There’s so much bad news lately that I thought you might want to hear some good news:

The heart attack death rate is down.

In fact, the death from heart disease has been cut almost in half since 1980. The real question is why.

This week’s New England Journal of Medicine has an analysis of the data.

About half of the improvement comes from better treatment, and almost half comes from better prevention, either with simple medicines, or from lifestyle changes.

Things have indeed changed for the better.

I remember the bad old days when I was in medical school in the late 1960’s.

People would come in with heart attacks and you put them to bed for a couple weeks. And often they would die on you as soon as you got them out of bed. Coronary care units were just starting back then.

Now we give them medicine to open the blockage: even simple aspirin or heparin helps, and medicine (e.g. streptokinase) to declog the blockage or doing a “rotorooter” (angioplasty, where you thread a wire to the heart into the blocked area and stretch it open or zap it with a lazer) of the blocked vessel is also being done.

High blood pressure was another problem. When your blood pressure was high, the heart had to work a lot harder and the pipes are more prone to burst. (It’s like running your car in first gear at 50 miles an hour…a great way to wear out your engine)..yes, there were medicines, but they didn’t work very well, and had lots of side effects, or only worked in mild cases like Reserpine, based on a herb from India.
Now we have a dozen medicines, many with few side effects.

Forty years ago, there were few treatments for congestive heart failure. This is when the heart doesn’t pump well, and they fill up with fluid. Their legs would swell, and often they had to sit up to breathe.

Back then the treatment was bedrest, with maybe a shot or two of a mercury diuretic to help things along.

Digitalis leaf (or the newer safer extract digoxin) was used to make the heart beat more efficiently, and we were still using it in the method described by Withering 200 years earlier: give it until water was produced, either urine, vomit, or diarrhea (vomiting, diarrhea were signs of an overdose, a problem that could be fatal).(Now we rarely use digoxin, and a simple blood test can warn us to lower the dose.)

Then we got fluid pills—first thiazide diuretics and then loop diuretics like Lasix/furosemide.

A miracle. The thiazides were well tolorated and if taken daily not only prevented fluid build up, but kept your blood pressure down, and  the loop diuretics could put out two liters of water in two hours.

Yes, we still see people with congestive failure, but not as many as in the old days. And most cases are treated at home.

Back then, we  treated angina pectorus with nitroglcyerin pills and rest. Angina is when there is a blockage of a blood vessel so if you walk you get terrible chest pain. Some angina is “stable” and we treat with medicine, and some is a warning you are going to have a heart attack.

Nowadays, we often treat the partial blockages of the heart’s blood vessels with stronger medicines: We lower the blood pressure and give medicine to keep it from going too fast. We still use Nitroglycerin to open the arteries, but usually long acting pills or patches. And we give aspirin to keep the blood from clotting in the narrow areas.

But if the symptoms are bad, or getting worse, we can open up the blockage by a procedure that resembles the “roto rooter” to open clogged drains. (angioplasty…film here) and put in a stent to keep the vessel open.

Or if there are lots of blockages, just bypass the blockages with another blood vessel, a procedure commonly called a “cabbage” (cabbage= “CABG” or coronary artery bypass graft.) And in the future? One day bypass surgery? Bone marrow stem cells regrowing heart muscle with new blood vessels? Who knows.

But the real breakthrough is cholesterol medicine. Diet will lower cholesterol a bit, but staying on the strict diet is almost impossible for most people. The old medicines didn’t work too well. or like Nicotinic Acid had side effects ( hot flashes from hell) so people wouldn’t take them.

Now the mainstay of heart disease prevention are the Statin drugs (e.g. zocor, lipetor). When we first used them, the data wasn’t too clear (the joke was that it lowered your rate of heart disease, but the death rate was the same…due to an increase in homicide/suicides) But as we started using them in higher doses in people who already had heart attacks or people with high cholesterol, and the rate of heart attacks went way down.

Finally, another wonder drug was discovered: the simple aspirin tablet. By making the blood a little thinner, the risk of the blood clotting in partially blocked areas went down too.

But all these things are medical.

There are other things that have cut down the heart attack rate.

Stopping smoking is one of the big ones. And even when people smoke, they often smoke fewer cigarettes due to the increase in prices and the hassle of trying to find somewhere to puff away.

Another big reason is that people exercize more.

A third reason is better diet. Less fried foods, more salads. More fiber.

So Hippocrates
was right:

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”

On the other hand, if you have inherited high cholesterol genes from your parents, a little Zocor might be a good idea.

The summary of the NEJM article has the details:

From 1980 through 2000, the age-adjusted death rate for coronary heart disease fell from 542.9 to 266.8 deaths per 100,000 population among men and from 263.3 to 134.4 deaths per 100,000 population among women, resulting in 341,745 fewer deaths from coronary heart disease in 2000. Approximately 47% of this decrease was attributed to treatments, including secondary preventive therapies after myocardial infarction or revascularization (11%), initial treatments for acute myocardial infarction or unstable angina (10%), treatments for heart failure (9%), revascularization for chronic angina (5%), and other therapies (12%). Approximately 44% was attributed to changes in risk factors, including reductions in total cholesterol (24%), systolic blood pressure (20%), smoking prevalence (12%), and physical inactivity (5%), although these reductions were partially offset by increases in the body-mass index and the prevalence of diabetes, which accounted for an increased number of deaths (8% and 10%, respectively).

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Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays to HeyDocXanga Blog 

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