By: Anuradha Rao, MD
Why did you go into Cardiology? I am asked that question a lot. I have no simple answer but if you ask me what I love about Cardiology I can perhaps answer that better. It’s a pretty amazing field that is constantly advancing and new solutions are being found for ancient problems. Problems that once couldn’t be treated are now treatable and often curable.
‘Barry’ was a 38 year old construction worker I took care of in the late 90’s. He was hospitalized with acute congestive heart failure and got better quickly with medical management. He was found to have cardiomyopathy. His disease was idiopathic and his coronaries were clean. He had a young family. I had advised him many times he needed to avoid doing heavy lifting especially in the heat as his heart failure may decompensate and perhaps result in arrhythmia and sudden cardiac death. He had a big grin and would flash it at me while he told me he had to support his family and he’d be fine working his job. He tried to take all of his meds but many were not generic. We tried to load him up on samples but couldn’t always keep up. Trials were being done at that time in patients with prior MI and had he had CAD he may have had guided therapy and an ultimate ICD. Barry did unfortunately die of sudden cardiac death on a hot summer day while working his construction job. Studies and subsequent indications for patients with nonischemic cardiomyopathy didn’t occur until a few years later. He would have been a good candidate for an ICD by today’s standards. He may also have been a candidate for a biventricular ICD and have had a resultant normalized ejection fraction. He would have been able to afford all of his medications which are now generic. I often think of him and his broad grin when recommending an ICD to a patient with cardiomyopathy especially nonischemic cardiomyopathy.
I did my residency in Michigan where we saw the snowstorm effect on heart attack rates. I was at a hospital which was at the cutting edge of cardiology in the late 1980s. As medical residents we admitted many patients who were having primary angioplasty instead of thrombolysis for heart attacks. I saw interventional cardiologists work day and night on the many patients presenting with massive heart attacks. (We don’t see as many of these massive heart attacks these days.) Primary angioplasty was the treatment of choice at my institution and data was collected which would later prove the superiority of primary angioplasty over the use of clot busting thrombolytics. Data was also being collected and the amount of time it took us to get the patient prepared for the cath lab for an emergent intervention was scrutinized. Each minute was examined and if the patient didn’t get to the cath lab within 60 minutes of hitting the door with an ST elevation myocardial infarction (STEMI) we knew there would be a price to pay. I remember a young woman ‘Patty’ in her 40s who had just been injected with an anesthetic that contained epinephrine for bleeding control at her dentist’s office. She developed severe chest pain and her dentist sent her to our ER, a few blocks away. She was indeed having a STEMI. We all worked together and the patient got to the cath labs and had balloon angioplasty in less than 60 minutes. The next day in morning report our every step was scrutinized for potential for improvement in the time taken to get her to revascularization. Patty went home a few days later and to my knowledge did well. She returned to work in less than a week and fortunately had no residual disease. Now as a cardiologist, I remain very aware of door to balloon time (D2B). D2B is measured and reported by most hospitals now and is a measure of a hospital’s success with MI care and in preventing permanent myocardial injury.
Finally as a 4th year medical student I witnessed my grandmother have a stroke while visiting her in India. My mother and I stood by helplessly as she lost her ability to speak and walk in front of our eyes. She never regained either. She was a diabetic and had high blood pressure. She didn’t understand the implications of either and neither was treated aggressively which was pretty well the norm back then. Now as a cardiologist I’m pretty aggressive with prevention. I think of her and that she may well still be living had she lived in the era of more aggressive prevention. Her uncontrolled hypertension and diabetes would currently not be inevitable.
The basic medicines of cardiac care are now almost all generic and more accessible. Education has improved the general public’s understanding of CAD and women, who often presented to the ER many hours later than their male counterparts with symptoms of MI, are now presenting much earlier. Healthcare workers are recognizing atypical symptoms more quickly in women, diabetics, and the elderly. Angioplasty now has the adjunctive therapy of drug eluting stents preventing restenosis, emergent CABG, and recurrent myocardial injury and subsequent cardiomyopathy. ICD’s are preventing sudden cardiac death in the patients with the weakest hearts or the potential for fatal arrhythmia. Abdominal aortic aneurysms are being stented, and keyhole surgery is being done for CABG and valve surgery. Soon, many valves may be treated percutaneously and event monitors may be injected under the skin instead of being implanted or worn in a cumbersome manner. I think of many patients who have benefited from current diagnostics and treatment and a few who would probably still be alive or have lived longer had they had access to current state of the art care. I also think of the countless patients in whom heart disease has been prevented by treatment of cholesterol, blood pressure, and with lifestyle changes who are now outliving many of their family members who didn’t have access or understanding of prevention. The effects of prevention with medication and lifestyle changes is now being reflected in declining rates of MI, and declining need for interventional procedures and CABG. I am in awe when I look back at how much has changed in Cardiology. We’ve come a long way since the days of Foxglove aka digitalis purpurea and from the days when bedrest was considered a must for the cardiac patient. Having coronary disease, stroke, or cardiomyopathy is no longer the inevitable cause of death and disability it once was.