Good Health Magazine : MEDICINE...
TEN MINUTES INTO an early-morning jog through Boston Common on a hot summer day, my rib cage suddenly felt as though it was about to explode. I started clutching at my heart. My wife, Iris, who hardly ever exercises and yet manages to stay thin as a rail, teased me. “C’mon, slowpoke. The heat getting to you?”
But this was no ordinary runner’s cramp. I found the nearest tree, leaned against it, then crumpled to the ground. I felt the blood draining from my face.
After 10 minutes, the crushing chest pain disappeared. Iris helped me as I hobbled back to our hotel room. I had no idea what could have caused the ache. I had run in dozens of weekend 10K races and had ribbons to show for them. I chalked up the pain to a too-big dinner the night before and the high New England humidity. For the rest of our vacation in June, 1988, the heat wave continued. We did nothing more strenuous than stroll across the Charles River to Cambridge.
Back home in San Francisco a week later, I resumed my four-mile-a-day jogging in Golden Gate Park. I soon forgot, or at least blocked out of my mind, the mysterious pain.
The elephant that sat on my chest in Boston Common didn’t return, but as June faded into July, I became aware of a definite sensation deep in my right arm. It wasn’t a raging fire; it was more a smoldering burn.
Still, the ache didn’t seem to be cause for alarm. If it was heart-related, it would radiate from my chest or left arm, wouldn’t it? Maybe I had strained my right arm playing softball. Or maybe I had pulled a muscle when I hauled our old sofa from the basement for a summer garage sale.
But the pain persisted and gradually got worse. It began whenever I started exercising. Ten minutes of running, and the dull ache in my arm was so fierce that I’d have to stop. I switched to bicycle riding, hoping that jogging was somehow aggravating my arm muscles. But when I cycled, the pain returned with the same persistence. I lost a couple of nights’ sleep and wondered: What the hell was happening to me?
In early August, I went to a local sports-medicine clinic staffed by the doctors who treat the San Francisco 49ers. But during my examination, a young orthopedist ruled out any muscular or skeletal problems. He shrugged. He really didn’t know what ailed me. The lack of a diagnosis alarmed me. I knew there was something wrong, and, damn it, I wanted the orthopedist to tell me what it was.
That same day, I took Iris, who had a sore throat, to our internist, Dr. David Mackler. In passing, I mentioned my pain to the doctor. He immediately hooked me up to an electrocardiograph, attaching six sensors to my chests, arms and legs to get an image of my heartbeat. The results were normal. Still, he urged me to see a cardiologist. “It’s probably nothing, but don’t ignore the pain. Have it checked out,” he told me. When I balked, he picked up the telephone and made an appointment for me the next day with Dr. James Mailhot.
I had a creepy feeling as I waited to see this physician whose specialty--the heart--is the venue of love, emotion and life. I was the youngest in the crowded waiting room by 30 years. I shared stacks of Modern Maturity magazines with a frail man poised over a cane and a woman in her 70s whose fine hair matched the color of her ivory gloves. A beefy woman shuffled behind an aluminum walker and then plopped down with a whoosh on the Naugahyde sofa beside me.
When my name was called, I went into an examination room and put on my favorite T-shirt and my cotton shorts and laced up my running shoes. As I stepped onto the treadmill, I was ready to run down Carl Lewis. But after three minutes, Mailhot’s eyebrows shot up. He stopped the machine, motioned me to a chair and handed me a cup of water. Considering what he was about to tell me, I could have used something stronger.
“There’s definitely an irregularity. It seems that your heart is not getting enough blood,” Mailhot said. He suggested taking a picture of my heart, called an angiogram. “We’ll make arrangements for you to stay at the hospital overnight.”
Boom! Heart problems at 36!
Whatever else Mailhot said was lost on me. My mind was reeling. I was first ashamed, then infuriated. In the sterile medical office, I felt dazed, trying to grasp what this stranger in a white coat was telling me. Was I going to die? Was I destined to be the kind of father whose kids are not supposed to upset him because of “Daddy’s heart”? What was in store for me? Pills, a required diet of water-packed tuna, beans of all kinds, oat-bran muffins washed down with carrot juice?
