Heart and Soul

“My mother had it, too,” she had told me in the past, “but she fought to the very end. I plan on doing the same.” Her hands were petite and cracked with decades of hard work that one could only acquire from a family farm. They were the kind of hands that longed to be touched, frequently pulling you in for a short embrace at your every meeting, when doing such a thing wasn’t taboo in the midst of a global pandemic. She sat in the same chair every session. It had a light blue color that would seem even lighter in the glow of the sun that radiated through the infusion center windows in the late morning. Her headscarf would change every time I saw her, which wasn’t a coincidence, being somewhat of an inside joke between her and the other patients whose sessions typically fell on the same days. That loud personality, which always reminded me of the blown bubbles on the top of a milkshake on a hot summer day, was what made her “her.” These are the human elements that can get lost in modern medicine but make all the difference. The melding of cardiology and oncology disciplines, albeit in its infancy as far as recognized subspecialties go, has an incredible opportunity to treat the whole patient again. The totality of treatment can encompass physical, mental, emotional, and spiritual health across multiple fields. But I’ve always asked myself, what is my best role as her cardiologist? How can I treat her to the best of my ability?

In order to do no harm, a portion of the Hippocratic Oath we all take in medical school, we analyze risk/benefit ratios. This ratio is frequently in the form of the number needed to treat (NNT). This metric being typically to prevent, either alone or in combination of, death or major adverse cardiac event. Consider a patient having a myocardial infarction, for example. On top of primary revascularization, which is by far the most impactful treatment we can provide, we are quick to prescribe high-intensity statins and aspirin as essential medications for guideline-directed medical therapy. Similarly, for heart failure patients with a reduced left ventricular ejection fraction, we prescribe even more medications and, in some situations, recommend implantable devices to improve the synchrony of ventricular contraction with the goal to make them live longer and feel better. Depending on the trial you draw information from, the number needed to treat for statins (in patients with and without a prior heart attack) is anywhere between 47 and 128.¹  For aspirin, the NNT to prevent another non-fatal heart attack or death is quoted to be 333 and 77, respectively.² The statistics for heart failure are even more defeating, and for a practitioner wanting to make a meaningful impact on each patient, this can seem like a long road to the inevitable.

She told me that her favorite color was teal, all three of her children were grown up, and her husband, which she fondly referred to as her “fourth child,” was back at home on the farm. Her favorite flavor ice cream was orange creamsicle, which reminded her of summers as a child at the public pool. Her biggest fear was what would happen to her fourth child if her battle with cancer were to end prematurely. Spreading kindness to all she could touch in the meantime was her short-term goal. But as with all sessions, this one flew by thanks to good conversation and we parted ways. We exchanged “see you later,” which always was her preference to “goodbye.” The latter felt too definitive for her taste.

Instead of walking her out this time, I stayed in my seat. The rays of sunshine now shining down from a higher portion of the long windows. I started to reflect on how to best impact the health of my patients moving forward but was interrupted by a strong, petite women in a colorful headscarf. She turned back before exiting the infusion center and with a cautious smile and glistening eyes simply said, “thank you.” At that moment I had found my path. Cardio-Oncology has an incredibly unique opportunity to participate in the multidisciplinary care of complex patients that are going through the most difficult times in their lives. However, the diagnosis and medical treatment are but a small piece of a bigger puzzle. I hope to never forget the impact a thoughtful conversation can have on the well-being of a patient, and with cardiovascular disease and cancer remaining the top two causes of mortality in the United States, a statistic that is hard-pressed to change anytime soon, there is plenty of opportunities for providers to step in and have that impact. It seems there is a chance to narrow the NNT to as low as one, which is a much-needed breath of fresh air in these darker days when many people feel alone and alienated. Who am I to reject that chance?

Bibliography: 

1.        Roger Chou, MD; Tracy Dana, MLS; Ian Blazina, MPH; Monica Daeges, BA; Thomas L. Jeanne M. Statins for prevention of cardiovascular disease in adults. JAMA 2016; 97239 (19): 2008–2024.

2.        Trialists A & Collaboration ATT. Aspirin in the primary and secondary prevention of vascular disease : collaborative meta-analysis of individual participant. Lancet 2009; 373 (9678): 1849–1860.