In the daily work of seeing patients, I was cognizant of the advances made in cardiology and their contributions to improving patients’ lives, but it was when I compiled a slideshow for a retiring colleague in 2014 that I reviewed the progress made over the nearly five decades I had spent in medicine. It was truly revolutionary.
A Retrospective
When I became a nurse in the 1970s, pacemakers were so large that they had to be inserted into the abdomen; several years later they were small enough to be inserted into the chest. It wasn’t until the 1990s that medications were available to treat heart failure and that procedures were developed to open arteries and insert stents.
Clot-busting drugs successfully opened arteries, but they posed the danger of uncontrolled bleeding and hemorrhagic strokes. Defibrillators improved the treatment of life-threatening heart rhythms. And instead of open-heart surgery to replace a heart valve, a catheter-based procedure is now often used.
The advances in our understanding of cardiac pathology leading to better diagnostic testing and superior treatment options have been nothing short of extraordinary. It was so rewarding to participate in cutting-edge research and to offer patients new options and improve their health and longevity.
As a nurse practitioner, I was the primary investigator on a phase III clinical trial on early beta blockers for hypertension and angina pectoris. Later during my training and early years in practice, the medical community closely followed other phase III clinical trials for additional medications to treat angina and heart failure as well as other important clinical breakthroughs.
Loving Cardiology
As a career choice, cardiology is unpredictable and therefore fresh and exciting. There is no typical day in the office because the schedule can instantly change when a patient needs emergency treatment. One minute you are sitting in the office reading test results and the next minute you are running through the hospital corridors to answer alarm bells.
Early in my career at Highland Hospital, I cared for a man in his 40s with cardiac sarcoidosis, a rare condition in which clusters of abnormal cells including T lymphocytes form granulomas in multiple organs, including the heart. When he felt life-threatening heart rhythms, I admitted him to the hospital and stabilized him with medications. When defibrillators came available, he was one of the first in Rochester to receive one.
Eventually, he decided to move out of the area to be closer to family but delayed the move because he had so much trust in me and the EP cardiologists who cared for him. It was gratifying to know that the medications and defibrillator extended his life expectancy.
Many patients that I initially treated at Highland Hospital followed me to Unity Hospital, where I continued to treat them for years. One woman had an acute heart attack at age 50. At my insistence, she quit smoking, but unfortunately suffered a stroke, which slowed her recovery. She eventually regained a good quality of life, although she naturally developed other cardiac issues as she aged. Our friendship grew, and to her I became Joan instead of Dr. Thomas.
One 35-year-old patient arrived at my office with shortness of breath. Her echocardiogram showed severe aortic insufficiency and mitral stenosis and the need for a double heart valve replacement. Because she was young, she needed valves made of metal rather than tissue to ensure they would last for the rest of her life.
As is standard in these situations, she needed to be on a blood thinner but developed a rare resistance to the medication. I started her on a different medication that required self-injection. Because she disliked the injections, she did it only sporadically. This led to a condition called pannus, or a restriction of the heart valves. Now we had an emergency situation. An emergent second surgery inserted two tissue valves in place of the original metallic valves.
She did well for a few years but again developed shortness of breath. The echocardiogram showed one of the valves leaking badly, which meant a third open-heart surgery. At the time she was only in her 40s. She recovered only to find, some years later, that her tissue mitral valve was deteriorating. She trusted me to figure out her best options.
I was determined that she avoid another heart surgery and so sent her to the Cleveland Clinic for a catheter-based surgery to fix the problem. She was fortunate to benefit from advances in cardiac technology. Had she developed these conditions a decade earlier, her life expectancy would have been short. Today she is a proud grandmother living a full life.
Treating Young and Old
It is particularly rewarding to give relatively young patients the opportunity to live a long life. One patient, who participated in amateur golf tournaments, arrived at my office with heart failure and needed a special device that was a combination of a biventricular pacemaker and defibrillator. His health improved enough for him to resume golfing. Years later, I saw him for a routine checkup and was disturbed to see that he had lost weight and was short of breath. He looked terrible. Despite the heart medications and devices, his heart function had declined to the degree that he needed a new heart.
Cardiac transplants are complicated because the blood type of both donor and recipient must match. Certain blood types and ethnicities can make a match challenging. He was hospitalized and placed on intravenous medication to boost his heart function and then fitted with a left ventricular assist device, which is a small pump in the heart powered by batteries stored in a small fanny pack. Fortunately, he had good family support and was able to return to golf. He would joke that he would help me with my golf game in return for the care, but I had little time for golf then.
Technological advances not only save young lives but can give the elderly more years of quality living. A 91-year-old patient presented with severe aortic stenosis, a condition in which the valve no longer opens sufficiently wide to allow blood to leave the heart and circulate through the body. This results in shortness of breath and sometimes chest pressure and is diagnosed via echocardiogram and then an angiogram to ensure that there is no other heart issue.
It wasn’t long ago that these patients would have to undergo open-heart surgery to replace the valve. I explained to her that we now had a catheter-based procedure, and she quickly agreed to it. The day after the procedure, she was dancing in the hospital corridor when my colleague arrived to discharge her. When the only choice was open-heart surgery, such candidates might not have survived the surgery. But with the advancements in catheter-based procedures, she was able to return to independent living.
The Human Side
Sometimes when treatment avenues are exhausted it is necessary to have difficult discussions with patients about end-of-life issues. In such cases, I needed to guide patients to assess their own personal views on the value of quality of life versus quantity of life.
These discussions must be approached with the utmost compassion. Often both of us were teary as I explained that it was time to consider a palliative, dignified approach that would allow the patient to spend final days at home with family rather than in a hospital bed. I had fewer of these discussions late in my career, as there were more treatment options.
It was always disappointing and sad to lose a patient, but I had reconciled myself to the truth that medicine cannot save everyone. Sometimes I would receive letters thanking me for my efforts, and I was grateful and humbled that my patients or their families took the time to connect with me. The wife of one patient who had been treated for coronary artery disease, but later died of cancer, wrote:
Dear Dr. Thomas,
I want to thank you for all you have done for [my husband] to keep his health together. Without you he never would have made it all these years. You are a very caring doctor. He and I always felt so much better after an office call with you. I remember the first time he came to your office. You said, “I am going to make you feel much better” and you did. Thanks again for all your care, patience and understanding. You are a special person.
Fond regards,
E.
Adapted from The Heart of the Story: My Improbable Journey as a Cardiologist by Joan L. Thomas, MD, CPE, FACC, with Sandra J. Parker.