State of the Heart: Exploring the History, Science, and Future of Cardiac Disease

by Haider Warraich

No one is more singularly associated with the birth of medicine than Imhotep, who lived during the twenty-seventh century B.C. and was one of only two commoners ever elevated to the honor of full deification.

By the time the Rosetta stone blew humanity’s collective minds, Egyptian knowledge had gathered two millennia worth of dust, and it was the Greeks and Arabs who came to define our modern knowledge of the heart and the human circulation. A scientific theory originating in ancient Greece and popularized by the scholars Hippocrates and Galen defined not only how we thought of the human body but also the human soul. For the almost two millennia that separated the creation of the Rosetta stone to its eventual rediscovery, civilization found itself neck deep in blood, phlegm, black bile, and yellow bile—the four humors.

Unlike those before him, Ibn al-Nafis did open a human heart, and he realized that there was in fact no connection between the right and left side of the organ.

Ibn al-Nafis’s accounts, though, while accepted in the Islamic world, failed to convince many Europeans, including Leonardo Da Vinci, who also was housed in the Galenic view of the world. Galen’s influence consumed medical science, and it persisted until an English physician, William Harvey, appeared on the scene in the seventeenth century and who debunked centuries of dogma.

The one thing that was common to all those opposing Harvey was that they didn’t actually perform experiments to disprove his claims. In fact, one of the only adversaries of Harvey who used physical experiments to challenge his claims actually converted to Harvey’s theory of circulation, convinced by his own experimentation.

The one thing that was common to all those opposing Harvey was that they didn’t actually perform experiments to disprove his claims. In fact, one of the only adversaries of Harvey who used physical experiments to challenge his claims actually converted to Harvey’s theory of circulation, convinced by his own experimentation.

it is surrounded by a thin, double-walled fibrous sac called the pericardium. The pericardial sac contains about 30 milliliters of a transparent fluid called pericardial fluid. The pericardium does many things—it lubricates the heart, allowing it to continue pumping while expending the least amount of excess energy. The pericardium also shields the heart from infections that might occur in the tissues around the heart. Unlike the heart, which floats like a fetus in its sac, the pericardium is attached to the tissues and bones around it, effectively anchoring the heart in place, which would otherwise just be flopping around in the chest. And finally, because of its inelastic nature, the pericardium restricts the heart from ballooning out of control.

Furthermore, what the history of the heart also teaches us is the fragility and reversibility of scientific progress. Ancient civilizations went from being this close to putting the theory of human circulation together, perhaps being one tourniquet around the elbow from revealing the true nature of the cardiovascular system, to descending into almost fifteen hundred years of darkness. How can such progress be so brittle?

Our history makes clear that we must always remain vigilant and protect what we now finally know after millennia of setbacks.

Any condition that chronically raises the level of inflammation in the body can raise the risk of heart disease. This is true, as we found in an analysis I published with colleagues, even of diseases such as the skin condition psoriasis.

In 1923, when Warren Harding, the twenty-ninth president of the United States, died in a San Francisco hotel room from chronic heart failure, the only medical person he trusted was a homeopath who had been treating him with laxatives in the days leading up to his demise.

While it sounds simple enough, and is probably measured billions of times every day, to date, few know how to take a blood pressure correctly. Shockingly, when medical students were recently tested on the steps required for accurate blood pressure measurement, only 1 of 159 incorporated all eleven elements.35 These steps include assessing blood pressure after five minutes of rest with the patient sitting with their legs uncrossed and using the appropriate cuff size.

lowering blood pressure can save more lives than any other clinical intervention known to mankind.

Woodrow Wilson, who was next to take office after Taft, had a series of devastating strokes because of high blood pressure that left him completely debilitated. His wife, Edith Wilson, hid him from public view, even from his own cabinet, assuring them he had a nervous breakdown while effectively taking over the day-to-day work of the president.

most prominent physicians of that time thought that lowering blood pressure would in fact be harmful.

the elevation of blood pressure was (and is still) referred to as essential hypertension, given that a greater force was thought to be essential to help blood reach all the important organs in the body.

In a report published in 1925 by the Actuarial Society of America, the direct relationship between both rising weight and age with increasing blood pressure and the association between hypertension and death were described.44 These findings, however, failed to pique the interest or curiosity of the leading scientific minds of that time, yet the insurance companies kept persevering.

