Heart: An American Medical Odyssey Read online

  Although noted for hundreds of years, atherosclerotic heart disease is largely a malady of the twentieth and twenty-first centuries, killing more people than any other disease in the United States every year since 1900 with the sole exception of 1918, when the Spanish influenza pandemic infected 28 percent of Americans and killed a staggering 675,000 people. Atherosclerotic disease developed in the United States during an era of increasing life expectancy brought about by a precipitous decline in death due to infectious causes and a concomitant improvement in nutrition and wealth.

  In 1971, Abdel Omran, an epidemiologist, published an influential paper, “The Epidemiologic Transition: A Theory of the Epidemiology of Population Change,” in which he described how a population’s death rate changes as a country industrializes. This landmark work described three progressive stages in the evolution of population longevity. In the United States, the first stage, what Omran called the “Age of Pestilence and Famine,” a period of high mortality and low life expectancy, when the top ten causes of death were all infectious diseases, persisted until about the year 1900. Prior to that time, the average life expectancy in the United States was only forty-eight years.

  The second stage, the “Age of Receding Pandemics,” a time when mortality began to decline, occurred in the first half of the twentieth century. During this period, there were steep reductions in deaths in this country from diseases such as dysentery, typhoid fever, and tuberculosis. Food-borne diseases declined following key improvements in food quality fostered by safeguards like the Pure Food and Drug Act of 1906. The discovery of penicillin by Alexander Fleming in 1928 led to the antibiotic era. Polio mortality dropped sharply after the introduction of the Salk vaccine in 1955. These steep declines in deaths from infectious diseases contributed to a significant increase in the nation’s average life expectancy, which reached sixty-eight years by midcentury, ushering in the third stage (the modern era), in which chronic diseases and cancer predominate, and no other disease kills more Americans than heart disease.

  The rise of coronary heart disease occurred in part because Americans were living long enough to develop this illness, which most commonly presents in the fifth through seventh decades of life and also because life itself was changing in this country. As we became more affluent and more urbanized, the nation shifted away from a traditional low-fat, agrarian diet and toward a diet high in saturated fats, found mostly in beef, pork, and lamb, as well as associated by-products such as lard, cheese, and cream.

  • • •

  On the eve of World War II, the US Army solicited the assistance of a University of Minnesota physiologist to help design a mobile diet for paratroopers. The components of the meal, initially acquired from a Minneapolis grocery store, were hard biscuits, dried sausage, chocolate, and hard candy; they were intended to provide soldiers with thirty-two hundred calories per day in a compact and easy-to-carry package. The final product, which also included Spam, Wrigley’s spearmint gum, and a four-pack of Chesterfield cigarettes, was assembled in a rectangular cardboard container resembling a Cracker Jack box and was called a “K-ration” in honor of its developer, Ancel Keys.

  Following the war, Keys returned to the University of Minnesota interested in deciphering the puzzling increase in US deaths from heart attacks. Despite harsh conditions during World War II, the incidence of heart attacks had dropped significantly in many parts of Europe, but they were on the rise in the United States, where people had been relatively well fed. Beginning in the late 1940s and continuing over the next fifteen years, in what was likely the first-ever prospective cardiac epidemiology study, Keys followed several hundred businessmen from Minneapolis and St. Paul and demonstrated that the higher their cholesterol levels were, the greater their risk was of developing coronary heart disease.

  In the 1950s there remained much uncertainty concerning the interaction between diet and cardiovascular risk, which was reflected in the conclusion of a somewhat ambivalent 1957 American Heart Association report:

  The evidence at hand suggest a general association with high rates of consumption of fat, but it is difficult to disentangle this from caloric balance, exercise, changes in body weight, and other metabolic and dietary factors that may be involved. Thus the present evidence does not convey any specific implications for drastic dietary change, specifically in the quantity or type of fat in the diet of the general population, on the premise that such changes will definitely lessen the incidence of coronary artery disease.

