Throughout my residency, I’ve had the opportunity to perform autopsies on many different people from different walks of life. One case in particular stood out to me. The decedent was not in the greatest state of health at the time of death and subsequent postmortem examination. After I removed his heart from the pericardial sac and began dissecting each coronary artery in sequential tangential sections back to their origins on the ascending aorta, I was shocked to see focal luminal occlusion of over 95 percent in one of the main branches. I wasn’t expecting this severity of coronary artery disease (CAD), frequently the dominant manifestation of patients with atherosclerotic cardiovascular disease (ASCVD), in someone years younger than me. I’m now 30.
ASCVD is the most common cause of morbidity and mortality worldwide. It describes atheromatous blood vessel-related diseases, including (but not limited to) CAD, peripheral artery disease (PAD), and cerebrovascular disease (CVD). CAD is the most common type of heart disease in the United States and affects about 1 in 20 (5 percent) of people age 20 or older. It is the leading cause of sudden cardiac death (SCD), even in younger adults less than 50 years old, and is characterized by yellow, fibrofatty plaques that begin enclosing the lumen as they thicken. Sometimes, if severe, they can calcify and become an exceptional challenge to examine during autopsy (I’ve broken blades on these before).
Ever since this autopsy, my views on life and my heart health have forever been changed. February is recognized by the American Heart Association (AHA) as American Heart Month. According to the Centers for Disease Control and Prevention (CDC), over 356,000 people experience an out-of-hospital cardiac arrest each year in the U.S., with about 60 to 80 percent dying before reaching a hospital. “Cardiac arrest” literally means heart stoppage, describing the terminal event of some pathophysiologic, life-taking process (or “”chain of events”). This term is nonspecific, though, and doesn’t explain why someone dies; it only states the endpoint. Nevertheless, CAD is frequently cited as an attributable cause.
There is an inheritable component to CAD with an estimated heritability rate of about 40 to 60 percent. However, a recent twin study suggests that there may be a stronger environmental influence compared to the inheritable component—i.e., CAD may be more preventable than once believed. Though CAD tends to develop slowly over decades, according to experts, the case described above reminds me that there should be an urgency in establishing healthy lifestyle habits as early as possible. Major preventable risk factors like high cholesterol, hypertension, obesity, and sedentary behaviors are important to combat with proper diet and exercise, but even marathon runners can experience SCD by way of CAD. Additionally, many heavy cigarette smokers may never experience angina (cardiac-related chest pain) in their lives (not that I am endorsing this behavior).
The point is that you’re never too young or too old to start taking care of your heart health and overall well-being. Medicine, and the science behind preventing CAD, is not perfect; nothing in life is. But if someone younger than me can develop coronary artery luminal stenosis to the point of near-total occlusion, I am not immune to it either. Additionally, every autopsy I’ve performed or seen, especially on persons younger than me or about my same age, is a sobering reminder that my time on Earth is finite.
As I steadily get older and continue learning how to practice medicine in today’s fragmented health care (and medical education) system, I’ve considered more the impact that chronic stress has on not just my overall sense of well-being but my heart health. Stress describes the feeling of tension in response to some challenging situation or threat we all face in our daily lives. Some stressors are positive and can motivate us to do better, experience personal growth, or even feel excitement (eustress). However, other stressors have the exact opposite effect (distress) and can result in feeling too overwhelmed to handle or perceive things positively. The latter is common among physicians, as just under 50 percent of us reportedly feel burnout, which is a notable decrease from recent years.
When I look back on my life ever since starting medical school, stress has become my most significant cardiac villain. I’m not alone in this: You’ve also probably had days when you ate poorly, couldn’t sleep, and neglected to exercise because you were too “stressed out.” We’re all human; life can be hard to live sometimes.
If there’s one piece of advice I hope to extend to others, particularly medical students and trainees, it’s to own your stress levels now. We all can fall victim to the meritocratic nature of our field and sacrifice significant time, money, and happiness to take on extra demands. But life needs to be lived and enjoyed. Not everything is “urgent” or needs immediate attention. If you work too hard and take on too much, your ability to provide care for others will suffer. Your health, relationships, and personal well-being may begin to fracture, too.
Take it all in moderation. What we do is serious work, but what’s the point if you’re not building strong relationships or having fun? I’ve made it a point to slow things down at work and take it all in better stride. I’m focused more on living a longer, happier life and enjoying the process as much as possible. Writing about my experiences has helped me cope with living better than any medication could.
In conclusion, take care of your heart, and don’t forget to prioritize your health. Start doing this as early as you can. Our hearts are like ticking clocks; once they stop going tik … tok … tik … tok … so do we. If you need more convincing, visit your local morgue and dissect a human heart with coronary arteries full of plaque and calcium in someone years—or decades—younger than you.
Casey P. Schukow is a pathology resident.
