Hearts and Minds

By Tony Dajer|Monday, December 01, 1997
RELATED TAGS: HEART DISEASE
She was a nice new yorker in her mid-sixties--probably read the Sunday New York Times, probably believed in Galileo and Darwin. Chest pain, the chart read--an emergency room doctor’s bread and butter.

So how can I help you today, Mrs. Weiss? I inquired.

She fixed me with a look and shot back, Do you practice holistic medicine?

Huh?

Do you use cayenne pepper?

What?

She rolled her eyes. I don’t want any of your medicines, just cayenne pepper.

I’d started medical school vowing to include all of my patients’ social, psychological, spiritual, and biological makeup in the healing process. Above all, I would keep my eyes open to medicine’s limitations and to the beneficent mysteries of other belief systems.

That was 18 years ago.

In an even tone I answered, Mrs. Weiss, you seem to have arrived in my emergency room. Your chest pain suggests a serious heart problem. And you don’t seem like a complainer.

She allowed me a small smile.

I can only give you the best care I know. As for cayenne pepper, I have no idea what it is or how to use it. I only know how to practice medicine one way.

Your way, right? she replied.

’Fraid so, I said, smiling.

Eighteen years had taught me one simple lesson: real disease exists. And heart attacks don’t stop to inquire whether you are an allopath, a homeopath, or a Zoroastrian.

Mrs. Weiss eyed me for another long moment, then shrugged. I’m here, aren’t I?

So you are, I said.

But how about just a little? she asked.

I laughed. So much for my new convert. But tell me, how long have you had this chest pain?

Just a few days. I have aortic stenosis, you know. My regular physician, Dr. Rosenblatt, treats me for it.

The aortic valve, which lets oxygen-rich blood out of the heart’s left ventricle (its main pumping chamber) and into the bloodstream, is the circulation’s choke point. When the ventricle pumps blood through the aorta, the largest of our body’s arteries, the blood flow flattens the aortic valve’s three flaps against the artery walls. When the ventricle relaxes, reducing pressure, the flaps spring back into place, closing the valve and preventing blood from rushing backward. Though astonishingly durable, the valve is vulnerable. It can be scarred by rheumatic fever or narrowed by congenital malformation. And years of wear and tear can allow calcium buildup to narrow (or stenose) it.

With aortic stenosis, the extra squeeze needed to overcome the bottleneck can require the ventricle to pump nearly twice as hard to force blood through the narrowed valve. At that point, patients get winded because oxygen-laden blood backs up in the lungs, or they feel the viselike grip of angina as the coronary arteries fail to supply enough oxygen-rich blood to the bulky and overworked left ventricle.

And all because of a little calcium.

Rosenblatt? I said, surprised. I know him well. He’s a great doctor. When did you last see him?

Well, Mrs. Weiss answered sheepishly, I actually haven’t seen him for a while.

Uh oh, I thought.

I’ve been seeing Dr. Gorman. He uses chelation therapy. You know, edta.

I see.

It absorbs calcium.

Right.

From the valve.

Chelation therapy involves using chemicals to bind metals and minerals and remove them from the body. Cases of lead poisoning, for example, have been treated with the chemical compound edta since it was developed in the 1940s. It binds (or chelates) lead and is then easily excreted by the kidneys. Before long someone had a bright idea: If it works for lead, why not calcium? Calcium is, after all, a major component of the arteriosclerotic plaques that cause strokes and heart attacks. If aging causes calcium buildup, the logic went, then removing the calcium should undo the aging--a bit like the argument that since meningitis is associated with fever, lowering fever should cure meningitis.

Four decades later, none of the clinical studies of edta have shown any benefit for arteriosclerosis. But a school of chelation therapy flourishes nonetheless. One leading apostle--an M.D.--claims he hasn’t lost a patient to congestive heart failure in ten years, whereas traditional doctors lose 50 percent in two. My patients just don’t seem to die, he writes modestly.

The trick, of course, is to concoct a very liberal definition of congestive heart failure. Patients may do well simply because they weren’t that sick to begin with.

But chelation or no chelation, Mrs. Weiss wasn’t giving me a classic story for aortic stenosis.

I’ve only had the pain two days, she insisted.

And when you climb stairs?

Oh, a little out of breath. Nothing major.

Nothing? You’ve done your regular activities, all of them, right up to two days ago?