Most of all, I thought, this must be some mistake. The EKG must have been wrong. There was no way my heart was failing me. I was healthy and in shape. My cholesterol was medium-high--in the 250-range--but not astronomical. My blood pressure was a respectable 130/75. My diet was sound. I nibbled on red meat less than twice a week, hadn’t eaten a Big Mac for five years and never downed more than a couple of beers a week. Throughout my life, I had smoked fewer than 50 cigarettes. My last taste of caffeine was in a coffeehouse in 1970 to impress a girl on a blind date.
Although my father had suffered a mild coronary attack at age 53, he was alive and robust now, 17 years later. But hearing that your father had a heart attack was one thing; hearing that your own heart was diseased and that you could die soon was quite another.
I called Iris from the doctor’s office. “I flunked the EKG test,” I blurted out. “They don’t know what’s wrong. They think there’s some blockage.”
“It’ll be OK. C’mon home,” Iris said. She was waiting for me at the top of the steps as I arrived, and she hugged me. That night, we were too shocked to talk much.
“I’m sorry for Iris,” I told my sister on the phone. When I gave the news to my parents, they kept saying, “Are they sure? You’re so young.” I couldn’t get out of my mouth that the suspected blockage was in a heart vessel. Instead, I said it was in my upper chest, near my neck. That seemed to relieve them but made me feel worse.
The next day, I underwent the angiogram. A tube was threaded through a thigh artery to my heart. It carried a dye to allow the narrowed coronary vessels to show up on an X-ray, which later confirmed that a small portion of my heart’s left anterior descending artery was about one-tenth the diameter it should be. If a normal artery looks like a supple, flexible tube, my diseased vessel resembled a stiff, rigid straw filled with hardened toothpaste.
Something had to be done to stop the artery from shutting down completely. Left alone, it would close; more blockages would probably occur in other arteries. One day in the next year or so, I would be a sure bet for a serious heart attack. The indicated procedure was an angioplasty. A balloon catheter would be threaded to the clogged heart vessel and pumped with air. The balloon would stretch the artery’s taut walls and would restore normal blood flow to my heart.
Thus began an episode that pushed me deeper and deeper into a medical detective story. I probed my own illness and examined the ferocious battle to control coronary artery disease, a malady that affects millions of Americans and leads to more deaths than all types of cancer combined. Through a 20-month period, I underwent three heart procedures--two of which were experimental, at the time not approved for wide-scale application by the Food and Drug Administration. I became a guinea pig.
There isn’t a good time in anybody’s life to have a life-threatening disease discovered. Almost all of us have “everything to live for.” I was no exception. Iris and I didn’t get married until we were 35. We were very much in love, living in a cozy, 80-year-old, three-story Victorian six blocks from Golden Gate Park and preparing to start a family.
For the past 14 years I had been a newspaper reporter, writing about everything from murders to medicine. I had worked for papers in Chicago, Dallas and Los Angeles and been a foreign correspondent in Brazil; I spoke a couple of foreign languages. My life was going as I wanted it to go. Before work each morning, before the fog rose from the moist ground, I jogged around the park’s polo field, past the band shell and the Hall of Flowers and through the Rose Garden. Other than an appendectomy nine years earlier, the only times I had been in a hospital were to write stories about other people’s misfortunes.
This time would be different. I was the patient. The doctor said I was a perfect candidate for angioplasty--young, fit, in otherwise good health. The bulk of my arteries were pliable and clear. During the procedure, which in 1989 was performed 270,000 times, cholesterol deposits would be pushed to the sides of the artery wall, leaving a clear path to carry oxygen-rich blood to the heart. Performed under local anesthetic for a total of about $12,000, a quarter of the cost of bypass surgery, patients need take off no more than two days from work to recover from the procedure.
