s the number one killer [of women].” Looking back, she recognizes that her heart attack could have been addressed at several junctures. The urgent care center’s EKG may have detected something wrong four days before she was rushed to the hospital. But the care offered was too little too late. An angiogram may also have headed off a heart attack by detecting Wills’ artery blockage earlier. “Maybe my blockage would have been only 70 percent, as opposed to catching it Sunday, when it was 100 percent.” To other women with symptoms of CVD, Wills says, “You have to be your [own] strongest health advocate.”
This is especially important for black women. According to a recent AHA study, CVD rates in the United States are significantly higher for black females compared with their white counterparts; about 286 per 100,000 black women versus approximately 206 per 100,000 white women. This data parallels a substantially lower rate of awareness of heart disease and stroke that has been documented among black versus white women.
“There are genetic variants that contribute to high blood pressure that are more prevalent in the African American population than there are in the Caucasian population,” says Dr. Elizabeth McNally, a professor of medicine and human genetics at University of Chicago Medicine (UCM). “But there are also a number of environmental influences.” McNally cited higher sensitivity to salt intake, obesity and less access to care among African Americans as prominent environmental factors. If an individual also has less access to care to treat these conditions, then outcomes may be [worse]. Wills began seeing Mendelson at NMH about a year ago because she wanted a physician focused on women’s cardiovascular health.
Mendelson’s advice to women is blunt, yet vital: “You need to know and perfect your numbers. You need to know your blood pressure, your cholesterol, your weight and your body mass index. “If you’re a woman who has risk factors, even just one—and these include high blood pressure, diabetes, high cholesterol, family history of early coronary disease, smoking, early menopause, obesity or polycystic ovary syndrome—if you have one of these and chest pains, you need to have it evaluated. “There are studies that show that women will drive their husbands to the hospital if they have any symptoms, but women with those same symptoms themselves will stay home. We can’t help women if they don’t come in.”
Let’s bracket this story for a second and discuss the actual biological ramifications of heart disease because, despite daily bombardment by drug advertisements and CVD public service announcements, many Americans lack an understanding of exactly what high cholesterol or hypertension are and how they can lead to a heart attack. The complexity of CVD makes heart attacks, even with the sexiest of modern technology, extremely hard to predict.
Dr. Martha Grogan, a cardiologist at the Mayo Clinic says, “People tend to think that if you get a lot of cholesterol clogging up your arteries, then you’re going to have a heart attack at the area where you have the tightest narrowing, but that’s often not really the case.” Here’s how Grogan broke it down: We all have a thin lining on the inside of our hearts, arteries and all of our blood vessels called the endothelium. Cholesterol, which the AHA defines as a soft, fat-like substance found in the bloodstream and in all your body’s cells, can accumulate inside the endothelium along with calcium, fat, cellular waste and other substances, creating plaque deposits. This causes blood vessels and arteries to harden and narrow. The big problems, though, like a potential heart attack, happen when the plaque deposits rupture the surface of the endothelium and spill out into the blood stream.
“Your body gets confused when that plaque ruptures,” says Grogan. “It sees that as a hemorrhage and sends all of these clotting substances and platelets to that area to try to repair the injury in the lining of the artery or blood vessel. Except, in this case, you’re not bleeding externally—you’re bleeding internally—and the blood clot can completely block blood flow to a part of your heart and cause a heart attack.”
“Kind of an inelegant way to say it is that it’s a little bit like acne,” Grogan says. “Predicting when a pimple might burst is hard. There are a lot of things that will contribute to an outbreak of acne. So you can’t really predict when or where a heart attack might happen, but we know the factors that put people at risk and what will make it worse.”
The Cop Finally Takes Control
One of the deadliest factors is also one of the most controllable: high stress.
“There’s no question that [psychological], social and emotional stressors—particularly if they’re chronic and persistent—have an adverse affect on the cardiovascular system,” says Dr. Paul A. Jones, chairman of cardiovascular services at Mercy Hospital Heart and Vascular Center.
Stress took a toll on the heart of Terry Hillard, a 69-year-old patient of Jones’.
To say that Hillard endured a stressful career would be putting it mildly. Following a stint in the Marine Corps and a tour of Vietnam, he joined the Chicago Police Department on March 11, 1968 (Hillard has memorized the date of every major event of his life). He steadily climbed the ranks, holding many positions from patrolman on up to superintendent, which he held from 1998 to 2003. He was even the first African American chief of detectives for the city of Chicago. Along the way, he was shot in the line of duty during an altercation in 1975; once in the wrist and once in the elbow, and beat colon cancer after being diagnosed in 1993.
“Dr. Jones was my doctor when I was superintendent back in ,” Hillard says. “I would go to see him, and he was always wondering when I was going to get out of that stress-filled job that I was in.” Hypertension ran in Hillard’s family. His mother had high blood pressure her whole life, eventually leading to two brain aneurisms. All eight of his living siblings suffer from hypertension pressure, as well. Blood pressure is recorded as two numbers: the systolic pressure (as the heart beats) over diastolic pressure (as the heart relaxes between beats). Below 120/80 mmHg is considered healthy. When Hillard retired in 2003, his blood pressure was 185/90 mmHg.
“It took him a while to get me on the right medication,” Hillard says. “My high blood pressure wouldn’t go down, but finally he got me on the right one, and it’s been down ever since.” But for Jones, getting Hillard to lower his stress was every bit as vital as finding the right medication. “Often, it is a bit of a challenge to lower blood pressure in light of all the persistent stressors,” Jones says. “Rather than continuing to add medication, I work in the arena of stress reduction to help improve a patient’s blood pressure control.”
