The Heart of the Matter

GUEST: Dr. Frederick Feit
Title: “The Heart of the Matter”
VTR: 9/9/97

I’m Richard Heffner, your host on The Open Mind. And it was more than 40 years ago that Dr. Simon Dack, then president of the American College of Cardiology, and two other distinguished cardiac specialists joined me on this program to discussed what we then called “the causes of heart trouble.” When I once read again the transcript from our January 20, 1957 program, I was reminded of and astounded by what the medical world knows now about our hearts but didn’t know then. And, of course, I’m grateful too, as one of the several hundred thousands of Americans who this year alone will have reaped the benefits of newer cardiac procedures. For me, the result only a few months ago was heart angiography; the identification of 98 percent occlusion of my left anterior descending artery. Then balloon angioplasty, the insertion of a stainless steel stent, and then some fervent hopes that there won’t be early restenosis, or reclogging, of the artery, which does happen, for the failure rate is still rather high.

What someone called “cardiac immortality” is not guaranteed.

Well, as a coward by training and conviction, I had fought against angiography for years, being a wiseguy and telling my doctors that if this procedure were essentially for diagnostic purposes, they should wait and come to the autopsy. Ultimately, however, cardiologist Martin Kahn’s wiser counsel prevailed, and fortunately I was referred to my guest today, Dr. Frederick Feit, the Director of Cardiac Catheterization Services at the New York University Medical Center, who performed my angiography and subsequent angioplasty despite all of my pain-in-the-backside probing and questioning.

Of course, I was not alone. Hardly. More and more Americans each year experience these cardiac miracles. Indeed, proportionately, we Americans do so much more than people in other medically advanced nations. And I want to ask Dr. Feit lately just why that’s true. But first, Dr. Feit may want to tell us, as I couldn’t, a little more about the heart of the matter. And I know he didn’t come empty-handed.

Thank you for coming, with your heart not on your sleeve, but on the table. But tell us a little more about this whole process.

FEIT: Well, first of all, thank you so much for having me. And it was a privilege to take care of you, as it is anybody that we can help. And heart disease is something that I take very, very seriously. It remains, coronary artery disease remains the leading cause of death in this country. And I think we need to have tremendous vigilance to just be aware that this is something that can strike anybody, as it afflicted you, and could afflict me.

What we are really talking about is this muscle, which is the heart. And the heart is supplied by three arteries. One is the right coronary artery, one is the left anterior descending coronary artery that runs on the front of the heart, and the third one is the left circumflex coronary artery that runs on the back of the heart. And when we start out these vessels are smooth and they’re beautiful, and then, for a combination of reasons, some of them that we have a lot of control over, like our diet, our state of mind, whether or not we choose to exercise, whether or not we choose to learn what our cholesterol is and have it corrected, many things that we can control, and then a few things that we can’t, such as whether or not we happen to have diabetes, or very poor, or if we’re dealt a very poor genetic hand, if everybody in our family had a heart attack by the age of 30, there may not be as much that we can do. But over time we develop plaques inside the arteries: the buildup of fatty material and calcific deposits, that can narrow these beautiful channels of bloodflow. And over time these plaques can become progressively severe and lead to either a syndrome of chest pain or really worse, a heart attack.

HEFFNER: And the numbers, the numbers of people who perhaps haven’t paid attention to the warnings that you and others offer, what’s the number-fact in this country each year?

FEIT: I think it’s really a very huge number. We are doing probably around a million cardiac catheterizations a year. About 500,000 interventional procedures: balloon angioplasty, stent placements. But that numerator is really paled by comparison to the denominator of all the people who are walking around having coronary artery disease and not knowing about it. And a lot of times what we hear is, “I just had a checkup. I just had a cardiogram. Nobody told me anything was wrong.” And some of those screening tests are really inadequate. What really needs to be done is to take a very, very careful history about any symptoms — tightness in the chest, pressure, indigestion that comes on with exercise, squeezing in the neck, pain down the arm — and if there’s anything suspicious, or a bad family history, we probably have to go further and perhaps evaluate with a stress test, which is something that could detect blockages before they become critically severe, before there’s a major clinical event.