  Ancel Keys continued to investigate the interaction between diet and cardiovascular disease and conceived an enormous, international epidemiological project, called the Seven Countries Study, which began in 1958 and has continued for more than fifty years. The study followed nearly thirteen thousand men from the United States, the Netherlands, Finland, Italy, Croatia, Serbia, Greece, and Japan and collected detailed diet and risk factor data such as cholesterol levels and blood pressure. Keys found that meat consumption was high (more than 7 ounces a day) in the United States, Italy, and parts of Yugoslavia and almost nonexistent in Japan. In contrast, fish consumption predominated in Japan but was very low in the United States. The higher the content of dietary saturated fat and the more prevalent meat was in the diet, the higher was the average serum cholesterol level, and the higher was the death rate from heart disease.

  In 1961, the American Heart Association appeared a little more convinced about the role of fat in the genesis of heart disease:

  The reduction or control of fat consumption under medical supervision with reasonable substitution of polyunsaturated for saturated fats is recommended as a possible means of preventing atherosclerosis and decreasing the risk of heart attacks and strokes. . . . More complete information must be obtained before final conclusions can be reached.

  Later that same year, Ancel Keys was profiled in a cover story in Time magazine, titled “The Fat of the Land,” in which he promoted his version of a lower-fat diet:

  Eat less fat meat, fewer eggs and dairy products. Spend more time on fish, chicken, liver, Canadian bacon, Italian food, Chinese food, supplemented by fresh fruits, vegetables and casseroles.

  • • •

  As the nation’s diet changed, so did its addiction to cigarettes. According to the American Lung Association, at the turn of the last century, Americans smoked 2.5 billion cigarettes per year. Over the next several decades the US population tripled, but cigarette consumption increased by a factor of 250, peaking at 640 billion cigarettes sold in 1981.

  Despite a greater than 50 percent decline in the prevalence of smoking over the past fifty years, 46 million people in the United States currently smoke, and the drop in tobacco use has not occurred with equal vigor in all socioeconomic groups. For instance, although the overall prevalence of tobacco use in adults is about 21 percent, it is about 28 percent for those with less than a high school education, those living below the federal poverty line, and those with no health insurance.

  Several years ago a sixty-five-year-old obstinate smoker in my practice with severe coronary artery disease inquired whether my sister had been able to stop smoking. This patient, who resumed smoking after multiple operations, including both heart and leg bypass surgeries, knew that my older sister, Melanie, also struggled with smoking, a habit she hesitated to abandon for fear of gaining weight.

  “Yes,” I told her. “As a matter of fact she did quit.”

  My patient’s eyes brightened, and a smile came across her face when she asked me how Melanie did it.

  “She got lung cancer,” I replied, mustering all the verbal tenderness of a punch in the nose.

  Melanie didn’t fit into any of the disadvantaged groups. She was well educated and had an MBA in marketing, she wasn’t poor, and she did have health insurance, but she started smoking when she was a teenager and she couldn’t stop. Currently, about one in five US high school students smoke, and each day about four thousand kids under the age of eighteen try cigarettes for the first time. About a third of
those who become regular smokers ultimately will die as a consequence. When Dick Cheney attended Natrona County High School in Casper in the 1950s, more than half of American high school students smoked.

  Once begun, smoking is an extraordinarily difficult habit to break. The American Cancer Society estimates that only 4 to 7 percent of people will succeed in quitting on any given attempt, a statistic that increases to only about 25 with the aid of medications like nicotine patches, bupropion (Wellbutrin), or varenicline (Chantix). For many patients, however, a heart attack is a potent behavioral modifier, and at five years following the event, about half the patients who smoked prior to their heart attack remain abstinent from tobacco.

