In my last Brownstone article: The Rise of the Meme Disease, I cast the healthcare profession that I have devoted my life to in a very unfavorable light. However, before everyone writes off the healthcare industry as a total fraud, let me assure you that there are instances where medical advancements have been of great value. In fact, the reason I have outlived close members of my family by 20-30+ years is almost certainly due to treatments available to me that were not available to them.
During the 1970s, when I attended medical school and did my residency training, engineering as a profession was absolutely dead. As a consequence, a large number of pre-engineering students switched to pre-med. For decades, I have believed that the era from the mid-1970s to the mid-1990s saw the greatest technological advances in medicine ever seen before or since, largely due to the number of engineering students who went into medicine.
Examples of advances that occurred during this era included the addition to our diagnostic armamentaria of CT, MRI, and radioisotope scanning, sonography, angiography, flexible scopes, and advanced blood testing. In addition, pharmaceutical product development took off, with one of the most important additions, in my opinion, being better treatments for hypertension.
While my last Brownstone article focused on how some of these advances caused harm, I will now focus on some of the advances in the treatment of heart disease that improved patients’ lives significantly. I will also include some of the important missteps and detours that occurred along the way. In addition, I will discuss the challenges that must be overcome, some of which risk jeopardizing the gains that have been made. I will do this from my perspective as both a healthcare professional and patient.
Going into the 1970s, there were basically two classes of oral medications used to treat hypertension: diuretics and a chemical active in the central nervous system (brand name, Aldomet). They were somewhat effective in lowering blood pressure. However, there was no evidence that their use delayed the onset or reduced the severity of heart disease or other vascular conditions.
Another class of oral antihypertensive medication, beta-blockers, first developed during the 1960s, saw increasing use during the 1970s. Beta-blockers were quickly followed by alpha-blockers, calcium channel blockers, ACE (angiotensin converting enzyme) inhibitors, ARBs (angiotensin receptor blockers), and other less frequently used medications.
Concurrently, our ability to study the anatomy of coronary arteries using angiography, and the ability to actually intervene via coronary artery bypass grafting (CABG) and, beginning in the 1980s, angioplasty, provided us with the ability to delay the onset of heart disease (using antihypertensive medications), and mitigate the damage when it did occur (using CABG and angioplasty).
While the availability of these additional classes of antihypertensive medications made it possible to reduce blood pressure in just about all patients, it took a number of years to obtain good data demonstrating which combination of classes yielded the best outcomes in terms of delayed or reduced incidence of heart disease or other vascular events, such as stroke. Overall, I believe that by the 1980s, we reached the point where the benefits of treatment had been optimized.
Here’s where my own personal story comes into play. I’ve had severe hypertension for more than 30 years, to the point where it requires 3 medications with 4 active ingredients for good control (diuretic, beta-blocker, alpha-blocker, and ARB). It took more than a year to come up with a regimen that controlled my blood pressure with minimal side effects, and I’ve remained on that regimen, unchanged, ever since. On the few occasions where I had to minimally reduce my medication dose for a specific procedure (such as a stress test), my blood pressure would increase from 120s/70s to 180s/110s within a matter of a day or two! This is important, because in my family, early death from heart disease or stroke had occurred in two close relatives with severe hypertension, namely my dad and his mom. When they were alive, the only antihypertensive agents available to them were diuretics.
My dad died suddenly in 1969 at age 42 from what was found on autopsy to be his third myocardial infarction. While he was known to have severe hypertension, based on the few times that he allowed his blood pressure to be taken, he was never treated; the irony being that while he wanted me to become a doctor, he never trusted them. His mom, who was known to have severe hypertension, may have been on a diuretic when she died suddenly in 1954 at age 56 from a hemorrhagic stroke. I will turn 75 in a few months, and while I have evidence of heart disease, I have no physical disability from it. I have no doubt that good blood pressure control has been an important factor in that outcome, as it has for millions upon millions of people over the past 30-40 years.