But Mailhot warned me that in 30% to 40% of the angioplasties involving the left anterior descending vessel--the artery that was narrowed in my heart--the vessel shuts down again within eight months. If that happens, the patient’s options are limited: Repeat the angioplasty, undergo bypass surgery or submit to an atherectomy, the experimental procedure that would attempt to remove the plaque, also known as atheroma.
In the meantime, in case of pain, Mailhot insisted that I carry a small, brown-tinted bottle of nitroglycerin, a drug that causes the heart vessels to open within seconds.
With the nitro in my pocket, I sought out several cardiology professors at the University of California at San Francisco Medical School. Many of them didn’t practice angioplasty but had trained pioneers in the field. I wasn’t comfortable with the hospital where Mailhot would be performing the procedure. It was old, its facilities were outdated and the cardiac catheterization lab there didn’t have a long track record. Instead of blindly following our internist’s recommendation, I wanted to select the person to whom I’d be entrusting my life.
On my 37th birthday, Iris and I met with Dr. Kanu Chatterjee, the Lucie Stern Professor of Cardiology at UC San Francisco. He was a cordial, soft-spoken man who agreed to see us on a Saturday at his university office, even though he didn’t know us and we hadn’t been referred to him by another physician. Chatterjee viewed tapes taken during my angiogram and suggested an angioplasty to be performed by a group of cardiologists in Palo Alto headed by Dr. John Simpson. Two days later, I met with Dr. Bruce McAuley, one of Simpson’s associates. McAuley was only 38. Should I be entrusting my life to a man just a year older than I? Perhaps because of our closeness in age, he seemed genuinely sympathetic, and I felt on an equal footing with him. When I asked him point blank how many angioplasties he had performed, he didn’t hesitate, saying 550.
In early September, Iris and I drove to Sequoia Hospital in Redwood City, 25 miles south of San Francisco. After I checked in, I waved off an orderly who had instructions to shave me from neck to toe. We reached a compromise, a shave from navel to thigh. Half an hour before the operation, a nurse gave me a sedative that made me drowsy almost immediately.
“Don’t let them hurt you,” Iris whispered as I lay waiting, my lids drooping like window shades. She kissed me. While being wheeled to the operating room, I caught a glimpse of her over my right shoulder. Her eyes were damp with tears. What had I gotten this woman into?
Another sedative, administered intravenously, kept me groggy. The only part of my body not covered with the green surgical cloth was a fist-sized area on the left side of my chest. Should the angioplasty fail, surgeons would need quick access to my heart for a bypass operation.
As the procedure began, an anesthetic was injected into my groin. “This will burn,” McAuley warned. Thirty seconds later, he punctured the skin covering my femoral artery with a scalpel.
Tubes, tubes, lots of tubes were being handed from nurse to nurse to the three attending cardiologists. There were so many tubes that I thought I must have been in the middle of an enormous home aquarium. There was no pain, but I had an eerie sensation. I could see my own insides on a monitor about six feet above my left elbow. McAuley encouraged me to watch. The monitor was his only guide as he inched the catheter toward my heart. As the tube moved forward on the screen, I could feel it snaking through my body. I was able to follow the tube all the way to the injured heart vessel.
I’m not sure if it was the anesthetic or a fit of whimsy that seized me in the operating room. The scene reminded me of an episode of “Dr. Kildare,” except that everyone in this operating room seemed calmer than on television. Some of the nurses were fat; some were thin. None looked like Yvette Mimieux. The anesthesiologist was bald and wore a pinky ring. With their faces behind gauze masks, the cardiologists looked like benevolent bandits. I half expected the whole lot to break out in song and synchronized dance.
Suddenly, I was jolted from my reverie. Watching the monitor, I saw the obstruction in my own heart vessel. And I was amazed at what my own body had been harboring. The vessel changed in size from a small tube to an even smaller tube. It looked as though someone had taken a straw and kinked it shut in the middle.
