Like snowflakes, but a lot more lethal, no two heart attacks are alike. Take the stories of Nicolas Brenner of Woodstock and Alexander Cohen of Clinton Corners. Brenner, an artist and lifelong athlete at 67, was hiking Overlook Mountain about two months ago when he noticed his heart racing—something that had never happened before. "I'd never taken a medication in my life," says Brenner. "I had low blood pressure, low cholesterol. I'm a vegetarian and I don't smoke. You name the sport, I play it—tennis, biking, racquetball. Every checkup I've gone to has been perfect, and when a doctor asks about medical history I've always said, 'There is none.'" Another unlikely candidate for heart disease and a physician by trade, Cohen (whose name, like Brenner's, has been changed for anonymity) has always been trim and active. He did, though, have a few silent risk factors, like higher than normal cholesterol. But when Cohen, then 62, was tromping through horse pastures 10 years ago after the first big snow of the season, he hardly expected to develop the nausea and fatigue that, in his case, signaled a heart attack. Although neither man had the classic symptoms of chest or arm pain, both were surprised to discover at the hospital that they had major blockages in their left descending coronary artery—known as the widow maker for its capacity to strike a deadly blow. The protocol: emergency angioplasty, involving a balloonlike dilation of the artery and the insertion of a stent to prop the vessel open and restore proper blood flow. "They kept me in the hospital for three days and then shipped me out with all this medication," says Brenner. "And here I am. I'm drumming and feeling fine and ready to play baseball next week."
An Enigmatic Disease
Not everyone is as lucky as Brenner and Cohen. Heart disease is the number one killer in the US—the leading cause of death for both men and women. Coronary heart disease, or blockage to the arteries—the most common type of heart disease—kills more than 385,000 people each year and costs the US about $109 billion annually in health-care services, medication, and lost work time. Despite the dire numbers, we've made quite a bit of progress in this arena, though we still have a long way to go. According to the Centers for Disease Control and Prevention, the death rate from heart disease in the US dropped by 50 percent from 1980 to 2000, likely due to advances in medical treatments and a reduction in risk factors like smoking. Yet the specter of the ailing heart looms large, and many aspects of the disease remain elusive—leaving room for experts to debate its causes and to challenge long-held beliefs. A 2012 book, The Great Cholesterol Myth: Why Lowering Your Cholesterol Won't Prevent Heart Disease—and the Statin-Free Plan that Will, claims that we've had our eye on the wrong ball all along; the authors, nutritionist Jonny Bowden and cardiologist Stephen Sinatra, say that not cholesterol but inflammation and sugar are the real villains in heart disease. The book has Paleo Diet advocates and cheeseburger lovers rejoicing. But not everyone is willing to toss away decades of research finding a strong correlation between elevated cholesterol and heart disease.
Controversies like the one over cholesterol may rattle experts who stand on opposite ends of the opinion spectrum, but they serve an important purpose: They reveal the disease's complexity. Why do many people suffer from heart attacks despite the absence of common risk factors like high cholesterol and high blood pressure? Why do some lucky folks metabolize saturated fats more easily while others experience a rise in LDL cholesterol (the "bad" cholesterol) just looking at a pint of ice cream? "Heart disease is multifactorial," says David Weinreich, MD, a cardiologist practicing in Poughkeepsie with the Hudson Valley Heart Center group. "We know that cigarette smoking aggravates it, as do high-fat diets, lack of exercise, and weight. Stress plays a role, and family history is a factor." Some variables you can change, like diet and lifestyle, but others are immutable—like older age and simply being male (men are twice as likely as women to die from heart disease). And some variables are just plain mysterious. Says Weinreich, "There's more that we don't know than what we do know about heart disease."
Flames of a Debate
In the case of Cohen, high cholesterol was not the only lurking demon; he also had another quiet nemesis in his bloodstream. It was C-reactive protein (CRP), a bio-marker of inflammation. As he knew from a simple blood test, a painful condition in Cohen's shoulders had elevated this number, which researchers have linked to increased heart disease risk. "My C-reactive protein was off the charts," recalls Cohen. Could this have been a tipping-point variable in the constellation of elements that culminated in his heart attack on that cold December day?