For the past 4 weeks, I have spent my days (and frequently, my nights) working up patients young and old for heart problems on the coronary care unit. Most of these problems are related to coronary artery disease, the three word phrase synonymous for gunk in your arteries that causes heart attacks, strokes, and chest pains. Having people present with chest pain to hospitals is so common in America that we have become incredibly efficient with algorithms with how to stratify risk and treat patients depending on chemical blood markers, EKG, and clinical symptoms.
If symptoms and tests are concerning enough, the patient gets sent to the "cath lab" which doesn't contain any Bunsen burners, but does has fancy xray equipment that specially trained cardiologists use to visualize the coronary arteries. That is, after they consent the patient regarding risk/benefits of this invasive test (including the risk of losening a plaque in the process, releasing it into the blood stream and causing a stroke, which--though rare--did happen to a patient of mine this month). Once inside the lab, the masked cardiologist drapes the patient and him/herself with layers of sterile blue and inserts a wire up through an access point (usually an artery in the arm or leg) and inject dye. The xray takes a multiple images of the dye flow through the arteries and the patterns coalesce like a movie. Cardiologists examine the films of the dye pattern filling (or not filling) the main arteries and any auxiliary arteries over a period of just a few seconds. They repeat the same film over and over, much like conspiracy theorists watch the grassy knoll tapes of JFK's assassination. There are standard angles to capture in 2D a moving and dynamic 3D organ. However, the interpretation of these films is where precision and art meet. Cardiologists are trained for an additional three years after their internal medicine residency and in so doing learn to interpret "lesions" as they call them (read: plugged arteries) and where TIMI flow III exists (read: blood flow isn't compromised). But where an angle of an artery is bent or there is blurred filling pattern, one cardiologist might see constricted flow and another may see free flow. To make it more complicated, the cardiologists have to make sure that the compromised vessel is the one causing the pain, as patients with severe disease can have many vessels that are partially occluded and it is important to try and address the one that is most likely the culprit. "If it aint broke don't fix it" as they say, but when everything looks broke, it's sometimes hard to assess which is the most broken.
When the interventionalist (which is what the wire-inserting cardiologists are called) feel comfortable with determining a certain vessel could be causing the chest pain and EKG changes they place a stent (think a mini- culvert to keep open the vessel) or blow up a mini balloon (angioplasty) to open up the vessel and improve blood flow. After a stent is placed, patients must take a drug that prevents the stent from clotting or occluding for at least a month and generally a year, called Plavix. If you don't take Plavix or can't afford it at $200/month, you might not be a candidate for a stent at all. I have seen patients who, because they couldn't afford the Plavix, don't get a stent. (It went generic briefly a year or two ago, but the pharma company that makes it quickly fixed that!)
When there is disease in many of the main vessels, interventionalists usually don't bother placing a stent and simply call the cardiothoracic surgeons, as that patient has likely bought a ticket to have his/her chest cracked for open heart surgery. At that point, the surgeon will harvest certain veins (usually a leg vein) to "bypass" the occluded blood vessels in the heart (think taking an alternate route during a traffic jam). He/she can also use existing artery closer to the heart, depending on how many vessels are needed. That way, even if the native artery eventually occludes with plaque, the patient will have the alternative route for blood flow. CABG (coronary artery bypass grafting) can buy people many years, but it's not without it's own risks, months of recovery, and I haven't even talked about the fist fulls of medicines patients are sent out with...whether they get a cath or surgery or are medically managed (some people who have heart attacks don't get caths or CABG).
So... it was a typical day last week. We had a patient, who was actually known personally by my very kind and dry-humored attending physician (fancy name for grey-haired boss) who had been experiencing heartburn-like symptoms (read: chest pain and he should have known better) for months. He finally went in to be checked out and after a catheterization due to ongoing chest pain, was found to have multi-vessel disease. Pop quiz students: what does he get next? That's right: surgery consult. In breaking the news that the patient would need surgery, my attending physician was trying to soften the blow as best he could to this stoic, professional man who did not want surgery. In doing so said, "You know, by a certain age, CABG is a rite of passage when you are an American."
I almost swallowed my teeth. No. No it's not. Voting at age 18 is a rite of passage...getting your driver's license and driving with the radio up so loud your ears hurt is a rite of passage ...even unsolicitously receiving your first edition of the AARP magazine at age 49 is a (not warmly received) rite of passage as an American. But CABG, far and away, is preventable. If you look at the risk factors for coronary heart disease, they are almost all modifiable: high blood pressure, high cholesterol, diabetes (which is 90% type 2 and related to obesity and diet), smoking. Only family history is the non-modifiable risk factor, which, when people do have it (defined by someone in your family having a heart attack before age 55) is a major player, but not the only player. When someone is having chest pain, we don't want to blame the victim at least in the time of crisis when he/she is facing a major operation and a brush with death. But for the rest of us who never want a CABG, and for those who don't want a cath or surgery again, we CAN change the course. (I'll site some literature on the subject...next time...as this will be an ongoing topic)
And so, I continue to believe in healthy living, more than ever. Not in a punitive way because I'm afraid of dying. Everyday I work in the hospital I become more aware that I will die. But because it makes me happy to take care of my body and feel good doing so. Day by day. And ok, I admit it: I'm more than a little scared of having a wire stuck up my heart!
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