The procedures that we’ve been discussing are usually performed in cases where only one or two arteries are blocked, though there are exceptions. It’s important for you to realize that such procedures are palliative-that is, they relieve the condition, they avoid heart surgery, but they do not free the patient of coronary artery disease. These procedures are more likely to be effective when patients are ready to take charge of their own destiny by giving up cigarettes, by exercising daily, by reducing stress when possible, and by learning better methods of stress management. And, of course, lowering cholesterol is important.
Even under the best of circumstances, these procedures

require, before you submit to them, that you talk openly with your doctor about an alternative plan. Once again, if the doctor is offended or evasive in response to such questions, or if you have the impression that the doctor is too busy to answer your questions, you may need to find another doctor. Again, it’s your job to be courteous, open, and nonthreatening. It’s the doctor’s job to give you all the information you ask for.

It’s true that some patients don’t want to know. But if you were one of them, you wouldn’t be reading this book. In general, the better informed you are about a procedure and about what may follow, the less worried and the less anxious you’ll be. And the less worried you are, the better for your heart.

One patient who had refused angioplasty treatment later explained: “It wasn’t that I didn’t want the angioplasty. But the doctor seemed in such a big hurry, like I wasn’t important to him, I guess I was just scared. I wish I had asked more questions.” Take those words to heart. If things are moving faster than you’re comfortable with, slow them down. Ask your questions. (You’ll find more on this subject in Appendix 1, “Your Rights as a Patient.”)

Procedures involving the heart-coronary bypass surgery. angioplasty, stenting, or atherectomy-can be stressful anc even scary. Ease your mind by asking questions and gaining knowledge. Besides relaxing you and relaxing your doctor, this tactic lets the doctor know that, as an inquiring and informed patient, you have high expectations of him or her and of the hospital.

Now let’s look at a slightly different angle. Because Dr. Schaeffer doesn’t consider Bigger’s condition immediately threatening, and because Bigger is a cooperative and smart patient, the doctor has decided to begin treatment with methods that aren’t invasive. If after a few months the improvement isn’t what Dr. Schaeffer has hoped for, he still has several resources he can turn to instead of surgery. Remember that coronary disease means that the arteries are dogged and therefore the heart isn’t getting enough oxygen-rich blood. Whatever the treatment, it must address that basic problem. In the case of a patient for whom exercise, diet, and stress- relief measures don’t bring about the necessary improvements or stability, there remain several options for nonsurgical treatment. These include angioplasty, stenting of an artery, and atherectomy.

Angioplasty

The most common of the treatments we’ve named is angioplasty. It’s an outpatient procedure-that is, you usually go home the same day the procedure is performed or the next morning-pc formed by a cardiologist, in the cardiac catheterization lab 0= hospital.

The procedure itself begins with the insertion of a sn: wire, called a catheter, into the blocked coronary arteries. A c. loon is attached to the end of the catheter and the catheter advanced into the arteries that surround the heart. The cardio. gist can monitor the progress of the catheter on a TV sere called a fluoroscope. With the heart and the blood vessels t. surround it always in view, the cardiologist steers the balloor; the center of the blocked artery. Then the balloon is infla.. causing the blocked vessel to reopen.How does the catheter find its way to the blood vessels of the heart? \Nell, it’s a little bit like following the yellow brick road. The catheter is inserted in any large blood vessel-usually in the groin area-that leads to the heart. From there, the catheter just follows the path back to the heart.
Angioplasty is usually recommended for patients who have one, or sometimes two, severely blocked coronary arteries. It is also performed in situations where, for whatever reason, heart surgery is considered dangerous or impractical. Generally, angioplasty is painless and straightforward. The patient is mildly sedated with a local anesthetic (that is, the area to be treated is numbed, just as it is in your dentist’s office). Angioplasty is a common procedure, performed in university hospitals, teaching hospitals, and community hospitals all over the country.
Naturally, in this treatment as in all medical treatments, there can be a downside. In this case, the risk is that the blood vessel that’s been opened can close again, or the blood vessels can tear open (rupture). You can playa significant part in raising your odds of having a successful procedure by finding out as much as you can about the product,
which, in this case, is your doctor’s competence and experience, and the reputation of the hospital in which the procedure will be performed.
You need to ask your doctor how many angioplasties he or she has done and the success rate of these procedures. Don’t be embarrassed. You have an absolute right to know. So ask the following questions, politely but firmly, and expect answers:

•    How many angioplasties have you personally perform- .
•    In what percentage of the angioplasties you perform d
the arteries close again?
•    What is your success rate?
•    What happens if the angioplasty doesn’t work?
•    What complications are possible, and how do you deal
with them?

