Heart attack: is it a clogged pipe or a popped pimple?

10 Jan

by Carolyn Thomas      @HeartSisters

decisionsWhen my little sister Bev was booked to have her tonsils removed at age six, our family doctor declared that I must have mine out at the same time – not because there was anything at all wrong with them, but because I was already 12 years old and, for some inexplicable reason, I still had my tonsils intact!  (Back then, kids with tonsils were apparently an endangered species. As New York ear/nose/throat specialist Dr. Steven Park described the historical take on tonsils: “In the 50s to 70s, it was a given that if you had tonsils, they were removed.”)

On our designated procedure date, Bev and I were admitted to the pediatric ward at St. Catharines’ Hotel Dieu Hospital together.  I remember this experience vividly because the archaic rule at the Hotel Dieu back then was that all pediatric patients had to wear diapers overnight.  DIAPERS! As a humiliated almost-teenager, I pleaded with my mother to convince the ward nurses that I most certainly did NOT need to wear diapers at my mature age! But rules were rules, and I somehow managed to survive both an unwarranted surgical procedure and its associated diaper humiliation.

It turns out I wasn’t the only person questioning the wisdom of taking out a perfectly fine pair of tonsils based on flimsy if any medical evidence.  Decades later, many researchers – including in this U.K. study published in the journal Archives of Disease in Childhood (1) – blamed not only the physicians who recommended the routine surgical removal of tonsils (and often adenoid glands at the same time) to treat childhood sore throat, but also “parental enthusiasm” as the factors influencing an entire generation of higher-than-necessary rates of surgery.

“Despite the enthusiasm with which tonsillectomy is offered and sought, there is little evidence of efficacy.”

I like this tonsil analogy to illustrate how medical attitudes, no matter how pervasive, can indeed change over time as our physicians rethink the status quo in order to embrace evidence-based medicine.

In other words, just because we’ve been doing this for a long time, is there any evidence that it’s actually what needs to be done? 

Cardiology is not immune to the shifting popularity of longheld medical beliefs.

Cardiologist Dr. Michael Rothberg at the Cleveland Clinic warned his colleagues in the journal Circulation(2) that their profession has had a hard time letting go of a significant misconception about coronary artery disease, specifically about what causes heart attacks.

Popular Misconception: Narrowed Arteries are the Problem

As Dr. Rothberg explains, this belief in the clogged pipe theory of heart attack has been popular since the 1970s, when cardiac researchers observed that the degree of coronary artery obstruction (blockage) seemed to be directly linked with a higher risk of having a heart attack.

The culprit at the time was believed to be cholesterol plaques building up within the coronary arteries.  Diagnosis was confirmed with tools like the treadmill stress test that looked for supply-demand mismatch; the treatment based on this theory included trying to re-open (revascularize) these blocked arteries through coronary bypass surgery or stents (the small mesh tubes that are used to open blocked arteries and restore blood flow to the heart muscle), much like a plumber re-opens clogged pipes under your kitchen sink.

But as Dr. Rothberg warned:

“Results of such revascularization procedures are visually striking and, in stable disease, may lead to the erroneous conclusion that the plumbing problem has been fixed.

Doctors should begin by explaining to patients that coronary artery disease is an inflammatory disease in which cholesterol from the blood is deposited in artery walls, causing an inflammatory reaction like a pimple.

“When those pimples pop, they cause the blood in the arteries to clot at the site. If the clot closes off the entire artery, that causes a heart attack, and emergent medical attention is required to remove the clot.”

He further explained that this inflammatory disease model makes it clear that most attempts to revascularize partially blocked arteries are doomed to fail because dangerous vulnerable plaques cannot be identified or stented before rupture.

This reality helps to explain why even a small blockage can sometimes result in a rupture causing a dangerously blocked artery, or why a patient sent home from hospital with “normal” cardiac diagnostic test results on one day can suffer a heart attack on the next.  See also: Slow-onset heart attack: the trickster that fools us

Dr. Rothberg is not alone in trying to educate us about the outdated plumber’s pipe theory of heart disease.

Experts at the Harvard Medical School warn that chronic low-grade inflammation is “intimately involved in all stages of atherosclerosis”, and this means that inflammation could be setting the stage for heart attacks, most strokes, peripheral artery disease, and even vascular dementia.

