[Maru]

Why So Many of Us Die of Heart Disease
https://www.theatlantic.com/health/a...isease/554951/

Why So Many of Us Die of Heart Disease

The Assyrians treated the “hard-pulse disease” with leeches. The Roman scholar Cornelius Celsus recommended bleeding, and the ancient Greeks cupped the spine to draw out animal spirits.

Centuries later, heart disease remains America’s number one killer, even though medical advances have made it so that many more people can survive heart attacks. Some parts of the country are especially hard-hit: In areas of Appalachia, more people are dying of heart disease now than were in 1980.

Haider Warraich, a fellow in cardiovascular medicine at the Duke University Medical Center (and an occasional Atlantic contributor), is at work on a book about how heart disease came to be such a big threat to humanity. We recently spoke about some of the insights he’s come across in his research and practice. An edited transcript of the conversation follows.

Olga Khazan: So, you say evolution is the main reason you see a lot of heart disease in humans. Why is that?

Haider Warraich: If you look back and see what it was that has threatened human beings for more than 95 percent of our existence, it’s been three main things: infections, injuries or wounds, and malnutrition. In that setting, the most successful human being was the one who had the most paranoid and xenophobic immune system, which would detect any outside activity and then try to destroy it as soon as possible.

Now, that of course, has changed. We don’t have the burden of infections, especially in higher-income countries, but what has happened is that we have been self-selected to have a very, very robust immune system.

For most of human history, things like being bitten by some wild animal or having any type of traumatic injury has been a part of routine human life. The way that we’ve always combated that has been with inflammation. When the immune system is activated, it results in inflammation. For example, you get a viral infection and you have a fever. That fever is really as a result of the inflammation that’s being caused by the immune system.

What we’re learning is that inflammation is in fact at the heart of atherosclerosis, which is basically at the heart of all heart disease, stroke, and heart attacks. White blood cells, many of them, are full of cholesterol, and they’ll start depositing. Over time, as these plaques build up, they result in blockages that can lead to heart attacks and strokes.

These very robust immune systems are in some ways like a post–Cold War nuclear arsenal, in which you don’t have that threat anymore, but these weapons are still lying around. That’s why we see all these autoimmune diseases, and also we see such a high prevalence of atherosclerosis.

[In a similar way,] even though our nutrition has changed a lot, adaptive mechanisms that were meant to protect us from starvation have now, in fact, led to the dual epidemics of obesity and diabetes, which are some of the main reasons why heart disease remains the number-one killer of people around the world.

Khazan: I noticed that heart-disease deaths are actually going up in certain parts of the country, in a reversal of course. Do you know why that is?

Warraich: There are two things that are happening. Many of the newest cohort that has entered older age in the United States are much more obese than people in the past. It is resulting in a lot of those people getting older and now dying from heart disease.

The other thing is—if you look at the paradox in heart disease, which is different from diseases such as cancer—for most heart disease, you actually have very, very effective ways of preventing and treating it. We have good medications, but we’re losing the battle for information and trust. Many people just don’t trust doctors when it comes to the prescriptions or the advice they give.

There’s still a lot of suspicion about very common, but very effective medications such as statins. We still have a lot of problems getting the right medications to the right people.

Khazan: You’re saying patients don’t trust doctors enough to take the statins they’re prescribed?

Warraich: [Studies show that even] patients who have already had heart attacks are not taking statins or are not on the appropriate dose of statins. That’s a huge deal.

One of the ways this manifests itself is in the so-called “nocebo effect.” The nocebo effect is the evil cousin of the placebo effect. If patients expect harm, or they expect something bad to happen, then that will, in fact, manifest itself in a very real and physical way. One of the things that is most commonly noted about statins is that they [supposedly] cause muscle aches and weakness.

If you look at randomized trials in which patients did not know if they were taking placebo or if they were taking statins, not a single large trial has shown increased prevalence of aches and weakness in patients taking statins.

Now that statins are well-known, many patients come in with this idea. They’ve talked to other people or they’ve heard on TV or they’ve read on the internet that statins cause a lot of symptoms. Patients come in overwhelmingly expecting that statins will not make them feel good.

We, as a scientific community, have to convince patients that they can trust us.

Khazan: Well, and at the same time, you said that experts have historically been very wrong about heart disease. What do you mean by that?

Warraich: When they first discovered blood pressure, physicians thought that high blood pressure was necessary for blood to reach the most remote or the most difficult-to-reach parts of the body.

It was actually the insurance companies who, in millions of their beneficiaries, are collecting data showing that high blood pressure was associated with more people dying. Yet, none of this information was ever followed by the scientific, the cardiology experts of their time.

[Oliver_W]

I have a heart condition called Brugada Syndrome. If you die from it, it's completely undetectable, so a postmortem would show what it did to the heart, but not why it happened, if that makes sense. It's only visible when a certain test is carried out, and that would only be done if someone survived a heart attack and no other disease was known of, and then to the person's relatives.

When athletes etc collapse and die for no apparent reason, they probably had this too!