Most well-trained board-certified cardiologists will have no tr: ble answering these questions freely and openly. If your docto: defensive, refuses to answer your questions, or seems offended, t should raise a red flag. You need to what you can to keep the commun.: tion going, and that means asking: questions again, if necessary, in most friendly and unthreatenin~ ” you can. If you still don’t get a satisf: tory response, you’d be wise to ref the procedure with that particular c. diologist. You can find a better more open to his or her patients, more likely to win your cor dence. You want no less. After all, next to God, the cardiologis: the person who will carry your life in his or her hands.

Stenting

A second nonsurgical procedure for opening blockages in a y;; sel, and which is used in conjunction with angioplasty, is stenti A stent is a very small coil that keeps a blood vessel open once has been cleared by angioplasty. The cardiologist first locates t. “culprit” artery-the one where the trouble is. He or she opens that vessel with an angioplasty procedure. The cardiologist then inserts the stent. It’s that simple. Although the results vary, depending on the extent of the damage and on the cardiologist’s experience, in general, angioplasty with stents works even better
than angioplasty alone.

Atherectomv

Finally, your cardiologist may suggest, rather than angioplasty or stenting, a procedure called atherectomy. Here, a small device is inserted into the blocked artery and cuts through the blockage. Atherectomy is only performed by the most experienced cardiologists and, in general, it’s less effective than angioplasty or angie-
plasty with a stent.

Exercise is an essential part of heart treatment. Exercising regularly lowers blood pressure and cholesterol. It lowers cholesterol by allowing your body to metabolize it more effectively-that is, to burn it off. We often forget that the heart is a muscle and that it needs exercise just as other muscles do in order to remain efficient and strong.

Excess weight means more work for your heart-more wear and tear. Talk to anyone who works out at a gym or at homeabout how exercise lowers stress lev-els. Life is stressful, and it can be especially stressful for African Americans. Although we can’t always eliminate the causes of stress, we can do something about the effects. In chapters 5 and 10, we describe exercise routines that are easy, fun, and uiat relieve stress and bring about the other good things we’ve described.Maybe you’re going to tell us that you know lots of people who exercise regularly and still have heart attacks. Maybe you even remember the famous Flo To, who died of a heart problem despite being in ultimate shape. It’s true: Life isn’t always fair, and life isn’t always consistent. We know a lot about the heart, but mysteries remain.

What isn’t a mystery are the odds. For every ten people whc keep in shape and nevertheless die of heart disease, thousands die due to lack of exercise, and because they don’t control their cholesterol and blood pressure levels. You’re smart enough tc play the odds. Exceptional cases like that of Flo Io aside, if you have a strong heart as a result of exercise and conditioning, even if you have the misfortune to suffer a heart attack, your chances of surviving are greatly increased. Do you want to live longer and live better? Play the odds.

WE’VE BEEN TALKING ABOUT what the symptoms of coronary artery disease( CAD) tell you if you listen to them. We haven’t said much about what happens
after the doctor tells you that you have coronary artery disease. Is surgery the only solution? And, if not, how do you and the doctor choose between treatment options?

Let us introduce you to Bigger Gordon. Bigger has a lot going for him. He’s bright, energetic, and takes pretty good care of himself. He doesn’t drink, and he plays basketball once a week in his church league. True, he smokes-”a little,” according to Bigger, and “a lot,” according to his wife. But, he says, his work has its tensions, and cigarettes and an occasional CIgar help him to handle stress.