HEFFNER: And then when the stress test indicates the possibility?

FEIT: If the possibility is indicated either by a stress test or is indicated by symptoms which may be suggestive of the presence of coronary disease, probably the safest and best thing to do is to perform an angiogram and make sure that we’re not dealing with significant blockages inside the arteries. We have to keep going back to the fact that, by far in this country, for all we hear about cancer, for all we hear about AIDS — and these are very important, serious problems that need to be dealt with — that by far coronary artery disease remains the leading cause of death.

And one thing that I didn’t mention on those preventable things that you have control over: the leading cause of premature coronary artery disease and heart attacks in this country is smoking. And smoking is the single risk factor, of all of them, that you have the most control over. I said, you know, you could get stress out of your life. That’s not necessarily an easy thing to do.

HEFFNER: I wondered, when you said that, what in the world you meant.

FEIT: No. For people like you and me, I wake up worrying and go to sleep worrying. One of the extra things that I have to worry about since I met you is you. You know, we start out each conversation by me asking how you’re doing.

HEFFNER: But seriously about that, do cardiologists generally think in terms of stress, exercise, diet, as well as genetics and smoking?

FEIT: I think really the first thing I think about is diet and knowing the cholesterol. Because there are wonderful drugs that we can use to treat abnormalities of the cholesterol and the lipids these days. Smoking just has to be stopped by whatever technique is necessary, and there are ways to do that as well. Diet is very, very important. And then we can bring in things like exercise. See, exercise, what exercise probably does is two things: it helps to raise what is called the “good cholesterol,” the HDL cholesterol. It doesn’t do anything to reverse what blockages are there. But somebody who gets into the mindframe that they’re going to join an exercise program is probably going to be careful about the other things that they’re doing: watching their cholesterol, not smoking, watching their diet. Diet is also very important.

HEFFNER: Well, there’s no question, since I’m so personal about it all, for good reason, that since I began in cardiac rehabilitation and exercise, my HDL has gone up quite considerably.

FEIT: That’s terrific.

HEFFNER: Is exercise the only thing that helps HDL?

FEIT: Well, exercise and medications.

HEFFNER: And medications. Now, I asked you a question before, and probably didn’t put it very well. It has to do with the percentages of cardiologists who get involved in preventive medicine. I didn’t use that. But who pay attention to these different modalities of “You can do this to help yourself.” How sophisticated is your profession?

FEIT: Boy, that’s very tricky. I think it varies tremendously from cardiologist to cardiologist. And personally I like the type of cardiologist who has a little bit of a bootcamp mentality, who, when you become his patient… Sometimes patients will come to me, they’ll just show up in the emergency room with chest pain for the first time, and we’ll do something corrective for that patient. As you know, working in the catheterization laboratory is pretty much a full-time commitment. And I want to find somebody to take care of that patient after we do whatever immediate procedure we do, who will have the same mentality and diligence with that that I have in the catheterization laboratory. So the type of cardiologist that I am looking for patients is somebody who will say, “Now we’re partners. We have to learn what your cholesterol is. This is what your diet is going to be. This is the type of exercise program I want you in.” There are some cardiologists who are, I think, not as good at that. There are some cardiologists who will just see their patient every six months, not inform the patient what his cholesterol is, maybe not have the patient in as optimal a situation in terms of trying to modify all the risk factors. And, of course, not every patient is amenable to following the prescription.

HEFFNER: Psychologically.

FEIT: Psychologically and whatever else. I mean, there are some people — and you might find this hard to believe, having been on the other side — who, after you get them through whatever episode that you’ve gotten them through, maybe for a month or two they’ll be very serious about their diet and not smoking. But a lot of people, two months later, will stop exercising, start eating all the wrong foods again, and start smoking again, believe it or not.