The Framingham study investigators thought their job was done after they began publishing their landmark findings but quickly realized they had run into a wall—that wall was their fellow physicians. The overwhelmingly strong data they had generated failed to change the practice of either the most preeminent doctors of their time or those running mom-and-pop-style clinics in the country. And all this time, people continued to die of untreated high blood pressure by the millions—after the Second World War, every other person died in part due to hypertension.

Moments before Roosevelt had a hemorrhagic stroke, his systolic blood pressure was noted to be greater than 300.

Kidneys are always scanning the blood passing through them to make sure they have the right balance of electrolytes. And of all the electrolytes—like potassium, calcium, and chloride—kidneys care most about sodium.

After undergoing brain surgery, a nineteen-year-old woman in France started to have seizures. Rather than seeking medical treatment, her loved ones were convinced that she was bewitched. Her religiously inclined family took her to a local cleric, who recommended an exorcism.57 The exorcism started at 11:00 in the morning in the presence of her parents and brother. The many “treatments” she received included severe flogging with a reed. By the time the exorcism ended around 5:00 in the evening, the girl could barely breathe and lost consciousness. She was taken to a nearby hospital, where she died. What had killed her was not the flogging but the salt water she was forced to drink during the ritual. The sudden rapid ingestion of salt caused her lungs and brain to fill with fluid. Her brain got so swollen that it started to try to come out of her skull.

Turns out that 75 percent of the salt in our diets doesn’t come from the shaker; it comes in processed, packaged, and restaurant-made foods.

“Salt masks everything, and when you start using lesser amounts, you really begin tasting the natural savoriness of meat, beans, grains, nuts, and vegetables.”

The study was offered as an alternative to military service for conscientious objectors—they could either go fight in the war or allow themselves to be actively starved for months. In 1944, thirty-six white men who had been vigorously screened to be both physically and mentally healthy were enrolled. Over the course of the study, which lasted for a year, most of the men were starved to prunes until they began to resemble survivors from concentration camps. The study also offered a gruesome insight into the psychological effects of starvation—almost all the men experienced extreme emotional distress and depression, with one chopping off three of his fingers with an ax.

While this may seem like a lot, in patients who had experienced a heart attack or had confirmed significant disease in their coronary arteries, a third were not using any statin. Almost half of stroke patients weren’t using statins either. These patients are most likely to benefit from a statin, and yet a very large number of them are still not using what can be certifiably said to be a lifesaving medication.

of all the shiny, colorful confections in doctors’ candy stores, nothing riles up and infuriates a large and incredibly loud segment of the masses like statins. To many, statins are an elaborate, multinational plot funded by Big Pharma and fronted by bespectacled, white coat–wearing physician-scientists. Conspiracies, amplified by the internet and social media, are a hallmark of modern human society.

I had written an op-ed for The Wall Street Journal decrying the fact that so many parents in the United States were not allowing their children to receive measles vaccinations, which in turn had led to a spike in cases of this hypercontagious disease.31 The envelope was a cornucopia of vaccine conspiracies with a typed note specifically addressed to me. Instinctively, I looked around but saw no one who wasn’t supposed to be there. Someone had to have known where I sat and worked and dropped it there. It was one of the creepiest things to ever happen to me.

The nocebo effect is the evil cousin of the placebo effect—it encompasses any negative symptoms that patients may experience even if they are taking a placebo medication.

Each and every medical or nursing student is taught repeatedly that these lifesaving drugs can cause depression and increase fatigue. Turns out that if you look at the data from clinical trials, beta-blockers don’t cause any more fatigue than the placebo and, in fact, improve depression and depressive symptoms.42 Yet most patients who are started on a beta-blocker are warned of these two symptoms, increasing the chances that they will go on to experience them.

news stories that have incorrectly portrayed statins in a negative light are associated with increased heart attacks and deaths presumably due to fewer people taking them

when patients receive a sugar pill and they are warned that they might expect to feel exhausted, more than a fifth may feel it even though they are ingesting nothing more than a suggestion.

