I want you to make a fist and hold it just to the left of the centre of your chest. Just under your ribs, is an organ, around that size, which will beat around 3 billion times in your lifetime pumping blood around the 100,000 miles of vessels that supply every part of your body.
The heart is a miraculous product of evolution, and one which plays a role more critical in the fact that we are alive, and the fact that we could die – than any other organ in our body. Perhaps unsurprising therefore that even with our advances in medical science, cardiovascular disease remains the largest single health burden to humanity, contributing to over 30% of all deaths worldwide and costing the global economy over $1 trillion each year.
The primacy of this organ has stimulated some of the finest art, literature and philosophical reflection of our society but we have yet to give the diseases of the heart the cultural, social and political significance they deserve.
To understand more about the reality of cardiovascular disease, I spoke to two of the world’s most preeminent cardiovascular physicians, Dr. Haider Warraich (Author of: State of the Heart, Exploring the History, Science and Future of Cardiac Disease) and Dr. Sandeep Jauhar (Author of: Heart: A History)
As a physician, writer, and clinical researcher, Haider Warraich wears many hats that have come together in his new book, State of the Heart – Exploring the History, Science and Future of Cardiac Disease (St Martin’s Press/Macmillan).
The book is unlike other books written about heart disease in the past since it doesn’t just focus on the history of heart disease, it touches on aspects that few have addressed. This includes growing knowledge about heart disease in women, which remains a blind spot for other contemporary books in this area. The book also explores the close relationship between two of humanities’ greatest killers – cancer and heart disease – how they are connected and how they differ. Most importantly, while heart has long been referred to as organ which is the first to live, and the last to die – primum vivens ct ultimum moriens – this books delves into the implications of a brave new world, where technology might as well make the heart redundant. This book tells the story of the brave men and women who live with hearts that can stop at any given moment, who may need engineers not doctors when they fall sick, and what their lives mean for the rest of us as we look to a future where man and machine may become one.
He writes most frequently for the New York Times but also contributes to the Guardian, the Atlantic, the LA Times and the Boston Globe amongst others. He writes about all things that fall within the purview of healthcare, from health policy to the daily interactions between patients and their physicians.
Dr Warraich completed internal medicine and cardiology training at Beth Israel Deaconess Medical Center, Harvard Medical School and Duke University and will be the Associate Director of Heart Failure at the Boston Veterans Affairs Hospital, Associate Physician at Brigham and Women’s Hospital and Instructor at Harvard Medical School in the Fall of 2019. He has appeared on CNN, Fox, CBS, PBS, and on NPR shows like Fresh Air with Terry Gross, The Diane Rehm Show, The World, Marketplace and the BBC World Service.
Dr Warraich is also a prolific clinical researcher and has published in the New England Journal of Medicine and Journal of the American Medical Association amongst others. His research focuses on end of life care for patients with heart disease.
Sandeep Jauhar has written three books, all published by Farrar, Straus, and Giroux. His first book, Intern: A Doctor’s Initiation, was a national bestseller and was optioned by NBC for a dramatic television series.
His second book, Doctored: The Disillusionment of an American Physician, released in August 2014, was a New York Times bestseller and was named a New York Post Best Book of 2014. It was praised as “highly engaging and disarmingly candid” by The Wall Street Journal, “beautifully written and unsparing” by The Boston Globe, and “extraordinary, brave and even shocking” by The New York Times.
Heart: A History, his latest book, an Amazon Best Book of the Month, tells the colorful and little-known story of the doctors who risked their careers and the patients who risked their lives to know and heal our most vital organ. It has been praised as “gripping…(and) strange and captivating” by The New York Times, “fascinating” by The Washington Post, “poignant and chattily erudite” by The Wall Street Journal, and “elegiac” by The American Scholar. It was named a best book of 2018 by the Mail on Sunday, Science Friday, Zocalo Public Square, and the Los Angeles Public Library, and was the PBS NewsHour/New York Times book club pick for January 2019.
A practicing cardiologist, Jauhar is currently a contributing opinion writer for The New York Times. He has appeared frequently on National Public Radio, CNN, and MSNBC to discuss issues related to medicine, and his essays have also been published in The Wall Street Journal, Time, and Slate. To learn more about him and his work, follow him on Twitter: @sjauhar. He is represented for all speaking engagements by the BrightSight Group.
Q: Where did your fascination for the heart come from?
[Haider Warraich]: Growing up in Pakistan, I saw so many people with heart disease and having heart attacks – it felt almost biblical – it was catastrophic. At the same time, I also saw physicians doing really dramatic things to help people who had heart attacks. Unlike a lot of diseases, there wasn’t much a cultural footprint for heart disease – it’s not something you hear about on news or TV shows…. You don’t see much advocacy done around it.
