This week, I’ve been reading Yale Medical School professor Dr. Sherwin Nuland’s amazing book How We Die – which is not nearly as grim as it sounds. In fact, it’s an endlessly fascinating read. For heart attack survivors, the concept of death can become more interesting than we ever imagined it to be.
We live in a death-denying society. People don’t want to think about death, much less talk about it. As Dr. Nuland writes, death to most of us occurs “in sterile seclusion cloaked in euphemism and taboo”. We don’t even like using the ‘D’ word. Instead of ‘dying’, we prefer to “pass on”, or “pass away” or “go to be with Jesus”.
Sometimes it seems that we even consider death to be a terrible mistake that should never ever happen, instead of the inevitable end result of being born. Let’s face it, my heart sisters: none of us is getting out of here alive….
Maybe it’s so many years working in end-of-life hospice/palliative care (where staff tend to chat easily about death and our own mortality) that has made me so intrigued by life’s final chapter.
Dr. Nuland’s unique book looks at the medical physiology of how most of us are likely to die – from cancer to Alzheimer’s to AIDS and, yes, cardiovascular disease.
But even if I have no immediate plans to die anytime soon, it is still intriguing to read Dr. Nuland’s description of our coronary arteries as “friends of the heart” when we are healthy, but “when they are diseased, they betray it at its most needful moments.” He explains:
“So commonly do coronary arteries betray the heart whose muscle they are meant to sustain, that their treachery is the cause of at least half of North American deaths.
“Problems with these ‘now I love you, now I don’t’ vessels begin when their victims are young. Varying degrees of vessel obstruction can be found in virtually every adult, having begun in adolescence and increasing with age.
“An individual myocardial infarction (heart attack) involves that part of the heart muscle wall supplied by the particular coronary artery that is occluded (blocked), usually measuring two or three square inches in surface area.
“The culprit about half the time is the left anterior descending artery. Half of all infarctions thus involve the front wall of the left ventricle. The right coronary artery, supplying the back wall of the heart, accounts for 30-40% of occlusions; the left circumflex coronary artery, supplying the lateral wall of the heart, contributes 15-20% of all heart attacks.
“The left ventricle, the most powerful part of the cardiac pump and the source of the muscular strength nourishing every organ and tissue in the body, is injured in virtually every heart attack. And each cigarette, each pat of butter, each slice of meat and each increment of hypertension make the coronary arteries stiffen their resistance to blood flow.
“When a coronary artery suddenly occludes, a period of acute oxygen deprivation ensues. If this period is long and severe enough that the stunned and bloodless heart muscle cells cannot recover, the pain of angina is replaced by infarction.
“The affected heart muscle tissue goes from the extreme pallor of ischemia to frank death. If the area of muscle death is small enough and has not killed the patient by causing electrical abnormality of heart rhythms, the involved heart muscle, now puffy and swollen, will be able to maintain a tenuous hold on existence until, with gradual healing, it is replaced by scar tissue. (Also read Time Equals Muscle During Women’s Heart Attacks).
“The area of this damaged tissue is incapable of participating in the forceful thrusting of the rest of the myocardium. Each time a person recovers from a heart attack of any size, he/she has lost a little more muscle to the increasing area of scar tissue, and the power of the ventricle becomes a bit less.
“Coronary occlusions or spasms in smaller branches of the main vessels may give few signals to announce themselves, but they continue to diminish the force of cardiac contraction. Thus it is the chronic disease of heart failure, and not the sudden cardiac arrest, that carries off about 40% of victims of coronary artery disease.
“But the heart is far more than just another stolidly stupid pump, but a responsive dynamic participant in life, capable of adaptation, accommodation, and sometimes even repair.
“Back in 1772, a properly designed exercise program to rebuild the heart’s ability to function was described like this by one observer:
“I know of one who set himself a task of sawing wood for half an hour each day, and was thus nearly cured of heart disease.”
“Although the handsaw has been now replaced by the treadmill, the principle is the same.
“A wide variety of cardiac medications are also available now to help the heart muscle and its conduction system. There are even drugs used within the first few hours of an occlusion to dissolve a brand new clot. There are drugs to decrease myocardial irritability, prevent spasm, dilate arteries, strengthen the heartbeat, diminish accelerations of rate, drive out excessive loads of water and salt, slow down clotting, decrease cholesterol levels in blood, lower blood pressure, allay anxiety – and every one of them carries with it the possibility of undesirable side effects.”
And finally, Dr. Nuland writes of the “wizardries of technology” that allow cardiologists to:
- reroute blood around obstructions in coronary arteries
- widen narrowed vessels with balloons and stainless steel stents
- have the whole heart chucked out and replaced with a healthy secondhand one.
All these procedures, he says, have high rates of success, when the candidate is carefully chosen.
“And yet, after each one, the process of atherosclerosis continues to lick at life. Widened arteries frequently plug up again, grafted vessels develop occlusions, and ischemia symptoms too often return to their old myocardial haunts.”
And there’s the rub, my Heart Sisters: like all heart attack survivors, I do, alas, have a chronic and progressive disease. They can patch me up, pump me up with drugs, pat me on the head and wish me well – and in spite of the miracles of acute medicine and all those wizardries of technology, it’s a fair bet that I’ll be saying: ‘Hello again!‘ to the Coronary Intensive Care unit staff in our cardiac hospital one day.
I’ll leave the last words to the profound Dr. Nuland:
“Nature has a job to do. It does its job by the method most suited to each person. It has made this one susceptible to heart disease, and that one to stroke, and yet another to cancer, some after a long time on this earth and some after a time much too brief.
“Death is not only the ‘way of all flesh’ but the way of all life, and it has its own plans for us. Though we find clever ways to delay, there is no way to undo those plans.”
And right now, my plans are to head out the door to walk along the ocean in the sunshine so I can contemplate LIFE for a while….
Find out more about Dr. Sherman Nuland’s book, How We Die.
UPDATE: Dr. Sherwin Nuland died of prostate cancer at the age of 83 on March 4, 2014 in his Connecticut home. His daughter recalled that he had told her he wasn’t ready for death because he loved life: “I’m not scared of dying, but I’ve built such a beautiful life, and I’m not ready to leave it.”‘