Bigger is a well-educated man who graduated at the top of his class from Hampton University in Virginia, and his life has been good so far. He’s an excellent father to his two kids, and: and his wife are the best of companions. As for his job, it’s the je he was born for, as he often says. As the first African American ~ hold the position of vice president of finance in a multi-rnillio:’. dollar company, he’s determined to be better than the best. Tl.. means some stress, but he seems to thrive on it. There’s nothi-’. Bigger has looked forward to more than going to work ea, mornmg.

But all that has changed for Bigger since the spring of 199 when, after two weeks of slight pressure in his chest, he awo. one morning with alarming chest pain and presented himself L examination at the local emergency room. Bigger had a pret: good idea of what he was in for. Coronary artery disease runs : his family. He saw his mother die from it, and his father becan: . a semi-invalid because of congestive heart disease.

In the emergency room Bigger was put through a full cardia: workup: physical examination, lab work, chest x-ray, and electrc cardiogram (EKG). Meanwhile, the emergency doctor called in cardiologist, who, on the basis of the examination and test; agreed with the diagnosis of unstable angina.

“Tell you what, Mr. Gordon. Let’s do one more test-a corenary angiogram. That’ll give us a closer look at the arteries ar; help us to evaluate any potential damage. From there, we C2know better what we have to do.”

What the cardiologist, Dr. Schaeffer, came up with wasn’t “l. ~ best of news, but it wasn’t the worst either. He found that tl: ~ main artery that feeds the heart was 20 percent blocked, and ther: was blockage in several minor arteries. But Dr. Schaeffer didr: recommend surgery. “I think that this can be satisfactorily treate : without that,” he said. Bigger took the news with mixed feelings. Nobody loves the idea of going under the knife. At the same time, the analytical part of his mind was uneasy. “Look, Dr. Schaeffer, I certainly don’t want surgery if I don’t need it, but I need to get this fixed, I don’t like the idea of messing around with it for years, waiting for the other shoe to fall. Maybe it would be better to go in and get the whole thing taken care of now-you know, to have the surgery and get this all behind me.” ”I’ll tell you what, Mr. Gordon. You listen to what I have to say. Then, if you still feel uneasy about my recommendation, we’ll call in another cardiologist.” Bigger knew how to listen. And what he heard was roughly this: In a sense, heart issues are lifestyle issues. The way we eat, the way we spend our days, the substances we ingest, the way we manage the inescapable stress in our lives-it all bears on the health of our heart. If all Americans consciously controlled their cholesterol, their blood pressure, their diabetes, if they smoked and drank less and exercised more, coronary artery disease would be much less of a problem than it is.
Much of what hurts the heart is avoidable. And, though most people aren’t ready to hear this until after they’ve had heart trouble, even after the heart has suffered injury it’s not too late to change habits, and, by changing them, to help the heart to heal. The patient is in large part his or her own doctor. For instance, before he even mentioned medication, Dr. Schaeffer told Bigger at once that an essential part of his treatment was to stop smoking. “It’s up to you, Bigger;’ he said. “I can only give you the facts, and the facts are these. Cigarette smoking is dangerous and can be lethal to every organ in the body, and especially to the heart. The chemicals in cigarettes directly cause damage to coronary arteries-damage that will eventually lead to blockage, heart attacks, and strokes.” “Yeah, well, I don’t want to sound cynical, but what’s the difference now, when the damage has already happened?” Bigger asked.
“Let me give you another fact,” said Dr. Schaeffer. If you keep smoking, whether you are treatec medically or surgically, your chance of recovery is decreased. Ii you have bypass surgery, smoking will lead to premature closure of the bypass grafts and will leave you as bad off as when yotstarted. I know, you hear a lot of people say, smoking’s not the worst thing in the world. They’ll tell you about friends and relatives who lived to be eighty and smoked down to their last dai Sure, it happens. But for everyone of those, thousands die of hear: attacks or heart failure for which smoking was a primary cause Those are the facts. You make the choice.”

