During my first evening attending our “Heart to Heart” 7-week education series for recently diagnosed heart patients, 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 “widow maker” 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:
“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 now call the unspoken Hierarchy of Heart Disease.
Herein I offer my unofficial and highly subjective personal rankings in the Hierarchy. If any of these cardiology terms seem foreign to you, check out my patient-friendly, no-jargon glossary to translate any confusing words and abbreviations. And feel free to interject your own choices or changes to this list:
#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 blockages in coronary arteries. When it comes to CABG on our unofficial Hierarchy, more is better. Multi-vessel heart disease (affecting more than just one of the heart’s major arteries) is more often seen in men; women are more likely to have single-vessel disease.(1) Triple bypass tops double, quintuple beats quadruple. You get the picture.
And thanks to a suggestion from my longtime reader, Mary (see comments bel0w), I’m also adding Dissecting Aortic Aneurysm to this category, especially since this sudden tear in the inner layer (lining) of the aortic wall is usually a very painful and very urgent event.
#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 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 may need to be opened up (“revascularized”) to restore blood flow to the affected heart muscle but not necessarily through major surgery like CABG, possibly preventing a myocardial infarction (heart attack) if you haven’t already had one by the time you make it to the hospital. Solutions can include invasive balloon angioplasty (inflating a tiny balloon inside the blocked artery to smoosh the plaque), 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 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 extra points if the arrhythmia involves especially serious inherited heart abnormalities like 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 (also mentioned above) is a terrible, awful name (that needs to be changed) for a fairly common condition that affects heart function if the heart becomes less able to efficiently pump oxygen-rich blood to the rest of the body. 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 stable angina symptoms, and beta blockers, ACE inhibitors, calcium channel blockers, statins, blood-thinners or anti-platelet drugs for coronary artery or heart arrhythmia issues.
One of my heart sisters recently reminded me that I had neglected to add here the vasospasm condition called Prinzmetal’s Variant Angina to my Hierarchy. Double points if you have Prinzmetal’s, mostly because its spasm 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
(1) The Cleveland Clinic Cardiology Board Review. Lippincott Williams & Wilkins, 2012. Chapter 46, p 843.
NOTE FROM CAROLYN: This post was originally published here on Heart Sisters in July, 2010. I wrote more about this Hierarchy in my book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press) in Chapter 7 (the infamous chapter that the anonymous Johns Hopkins cardiologist who reviewed the manuscript before publication wanted to delete because he called it “irrelevant to female heart patients”).
Q: Did I miss something on this hierarchy list? If so, where would you put it?