[Maru]

Originally Posted by Oliver_W

I have a heart condition called Brugada Syndrome. If you die from it, it's completely undetectable, so a postmortem would show what it did to the heart, but not why it happened, if that makes sense. It's only visible when a certain test is carried out, and that would only be done if someone survived a heart attack and no other disease was known of, and then to the person's relatives.

When athletes etc collapse and die for no apparent reason, they probably had this too!

I'm surprised you know you have it, then. Wow. We have had kids and athlete collapse here, but I always figured that was due to high heat in most cases...

My grandmother's afib (irregular heartbeat) was caught when hospitalized for a staph infection (that apparently stays in her blood). They "accidentally" hooked her up to a portable heart monitor, and that's how they picked it up. It took a few trips to her outpatient physicians to pick it up on EKG, and took a 24hr test to see it... now shows up during regular visits no problem. It's so weird.

She's on a CPAP for sleep apnea likely due to the fluid build up in her lungs. In either case, her doctors still classified her as "early" CHF, but you can live 10-15+ years no problem I had read... and it's because they have been constantly improving things with the heart. They know so much more now.

[Kizzy]

I suppose that would make it imperative you eat well and exercise Oliver? My son has a heart condition too (bicuspid aortic valve) we found out when he was 15.
It is choice what you put in your body and how much you move,but it's a shame that foods we think are healthy are misleading with regard to sugar content and packaging.

Advertising and portion sizes are important factors we are constantly bombarded with images and offers of huge portions of very fatty, salty or sweet foods.
You have to have a will of iron to resist, it's not easy

That is the only way to ensure your heart stays healthy, as was advised years ago everything in moderation... Was scoffed at in the 80s when all the faddy diets and 'diet' foods were beginning to be pushed. Fat was considered the enemy now it's known to be sugar that is the cause of heart issues as well as diabetes, NAFLD ( which I have) and obesity.

[Oliver_W]

Originally Posted by Maru

I'm surprised you know you have it, then. Wow.

My dad survived a heart attack, which is how it came to light. Everyone in the family went for the test after that, now some of us have matching heart implants haha...

My grandmother's afib (irregular heartbeat) was caught when hospitalized for a staph infection (that apparently stays in her blood). They "accidentally" hooked her up to a portable heart monitor, and that's how they picked it up.

Blimey, thank goodness for that "accident" then!

[Oliver_W]

Originally Posted by Kizzy

I suppose that would make it imperative you eat well and exercise Oliver?

Not especially - this thing can strike at any time, and it's not influenced by fitness or diet, and it doesn't make me more likely to develop other heart conditions. My uncle took up fitness shortly after his ICD was fitted, and ran the marathon. But the ICD "misunderstood" his exertion as danger, and delivered a shock to his heart. That put me off a bit!

I'd have hated for mine to have come to light at 15, I don't know much about BAV, does that necessitate exercise and a good diet?

[Kizzy]

Originally Posted by Oliver_W

Not especially - this thing can strike at any time, and it's not influenced by fitness or diet, and it doesn't make me more likely to develop other heart conditions. My uncle took up fitness shortly after his ICD was fitted, and ran the marathon. But the ICD "misunderstood" his exertion as danger, and delivered a shock to his heart. That put me off a bit!

I'd have hated for mine to have come to light at 15, I don't know much about BAV, does that necessitate exercise and a good diet?

Ah, oh dear yes I guess overexertion is as bad as being a couch potato :/

Yes it does as he has mild regurgitation (murmur) so keeping the blood as 'clean' as pos it good triglycerides and such gum up arteries, the dangers of obesity and such trying to explain that to a lad at 15?... Nightmare.

What do you do to prevent any further complications?

[Oliver_W]

Basically there's very little I can do, apart from having the batteries in the ICD changed every 5-8 years! Nothing I do will make it more or less likely to happen, so I have to plod on through life hoping for the best, and not do any strenuous activity which could dislodge it, and not get too close to any magnets which could affect it.

I don't know what to say, having to tell him that, at that age, must have been pretty tough :/

(If you don't know, an ICD is an implantable cardiac defibrillator, aka an internal version of those things doctors shock patients with when they say "one, two, three, CLEAR!")

[Kizzy]

Originally Posted by Oliver_W

Basically there's very little I can do, apart from having the batteries in the ICD changed every 5-8 years! Nothing I do will make it more or less likely to happen, so I have to plod on through life hoping for the best, and not do any strenuous activity which could dislodge it, and not get too close to any magnets which could affect it.

I don't know what to say, having to tell him that, at that age, must have been pretty tough :/

(If you don't know, an ICD is an implantable cardiac defibrillator, aka an internal version of those things doctors shock patients with when they say "one, two, three, CLEAR!")

I see, so moderation is the key for you too then I guess to keep as healthy as poss, and chilled out

[Maru]

Originally Posted by Oliver_W

Basically there's very little I can do, apart from having the batteries in the ICD changed every 5-8 years! Nothing I do will make it more or less likely to happen, so I have to plod on through life hoping for the best, and not do any strenuous activity which could dislodge it, and not get too close to any magnets which could affect it.

