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7. THE HEART AND BLOOD
Stopped.
—LAST WORD OF THE BRITISH SURGEON AND ANATOMIST JOSEPH HENRY GREEN (1791– 1863)
WHILE FEELING HIS OWN PULSE
I
THE HEART IS the most misperceived of our organs. For a start, it looks nothing like the traditional symbol associated with Valentine’s Day and lovers’ initials carved into tree trunks and the like. (That symbol first appeared, as if from out of nowhere, in paintings from northern Italy in the early fourteenth century, but no one knows what inspired it.) Nor is the heart where we place our right hand during patriotic moments; it is more centrally located in the chest than that. Most curious of all, perhaps, is that we make it the emotional seat of our being, as when we declare that we love someone with all our heart or profess a broken heart when they abandon us. Don’t misunderstand me. The heart is a wondrous organ and fully deserving of our praise and gratitude, but it is not invested even slightly in our emotional well-being.
That’s a good thing. The heart has no time for distractions. It is the most single-minded thing within you. It has just one job to do, and it does it supremely well: it beats. Slightly more than once every second, about 100,000 times a day, as many as 3.5 billion times in a lifetime, it rhythmically pulses to push blood through your body—and these aren’t gentle thrusts. They are jolts powerful enough to send blood spurting up to three meters if the aorta is severed.
With such an unrelenting work rate, it is a miracle that most hearts last as long as they do. Every hour your heart dispenses around 70 gallons of blood. That’s 1,680 gallons in a day—more gallons pushed through you in a day than you are likely to put in your car in a year. The heart must pump with enough force not merely to send blood to your outermost extremities but to help bring it all the way back again. If you are standing, your heart is roughly four feet above your feet, so there’s a lot of gravity to overcome on the return trip. Imagine squeezing a pump the size of a grapefruit with enough force to move a fluid four feet up a tube. Now do that again once every second or so, around the clock, unceasingly, for decades, and see if you don’t feel a bit tired. It has been calculated (and goodness knows how, it must be said) that during the course of a lifetime the heart does an amount of work sufficient to lift a one-ton object 150 miles into the air. It is a truly remarkable implement. It just doesn’t care about your love life.
For all it does, the heart is a surprisingly modest thing. It weighs less than a pound and is divided into four simple chambers: two atria and two ventricles. Blood enters through the atria (Latin for “entry rooms”) and exits via the ventricles (from another Latin word for “chambers”). The heart is not really one pump but two: one that sends blood to the lungs and one that sends it around the body. The output of the two must be in balance, every single time, for it all to work correctly. Of all the blood pumped out of your heart, the brain takes 15 percent, but actually the greatest amount, 20 percent, goes to the kidneys. The journey of blood around your body takes about fifty seconds to complete. Curiously, the blood passing through the chambers of the heart does nothing for the heart itself. The oxygen that nourishes it arrives via the coronary arteries, in exactly the way oxygen reaches other organs.
The two phases of a heartbeat are known as the systole (when the heart contracts and pushes blood out into the body) and diastole (when it relaxes and refills). The difference between these two is your blood pressure. The two numbers in a blood pressure reading—let’s say 120/80, or “120 over 80” when spoken—simply measure the highest and lowest pressures your blood vessels experience with each heart-beat. The first, higher number is the systolic pressure; the second, the diastolic. The numbers specifically measure how many millimeters of mercury is pushed up a calibrated tube.
Keeping every part of the body supplied with sufficient quantities of blood at all times is a tricky business. Every time you stand up, roughly a pint and a half of your blood tries to drain downward, and your body has to somehow overcome the dead pull of gravity. To manage this, your veins contain valves that stop blood from flowing backward, and the muscles in your legs act as pumps when they contract, helping blood in the lower body get back to the heart. To contract, however, they need to be in motion. That’s why it’s important to get up and move around regularly. On the whole, the body manages these challenges pretty well.
“For healthy people there is a less than 20 percent difference between blood pressure at the shoulder and at the ankle,” Siobhan Loughna, a lecturer in anatomy at the University of Nottingham Medical School, told me one day. “It’s really quite remarkable how the body sorts that out.”
As you may gather from this, blood pressure isn’t a fixed figure, but changes from one part of the body to another, and across the body as a whole throughout the day. It tends to be highest during the day when we are active (or ought to be active) and to fall at night, reaching its lowest point in the small hours. It has long been known that heart attacks are more common in the dead of night, and some authorities think the nightly change in blood pressure may somehow act as a trigger.