On the other hand, the recommendations for determining the level of blood pressure at which treatment should begin keeps being lowered, even though the strength of the evidence supporting these recommendations has been less than optimal. These recommendations have relied too much on Consensus Statements by “expert” panels or advocacy by the pharmaceutical industry, both of which have a track record of being less than reliable. As such, we need to be very careful that we don’t take a modality that has worked for properly selected patients, and stretch it to the point where the benefits start to disappear.
Another area where it took time to determine the proper indications for a procedure involved CABG and angioplasty. For years, these procedures were done solely on the basis of coronary artery anatomy. We now know that in the absence of symptoms, these procedures offer no benefit. Once this distinction was recognized, it became clear that approximately 60% of the procedures that had been done were not necessary. In the case of CABG, which was done in very large numbers during the 1970s and into the early 1980s (after which, angioplasty became available), there were devastating consequences. That’s because the procedure, on average, required transfusion of about a dozen units of blood.
Given that we were not able to screen the blood supply for HIV and hepatitis C until the early 1990s, there was a significant incidence of death from HIV infection and/or liver failure from hepatitis C in CABG patients. Given that 60% of the procedures were unnecessary, that’s a lot of cases of HIV and/or hepatitis C that need not have happened. The most famous patient who died of HIV after CABG was tennis star Arthur Ashe. In his case, however, he had had a heart attack prior to the procedure, and continued to have symptoms, so the indications to do the procedure were present.
I have been personally impacted by this, since I have had documented partial coronary artery blockages for the past 5 years that would have made me eligible for angioplasty under the original indications. However, due to absence of symptoms, the procedure has not been recommended, and I have not had the procedure done.
Here’s another detour. During the 1970s and 1980s, in parallel with the CABG/angioplasty issues, Type A Personality (hard driving, deadline-oriented) was thought to increase risk of coronary artery disease. It turned out that this was an incidental finding from a Tobacco Institute researcher. The findings were then used by the tobacco industry to deflect attention from the ravages of smoking. This resulted in large investments in treatment clinics that dealt almost exclusively with this issue. Eventually, the smokescreen (excuse the pun) was exposed, and these clinics quickly disappeared.
Type A Personality turned out to be just another meme!
A key element to proper treatment of anything, and consistent with the dictum: first, do no harm, is to match the patient’s clinical presentation with the available treatments. I was told by an elderly general practitioner early in my practice that 90% of the patients that come to my office will get better by doing nothing, 5% will die no matter what I do, and 5% will be significantly impacted by what I do or don’t do.
As such, the art of medical practice is to determine which group an individual patient falls into. Using algorithms providing a one-size-fits-all metric is the polar opposite approach, but has become the standard in current medical practice. Add the incentives from the pharmaceutical industry to generate ever widening parameters for treatment, and you have a grossly overmedicated society that seems to be getting sicker. I have often stated (only half in jest) that when my mom passed a month short of her 93rd birthday, the last woman in the country over the age of 12, who was on no medication, had died.
We have progressed to the point where most Americans with heart disease now reach an average life expectancy. I believe that the healthcare profession has had an important role in that outcome, as I’ve described. The focus should now be on finding ways to improve, to the degree possible, the quality of life during those added years. In my humble opinion, that’s not what is happening. Instead, we are barraged with all kinds of pills and potions and lifestyles that promise to keep us alive and in perfect physical and mental balance to at least 100 years of age…and the public, by and large, has bought into this way of thinking.
Given that life expectancy in this country has stagnated over the past 12-15 years, and it is universally acknowledged that chronic disease has risen, it’s past time that we step back and take a hard look at what we’ve done, both the good and the bad. I believe we have the data necessary to make the correct choices. Maybe a properly functioning AI program, free from the special interests that have negatively impacted the healthcare profession, will get us to where we need to go. Or, is that too much to ask?
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