The seven levels in the ‘Hierarchy of Heart Disease’

by Carolyn Thomas  @HeartSisters

During my first evening at our “Heart to Heart” support group, the man sitting next to me leaned over and asked me: “What are you in for?”

I told him that I’d had what doctors call the “widowmaker” heart attack two weeks earlier, and that I now had a stainless steel stent implanted in a major coronary artery that had been 99% blocked.  He interrupted me with a cheery:

“Me too! But I have THREE stents!”

As he went on and on in exquisite detail about his cardiac event, I felt like my own was suddenly pretty puny by comparison. Three stents? How could I possibly compete with that? My previously-fascinating heart attack misdiagnosis story now seemed hardly even worth mentioning, really.

I came to observe during the  following weeks and months that heart patients, consciously or not, seem to slot themselves arbitrarily into what I call the unspoken Hierarchy of Heart Disease

Herein I offer my very unofficial and highly subjective personal rankings in the Hierarchy.  Feel free to interject your own choices or changes:

#1  Heart transplant is the undisputed winner in the heart disease sweepstakes. Anybody who’s survived a heart transplant (or is on the transplant waiting list) has experienced something so profound that, even among other organ transplant cases, there is simply no medical procedure to trump this one. If you ever meet a heart transplant survivor, do not under any circumstance mention a lesser medical condition you may have. Trust me: when there’s a heart transplant in the building, nobody cares about you.

#2  Coronary artery bypass graft surgery (CABG, or what we affectionately call “cabbage”).  This is major open heart surgery, sometimes  under emergency conditions, may or may not be associated with heart attack. Extra points if your CABG was preceded by an actual heart attack.  The procedure is similar to a detour on the highway when there’s a roadblock, except here blood vessels from elsewhere in the body are harvested to form new grafts in order to reroute the blood flow around heart blockages.  When it comes to CABG on our unofficial Hierarchy, more is better.  Triple bypass tops double, quintuple beats quadruple. You get the picture.

#3  Heart valve repair or replacement requires major surgery and, like CABG, usually means having your sternum cracked open like a chicken carcass to get to your heart’s faulty aortic, tricuspid or mitral valves. You earn extra points if you have more than one valve involved. For the sheer novelty value, add an extra point if you’ve avoided the carcass-cracking by having the new minimally invasive or “keyhole” closed-chest surgery.

#4  Blocked plumbing means that a coronary artery is significantly blocked by a clot or ruptured plaque and needs to be opened up (“revascularized”)  immediately to restore blood flow to the affected heart muscle and prevent a myocardial infarction (heart attack), but not necessarily through major surgery like CABG.  Solutions can include invasive balloon angioplasty (inflating a tiny balloon inside the blocked artery), or atherectomy (using a tiny Roto Rooter-type burr to grind the plaque into tiny bits), or a laser catheter (vaporizing the plaque).

Add one extra point if a stainless steel stent is  implanted into the artery during an angioplasty procedure. But just as with CABG, the more stents, the higher your score. (The Journal of the American College of Cardiology has actually reported the extraordinary case of a 56-year-old patient with 67 implanted stents, a kind of full metal jacket on steroids and definitely the all-time winner in our Stent Sweepstakes!) Please give yourself two extra points if your stents were implanted because you were having a heart attack, or if your heart attack was due to a Spontaneous Coronary Artery Dissection (SCAD) which is a relatively uncommon and potentially deadly cause of heart attack usually seen in young, apparently healthy women with few if any cardiovascular risk factors.

#5  Arrhythmia means abnormal heartbeats, often requiring an electrical correction of some sort, such as pacemakers, ICDs (implantable cardioverter defibrillators), cardiac ablation, cardioconversion.  Heart failure (formerly called congestive heart failure) is also sometimes treated with pacemakers or ICDs.  Add two points if the arrhythmia involves especially serious inherited heart abnormalities  called Brugada syndrome or Long QT syndrome that usually affect young healthy adults, or if sudden cardiac arrest was your diagnosis. Deduct half a point if your benign arrhythmia is nicely managed with drugs alone.