  We now know that cigarette smoking is unsafe at any dose. There are more than seven thousand chemical substances in tobacco or tobacco smoke, including hydrogen cyanide, cobalt, benzene, and arsenic. The complex chemistry of cigarette smoke likely contains many more carcinogens and hazardous constituents and results in increases in blood pressure, coronary plaque deposition, arterial wall injury, and the propensity for blood to clot, a perilous mix increasing the likelihood and decreasing the age at which coronary disease will develop. On average, active smokers experience their first heart attack five to ten years earlier than people who have never smoked.

  • • •

  On a hot July day in 2007, my smart and successful sister, a woman who loved fashion, family, and all things wonderful, died at age fifty-two. Her cancer was in no rush, first taking Melanie’s left lung and a piece of her esophagus, then her ability to eat or talk, and then her ability to breathe without a ventilator. My sister had the longest ICU stay of any patient I have ever come across in my twenty-seven years as a physician. Melanie was brave and beautiful and doggedly refused to leave her husband, Marty, the love of her life, until the relentless disease finally consumed her with its singular, terrible malice. I remind patients who continue to smoke that there are consequences even worse than another heart attack. There are some that are even worse than death.

  • • •

  The identification of individual behavioral and physiological characteristics associated with an increased likelihood of developing atherosclerotic heart disease (risk factors) was achieved in large measure through the efforts of a long-term study run jointly by the National Heart Lung and Blood Institute and Boston University. The study, which began in 1948, enrolled 5,209 men and women from the town of Framingham, Massachusetts, and followed these subjects every two years with physical examinations, blood work, and detailed interviews with the goal of identifying common factors associated with the development of heart disease. Over the past sixty-five years, the still ongoing Framingham Heart Study has identified hypertension, diabetes, tobacco use, high cholesterol, obesity, physical inactivity, and male gender as risk factors for heart disease.

  Framingham investigators have developed a variety of tools, now accessible with online calculators, that use readily available clinical data such as age, weight, blood pressure, and cholesterol to predict an individual’s risk of developing heart disease. At the time of Dick Cheney’s heart attack in 1978, he was thirty-seven years of age, had a blood pressure of 125/70 mmHg (normal) and serum cholesterol of 271 mg/dl (high), was an active smoker, and was 5 feet 9 inches tall weighing 196 pounds. Using these variables, the Framingham model estimates that Mr. Cheney had an 8.2 percent ten-year risk of developing heart disease (similar to that of a fifty-year-old man) compared to a normal risk of 3.4 percent and “optimal” risk for a man his age of 2.6 percent. Subtract the history of cigarette smoking from the model, and Mr. Cheney’s ten-year cardiac risk drops in half to 4.1 percent.

  Although disease of the coronary arteries typically announces its presence in middle age, a heart attack is usually the culmination of a process that begins decades earlier, typically when we are still children. It’s in childhood that we develop our eating habits and exercise patterns and, importantly, when we have our first cigarette. In the 1970s, doctors at Walter Reed Army Medical Center examined the hearts of soldiers killed in Vietnam and noted that although the young men were on average only twenty-two years old, evidence of atherosclerosis was identified in almost half.

  The seeds of heart disease are planted early.

  CHAPTER 2

  Echoes of Ike

  VICE PRESIDENT CHENEY

  Although I’d suspected something was wrong when I woke up in the middle of the night with a strange sensation in my arm and hand, hearing the words was a blow: “You’re having a heart attack, Mr. Cheney.” Hours earlier, I was a thirty-seven-year-old in what I thought was great health, going all out, working around the clock, to try to win Wyoming’s congressional seat. I felt young and invincible. Now I was lying in the ER at Cheyenne Memorial Hospital, having passed out shortly after I arrived. I came to as physicians and nurses scrambled around me. I had a million questions. How could this have happened to me? Was my life at risk? How would this change my life? How would it change my race for Congress? Would I have to drop out of the race?

  Nobody had many answers in those first few hours. I was admitted to the hospital and began what would be an eleven-day stay. Although there were no cardiologists in Cheyenne in 1978, I was fortunate that my case was assigned to an internist named Dr. Rick Davis. I have never forgotten the advice he gave me in the first days after my first heart attack: “Hard work never killed anybody, Dick.” He told me that spending time doing work you don’t want to be doing is far more stressful and potentially harmful. I took his words to heart as I thought about how this heart attack might have to change my life.