Okay,” Bigger said. “You’ve convinced me. I’ve always tole myself I could quit when I chose to. Now I choose to. But SOlI: of this other stuff isn’t under my control. You tell me my bloc pressure is high. Well, so was my mother’s and my father’s an ~ their mother’s and father’s before them. Not much I can do abor that, is there?” “I don’t want to sound smug,” Dr. Schaeffer said, “but tl.. answer is: ‘Actually, quite a lot.’ For example, you can exercise.” “But I do, once a week-basketball in the church league. You should see me go at it. They call me “Air Bigger.”
Dr. Schaeffer agreed that was fine. “But it’s not enough,” he said. He explained that they could bring Bigger’s blood pressure down with medication, but it was more important in the long run for Bigger to bring it down by himself.
“I’ve got patients who swear by meditation. Not only do they swear by it, but as far as I can tell, it works for them. It’s one way of getting in touch with the part of yourself that isn’t stressed and that doesn’t need to run at full throttle all the time.
“We also have to look more closely at your exercise regime.

Playing basketball once a week is fine-or was fine-we won’t have you doing that until we get your heart in better shape. But the point here is that you need something regular-say three times a week in a gym, with at least 20 minutes of aerobics each time. Regular exercise lowers blood pressure. Once we have you fixed, that’s something you need to make time for. “Your cholesterol is too high. If we don’t change that, it won’t do us
much good to correct the damage that’s already been done. For you, high cholesterol means more damage to the arteries.” “So you’re going to put me on a diet of fish and broccoli for the rest of my life. Man, that’s going to be tough. I love to barbecue on the weekends.” Nothing that bad. My view is, if you’re not eating some of the things you enjoy, you may cut the cholesterol, but you’ll add to your stress,” explained Dr. Schaeffer. “The diet I’m going to recommend allows you to eat a variety of tasty things, but it requires you to keep mental tabs on how much cholesterol you take in. [The reader can find out more about this diet”I’m not saying that this isn’t a drag. vVe all want to eat what we want to eat when we want to eat it. But you’ve got to think about the trade-off. What you’re going to find, Bigger, is that, if you stick to the regime we’re plotting out here, you’ll feel better than you have for years.

“I have to say that for you it isn’t all going to be lifestyle remedies. Your blood pressure is too high, and we have to address this immediately. For a while, at least, I’m going to put you on medication. Then, when we lower your blood pressure to where it should be, we’ll see if we can gradually control it without medication.

“My guess is that if you watch what you eat, stop smoking get into a regular exercise routine, and, if it suits you, some meditation as well, we can get you in reasonably good shape. I don’t want to kid you on this. You do have coronary artery disease, and nothing can make it entirely undone. But we can have you living a healthy, normal life, and playing as much basketball as you want, but you have to stick to the plan we’ve talkec about here.

“Let me sum this all up. You have coronary artery disease that your smoking and high blood pressure have contributed tc I’m going to treat this in two ways. First, I’ll give you medicatior, nitroglycerin, that will help increase the blood flow to your heal’ when your heart is stressed. It does that by opening up the arte:ies around the heart whenever the heart needs extra blood.

“I’m also going to put you on medication to help contrr your blood pressure. [The reader can find out more about hit blood pressure, also called hypertension, in chapter 8.] But, as I’ve said, medication can’t do the whole job. You have to support it. And you do that by, first, not smoking; second, by exercising three times a week; third, by keeping your weight down; and, fourth, by eating low-fat and low-sodium foods. You’d be surprised at how tasty and varied such a diet can be-and I speak from experience. And on Sundays I’ll give you time off for good behavior and you can barbecue and eat what you want, but in moderation.
“You stick to this plan and we’ll stop the progression of your coronary artery disease-maybe we’ll even reverse some of it. I’d like you to make an appointment for a month from now. At that time, I’ll examine you and check your blood pressure and cholesterol levels, and we’ll see if you’re really in shape, Air Bigger.” Dr. Schaeffer smiled at Bigger. Bigger was lucky in one respect. He didn’t have a serious weight problem and he knew something about exercise. What if he hadn’t? Dr. Schaeffer would have told him much the same thing, but he might have had a harder time convincing him. Excess weight, or obesity, which is disproportionately high among African Americans, and especially
among African American women, is a major risk factor in matters of the heart. Often, overweight people have stopped exercising, or never did exercise.

