On Having Heart Disease, Part II

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The discovery that I have coronary artery disease and the resulting two stents has been, in some ways, a great blessing. Now I know why I have had symptoms for fifteen years—the calcium buildup was narrowing three of my coronary arteries. The stents have helped me feel better, and I have been eating lots of veggies, fruits, and nuts, with the only meat being white meat from chicken or turkey. Exercise on my treadmill is now up to four to five days a week, and distance and calories burned have been steadily increasing.

One of the strangest benefits for me is that when I was in the cath lab, I knew there was a slight risk of death, but I was ready for whatever happened. For a few moments I was not afraid, and I trusted in God. While I still have my moments of fearing death is annihilation, those moments do not come as often as they did before my hospital stay. There are too many coincidences not to believe that God was involved in my recovery. I have tried to pray more, though the discipline is difficult, and I particularly like the early morning “Lauds” service on the Common Prayer I consciously think about God much more often and see God’s handiwork in the beauty of nature—even in this fallen world.

There are, of course, negatives. I know that coronary artery disease is chronic and that the battle against its spread must be thorough and constant—and there are no guarantees that more blockages would never occur or that my 50% blockage will never grow. There is also small vessel disease. My heart, the organ that keeps me alive in an immediate way more than other organs, is utterly contingent. Will a new blockage form? Will a clot form in a coronary artery and cause a myocardial infarction? Will the blockages already present make my heart electrically unstable and throw it into a fatal ventricular arrhythmia? While I work out and am not afraid, in the back of my mind I know these events are possible, and I keep my nitro handy in case I need it—hopefully I never will.

A few years ago, I read a memoir of a man who had suffered a heart attack—I do not remember his name, but the book was well-written. He said that his MI was a blow to his ego, especially to his sense of sexuality—he felt “less sexy” for having a heart attack. Perhaps it is the myth that a man has to be strong, and his heart attack seemed to reveal him as weak. In me, the effect was stronger due to some peculiarities of personality, most likely related in part to my mild autism (Asperger’s Syndrome). Now these are personal matters (read no further if you want to avoid sensitive topics) that I explored in my novels, End of Summer and Unpardonable Sin.  I have always been fascinated with the heart, and when Daddy brought a stethoscope home (he was a dialysis technician), I was mesmerized when I listened to my heartbeat or to other’s heartbeats. With the onset of puberty, the sound of a woman’s heartbeat became a fetish of sorts (actually “of sorts” puts it almost infinitely too mildly) for me. I also liked a woman to listen to my heart. Having a strong heart for me was part of my sexuality, and when this current situation with my heart took place, I felt (and still feel) very unsexy, even though there was no heart muscle damage. It is like a flaw in my manhood. This is irrational, I know, but given that it is tied to such powerful feelings, it is almost impossible to shake. But I am willing to take this small negative for the positives, especially the continuation of my life, for which I thank God every day. I trust that He knows what is best for me, in life or death.