Much of the early research on blood pressure was done in a series of decidedly gruesome experiments on animals conducted by the Reverend Stephen Hales, an Anglican curate of Teddington, Middlesex, near London, in the early eighteenth century. In one experiment, Hales tied down an aged horse and attached a nine-foot-long glass tube to its carotid artery by means of a brass cannula. Then he opened the artery and measured how high blood shot up the tube with each dying pulse. He killed quite a number of helpless creatures in his pursuit of physiological knowledge and was roundly condemned for it—the poet Alexander Pope, who lived locally, was especially vocal on the matter—but among the scientific community his achievements were celebrated. Hales thus had the double distinction of advancing science while at the same time giving it a bad name. Though Hales was denounced by animal lovers, the Royal Society awarded him its very highest honor, the Copley Medal, and for a century or so Hales’s book Haemastaticks was the last word on blood pressure in animals and man.
Well into the twentieth century, many medical authorities believed that high blood pressure was a good thing because it indicated vigorous flow. We now know, of course, that chronically elevated blood pressure very seriously raises the risk of a heart attack or stroke. A more difficult question is, What exactly constitutes high blood pres-sure? For a long time, a reading of 140/90 was generally considered the baseline for hypertension, but in 2017 the American Heart Association surprised nearly everyone by abruptly pushing the number downward to 130/80. That small reduction tripled the number of men and doubled the number of women aged forty-five or under who were deemed to have high blood pressure and lifted practically all people over sixty- five into the danger zone. Almost half of all American adults—103 million people—are on the wrong side of the new blood pressure threshold, up from 72 million previously. At least 50 million Americans, it is thought, are not receiving appropriate medical atten-tion for the condition.
Heart health has been one of the success stories of modern medicine. The death rate from heart diseases has fallen from almost 600 per 100,000 in 1950 to just 168 per 100,000 today. As recently as 2000, it was 257.6 per 100,000. But it is still the leading cause of death. In the United States alone, more than eighty million people suffer from cardiovascular disease, and the cost to the nation of treating heart disease has been put as high as $300 billion a year.
There are lots of ways the heart can falter. It can skip a beat, or more usually have an extra beat, because an electrical impulse misfires. Some people can have as many as ten thousand of these palpitations a day without being aware of it. For others, an arrhythmic heart is an endless discomforting ordeal. When the heart’s rhythm is too slow, the condition is called bradycardia; when too fast, it is tachycardia.
A heart attack and a cardiac arrest, though usually confused by most of us, are in fact two different things. A heart attack occurs when oxygenated blood can’t get to heart muscle because of a blockage in a coronary artery. Heart attacks are often sudden—that’s why they are called attacks—whereas other forms of heart failure are often (though not always) more gradual. When heart muscle downstream of a blockage is deprived of oxygen, it begins to die, usually within about sixty minutes. Any heart muscle we lose in this way is gone forever, which is a bit galling when you consider that other creatures much simpler than we are—zebra fish, for instance—can regrow damaged heart tissue. Why evolution deprived us of this useful facility is yet another of the body’s many imponderables.
Cardiac arrest is when the heart stops pumping altogether, usually because of a failure in electrical signaling. When the heart stops pumping, the brain is deprived of oxygen and unconsciousness swiftly follows, with death not far behind unless treatment is quickly applied. A heart attack will often lead to cardiac arrest, but you can suffer cardiac arrest without having a heart attack. The distinction between the two is medically important because they require different treatments, though the distinction may be a touch academic to the sufferer.
All forms of heart failure can be cruelly sneaky. For about a quarter of victims, the first (and, more unfortunately, last) time they know they have a heart problem is when they suffer a fatal heart attack. No less appallingly, more than half of all first heart attacks (fatal or otherwise) occur in people who are fit and healthy and have no known obvious risks. They don’t smoke or drink to excess, are not seriously overweight, and do not have chronically high blood pressure or even bad cholesterol readings, but they get a heart attack anyway. Living a virtuous life doesn’t guarantee that you will escape heart problems; it just improves your chances.