It was inspiring and heart-wrenching….. and I felt like I wanted to do something – and what better way than to train to be a cardiologist?
I felt that there was so many really, really interesting and heart wrenching but also thought provoking stories of people with heart disease, and of the people who are doing everything they could to treat it, that I really felt that there is really a gap there and I wanted to be able to fill that. And what better way to do it than train to be a cardiologist?
[Sandeep Jauhar]: My interest in the heart came from three places.
I have a malignant family history of heart disease; it’s disproportionately common in South Asians for reasons we don’t yet understand. My paternal Grandfather died suddenly from a heart attack while he was having lunch, I was only 13 at the time. It affected my father tremendously and- by extension- us kids. I grew up with a fear of the heart as an executioner of men in the prime of their lives. I later came to learn that I myself, have the beginnings of coronary artery disease. I learned this in my mid-40s, and it really impelled my interest in the heart and my wish to write about it.
The heart is a fascinating machine. It beats 3 billion times in a typical human lifetime, consumes so much energy, and does so much work that if you attached a heart to a typical swimming pool – the heart would empty the pool in about a week. The amount of blood being pumped through the heart every single day of the week is just stupendous, and it pumps this blood through 100,000 miles of blood vessels in the body. Once that work stops, once the heart stops pounding, we die. We’re extraordinarily vulnerable to the functions of our heart, no other organ can cause sudden death.
I’ve also been fascinated by the advancements in our understanding of the heart – and the individuals that have conducted research (sometimes on themselves!) to advance our field to the point where we are saving millions of lives a year.
Q: Why has the heart always occupied such an important cultural role?
[Haider Warraich]: The first story we think was recorded, was the Epic of Gilgamesh – discovered on stone tablets dating back to around BC 2700. Even in that story, the heart plays a central role – a window to the human spirit.
The heart is dramatic. Many of your other crucial organs – your liver, your kidneys- do their work in bureaucratic silence. Your heart is dramatic and reacts to how you feel. If you’re scared or nervous… it beats fast… you can feel it. Your heart moves with your emotions, it quiets down when you’re about to sleep, or when you’re relaxed….
It is this dramatic connection between what the heart does, how it functions and how you can really sense it with you and changing with how you feel that’s really made it central to not only our scientific endeavours but really our poetic and metaphorical endeavours as well.
Diseases of the heart are sometimes thought of as forgotten diseases, which is ironic as they still kill more people than any other condition on the planet… and are on the rise in some of the largest countries in the world like China, India, Pakistan and Indonesia. The number of people dying of heart disease is increasing in practically every country that adopts what is sometimes referred to as a ‘Western’ lifestyle.
Heart disease is not just a disease of our past, it’s very much a disease of our present and future – and it’s interesting therefore that it doesn’t get the same amount of attention as other conditions.
There is also a huge cultural misconception that heart disease is the patient’s fault, they did something wrong to themselves. In some cases yes, it’s true that lifestyle can increase the risk of heart disease, but there many cases where that is not the case – and when we blame individuals and not the society that created those risk factors and behaviours, we don’t react as forcefully as we could.
[Sandeep Jauhar]: The heart is at the centre of our body, and is the only organ that discernibly moves. Perhaps it was this that tipped our ancient philosophers and thinkers off to the idea that it was pretty important. As to the reasons why the heart has assumed metaphorical and emotional significance? That remains unclear. What we know is that ‘cardioid’ heart shapes are common through nature – it also resembles the seed of the plant Silphium Perfoliatum which was used for birth control in the middle ages; perhaps adding to the significance of the heart as a symbol of love and sex.
We do know that it has assumed a very significant meaning in psychology, in human thought, human culture, religion. The sacred heart of Jesus is a very strong symbol of monastic love… we understood its biological significance early in culture, and we certainly thought of it as a highly metaphorically significant object.
Q: What is heart disease?
[Haider Warraich]: It is because we use a generic term like heart disease that we can see how little we really understand it in the public realm. Today, heart disease kills more people than any other people on the planet – and in most cases, this is because of a maladaptive, pathological process in the body called atherosclerosis (the slow build-up of cholesterol filled plaques in your blood vessels) which can start at any point when you are an adult or preteen. It’s a really slow process, and takes a long time to build up – and the resulting blockages can affect blood vessels in your limbs, your brain, and- crucially- those supplying oxygenated blood to your heart. You could then have a catastrophic event that results in a rupture of one of those plaques – a thrombosis – caused by anything from inflammation to illness. As soon as that plaque ruptures, the body tries to form a clot – and this causes a total occlusion. Most heart attacks occur when a plaque, full of cholesterol, ruptures- and the body forms a clot – obstructing blood flow to part of the heart, causing it to die-off and thus, cause a heart attack. This is the same process you see for many strokes.
