LURKING BLOCKAGES

Last week, the day after Mardi Gras, Christian believers received ashes on their forehead as a reminder of their mortality, with the minister or priest saying "remember that you are dust and to dust you shall return."  Words taken to heart by most save for, in general, maybe the young.

​There are other things in life which cause one to reflect on how long they might have left on earth.  Events and things that tend to yank a person from their busy and noisy world.  For example, the death of one's child, surviving a near-fatal accident, or attending as a 50 or 60 year old the funeral of a classmate, just to name a few.

​But on this list, with a few others, should be included a lesser known experience.  And that is, being shown a video catheterization of your coronary arteries and looking at lacking blood flow bottle-necking its way to challenged heart muscle like a mouse squeezing through a half-inch hole.

​I happened to run into Dr. Hermes a few weeks ago at a meeting in New Orleans and he shared his recent experience with me, an experience which is becoming more common.  Dr. Hermes is a primary care doctor, a year behind me in medical school, enjoys and works long hours, and thought he was in perfect health -- until last year.

​For most of his adult life he's eaten a heart-healthy Mediterranean diet -- fish, fruits, veggies, beans, grains, nuts and olive oil.  He's a runner, having run four marathons, and has been an avid distance walker in his later years.  His cholesterol has averaged 168 for decades, well under the current normal of 200.

​Last year he developed an irregular heart rhythm, atrial fibrillations (AF), which began intermittently but then became persistent.  It caused him to have weakness with extreme exertion.  But he never had chest pain.  His cardiologist controlled his heart rate with medicine but the AF continued.  An electrical cardioversion corrected the AF for 48 hours but then it flipped back to AF.

​A treadmill test, ECHO ultrasound, and nuclear scan of the heart were all normal!

​While waiting for his appointment to have an ablation of the erratic electrical impulses in the left upper heart chamber, his cardiologist ordered a CT calcium scan score, a test that digitally calculates the amount of calcium in the heart.  His score was very high, which necessitated a heart catheterization to determine if the calcium (found in clogged arteries) was inside or outside the arteries.

The catheterization revealed four lesions, or strictures, on the order of 75% to 95% blockage.  In other words, four of the main heart arteries had only 5% to 25% of the normal blood flow going through them.  The one providing two thirds of blood flow to the heart was 85% blocked. 

​Dr. Hermes said that when he was first told this bad news that he couldn't believe it and was indignant and upset because he had maintained such a healthy lifestyle.

​The surgeon, understanding Dr. Hermes' indignation, attempted to shed insight for Dr. Hermes' benefit and retrieved a monitor and proceeded to let the good doctor see for himself the bottle-neck strictures.  Dr. Hermes said he is not a very emotional person but said that when he saw each of the four lesions, with the surgeon pausing the video at each one, that his eyes widened and he was suddenly aware that he had a problem.  He said it was like a pregnant woman seeing her baby for the first time on ultrasound, experiencing the joy and elation that new life was coming soon.  But for Dr. Hermes, instead of elation he realized that doom could happen any moment.  He became sad.

​His choices were do nothing, and risk a fatal heart attack, or submit to a bypass (the lesions were not stentable).  He opted for the surgery.

So now, we're in the same club.

​While treadmill tests are for the most part accurate and helpful in screening for pathological heart disease (partially blocked heart arteries), know that a normal treadmill test doesn't necessarily inform you that your heart arteries are clear -- especially if you have risks like high blood pressure, diabetes, atrial fib, obesity, or a family history of heart disease (like one or both parents who had it).  Dr. Hermes' mother had it.  In this instance, it is often prudent to obtain a CT scan calcium score to make sure.  A normal treadmill and normal CT calcium score together essentially rules out pathological heart disease.  But a high CT calcium score calls for additional testing, usually a catheterization.

​By the way, normal cholesterol is under 200.  But 35% of people with a cholesterol between 150 and 200 have heart disease or heart attacks.  Keep it below 150.

​Dr. Hermes and I both appreciate the recent improvements to our health, and intend to take advantage of the opportunity.  We are grateful and in awe at the skill sets of men and women who are able to extend our lives and remove life-threatening risks in this way.  But -- at the end of the day -- we will all be returning to dust.  And it's only then that things truly become problematic.