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The Changing Heart

At one time, nothing could be done about heart disease. As someone clutched their heart and gasped, we could do nothing but look on in pain. As we learned more about the heart, we developed drugs and learned how to cut open the body and partially repair the heart. Today, the death rate for all heart-related diseases is 45 percent of what it was in 1963. Many claim that drugs and surgery are the reasons for this.

But, if this is so, why is "progress" slowing down? According to the Harvard Health Letter (January 1998), there appears to be a slight rise in the incidences of stroke and kidney disease, and a leveling of the death rate from heart disease among U.S. adults. In other words, perhaps the well-established paradigm - drugs and surgery - is not the best answer. Perhaps it is time to review our past and see what we can learn. Perhaps it is time to change the paradigm.

History
The history of the heart and its diseases, like all medical history, is a history of ideas: an initial idea, reinforcement of the idea, rebukes to the challenges, and, perhaps, a new idea.

One of he first ideas was put forth by Erasistratus of Alexandria, who dissected animals and humans (probably Egyptian mummies) 2,300 years ago. He discovered the veins, arteries, and nerves, and postulated that the heart is nothing more than their junction and that the arteries contain not blood, but air, spirit, or soul (called pneuma). This entered the body through the nose.

Parts of this idea were reconfirmed, but many more were challenged and disproved. The great physician of the Roman Empire, Galen, confirmed that veins contain blood, but did away with the idea of pneuma. He saw that the heart is more than a "circulation junction" and that blood flows throughout the body, but believed it ebbs and flows with the heartbeat. Galen was such a great influence upon the medical world that his ideas became "medicine" . They were codified, made rigid, and acknowledged as the "limit" to medical information.

Cardiovascular diseases (CVD) - which encompass events such as heart attack, stroke, angina pectoris, atherosclerosis and arteriosclerosis, and high blood pressure - are the No. 1 killer in North America. In the United States, somebody dies from heart disease every 33 seconds, and from a heart attack every minute. In Canada, in 1992, CVD accounted for 38 percent of all deaths.

The Renaissance saw the first revolt against the dogmatic rules that Galen's ideas had become. The Swiss physician Paracelsus rejected much of Galen's thought and spoke forcefully against the tendency to accept Galen's ideas as truth:

"Who does not know that doctors make terrible mistakes, greatly to the harm of their patients? Who does not know that this is because they cling too anxiously to the teachings of Hippocrates, Galen . . . "

For daring to challenge the status quo, he was condemned to a nomadic existence, traveling from town to town.

Andreas Vesalius, born in 1514, continued the challenge to the medical status quo. He compiled the complete anatomy of the human body and, in doing so, discovered and exposed more than 200 errors by Galen. In undermining much of this medical authority, he became controversial at best, and a pariah at worst. He was attacked by many of the pro-Galen forces and retired from academic pursuits embittered and disillusioned.

William Harvey, known as the grandfather of cardiology, drove a stake into the heart of the old school of cardiology. He understood that the heart and blood are elements within a closed system, described correctly how blood flows through the heart, and saw that the heart is the engine that pumps blood. He saw that the heart, lungs, and blood vessels are interdependent and that what we call heart disease may actually originate somewhere other than the heart, especially in the arterial systems.

A common thread that runs throughout this brief history (and, as we shall see, continues today) is that ideas become a rigid status quo (often through no fault of the ideas' originators) and that when they are challenged, the challenger is repudiated, discredited, and often driven out. It is reported that even Harvey, after publishing his ideas, suffered an immediate decline in number of patients because of his "strange theories."

"Strange theories" . . .
The notion that new ideas are "strange theories" continues in modern times. In the '60s and '70s, Nathan Pritkin was persecuted as a quack and incompetent rebel when he concluded that most heart disease is reversible through a combination of diet, exercise, and stress management. The medical profession was relentless in its criticism, accusing him of giving patients false hope and defrauding them by selling them his program of lifestyle changes ot prevent heart disease.

The 1960s saw another alternative opinion shot down by the medical community. Kilmer S. McCully, M.D., then a professor of pathology at Harvard University Medical School, went against the "killer cholesterol" tide when his studies pointed to an amino acid, homocysteine, as a major cause of heart disease.

McCully had come across research that noted that some mentally retarded children were dying of heart disease before reaching puberty, and the reason was due to high blood levels of homocysteine. In 1969, after studying this issue, McCully proposed that many Americans suffer from cardiovascular disease due to high homocysteine levels, not cholesterol. More radically, he proposed that all one has to do is take B-complex vitamins to solve this problem.

McCully's Theory
One drawback to the "cholesterol is king" theory of cardiovascular disease (CVD) is that many people with no risk factors suffer from heart problems.

Indeed, an article in the June 26, 1996, issue of the Journal of the American Medical Association notes that the traditional CVD risk factors (age, genetics, gender, smoking, blood pressure, cholesterol, sedentary lifestyle, diabetes, weight, stress) only explain about 50 percent of all CVD. The amino acid homocysteine may be the reason.

Homocysteine is formed when the body breaks down protein, especially the protein found in meat. Meat protein contains the essential amino acid methionine, and when methionine is digested, it produces homocysteine. According to McCully's theory, if homocysteine levels increase, the result is the buildup of plaque, which, of course, may lead to atherosclerosis, heart attacks, strokes, and death.

Homocysteine builds up if we eat too much meat or do not get sufficient amounts of vitamins B6 and B12 and folic acid. These three vitamins are integral in the process of recycling and excreting homocysteine. If we do not have sufficient amounts of these vitamins, homocysteine levels rise.



For the next few years, McCully struggled against the cholesterol tide and in 1978, had to leave Harvard. In his book, The Homocysteine Revolution, he notes that hew was told he had "failed to prove his theory."

Become Mainstream
Pritkin and McCully, like Vesalius and Harvey before them, were proven correct. In the late '80s, Surgeon General C. Everett Koop took the bold step of reversing decades of medical thought when he declared that 75 percent of the deaths in America are caused by lifestyle decisions on diet, smoking, and consumption of alcohol. Today, the National Heart Association publishes a list of dietary recommendations that echo Pritkin's earlier conclusions.

McCully was also vindicated. Articles on homocysteine began reappearing and, in 1995, studies in the Journal of the American Medical Association reported that homocysteine is a major risk factor in CVD. Today, homocysteine is considered an independent risk factor - it is not influenced by other factors, such as smoking, cholesterol, and physical activity. It is also acknowledged that adequate amounts of vitamins B12 and B6 and folic acid can reduce high homocysteine levels and lower the risk of CVD.

Today, there is more and more emphasis on lifestyle as the key to cardiovascular health. Virtually all heart organizations acknowledge that diet and exercise are keys in preventing heart disease and recommend a diet that is low in total fat, saturated fat, and cholesterol and rich in fruits, vegetables, and fiber.

The paradigm changes
The paradigm underlying these new ideas is that we are responsible for our health. If bad lifestyle decisions are responsible for 75 percent of the deaths in America; if most heart disease is reversible through a combination of diet, exercise, and stress management; if nutrition combats high homocysteine and cholesterol levels, it means that we have it in our power to control our health destiny. We do not have to wait until the crisis and then rush to the doctor or hospital; we can take steps to lower our risk of, and prevent, CVD.



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