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Perspectives
Science: Up Close and Personal
At certain times in their lives, certain people are driven to make a special connection with scientific knowledge as something to be captured, known, and in a particular way owned. That encounter, that relentless hunger to possess more understanding, to shape scientific data to one's immediate needs, often comes in the face of something life threatening, like a toxic dump near one's back yard or the chronic stench from a nearby chemical plant.
Or in my case the jolting revelation of a disease.
Questions drench the mind. How did it happen, what can be done, what can be undone, what do I need to know, where is the blame? Igniting the impulse to act is the necessity to do something about this rude imposition because not doing so amounts to an act of surrender to sets of slanted expertise that just might overlook or, worse, ignore the sorts of phenomena I am seeking to understand. That is the point of possessing, actually owning and growing with, the science that pertains to you.
My disease, my possession, was atherosclerosis and the treatment was coronary bypass surgery, experiential ordeals that for me blended the scientific and technological facts as they ought to be known with life as it ought to be designed, and lived.
That blending could only have evolved from feelings of helpless numbness on being declared a victim of heart disease-my first disease since scarlet fever at age three-plus the anxiety of facing a surgery of the most violent kind, plus the fear that held hold of my family during their time of sympathetic and prayerful waiting, plus the thoughts of my readiness to die in surgery, plus my surprise encounter with immediate end times when my repaired heart went into chest-thumping arrhythmia two nights after surgery. But despite the episodes of fear that I experienced and shared, what also persisted was an underlying exuberance that this was a condition that was caught in time, giving me new entry into a new, longer, and more exploratory life.
The diagnosis came in November with a smothering sense of shock because my physical condition was a source of strutful pride. I was a low risk person-in pretty good shape, a non-smoker, only a few pounds over the ideal weight of around 165, non-diabetic, cholesterol numbers not too far off normal, and upbeat in general about the depths and surfaces of life. My major eating vices, however, were a morning pastry that because of my condition I felt I could serenely savor, and swabs of butter liberally applied on most things edible, some things questionable. I was no longer running six-minute-even eight-minute-miles but I put that down to time-honored aging.
My smugness dissolved with the results of a stress test done after a checkup with my primary care physician. It wasn't his idea, oddly, it was mine. The idea came out of some inner voice that told me to be a little more thorough about my condition this time around. Once a competitive runner, and of late mostly a 13-minutes-to-the-mile walker cum occasional sprinter, I had no sense that I could actually flunk the test. What I was expecting was an oh-how-fine-I-am confirmation of my good health.
But flunk I did. After only five fatiguing minutes on the treadmill, my electrocardiogram assumed a squiggle indicating ischemia--lack of enough blood to my heart muscle to handle the exertion. A subsequent angiogram showed severe blockages-spots of fatty and calcified material--in all my major coronary arteries, so much so that angioplasty-mechanical means of widening the passages-- was no option. The only alternative was coronary bypass surgery. So said one cardiologist who examined the images; so said another to whom I went for a second opinion.
Well, not quite the only option. The other choice was avoiding surgery and eating foods with no cholesterol and saturated fats, swallowing daily rafts of vitamin supplements, and most critical of all taking medications known as statins, fabulously successful, lavishly promoted, but nevertheless questionable drugs that inhibit production of cholesterol in the liver, lower the Low Density Lipoprotein (yes, LDL, that sinister enemy of the people), and reduce inflammatory processes that invite the deposition of fatty plaque on the arterial walls.
