I do not smoke. I am not diabetic. Among family and friends, my low tolerance for alcohol is a subject of ridicule. For the past 25 years, I have been a faithful visitor to the gym three times a week, on average, observing a tedious but beneficial regimen of cardio and weightlifting routines. In the steamy heat of a Toronto summer, I could manage 90 minutes of singles tennis without fear of collapse. (I played badly, but I played.)
Like many men my age, I carried a few extra pounds at the midriff, but no one would have called me overweight. My diet, while not exactly a nutritional paradigm, was reasonably health-conscious. And if my cholesterol and triglyceride levels were slightly elevated on occasion, they did not alarm my family doctor. Nor did my blood pressure, which tended to fall on the low side. At 65, my reliance on daily pharmaceuticals began and ended with vitamin D.
At least on paper, then, I was not an obvious candidate for triple cardiac bypass surgery.
So much for paper.
I am one of many. Too many. In Canada, someone dies from heart disease or stroke – the two are inextricably linked – every seven minutes.
That's more than eight deaths an hour, about 200 a day, 70,000 a year. Heart and stroke constitute the leading cause of hospital stays in Canada (almost 17 per cent) and represent a staggering drain on the economy – almost $21-billion a year in physician services, hospital costs, lost wages and decreased productivity. Globally, cardiovascular disease claims 17 million lives a year.
Of course, heart disease used to be an even greater scourge. Over the past 70 years, the cardiovascular death rate in Canada has dropped by more than 75 per cent – more than half of that decline in the past decade. Cancer has surpassed it as the nation's biggest killer.
But the reprieve may be short-lived. Doctors speak ominously of diabetes as an impending epidemic. Already it is almost four times as common as all cancers combined, and more than half of patients with type 2 diabetes – the product of obesity and a diet of highly processed, sugar-infused foods – will probably die of cardiovascular disease.
Cardiac bypass and angioplasty, the procedure that clears less severely blocked blood vessels, have become so commonplace that there is a tendency to take them almost for granted. But anyone who looks at the looming diabetic tidal wave and sees surgery as a quick and easy fix had better think again – or talk to me.
Even my dreams tried to issue a warning
One day last November while walking to work, I became aware of unusual pain in my pectoral regions. My instinct was to dismiss them, surely the result of upper-body exercise. The pain persisted, however – I'd walk 100 yards and it would solicit my attention – and seemed to spread to my upper back, between the shoulder blades.
I'm a trained hypochondriac and tend to leap from mild pain to it-must-be-cancer in no time. But even so, I never felt short of breath, and the discomfort seemed to abate as soon as I sat down at the office. I was not particularly concerned.
In retrospect, there may have been other signs of trouble: a brief but acute pain (9 on a scale of 10) in one of my thumbs, a searing ache in my right shoulder that would frequently wake me at night, and, occasionally, whole-body chills, which left me trembling beneath heavy blankets.
Even my dreams, it seemed, were trying to issue a warning. One night, I dreamed that a menacing black Labrador came charging toward me and fixed its jaws firmly around the fingers of my right hand. Significantly, perhaps, the dog did not bite. The dream ended with my fingers lodged in its maw, as if awaiting judgment.
By mid-December, with chest and back pains continuing, I had made a self-diagnosis: angina pectoris, the classic symptom of coronary artery disease. Still, I did nothing until, one Thursday morning, just before Toronto Western Hospital's holiday shutdown, I mentioned my problem to Dr. Herbert Ho Ping Kong, whom I was seeing on a non-medical matter. The legendary internist promptly rose from his chair, walked down the hall and returned a few minutes later to tell me I'd be seeing a cardiologist, John Janevski, at 8 the following morning.
Despite my self-diagnosis, I felt guilty. The pains would surely go away, and I'd have wasted Dr. Janevski's valuable time.
Nevertheless, I spent the entire next day at the hospital, undergoing tests. The treadmill stress test did not go well. After only a minute, I experienced the now-familiar chest pain. The medics quickly turned off the machine.
At 4 o'clock, results in hand, Dr. Janevski delivered the news. The worst of it came from comparing printouts of two old electrocardiograms – he was 80-per-cent certain I had already suffered a minor heart attack, some time in the period from 2007 to 2009.
For a moment, I was in shock. "Wouldn't I have known I was having a heart attack?"
"Not necessarily," he replied, adding that the cardiograms would have had to be read by a proper cardiologist, to draw the right conclusion.
Only then did I remember. In May, 2007, on a boat cruise on the Dnieper River in Ukraine, I had, just after breakfast, inexplicably broken out in a profuse, beading sweat. There was discomfort and mild pain in my mid-back. I went to the boat's infirmary, where they applied liniment and told me to rest. No one suggested that I might have had a heart attack, and it didn't occur to me, then or afterward.