Lots of patients I see have very bad disease in the blood vessels of their legs – it’s the most common cause of amputations in high income countries and is more commonly known as peripheral arterial disease.
The other disease we have seen emerging is heart failure. This can be thought of as a common final pathway for diseases that prevent the heart from supplying the body with oxygenated blood, or drain the blood that’s been sapped of oxygen (so it doesn’t pool in your legs, your belly or your lungs). When the heart is unable to perform these tasks, we cause it heart failure – and we’ve seen that increase in prevalence around the world because we’ve become so adept at helping people survive conditions like heart attacks. We are able to help people live long enough so that they actually reach the phase where the heart is in this chronic condition!
Evolution may well have laid the foundations for us to have heart disease, but our society does everything in its power to test the limits of the heart through our diet, lack of exercise, smoking, stress and more.
Q: Do people understand the significance of heart disease?
[Sandeep Jauhar]: Heart disease is still the number one killer in the world, it’s the grand daddy of all disease and has maintained this position for the last century at least. Arterial disease is the largest cause of suffering in the world… heart failure, stroke, all of these things stem from that…
Q: Is there a link between our heart and our psychology?
[Sandeep Jauhar]: We know that acute and chronic emotional disruption can significantly affect the heart. We know the heart feeds-back with the brain and can cause anxiety and stress in and of itself. For example, if you have a heart arrhythmia, you can become anxious. Chronic and acute emotional stress can weaken the heart – and we have seen that grief can itself cause heart failure and cardiac death. Studies of tombstones in Europe suggest that spouses very often die within one year of each other, and that’s probably related to emotional disruption. There is a very strong link between the heart and psychology…
Q: Can we treat heart disease?
[Haider Warraich]: In the vast majority of cases, heart disease is not only treatable but preventable. The question is this; are we doing a good-enough job of getting to the people who need therapies and preventions. Heart disease isn’t like Alzheimer’s or some metastatic cancers where we are waiting for this breakthrough therapy; we have already developed many of the medicines and strategies to be able to help patients.
Here’s the thing, in the last few years in the United States, even with all the therapies we have – the prevalence of heart disease is going up. This means it has turned from a medical issue into a health policy and economic issue. Some of the great breakthroughs for heart disease cost pennies, and you can pick them up from any store or order them from Amazon! We are also seeing a lot of fake news and misinformation around common therapies such as statins – meaning we have difficulty getting patients to take these life-saving therapies
There’s also an attitude issue with regards to heart disease – people think of it as a ‘noise from your car engine that needs fixing at some point…’ rather than the way they think of cancer, which is akin to someone carjacking you.
Q: How well do we understand the heart?
[Haider Warraich]: We understand the heart about as well as any other single organ in the human body because so many people have invested their time, imagination and creativity in trying to figure out the heart and overcome its maladies. The big challenge we have is to make sure that the population understand the heart, and understand how it works, and how to maintain it!
Q: What can we do to prevent heart disease
[Haider Warraich]: Some of the things we can do to reduce the risk of heart disease are very simple. We have to stay active, ideally incorporating around 30 minutes of aerobic exercise into our daily routines…. We have watch how much we eat too – if you’re overeating any nutrient, whether protein, fat or carbohydrate, it can cause challenges for your body. The other obvious low hanging fruit is to stop people from smoking – especially in countries where smoking figures are on the rise like China, India and Pakistan.
Q: Have we extended our lifespan to the limit of what the heart can cope with?
[Sandeep Jauhar]: The question about whether humans can live longer than around 100 years is a hugely fertile research area. Some people think the 100 year limit is rather arbitrary, but we know that very, very few people live over 100 – it’s somewhat like an end-point is programmed into our genes.
I do know that arterial disease starts relatively early. If you do autopsies of young adults, they often have the beginnings of coronary disease – we know that from the studies of soldiers autopsied during the Vietnam War and find that even today, a significant number of adults aged 16-64 have the beginnings of cardiovascular disease.
When you think about the heart you have to think about death, because the heart is not just an organ of life, but it’s also the primary organ of ending life.
Q: What are the frontiers of research we need to cross in relation to the heart?
[Sandeep Jauhar]: There is a thought that perhaps we’re reaching the limits of what scientific medicine can do to fight cardiovascular disease. We have amazing drugs, we have angioplasty, bypass surgery, heart transplants, pacemakers, defibrillators and the mortality from heart attacks has dropped tenfold in 50 years…. How much lower can we go?
I think the next frontier is exploring the link between the heart and brain. We need to understand how psychology and heart interact at a personal, social and population level. We need to make as much progress in this area, as we have in the scientific medicine of the heart.