The condition in which the heart doesn’t receive enough blood is called myocardial ischemia. It occurs when the blood vessels around the heart that feed blood to the heart are clogged or blocked. Untreated myocardial ischemia can play itself out in three phases: angina (the general name for the condition in which the heart doesn’t get enough blood), heart attack (myocardial infarction), and sudden death.

In some cases (10 to 20 percent), angina is “silent”-that is, the patient experiences none of the usual symptoms. And angina can be stable or unstable. When it is stable, it is predictable. For example, exertion will always bring pain, and resting will always stop it. Unstable angina is more dangerous. Symptomatic pain may come when the victim is resting, or, if it comes during exer- tion, it may not go away when the victim is at rest. It is also more likely to lead to a heart attack.
But these distinctions aren’t essential to the patient. What is important is that he or she recognize the symptoms and seek appropriate care. Myocardial ischemia (the condition in which the heart does- n’t receive enough blood) can cause a heart attack, as you know. While angina is a symptom that the heart isn’t getting enough blood, in the case of a heart attack, the blood flow to the heart stops completely, and the part of the heart affected will die. The death rate for heart attack is estimated to be 8 percent to 10 percent, and may run higher.
Myocardial ischemia can-though only when there are rare complications-cause sudden death, and it’s common. The hear: goes into a dangerous arrhythmia (irregular beat) and then stops It is this kind of heart attack that’s most publicized by the medic. and that’s unfortunate. Such episode; happen, certainly, as we saw in the case of Reverend Johnson, but the’ are relatively rare. The damage don e by the wide publicity given to sue:’ cases, with all their drama, is the: people get a false sense of fatalisn. “See, nothing can be done. If it going to happen, it’s going to hal-” pen.” That’s one way we rationali: not taking care of ourselves.

The truth is that heart attacks usually follow warnings in f’ form of angina symptoms. And angina, when diagnosed ar. treated appropriately, usually has a good prognosis.

1.    Victims of heart disease usually die suddenly with no prior symptoms.

1.    If you have coronary artery disease there’s nothing you can do about it.

1.    Chest pains and discomfort or tightness in the chest are just signs that you’re getting older.

1.    Feeling tired all the time, or less energetic, is just another sign that you’re getting older.

1.    Once cardiac symptoms occur, there’s nothing you can do to reverse the process.

1.    If cardiac symptoms are ignored long enough, they usually go away.

If you answered false to all of them, you passed. These are all misconceptions that lead to delay in early diagnosis and treatment. They also lead to countless unnecessary deaths in all Americans, especially African Americans. Sure, it’s a misfortune to develop coronary artery disease. But it’s a far worse misfortune to ignore symptoms, which, when recognized, can point you toward treatment and recovery. All you have to do is recognize them early

DON’T IGNORE THE WARNING SIGNS Every day, across the United States, hundreds of African Americans die simply because they have ignored the warning signs of coronary artery disease (CAD). This is a message that has to be repeated over and over again. And, though we’ve touched on these signs before, they bear repeating:

• •    Pain in the center of the chest-or, mOJ,~ commonly, a pressure experienced as a tightening vice, or as an elephant sitting on the chest. This sensation is felt just under the breast bone, sometimes to the left side of the chest under the nipple.
•     Sometimes, a persistent pain in the left or right arm. Such feelings of pressure often occur while the victim is exercising, running, or out in the cold working, as Mr. Samson was. The pain can be urgent enough to require the victim to slow down or stop what he or she is doing.
•     Any chest pain or pressure that goes down the left arm or up to the throat, or jaw or back, or even to the lower back, and that lasts ten minutes or more.
•   Shortness of breath.

While these symptoms are common to most victims of heart disease, regardless of race, studies show that African Americans are less likely to attribute the symptoms to heart problems. True, the symptoms could simply be the result of an especially bad day or plain old age. But wisdom requires that, when the symptoms per-

sist, they be taken seriously. Only c. doctor, by an appropriate medica: examination, can determine hOIthreatening they are. The sooner thsymptoms are addressed, the bette: the chance of early diagnosis, medic, intervention, speedy recovery, an ;
extended life.