No two heart attacks are quite the same, it seems. Women and men have heart attacks in different ways. A woman is more likely to experience abdominal pain and nausea than a man, which makes it more likely that the problem will be misdiagnosed. Partly for this reason, women who have heart attacks before their mid-fifties are twice as likely to die as a man. Women have more heart attacks than is generally supposed. Twenty-eight thousand women suffer fatal heart attacks in the U.K. each year; about twice as many die of heart disease as die of breast cancer. Some people who are about to experience catastrophic heart failure suffer a sudden, terrifying premonition of impending death. The condition is commonly enough observed that it has a medical name: angor animi, or “anguish of the soul.” For a lucky few victims (insofar as good fortune can be attached to a fatal event), death comes so swiftly that they appear to feel no pain. My own father went to bed one night in 1986 and never woke up. As far as could be told, he died without pain or distress or indeed awareness. For reasons unknown, the Hmong people of Southeast Asia are particularly susceptible to a condition known as sudden unexplained nocturnal death syndrome. In it, victims’ hearts simply stop beating while they are asleep. Autopsies nearly always show the hearts to look normal and healthy.
Hypertrophic cardiomyopathy is the condition that makes athletes die suddenly on playing fields. It arises from an unnatural (and nearly always undiagnosed) thickening of one of the ventricles and causes eleven thousand sudden unexpected deaths a year among people under forty-five in the United States. The heart has more named conditions than just about any other organ, and they are all bad news. If you can go through life without experiencing Prinzmetal angina, Kawasaki disease, Ebstein’s anomaly, Eisenmenger syndrome, Takotsubo cardiomyopathy, or many, many others, you may consider yourself fortunate indeed.
Heart disease is now such a common complaint that it is a little surprising to learn that it is largely a modern preoccupation. Until the 1940s, the principal focus of health care was with conquering infectious diseases like diphtheria, typhoid fever, and tuberculosis. Only after many of those were cleared out of the way did it become evident that we had another, growing epidemic on our hands in the form of cardiovascular disease. The triggering event for public awareness seems to have been the death of Franklin Delano Roosevelt. In early 1945, his blood pressure soared to 300/190, and it was clear that this was not a sign of vigor but quite the opposite. When he died soon afterward, aged just sixty-three, the world seemed suddenly to realize that heart disease had become a serious and widespread problem and that it was time to try to do something about it.
The result was the celebrated Framingham Heart Study, conducted in the town of Framingham, Massachusetts, just west of Boston. Starting in the autumn of 1948, the Framingham study recruited five thousand local adults and followed them carefully for the rest of their lives. Though the study has been criticized for being almost entirely composed of white people (a deficiency since corrected), it did at least include women, which was unusually farsighted for the time, particularly because women were not thought to suffer unduly from heart problems then. The study is now in its third generation of volunteers. The idea from the outset was to determine the factors that led some people to have heart problems and others to escape them. It was thanks to the Framingham study that most of the major risks for heart disease were identified or confirmed—diabetes, smoking, obesity, poor diet, chronic indolence, and so on. In fact, the term “risk factor” is said to have been coined in Framingham.
The twentieth century could with some justification be called the Century of the Heart, for no other area of medicine experienced more rapid and revolutionary technical progress. In a single lifetime, we have gone from barely being able to touch a beating heart to operating on them routinely. As with any complicated and risky medical procedure, it took years of patient work by lots of people to perfect the techniques and devise the apparatus to make it all possible. The daring and personal risk that some researchers took on is sometimes quite extraordinary. Consider the case of Werner Forssmann. In 1929, Forssmann was a young, newly qualified doctor working in a hospital near Berlin when he became curious to know if it would be possible to gain direct access to the heart by means of a catheter. Without any idea what the consequences would be, he fed a catheter into an artery in his arm and cautiously pushed it up toward his shoulder and on into his chest until it reached his heart, which, he was gratified to discover, didn’t go into arrest when a foreign object invaded it. Then, realizing he needed proof of what he had done, Forssmann walked to the hospital’s radiology department, on another floor of the building, and had himself X-rayed to show the shadowy and startling image of the catheter in situ in his heart. Forssmann’s procedure would eventually revolutionize heart surgery, but it attracted almost no attention at the time, largely because he reported it in a minor journal. Forssmann would be a rather more sympathetic figure except that he was an early and ardent supporter of the Nazi Party and the National Socialist German Physicians’ League, which was behind the purging of Jews in the quest for German racial purity. It’s not entirely clear how much personal evil he engaged in during the Holocaust, but at the very least he was philosophically despicable. After the war, partly to escape retribution, Forssmann worked in obscurity as a family physician in a small town in the Black Forest. He would have been forgotten altogether in the wider world except that two academics from Columbia University in New York, Dickinson Richards and André Cournand, whose work was directly reliant on Forssmann’s original breakthrough, tracked him down and publicized his contribution to cardiology. In 1956, all three men were awarded the Nobel Prize in Physiology or Medicine.