I studied some of the alternative literature on non-invasive therapy with its claims to actually reverse the process of plaque formation, stabilize the deposits, and therefore bypass the bypass. The approach conformed to all my holistic proclivities but I decided to go with the surgery. Why? I concluded my arteries were too far gone, that the probability of some portion of the plaque breaking and generating stroke or heart attack were high. One cardiologist told me I would be "foolhardy" not to go ahead with the surgery if I hoped to return to a life of jogging, trekking, or the hot pursuit of championship horseshoe pitching. The surgery was coolly and professionally performed on me on January 10 at Inova Fairfax Hospital in Falls Church, Virginia. My willingness-enthusiasm is hardly a word of choice here--to go ahead with it was propped by the knowledge that the procedure had been so perfected over the decades that I would emerge from it safely. Of help, too, was the encouragement of friends who had already had it, were years later feeling terrific, and were urging me to move right into it and stop fooling with cultish approaches that could prove dangerous. Moreover, hospital staff during pre-operation discussion, took a look and me and my condition and declared me a "rabbit," a species of bypass humanity that would race into surgery and roar out into the world whole, improved, and radiant within days of the surgery.
There was the prospect, too, of doing a little journalism over this experience, plunging into a new domain with its issues of life and death, of personal transformation, and of some mighty important areas of biological science. No point in simply being a recipient of 21st century surgical engineering. It was my disease; I would claim it. I would know it. And I would pass on what I learn.
So that's the idea. And this is in a way a prospectus, an early cluster of facts, thoughts, questions, and intentions about something important to a few million unsuspecting people, a huge swath of population with coronary arteries that are doing mortal unbeknown mischief to their owners.
If I can reach an understanding of all relevant aspects to the whole phenomenon of heart disease, then I can begin to learn to what degree I can come to control most of my physiological destiny. In other words, live out some research outcomes, since it is knowledge I am seeking. I aim to partner with some ideal cardiologist so we can follow my progress together. I will seek to know enough to wonder why things should be as they are, why they had to happen as they did. I never asked for this disease, but on the other hand, maybe I did. So many others out there in the boomer world are inviting it without knowing it. One of my first calls after learning about my condition was to the National Heart, Lung, and Blood Institute and its cardiovascular research group director Momtaz Wassef who referred me to the November issue of the journal Nature/Medicine and its special set of feature articles, "Advances in Atherosclerosis." This has been my starting point and principal pedagogical source so far for learning how deeply and richly intricate are the molecular processes that produce the precisely structured fatty gunk along the walls of the coronary arteries. Since I was trained in biochemistry, I find a certain elegance to the process, accompanied by a certain feeling of wonder that we allow it to happen and then express surprise that it has gone so far. Plaque begins forming in infancy. If you're over 30 you have it, maybe not too much, but it's there. Unfortunately, it's usually not noticed until after a heart attack, after which that crucial surgical bypass step is often prescribed-355,000 nationally in 1999, about 1,000 a year at Inova Fairfax Hospital, for at least $50,000 a pop.
And oh that surgical step. Coronary bypass surgery is a brutal procedure; let's not mince descriptions here. One cardiologist described it to me afterwards as a form of butchery-yet, a butchery of a highly sophisticated type almost always resulting in the prolongation of life. Think of what's involved, and pause to marvel at it. The chest is opened by sawing down the sternum. The ribs are separated, pulled open, and held in their yawn by a special clamp. The heart, exposed and beating away, is then detached from its vascular connections to the rest of the body whose blood supply is provided by the classic heart-lung machine. Meanwhile the heart is stopped after being cooled to around 40 degrees F and is ready for the bypass vessels.
These vessels come from other parts of the body. In my case, it was decided I needed three because the blockages were so widespread and numerous. One was taken from my left leg, another from my left arm, the third from the interior of my chest. Each, no wider than 2 millimeters, was wondrously sutured to sections of the aorta at one end, and at the other, attached similarly to the heart's ventricle. Each of the three sections of my body bears incisions that have healed nicely. But even after a month a searing pain has persisted in the chest area where the interior mammary artery was "dissected." Nerve damage is the cause of that and complete repair remains months away. Eventually, I am assured, the pain is likely to subside. In a tiny number of cases, I hope not in mine, it can be chronic.