But inflammation doesn’t happen on its own. The Harvard experts explain that inflammation is the body’s perfectly natural response to a host of irritations like smoking, lack of exercise, high-calorie meals and highly processed foods.  

Cardiologist Dr. John Mandrola also neatly summarizes the link between heart disease and inflammation like this:

Heart disease is about inflammation

“The same mechanisms that cause the throat to swell from an infection, the skin to redden after an insect bite, and a scar to form after a cut are what cause heart problems.”

So instead of trying to convince stable heart patients of the need to open up every potentially blocked coronary artery through invasive procedures, Dr. Rothberg strongly urges the following:

“For patients who have stable coronary disease, it is crucial to take steps to reduce the inflammation, including both evidence-based lifestyle changes (smoking cessation, exercise, stress reduction, and a Mediterranean diet) and taking medications that reduce inflammation and prevent thrombosis (aspirin and statins).

“Doctors should state plainly that for preventing heart attacks, these are the only effective measures.

“If patients have symptoms like angina (chest pain), then they can be told that old plaques, like scarred old pimples, may partially obstruct arteries and cause symptoms and that these symptoms can be relieved with medications.

“Only if symptoms persist despite maximal medication therapy, patients could then be offered revascularization to relieve those symptoms.”

Dr. Rothberg’s 2014 study published in the JAMA Journal of Internal Medicine (2) suggests that even now, few cardiologists discuss the evidence-based reasons for recommending revascularization with patients diagnosed with stable coronary artery disease, with “some physicians implicitly or explicitly overstating the benefits.”

He blames both physicians and researchers who have embraced the plumber’s pipe model of heart disease.Their message, he says, has continued to insist on opening these blockages. Many physicians and researchers, he adds, are “working from an outdated conceptual model, mistakenly focused on improving the technology for keeping open flow-limiting lesions”, while claiming that better stents will eventually yield a mortality benefit in stable heart disease.

Dr. Lisa Rosenbaum, writing in The New Yorker (October 23, 2013), suggests that, for these stable patients with chronic heart disease, the benefit of opening an artery with a stent is far less certain.

“Longstanding coronary artery blockages tend to have hardened exteriors, which can shield the plaque from exposure to the clotting factors in the blood passing by it. Chronic blockages aren’t benign – they can give many patients chest pain. But when it comes to treating chronic disease, medications such as statins, aspirin and beta blockers are often as effective as stents.”

What to do to encourage the medical profession to loosen its grip on the clogged pipe model of heart attacks in the face of current practice guidelines?  Dr. Rothberg has this advice:

“Institutions like the American Heart Association should be more proactive in educating doctors about the inflammatory disease model, and how to communicate it to patients.

“Hospitals and doctors should stop using the old plumbing analogy in advertisements, websites, patient educational material, and when obtaining informed consent for any revascularization procedure.

“The current consent process – especially for patients with stable angina – is deeply flawed.

Most patients do not correctly understand the actual benefits of the cardiac procedure they are about to undergo, and many do not even have angina.”(3)

But Dr. Rothberg is also a realist, and admits that it will be a hard sell to convince his colleagues in cardiology to rethink what’s known as the oculostenotic reflex (a “See it, stent it!” term coined by cardiologist Dr. Eric Topol back in 1988) defined as the “irresistible temptation” to expand narrowed coronary arteries, even when evidence-based guidelines suggest it shouldn’t be done. (4) For example:

“These steps are likely to encounter opposition, partly because it is difficult to admit that in the past we got it wrong and performed what now appear to have been unnecessary procedures, but also because our current payment system continues to reward interventions based on the old model and cardiac procedures are an important source of hospital revenue.

It is unlikely that hospitals will begin to advertise the power of generic medications and lifestyle changes to combat heart disease.

“Nor will physicians quickly abandon a practice that both supports their income and seems to make sense.”

