Book Review...
The Heart of the Matter
Jesse Pittsley, PhD
“Unfortunately, the great disappointment of cardiology in the
1970s, 1980s and 1990s was that although the technology did save lives,
it didn’t work quite as well as it should have. Something was wrong.
Some piece of the puzzle was missing. All of the lifestyle stuff
– stop smoking, exercise more, change your diet – was based on the epidemiological
features of heart disease. It didn’t explain the biological processes
of heart disease. Everyone thought that the biological characteristics
were key to understanding heart attacks. But the biological features
weren’t making much sense.” -- Peter Salgo [1, p. 48]
Overview
Peter Salgo has experience on his side. He has practiced anesthesiology
and internal medicine at Presbyterian hospital in New York City for over
two decades. Along with his medical practice, he has worked for the
CBS television network to anchor the program America's Vital Signs,
has worked as a medical correspondent for CBS News (both radio and television),
and has taught anesthesiology and internal medicine at Columbia University.
In the process, Dr. Salgo has won numerous awards including an Emmy.
Overall, Dr. Peter Salgo is a rare combination of practitioner and communicator
who has the special gift of making the complicated understandable.
I stumbled across an interview with Dr. Peter Salgo while listening
to my local national public radio station. I was so impressed with
his ability to present an argument and with the content he was attempting
to share. I ordered his book the very next day. Admittedly,
I find scientific commentary on radio a little too exciting. Despite
that, I rarely fall prey to impulsive purchases on the premise that somebody
speaks well. We all know there are countless PhDs and MDs spending
their release-golf time pumping out page after page of opinionated material
with the hopes of producing the next diet, herbal, exercise, or pharmacological
craze. We cruise by these books when browsing bookstores. Occasionally,
the books contain solid arguments and valid points. But often, we
wish the author would have skipped writing the book and spent more time
with his or her family. Regardless, it is my opinion, Dr. Peter Salgo’s
book The Heart of the Matter is a step above those books.
The Risk Factor Hypothesis
While working in an intensive care unit, Dr. Salgo admitted to being
consistently perplexed that a strong percentage of those experiencing heart
attacks had shown no symptoms or gradually increasing angina prior to having
the myocardial infarction. This was a distinct collapse in logic
when viewing heart disease through its most popular model. The dominant
perception for decades was that heart attacks were caused by calcified
obstructions in the coronary arteries. Years of smoking, high fat
diets, inactivity and a genetic susceptibility caused the gradual accumulation
of plaque until the heart’s ischemic screams could be ignored no longer.
At this point the person was rushed to the hospital where he/she either
experienced an angioplastic crushing of the calcification, bypass surgery,
or death. Interestingly, if the person did survive, there was still
a strong possibility another heart attack would occur despite the clearing
of the coronary arteries. Therefore one must question, why is the
person having another heart attack if the obstructions have been removed
from the coronary arteries?
This must have drove cardiologists crazy! How could a person feel
good or even great (with no angina) right up to having heart attack?
How does our Uncle John progress from playing tennis and running road races
all his life to laying in the back of an ambulance fighting for his life?
Furthermore, how does a nonsmoking, normal-tensive, fit individual with
ideal cholesterol and no angina drop dead of heart attack? Salgo
epitomizes a physician's response to this problem rather well by writing
the following.
“In response, the doctor would most likely to do his best wide-eyed
impersonation of Ralph Kramden: ‘Hamana-hamana-hamana.’
Translation: ‘I don’t know.’” [1, p. 39]
The Framingham study, and other studies like it, provided strong statistical
relationships between hypertension, smoking, obesity, high cholesterol,
and heart attacks. Unfortunately, these have been correlational but
not causational findings. For years, healthcare professionals have
preached the importance of eliminating these risk factors. Not because
scientists knew the exact relationship between risk factors and heart attacks,
but only because the numbers hinted there was one. Hence, all the
health nuts in the world could be heard screaming for better diets and
more exercise. But all that screaming could be made quiet if somebody
simply asked those individuals to explain how high cholesterol or smoking
exactly caused heart attacks.