  The humor and thoughtfulness of my friends certainly helped lighten my mood during the long hospital stay. James Naughton, a well-known reporter for the New York Times, had covered the 1976 presidential race. He loved a good prank and was constantly playing practical jokes on his colleagues. Several of them came to me just after the election with an idea for a prank we could pull on Naughton. We convinced him to travel to the Catoctin Mountains in Maryland for what he thought would be an exclusive interview at Camp David with President Ford. We in fact set it up for a time when the president wasn’t in residence at the camp. Then we all enjoyed a good laugh when we heard the Marines at the Camp David gates had turned away a crazy reporter who had tried to gain entry to the presidential retreat. A few days after my heart attack, Lynne came into the hospital room laughing and handed me the one-line telegram from Jim. It said, “I didn’t do it. Naughton.”

  Another dear friend, Foster Chanock, a brilliant young man who had worked for me in the White House when I was chief of staff, spent a good deal of time calling all of our mutual friends telling them not to even think about sending flowers. Send campaign contributions, he told them.

  It may surprise some, but I wasn’t viewed as the most conservative candidate in the race. Most thought Ed Witzenburger, who had been the Air Force liaison to the Senate when Barry Goldwater was on the Senate Armed Services Committee, was more conservative than I was. Before my heart attack, I’d heard that Goldwater was planning a trip to Wyoming and thinking of endorsing Ed. The last thing I needed was a nationally known conservative endorsing one of my opponents. Before I had my heart attack, I’d placed a call to Dean Burch, one of Goldwater’s closest aides. I knew Dean from my time in the White House when he’d been a counselor to both Presidents Nixon and Ford. I told him I knew Goldwater was coming to Wyoming and asked if the former senator might avoid endorsing anyone in this hotly contested primary. Dean didn’t make any commitment to me, but he heard me out.

  Three days after my heart attack, Barry Goldwater came to Wyoming. He stopped in Cheyenne, and he didn’t endorse anyone. I am sure my call to Dean may have helped, but I imagine the fact that I was lying in a hospital bed having suffered a heart attack seventy-two hours before his arrival was also a pretty big factor in his decision not to endorse my opponent that day.

  When I was released from the hospital on June 29, I knew that I wanted to continue the
campaign. Dr. Davis told my hometown paper, the Casper Star Tribune, “The prognosis is excellent for Dick’s full and complete recovery. After a period of rest and recuperation at home he can expect to be able to resume a full and active schedule.” I spent most of my rest and recuperation in the shade of a large spruce tree in the backyard of our house in Casper. A good friend had just finished working with President Nixon on his memoirs and got me an advance copy, which I read while I thought about what to do next. Looking back thirty-five years later through the medical records from that period, I found something I hadn’t remembered. Both Dr. Davis and my hometown cardiologist, Dr. Wes Hiser, had noted their concerns about my continuing the campaign. Dr. Davis wrote:

  He and his family have been terribly concerned about the congressional campaign, and whether he should quit or not. It was my own personal feeling that it would probably be wisest to drop this at the present time, but I certainly didn’t press this on them at all. He understands that he has at least a two months convalescence without any active campaigning and it is currently his choice to keep the options open and continue with the campaign.

  I can understand why the doctors felt that way. I am confident neither of them had ever before treated a cardiac patient who was simultaneously a candidate for Congress. What is significant, though, is that neither of them wanted to focus solely on their personal responses. They listened to me and thought about the negative impact it might have if they placed limits on my aspirations. Thirty-five years later, I still consider Dr. Davis’s reminder that “hard work never killed anyone” some of the finest medical advice I have ever received. I believe it sustained me through my four subsequent heart attacks and the numerous other cardiac challenges I faced as I pursued my career in public service. For that, I will always be grateful.