While you’re waiting for your physicians to embrace this inflammation theory, check out this list of cardiac risk factors that can be reduced, eliminated, or treated to help lower your own risk of heart attack. It’s from Myocardial Infarction: More Complex Than Plumbing(5), written by Harvard’s Drs. Kathryn Melamed and Samuel Goldhaber. The specific culprits that can raise inflammation levels and the subsequent risk of heart attack include:

  • cigarette smoking
  • alcohol use
  • obesity
  • hypertension
  • diabetes
  • metabolic syndrome – a condition composed of obesity, abnormal lipids (cholesterol), and abnormal glucose metabolism that often leads to diabetes

 

(1) Lock C et al. Childhood tonsillectomy: who is referred and what treatment choices are made? Baseline findings from the North of England and Scotland Study of Tonsillectomy and Adenotonsillectomy in Children (NESSTAC). Arch Dis Child 2010; 95:203.
(2) Michael B. Rothberg et al. Coronary Artery Disease as Clogged Pipes: A Misconceptual Model. 1941-7705. Circulation: Cardiovascular Quality and Outcomes. 2013. doi: 10.1161/CIRCOUTCOMES.112.967778
(3) Rothberg MB et al. Patients’ and cardiologists’ perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med. 2010;153:307313.
(4) Topol EJ. Coronary angioplasty for acute myocardial infarction. Annals of Internal Medicine. 1988;109:970-980.
(5) Kathryn H. Melamed, MD, Samuel Z. Goldhaber, MD. Myocardial Infarction: More Complex Than Plumbing, Circulation. 2014; 130: e334-e336 doi: 10.1161/CIRCULATIONAHA.114.010614

Q:  Is Dr. Rothberg waging a losing battle in urging patients and doctors to abandon the plumber’s pipe theory of heart attack?

See also:

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14 Responses to “Heart attack: is it a clogged pipe or a popped pimple?”

  1. Kathleen January 10, 2016 at 9:48 pm #

    Great post, and I’m still getting my head around the pimple/inflammation model. Maybe I will reconsider those statins…

    Though most of my friends had them out, I had no idea routine tonsilectomy was the expectation. Reading that renewed my appreciation for my mother – an RN (Class of 1950) who really did march to her own drummer in how she raised her six kids. The only two who lost their tonsils really did have severe ear and sore throat problems; the other four of us still have them.

    Liked by 1 person

    • Carolyn Thomas January 10, 2016 at 10:39 pm #

      Way to go, Mom! My own mother, as was likely more typical back then, went along with whatever our family doc said…

      Like

  2. Jenn January 10, 2016 at 9:21 pm #

    Another great article, Carolyn! Without good research we’d be believing medical myths and old wives tales.

    My story is the reverse of the ones I’ve read. As a child (born in 1952), I had recurrent bouts of tonsillitis. However, my dad was an academic physician and knew most tonsillectomies in children were unnecessary. He and my pediatrician agreed the surgery would not be done; I would be treated with antibiotics when needed.

    When I was in my 30s, still getting tonsillitis regularly, I got a referral to an ear nose and throat doctor. He thought taking my tonsils out might solve my problem, but it was hard for me to go against my anti-tonsillectomy indoctrination. The ENT doc talked to me, then took me to a back room, gave me a pile of scientific studies to read and left me alone to consider my options. That was exactly what I needed.
    I had my tonsils out. It solved my problem. No more annual sickness with high fever and antibiotics. It’s a more difficult surgery and a much more difficult recovery for an adult than for a child, but I’m an anomaly. Most of those tonsillectomies done on children were unnecessary.

    Liked by 1 person

    • Carolyn Thomas January 10, 2016 at 10:32 pm #

      Thanks so much for sharing this perspective, Jenn. Most may have been unnecessary procedures – but not all. Most tonsils, says Dr. Steven Park (mentioned in my first paragraph) shrink down to very small glands by adulthood, but for some people (like you), they stay enlarged. He also reminds us that in the 50s-70s, most tonsils were removed due to recurrent sore throats, but now most tonsillectomies are done to address sleep breathing problems.

      Like

  3. Jaynie Martz January 10, 2016 at 3:45 pm #

    Arterial pimples! Oh my…I’m laughing while printing this out. Great descriptions and appreciate the multiple frames of reference Carolyn.

    Tonsils out at 5. Scary nurse shaking me to ‘stop crying’ as I regained consciousness in 1959 Appalachian Mtn hospital.

