New Tools in Combating Heart Disease
By Dr Syed Amir
Bethesda, MD
After a leisurely round of golf on a balmy Saturday afternoon in September 1955, President Eisenhower, the 34th president of the United States, suffered a near fatal heart attack. Initially, his chest pain was attributed to stomach upset and he was advised to take milk of magnesia, the standard treatment for gastric problems at the time. Even when the symptoms persisted, his personal physician failed to diagnose it as a heart attack since many of the sophisticated tests, now routinely used in cardiology clinics, were not available then. The president’s ailment was finally diagnosed with the help of electrocardiography; the technique was just coming into use and was considered state-of-the-art technology.
Having diagnosed the disease, there was little the physicians could do to avert the recurrence of the episode or help the president’s recovery. The science of cardiology a little more half a century ago was at a relatively primitive stage when measured by today’s standards. As was customary, the best physicians who attended the president recommended complete bed rest and administered injection of a blood thinner, heparin. Luckily, President Eisenhower recovered largely on his own, got reelected and served out a second presidential term. Meanwhile, he continued to experience periods of chest pains. He had been a heavy smoker all his life and continued with the habit as no one at the time appreciated the strong link between smoking and heart disease. Even the role of high cholesterol, saturated fats and lack of exercise was not understood at the time.
Life-saving surgical procedures such as bypass surgery and angioplasty were still decades away. At the end of his second term, President Eisenhower retired to his country farm near Washington, and eventually experienced a fatal heart attack in 1969.
Heart disease among the rich and famous has not been uncommon. In his diaries, published posthumously, President Ayub Khan has described the heart attack he suffered in 1968 as he was preparing to attend a banquet given by King Husain of Jordan in Islamabad during his state visit. In the following days, his life hung in precarious balance. He was attended, besides top Pakistani cardiologists, by an eminent British cardiologist, Professor Goodwin. Although Ayub Khan survived the heart attack, he never fully recovered or regained his health. He recorded in his diaries that he continued to experience excruciating chest pains years after he relinquished the reins of power and was leading a retired life in Islamabad. Apparently, his doctors had few effective tools available to treat or control his heart disease.
In May 1971, he came to the United States and underwent a bypass surgery procedure at Cleveland Clinic, renowned for offering the most advanced treatment for heart disease. The heart muscle, however, had been so severely impaired by that time that the former president was not helped by the procedure and he died on April 20, 1974, almost six years after his first heart attack.
Treatment for heart disease has achieved major advances since the days when Presidents Eisenhower and Ayub Khan suffered from it. Today, almost anyone who can afford the cost can receive excellent cardiac care in most countries of the world. Knowledge about the causes, prevention and treatment of heart diseases has grown spectacularly during the past decades. Consequently, there has been a sharp worldwide decline in morbidity and deaths due to stroke and heart disease. This decline has been attributed to a better understanding and control of major risk factors, such as high cholesterol, diabetes, high blood pressure and obesity.
Cholesterol, especially low-density cholesterol, has received much attention in the past decades because of its ability to form fatty deposits inside the arterial walls. According to conventional wisdom, heart attacks are precipitated when a segment of the cholesterol-laden plaque becomes unstable and breaks away, causing blood clots that block the supply of blood to the heart. A range of drugs has been developed and widely prescribed to patients with high cholesterol levels that cannot be reduced by diet and exercise. Among these medicines, the most effective and popular belong to a class of drugs known as statins, which are sold under a variety of commercial names. These have proven relatively safe and have been credited with saving millions of patients from the devastating effects of heart attacks and strokes.
Statins have been in use for well over a decade and much valuable information has accumulated about their dispensation and safety. Recently, based on empirical evidence, doctors have theorized that their beneficial effects probably extend beyond what might be explained simply by their ability to lower blood cholesterol. The most important reason for such speculations is the intriguing observation that not all heart attacks can be explained by high cholesterol levels. In nearly half the patients suffering a cardiac event, cholesterol levels are normal or below normal. It has been suspected that inflammation of coronary arteries, through an as yet little understood mechanism, is implicated in heart attacks. The body responds to inflammation by releasing a protein, called high-sensitivity C-reactive protein, or CRP, which can be readily measured in blood. And, fortuitously, statins are as effective in reducing inflammation, as they are in reducing cholesterol levels.
Sometime back, the results of a powerful clinical study involving some 18,000 volunteers, middle age or elderly men and women recruited in 26 different countries, provided strong support for the notion that inflammation plays a crucial role in heart disease. Furthermore, the benefits of statin administration, at least in part, can be attributed to its ability to reduce inflammation in the arteries. All participants in the study had normal cholesterol, but elevated levels of CRP, the biomarker of inflammation. They were given a daily dose of statin, and were closely followed over a period of two years. At the end of this period, it was noted that they had suffered half the expected rate of heart attacks or strokes and had 20 percent fewer deaths. The research was carried out by a team of cardiologists at several institutions and the results were reported in the New England Journal of Medicine, one of the world’s most prestigious journals (November 2008).
The authors estimate that the expanded use of statins in people who have elevated levels of CRP but normal cholesterol could potentially avert heart attacks and strokes in 25,000 people in America alone. However, while the findings have been universally hailed as ground-breaking, they have also provoked a lively debate among medical researchers. Should people who are healthy in every respect be tested for CRP and put on a life-long regimen of powerful drugs whose potential side effects in the long run are unknown? There is, however, no debate about the financial implications of such a practice. The testing and treatment will cost huge amounts of money at a time when medical costs are already burgeoning in this country. The investigators are optimistic that more definitive answers to these vexing questions will emerge in the future through the work of other scientists.
(Dr Syed Amir is a former Assistant Professor, Harvard Medical School, and a health science administrator, US National Institutes of Health)