An Eureka Moment
Early in the book, Dr. Salgo describes an important experience in his
evolution towards understanding heart disease [1, p. 34]. One night,
while working in an Intensive Care Unit, a 60 year-old man arrived clearly
having a heart attack. The patient was rushed to the cardiac catheterization
lab for an angiogram. After the dye injection, it became clear that
the patient indeed had an obstructed artery. But, what happens next
is even more interesting. As the physician injected more dye the
clot moved and the artery opened. Those in attendance concluded they
had seen a coronary thrombosis, that is, “a big gelatinous blob” (not a
calcified particle) that the dye had pushed out of the way. Salgo
admitted he had never seen this before. The attending cardiologists
said they had seen such an interesting site, but none had an answer for
it or how it might have occurred. As a result, Salgo began to ponder
that something besides hard calcifications caused heart disease and heart
attacks.
Another important advancement came while Salgo was attending a conference
for the American Diabetic Association at the Cleveland Clinic [1, p. 56].
At the conference, a cardiologist, Dr. Steven Nissen presented research
on a substance called “soft plaque.” Nissen used intracoronary ultrasounds
to find fatty deposits in the coronary vessel walls. This technique
was not designed to examine the actual blood vessels but instead to examine
their walls. In other words, using the analogy presented by Salgo
[1, p 58], the technique investigated the doughnut not the doughnut hole.
Nissen found that 60% of the subjects between the 30 and 69 had soft plaque
(i.e., cholesterol and other substances) in their coronary vessel walls.
The build-up was not necessarily causing a decrease in vessel diameter,
but a bulging “out” of the vessel walls. Consequently, the blood
flow was not significantly impaired and therefore induced no angina.
It started to become clear to those in the medical profession that heart
disease was an inflammatory condition that progressed over years.
Some people, with hard, calcified plaque would experience a progressive
angina until the inevitable heart attack. Others would show no hard
plaque, but instead would gradually accumulate soft plaque in the arterial
walls that potentially lead to a thrombosis and a hyper blood-clotting
immune response and the classic sudden heart attack. Medicine had
created diagnostic and treatment procedures for the first, but that latter
was slightly more complicated. Salgo explains in his book [1]
that coronary ultrasounds were primarily a research tool and, presently,
too difficult for daily medical practice. The other condition was
more subtle and difficult to detect. Salgo does a nice job of outlining
a model for heart disease that does not involve progressive angina and
is paraphrased here [1, p. 61].
Step One: Cholesterol in the blood works it way
to the coronary blood vessels where soft plaque begins to form.
Step Two: Certain bacteria enter the soft plaque.
Step Three: Through an inflammatory response the presence
of fatty deposits and/or bacteria causes other substances to enter the
site and enlarge the vessel wall. In time, as the immune cells
‘chew’ away and the bad guys and the blood vessel version of a boil forms
on the wall. Eventually the “puss” inside the boil leaks into the
vessel where the blood is exposed to all the remains of this battle lasting
decades. This thrombogenic substance potentially induces a severe
clot that induces the cardiac ischemia and the heart attack.
Considering the common arguments presented by the author that lowering
cholesterol and improving diet do assist in preventing heart attacks, procedures
such as angioplasty and bypass surgery do not solve all the problems.
With this stated, the purpose of this book was not to examine heart disease
but to explain how to prevent the disease from prematurely ending lives.
The author explains three primary things people should do. One involves
aspirins. The second is about statins, and the third
requires an understanding of antibiotics.
Aspirin
Dr. Salgo starts the chapter on aspirin by simply stating, “We’re going
to talk about aspirin because it’s simply the most amazing drug you can
imagine.” [1, p. 64] Derived from the chemicals found
in willow bark, aspirin has been used for centuries for pain relief.
Luckily, a German scientist named Felix Hoffman, of the Bayer Corporation,
identified its active chemicals around the turn of the 20th century.
This accelerated the conversion of aspirin to its pill form and has, fortunately,
prevented humans from wandering around forests and gnawing on willow bark
during bouts of fever.
Aspirin has been a recommended treatment for heat disease for a couple
decades. Dr. Salgo shares a story when he asked a cardiologist what
would the first thing he would tell a person who was having a heart attack.
Salgo expected to hear something like “tell the individual to call an ambulance.”
Instead, the cardiologist said, “I’d tell him to take an aspirin.” [1,
p. 68]
In the realm of heart disease, aspirin is traditionally identified as
a blood thinner. It serves as an anticoagulant by inhibiting blood
platelet formation. Platelets, stimulated by vascular injuries, are
thus prevented from forming and appearing in the coronary arteries.
