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David S. Jones’s “Broken Hearts: The Tangled History of Cardiac Care”

broken-hearts-coverBroken Hearts: The Tangled History of Cardiac Care

by David S. Jones

The Johns Hopkins University Press, 2013, 336 pages.

 

My first encounter with David S. Jones’ Broken Hearts was in April of 2016. I had packed it in my carry-on luggage as on-plane entertainment while traveling to Minneapolis, MN for the eighty-ninth annual meeting of the American Association for the History of Medicine (AAHM). How fitting, I thought, to read about the history of heart disease in the “cradle of cardiac care,”[1] a city that transformed America’s medical enterprise by developing many innovative inventions and techniques in the field of cardiology.

And fitting it was. The conference was teeming with allusions to the University of Minnesota’s cardiac legacy. Not only was there an exhibition on the history of cardiac disease epidemiology developed by the university’s School of Public Health, but there was also a guided tour of the Visible Heart Project, a research laboratory dedicated to reanimating mammalian hearts to gain insight into the organ’s physiology. The overarching theme of both the exhibit and tour was one of progress, as both of these special presentations emphasized how far we have come in terms of gathering accurate information about the human heart. Whereas the exhibit referenced the “exponential growth”[2] that the field of cardiac epidemiology has made in terms of understanding the risk and protective factors associated with heart disease, members of the Visible Heart Laboratory claimed that their research had provided unprecedented insight into the functional anatomy of the beating heart.[3] Over half a century after University of Minnesota surgeon Dr. C. Walton Lillehei preformed the first open heart surgery, and, with the help of Earl Bakken, developed the first battery-powered wearable pacemaker, I left Minneapolis thinking that the city continued to be at the forefront of cardiac care. Within the walls of the University of Minnesota, researchers were still developing innovative inventions and techniques that were transforming medical practice and saving lives.

The idea that unprecedented progress in cardiology has been made over the course of the last sixty years is not unique to researchers at the University of Minnesota. Many medical professionals believe that we now know more about the human heart than ever before, and that research conducted over the past sixty years has given us a deeper understanding of cardiac diseases and their causes. However, this black-and-white picture of medical progress is not as straightforward as these AAHM special presentations would have us believe. In spite of the mantra that health science researchers are “conquering cardiovascular disease,”[4] physicians still face many challenges in developing theoretical frameworks for heart attacks, and producing definitive knowledge about the safety and efficacy of cardiac treatments.

One of the first scholars to draw attention to some of these challenges is David S. Jones. His new work, Broken Hearts: The Tangled History of Cardiac Care, unpacks the complex history of how medical professionals have understood ischemic heart disease over time. By examining how American cardiologists have interpreted and responded to heart disease during the mid-late twentieth century (and beyond), Jones reveals the ambiguities and inconsistencies that persist at the core of cardiac surgery, and traces how these uncertainties underpin the development and evaluation of modern medical interventions. Using the history of heart disease as a lens through which to examine the challenges associated with making health choices, Jones presents a fascinating analysis of how the complexities associated with medical decision making influence the way that cardiac care is administered in the twenty-first century.

In order to explore this tangled history of medical knowledge production, Jones divides his book into three sections. In his first section, Jones examines how heart disease has been conceptualized by medical professionals from the early twentieth century to the present day. He starts the section off with the brief and simple statement: “while the heart, at a basic level, is one of the easiest organs to describe, it has been one of the hardest to understand, especially when it comes to coronary artery disease.”[5] The omnipresence of ischemic heart disease, and physicians’ willingness to perform medical interventions like coronary angioplasty, bypass surgery, or prescribe pharmaceuticals like statins and platelet inhibitors (even on a preventative level) suggests the medical establishment’s unwavering confidence in how cardiac care should be administered. However, Jones points out that there has been ambiguity about heart diseases’ underlying etiology since the early twentieth century, and that this uncertainty raises questions about the efficacy and safety of modern methods of treatment.

Providing archival evidence from thousands of medical journal articles, Broken Hearts reveals that, from 1910 onwards, medical professionals have debated the cause of heart attacks. Although most pathologists agreed that arteriosclerosis underpinned coronary thrombosis, many disagreed on the finer details of this process. Whereas some pathologists argued that thrombosis was the result of the rupture of an unstable plaque in the coronary artery (thus triggering a dangerous blood clot), others believed that myocardial infarctions stem from the progressive obstruction of the coronary arteries, which ultimately prevents blood from flowing through the vessel. Uncertainty over the diseases’ etiology has continued to circulate in medical communities up until the early twenty-first century. In fact, the inability of researchers to establish a stable evidence base for and reaching consensus on a particular theory of heart disease is one of the reasons why the ISCHEMIA trial was launched by the U.S. National Heart, Lung, and Blood Institute of the National Institutes of Health in 2011. By assessing whether revascularization reduces the risk of heart disease or death in patients with angina, this trial hopes to resolve whether the theory of progressive obstruction or unstable plaques underpins ischemic heart disease “once and for all”.[6]