HEFFNER: Well, it is hard for me to believe. My exercise class, if you’ll forgive me, is at Cornell New York Hospital…

FEIT: A fine institution.

HEFFNER: …and I can’t imagine any of my friends and colleague there now, men and women alike, young and old — which shocks the heck out of me — giving up or turning away from that. But after an identification of plaque, of heavy-duty problems in the arteries, you talk about angiography to identify that, and then angioplasty as a modality of treatment. I’m about to say that we’ll turn to the videotape, because you did bring a videotape with you. And I think it would be splendid now to look at that and you comment on it. We can look at it here.

FEIT: Okay, let’s look at the tape. This is actually the tape of your angiogram. And we place a catheter through the leg, and we’re injecting the dye. And this is a picture of your right coronary artery. And this is smooth and beautiful. Unfortunately, this other artery, the left anterior descending, you can see running horizontally, it looks like there’s a pinch right there on the left side of the screen where the artery goes from wide to narrow back to wide. Actually what we’re seeing is plaque inside the channel of the artery.

This is an animation of what the plaque looks like inside the artery, that yellow, fatty material. And what we can do is to place a wire down the artery, and inflate a balloon to open up that blockage sufficiently that we can place a stent, as we did in you. the stent is a stainless steel, cylindrical mesh mounted on the balloon. And you will see that appear. There is the cross-hatched metal, mounted onto a balloon, sitting there on the plaque. And now we inflate a balloon which will implant this stent into the artery. So the artery is now strutted open by this metallic stent.

And now we’ll see exactly how this looked when we actually did it on you. Here is a balloon in the vessel. This is just to open up a sufficient channel for us to put the stent in. And then we deflate the balloon and take a picture, and you can see that you hardly can see the blockage anymore, but in the area where the blockage was it’s still a little irregular, a little hazy. And now this next balloon is the one that has the stent mounted on it. So when we deflate that balloon we think the artery should look very beautiful, as it does. So this is 40 years of plaque buildup being dealt with in probably an hour’s worth of time. And we can see, finally, the picture on the left, which is before, with the severe blockage; and the picture on the right, where everything looks very, very nice.

Now, in truth, in terms of mechanical correction of coronary artery disease, there are really two types. One is what we do, which is called “interventional cardiology,” procedures that we can do what is called “percutaneously,” just making little entries into the femoral artery through the skin, very much like an IV, and then working through catheters and working inside the channels of arteries. And this is over the, let’s see, 16 or 17 years that I’ve been doing it, has advanced tremendously in terms of the available technologies, the safety, the ease of operation. And the other way that blockages can be, not really corrected, but dealt with, is bypass surgery, which is a situation in which your chest will be opened up, and nothing will be done to the blockage, which is very interesting, but rather a piece of vein or a piece of artery will be sewn into the healthy artery downstream, and the blockage will be bypassed.

And I have to say that we’ve done a lot of catching up. Surgery started first, and now, worldwide, many more patients get interventional procedures than bypass surgery.

None of this should be considered a cure. Although, in somebody like you, honestly, where the blockage is one, local spot, it can be a cure. But coronary disease, vascular disease, tends to be a relentless, progressive process. So the idea of doing an interventional procedure like we did in you is as a first step, getting rid of the main problem, and then you and your cardiologist have to do most of the work with this lifelong program of risk-factor modification and altered behavior to avoid the problem coming back.

HEFFNER: I’m doing it. I’m doing it. [Laughter]

FEIT: [Laughter] The last place either one of us want to meet again is in the single plain room at Tisch Hospital.

HEFFNER: Yeah, but let’s be straight about the fact that there is a fairly high rate of failure, or rate of restenosis. It’s not a failure of the procedure, but restenosis takes place.