This pharmacological mechanism makes aspirin a valid acute and, interestingly,
a chronic treatment for heart disease. There is also long-term evidence
to support this view. So, one could ask, if aspirin is only a blood
thinner, how does a daily ingestion prevent heart attacks? If it
worked only for its anti-platelets pathways, why prescribed the more powerful
anticoagulants. Odds are that something else is going on.
It appears that aspirin is also an anti-inflammatory. This has
been evident over the years in its treatment of the shivers and chills
associated with high fever and also the treatment of rheumatic fever (an
inflammatory condition) [1, p. 74]. If this is true, then aspirin
could be considered a drug that fights both ends of the condition.
First, it fights the reason for the platelets arriving (the inflammation)
and platelet formation (the anticoagulant). It is not clear why it is a
unique medication in this regard. Salgo sites similar durgs, such
as acetaminophen (Tylenol) which is not as effective in fighting heart
disease [1, p. 79]. Despite not knowing the exact pathway,
Salgo argues that aspirin is too valuable to not make it part of the general
heart disease prevention plan used by the majority of American. Salgo
states that evidence is still mounting that aspirin fights inflammation,
and he states, “. . .I must add a caveat here. The empirical evidence
for a primary protection is very new, but the data we have so far are powerful
and quite convincing.” [1, p. 75]
Statins
Regarding cholesterol and statins, Salgo states, “Why should a cholesterol
level in the low 200s be considered normal if people with these numbers
are still dying of heart attacks at alarming rates?" [1, p 93] He
has a point. If high levels of cholesterol cause heart disease, then
why would somebody want to be normal in a country full of fat people who
eat diets swimming in cholesterol?
Salgo doesn’t want a country with cholesterol values of 200-210.
He doesn’t even want them around 190. He’s shooting for real
change by getting values in the 170s (~ 80 for LDL). Unlike
his aspirin recommendation, which is arguably a relatively common intervention
used in the American population, Salgo’s approach toward cholesterol is
substantially more radical (and he sells it well).
Salgo reflects upon his early days in medicine as a 26 year-old intern.
He recalls treating patients like “naughty children” who he instructed
to eat nearly fatless, saltless, and nothing good diets to improve their
health. Regardless of his ranting, patients still ate the french
fries and ice cream. Who blames them! Fast food is cheap, accessible,
and satisfying. Salgo describes being frustrated with his patients.
Finally, though a combination of maturation and compromise, he accepted
that such changes were not always possible.
Salgo argues that, even through the traditional intervention of proper
diet and exercise cholesterol can only be lowered roughly 20%, (and that
some individuals may do everything right and still have high cholesterol
levels), statins may be the answer. Very simply, statins (brand names
of Zocor and Lipitor) are chemicals that shut off part of the cholesterol
manufacturing process. Salgo identifies six types of statins commercially
available with atorvastitin and simvastatin being the most cost effective
[1, p. 98]. He argues that most individuals need to include statins
in their heart disease prevention plan.
Placing statins in the class with multivitamins (and possibly aspirin)
is a radical idea in most minds. Listing a prescription medication
on everybody’s “to do” list may rank up there with seat belts in terms
of large-scale American changes. To support this sweeping change,
Salgo states that statins are effective by writing, “The bottom line on
statins is that they are truly miraculous drugs. Before statins we
[medical professionals] had the ability to wiggle your blood lipid level
maybe 10%. Statins do that without even taking a deep breath.
With statin therapy we can affect your blood lipid levels by 30% of so,
perhaps even more.” [1, p. 106]
Of course the question is still, even with statins lowering cholesterol,
"Does a low cholesterol prevent heart disease?" This is a great question
even though Salgo gives it a free pass. Throughout the chapter on
statins, he provides a couple research examples where those taking statins
had less frequent heart attacks [1, pp. 100-102]. Although very convincing
examples were stated, Salgo did not go into great detail about the relationship
between heart disease and cholesterol.
Another valid concern is whether statins are tolerated by those using
them. To answer this question, Salgo sites studies that show
that about 96% of the people who begin statin therapy are able to keep
taking the drug after one year. He further adds, “The truth is, almost
any drug, any therapy, will have a lower tolerability rate than 96%.
You could recommend a daily dosage of prune juice, and you’d likely find
less than 96% of the population could tolerate it for a full year.”
[1, p. 107]
Overall, if one accepts the relationship between heart disease and cholesterol,
Dr. Salgo does a nice job or arguing for the inclusion of statins in a
common heart disease prevention plan. He feels so strong about statins
that he finishes the chapter by writing, “You can divide all of cardiology,
all of medicine, into two eras: the era before statins and the era
after statins.”