    Liked by 1 person

    • Carolyn Thomas January 10, 2016 at 8:18 pm #

      Thanks Jaynie! Boy, it seems that some of our early tonsillectomies were more traumatic than we figured… 😉

      Like

  4. Jennifer Merhar January 10, 2016 at 9:45 am #

    I suffered for nine years with angina with cardiologists thinking the only way was diet and meds. Finally I received a stent and it was a “thank God” moment. I have my life back, so this article scares the daylights out of me. I don’t want a repeat of those nine horrible years of angina.

    Liked by 1 person

    • Carolyn Thomas January 10, 2016 at 12:12 pm #

      Good grief! Nine horrible years is far too long to have suffered! As Dr. Rothberg himself is quoted here: “…if symptoms persist despite maximal medication therapy, patients could then be offered revascularization to relieve those symptoms.” Sounds like your angina was not taken seriously, Jennifer…

      Like

  5. Pauline January 10, 2016 at 8:08 am #

    Wow, wow, wow! This article comes to me at the perfect time. I have 12 stents, but did have angina, sometimes resting, despite meds and diet. Now, after 1 1/2 years, I am symptom-free. And recently met up with the inflammation question due to bodily pain and slipping a long way in my diet. I decided to eat like the rest of the adults in the house, which included lots of fat, salt and sugar. I thought it would only make a small difference in my well being.

    Well, my recent cholesterol number turned out to be 489!!! Never, ever, saw that number before. I had also taken a short rest from my statin to see if it affected my pain level.
    Back on the statin I go, and back to my healthy diet I go. I never thought it would make such a huge difference!
    I am waiting to see if changing my diet will make a difference in my pain levels.

    Liked by 1 person

    • Carolyn Thomas January 10, 2016 at 12:15 pm #

      You’ve conducted your own personalized research trial, Pauline (n=1)! Best of luck to you ….

      Like

  6. Anna in France January 10, 2016 at 8:06 am #

    Thank you Carolyn for this concise and informative description of where we actually are in the scientific understanding of heart disease. Where else do we get the sane, intelligent view of what is going on in western cardiology?

    Will just throw my own tonsils and adenoids memory into what I am sure will be a big pot! I had mine out in Sunnyside (a misnomer) hospital in Cheltenham in England in 1958. I ran away after a ginger haired nurse gave me a very painful injection in the bum (butt to you). I remember running down the hill in my pyjamas hotly pursued by said nurse.

    Happy New Year all my Heart Sisters 🙂

    Liked by 1 person

    • Carolyn Thomas January 10, 2016 at 12:18 pm #

      Happy New Year to you, too Anna!

      You ran away from the hospital!? Who knew that childhood tonsil stories are filled with such vivid imagery… I too had a traumatic needle in the bum experience as a small child, which I wrote about here. Thanks for your kind words, as always.

      Like

  7. Judy Kendle January 10, 2016 at 5:56 am #

    Thanks for this, Carolyn. It relieves my mind a bit over the 70% blockage that apparently remains in one of my arteries after a stent was placed in the completely blocked LAD when I had a heart attack in 2012.

    Doctors were forced in that case to simply attend to the emergency and hope for the best – and I survived.

    Since then the regimen cardiologists prescribed – that includes all of the diet, exercise and medications you mention – seems to be working – fingers crossed. I still wish there was an easy, foolproof way to see if/when a heart attack is looming – maybe some day.

    (By the way, I too had tonsils removed in St. Catharines, Ontario, age 5, in 1945. Don’t think it was in the hospital you name, but I too was humiliated, in my case, not by diapers, but by the nurse, who insisted on carrying me to the elevator in her arms, when I was perfectly capable of walking – still remember my indignation over that.)

    Liked by 1 person

    • Carolyn Thomas January 10, 2016 at 6:47 am #

      Thanks for this, Judy! That 70% blockage is apparently considered the minimal blockage to be considered for revascularization. Sometimes even larger blockages – because of where they are located in coronary arteries – are similarly not stented with no further issues. And as Dr. Rothberg’s study shows, often it’s a far smaller unstable occlusion that ends up being the one to rupture, NOT the 70% ones.

      Your tonsils story reminds me of what a small world it is. I can just picture a nurse carrying a big 5-year old down that hospital corridor! Isn’t it funny how permanently such events are etched forever in memory? 🙂

      Like

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