Cover image for Saving the Heart : the battle to conquer coronary disease
Saving the Heart : the battle to conquer coronary disease
Klaidman, Stephen.
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Publication Information:
New York : Oxford University Press, 2000.
Physical Description:
xvi, 272 pages : illustrations ; 25 cm
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RC685.C6 K53 2000 Adult Non-Fiction Central Closed Stacks

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Though still the leading cause of death, coronary heart disease is now killing half as many people in the U.S. as in the 1960s, partly because of innovative treatments like bypass surgery, balloon angioplasty, and thrombolytic drugs. This book tells the stories of the bold researchers whodeveloped such treatments and explores the tough ethical questions raised by the big money being made in modern cardiology. Klaidman shows how clinicians, engineers, and entrepreneurs have devised radically new ways to treat a diseased heart. He examines the startling extent to which financial ambition has shaped the dynamics of cardiology--now a multi-billion dollar medical/academic/industrial/governmental hybrid--andthe inevitable conflicts of interest such ambition creates. Can a patient's needs come first when market share and profits skew the focus away from medical prudence? Can clinical trials be both free of bias and fast enough to keep up with the flood of new drugs and high-tech devices? Klaidmantackles these questions using real cases, often in the context of wrenching bedside decisions. Immensely readable and packed with vivid detail, Saving the Heart explores the past, present and swiftly developing future of a high-stakes medical specialty. And it weaves into the fast moving narrative advice on how to make the right treatment choices and identify the best cardiologists andsurgeons. If you are one of the 14 million Americans who suffers from coronary disease, Saving The Heart could save your life.

Author Notes

Stephen Klaidman is a Senior Research Fellow at the Kennedy Institute of Ethics, Georgetown University. He is the author of Health in the Headlines and The Virtuous Journalist (both OUP). He lives in Washington, D.C.

Reviews 4

Publisher's Weekly Review

Recent advances in the treatment of coronary artery disease based on collaborations between engineers, surgeons and cardiologists have led to procedures once undreamed of but now almost routine. Coronary angiography, bypass surgery, angioplasty and stent placement (supporting sagging arteries) have not cured coronary disease, which is still the country's leading cause of death, but they have contributed to a 50% decline in its morbidity rate since 1963. Klaidman's engrossing account traces the development of these interventions, the personalities behind them and the complex questions they raise. A senior research fellow at Georgetown University's Kennedy Institute of Ethics and author of Health in the Headlines, Klaidman finds that innovative surgeons share with artists the qualities of "courage, intuition, and imagination," but often bring monumental egos, arrogance and greed into the mix as well. Recognizing the obvious genius behind cutting-edge coronary research, Klaidman nevertheless suggests that high-tech interventions may now be overused, may be prescribed for the wrong reasonsÄincluding increased profits for companies in which doctors or surgeons hold financial interestsÄmay deflect attention in medical training away from important clinical skills, and may not offer patients better overall options than drugs. Klaidman offers specific guidelines for coronary patients and argues forcefully for balance between profit-driven research and patient-centered practice in this sometimes harrowing but always fair-minded analysis of some of the most pressing concerns facing modern medicine. 20 illustrations. (Jan.) (c) Copyright PWxyz, LLC. All rights reserved

Choice Review

In this easy-to-read description of various cardiac medical and surgical therapies specifically focusing on coronary artery disease, Klaidman (Georgetown Univ.) uses mostly lay terminology but does integrate more professional terminology when validating issues he makes with research. It is somewhat biased in that the author continues to interpret the technology, certain physician's styles, and what he thinks is or was actually driving the technology decisions for cardiac health. The book covers coronary artery bypass graft surgery, angioplasty, stent insertion, some pharmacologic therapies, and minimally invasive coronary artery "keyhole" surgery. The political and financial impact of managed care is a general theme throughout the chapters. The title is somewhat misleading because it implies that anyone with coronary artery disease can be saved. This, of course, is totally untrue. Not discussed are the issues of access for all people, gender differences in terms of symptom presentation, and that many people with coronary artery disease also have other comorbidities that impact their treatment. Hence, this book is for the layperson interested in the history of cardiovascular treatments for coronary artery disease and perhaps for the graduate student studying cardiovascular problems, as well as for professionals. S. C. Grossman; Fairfield University

Booklist Review

Journalist Klaidman, now a senior research fellow in bioethics, has written a book that should have a substantial impact on cardiology and among potential patients. He describes the personalities and work of the leading pioneers in cardiac surgical procedures--open-heart, bypasses, angioplasties, and stents--and he delves into the professional and financial motivations of these (mostly) men. While their experimental and clinical work is fascinating, their entrepreneurial activities as businessmen, consultants, and stockholders are of substantial importance, too, for does medical pertinence or possible financial gain decide which operation or procedure the surgeon selects? On this score, Klaidman gives examples of fuzzy communication between surgeon and patient as the two "try" to decide on a course of action. He concludes by urging changes in surgeons' attitudes toward their business affiliations and their patients. Carefully selected illustrations add to the fully documented, well-thought-out text. --William Beatty

