Recently, the skeptical cardiologist serendipitously found a small, hard-back book written by Philip Roth entitled Everyman in a used bookshop adjacent to the public library in Encinitas.
Prior to Roth’s death from heart failure at 85 in 2018 I had not read any of his work. However, upon reading his obituary I realized that I needed to fill that lacuna in my literary knowledge and since then I’ve read and greatly appreciated several of his novels.
Everyman, written in 2006, deals with death, aging and illness in typical Roth fashion.
To my wonder and surprise, the unnamed protagonist goes through one cardiovascular procedure after another without raising any significant questions for the physicians recommending and/or performing the procedures. Most of these operations were likely unnecessary and all of them were performed without a significant trial of medical therapy or even a minimal discussion of risks and alternatives.
Although the book was written in 2006 and there have been many changes in our understanding of optimal cardiovascular care since then there is much that everyman (and woman) can learn from the mistakes that the protagonist, aka everyman, made which ultimately led to his demise.
Thousands of patients to this day undergo similar unneeded risky cardiac tests and surgeries. Let’s look at some of the cardiovascular myths and patient errors that are revealed in Everyman.
I can’t get cardiac problems because I live a healthy lifestyle
Everyman begins at the funeral of the protagonist who suffered a cardiac arrest at age 71 years, an event which complicated the last of many (arguable unnecessary) cardiovascular surgeries he underwent. From here the narrator chronicles everyman’s life, focusing on the events and people surrounding the major health issues he suffers as he ages.
For twenty-two years after a burst appendix complicated by life-threatening peritonitis, initially misdiagnosed as a psychiatric problem but ultimately treated with surgery, everyman experiences excellent health and lives an exemplary lifestyle.
He swims on a daily basis but one day notes that “he couldn’t finish the first lap without pulling over to the side and hanging there completely breathless.” As he ponders possible causes he finds it preposterous that he could develop severe cardiac disease because he has had a “lifelong regimen of healthful living”, free of smoking, excess drinking and obesity and full of vigorous exercise in the form of swimming.
This is a common misconception and on a daily basis, hundreds of individuals needlessly die suddenly because they feel invincible. A healthy lifestyle improves your odds bu many who have inherited powerful risk factors, cannot overcome the cardiovascular cards they have been dealt.
For those at high risk due to family history of heart disease proactive diagnosis of subclinical disease using advanced biomarkers and imaging is warranted.
Once subclinical atherosclerosis is identified (by a test such as a coronary artery calcium scan) or markedly abnormal lipoproteins are noted, the inherited silent premature build-up of atherosclerotic plaque can be halted by the remarkable therapeutic tools available to preventive cardiology thereby preventing the need for stents, bypass surgeries and other vascular procedures.
Be Aware of False-positive ECGS
Alas, when everyman sees the doctor the next morning “his EKG showed radical changes that indicated severe occlusion of his major arteries.”
In reality, an outpatient electrocardiogram in a patient with everyman’s presentation rarely makes a clear-cut diagnosis of severe coronary artery occlusion. His symptoms of shortness of breath on exertion relieved quickly with rest are more compatible with stable angina and this disease we now know is best evaluated as an outpatient.
Abnormalities on ECGs are frequently false-positives, thus ECGs are frequently read as showing old heart attacks in patients with totally normal hearts. This is why a screening ECG performed on someone without symptoms is a bad idea (see here.)
Emergent/Urgent Invasive Angiography Only Warranted for Acute Heart Attack
In 1989, in New York (and most of America) the typical approach to a patient with shortness of breath and an abnormal ECG was to hospitalize them and perform an invasive angiogram (aka a cardiac catheterization) to directly look at the coronary arteries.
“Before the day was out he was in a bed in the coronary care unit of a Manhattan hospital having been given an angiogram that determined that surgery was essential.”
The risks of the invasive angiogram are significant and include death, stroke, heart attack, arterial bleeding (see here)
Since 1989 it has become abundantly clear that we don’t need to rush into doing the cardiac cath unless the patient is having an active, acute heart attack.
Avoid the Rush to Cardiac Surgery
In many of the hospitals I have worked at over the last 30 years, patients like everyman were not only rushed off for their cardiac catheterization with little discussion but as soon as the diagnostic procedure was completed they were told they needed to be rushed off to cardiac bypass surgery.
Barring evidence of an acute heart attack, it is rare that a patient’s condition requires such urgency.
There are very few individuals who have the temerity to question pronouncements as they are often told this is their only choice.
Roth’s everyman never questions anything the doctors recommend to him. He never asks for a second opinion.
“The only question was should the surgery be performed immediately or the next morning.”