I don't know what to say, having to tell him that, at that age, must have been pretty tough :/

(If you don't know, an ICD is an implantable cardiac defibrillator, aka an internal version of those things doctors shock patients with when they say "one, two, three, CLEAR!")

Yikes. Yeah my mother has a battery over her heart for Dystonia and it has to be replaced about the same length of time. It had to be pulled the first time due to infection, but she's been doing well since it's been put back in. It's hooked into a wire that runs to her brain and they've put in a piece of metal that sends shocks on a regular basis. It's performed miracles for her symptoms.


Aside from typical preventative (dietary, etc), I wouldn't be surprised if stress management becomes a big thing in the next 10 years or so with regards to even physical health. It was central to controlling my chronic pain, and I wouldn't be surprised if there weren't effects on the heart as well... it sounds like you've got a good grip on your situation.

Though I know a lot of people who avoid going to the doctor because of the fear of finding something wrong... especially the heart doctor, that seems to be one scary one that people are especially keen on dodging... but you know, it could seriously change your life for the better, to take control of the situation and to take control of your health... actually does make a difference in perspective when living your life, because your decisions now have more impact. Rather than sitting around and waiting for the "inevitable" to happen... as so many seem to do when it comes to their physical health.

[LeatherTrumpet]

It's how I am going to go

[DemolitionRed]

My sister has a heart condition called 'Spontaneous Coronary Artery Dissection' (SCAD) and the only symptoms is often sudden death. She went into complete heart failure almost a year ago but was fortunately in the right place at the right time. ECG's that were being carried out just before her heart stopped showed up nothing.

Its a rare but hereditary condition or rather 'Fibromuscular dysplasia' the thing that often leads to SCAD is hereditary and so her children and myself had to go through testing. Her youngest daughter has now been diagnosed with FMD. The rest of us are fine.

The hardest thing for her is finding heart specialists who understand this disease. I'm taking her to a leading SCAD specialist in Leicester in a couple of weeks time and hopefully he will take her off all the medication that's making her feel so ill.

[Kizzy]

Originally Posted by DemolitionRed

My sister has a heart condition called 'Spontaneous Coronary Artery Dissection' (SCAD) and the only symptoms is often sudden death. She went into complete heart failure almost a year ago but was fortunately in the right place at the right time. ECG's that were being carried out just before her heart stopped showed up nothing.

Its a rare but hereditary condition or rather 'Fibromuscular dysplasia' the thing that often leads to SCAD is hereditary and so her children and myself had to go through testing. Her youngest daughter has now been diagnosed with FMD. The rest of us are fine.

The hardest thing for her is finding heart specialists who understand this disease. I'm taking her to a leading SCAD specialist in Leicester in a couple of weeks time and hopefully he will take her off all the medication that's making her feel so ill.

So she only found out last year DR

[Oliver_W]

Originally Posted by DemolitionRed

My sister has a heart condition called 'Spontaneous Coronary Artery Dissection' (SCAD) and the only symptoms is often sudden death. She went into complete heart failure almost a year ago but was fortunately in the right place at the right time. ECG's that were being carried out just before her heart stopped showed up nothing.

Its a rare but hereditary condition or rather 'Fibromuscular dysplasia' the thing that often leads to SCAD is hereditary and so her children and myself had to go through testing. Her youngest daughter has now been diagnosed with FMD. The rest of us are fine.

The hardest thing for her is finding heart specialists who understand this disease. I'm taking her to a leading SCAD specialist in Leicester in a couple of weeks time and hopefully he will take her off all the medication that's making her feel so ill.

Thank god your sister was in the right place when it happened, it's a wretch that so few doctors know about her condition though :/

Her story is similar to my family's - my dad had a heart attack, but luckiily my stepmum knows CPR and kept him going until the paramedics arrived, and then all of us had to have the test, but as it's a rare condition we had to explain it to our GPs in order to get referrals ha... but it sounds like she has it worse, as we don't have to take medication or anything...

[DemolitionRed]

@Kizzy. She was previously diagnosed with fibromyalgia and therefore, any symptoms pointing to FMD were put down as a FM related.

@Oliver. There are plenty of heart specialists for common heart conditions but if you're unfortunate enough to have a rare condition, like you and your family or my sister and niece, then finding a heart specialist who has anything more than a basic understanding is equally rare. You really do have to become an expert of your own illness.

The reason my sister is on the medication she's on at the moment is because her heart specialist in Leeds is treating her the same way he treats people with more common conditions. Hopefully when she see's this SCAD specialist (He's the only one in the country) the treatment for her condition won't be as debilitating as the one she's presently on.

One of the things she did and I'm not sure if you've done this Oliver, was research her condition and find a forum where other people have the same thing. She found an American site and gained so much good information and support from people who have been through the same as herself. It seems the Americans really understand what this condition is and how to treat it.