Angina Pectoris, a film written and directed by J E F Riseman, won no Oscars, had no famous stars, and failed to secure even the most limited distribution deal. For those who have not seen the film, its actors are anonymous medical men demonstrating state of the art diagnostic assessment of patients with angina. A careful history of the characteristics of the pain and standardised investigation with resting and exercise electrocardiography are recommended. That all sounds familiar? Of course it does—not only professional bodies but even governments now issue guidance on such diagnostic assessments. The film was made in 1943.
Figure 1.
Fred C Pampel, Seth Pauley
Praeger Publishers, £22.99/$39.95, pp 248 ISBN 0 275 98151 7 www.greenwood.com/books/bookdetail.asp?sku=C8151
Rating: ★★
Pampel and Pauley's book was published in 2004. In what sense have we made progress? Consider diagnosis. Clearly, many new diagnostic tests have been introduced in the six decades since Riseman's film. However, the proportion of patients undergoing coronary angiography in whom no narrowed arteries are detected—20% to 30%—has changed little in the past three decades. This raises the question of how much progress has been made in selecting candidates for an invasive diagnostic test that carries a small risk of major complications. Consider morbidity. Although it is becoming less common for a doctor to write coronary heart disease on a death certificate (at least in high income countries), this is not the case with writing the same diagnosis on hospital discharge summaries. In other words, rates of hospitalisation for coronary disease are not declining in parallel with death rates. Consider prognosis. What improvements have been made in our ability to distinguish reliably between low risk patients with coronary disease, who can expect a normal life expectancy, and those who have a terminal illness, fatal within weeks? There has been some progress, but it is hard to quantify.
Pampel and Pauley pay little attention to questioning such different aspects of progress, preferring to focus primarily on declines in mortality from coronary heart disease. This focus is, of course, important; but theirs is a Whiggish interpretation of history: isn't it amazing how we got here, assuming that “here” (current mortality from coronary heart disease in the United States) is inevitable. This is not a critical account of decline in coronary heart disease mortality and of how each intervention, competing for finite resources, may have contributed. The authors summarise information in the manner of a Sunday newspaper supplement (without the glossy pictures) rather than make a new argument or stimulate debate. Here the usual suspects—drugs, surgical operations, devices, behaviour changes—are rounded up and described in the context of the triumph of modern, largely high-tech medicine.
Who is this book for? It contains much to irritate academics and little to educate clinicians in the management of patients. Neither statement is necessarily a criticism. Academics inveterately complain of how little we know, and this book offers some redress. Clinicians know that randomised trials synthesised in the context of previous understanding are required to answer the question “Is it new and better?” Clinicians will not turn here for this understanding. A lay readership, wanting that Sunday supplement, may be an appropriate audience.
Figure 2.
We love Lucy: but what can celebrity deaths tell us about progress against heart disease?
Credit: TOPFOTO.CO.UK
The book's standard fare is to use stories of Oscar winners and other US celebrities with heart disease or at risk of developing it. An actor (Lucille Ball), baseball star (Darryl Kile), broadcaster (Larry King), talk show host (David Letterman), and media mogul (head of Disney, Michael Eisner) are each given a role. US politicians are given special prominence: Eisenhower, Kennedy, Johnson, Ford, Reagan, Clinton, and Cheney are all brought into the story. (Bush senior and Bush junior are notable by their absence.) At the peak of the coronary heart disease epidemic a famous person with the disease may not have seemed so remarkable. The field of cancer medicine has long known the value of celebrities. Lance Armstrong, for example, has raised awareness and many millions of dollars for cancer research, having won the Tour de France six times despite a 60% chance of death from his cancer.
Celebrities have greater access to high tech medical care than the large section of the US population that is uninsured or underinsured. Furthermore, inequalities in coronary health may have wider societal causes beyond access to medical care. Yet Pampel and Pauley give little attention to how these differences may translate into a relative lack of “progress” against heart disease in certain groups. For example, the disproportionate prevalence of heart disease among black and Hispanic Americans is discussed in only three pages, sandwiched between two lists of “milestones” in clinical cardiology. Most people with heart disease do not live in the United States, yet the book is about that country only. Readers will need to look elsewhere for answers to questions such as why the decline in mortality from coronary heart disease is so much greater in Finland than in the United States and what explains the increase in mortality in the countries of the former Eastern bloc.
If the sequel to the film Angina Pectoris is ever made, or a second edition of this book is ever contemplated, then maybe consideration should be given to society as well as to celebrity.