Library Journal Review

Anyone facing treatment for a cardiac condition should read this book. KlaidmanÄwho's not a physician, he's a research fellow at the Kennedy Institute of EthicsÄconducted extensive interviews in order to examine the people, the business aspects, and the ethical issues relating to cardiology. Using clear lay language, he humanizes the history of cardiology and explains the evolution of many of the procedures commonly used todayÄincluding angioplasty, bypass surgery, and stenting. He also carefully weighs the advantages and disadvantages of commercialism in medical device technology. In the final chapters, he considers current research and hopes for future technologies, and concludes with a practical list of questions that patients might want to ask their doctors before making treatment choices. This useful book should help to remove some of the mystery and fear surrounding heart disease. Recommended for all public libraries.ÄTina Neville, Univ. of South Florida at St. Petersburg Lib. (c) Copyright 2010. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.



One prescription cannot suit all. The concern of medicine should be, while not losing sight of general principles, to fit the treatment to the patient. Let those humble themselves too who live by their prescribings, and cease from attributing to the groping, vanity and tricks of their calling results solely to be laid ... at the door of God, of nature in her wisdom and of moderation and temperate living. These are the words of Don Diego de Torres Villarroel (1693-1770), mathematician, priest, soldier, prognosticator, and picaró, who taught himself to be a physician in thirty days and in these excerpts displays learning greater than most of his contemporaries and some of ours. Both quotations are from The Remarkable Life of Don Diego: Being the Autobiography of Diego de Torres Villarroel (London: Folio Society, 1958), pp. 168-69 and 173, respectively. Chapter One A Heart Attack His arteries silted up like an old river. Early in 1984, David Allison, a 41-year-old political consultant in Juneau, Alaska, went to the hospital with pain in his chest. He saw the only cardiologist in town, who did an electrocardiogram and concluded that the probable cause of his pain was stress not coronary disease, and that he was not at risk for a heart attack.     Allison's primary-care physician, a stereotypically thorough and authoritarian German woman, thought the diagnosis was reasonable. But she had taken a medical history during which she discovered that Allison's father, mother, and older brother had all had heart attacks. As a precautionary measure, she ordered him to reduce his consumption of salt and fats and to monitor his cholesterol.     Despite his family history, Allison, like many Americans at the time, was only vaguely aware of cholesterol's potentially destructive effects. And he didn't make the connection between smoking and heart disease. When he asked her if he could step outside her office for a smoke, she lectured him severely: "You vill not smoke in zis hospital and you vill stop smoking," which he did, although it took him two years. Until that day Allison had never focused on the fact that by virtue of genetic predisposition he might be at greater risk than most people for a heart attack.     Heart attacks occur when a blood clot, a bit of fatty plaque, or more likely both block blood flow through one or more of the three main coronary arteries and their branches. These tiny vessels wind sinuously around the heart's surface, sometimes burrowing into the muscle, which they supply with blood. A blockage in a coronary artery can deprive part of the heart muscle of oxygen and nutrients, causing tissue to die. Dead tissue cannot contract and therefore the heart's pumping capacity is compromised. This is the event physicians call a myocardial infarction and the rest of us know as a heart attack.     But Allison was a marathon runner. He was convinced that his heart was a strong, healthy pump. And so it seemed to be for the next twelve years, during which time he remained symptom-free.     In 1996, Allison was working as an environmental lobbyist in Washington, D.C. Over several weeks he noticed that during physical activity he would get a kind of sludgy feeling in his upper chest; his lungs didn't seem to fill with as much air as they always had; it was harder to breathe. The air seemed thicker, somehow. These physical changes worried him, but he didn't do anything about it. "I didn't have insurance," he said. "I waited too long. I think I was in denial."     At Christmastime Allison drove from Washington to Miami, where he took a boat to the Bahamas to go scuba diving. It was a bad trip from beginning to end. He got seriously seasick during the rough sailboat crossing to the islands. And he had a couple of panic attacks while diving, after which he quit. On the rainy, fogbound drive back to Washington he slept only a few hours in the car, overdosed on steaks, eggs, bacon, sausage, and alcohol, and arrived in Washington exhausted. But he was happy to be home in time to spend a quiet New Year's Eve with his girlfriend Cindy.     The next night, after making love, he got up in the early morning hours to put on a pot of coffee for her. He got a few steps from the bed and suddenly felt a tightness in his chest and then pain in his stomach. He went to the bathroom and took an antacid. He also felt the familiar heaviness, the thickness in his breathing. Not knowing what else to do, he took a couple of aspirin. He was afraid that it might be his heart.     Then he broke into a cold sweat. Within seconds his entire body was drenched. "My chest felt like it was collapsing in on me," he said. "I took a deep breath and lay down. I took another deep breath and it hit me again. I had a pain like somebody had attached a 220 electric line to my chest. I curled up on the bed. I had pulled a blanket up over me because I was chilling. I looked at a clock and it was 6:20 A.M. I'm lying there looking at the digital numbers and I thought: `Well, this is really interesting; it's 6:20 A.M. and I'm having a heart attack.'"     He called out for Cindy, who saw his obvious distress. She asked if he needed to go to the hospital. He hesitated for a moment, but it quickly dawned on him that if he didn't get to a hospital fast he might die, right there on the floor of his house. He had taken a bus a few days before that went by the nearest hospital, D.C. General, so he knew where it was, only seven blocks away. He gave directions to Cindy, who drove him to the emergency room.     "I walked in," Allison said, "and there was a woman sitting at the desk. I ran over and said, `Help me, help me, help me, I think I'm having a heart attack, help me please,' and fell on the desk. I described pain in my jaw, my neck, my back, my arm was completely numb, clavicle was on fire. I didn't know at the time these were classic symptoms. I was crying. She asked me if I had insurance, I said, `No, I don't have insurance.' She never stopped. She was asking me questions and moving me to the emergency room. I was on the table and had a team on me I think within two minutes of coming through the door.     "A resident or a doctor said, `Tell me what your pain is, had I had a heart attack before, what's your level of pain from one to ten?' `It's horrible, one to ten, man, it's like a twelve or fourteen.' They were injecting me with something, asked me if there was anything I was allergic to. `We're gonna get rid of your pain, we're gonna give you morphine'; asked me if I'd taken any drugs. Kept asking me, `What's your level of pain?' They injected me with twelve units of morphine. I know that at five minutes of seven I was lying there and at ten after seven they were asking me for permission to use drugs that might be able to clear the blocked artery. `Where do I sign? Yes, do whatever to make this stop.' They asked me if they could do a cardiac catheterization. I said whatever you need to do. Pain is still a ten and coming in waves. I'm twisting around on the table. A doctor said, `Now this is what we call the twister response to MI [myocardial infarction].' Everybody laughed."     