FEIT: We have basically almost gotten rid of failure of the procedure, which was a problem originally. But now, with adjutant medication, meaning drugs that you can give during the procedure, plus the availability of stents, we’re close to 98-99 percent initial success rate. For the type of blockage you had, which is very localized in one place, recurrence may only be on the order of 10, 12, 14 percent. The recurrence rate or restenosis rate, the blockage coming back, the plaque building back up, tends to be very much related to the amount of plaque, the degree and length. The most important thing is the amount of the vessel that is involved. If the whole vessel is diffusely involved with atherosclerosis, focal therapies will not work for diffuse disease. So I think, in terms of restenosis, when I see a local blockage like you have, I’m very encouraged that it’s not a particularly likely event.

We have ways of dealing with it now. And I have to say that it’s probably more experimental. But things are looking very encouraging. In terms of, the restenosis process is different from the initial atherosclerosis. The initial atherosclerosis has its own set of things that provoke it, cause it, all those risk factors. The restenosis process is probably a response to injury. The fact that we inflated the balloon to high pressure inside your artery, and put a stent in there, a piece of metal, your body may react to that as an intrusion, not because of antibodies, but just because of injury, and form scar tissue and have what is really building back up is a scar tissue and not just the plain, vanilla atherosclerotic plaque. Now, that particular scar tissue we try to deal with ablative techniques, which is using different tools that will actually either shave away the plaque or remove the plaque from the vessel. That is encouraging.

And the other thing which is very encouraging and very preliminary is radiation therapy inside the stent if the blockage comes back. There’s a lot of excitement about things like gene therapy or this drug or that drug. Unfortunately, our basic scientists haven’t figured the whole thing out yet. So even that would be very clean, to find a specific gene, a specific protein, a specific something that you can just block and would not get restenosis, they haven’t figured it out yet. So what actually seems to work in a couple of small trials and may be applicable to a whole, broad population, is just, when you have what we call “in-stent restenosis,” or recurrent scarring inside the stent, narrowing inside the stent, plaque, whatever it is, scar-tissue buildup inside the stent, just to expand that material back to the side and then put in a radiation source, has some very encouraging initial results and is probably very safe and effective.

HEFFNER: Well, if you don’t mind, I’d just as soon not get involved with that.

FEIT: And me as well. [Laughter]

HEFFNER: But let me ask you this. I promised that I would at the beginning. We do this more often, seemingly, than other peoples do. And I’m talking about medically advanced societies. Why?

FEIT: Because, I think, we’re better. You know, I think we’re living in the greatest country in the world. And maybe we call came from different places, but we came here for a reason, and we avail ourselves of what is there, what can be used, almost regardless of cost. And I’m famous for this. I may get in trouble for saying it. But there is no procedure which is not so important that I won’t use the best equipment, try to do it in the safest possible way. If I have to use two balloons instead of one, or two stents instead of one, I will do it. It’s just my philosophy. So, I think a lot of people in this country have this philosophy. We took care of a 91-year-old patient. If the patient doesn’t have money, I’ll do it over at Bellevue Hospital; it works just as well. I have more time on my hands over there. I could do just as good a job over there. So I just think that if a person has an indication to have their artery fixed, we have the wherewithal to do it.

HEFFNER: Why is it mentioned though so often the disproportion, as a critical factor, whose who say, “Those Americans…”

FEIT: Well, I can’t say. Honestly. I don’t want to say anything critical about anybody else, because I think everybody is trying to do the best they can. But I don’t think that there are too many countries where a 91-year-old woman like we took care of last week, who came in with severe angina and a minor heart attack, who had two of her arteries completely blocked and the other one very severely blocked, would’ve even gotten an angiogram, let alone get a stent like you did. And I think for her that was very important. You know, for a country where somebody is saying, “We only have this many dollars to give out, and somebody who’s 91 is not going to get this,” that’s a value judgment; it’s not one that we’ve made here.

HEFFNER: Is there any indication in American medicine that we will, of seeming necessity, move in that direction though?