The next morning everyman undergoes a 7-hour open-heart bypass operation. Upon awakening, he learns he has received five grafts and has a “long wound down the center of the chest” and “a tube down his throat that felt as though it were going to choke him to death.”
Over the last 30 years on numerous occasions, I have stopped this mad, frenzied rush to the OR recommended by doctors (both invasive cardiologists and cardiac surgeons) who insisted that my patients needed coronary bypass surgery.
Coronary bypass surgery is preferred over medical therapy in some situations (most clearly >50% stenosis of the left main coronary) but in 2022 we know that the majority of patients with severely blocked coronaries can be treated successfully with aggressive medical therapy.
Think Twice Before Having Other Vascular Procedures: Medical Treatment Is Advancing
In 1998, when everyman was 65 years old his high blood pressure “would not respond to changes in medications.” and the doctors “determined that he had an obstruction of the renal artery.” Again, without any discussion of risk or benefits he underwent angiography of the renal artery, and “the problem was solved with the insertion of a stent that was transported on a catheter maneuvered up through a puncture in the femoral artery and through the artery to the occlusion.”
Until large randomized trials of this renal artery stunting procedure were performed in the early 2000s, there was enthusiasm for it as a treatment for difficult to control hypertension.
By 2014 several large trials had shown no benefit of renal stenting over optimal medical therapy in mortality, BP control, or kidney function.
The Final Procedures
Everyman goes on to have surgery (a carotid endarterectomy or CEA) on an obstruction in his left carotid the next year. In subsequent years he has multiple coronary stents implanted.
In the second part of this post I’ll write in detail about carotid surgery and whether everyman’s death during his second CEA could have been prevented.
Until then, I leave you with the epigraph of Everyman which will give you a sense of what you are in for if you decide to read the novel:
Where but to think is to be full of sorrow. Here where men sit and hear each other groan; Where palsy shakes a few, sad, last grey hairs, Where youth grows pale, and spectre-thin, and dies; John Keats, "Ode to a Nightingale"
With modern medical cardiac preventive therapies and when we choose wisely the procedures we undergo I feel we can forego growing pale and spectre-thin for far longer than everyman did.
Noninvasively Yours,
-ACP
N.B. For an excellent analysis of Everyman I suggest Nadine Gordimer’s 2006 NYTimes piece.
20 thoughts on “Lesson for Patients With Cardiovascular Disease Gleaned from Philip Roth’s Everyman”
Thank you for this review and for carrying the torch, so that instead of being spectre-thin we can:
Keep walking, though there’s no place to get to.
Don’t try to see through the distances. That’s not for human beings.
Move within, but don’t move the way fear makes you move.
Today, like every other day, we wake up empty and frightened.
Don’t open the door to the study
and begin reading. Take down a musical instrument.
Let the beauty we love be what we do.
There are hundreds of ways to kneel and kiss the ground.
--Rumi
What is your opinion of the effectiveness of statins on a old guy (74) with a new stent in my leg because of PAD. Runner, non diabetic, optimal weight. If I had started statins 30 yrs ago, I can see there value but I started them 2 years ago and then developed PAD. They obviously they didn’t stop any plaque build up. Could it really be to late from them to do any good and they may cause some harm?
Great info, as always. But with respect to some of it – such as years later them concluding that renal stenting didn’t provide better outcomes – isn’t it that, similar to what you say to commenter Kim visa vis her brother, that they made the best decision (or arguably the best) with what they knew at the time?
Also, you have a typo of “female” instead of “femoral” there.
I had a cardia cath procedure that turned out to not be necessary, but I had continually high troponin levels, after being seen for angina. But they found no occlusion (20% blockage, I was 60 yoa). But it turned out I’m a very rare case of always having abnormally high troponin levels (borne out with 2 subsequent tests much later). Or at least measuring as elevated troponin. I believe due to an antibody interfering with the assay. But at the time, I understand the cardiologist choosing a cardiac angioplasty procedure. Or, shouldn’t I be so understanding?
In Dec. 2021 my brother was taken to the ER due to Afib. Enzymes showed he suffered a heart attack and a week later he had a quadruple bypass. His transplanted kidney went into failure and has never recovered function. My brother is still in an acute care facility, suffering several setbacks in his recovery. It has been an exhausting 180 mile drive nearly every day to see him and keep his spirits up. Medical staff are still optimistic he will recover, albeit without a functioning kidney. As his next of kin, I wonder now if I made the right decisions along this path on his behalf. It has been the lowest point of my life.
I am so sorry about your brother. I lost my kidneys within 2 weeks due to catastrophic lupus, had a kidney transplant 2 months later. I then needed another transplant, and at the end of the surgery, had a heart attack. I have been under excellent cardiology care at UCSF since. But then my heart decided to go into AFIB. Life changing, really. I went on amiodarone—a dangerous drug but it keeps my sinus rhythm perfectly. Since the transplants and the AFIB episodes, life has never been the same, but I still struggle to reach a strong normal.