“See it there?” McAuley excitedly asked as though he had found the prize in a Cracker Jack box. “That’s the artery we’re after.”
A thinner tube with a deflated balloon on its tip was pushed through the first tube. The balloon was positioned midway in the clogged vessel. Then I heard the whir of an air pump. I turned my head to get a better look at the monitor. The balloon inside me expanded--110, 120, then 150 pounds per square inch. The diseased artery doubled in size, like a plump little sausage.
My chest suddenly ached. Flushes of nausea seemed to spread from my heart to my head. As the vessel inside me expanded, the waxy plaque deposits clamping it shut were being split apart. I felt like a soccer ball that had been kicked and stretched and was about to burst.
“Hang in there, Steve; just 10 seconds more,” McAuley advised. I grimaced and was about to pass out. Then the pain disappeared. The whir stopped. The balloon and tube were slowly pulled out of my body.
Two hours later, still groggy on a gurney, I smiled at Iris. “Piece of cake,” I mumbled. I managed a woozy thumbs-up sign.
The doctors pronounced the angioplasty a success, but in two months, while I was jogging in the park, the pain in my right arm returned. It played hide-and-seek with my body and, this time, with my psyche. Within a month, the ache came back with a vengeance. Carrying groceries up the 48 steps to the front door of our house one afternoon, I felt the pain, and this time, it flared to my right shoulder. The pain spasm was angina--restriction of blood to my heart.
Another angiogram revealed the problem. What was clogging the heart artery wasn’t cholesterol plaque but scar tissue from the angioplasty. The balloon dilation had imparted such trauma in stretching the artery that the vessel had become inflamed, and scarring in the narrow vessel was blocking blood flow. The artery was shut as tight as a Boy Scout’s knot.
Such a development after angioplasty isn’t unusual. Regardless of the cardiologist or the hospital, one of three angioplasties fails within six months. I had been warned by Mailhot and McAuley.
Forcing open the crimped blood vessel was imperative, or it would eventually become completely blocked. A regimen of drugs might stabilize my condition, but there could be no more jogging, no lifting, no strenuous activity. I’d have to be careful when my wife and I made love. The procedure being recommended was another angioplasty.
“No way!” I told McAuley. It had failed once, and I’d be damned if I was going to set myself up for another failure. My spirits were sagging enough.
I interviewed more cardiologists and learned about other options. Instead of simply dilating the vessel, there were experimental procedures that, by using a variety of mechanical techniques, would remove or bore through the scar tissue and cholesterol buildup. Some seemed like shams; others seemed plausible but sounded like Rube Goldberg inventions. Many of the doctors reminded me of competing car dealers, each claiming that his model was the best. These men--ordinarily mild-mannered physicians whose definition of competition is a Saturday morning round-robin golf match--seemed locked in a pitched battle. The doctors sniped at each other like jealous schoolgirls and raided each other’s staffs of bright assistants .
McAuley’s associate, Texas-born John Simpson, had the longest track record with his device, the Atherocath--a tiny, cylindrical device with a stainless-steel cutting edge. As it is twisted manually by the cardiologist, the device shaves plaque and scar tissue from the inside of the vessel wall and then extracts the material, which falls into a collection chamber. (It was fully approved by the FDA in September, 1990.)
“Simpson’s device can’t go around sharp corners because it’s rigid,” said Seattle-based David Auth, a University of Washington physics professor who invented the Roto-blador, a high-speed diamond-tipped drill that spins at 180,000 r.p.m. and pulverizes the clogging material. “Our device can go in and out of corners. His device is only good for a limited number of procedures.”
I went back to Simpson with the criticism, and suddenly I felt I was in the middle of a firing range. “Some physicians resent us,” he answered in a measured tone. “Some are struggling. But the medical marketplace is very unaccepting of technology that doesn’t work in the long term. If my device works well, it will survive.”
Auth fired a second round. “Let’s have a shoot-out. Let’s put some vessels on the table, and let’s see which is the best. Then we’ll be over with all this high-stakes grandstanding.”