FEIT: I don’t know. I certainly don’t foresee it happening where I am. And I’ve had no indication of it. I think what the challenge that we have to lay out is to the people who produce all these wonderful technologies to make them so that they are cost-effective. And, you know, now when we place a stent in somebody, if that person happens to be the first patient in the morning, we can place the stent, and because it’s so unlikely that there will be a problem in that vessel in the immediate period, we can remove the catheter from their leg, and they can go home the same day. So, in terms of the cost of the hospitalization and where the patient goes, it’s become very, very cheap. Stents right now in this country are a little expensive because there’s a relative monopoly on the manufacturing process. But in Europe, for example, stents are costing half as much as they do here. And I think with price competition, all of these wonderful technologies will become much, much cheaper and cost-effective.

HEFFNER: What’s going to happen in the future of medicine? You obviously, as a man very much in his prime, think in terms of what you’re going to see in the years ahead. What do you expect in the area of the heart?

FEIT: Oh, just talking about the coronary arteries, I think there are going to be tremendous advances. Just tremendous. First of all, we have to understand how all these risk factors come together a little better to cause the problem. And the better we understand the cause, hopefully some very smart people working in all those molecular biology facilities will figure out some forms of prevention, maybe a way in certain cases to get regression, or to get at least cessation of the progress. Certainly a way to prevent restenosis, I think, is coming. I would be very surprised if ten years from now we were talking about restenosis as a big problem. I think some combination of ablative techniques, of getting rid of the plaque that build up, of radiation or specific gene transfers will probably be effective for that. I think that the progress during my career has been logarithmic. That when I was a medical intern, when somebody came in with a heart attack, we used to just watch and make them comfortable and treat complications. Now somebody comes with a heart attack, which used to have 15 percent mortality in the hospital, 15 percent chance of dying, we bring them immediately to the cardiac catheterization laboratory, we can put a stent in their artery, and there is suggestive information that the chance of that patient surviving the hospitalization can be as high as 98 or 99 percent, maybe even higher than that.

So we’re really sitting on the precipice of tremendous advances. Hopefully things that will make a lot of what we do unnecessary. One thing that will probably happen in the next ten years is a way to image the coronary arteries non-invasively. So perhaps you wouldn’t have had to go through all that stress for all those years of wondering whether you had a blockage or what kind of blockage that you had. Maybe somebody can just give an intravenous injection and take a picture. I think that’s a real possibility in the next ten years. And then everything that will be going on in the cardiac catheterization laboratory will be therapeutic rather than diagnostic.

HEFFNER: Therapeutic.

FEIT: Something fixing something.

HEFFNER: Fixing something. But perhaps interventionally too.

FEIT: Correct.

HEFFNER: Right. You mentioned gene therapy. Explain, please. We just have a minute or so left.

FEIT: Well. Thank goodness. [Laughter] It’s not really an area of my personal expertise. But there is basically, genes are things which tell the body to make certain proteins. And everything is controlled by a gene. So if you could find the gene that causes you to get a fatty plaque in the coronary artery and block it, this would go a long way towards preventing the development of plaques. If you could find the gene that causes restenosis and block it, this would go a long way towards preventing restenosis. And there are catheters and devices through which you could transfer genes into the lining of the artery. The problem is that, I think, at this stage nobody knows exactly what they want to be transferring.

HEFFNER: What do you mean?

FEIT: Exactly what gene to transfer…

HEFFNER: I see.

FEIT: …and how to get the right concentration of it into the artery.

HEFFNER: But in terms of the major project about the genes, the location of everything, that shouldn’t be too long in the future.

FEIT: Maybe. I don’t know. My main thing is dealing with today. And there are a lot brighter people, I think, who are worried about solving all these problems. [Laughter]

HEFFNER: Never. Never, never. But thank you for dealing with me, and with my audience here today, Frederick Feit. Thank you.

FEIT: Thank you.

HEFFNER: And thanks too, to you in the audience. I hope you join us again next time. If you’d like a transcript of today’s program, please send $4 in check or money order to: The Open Mind, P.O. Box 7977, FDR Station, New York, NY 10150.

Meanwhile, as an old friend used to say, “Good night, and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.