A loud and rancorous segment of the population would rather believe that statins are worse than cyanide, that they cause side effects such as dementia and permanent muscle damage. Even more importantly, statin deniers are making arguments against the entire foundation of the lipid hypothesis—claiming that cholesterol is good and lowering it is bad.

the United States, one of the only countries in the world where pharmaceutical companies can advertise directly to patients,

drug costs are the fastest-rising sources of Medicare expenditures and that they might bankrupt the U.S. health system.

An important reason driving this turnaround might be a widening trend of scientific findings either being refuted or their effect diminishing in experiments over time. This effect has also been referred to as “regression to the mean,” pointing to initial outlier results slowly being overturned by outcomes much closer to the average over time.

The British navy recruited almost 185,000 sailors during that time, and almost 133,000 of those went either missing or were killed by a mysterious disease.

He gave two cider, two sulfuric acid, two vinegar, two seawater, two a mixture of nutmeg and garlic, and finally, gave two lemons and oranges. The results were remarkable—of the entire group, the patients who received lemons and oranges were fit for duty within a week and began nursing the others to health. This was, for most intents and purposes, the first “controlled” clinical trial performed in human history.

Newer medications are becoming increasingly expensive to develop, with a controversial analysis showing that it takes more than $2 billion to develop a good drug and the pipeline of promising therapies for heart disease is dwindling.

The truth is that before the Great War, academics and physicians the world over were in awe of the Nazi regime’s scientists, particularly as they set out to involuntarily sterilize anyone they deemed unfit for reproduction. American scientists and journals were falling over themselves to praise this movement, with one editorial in The New England Journal of Medicine in 1934 proclaiming, “Germany is perhaps the most progressive nation in restricting fecundity among the unfit.… The individual must give way before the greater good.”36 Involuntary sterilization, which was heavily directed toward immigrants and minorities, was legalized in almost half the American states, and even after the end of the Second World War, twenty thousand individuals underwent this procedure without their consent by 1963.

In 1932, the United States Public Health Service wanted to study the natural history of untreated syphilis. It enrolled several hundred black sharecroppers in rural Alabama under the pretense of giving them free medical treatment. These men were followed for almost forty years even though syphilis could have been easily treated. These men were never told they had the disease and ended up passing it to their spouses. Some even had children born with congenital syphilis, and others ended up dying of complications of syphilis.

even after some physicians complained that this study was unethical, the Centers for Disease Control and Prevention and the American Medical Association insisted that the study was necessary for scientific advancement. It wasn’t until one of the key whistle-blowers leaked details of the experiment to the press that decisive action was taken. The study broke in The Washington Examiner on July 25, 1972, and the next day was on the front page of The New York Times.

Almost every single research paper ever written ends with, “More research is needed.”

newspapers and websites are more likely to cover lower-quality observational studies than well-designed randomized controlled trials.53 In fact, studies that receive greater coverage are less likely to be replicated and confirmed.54 And oftentimes, those reversals are less well documented than the initial erroneous findings.

Observational studies are more likely to bring to light new relationships that might make for interesting headlines, like the finding that statins reduce the risk of cancer (they don’t). And when observational studies are covered, their limitations are rarely brought up.56 Subsequently published meta-analyses—papers that pool the cumulative research that has occurred in an area—that might go on to refute those early, exciting results are just not as sexy. In fact, research suggests that at least half of research studies that you may read about in a newspaper are not confirmed subsequently.

Yet here lies the tallest hurdle of all—getting patients to trust their doctors. When patients come to me and they feel good but have some lab values that don’t look so hot and maybe blood pressure that is not where it should be, they have to both be convinced that these things that cause no symptoms are truly bad, and in some instances, even after lifestyle changes haven’t worked, that they will have to take a pill every day, which might cause side effects, at times with no end in sight. In short, they have to trust I have their best interest in mind.

allopathic

In a recent study, Americans ranked twenty-fourth out of a survey of twenty-nine industrialized countries in how trusting they were of their doctors in a survey.

Winning the trust of our patients is probably most important when it comes to taking care of their hearts. Even if scientists don’t produce a single further innovation in heart disease, we have all the tools to cut heart disease down to size severalfold, which is why heart disease needs less of a breakthrough therapy than cancer and is taking on all the contours of an information war. To win the battle for people’s hearts, doctors need to win over their minds.

a recent study of cancer patients using alternative medicine found that while they were healthier at the outset than patients not using alternative medications, they were also likely to die sooner.

aseptic