Far more personally noble than Forssmann, and no less stoic in his capacity for experimental discomfort, was Dr. John H. Gibbon of the University of Pennsylvania. In the early 1930s, Gibbon began a long and patient quest to build a machine that could oxygenate blood artificially, to make open-heart surgery possible. To test the capacity of blood vessels deep within the body to dilate or constrict, Gibbon stuck a thermometer up his rectum, swallowed a stomach tube, and then had icy water poured down it to determine its effect on his internal body temperature. After twenty years of refinements, and much heroic swallowing of iced water, Gibbon unveiled the world’s first heart-lung machine at the Jefferson College Hospital in Philadelphia in 1953 and successfully patched a hole in the heart of an eighteen-year-old woman who would otherwise have died. Thanks to his efforts, the woman lived another thirty years.
Unfortunately, the next four patients died, and Gibbon gave up on the machine. It then fell to a surgeon in Minneapolis, Walton Lillehei, to improve both the technology and the surgical techniques. Lillehei introduced a refinement known as controlled cross-circulation in which the patient was hooked up to a temporary donor (usually a close family member) whose blood was circulated through the patient during the period of surgery. The technique worked so well that Lille-hei became widely known as the father of open-heart surgery and enjoyed a great deal of acclaim and financial success. Unfortunately, he wasn’t quite as impeccable in his private affairs as he might have been. In 1973, he was convicted of five counts of tax evasion and a great deal of very imaginative bookkeeping. Among much else, he had claimed a $100 payment to a prostitute as a charitable tax deduction.
Although open-heart surgery allowed surgeons to correct many faults they previously couldn’t get at, it couldn’t solve the problem of a heart that wouldn’t beat right. That required the device now universally known as a pacemaker. In 1958, a Swedish engineer named Rune Elmqvist, working in collaboration with the surgeon Åke Senning of the Karolinska Institute in Stockholm, built a pair of experimental cardiac pacemakers at his kitchen table. The first was inserted into the chest of Arne Larsson, a forty-three-year-old patient (and himself an engineer) who was very near death from a heart arrhythmia as a result of a viral infection. The device failed after just a few hours. The backup was inserted and it lasted for three years, though it kept breaking down and the batteries had to be recharged every few hours. As technology improved, Larsson was routinely fitted with new pacemakers and lived another forty-three years. When he died in 2002 at the age of eighty-six, he was on his twenty-sixth pacemaker and had outlived both his surgeon Senning and his fellow engineer Elmqvist. The first pacemaker was about the size of a pack of cigarettes. Today’s are no bigger than one American quarter and can last up to ten years.
The coronary bypass, which involved taking a length of healthy vein from a person’s leg and transplanting it to direct blood flow around a diseased coronary artery, was devised in 1967 by René Favaloro at the Cleveland Clinic in Ohio. Favaloro’s was a story at once inspiring and tragic. He grew up poor in Argentina and became the first member of his family to attain a higher education. Upon qualifying as a doctor, he spent twelve years working among the poor but came to the United States in the 1960s to improve his skills. At the Cleveland Clinic, he was little more than a trainee at first but quickly proved himself adept at heart surgery and in 1967 invented the bypass. It was a comparatively simple but ingenious procedure, and it worked brilliantly. Favaloro’s first patient, a man too ill to walk up a flight of stairs, recovered completely and lived another thirty years. Favaloro grew wealthy and celebrated and in the twilight of his career decided to return home to Argentina to build a heart clinic and teaching hospital, where doctors could be trained and needy people treated whether they could afford payment or not. All of this he achieved, but because of challenging economic conditions in Argentina, the hospital got into financial difficulties. Unable to see a way out, in 2000 he killed himself.
The great dream was to transplant a heart, but in many places it faced a seemingly insuperable obstacle: a person could not be declared dead until his heart had been stopped for a specified period, but that was all but certain to render the heart unusable for transplant. To remove a beating heart, no matter how far gone the owner was in all other respects, was to risk prosecution for murder. One place where that law did not apply was South Africa. In 1967, at exactly the time that René Favaloro was perfecting bypass surgery in Cleveland, Christiaan Barnard, a surgeon in Cape Town, attracted far more of the world’s attention by transplanting the heart of a young woman fatally injured in a car accident into the chest of a fifty-four-year-old man named Louis Washkansky. It was hailed as a great medical breakthrough, though in fact Washkansky died after just eighteen days. Barnard had much better luck with his second transplant patient, a retired dentist named Philip Blaiberg, who survived for nineteen months.