I rested for a few hours and, that night, felt well enough to attend the trip's final party and even perform, singing a satirical song.
I had been very fortunate, Dr. Janevski explained. The heart attack had not affected a major artery, and the organ's blood vessels had made a route adaptation around the plaque. But other, more serious blockages were probable.
Moreover, however fit or well-nourished I considered myself, I had no control over the key determinant of my cardiac health. My father suffered his first heart attack at 48, and died of another one at 73. Four of his siblings also succumbed to coronary disease.
Against the dominion of DNA, regular exercise and good diet are simply not enough. They are not irrelevant – my gym diligence, Dr. Janevski said, may explain why I survived on the Dnieper. But there is no escape from family history. In percentage terms, it's 80 for the genes, 20 for all the other risk factors.
And there was an additional complication – a case of polymyalgia rheumatica (PMR), an inflammatory auto-immune disorder for which I had been treated the year before the boat trip. Research has yet to establish a firm link between PMR and heart attacks, but my doctors believe that there is some connection.
Regardless, it was time for the next step – an angiogram to determine just how bad the problem was.
When it comes to pinpointing cardiac blockages, the angiogram – essentially a motion picture of the heart, complete with close-ups of veins, arteries and chambers – is the gold standard.
The half-hour procedure (devised in the 1920s by Antonio Egaz Moniz, the same Portuguese physician who invented the lobotomy) uses fluoroscopy, a technique that allows doctors to see the lumen (the interior wall) of the heart's blood vessels. A tiny catheter is inserted into the body and guided to the coronary arteries. Then, a radiographic dye containing iodine is injected into these arteries.
The amazing part is that, lightly anesthetized, the patient can watch on a bedside monitor (albeit in black and white) as the film is being shot.
'We could send you home, but I recommend you stay'
I spent two, anxiety-filled weeks waiting for the angiogram. Afterward, surgeon Alan Barolet leaned on my gurney rail and reported, in a hushed tone: "I'm afraid you have a significant blockage."
"Really?" I replied, as though he were given to making jokes about heart disease.
"Three, actually," he said. "One at 99 per cent. Two at 70 per cent."
Gulp. Virtually total. Even under the fog of the anesthesia, my attention was riveted.
"Can they be stented?" The stent procedure – in which blocked vessels propped open during angioplasty are reinforced with mesh – was, I knew, less invasive and less risky than bypass surgery.
"Possibly," Dr. Barolet said. "But we think that's likely not the best approach in your case. A stent will repave part of the road. A bypass is an opportunity to build you a new highway."
Surely, I thought, there must be some mistake. Medical psychologists have a word for this: denial.
"When might this be done?"
"As soon as possible. We could send you home, but I recommend you stay until you have surgery."
So much for denial. At this point, resistance would have been, if not futile, extremely foolhardy. I spent a long, ruminative weekend at the hospital. My roommate was an elderly European, recovering from the very procedure I would soon be having. He moaned through the night – comforting neither as sound track nor as omen.
The risks, I knew, were not trivial. With my son, Sam, a lawyer, I drafted a handwritten will, something I had managed to avoid doing for too many years.
Early Tuesday morning, a male orderly arrived to shave my chest. A nurse delicately – okay, as delicately as she could – administered an enema.
My daughter, Susan, working in California, had flown home. In my hospital room that morning, we decided to Google the ratings for my surgeon, Terrence Yau. They were glowingly positive.
"Yeah," I said, trying to joke. "He probably got his mother to write them."
At that moment, Dr. Yau entered the room, not (I could only hope) having heard me.
He was straight out of Central Casting – erect, focused, succinct, exuding confidence. My case, he said, looked straightforward. He anticipated no complications, but he was required to note that a small percentage of patients don't survive, and a slightly larger percentage suffer strokes and other disabilities.
The good news, he said, was that, notwithstanding my blockages, the heart muscle itself appeared healthy.
My attitude was one of sober resignation – the approach I take whenever I board a commercial airliner. Whatever happened next was entirely beyond my control. I was consigning my life to the pilot, Dr. Yau.
Bypass operations have come to seem routine – after all, more than 500,000 are performed annually in North America. But cardiac surgery is still a relatively recent development (the first successful one was in 1960 in New York) and not something to be taken lightly.
After anesthesia, the surgeon saws open the sternum (breastbone) and removes segments of the thoracic artery and the leg's saphenous vein to use in bypassing the blockages. The surgical team then goes "on pump," turning off the heart as if it were a light switch. The pump, or heart-lung machine, does the heart's work while the grafts are connected to the coronary arteries (at one end) and the aorta (at the other). The engine of the heart is then rebooted, excess blood is drained from the chest cavity, and the broken breastbone wired back together.
