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.
N.B. For an excellent analysis of Everyman I suggest Nadine Gordimer’s 2006 NYTimes piece.