Richard A. Stein - Outliving Heart Disease: The 10 New Rules for Prevention and Treatment

Table of Contents

This book is dedicated to my wife, Roselle Shubin. Her love of life, her acts of caring, and her passionate sense of fairness are attributes I continually try to emulate.

The love that we share is a precious gift, for which I am thankful every day.

Our children, Ken and Beth, Beths husband, Chris, and our grandson, Charlie, are a truly amazing source of pride, delight, and energy.

My mom, Jean, whom I remember every day, and my dad, Jacob, have given us the most precious gifts parents could givelove, self-esteem, and their avid interest in our lives.

Roselles parents, Jeanette and Joe, gave us their love, their time and joy, and by example their profound sense of goodness to all.

I remember clearly when I first made the decision to become a cardiologist and focus my work on preventing heart attacks. I had just begun my internship at Kings County Hospital in Brooklyn, New York. My wife, Roselle, and I lived a block away from the hospital and we were eating dinner (spaghetti, so that we could save money for a trip to Italy). It was my first night on call and I remember worrying about spilling tomato sauce on my still-stiff white pants and jacket. Like a kid on his first day of school, I was excited but nervous, wondering what the evening would bring. I was twenty-five years old.

At about 8:30 my beeper went off: my first patient had arrived in the ER. By the time I got there hed been moved to the acute care room. Five residents were gathered around, trying to resuscitate him as he lay face up on the stretcher. He looked like a young man, perhaps in his late thirties. A breathing tube had been placed in his throat and connected to a respirator. Two intravenous lines were running into him and a defibrillator was being used to shock his heart at least three more times while I stood by. An electrocardiogram (EKG) machine was also running, its long paper strip collecting on the floor. One of the residents looked up and saw me, and from his expression I knew that their work was done. They stopped what had been an aggressive and prolonged effort to restore the patients heartbeat.

Since I arrived before he was pronounced dead, he was technically my first admission. It was my job to tell his wife, who was waiting outside the room, that her husband had died. I had never done that, and I truly do not remember how I told her or what I said. We sat for a while and she told me that her husband, a science teacher at a nearby high school, had been on the floor playing with his kids when he suddenly collapsed. After a nurse explained about arrangements for her husbands body, I walked her outside to get her a cab. As we approached the curb, she turned and asked me, How do I tell our two children that their Daddy isnt coming home?

Ive lived with that question every day since then. I talked with Roselle about it that evening when I got home, and in the years that followed came to understand that I would never have a good enough answer, for that patients wife or for any of my other patients loved ones. But if I became a cardiologist, I could work to reduce the number of times the question was asked.

Today I am the Director of the Urban Community Cardiology Program at the New York University School of Medicine in New York City and the Co-President of the Founders Affiliate of the American Heart Association (New York, New Jersey, Connecticut, Massachusetts, Maine, Vermont, Rhode Island, and New Hampshire). I spend a good deal of time developing programs, administering the department, and mentoring young physicians, but the most challenging and most rewarding part of my work is the time I devote each day to learning about my patients and from them, and using the experience and knowledge I have gained during my career to provide them with the best possible medical care and the best possible strategies to outlive heart disease. What challenges me every day is crafting the information from the new science and clinical studies that have been published since my time as a resident into practical medical strategies that keep heart disease a chronic condition rather than a death sentence. These strategies include appropriate medications, diet, exercise, and mind work that I often prescribe for my patients and which I describe in the pages of this book.

Ive also learned from my own reactions to a disease to which almost no one is immune, including cardiologists. During my first year of training in my new specialty, I was assisting one of the senior cardiologists in examining X-rays of the coronary arteries of two young men whose only complaint had been chest pain. In both cases we found extensive blockage, and both patients were sent for immediate open-heart surgery. These two men were hardly older than I was at the time. The next morning I awoke with a racing heart that lasted almost 30 minutes, and returned on and off throughout the day. It must be my nerves, I thought, then wondered if thats what these two men had thought as well. My racing, jumping heartbeat lasted for a whole week, and ended only after I consulted a cardiologist, who assured me that I was suffering from stress, not heart disease. But that day I learned that heart disease is both a disease of the body and of the mind, and that to prevent it, and even more crucially, to outlive it, we needed to address both aspects in our treatment.

Our knowledge today about what causes heart disease is light years ahead of what we knew during my schooling (I graduated medical school in 1967 and finished my cardiology training in 1974), and I devote the entire Introduction that follows to the New Science involved in the way cardiology is practiced today. Smoking was identified as a risk factor, clinically, only in the mid-fifties, and wasnt recognized by the general public as such until the late sixties. (The Surgeon Generals famous warning label on cigarette packages wasnt made mandatory until 1965, and television and radio cigarette advertising was banned in 1969. The package warning label did not mention heart disease risk until 1981.) In fact, many of the doctors with whom I worked, or by whom I was taught, were themselves heavy smokers and maintained that there was no connection between that nasty habit and heart disease. I remember spending many hours of my internship and residency at Downstate Medical School in Brooklyn poring over books in the Perrin-Long Library, named after one of the schools earliest chiefs of medicine, Dr. William Perrin-Long. Hanging over an ornate conference table in the main room of the library was an imposing portrait of the doctor, formally dressed in waistcoat and vest. It wasnt until after Id chosen cardiology as my specialty that I finally noticed that in the good doctors right hand, poised elegantly between two fingers, was a smoldering cigarette.

Our ignorance extended to other so-called lifestyle issues. The doctors who trained me were not convinced that fat and cholesterol had anything to do with atherosclerosis. Doing some sort of regular exercise was considered a good idea as a way to maintain overall health, but not because we knew of any direct connection between a sedentary lifestyle and the incidence of heart attack. Even after the famous Framingham study (see New Rule No. 2) began proving all these things to be determining risk factors of heart disease, doctors were reluctant to discuss behaviors such as smoking, diet, and exercise with their patients, or indeed to modify their own risky behaviors accordingly. Doctors, like everybody else, didnt want to give up their cigarettes and butter.