Sunday, June 2, 2019

Book Review: 'State of the Heart: Exploring the History, Science, and Future of Cardiac Disease' by Haider Warraich



The human heart is undergoing both scrutiny and transformation as it never has before. The steep learning curve is teaching us how hearts interact with other organs, how lifestyles and medicines affect it, and how the medical fraternity can mediate its weaknesses and failures. In State of the Heart, cardiologist Haider Warraich continues his documenting of the process.

It is a collection of anecdotes and rants, peppered with dips into history and controversy. He loves teasing a term or a fact, coming back to explain it only further down the page. There is a lot of detective work, with someone’s life at stake for a wrong deduction. Many, many times, Warraich explains that no one had ever seen this before, be it a symptom, a reading or a reaction. The experiences he relates are mostly his own. In one case, the patient died, but his artificial pump kept his blood circulating until Warraich called tech support and learned how to shut it off.

The life of a cardiologist is the other side of this:
 “Being sick is like being given a new job that you didn’t ask for, didn’t want anything to do with, in fact. And now you are stuck with it. The moment you wake up, you swipe in until you fall asleep and you swipe out. There are no days off. Being sick is even worse when you have a chronic disease, like when you develop heart failure, because there is almost no chance you will get to have retirement party and ride off into the sunset. If anything, as you get older, chronic disease just gives you more work to do: more medications to take, more visits to the hospital, more limitations on your daily life, with a diminishing chance of a return to normalcy.”

The chapters are neatly divided into issues. They include history, cholesterol, meds, surgery, devices, women, cancer’s relation to cardio, transplants, and end of life. The meds chapter focuses not on benefits of individual drugs, but testing, placebos and studies. The chapter on devices tells the history of catheters, balloon angioplasty, stents and electronic implants. The stories include serendipity, dumb luck, pure accident, and arrogant persistence. Warraich goes into the failings and weaknesses of these devices, and the anatomy lesson they entail is most valuable.

Of particular interest to me was the chapter on women. Women manifest heart ailments differently than men. Their hormones protect them, but taking hormone replacements does no good whatsoever. Pregnancy and birth are stressful and traumatic, and the effects can linger for life. Doctors have long dismissed women’s cardiac issues, calling them cardiac neuroses. Male doctors tend not to believe their female patients. Instead, they believe their own misogynist stories that women don’t get heart attacks as much as men (they get more). They also suffer more depression and anxiety, the feeding grounds for heart ailments. Women are bigger deniers than men, postponing diagnosis and treatment due to family responsibilities, guilt, altruism and even vanity (I hadn’t even brushed my teeth – ugh – is a real excuse he cites). Cardiac issues kill far more women than breast cancer ever has. This chapter alone needs to be read out loud for all to hear.

At the other extreme is the chapter on cholesterol. Warraich explains it well enough, but the chapter turns into a commercial for statins. He finds nothing whatever to keep anyone from taking them for life. He presses this point continuously. He doesn’t address the scoring system, where good and bad cholesterol are lumped together and the total is always bad. Doesn’t matter if you have a great balance between HDL and LDL, the sum total is too high for the medical establishment. He doesn’t even say what good numbers would look like. The fact is the drugmakers are continually pushing to lower that threshold, so that essentially everyone in the world has too high a score all the time and should therefore take prescription statins every day for life. There is no medical basis for it, other than the current thinking is lower-is-better. We don’t really understand why the body produces LDL at all or what the optimum level might be. This is a major gap in the chapter, and makes me wonder what he has left out elsewhere.

Less newsworthy are the deleterious effects of modern life. Constant stress shows up in the heart. Bad food, lack of exercise and relaxation are life enders. People are 27% more likely to have a heart attack on their birthday than any other day. Stress is a major driver of obesity and overeating, major factors in heart disease. The human body has not evolved to keep up with constant stress. It still focuses on infection, and its solution to everything is inflammation. Inflammation means heart ailment, blocked circulation, weakened hearts and hearts out of control. ”I am here to tell you that inflammation is the central mechanism of atherosclerosis and that how we have evolved has led to more inflammation afflicting more people than any other disease in our times,” he says. Our labor-saving devices necessitate the invention of heart-saving devices. It may not be a great bargain.

The thing about cardiac death is that it is usually sudden, silent and painless. Warraich shows that heart interventions near death can prolong suffering and add extra, extreme pain. For example, electric assists (LVADs) are programmed to massively shock the heart if it falters, even if death is near. It is the equivalent of being dropkicked in the chest by a horse, Warraich says. Yet doctors rarely, if ever, inform patients they can have the device turned off. Some doctors don’t even know this themselves. Technology, as in so many areas, has taken off in its own direction, and left humanity behind.

State of the Heart is intense and both inspiring and massively uncomfortable. It could not be otherwise.


Editor's note: This review has been published with the permission of David Wineberg. Like what you read? Subscribe to the SFRB's free daily email notice so you can be up-to-date on our latest articles. Scroll up this page to the sign-up field on your right. 





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