It was fascinating stuff, but it involved my life. I was as much a guinea pig for their fame and personal wealth as I was for my own health.
In my days of researching procedures, the question of my own mortality started to gnaw at me. Were these cardiologists like Laetrile hawkers to cancer patients, preying on people by offering miracle cures? The possibility of dying was no longer an abstraction to me. I began to feel like Ben Gazzara in “Run for Your Life.” The mere specter of angina--not actual angina--was a thorn in my side that underscored my own fragility.
I turned into a bear to live with. I’d stop Iris in mid-sentence whenever she mentioned long-term plans. “What’s the use?” I’d ask. “I don’t even know if I’m going to live until the end of the year.” I was downing pills, six of them with breakfast each day, surely not a harbinger of physical well-being. With every step I took, I felt the bottle of nitro in my pocket.
One evening, Iris and I arrived at a compromise. We would plan a summer trip to northern Italy, a place we had always talked of visiting. By then, we thought, I should be fully recuperated, back to normal. My goal was to reach Siena, where we would lift two glasses of Chianti in celebration.
While shuttling back and forth to cardiologists, I tuned into a local radio talk show. Two cardiologists were describing the wonders of angioplasty. The host, usually a blustery loudmouth, blurted out, “But sticking a balloon in your arteries, that’s grotesque!”
Maybe it is. The whole issue of how I got where I was at age 36 alternately fascinated and depressed me. Was I somehow responsible for my condition? Was there something I did that prompted my arteries to be filled with deposits of cholesterol and then with scar tissue?
Since the first angioplasty, I had done everything right. With the drug lovostatin, I had dropped my cholesterol level to a bare-bones 125 milligrams per deciliter. The American Medical Assn. says safe cholesterol levels are 200 mg/dl or below.
But my sense of reason told me I was not an innocent bystander to my body’s condition. Stress is the unknown factor in coronary-artery disease. When people perceive themselves under stress, their sympathetic nervous system causes heart rate and blood pressure to rise. That eventually can lead to tears and abrasions in arterial walls. Cholesterol races to the arteries to make repairs. Once there, the substance can multiply wildly, creating millions of fatty cells. With no place to go, they block otherwise healthy vessels. The cholesterol is like rust on the inside of a pipe; the buildup accumulates until it fills the opening. Could I have pushed deadlines and sublimated anger for so long that my body was subverting its own best interests?
I was a man obsessed. For the sake of my body and mind, I needed to find some answers. One physician I talked to, Dr. Dean Ornish of Sausalito, had a control group of patients who were put on a low-fat vegetarian diet. They practiced yoga twice a week and attended stress-management classes regularly. Ornish’s thesis was that these patients were actually able to reverse narrowing of the heart arteries, or atherosclerosis.
But I was not prepared to turn into a vegetarian. I didn’t want to practice yoga. I didn’t want to sit in a room of strangers and practice relaxation techniques. I wasn’t being stubborn or old-fashioned, but that lifestyle wasn’t for me. I wanted a scientist to give me fact. I didn’t want hocus-pocus, smoke and mirrors. I wanted something that even a cynic could believe in.
Unless I wanted to undergo another angioplasty, the Simpson device was really my only immediate option. It had been around the longest--used in about 140 successful procedures (It has now been performed 1,400 times worldwide). And Simpson was widely respected as a cardiac whiz kid. But because the procedure was so new, there was no long-term diagnostic follow-up on these patients. So it was a crap shoot. Did the action of Simpson’s “pencil-sharpener"-type blade against the inside walls of the artery create even more trauma than a routine angioplasty and therefore create more scar tissue? I didn’t know. No one knew.
Something else helped persuade me to go with Simpson. The giant drug company, Eli Lilly, had just bought Simpson’s device. The week I was scheduled to undergo the procedure, Lilly had invited hundreds of cardiologists from around the world to witness the company’s device, used on patient-volunteers. While nibbling croissants and sipping coffee, the assembled cardiologists were to watch the procedure telecast live to a hotel ballroom from a nearby hospital operating room.