Antibiotics
Just when I thought I wasn’t going to read anything else that was going
to surprise me. Dr. Salgo presents a chapter on the relationship
between infection and heart disease. He starts the chapter by stating
that bacteria infection causes heart attacks in some people and that there
growing percentage of the medical community that is beginning to accept
this theory. Therefore, if some heart attacks are caused by bacteria,
then giving people antibiotics may prevent some heart attacks.
Twenty years ago, physicians felt ulcers were directly caused by stress
and bad diets. To fight ulcers people needed an extended vacation,
an easier job, and a yoga class. Presently, as Salgo states,
“ulcers are caused by infectious disease, specifically a bacterium known
as H. pylori which is exacerbated by stress and spicy foods” [1, pp. 108-109].
So, if the two martini lunch didn’t exactly cause the ulcer, one could
raise the interesting question: "What other ailments are caused by
bacteria?" You guessed it; Salgo believes heart disease is one of
them.
The culprit appears to be the bacterium Chlamydia pneumoniae.
Not to be confused with the sexually transmitted disease, C pneumoniae
is found in the lungs and also estimated to be in 50% of human (and more
often in men). Furthermore, it is more common in those who smoke.
The bacterium is inhaled in the body and, unlike the flu and a cold, does
not make you feel rotten. It can sit in a host for years without
anyone noticing. But according to Salgo, that does not mean it is a placid
organism. Salgo states that between the years of 1988 and 1999, there
were two dozen studies investigating the relationship between C pneumoniaea
and coronary artery disease. Four of those studies were negative
and the rest were positive [1, p. 116]. Data from animal studies
suggest that the infusion of C pneumoniae accelerates heart disease.
If it is not possible to pinpoint the exact relationship between this
bacterium and heart disease, one could investigate its threat by analyzing
the presence of heart attacks when the bacterium is eliminated. Thus,
if a host is given an antibiotic that eliminates the bacterium and heart
attack occurrence decreases, then one could conclude that the two are related.
Unfortunately, Salgo was not able to reference literature that has progressed
far enough to test this hypothesis in human. Although animal modest do
suggest a relationship, the jury is still out.
Dr. Salgo states that C pneumoniaea may be the source of heart disease
exacerbation. As a result, he proposes a rather bold idea that most
Americans should undertake acyclic pattern of antibiotic treatment to regularly
clear Chlamydia pneumoniae. To start, he proposes people should walk
into their doctor’s office and ask to be treated for a possible Chlamydia
infection. Furthermore, he states that the country should develop
a national rotation for the antibiotics to avoid the overuse of a single
drug and the evolution of a “super” bacterium [1, p. 112]. So, if
you need a review of your morning routine, it is a 1, 2, 3, and 4 combination.
1. Daily vitamin
2. Aspirin
3. Statin, and
4. Antibiotic
Final Thoughts
Dr. Peter Salgo didn’t write a book with the hope of subtle changes.
His dreams are for more expansive. He wrote a book about how people
should best use modern medicine to prevent heart disease. In the
process, he developed a strong case for the use of aspirin, statins, and
antibiotics for the long term prevention of premature heart disease.
The tone of this book is not of one attempting to sell products.
Salgo does not appear to be a traveling salesman pitching his cures to
those with irrational insecurities and full pocketbooks. Instead,
I sense that Salgo is honestly attempting to explain to the American public
that, with the advancement in medicine, there are actions available that
may ease this madness of heart disease.
Critical thinkers in modern medicine understand that eating our greens
and walking a daily 10,000 steps is not going to prevent all pathology.
Salgo isn’t screaming the 20th century, “take this pill and forget about
it,” slogan. But, instead builds the argument that it would be inappropriate
to ignore where modern medicine has taken us and that we should be more
aggressive towards the prevention of heart disease. This also raises
some interesting questions for exercise physiologists. For example,
what is the role of exercise physiologists in the discussion of risk factors
for different diseases? To what extent should exercise physiologists
embrace the content in Salgo's book or other books like it? How has
not having our own professional organization kept us from thinking as healthcare
professionals?
Reference
1. Salgo, P. and Layden, J. (2004). The Heart of the Matter:
The Three Key Breakthroughs to Preventing Heart Attacks.
William Morrow Publishers.
