Spreading the Word
Some of these potential risk factors, such as those related to bacteria and viruses, simply identify individuals who need to be monitored more carefully-such people might do well to watch their cholesterol, weight, and blood pressure more closely. But other potential risk factors could indicate new ways to stave off heart attacks. For example, beta-blocker drugs are beneficial in treating long QT in some children, because they slow down the heart and make the heart muscles less responsive to adrenaline, and thus decrease the possibility that the heart will become unstable. In children on whom these drugs do not work, surgeons have implanted devices that will deliver an electrical shock if the heart needs to regain stability.
The results of acting on good information can be impressive. Roger R. Williams, a cardiologist and genetics researcher at the University of Utah in Salt Lake City, has proven as much. He and more than 20 other physicians interested in the genetics of cholesterol have set out to locate people with the gene for familial hypercholesterolemia, or FH. Toward this end, they have formed a 10-nation network called MED-PED-FH, which stands for “making early diagnosis to prevent early deaths in medical pedigrees with FH.” Workers process questionnaires from the blood relatives of known FH victims and track down carriers of the gene. In Utah, such efforts have paid off with the identification of 800 carriers of the FH gene from a base of only 50 known victims. All could be candidates for drugs named statins that Bristol-Myers Squibb, Merck, and Sandoz have developed; based partially on Goldstein and Brown’s research, these drugs block a key enzyme involved in cholesterol production.
For people who may be prone to heart attack because they are depressed, drugs such as Prozac and Zoloft and psychologist-led therapy show much promise. Although doctors still lack an economical way to tell whether specific patients are likely to develop high blood pressure if they consume too much salt, discovery of the gene responsible for such sensitivity has spawned a new class of drugs called “angiotensin converting enzyme inhibitors” that help the kidneys handle salt more effectively. And Searle has recently come out with a drug to control blood pressure that is designed to deliver its peak dose in the morning hours, when, as Muller’s research on heart-attack triggers has demonstrated, people are particularly vulnerable.
At least three major studies could help pin down some of the new risk factors that have been proposed. The World Health Organization’s MONICA project (for “multinational monitoring of trends and determinants in cardiovascular disease”) is charting heart attacks and heart-attack deaths at 38 locations in 21 nations, with final results expected by 1998. The Atherosclerosis Risk in Communities study-the one that has already turned up much of the information linking heart attacks to bacterial and viral infection-will also be completed in 1998. And a newer study called Enhancing Recovery from Coronary Heart Disease, sponsored by the National Heart, Lung, and Blood Institute, began in October 1996 to look specifically at loneliness and social isolation as heart-attack risk factors.
But new findings are not enough. In fact, even the new interventions that may grow out of those findings are not enough. The professional organizations that represent doctors in practice-for instance, the American College of Cardiology, the American Heart Association, and the National Heart, Lung, and Blood Institute-must spread the word about the latest research. They need to convince doctors that it is based on sound science and that it will help them deliver better care to their patients.
Such efforts could enable medical workers to save many patients around the world from untimely death or disability. To be sure, more people with established high-risk conditions such as diabetes or high blood pressure need to be identified and convinced to take their medications, follow their diets, keep their appointments, stop smoking, or make other changes in their behavior. And those who have already suffered from heart problems need the kind of rehabilitation and education that could keep their situation from deteriorating. Physician Sidney C. Smith Jr., a recent president of the American Heart Association, reports that only about 30 percent of patients who have had heart attacks or procedures like bypass surgery are being sent on to rehabilitation, and that few are being counseled by their doctors to stop smoking and eat a healthful diet. Still, the importance of ferreting out new heart-attack risk factors cannot be overestimated. Until we know more about the conditions that contribute to heart disease, prevention programs will remain sadly limited.