You are a good sister visiting him. Could he try to get our of the care facility for a class of some sort? I found that a lifesaver. The more I got involved in school, the better I got.
I’m sorry you have endured your fair share of hard times as well. My brother’s care team are now working on finding the root cause of his low blood pressure. They believe that if they can resolve it, he can progress into more rehab. His low bp has sapped his energy and made it hard for him to stay motivated, understandably, so I’m hopeful that if he can just get this issue resolved he will be more motivated to do the work he needs to do and come home. Thank you for sharing your experience.
Kim,
Very sad turn of events. Very hard to know the best course to follow in such a complicated situation.
For patients with kidney disease who have not reached the point of being on dialysis, the contrast dye utilized for invasive angiograms (and noninvasive coronary Ct angiograms and other CT scans) can cause complete kidney failure thus we have to be very careful when selecting such tests. Likewise, kidney failure always raises the risk of surgical procedures and cardiovascular procedures can be particularly stressful for the kidneys.
Try not to second guess yourself as I’m sure you were relying on the best information you could obtain from experts on his case and you were doing the best you could to navigate through those tough situations.
Dr P
Thank you, Dr. P. I am not giving up hope yet that he will recover and thrive, even with dialysis. He has a strong will to get better and come home, and I encourage him daily to keep his eye on the prize. His biggest hindrance right now is low blood pressure, and they are transferring him to the main hospital for evaluation. If they can figure out the cause, he has a chance.
Female artery to access renal artery–New anatomy !!
My youth and Philip Roth. I read Portnoy’s Complaint more than 50 years ago. And of course, Goodbye, Columbus.
What are your thoughts on ablation for A-fib?
I understand first line of intervention?!
Thank you
Evangeline,
You can find my thoughts on this website in the various articles I have written on medical management of AFIB
I believe most patients can be managed without ablation.
When a very good trial of medical management fails I discuss ablation as an option with the patient.
They need to understand the vast majority of initial ablations are not successful, that frequently medications are needed after ablation, that there are significant complications, that they will need blood thinners lifelong. They need to get a full disclosure on success rates and complications rates from the operator.
Dr P
Dr P,
You have the current situation well described here I think. The conservative approach is still best. I also believe that there are strides being made for the future. Electroporation holds the promise of treating myocardial tissue only, with no adjacent damage such as often occurs to the phrenic nerve, ganglia associated with cardiac function, and, tragically, the esophagus. The freeze-or-burn available now is tissue-indiscriminate. Nothing’s perfect, but electroporation seems better. As is so often the case, more research is needed. Thoughts?
There’s still differing opinion around the notion that rate control might be better than rhythm control – or not. Doesn’t rate control leave you in AF with associated remodeling and disease progression? Dysfunction?
I find the following article an affirmation of my personal choice of rhythm control:
https://www.medscape.com/viewarticle/970991
(Follow-up)
Pulsed Field = electroporation. New article:
https://www.medscape.com/viewarticle/972147#vp_1
Interesting and thought provoking as always so thank you for taking the time to do these pieces. Could you do a piece on options for people who have an enlarged aorta? Thank you.
Michael,
I was just working on something on the measurement of the ascending aorta which is relevant.
If time permits I’ll get that out and perhaps briefly discuss treatment.
dr P
Two great minds 🙂 I went to the Cleveland clinic years ago which was fantastic but stents were not an option, and I try to check each year for new options but I haven’t seen anything. If my hear was to enlarge I would need open heart surgery but I don’t fancy that. I was relatively young when my condition was discovered and I’m now 58 years old. I was wondering if stem cell therapy may hold some hope. Thank you Dr. Anthony.
Do you have an opinion regarding when mitral regurg. warrants a valve job? (not asking for a friend)
Steven,
When mitral regurgitation (MR) should be operated on is an incredibly complicated issue.
I can tell you that I have stopped quite a few patients from going for unneeded mitral valve surgery.
With medical therapy we were able to improve LV function which in turn improved or eliminated the MR.
MR can develop with atrial fibrillation and is often reversible with maintenance of sinus rhythm.
The severity of MR is often overcalled from echocardiograms.
I have lots of opinions on MR. I have seen lots of patients undergo inappropriate valve procedures.
Dr P
My cardiologist isn’t telling me I must have it NOW, but he’s clearly uncomfortable. My (twin) brother had a mitral annuloplasty about 13 years ago and in his words has “never been the same”. Hoping for a viable trans-catheter solution before I become symptomatic.