Before granting general approval to any new coronary procedure, the FDA requires that the technique be tried on human cadavers, then animals and then humans with blockages in the arms and legs. After that, it can be used experimentally on cardiac vessels. Finally, after more than 500 successful procedures, with follow-ups on each after six months, the FDA will approve the technique for general use.
So in early December, 1988, I underwent the experimental procedure. I figured the attending cardiologists would be particularly careful. They wouldn’t want to muff an operation in living color in front of so many of their colleagues. Via closed-circuit TV, in front of the breakfasting cardiologists, my cholesterol deposits and scar tissues would be shaved and then extracted from inside the artery. The attending cardiologists would be hooked up with microphones and earpieces to answer questions from their colleagues. It was like a live football game being played for the benefit of coaches who wanted to catch a glimpse of a promising new kind of ball.
The atherectomy (so called because the atheroma is removed) was similar to the angioplasty, only longer and more painful. At one point, when the device was inside my plugged artery, I felt a sharp, piercing sensation. “Ouch!” I yelled. A dose of morphine was administered through my thigh. And, within 10 seconds, I had the singular sensation of leaving my body, rising six feet off the operating table. I hovered above my flesh and bones for several seconds and then floated back. I was numb, as much from the drug as from the experience.
Too groggy to follow the rest of the procedure, I remember flashing a victory sign with my index and middle fingers to the assembled heart doctors just as the tubes were drawn from my femoral artery.
Both I and the breakfasting cardiologists were able to see the sticky gunk removed from my arteries. Placed on a tray at the end of the operating table, the stuff looked like dry white and yellow paste. The cardiologists seemed to think the procedure was grand. My own doctor said the procedure went without a hitch.
But that’s what I had been told the first time. There were complications this time, too.
Six months later, I developed the same pain in my right arm that precipitated the original medical episode. I underwent another atherectomy, during which more waxy deposits and scar tissue were removed from my body.
By now, I must have the cleanest arteries of any 39-year-old. Time will tell. It’s been almost three years since the last atherectomy. During my most recent treadmill test, McAuley said there were signs that my blood flow has actually improved.
I’m back to running four miles a day, three times a week, on my same path in Golden Gate Park. There is no more pain in my right arm.
But every day, I am acutely aware of my body. Every muscle twinge in my right arm sends my mind reeling back to two years of doctors’ visits, tubes, the “Dr. Kildare” scene in the operating room. An itch near my chest makes me uncomfortable. Could it really be the beginning of a recurrence?
In the past two years I’ve received dozens of calls from acquaintances, from friends of friends. “What was your cholesterol level?” “Exactly where was the pain that led to the heart procedure?” “I have tennis elbow but don’t play tennis. Think I should check it out with a cardiologist?” I usually answer these queries in good spirit. My mother had always wanted me to become a doctor; finally, I am at least playing one.
But talking about my own experience is painful. Somehow it’s easier to talk to strangers about this than to people who know me. It’s like pricking an old wound. If I sense a friend or a colleague edging toward the subject, I steer the person away. I’m not ashamed of what I went through. I simply want to move on.
I watch my diet, but I’m not a fanatic. I have guilt when I splurge on a pizza or ice cream. I have learned to live with the uncertainty of my health. One day at a time, and when there is no pain, it becomes another small victory. The accumulation of days has given me breathing room.
Last summer, Iris and I took our long-planned trip to Italy. On an exceptionally beautiful day, with warm breezes billowing our loose clothing, we found a splendid outdoor cafe in Siena. Just as the sun was setting, we raised two glasses of Chianti, as we had promised.
The drinks seemed to close one episode of our lives and open another. Last Sept. 24, Iris checked into a hospital, the place of so much pain and disappointment for me over the last two years. But this time, it was to deliver a beautiful baby boy. We have never felt so fortunate.