Heart Disease, or Heart Health?

Normality can be dangerous.

That’s the conclusion of a new, large VA study of heart disease. Tens of thousands of veterans with chest pain were catheterized to check for their level of cardiac artery narrowing.   Those with “non-obstructive” heart disease – with narrowing of 20-70% of any coronary artery – died at a much higher rate than those with little or none.

But the “non-obstructors” were not treated aggressively. Because of their “normal” studies, many were not treated aggressively at all – though those with two or more “non-obstructed” arteries died at around four times the expected rate.

Why Were They Not Treated?

Because catheter based treatments only “work” for those with greater than 70% blockage.  From the standpoint of interventional cardiology, such folks are “normal.” No point in shoving in a balloon with a stent to “open up” those arteries.

Sadly, these mortality fit very well with British research showing that the majority of heart attacks in people undergoing cardiac stress tests occurred in those who were “normal.”

For normalcy is determined not by issues of overall health or risk, but by the specific forms of “effective” medical intervention. If you’re not a candidate for interventional cardiology – that’s just bad luck. In American medicine, health care often trumps health.

How Did Such Risks Get Overlooked for Decades?

The reasons are economic, financial, sociological and psychological.

First came the rise of interventional cardiology. After Andreas Gruentzig helped develop balloon catheterization in the 1970s, the landscape of cardiac treatment transformed.

No longer were cardiologists handmaidens to better paid cardiac surgeons.

With the development of coronary bypass from the 1950s, a revolutionary procedure where tiny veins were transplanted directly onto often tinier coronary arteries,  like a walkway over a highway, cardiac surgery really took off. Cardiac surgeons became well paid heroes, with remarkable clinical successes.

Interventional cardiology represented a new world. By pushing catheters through leg and arm arteries, cardiologists could treat many illnesses that cardiac surgeons treated –  sometimes better.

No cracking open of the chest. No time spent on cardiac pumps, with platelet clots clogging the brain. Interventional cardiologists could act emergently stenting open arteries as chest pain appeared, even cleaning out clots in heart (and brain) as they arose.

The work paid well, for sure. But interventional cardiology was also gallant, exciting work, “saving lives before your eyes.”

So if your “obstruction” was less than 70%, that was too bad. Other folks could take care of you – at least until you aged or got sick enough for the “real work” to be performed on your arteries.

Basing health care choices on the most expensive, invasive treatment options – however effective – also obscured the fact that coronary narrowing is a continuous variable. As the VA study shows, the greater the narrowing, the greater the risk – starting with a quite low base.

This is the same issue seen with blood pressure. Just because treatment is “required” by guidelines and health insurers at pressures of 120/80 does not mean that 119/79 is automatically normal. This guideline approach to treatment – now to be enshrined with “incentive” payments by insurers – may prove particularly pernicious. For blood pressure varies about 15% by time of day. You will “require” treatment when you see your internist at 5 PM, when your blood pressure is 135/85; you don’t if you see her in the morning, when it runs 120/75. The lesson is simple: if you come in the morning, no pills. Come in the evening, and your internist gets paid extra to push pills – even though your blood pressure is only showing entirely normal biological clock determined daily variation.

What Is To Be Done?

As Jane Brody points out in a recent article in the NY Times, medication options include aspirin and statins.

Aspirin is a particularly attractive choice. Aspirin’s decrease in cancer deaths is much more powerful than its ability to stop cardiac deaths – a fact few in the public know. Aspirin does cause bleeding, yes. But it’s cheap, easily available, and might  save millions of lives. Guidelines for statins – liberally interpreted by guideline writers with ties to drug companies – make it that virtually everyone over sixty-five will be “recommended” statins. Such  advice is probably wrong. Still, American lifestyle leads to a lot of heart disease, and statins have a big role in overcoming cardiac deaths in the populations.

But other means should help more.

Getting People Healthy

Health is synonymous in many minds with medical care. The VA study and thousands like it should strike a blow at that mindset. For too long, health care has been determined by what treatments and procedures are backed by large economic actors – and how much they pay.

Looking instead to a four fold path to health – physical, mental, social and spiritual – should produce far more benefits to heart patients – and most of the population.

People who walk get less heart disease. People who eat a Mediterranean or similar diets get less heart disease. People who routinely sleep at standard hours get less heart disease.

From the standpoint of mental well-being, seeing the world in terms of solutions – not problems – works well. This cognitive approach really cuts down on depression, a major risk for heart disease.

It’s also been known for decades that the more friends (real face-to-face friends, not necessarily the Facebook variety,) colleagues and acquaintances one has, the less the risk of heart disease. That’s the social option to well-being – a very underutilized part of public health.

Last, when people have a sense of meaning and purpose in their lives, there is less heart disease. And members of religious communities for example, show fewer cardiac deaths.

How much is the “health care industry” incentivized to provide people the knowledge to get healthy through physical, mental, social and spiritual well-being? Just about zero.

Sorry, folks. If health is the goal, you’ll probably just have to do it yourselves. Your physicians will be too worried trying to meet numerical guidelines to deal with the real facts – that the population’s health is determined not by medical care, but how you live.