Allison's pain finally began to subside; he felt he was able to breathe normally, "shallow and relaxed." Because of his twisting, the medical team couldn't do emergency angioplasty, the cutting-edge procedure they thought would be best, which involves inserting a catheter and blowing up a balloon inside the artery to unblock it. They gave him a clot-busting drug intravenously instead. This is slightly more dangerous because it is more likely to loosen bits of arterial plaque, which can migrate to the brain and cause a stroke.     The next thing Allison remembers is being in an operating room under a bright surgical light. Someone was shouting, "`Get the [defibrillator] paddles, I think we're losing him.' I'm clear as a bell. My mind's working fine. Now, this is silly. They're not losing me. I've just got to tell them I'm okay. I'm using every bit of energy I've got. I'm trying to peel my eyes open. And they open. And there's this guy standing there in all kinds of blue. And I feel like I'm in a TV show or something, all these people standing around looking at me and someone says, `It's coming back up,' and there's this guy standing there with these freaking paddles.     "No, this is not something that's happening, and I moved my head and I looked up and I wasn't in an operating room. I was still sitting in the emergency room. There was no operating room light there." The defibrillator was real, though. Allison's blood pressure and heart rate had dropped precipitously, bringing him close to death.     The D.C. General staff had not called Matthew Parker, Allison's personal physician. "When I called him and told him" what had happened, Allison said later, "he was livid. He told me to get out of D.C. General as quickly as I could." Parker wanted Allison transferred to the Washington Hospital Center, which has a world-class cardiology and cardiac surgery program. "I said I didn't have any insurance. He said, `Get out. We'll make arrangements. The important thing is for you to be alive.' But I was really scared of leaving the doctors who had been taking care of me. I had all these students and this intern. I was afraid to leave and go to someplace new. I wanted to stay for the [angiogram] they wanted to do. I felt very comfortable. I felt a great deal of confidence. They seemed confident."     A couple of days later, a cardiologist at D.C. General performed the angiogram. In this procedure, radio-opaque dye is squirted into the arteries, making blockages visible when X-ray pictures are taken. The cardiologist told Allison that he had had a total blockage of the left anterior descending coronary artery, which courses down the front of the heart and supplies blood to the left ventricle, the heart's main pumping chamber. Even after injection of the clot-busting drug tissue plasminogen activator (tPA), this artery still was about 80 percent blocked.     Allison was also told that there were 40 percent and 25 percent blockages in two other arteries and that an area of his heart muscle had died. Since the part of the muscle supplied by the major blocked artery had died, they said, they had no plans to do angioplasty or bypass surgery.     Two days later, Allison was sent home. He went to see Parker, who sent him to Cardiology Associates, a large group that practices out of the Washington Hospital Center. They did an electrocardiogram and scheduled him for a thallium stress test, a procedure that measures blood flow through the coronary arteries and heart. Meanwhile, Parker told him he'd had a major loss of heart function resulting from his heart attack and asked him to call his office before nine each morning to report on how he felt. "I was scared again after that discussion," Allison said. "I was told that I'd lost the functioning of about a third of my heart after the stress test. I didn't want to believe that this was a permanent condition.     "They told me that the lost function meant blood was pooling and therefore there was a potential for clotting and that I would have to take Coumadin [a blood thinner] for the rest of my life." This meant that Allison, an outdoorsman and fitness enthusiast, would have to avoid risky physical activities because an injury could result in uncontainable bleeding. Allison was also told by a physician at Cardiology Associates that there was to be no interventional procedure--not surgery and not angioplasty--because the area of heart muscle normally supplied by the still badly blocked artery was dead; it no longer could contract and pump, therefore there was no use supplying it with blood.     Allison, glad to be alive, took the Coumadin and other medications and was fine for several months, but then symptoms began to recur. The doctors at Cardiology Associates were concerned and ordered him back into the hospital. Surprisingly, an angiogram showed that there were pockets of viable heart muscle in the area supplied by the clogged left anterior descending artery, which was why he was having symptoms. Because this vessel was still supplying blood to some living tissue, they did an angioplasty to open it to 50 percent or more and increase the supply.     The procedure was successful. Allison was taken off Coumadin and told he could exert himself in any way he wanted, even train to be a triathlete. But it was important for him to remember that he had suffered a heart attack, as had both of his parents and his brother. He still had a high-risk profile. Moreover, there is no cure for coronary artery disease. There is only palliation. He would have to watch himself for the rest of his life.     David Allison's experience is instructive because he was a possible candidate for each of the three groups of treatments available for coronary artery disease at the end of the twentieth century--bypass surgery, interventions such as angioplasty and stenting, and drug therapy.     The pertinence of Allison's case becomes obvious when viewed against a decade-by-decade timeline. Had he had his heart attack in 1976, he probably would have had open-chest bypass surgery through a foot-long incision. Had it occurred in 1986, he would have had open-chest bypass surgery or angioplasty. In 1996, as we know, he was given clot-busting drugs and later angioplasty. But if he had been taken directly to the Washington Hospital Center instead of D.C. General Hospital he might just as easily have had bypass surgery done through a three-inch incision without the use of a heart-lung machine while his heart continued to beat, or perhaps angioplasty combined with the insertion of a tiny metal scaffold called a stent to keep his artery from shutting down.     But if David Allison had had his heart attack in 1966 or earlier, he would have been put to bed and given frequent doses of nitroglycerine to relieve his pain. At that time, by way of treatment, that's essentially all there was.     What follows is the story of how clinical scientists, biomedical engineers, and entrepreneurs working together developed today's generally effective treatments--not cures, but life-enhancing and sometimes life-extending treatments--for this devastating condition. It begins with a brief historical sketch of medicine's quest to understand and respond to coronary artery disease, from Galen, a great second-century Greek physician, to John Gibbon, the patrician Pennsylvanian who invented the heart-lung machine.