After the wound is closed, the patient is shipped to the intensive care unit. Barring complications, the procedure takes about four hours.
In 2005, Francis Duhaylongsod, a surgeon working in Hawaii, developed a new, minimally invasive technique that requires neither breaking the breast bone nor using the heart-lung machine. Instead, three small incisions are made, allowing access to the heart. As a result, healing times are faster and the risk of infection reduced. Only two hospitals in the Toronto area – Sunnybrook and Trillium in Mississauga – offer the new approach. But I was not a suitable candidate for the procedure, or so I was told.
I was soon out cold and would remember nothing
The cavernous operating theatre was lit like a movie set. The anesthetist, a muscular Russian, began attaching intravenous lines. A brief discussion of my case would precede the procedure, he started to explain … I was out cold before he finished the sentence. I would remember nothing – no white lights, no tunnels, no ethereal voices, no out-of-body experiences.
I awoke in a stupor, my mouth full of tube. My body had become a motherboard, a matrix of wires plugged, it seemed, into every part of me. My loved ones, gathered at bedside, stared collectively aghast at the sallow-faced ghost that lay before them. I was only dimly conscious of them, but did somehow register the extraordinary attentiveness of my ICU nurse, who patiently explained everything before she did it, with care and tenderness.
Dr. Yau's assumptions had been justified. When he met my family afterward, he said the surgery had been "boring, but in a good way." On the other hand, my blood pressure had dropped precipitously, and more than 12 pounds of dopamine solution had to be injected to elevate it. I would spend the next six days in intensive care, about four more than is customary, while my blood pressure stabilized, and four more on the regular cardiac ward, while I expelled the excess fluid. Only when my body weight returned to pre-surgery levels would I be released.
Seriously uncomfortable, barely able to move, often sleepless, I was unable to take more than shallow breaths because my lungs had collapsed (a result of the surgery) and its air sacs had filled with mucus. I was dosed with a liberal pharmacopia – blood-pressure elevators, blood thinners, cholesterol reducers, fluid reducers, stool softeners, hemoglobin boosters, heartbeat slowers and, of course, painkillers, including morphine. The latter I can recommend.
My aching left leg, from which the vein had been extracted, was a purple blotch from groin to knee. Swollen on dopamine, my feet resembled the gnarled limbs of some ancient oak. I could not feel them. I needed help getting to and from the washroom. Every step was tentative and painful.
The level of care extended was extraordinary – an endless parade of solicitous cardiologists, anesthetists, respirologists and nurses. They not only read my chart, they also stopped to chat and offer encouragement. One therapist gave me a small heart-shaped pillow to hold against my chest when I coughed, sneezed or, god forbid, laughed. It proved no match for the pain. Another brought me something called an incentive spirometer, a long horizontal tube fitted with a mouthpiece. I was to suck air out of the tube, trying to suspend a small white marble in a vertical cylinder for three seconds or more. By breathing deeply, you force air into the lungs, and open the air sacs.
Alas, I sucked at sucking. For several days, I could barely keep the marble suspended for one second. My ability to walk was equally impaired. A single circuit around the ward was taxing. In my head, I wanted to push myself, but my body rebelled.
I had survived, and was thankful, but didn't really like that I was part of a grand success story.
The big decline in Canada's cardiovascular death rate stems both from improved surgical techniques and from new drug therapies.
More concerted prevention efforts also play a role. Cardiologist Matthew Sibbald of Toronto's University Health Network says lifestyle changes – regular exercise, smarter diets and, most significantly, the decline in smoking – are beneficial.
But the key factor, he maintains, are the drugs, so-called statins such as Lipitor and Crestor, which reduce "bad cholesterol" (LDL) levels in the blood.
"Drugs like Lipitor," Dr. Sibbald says, "have changed the burden of disease in this country."
The numbers certainly support the argument. Since the big push for controlling cholesterol began a decade ago, there has been a dramatic, 30-per-cent decline in rates of heart attack and bypass procedures. (In the United States, bypasses have fallen even farther, by 38 per cent, since 2001.) As well, there are fewer stent procedures, and fewer patients with blockages are turning up in hospital emergency wards.
Controversy still surrounds bypass surgery
My own need for surgery had never been up for discussion. My angina had been categorized as unstable – the pain could appear at any time, even at rest. I had already suffered one heart attack and was at serious risk for a second. Given the arterial blockages, Dr. Sibbald, who assisted on my angiogram, told me that, if I had experienced another cardiac event, I probably would not have survived the trip to the hospital.
