You’re all gonna die!

The good news is, probably not today or even tomorrow.  That’s where you and I get to work together.  Some random acts of fate we just can’t prevent, but statistics tell us that most of us will die of heart disease, strokes, or cancers.  Since heart disease is the single largest killer of Americans, doing in more than a quarter of us, let’s start there.

Research on heart disease has three broad focuses: biology, prevention, and treatment.  While early thinking on heart disease focused on “plumbing” (artery clogs, blood flow decreases, heart dies), it turns out, as it often does in medicine, that things are a bit more complicated than that.

The heart, showing the right coronary artery and left anterior descending artery

The heart is a muscle, your most important muscle, and the one that is never permitted to rest.  All of this work requires oxygen brought to it by blood vessels called “coronary arteries”.  When the heart works harder, it needs more oxygen and blood.  That blood and oxygen has to move through the coronary arteries.  The traditional view of heart attacks (only one of the ways heart disease can kill you) is that the arteries to the heart become progressively clogged. As this happens, flow through the pipes is limited.  When you work harder—say climbing the stairs—you can’t get enough through the arteries, the heart is starved of oxygen, and it hurts.  When you rest, the work of the heart goes down as does its need for oxygen, and you feel better.

Narrowed coronary artery

But it’s a bit more complicated than that.  While we may discover significantly narrowed arteries in people with heart disease, the one that causes a heart attack may not be very narrow at all, and not being narrow, may not cause symptoms of chest pain with exertion.  Small plaques in the coronary arteries may become unstable and rupture suddenly, causing a heart attack with little or no warning.

So, if a patient isn’t having symptoms, how can we possibly prevent a heart attack?

By knowing the underlying biology.

Coronary artery plaques form in the presence of elevated cholesterol levels, smoking, diabetes, and other risk factors.  These plaques can remain stable for a long time, causing no symptoms, but under certain conditions can rupture suddenly, causing the artery to close down with blood clot, and leading to a heart attack.  The rupture of unstable plaques is the cause of a large percentage of heart attacks.

As physicians and patients we need to prevent both the formation of these plaques, and their rupture.  These plaques form because of exposure to vessels to stress and inflammation.  High blood pressure, tobacco use, diabetes, and LDL cholesterol all contribute significantly.  Risk reduction is accomplished by exercise, diet lower in LDL cholesterol producing foods, control of diabetes and blood pressure, and avoidance of tobacco.  And judicious use of drugs.

We know that statins, drugs like pravastatin, atorvostatin, and other HMG CoA reductase inhibitors, can prevent heart attacks, likely by both lowering LDL levels (something that can also be done with diet and exercise, but not always sufficiently) and by reducing plaque inflammation and stability.

Heart disease is a major killer, but the application of medical science has made enormous gains, far beyond the story here.  Over the last twenty years, it has been some of the most important bench-to-bedside research, with scientists and clinicians working together to prevent and treat an important disease.

It’s also a lot of fun.


  1. Shirah

     /  September 6, 2011

    Also VERY grateful to the people who worked (and those who continue to work) so so hard to make it possible for things like overtime weekends, holidays (and holiday pay), sick leave and safe work places/ hours. Safe work places and hours benefit both the employee AND the patient/customer.

    I’m also very., very, very, very thankful that the coffee shop near work was open today. The delicious caffeine the coffee shop makes has been the saving grace of several long shifts.

    • Shirah

       /  September 6, 2011

      Ha! That comment was meant for the post about Labor Day. It may be that trying to navigate/comment on a new blog format after one of the aforementioned busy shifts wasn’t my best plan.

  2. Karl Withakay

     /  September 6, 2011

    “The rupture of unstable plaques is the cause of a large percentage of heart attack”

    This is why it seems to me that even if chelation worked for removing plaques form arteries (which we know it doesn’t), it might not be such a good idea anyway.

  3. All these intertwining factors can be frightening. At 36, my wife had a heart attack. Fortunately it was just a mild one. Her cholesterol was good, her A1C was 6 (she’s diabetic but under control), her BP was good, she’d never smoked a day in her life and had no family history of heart disease. Her weight was high, but with all her other numbers doing so well, we weren’t too concerned. Then, BAM. It’s terrifying that our bodies can just crap out on us at any time.

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