On Having Heart Disease, Part I

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I knew my genetics sucked, but I thought that somehow I would avoid my family’s scourge of heart disease. For twenty-plus years I jogged regularly until arthritis slowed me down to a brisk walk. For most of those twenty years, I did not eat too much unhealthy food—but unfortunately that had changed lately, with too many trips to the fast food joints. For years sudden exertion had made me breathless, but since I could walk at a brisk pace for 45 minutes on a treadmill I thought my shortness of breath was from getting older. Last month woke me up big time—I felt chest pain on exertion. I passed a stress test with flying colors in June, so the cardiologist thought my problem had to be something other than heart disease. I had to be sure, so I hooked myself up to my portable EKG, got on the treadmill, and started walking, keeping an eye out for the S-T segment depression that would reveal a lack of oxygen to the heart muscle. It did not take long for that to happen—within three minutes there was deep S-T depression. I stopped and foolishly waited for my wife to get home. I did not reveal any alarm in my voice, so she told me to call the doctor’s office to talk with a nurse (this was in the evening, and the office had a nurse manning the phone). The nurse told me to get to the ER immediately, so Karen took me to Cape Fear Valley Hospital in Fayetteville, North Carolina, where I was seen. All the tests came out normal—EKG, cardiac enzymes, and the rest of the blood work, though my bad cholesterol was too high and my good cholesterol was too low. I showed the EKG to a cardiac physician assistant, who had enough doubts to get the staff to admit me to the chest pain unit. This was on a Sunday, and Monday I chilled out with a heparin drip and waited for the angiogram scheduled for Tuesday. The cardiologist did not expect to find anything other than, perhaps, small vessel disease which is treated medicinally. I remember how cold the room was where the test was done and the skipping of my heart (probably a short run of ventricular tachycardia) when the dye was injected. It took only seconds for the doctor to say, “You have three major blockages: a 99% blockage in the right coronary artery, a 75-80% blockage in the “widowmaker” (the left anterior descending [LAD] coronary artery), and a 50% blockage in one of the circumflex arteries. Initially the doctor wanted to do bypass, but I told them when my mother had bypass surgery all her bypasses failed. The doctors ran the statistics, and stents vs. coronary bypass had about equal results. Of course I chose stents. The first stent was put in later that day (Tuesday afternoon) in the right coronary artery. The doctor was brilliant in cutting through hard calcium with the “roto-rooter” to clean out the artery. He had great difficulty, and I think any other doctor would have given up, but Dr. Daka is an extremely skilled interventional cardiologist, and I thank God for his fine work. My chest hurt for about thirty minutes, and my body went into mild shock, causing me to sweat through my pillow. The right side of my heart had adjusted to low oxygen, and with the vessel open it asked, “Where the hell is all this oxygen coming from?”

The second stent was put in on Thursday. It was much easier to place, and I slept through most of the procedure. I returned home Friday to rest and allow my arm and groin to heal. After I was able to walk, I found that I could handle sudden exertion. I could walk up the stairs at the university at which I teach without getting out of breath. I feel so much better.

I am grateful most of all to God for working with the doctors and nurses to save my life. Dr. Daka and the staff at Cape Fear Valley Hospital were excellent, and even the hospital food was good. There was no heart damage, and my ejection fraction is a high normal of 60-65%. I have made major changes in my diet and exercise for an hour almost every day on my treadmill. As of today I have lost 24 pounds. So many things had to work out perfectly to get me into the chest pain unit, to get the cardiologist to order an angiogram, to get a master interventional cardiologist to do my stents, to avoid a myocardial infarction despite the 99% blockage. I was probably hours away from a major heart attack, and God spared me. My faith is stronger than before, and I thank God every day for saving my life.

Part II will deal with some of the emotional reactions I have had to living with heart disease, both positive and negative.

Your Brain is Trying to Kill You

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[I am open to correction in any point of the post below].

….all diseases may, in some sense, be called affections of the nervous system, because in almost every disease the nerves are more or less hurt; and in consequence of this, various sensations, motions and changes, are produced in the body.

–Robert Whytt (1714-1766), Scottish Physician

 

One of my obsessions as a child (and as an adult) is probably related to my having Autism Spectrum Disorder, Level 1 (in my case, what used to be called “Asperger’s Syndrome). I have always been fascinated by the heart and death and why a particular medical condition caused the heart to stop beating, especially if the condition was not itself a heart disease. I’d wonder about how a gunshot that missed the heart could sometimes cause rapid (or in the case of certain head wounds, nearly immediate) cardiac arrest. I would see Daddy shoot a rabbit, and it would run for ten or twenty yards, then collapse, dead. Why did its heart beat strongly enough to support its running, then suddenly stop. Or, in another scenario, why can a human being hold her breath over three minutes (and for free divers, close to ten minutes), yet someone who slips underwater or chokes on a piece of meat suffers cardiac arrest, in some cases, in a minute or two. Recently I heard of a case of a twenty-eight year old man who choked on food, and when rescue arrived two minutes later, his heart had already stopped. He was revived and had no neurological effects—but what caused his heart to stop so quickly.