That’s right, Doctor.

A typical case of aortic stenosis worsens gradually. As the valve narrows slowly over time, the pain begins to grow--slowly and steadily. Now I was worried: sudden onset of pain means something else. Mrs. Weiss was most likely having a more acute event. Like a heart attack.

But when we performed an electrocardiogram, which measures the electrical activity of the heart, Mrs. Weiss’s results were normal, without the signature high spikes and deep troughs of a straining left ventricle. I listened to her lungs and heard a few faint crackles. Fluid accumulation, I thought. When the alveoli, the tiny air-trapping pockets in the lung, get too wet, they stick together. The result is a popping sound. Sliding my stethoscope around to the front of her chest, I encountered two hard and highly unholistic mounds. Breast implants.

Mrs. Weiss intercepted my look of surprise.

Only mediocre minds eschew contradiction, she pronounced. And I’ve had a face-lift too, in case you were wondering.

Last year Americans spent $14 billion on alternative medicine. Andrew Weil, M.D., bearded and wise, graced a recent cover of Time magazine. His latest book on herbal medicine, nutrition, and well-being tops the best-seller lists. Homeopathy, developed in the early nineteenth century, is coming back. Naturopaths, crystal healers, massage therapists, and chiropractors attract people in droves.

Ironically, the wisdom inherent in all these alternatives found its greatest promoter in William Osler, the father of American medicine. A century ago doctors inflicted such a phantasmagoria of purges, bleedings, and home-brewed remedies on their patients that they easily killed more than they cured. As the physician Lewis Thomas wrote in a brilliant essay, those practitioners and their patients were acolytes and ministers of the shaman/healer/medicine man’s timeless imperative to do something.

Osler, born and trained in Canada, was aware of European reports that mere supportive care often worked as well or better than aggressive purges and bleeding. When he arrived at the University of Pennsylvania as professor of medicine in 1884, he promptly stamped out dubious remedies, encouraging a more scientific approach to treating patients. At the time, that left precious little to offer patients except good food, clean sheets, pure water, and sunlit rooms. Thus did the school of therapeutic nihilism invade America. It soon yielded a startling result: patients, more often than not, got better on their own.

I wasn’t ready, however, to leave Mrs. Weiss to recover on her own. Still pondering contradictions, I asked her to lie flat.

Ow, she grimaced. That hurts.

What, I asked quickly, the lying back?

Yes.

I sat her up, then lay her down again. Better sitting up?

She nodded.

Any colds lately?

Oh, maybe a minor one last week.

I won’t ask what you took for it.

The pain of pericarditis--an inflammation of the smooth membrane that envelopes the heart--worsens with lying flat and eases with sitting up and leaning forward. Her ecg didn’t show a typical pattern for pericarditis, but the inflammation often follows a viral syndrome and it would explain the rapid onset of her symptoms. Moreover, the nitroglycerin tablet I popped under her tongue did not relieve her pain at all. Nitroglycerin can relieve angina or heart attack by causing blood vessels to dilate, thus improving blood flow. Since the tablet didn’t help, a coronary artery problem like angina or a heart attack was less likely.

Luckily, pericarditis usually responds nicely to anti- inflammatories and rest. So I decided to wait for blood tests and X-rays. These results would help me exclude grave conditions like a heart attack.

Mrs. Weiss was making sense.

Osler’s age of therapeutic nihilism lasted half a century, then vanished with the advent of penicillin. Finally there was a treatment that was much better and safer than doing nothing. At the same time, the rise of diagnostic technology offered doctors hard targets for their magic bullets. Henceforth it would be tempting to consider a patient’s symptoms real and treatable only if confirmed by tests or images.

But the elegant designs of modern medicine foundered in the muddy waters of human subjectivity: most of the headaches, backaches, blues, and malaise of daily life generate no hard targets.

Into that breach stepped the alternative therapies. Homeopathy, for instance, addresses only symptoms. Its remedies (ultradiluted substances meant to stimulate the immune system with a low-grade reproduction of the illness) are custom-tailored to each patient’s perception of what’s wrong. To a homeopath, the subjective is the disease, and he or she must treat all a patient’s symptoms and affirm their importance, not quickly weed out the nonorganic ones. From a scientific standpoint homeopathic (and crystal, aromatic, and star-gazing) remedies are, of course, nothing but wishful thinking in a bottle. But the power of suggestion is such that in a Canadian trial of prostate drugs the placebo group--303 men--insisted at study’s end on continuing their pills. The pills contained only wheat flour.