In the medical world, however, a good deal of controversy still surrounds the efficacy of bypass surgery. Many cardiologists maintain that patients with stable angina (mild, occasional chest pain) do not need it. What causes heart attacks, they insist, are not cardiac blockages per se, but plaque that somehow loosens from the cell wall and stops arterial blood flow. That can happen inside new grafts as well.
Moreover, about 10 per cent of bypass patients do not survive more than 24 months – typically, the elderly, the obese, the diabetic or those who can't or won't change their lifestyles.
"There's no real debate about the statins," Dr. Yau insists. "It's one thing if you've never had artery disease. But anybody with a history should be on medication to control cholesterol levels and drive them lower."
Still, statins can cause a range of pernicious side effects, including muscle pain, mental confusion, constipation, headaches and impotence. Beta blockers, which slow the heartbeat, may induce fatigue, upset stomach, dizziness and loss of libido. Given that I now have "a history," I'm on both, as well as a daily dose of blood-thinning Aspirin. Many bypass patients also take pills to control blood pressure.
"A lot of people have trouble with the notion of taking pills for the rest of their lives," Dr. Sibbald allows. "But there's a sea of random evidence to suggest that statin medicines save people from heart disease and make people live longer."
But what of our collective prognosis? Thirty years ago, the medical world identified dietary fat as the principal villain of heart disease. An enormous and successful campaign was begun to reduce levels of fat in food. But to maintain flavour, food manufacturers began to increase sugar levels, typically fructose, that many researchers now believe are responsible for the alarming growth of obesity and type 2 diabetes.
In his book, Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity and Disease, U.S. endocrinologist Robert Lustig calls sugar "the biggest perpetrator of our current health crisis … a toxin, pure and simple."
Studies show that people who consume large quantities of sweeteners – corn syrup, table sugar, maple syrup, honey – have lower blood levels of "good HDL" cholesterol and higher triglyceride levels. Increasingly, a sugar-saturated diet is being seen as a major contributor to cardiovascular disease.
'Not a licence to eat KFC three times a week'
Ten days after surgery, I went home. It was the dead of winter, too cold to walk outside, so I walked indoors, a 57-second circuit through the dining room, living room and kitchen.
I tried to increase my endurance every day. Five minutes one day, six minutes the next, etc. Tedious but essential. In a few weeks, I was up to 15 minutes. The first stair climb to the bedroom was agonizingly slow, but got easier.
Two months after surgery, I formally started cardio rehab at Toronto Western Hospital – a combination of treadmill walking, stationary bicycle and arm cycling. Attendants recorded my pulse and blood pressure before and after each session.
A month after that, able to walk at a brisk pace for half an hour, I decided to see if I could run. I had to stop after less than a minute. The next day, I tried again, and was able to run a whopping one-20th of a mile. These results were discouraging, but I kept at it, adding a little more distance with each outing. By late July, I could run just under 2.5 miles without stopping. My pace was glacial – 14 minutes a mile – but I was not about to complain. Lately, I am running shorter distances (two miles), but slightly faster (27 minutes).
Meanwhile, I worked on my diet. Out went food I loved – most breads, cheese and sweets. In came more beans, fish and greens once alien to my dinner plate (kale, Swiss chard, rapini) but now savoured for their antioxidant-rich, heart-healthy features. So far this year, I have consumed exactly one steak, one hamburger and one spare rib. My morning habit of stopping at Tim Hortons for a toasted bagel and a double-double is history. As Dr. Yau says, "Having bypass surgery is not a licence to eat KFC three times a week."
Now, nine months since the operation, my cholesterol levels are lower. My weight is down. My scars are barely visible. I have resumed my normal life.
But my sudden encounter with mortality has doubtless changed me. I take the commitment to more exercise and a healthier diet seriously. In a sense, bearing the burden of my heredity, it's more important – not less – to minimize the potential impact of other risk factors.
Beyond that, I am more conscious than ever of time's winged chariot. I have made carpe diem (seize the day) my unofficial mantra. The future is less important than the now. Tomorrow is less important than today. The present is all we really have. Therefore, as best you can, try to be ever present.
Dumb, tired clichés, I know. Or so I used to think.
The recognition of my shortening horizon yielded another life change. Even before the surgery, I had contemplated a career shift. There were things I wanted to do – books to write, places to see.
I was still in consideration mode when my employer offered its staff a buyout package. I signed on and joined the ranks of the semi-retired in July. I tell myself every day how lucky I am – for the care I received, from surgeon to hospital orderly, and for the precious extra time I have been given to be with those I love.
Life has kindly extended my visitor's visa. I intend to make the most of it.