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Cardiac Complications : HEART FAILURE: A Critical Inquiry Into the Revolution in Heart Care, by Thomas J. Moore (Random House: $19.95; 320 pp.; 0-394-56958-X)

October 08, 1989|Bruce J. McAuley | McAuley is a cardiologist practicing in Palo Alto, Calif

Advances in the understanding and treatment of cardiovascular disease have been dramatic and widely chronicled in the last two decades. Armed with a more precise understanding of the events triggering a heart attack, cardiologists now can administer potent clot-dissolving agents to abort the attack. Technological breakthroughs in X-ray equipment and catheter design allow physicians not only to precisely identify cholesterol deposits in coronary arteries but also to treat the plaque non-surgically with devices that expand, vaporize, scrap and pulverize the deposits. Cardiac surgeons have ascended the therapeutic pedestal for the wondrous reconstructive surgery that can be performed on the heart--from the now commonplace coronary-bypass grafting to more challenging, exotic operations such as heart and lung transplantation, repair of birth defects and surgical treatment of electrical abnormalities of the heart.

This rapid and heady growth has not occurred without its critics. Thomas Moore, an investigative journalist, joins the ranks of those who would question the uncritical acceptance of these advances in his provocative and unsettling "Heart Failure: A Critical Inquiry Into the Revolution in Heart Care."

Moore acknowledges and is appreciative of the gains that have been made in treating heart disease. But his task is not to heap praise on the pioneers of balloon angioplasty or bypass surgery but to address the most controversial and frequently painful questions surrounding the advances in cardiac care. Does available scientific data support the massive government-led campaign to identify and treat those individuals with elevated cholesterol levels? What accounts for the widely differing mortality rates among cardiac surgeons, and what is a prospective bypass patient to make of these disparities? Can the public trust physicians to police themselves and assure quality of care?

The complexity of these issues is monumental, and an effort to make them accessible to the lay and medical audience alike is laudable. However, to try and identify truths in this morass can be as challenging as the Gordian knot is fast. Moore has set no easy task for himself and attacks an array of mighty monoliths. Cholesterol is becoming a watchword of our time--the topic of best-selling books, on the cover of national magazines, and a tidbit of medical data that all patients seem to know. Interest in cholesterol levels may replace astrological signs as a conversation opener at cocktail parties. Is all this excitement about cholesterol warranted?

Moore takes to task a government panel of health experts for a seemingly biased interpretation of large-scale clinical trials addressing the importance of elevated blood cholesterol. Despite the drop in rates of coronary heart disease achieved by lowering blood cholesterol, there has been no difference in overall mortality between treated and untreated groups. Those individuals in the treated group had a higher rate of violent deaths (accidents and suicides) that canceled the benefit of lowering the rate of heart disease.

The author teases apart the threads of the cholesterol story in great detail. Sedulous research of an impressive number of scientific articles obviously has gone into his account, and in learning of the way in which clinical trials are implemented and interpreted, he has discovered their strengths and weaknesses. Much of medical progress justifiably rests on the results of the randomized clinical trial. Yet, it is an imperfect tool, and because of an overwhelming number of uncontrollable variables, it does not lend itself to the unambiguous conclusions that can be reached by the basic laboratory scientist. The national campaign to identify and treat those with elevated cholesterol levels rests on trials that Moore finds not only lacking in scientific proof but potentially leading to a conflict of interest. According to the author, the cholesterol-education program promulgated by medicine and industry ". . . was not exactly a public-service campaign but a business scheme to sell physician's services and other products."

If the reader is hoping for prescriptions, Moore does not proffer them. His efforts are confined to exposing the roots of the controversy. In respect to cholesterol lowering, we are left with the less-than-encouraging prospect that, in the words of one expert: "The effect of all our interventions may be analogous to stewards rearranging the deck chairs on the Titanic."

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