Following Barnard, other nations moved to let brain death be used as an alternative measure of irreversible lifelessness, and soon heart transplants were being attempted all over, though nearly always with discouraging results. The main issue was an absence of a wholly reliable immunosuppressive drug to deal with rejection. A drug called azathioprine worked sometimes but couldn’t be relied on. Then, in 1969, an employee of the Swiss pharmaceutical company Sandoz named H. P. Frey, while on holiday in Norway, collected soil samples to take back to the Sandoz labs. The company had asked employees to do so when traveling in the hope that they would find potential new antibiotics. Frey’s sample contained a fungus, Tolypocladium inflatum, which had no useful antibiotic properties but proved excellent at sup-pressing immune responses—just the thing needed to make organ transplants possible. Sandoz converted Herr Frey’s little bag of dirt, and a similar sample subsequently found in Wisconsin, into a best-selling medicine called cyclosporine. Thanks to it and some associated technical improvements, by the early 1980s heart transplant surgeons were managing success rates of 80 percent, an extraordinary achieve-ment in a decade and a half. Today some four to five thousand heart transplants are performed globally each year, with an average survival time of fifteen years. The longest-surviving transplant patient so far was the Briton John McCafferty, who lived thirty-three years with a transplanted heart before dying in 2016 aged seventy-three.
Incidentally, brain death turned out to be not as straightforward as originally thought. Some peripheral parts of the brain, we now know, may live on after all the rest has grown still. At the time of this writing, that is the issue at the center of a long-running case involving a young woman in the United States who was declared braindead in 2013 but who has continued to menstruate, a process that requires a functioning hypothalamus—very much a key part of the brain. The young woman’s parents argue that anyone with even part of the brain functioning cannot reasonably be declared brain-dead.
As for Christiaan Barnard, the man who began it all, success rather went to his head. He traveled the world, dated movie stars (Sophia Loren and Gina Lollobrigida notably), and became, in the words of someone who knew him well, “one of the world’s great womanizers.” Even worse for his reputation, he made a fortune claiming rejuvenative benefits for a range of cosmetics that he most assuredly knew were bogus. He died in 2001, aged seventy-eight, of a heart attack while enjoying himself in Cyprus. His reputation was never again quite what it had been.
Remarkably, even with all the improvements in care, you are 70 percent more likely to die from heart disease today than you were in 1900. That’s partly because other things used to kill people first, and partly because a hundred years ago people didn’t spend five or six hours an evening in front of a television with a big spoon and a tub of ice cream. Heart disease is far and away the Western world’s number one killer. As Michael Kinch has written, “Heart disease kills about the same number of Americans each year as cancer, influenza, pneumonia, and accidents combined. One in three Americans dies of heart disease and more than 1.5 million suffer a heart attack or stroke each year.”
Today the problem is as likely to be overtreatment as under, according to some authorities. Balloon angioplasties as a treatment for angina (or chest pains) are a case in point, it seems. With an angio-plasty, a balloon is inflated inside a constricted coronary blood vessel to widen it, and a stent, or piece of tubular scaffolding, is left behind to keep the vessel permanently open. The operation is unquestionably a lifesaver in emergencies, but it has also proven highly popular as an elective procedure. By 2000, a million precautionary angioplasties were being undertaken in the United States every year, but without any proof that they saved lives. When clinical trials were finally undertaken, the results were sobering. According to The New England Journal of Medicine, for every one thousand nonemergency angioplasties in America, two patients died on the operating table, twenty-eight suffered heart attacks brought on by the procedure, between sixty and ninety experienced a “transient” improvement in their health, and the rest—about eight hundred people—experienced neither benefit nor harm (unless of course you count the cost, the loss of time, and the anxiety of surgery as harm, in which case there was plenty).
Despite this, angioplasties remain extremely popular. In 2013, the former president George W. Bush had an angioplasty at the age of sixty-seven, even though he was in good shape and had no sign of heart problems. Surgeons don’t usually publicly criticize colleagues, but Dr. Steve Nissen, head of cardiology at the Cleveland Clinic, was scathing. “This is really American medicine at its worst,” he said. “It’s one of the reasons we spend so much on medicine and don’t get a lot for it.”