After tracing the history of debates surrounding the underlying causes of cardiac disease, Broken Hearts moves on to consider how this theoretical ambivalence on the underlying cause of coronary thrombosis has influenced how cardiac interventions have been developed and assessed. In the book’s second section, Jones looks at the historical development of coronary angioplasty, bypass surgery, statins and platelet inhibitors, and chronicles medical discussions over which one of these methods provides the best treatment for patients. By showing that the popularity and use of medical treatments is predicated on a multitude of factors besides disease etiology, including ideas about cost, convenience, and effectiveness Jones challenges the popular and professional belief that the benefits of cardiac intervention always outweigh its risks. By arguing that doctors devote more energy to proving that treatments work than they do ascertaining complications—thus producing an asymmetrical knowledge base more focused on efficacy than patient safety. This can be seen in the example of bypass surgery as, in their attempt to demonstrate the validity of this revascularization technique in the face of theoretical ambivalence, cardiac surgeons neglected the cerebral complications that often arose as a result of the procedure.

In his last section, Jones raises the issue of geographic and racial variations in medical practice by showing how cardiac care is not practiced in a uniform way across cities, states or populations.

Through looking at how factors like race and place influence how a doctor will identify and respond to cases of ischemic heart disease, Broken Hearts illustrates the often-equivocal nature of cardiac care and the messiness of medical decision making more general. Although Jones doesn’t offer any hard and fast solutions to these problems, he highlights the need to integrate patient and physician priorities, values and preferences into account when developing new models of medical decision making. He also emphasizes the importance of acknowledging the complex social dynamics that underpin “the diseases we suffer, the treatments we can access, the outcomes of those treatments, and our knowledge of those processes.”[7]

All in all, Broken Hearts is a captivating study of the history of cardiology. By moving away from the longstanding tendency to frame the history of cardiology as a progress-narrative, this book makes a great addition to the emerging body of literature that adopts a critical stance towards cardiac care, including Anne Pollock’s Medicating Race [8], and Janet Shim’s Heart-Sick. [9] Although this book is definitely geared to an academic audience, because it unsettles contemporary ideas about the coherence of cardiac care, the soundness of medical treatments, and the logic underpinning medical decision-making, I think that Broken Hearts has important lessons for the lay reader as well. Especially for people who are currently undergoing treatment for coronary artery disease.

 

Jennifer Fraser is a fourth year PhD student studying the history of medicine at the University of Toronto. Her dissertation charts the history of Canadian cancer epidemiology, focusing specifically on how cancer control campaigns were advertised and applied to Indigenous communities during the mid-twentieth century.

 

Bibliography

“About.” Heart Attack Prevention: A History of Cardiac Disease Epidemiology, Department of Epidemiology; University of Minnesota. 1 May 2016. http://www.epi.umn.edu/cvdepi/about/

“About the Lab.” The Visible Heart Laboratory, Department of Surgery; University of Minnesota. 1 May 2016. http://www.vhlab.umn.edu/about.html

“Conquering Cardiovascular Disease.” National Heart, Lung and Blood Institute. 27 October 2016. https://www.nhlbi.nih.gov/news/spotlight/success/conquering-cardiovascular-disease

Pollock, Anne. Medicating Race: Heart Disease and Durable Preoccupations with Difference. Durham: Duke University Press, 2012.

Shim, Janet K. Heart-Sick: The Politics of Risk, Inequality an Heart Disease. New York: New York University Press, 2014.

Smith, Monica M. “Medical Alley: Tight-Knight Community of Tinkerers Keeps Hearts Ticking, Minnesota (1950s).” In Places of Invention, edited by Arthur P. Molella and Anna Karvellas, 86-110. Washington: Smithsonian Institution Scholarly Press, 2015.

 

Notes

[1] Monica M. Smith, “Medical Alley: Tight-Knight Community of Tinkerers Keeps Hearts Ticking, Minnesota (1950s),” in Places of Invention, eds. Arthur P. Molella and Anna Karvellas, 86-110 (Washington: Smithsonian Institution Scholarly Press, 2015), 86.

[2] “About,” Heart Attack Prevention: A History of Cardiac Disease Epidemiology, Department of Epidemiology; University of Minnesota, 1 May 2016. http://www.epi.umn.edu/cvdepi/about/

[3] “About the Lab,” The Visible Heart Laboratory, Department of Surgery; University of Minnesota, 1 May 2016. http://www.vhlab.umn.edu/about.html

[4] “Conquering Cardiovascular Disease,” National Heart, Lung and Blood Institute, 27 October 2016. https://www.nhlbi.nih.gov/news/spotlight/success/conquering-cardiovascular-disease

[5] David S. Jones, Broken Hearts: The Tangled History of Cardiac Care (Baltimore: Johns Hopkins University Press, 2013), 3.

[6] Jones, Broken Hearts, 96

[7] Jones, Broken Hearts, 228.

[8] Anne Pollock, Medicating Race: Heart Disease and Durable Preoccupations with Difference (Durham: Duke University Press, 2012).

[9] Janet K. Shim, Heart-Sick: The Politics of Risk, Inequality an Heart Disease (New York: New York University Press, 2014).


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