Table of Contents

1 A Heart Attack: terrifying experienceDavid Allison's
2 The Revolution of 1912: insists that heart attacks are causedby clots and are survivableJames Herrick
3 Creating the Platform: make thediscoveries that make treatment possibleJay McLean and Werner Forssmann and John Gibbon
4 Groping in the Dark: Primitive attempts at coronary surgery, and Mason Sonesinvents the diagnostic test that makes bypass surgery possible
5 Accidents and Innovations: How bypass surgery began, how Rene Favaloro madeit matter, and how three big clinical trials tested what it could do
6 Surgeons: and what it takes to be a heart surgeonJohn Kirklin and Paul Taylor
7 Smart Operators: put engineering andentrepreneurship at the service of surgery, and vice versaWesley Sterman and Chuck Taylor
8 A Momentous Decision: decides to have beating-heart surgeryLewis Hollander
9 Angioplasty: A Balloon on a Snake: Andreas Gruentzig invents angioplasty andflames out in a storm over Georgia
10 The Interventionalist as Entrepreneur: invents a bettercatheterJohn Simpson
11 Trials and Errors: East and Bari, two big, well-conducted clinical trialsthat might not have warranted the multimillion dollar investment of taxpayerdollars
12 Interventional Cardiology Expands: invents the coronary stentJulio Palmaz
13 How healing can harm the hunt for the molecular causes of heart attacks
14 What Shall We Make of All This? A critical summation
Appendix A Designing and Mounting Clinical Trials
Appendix B What Patients Need to Know