Probably the most amazing part of the procedure is the anesthesiology, which is a process of continuously monitoring and tuning of every relevant body sign, from the condition of the heart, to the level of blood electrolytes, to the condition of the kidneys. Corrections and alterations of drugs and other agents are made continuously for keeping that yellowed, vulnerable body in homeostatic balance. I can only imagine the toots and whistles, the oscilloscopic lines and curves in the operating room as the monitors tracked processions of fluctuations in my vital signs.
The first few hours in recovery consist of continuous monitoring and drainage of fluid that collect within the body cavity as a result of the trauma. There is probably no more severe a surgery than this type. It is not the piece of cake many recipients boast that it is. The wonder is that it is safe. Medieval, for sure, but safe. But it is not difficult for me to conclude, after the experience, that there has to be a better way. What I mean is that the science of cardiology ought to be moving in directions that lead to outcomes that phase out the hydraulic approach of bypass surgery as the primary treatment. Easily said, but complicated to prescribe.
The better way will indeed come through research, but not only that. It will come through education and motivation that are the essence of prevention. People have to be taught early in life to eat better, keep down the fat, stay off foods with substantial amounts of triglycerides and cholesterol, shun butter, cease smoking, control weight, and reduce stress. The American Heart Association publicizes such guidelines. They are not news. No innovative research here. Only some quantum leaps in public relations. There is the whole issue, too, of public understanding, which needs to be rethought in terms of people claiming knowledge as their own to use and to feed back to their physicians. Patient passivity in the face of expanding knowledge is, shall we say, rampant. And the drug companies, with their barrage of hyperactive ads on evening television, are hardly any help. Critical inquiry is, to say the least, uninvited.
Pre-heart attack people aren't listening to the mere dietary basics, which is why hospitals are expanding their cardiac surgery units and drug companies are hailing growth in sales of their booming cholesterol-lowering drugs. Still, in most cases heart disease is preventable. But in some cases it is less so. Genetics plays a powerful role. If heart disease runs in your family, you are susceptible however healthy your lifestyle. Certain genes promote its development. The medical system must also find ways of detecting it more quickly, certainly much earlier than in my own case. That is the scandal and the embarrassment here. I underwent an expensive surgical procedure, paid for by insurance, but a procedure that could have been prevented by the acquisition of vascular information beginning as early as childhood.
That takes us to the future, to an understanding of the mechanisms of how and why plaque happens. It also takes us back to me and where my heart and I are today. Let's just put down here an impressionist few of the basic steps that add up to the formation of deadly plaque and report on what scientists are saying about tomorrow's therapies, or as one researcher has put it, "the shift from hydraulics to biology."
Two things happen to cause heart disease, or the buildup of plaque. The first is the transformation of cholesterol into a form that is easily taken up by lipids (fats) to form globules and attach themselves to the walls of the coronary vessels. That sentence was easy to write. The processes implied within those words, however, are complex and mysterious. They involve the oxidation of cholesterol, turning it into a poison, the buildup of odious foam cells on the artery walls as precursors to plaque. Dirty business. But not so mysterious that researchers lack clues about where to attack with future chemical agents, such as at the step that oxidizes lipid-bound cholesterol into a poison. The point, the goal, is therapeutic interception of each critical chemical step along the way.
The second set of processes is inflammation of the arterial walls. Daniel Steinberg of the Department of Medicine at the University of California, San Diego describes the inflammatory process as "complex interactions between the resident cells of the artery wall and the invading monocytes and T cells." Agents such as cytokines and growth factors are involved, he says, as well as cell-cell interactions that affect rates of lesion development.
Don't ask for definitions or clear images at this point, just appreciate the intricacies. Imbibe one image by one researcher depicting the whole scenario: "cells engaged in a bewilderingly complex torrent of cross-talk." The intellectually sweet thing to know is that these are step-by-step processes, "key processes," says Steinberg, "that could then be targeted to inhibit progression of the disease and its complications."
Where me and my blood vessels are is in a state of cleanliness. I am officially designated as having heart disease, but I don't see this as quite right. I am much less diseased than I was on January 9, 2003, even 20 years ago, when I walked the earth as officially a low-risk case. The old, blocked coronary vessels remain where they are, in the heart, still occluded and certain to gum up further until the vessels are totally closed. So the cardiologist says. The new vessels, however, are clean and the goal now is to keep them that way. Is that possible?