Jones, like other cardiologists, utilizes cholesterol-lowering drugs, or statins, to improve Hillard’s blood pressure. However, many of these drugs carry harmful side effects such as headaches, nausea, muscle pain, and, in rare cases, liver failure. In a vast majority of cases, the most effective way to improve blood pressure combines medication (if needed) with proactive measures on the part of the patient to get fit and eliminate harmful factors.
Drugs alone are not enough.
Encouraged by his wife Dorothy, 66, who was also a patient of Jones, Hillard gave himself a new job in his retirement days: taking proactive steps to lower his blood pressure. “You know, I didn’t go all out, but I did a little walking,” he says. “But mainly, mainly, it was mostly with my diet and starting to learn how to not let these stressful things control me. “I love soul food—that’s all there is to it—’cause I’m from the South. But I cut back [on it], and I started eating a lot more salads than I used to. I stopped eating fried foods as often. I’m just following Dr. Jones’ advice.”
Then, Mayor Richard M. Daley asked Hillard to return for a 10-week stint as police superintendent while the mayor-elect Rahm Emmanuel searched for someone to fill the position permanently. When asked by reporters whether he would consider taking the job full time, perhaps Hillard thought of Jones’ advice before he responded, “No. N. O. No, no. Read my lips: No.”
The path to a heart-healthier future is not without its own interesting and appealing breakthroughs. Dr. Fred Leya, professor of medicine and director of interventional cardiology at Loyola University Chicago Stritch School of Medicine, is performing “transcatheter aortic valve implantation,” or TAVI, as part of a clinical trial at Loyola.
Only two years prior, a patient suffering severe aortic stenosis would have needed to undergo open-heart surgery to replace his diseased aortic valve. Severe aortic stenosis, however, afflicts many people in their 70s, 80s and 90s, for whom open heart surgery is not an option. Now, using TAVI, an artificial valve can be delivered and deployed with a catheter. Once in place, the artificial valve takes over the function of the narrowed, failing aortic valve, ensuring that oxygen-rich blood flows into the body’s main artery.
Leya performed the minimally invasive procedure on Georgiana Becker in August 2011, who was 90 years old at the time. Becker, a once fiercely independent Cicero resident, had been in and out of hospitals for the past year until TAVI became available. Recalling the procedure, Becker’s daughter Debbie says, “The day after surgery, she was in intensive care, but she was sitting up in the chair and saying ‘I want to get out of here. I don’t want to be in this hospital.’ She was really spunky. I was amazed.”
Two months later, Becker was once again living independently, although she has since employed a caretaker to assist with unrelated complications. Leya hails minimally invasive procedures like TAVI as emblematic of the future of cardiovascular surgeries. “It’s a major accomplishment, and we are all anxiously awaiting the results of the trials and, hopefully, FDA approval,” he says.
Insurance for Broken Hearts
Meanwhile, a road less traveled—the preventative approach to cardiovascular care—winds precariously forward.
According to Dr. Kameswari Maganti, medical director of the cardiac rehabilitation program at NMH’s Bluhm Cardiovascular Institute, a key component in the fight against CVD depends on Medicare shifting gears to fund preventative, proactive care targeting patients at a young age to achieve a lifelong goal of healthy living, rather than remaining staunchly reactive.
“Medicare has approved treatment, so far, for six indications for cardiac rehabilitation,” says Maganti. “They are angina, a recent heart attack, bypass surgery, heart valve surgery and heart transplantation. Heart failure patients are among the sickest patients we have in cardiology, and they’re the ones who will benefit the most from cardiac rehabilitation, but Medicare hasn’t approved it [for coverage].
“Primary prevention is often overlooked,” Maganti adds. “Primary prevention should be the key because you don’t want people to have any [CVD] events to begin with.” Maganti’s focus is on primary and secondary prevention, utilizing cardiac rehab to prevent a second episode, such as a heart attack, from occurring after the initial heart trauma. “The cardiac rehabilitation program is a multidisciplinary program,” Maganti says. “We typically do exercise training, education, counseling regarding risk reduction and lifestyle modification, and frequently, behavior modifications in patients with cardiac events or chronic cardiac conditions. We give an individualized exercise prescription to each and every one of our patients because an exercise prescription given to someone in their 20s or 30s is significantly different [from] what we would assign [to] someone in their 70s or 80s.”
On a national level, however, there is room for improvement. Maganti cited a system-based error in which, 30 percent to 50 percent of the time, physicians do not put in orders to ensure that a patient, once discharged from the hospital, follows up with cardiac rehab. In addition, barriers are also seen in referral patterns that often seem to negatively affect the elderly, women and minorities from being referred.
When asked why she thought patients weren’t being referred, Maganti cited a focus on cutting-edge changes in the treatment of CVD, which are relatively less time-intensive, like medications, interventions and surgery. Though crucial in their own right, there’s also a lack of attention paid by many patients and physicians alike to the more arduous, lifelong tasks of diet and exercise.
“I think if you look at what we do in cardiac rehab, we are pushing lifestyle modifications, which is a combination of exercise training with risk-factor modifications. I think there isn’t anything sexy or new about this. It’s something that’s been around for 70 years. Prevention, especially secondary, has been proven over and over again to have a positive impact. It’s not open heart surgery.”
Published in Chicago Health Winter/Spring 2013