#6  Functional malfunctions are potentially serious heart conditions like cardiomyopathy (possibly linked to viral infection) or endocarditis (infection of the heart lining or valves) or myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the outer membranes surrounding the heart).  Congenital heart defects are those that babies are born with, and often lead to ongoing cardiac issues into adulthood. Heart failure is a terrible term for a fairly common condition that affects heart function. The most dangerous loss of heart function is sudden cardiac arrest.  Quadruple points for that one.

#7  Drug therapy by itself without the need for any invasive cardiac procedure is used to manage some types of heart disease, like taking nitroglycerin for angina symptoms, and beta blockers, ACE inhibitors, calcium channel blockers, blood-thinners or anti-platelet drugs for coronary artery or heart arrthymia issues. See also: What You Need to Know About Your Heart Medications

One of my heart sisters recently reminded me that I had neglected to add the vasospasm condition called Prinzmetal’s Variant Angina to my Hierarchy.  Double points if you have Prinzmetal’s, mostly because its symptoms are debilitatingly painful, rarely diagnosed correctly, and seen most frequently in women.  Ditto for Inoperable Coronary Microvascular Disease that affects the tiniest of our tiny coronary arteries – too small to stent or bypass, but this diagnosis can be shockingly debilitating, too.


♥  Now if an actual heart attack (myocardial infarction) has preceded anything on this list, score an extra two points . . .

© Carolyn Thomas – Heart Sisters


See also:


Did I miss something on this list?  If so, where would you put it?


9 thoughts on “The seven levels in the ‘Hierarchy of Heart Disease’

  1. lol!! I’m sorry to laugh, but yes, it’s true… we do seem to compete/compare with each other in terms of “battle wounds.”


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  3. Gee, shame on me for feeling a little sorry for myself and needing to talk about my 6 stents, heart attack, A-Fib, long QT, and unstable angina. After all, my heart is only the main organ that keeps me alive. I think I will stop talking about myself because no one acts as if they care anyway, and go party down tonight.


  4. You are so right. Those transplant survivors are due the top drawer of respect. We have a young boy in our town who has survived two of them both before he was 6 years old. Our Open Heart Society Chapter sponsored participation in a run for research last year. He is 13 now. What a remarkable story he has to tell. My hat is off to him and he can stay at the top of any list he wants.

    I am with “growfamilygrow” …. I would rather have negative points and be off the list. Thanks for your encouragement and helping us put things in perspective. — Gloria —


  5. Great article! Yes, I’ve noticed this also. But I guess since I had the CABG at the beginning of my journey, I started near the top! tee hee But to digress a bit, my experience was an excellent one! I had no recovery back sliding, hit all the recovery milestones, overall good experience……until my graft closed.

    Then, I started having “my moments!” I am so thankful for modern pharmaceuticals, recovery, and less invasive procedures! I’m happy to stay near the bottom, and as our minister said last Sunday: “It could have been worse – much worse!”



  6. Geez, #7 Drug Therapy seems so, so, so, well…puny. When the every day chest pains are “ER” quality and reduce you to 85 year old functionality (at times), it’s just seems hardly worth mentioning when you can “manage” them with nitroglycerin stuck onto you day and night. Love those “On Golden Pond” moments! “Norman, old fool!

    But, you look so GOOD!

    Best, MaryLG


  7. Loved this!!

    Levity makes the lesson easy to learn – I didn’t know there were that many procedures/therapies related to heart disease!

    I also took some time to surf around your website, which I haven’t done for a long time. It’s great to see so many people/organizations posting your articles on their websites via links. Keep up the good work!

    Liked by 1 person

  8. Okay, so I’m at number X plus Y points, that puts me at …. oh forget that, can I be bottom of the pile please? Better still, can I not be on the list at all?

    It certainly is true though. I did cardiac rehab for years and there were always a few that played this game. Suffering is always relative. I rather think that in this game we’re all winners, we’re all still here and fighting.


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