Probably not and the question is why not. And this is where mechanism enters the picture, the question of those series of molecular steps-that cross-talk--beginning with the ingestion and production of cholesterol and the processes that carry it in oxidized lipid form to the walls of the coronary arteries where it builds, builds, and builds while attracting other varieties of grime. All so mysterious, all so debated. Other theories, involving the role homocysteine and methionine metabolism are also competing for attention, challenging the cholesterol theory, insisting a major cause is defective protein metabolism in which homocysteine is a direct cause of inflammation and plaque buildup. Treatment under this theory involves taking vitamin B6, folic acid, and vitamin B-12 supplements.
"There is no magic bullet now," says NIH's Wassef. "The disease is multifactorial. It has environmental as well as genetic aspects. For the genetic aspects we need to find the right genes so that we can some day administer gene therapy." And yet, I ask, who knows whether addressing one genetic target might not affect other parts of the body not so well? "We have to interfere with some mechanism," Wassef adds. "There is no one atherosclerotic plaque affecting one vessel. There are many forms of plaque affecting three or four vessels and they exist at various stages of progression. The thing that should work best, in my opinion, is some system that can combat the disease itself along one or more of the crucial steps."
Well, all right. So what does it all come down to, so far, after this experience? One major point of, let's call it, righteous indignation.
This whole affair, like some guerilla force, snuck up on me and occupied critical territory. I can visualize the gradual accumulation of those lipid bodies attaching themselves to the toxically conditioned walls of my coronary arteries while I was oblivious to the whole deadly process. Modern medicine neither insisted on nor offered any procedure for detecting the tiny piles of fatty debris clogging my indispensable coronaries. Modern medicine, in short, was ignoring my kind of guy.
When I asked my primary care physician why this had to have happened he merely shrugged and said I lacked the risk factors that would have led any physician to suspect any problems and that the solution was simple prevention: eat right and do all the right things, and don't ask too many complicated biochemical questions that would only amount to a confusing informational overload. No rage, no sense that maybe something was wrong about the way he and his army of colleagues went about things.
His assumption is that cases like my own-cases, not persons, mind you-will be detected only after some coronary event, a heart attack or a stroke or something lesser but dire like dizziness or chest pain which by then will have indicated that things went too far.
So right now I am seeking all the right questions to be asking, such as the right kind of cardiologist to have, one who is willing to be a partner in higher levels of understanding, and how to find this rare paragon of a person. I am also asking about the Lipitor I take, the cholesterol-lowering fabulist drug that works in the liver to inhibit the enzyme that catalyzes the production of cholesterol.
Lipitor is the largest selling drug in the category called statins. It is made by Pfizer, which also makes Viagra. At $7.5 billion a year in 2001, it outsells Viagra by about five to one. But do I really and truly need it? The data shows it does its job. But it lowers essential body chemicals known as Coenzyme Q and Coenzyme A, responsible for all sorts powerful effects in the cell. It also has other side effects. Are there alternatives? Maybe, maybe not. I'll find out. Some believe the homocysteine theory holds key clues to future chemical interventions. What I do believe at this point is that Lipitor and any other statin will have to eventually go. The drug companies won't like that. But they'll have to do better. Fooling with one's cholesterol metabolism is risky business, no good for the long term, overall health of the body.
So this up close and personal encounter with science begins. But if we really want to talk deep here, in the language of the heart, what I've already found out so far with genuine finality is to give thanks. Give thanks for the chance at a new start, at a presumed prolongation of life, for the chance to make bigger all those essential aspects of life I once deemed trivial against career pursuits or other personal agendas. Also for the presence of friends and family who gathered round in a circle of affection and care, and for the chance at fabricating this fresh acquaintance with science in dimensions yet to be perceived. |
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