Now I am not a medical doctor; the furthest I got in the medical field was as an EMT-Basic who was not even certified to give IVs or advanced cardiac life support. However, I can read, and over the years I learned that people shot often bleed out and that people who drown in fresh water can suffer cardiac arrest within a couple of minutes from electrolyte imbalances, but what about the choking victim. In the case of the gunshot victim, why does the loss of 30-50% of blood volume arrest the heart? Surely that is enough blood to stretch the sarcomeres enough for systole to continue.

I used to blame the heart—it was strong, yes, but also very fragile—too fragile, and stops too easily or too quickly for doctors to halt the underlying cause of the arrest in time to avoid brain damage or death. It turns out that often the real culprit is not the heart, but the brain.

The brain responds to bodily trauma in a way that is often destructive to the body. True, there is the diving reflex that diverts blood flow to the heart and brain that allows some drowning victims to survive. However, the rapid release of neurotransmitters in trauma or asphyxia or even in a myocardial infarction (heart attack) can result in stoppage of the heart. In effect, the sympathetic nervous system which speeds up the body, with its neurotransmitters, conflicts with the parasympathetic nervous system, which slows the bodily functions, and this conflict can lead to cardiac instability and a fatal arrhythmia. While the electrical instability of the heart itself can cause a fatal ventricular arrhythmia during an MI, often the big straw that breaks the small camel’s back is a massive release of stress hormones that is “ordered” by the brain. In the case of severe bleeding, such as occurs in gunshot wounds, a nervous system mechanism causes the heart to slow down (“brady down”) and stop after 30-50% of blood volume is lost. Some head injuries, such as bullet wounds that affect key areas of the brain associated with the brain stem, cause, according to a military medic with whom I talked, almost immediate Torsades de Pointes (a chaotic heart rhythm) which progresses to ventricular fibrillation and death. The military uses pharmacological blockers to cut off sympathetic and parasympathetic signals to the heart, and sometimes that buys extra time to treat the patient. A recent animal study published by the National Academy of Sciences found that it is the release of neurotransmitters with conflicting effects on the body that leads to cardiac arrest, and when such parasympathetic and sympathetic signals are blocked, it buys several minutes in which the heart continues to beat until oxygen is totally exhausted. Yet this time could allow doctors to reverse the asphyxia without going through the (far more often than not) unsuccessful CPR and advanced cardiac life support in the face of cardiac arrest. Some scientists are not suggesting that in cases of asphyxia cardiac arrest, animal studies be done to determine whether pharmacological blocking agents to stop both parasympathetic and sympathetic signals from reaching the heart during asphyxia crises will keep the heart beating longer. Apparently there is a pattern to the course of dying in such cases, and knowing the pattern can help the timing of intervention. If blocking agents work in animals, this may be an option for human treatment.

Thus I should stop blaming the heart for early cardiac arrest in these conditions, at least in most cases, and blame the brain instead. A person with the strongest heart in the world could go into cardiac arrest quickly from asphyxia or blood loss if her nervous system effects cause the arrest.

As a philosopher of religion, this raises some issues for intelligent design arguments, at least those in the British natural theology tradition. Animal bodies are filled with examples of poor design; Francis Collins, who is a devout Christian, mentions some of them in his attack on intelligent design arguments (one of the design flaws is that instead of a totally separate, two-tube system for food and air, we have a system in which a flap closes the airway while we eat so that air goes into the trachea rather than the esophagus. Collins points out that any human engineer would have enough sense to avoid such a flawed design. The fact that our brains “try” to kill us during severe disease, trauma, or asphyxia does not suggest intelligent design—it suggests that some of the so-called protective mechanisms of the brain can make cardiac arrest occur more rapidly, resulting in less time for doctors to focus on underlying causes and resulting in the deaths of many people who would not otherwise die. Give me a good cosmological contingency argument any day over an intelligent design argument. Now I am not calling God incompetent; I believe it is possible that evolution became flawed due to an angelic fall (as we see in J. R. R. Tolkien’s mythical account, in which Melkor (or Morgoth) and his allies damaged nature itself in their rebellion against Eru (God).

I suppose the satisfaction of curiosity is a good feeling, but I am also frustrated with the slow progress of medicine in this area in which very few studies have been done. I am glad some scientists are working in this seminal area of science and medicine and hope that their efforts result in lives saved from an early death.