When I started my first internship, back in Sweden in 1979, I worked under a fifty-something cardiologist who spoke slowly with a southern drawl – yes, there is a southern drawl there, too, slightly reminiscent of Danish, spoken not far from where my supervisor grew up.
He epitomized the the old school of cardiology, before it became a procedural specialty. He diagnosed heart murmurs by auscultation with his stethoscope, and he even claimed he could hear faint cardiac rubs or pulmonary râles in patients who were having a heart attack. He seemed to share the temperament of neurologists – slow and methodical master diagnosticians with, very much then and to a degree also today, limited or no treatment for a substantial portion of the diseases they diagnose.
In 1979, color Doppler echocardiography was not yet invented, and coronary angiography was not available where I worked. Cardiology was a purely cognitive specialty. The most important condition cardiologists treated, angina pectoris, was diagnosed on the basis of history, physical exam and at most a stress EKG.
Over just two decades, cardiology became a procedural specialty, and the diagnosis and management of angina became high tech with nuclear imaging, coronary angiography, cardiac stenting and bypass surgery. The view of angina became focused on stentable, “critical” lesions.
But people still died from heart attacks, even with only minor blockages on angiography and normal nuclear stress tests. And patients with classic angina symptoms were told they had non-cardiac chest pain if their stress EKG was abnormal but their nuclear scan was normal, or if the EKG and scan were abnormal, but the angiogram showed no critical stenosis. For over 100 years, the term “pseudoangina” was used to characterize this syndrome.
Every few years I would ask whichever consulting cardiologist seemed the most approachable, and every time I would get essentially the same answer: Angiogram trumps MIBI, MIBI trumps EKG, EKG trumps clinical history, kind of like the old rock-paper-scissors game.
Ironically, in 1973, the year before I started medical school, Harvey Kemp coined the term “Cardiac Syndrome X” for effort angina with normal coronary arteries. We now have some understanding of the mechanisms behind this condition, and this has led to some techniques for proving and studying it, but the diagnosis is largely clinical. We essentially don’t do coronary angiography with injection of adenosine or acetylcholine, measurements of coronary flow reserve, single photon emission computed tomography, positron emission testing or stress cardiac magnetic resonance imaging, at least not at Cityside Hospital. One thing we have learned is that this condition does progress relentlessly in 20-30% of cases and causes heart attacks and death in some patients, even though this was initially thought to be very rare.
The most dramatic development in cardiology in the last twenty years is probably our understanding that rupture of non-critical cholesterol plaque, small enough to go undetected during routine EKG or nuclear stress testing, accounts for somewhere around 85% of all heart attacks.
So much for all the angiograms, elective stents and bypasses cardiologists have been doing. In acute coronary syndrome, which is unstable angina or a heart attack without classic EKG changes of a completed heart attack, there is still an important role for urgent cardiac catheterization, but its role in stable angina or asymptomatic coronary stenosis is debatable at best.
So, now cardiologists are having to reconcile that their angiograms are a most imperfect predictor of disability and death, their stents don’t save lives except in acute coronary syndrome, and more and more of their patients will be plodding along with medical management of coronary disease that doesn’t show up on angiograms. They may find themselves tinkering with medical management of an incompletely understood syndrome, choosing drugs and dosages based on -gasp- patients’ subjective histories and clinical experience.
The pendulum is swinging back; a circle seems to be completed. Will cardiologists become slow and methodical internists again?
A Country Doctor Writes: 
Very interesting. No, I don’t think that cardiology will return to the model of internal medicine. Too many are trained in the elective stents, angiograms, etc. Our society is trained-programmed for electronic testing and cures, a pill for everything, and this is the mind set of most doctors and patients. I find it odd, when thinking of this, as the most technology savvy doctor that I have is my oncoligicol radiologist would get along quite well with your Southern Swedish cardiologist. I am cancer free-from a rare incurable, thanks to his vision and skill. He was waiting and trying to find a patient with this to try a new technique-I was very lucky. He takes the time to think things out and consider different factors in a person’s health history and what he sees and hears in front of him. He’s not shy in contacting my other providers if there is a problem. He found me a PCP that would reduce my thyroid HS, instead of telling me to loose weight and take BP meds. I had lab work that showed I was out of range for 5 years. I went through this with 4 PCPs. He was trying to be careful and not step on anybody’s toes. One PCP was very angry that he’d be talked to by an oncologist. So, yes, this very high tech thinks like an internist.
Thank you for this line of thought.
I discovered your blog some time ago and, apparently we share the same background – Scandinavian – as well as the same training and have been in practice for approximately the same number of years.
I am sure that you, as well as I, can remember large postmortem studies (in Europe) which clearly showed that the majority of heart attacks were from acute rupture of relatively small plaques in the coronary arteries.
We now have extremely expensive and sophisticated investigations which allow us to now feel comfortable with the information that was available 40 years ago.
The current reimbursement system in this country rewards intervention and punish nonintervention to the extent that no physician is likely to give up any procedure which can be justified.
Recent reviews of interventional cardiology for people with stable, exercise angina clearly shows that the procedure is for relief of symptoms, and does not affect mortality. The analogy would be lumbar disc surgery for those individuals with sciatica.
I think with his long as we are clear with the patient that we are simply using this to relieve his symptoms, I don’t see any major ethical problem with this. However, many of our patients are under the belief that her life was saved by the cardiologist and I suspect at some point this disingenuous behavior should probably be addressed.
Many thanks for an excellent column.