Besides tapping the placebo effect and satisfying the itch to do something, alternative therapies immerse health-seekers in the invigorating spa of personalized, soul-probing attention. It is Osler with bells and whistles, a repackaging of the caring and compassion indispensable to all healing. And it is infinitely less objectionable than the appalling habit of M.D.’s who ladle out antibiotics--often without even seeing the patient- -for bronchitis, sore throats, colds, and other innocuous maladies.

But real disease exists. And the deadliest practitioners of post- Oslerian witchcraft are those who, like Mrs. Weiss’s chelator, claim without evidence that their remedy saves lives. The only treatment for severe aortic stenosis is valve replacement. Scared of open-heart surgery, Mrs. Weiss probably figured chelation was worth a shot. As did, of course, her no doubt well-paid practitioner.

And then Mrs. Weiss threw her curve ball.

I feel short of breath, Dr. Dajer. And boy, does my back hurt.

Her blood oxygen saturation--the measure of oxygen her blood carried--had drifted down to the low 90s. Normal is 99 to 100 percent. Her systolic blood pressure, the peak measure of the force with which blood is leaving the heart, had been a decent 100. Now it was an unsettling 80. A whole new grab bag of lethal possibilities sprang to mind, foremost among them aortic dissection, a catastrophic shearing of the aortic wall. Back pain is a common sign of aortic dissection because the aorta lies close to the spinal cord. And now her lungs sounded wetter.

Symptom-wise, Mrs. Weiss was lighting up like a Christmas tree.

Her first chest X-ray had shown some fluid in her lungs. A second chest X-ray confirmed that her lungs were getting worse. But it would take a ct scan to see the halolike fraying of the aorta that is the sign of a dissection. Her cardiac enzymes--substances that dying heart cells release during a heart attack--were negative, but they often take hours to turn positive. I needed to explain all her signs and symptoms, and fast.

How do you feel, Mrs. Weiss? I asked one last time.

She caught my worried look. You sure cayenne pepper wouldn’t help?

You’re not going to get this leopard to change its spots that quickly, I retorted.

She laughed.

It was a Sunday afternoon--no cardiologists in the hospital. My friend Rob Dunne was on call, but he worked 80-hour weeks and this was his only day home. I decided just to pick his brain. But low blood pressure and back pain prompted an immediate reply.

I’m on my way.

No, Rob, wait. . .

Not a problem. My daughter needs to run an errand downtown. We’ll both come.

Fifteen minutes later, Rob and his eight-year-old daughter wheeled an echocardiogram machine into the emergency room.

He graciously introduced himself to Mrs.Weiss, then applied the probe that would deliver sound waves to the left of her breastbone. By bouncing sound waves off the underlying aortic valve, Rob could measure Mrs. Weiss’s worrisome blood flow with a precision Osler could barely have hallucinated.

Whew, he whistled after ten minutes. She’s got one heck of a gradient. Terrible valve. But the ventricle’s great, no sign of a heart attack.

In short, though Mrs. Weiss’s ventricle was pumping out a lot of pressure, the force wasn’t making it past the narrowed valve.

Very strange, Rob said. I’ve never seen aortic stenosis present this way. Just to be safe, we should still ct scan her.

But the ct scan showed no sign of aortic dissection. We could now place all blame solely on the valve: sluggish blood flow through the malfunctioning valve had starved every other organ in Mrs. Weiss’s chest of oxygen. Her back pain and shortness of breath was a way of crying Uncle! But the real blame, of course, lay elsewhere.

I asked Rob one last question, Ever heard of cayenne pepper?

Isn’t that capsaicin? he answered, the new painkiller that comes as an ointment? They say it works well for arthritic pain and diabetic neuropathy.

You mean, it’s a real medicine? I spluttered.

Yes, Rob answered, smiling. But this lady needs a new valve.

Mrs. Weiss did get her valve. All her postoperative tests showed virtually normal heart and lung function. By any objective measure she was doing great. I called her a month later.

So. You must feel a lot better, I nudged.

Some. Just a little, really, she replied.

Spot for spot, leopard.
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