Advances on heart disease bringing new problems

Published: Sunday, January 19, 2003 at 6:01 a.m.
Last Modified: Saturday, January 18, 2003 at 9:42 p.m.
The numbers have been inching down for decades, but only lately have doctors begun to appreciate how profoundly things have changed for heart attacks and strokes.
They remain the leading cause of death in the United States, but their toll is nothing like what it used to be.
They kill proportionately fewer people and - in another major change - they strike far later in life.
Despite the obesity epidemic, the trends are continuing with no end in sight.
The stereotypical heart attack patient is no longer a man in his 50s who suddenly falls dead.
Instead, the typical patient is a man or woman of 70 or older, who survives.
Statisticians at the institute calculate that if death rates were the same as those of 30 years ago, 815,000 more Americans a year would be dying of heart disease and 250,000 more of strokes.
Dr. Eugene Braunwald, a cardiologist who is the chief academic officer at Harvard Medical School's Partners Health Care System, said the reductions in the death rates were "one of the great triumphs of medicine in the past 50 years."
But these triumphs have brought new problems. Many more men or women in their 70s and 80s are surviving heart attacks only to live on with severe heart disease.
"These people aren't cured," Braunwald said. "They are maintained alive. We have converted heart disease from an acute illness to a chronic disease."
"People talk as if the stopping of dying from heart disease is always a good thing," said Dr. Joanne Lynn, who directs the Washington Home Center for Palliative Care Studies.
"That may be true if you are talking about a heart attack in a 45-year-old man," Lynn said. "But if you are talking about an 85-year-old man, what is often left is frailty and dementia. Is it worth it?"
The plunging death rates have come about for an array of reasons - new drugs, new treatments, changes in behavior. The incremental advances have added up.
Thirty years ago, there were no good ways to lower cholesterol. Now there are pills, cholesterol-lowering drugs called statins. Tens of millions of Americans are taking them.
A more important factor, said Dr. Lee Goldman, a professor or medicine at the University of California at San Francisco, is that treatment for heart attacks has changed radically.
Now, doctors give drugs to heart attack patients to dissolve blood clots, opening blocked arteries. They operate, with much better surgical results. Recently, device makers developed implantable defibrillators that can shock a fluttering heart into beating steadily, preventing death in patients with damaged hearts.
"That death rate is so low now that we're no longer able to track it," said Dr. Teri Manolio, director of the epidemiology and biometry programs at the National Heart, Lung and Blood Institute. "It's almost gone."

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