The advances in cardiac care over the past half century can perhaps be reflected in a single statistic: in the late 1960s, the death rate for patients admitted to hospital with a heart attack was more than 40 per cent. Today, at the University of Ottawa Heart Institute, it is less than 4 per cent.
This advance has been accompanied by improvements in survival for patients with all types of heart disease and disorders, including valve disease, heart rhythm disorders, congenital malformations and more. The options for cardiovascular care have undergone a massive evolution in the 40 years since Dr. Donald Beanlands joined the Heart Institute as the founding Chief of Cardiology in 1975.
“When I started out in medicine in 1952, pacemakers hadn’t been invented. We had no drugs to offer except for morphine and digitalis,” recounted Dr. Beanlands. “Surgeons weren’t doing bypasses yet, and we didn’t do coronary angiograms. Heart attacks were treated with six weeks in the hospital on bed rest, not rehabilitation. I think cardiac care has been the most exciting area of medicine in my lifetime in terms of the tremendous advances made.”
These advances came in tandem with breakthroughs in other areas of modern medicine, which also helped improve cardiac care; for example, the widespread availability of antibiotics that led to the near elimination of rheumatic fever in Canada. Rheumatic fever was formerly a major cause of debilitating valve disease, remembered Dr. Beanlands. “You don’t see that anymore, and we used to see a case a week.”
The Rise of Preventive Medicine
The rise of preventive cardiac medicine has given doctors a new set of tools to use against heart disease that includes both drug therapies and lifestyle changes. “Someone coming in now with a heart attack is going to be sent home with five new medications,” none of which existed 50 years ago, said Dr. Christopher Glover, an interventional cardiologist who joined the Heart Institute staff in 1997.
Dr. Glover’s residency coincided with the rise of preventive cardiac care, which, he recalled, was not always an easy sell to established physicians at the time. “I remember working with some of the older cardiologists when I was a medical student. They weren’t as convinced as the trainees about the role of diet, exercise and other lifestyle factors.”
Today, prevention—both primary and secondary—plays a major role in the clinic. “I tell all my patients that if everyone walked 30 to 60 minutes a day, ate lots of fruits and vegetables, stayed away from fatty foods, watched and treated their blood pressure, treated their cholesterol if it’s high and didn’t smoke, we cardiologists would be half as busy,” he said.
This advice applies across the board, Dr. Glover stressed, including for patients with a strong family history of heart disease, who tend to be more fatalistic. “It’s true that we don’t fully understand the genetic factors, but lifestyle still matters. For patients with strong genetic risk, if they didn’t smoke, watched their weight, and exercised, they may still end up with heart disease, but maybe it would have been delayed 10 or 20 years,” he explained.
Stopping a Heart Attack Before It Starts
Though genetics is known to account for up to half the risk of developing heart disease, cardiovascular genetics research has yet to help tease out risk for individual patients, said Dr. Glover. “We still don’t fully understand why some people get heart disease and other people don’t. There are lots of patients I’ve done angiograms on who ‘should’ have coronary disease because they have lots of risk factors, and yet they don’t have it. I’ve seen lots of people who have it and you think ‘How can they have coronary disease?’ because they have no or few risk factors.”
“I think there must be a missing factor, some type of interaction between genes and lifestyle that we don’t fully understand yet,” he continued. Both physicians agreed that besides helping to identify patients at risk for developing life-threatening atherosclerosis, a vital piece of missing information that genetics research may eventually supply is an understanding of why arterial plaques rupture—the end cause of a heart attack.
An individual plaque does not have to be severe to rupture and cause a sudden blockage, which makes the reason that some rupture and others do not even more of a mystery, said Dr. Beanlands.
“In the future, the most important thing that anybody could do to get the mortality from cardiovascular disease down further is to find something that prevents heart attacks from occurring—that prevents plaque rupture,” explained Dr. Glover.
“As cardiologists, we see people after a heart attack or in the middle of one. We try to abort the heart attack, and then we try to help them recover and prevent another episode. The biggest advance that could change the whole landscape would be a medication or a strategy where you could identify people who had plaques vulnerable to rupture and pacify that plaque in some way, preventing the first heart attack from ever happening,” he continued.
This discovery will be aided by modern cardiovascular imaging techniques that are currently used to understand the heart’s structure and functioning, including computed tomography (CT) and positron emission tomography (PET). PET currently plays an important role in identifying functional heart tissue that can be saved with a heart bypass, helping to avoid heart transplantation in some patients, explained Dr. Beanlands.
What Can Be Done and What Should Be Done
The myriad interventions available in the modern cardiovascular clinic raise a new set of dilemmas for doctors as the average age of patients with heart disease continues to rise.
Fifteen years ago, recounted Dr. Beanlands, “there was a lot of ageism out there” in terms of doctors’ reluctance to treat older patients. While this is no longer the case in academic centres in Canada, he continued, the newer, more aggressive approach to treating older patients comes with its own hazards.
“We don’t have an age cut-off for procedures, but the older you are, the more important quality of life becomes and the length of life less important. Technically, we can do anything—we can send them for coronary artery bypass, we can do angioplasty, put in a CoreValve® (transcatheter aortic valve implantation), and I think the big question now is whether we should be doing it in some people,” said Dr. Beanlands.
“We have to look at the whole patient, not just their heart,” agreed Dr. Glover. “We can fix a heart problem, but if a patient is debilitated for other reasons, it won’t necessarily improve their overall functioning, their overall quality of life.”
But for older patients in good health, modern cardiovascular care can greatly reduce the role that heart disease plays in the later years of life. “I have a lot of 80-year-old and 90-year-old patients whose biggest complaint is not their heart—but their joints, or back or hip. I think it is incredible what we can do today,” he concluded.