Shortness of breath, heavy breathing, and the feeling ofbeir: ~ hungry for air mean that the heart isn’t doing its job. And the> are other signs:

•   Swelling of the feet or legs
•     Feeling tired all the time and lacking energy
•     Loss of appetite

These last signs may be symptoms of Congestive Heart Failure, a condition we will take up in chapter 7. For the moment, it is enough to say that these symptoms of CHF mean your heart isn’t pumping as efficiently as it should. It isn’t doing its work properly because it isn’t receiving the blood it needs. It isn’t receiving the blood it needs because the arteries that supply the blood are dogged.
The causes of CHF are various. It can simply be a late stage of coronary disease, or the result of high blood pressure or valve problems in the heart. But it can also be caused by viral or bacterial infection or alcohol abuse. Its symptoms too can vary. vVeight gain, shortness of breatl: poor energy, and other unspecific symptoms can be indicators Unlike coronary disease, CHF does not provide such specific symptoms as chest pain. The essential point is that coronary disease results from a blocked artery or arteries, while CHF mean: the heart is not working well because some of the heart muscl: is dead.
But the most common reason for heart failure is underlyin; coronary disease, which is ignored by thousands who suffer fror; symptoms every day, particularly African Americans. Only third of African Americans who su=• fer from the symptoms we”. described will attribute them to tl: c heart, whereas half of the white pOi’” ulation will do so. Part of the prot• lem is lack of knowledge-which tl: book was written to address. B~’ there are other problems: fear of knowing the truth; a gener. paranoia about doctors, nurses, hospitals, and, indeed, a dee. mistrust of health care providers; and a lack of insurance or access to health facilities.

We address the fear and mistrust later in the book. Our 01′ attitude is that knowledge brings power. The earlier the diagn sis, the better your chances. The only way to know if the pain ‘. discomfort you experience in the chest area is a sign of corona .. disease is to get a complete medical workup-that is, a comple medical examination, including an EKG, a chest x-ray, the app:” priate blood or other lab work, and/or invasive or noninvas: cardiac testing. Such a procedure often means the differer . .: between life and death. Lack of knowledge, poor access to health. facilities, and paranoia among black Americans-though they can have real social and economic causeshave too often led to inadequate treatment, treatment that comes too late, and deaths that could have been avoided.
Let’s change that-starting here, starting now. Here’s another lesson that could help you to live a longer and more productive life. The heart is a muscular pump that, like all muscles and organs of the body, needs blood to survive. Blood vessels around the heart deliver blood to the heart muscle. When the heart doesn’t receive enough blood, heart symptoms occur.

ALEXANDER  didn’t feel well one January morning, but he had his pride. Over coffee he joked to himself: ”A man’s gotta do what a man’s gotta do.” And what he had
to do that day was take down the Christmas lights from the front of his house.

“Get someone else to do it and you stay here and help me take the tree down and clean up this house,” said his wife Judith. But no, he’d rather work outside, and alone.

By the time Alexander had lugged the ladder from the garage to the front of the house, he already was short of breath and felt a heaviness in the middle of his chest. But this was nothing new. He’d been tired a lot lately, and the trouble brea~hing and pressure in his chest were just part of that. He’d expected a livelier retirement, but he didn’t feel like doing very much. Anyway, why should he? He’d worked hard for thirty years. Why run around now? When neighbors or church members or his sons and daughters asked how he was doing, his answer was always the same: “Fine. I’m getting along just fine.” And in most respects he was. He’d never had a long illness or had to go to the hospital except for a few stitches to close up a wound he’d gotten at work. And though somewhere down the line a doctor had told him that he had “high blood pressure and a touch of the sugar,” he’d never done much about it.

Despite the hard job of lugging the ladder and climbing it Alexander felt the bitter cold. He hadn’t worked long before his chest began to hurt him worse than before and he couldn’t catch his breath. He came down the ladder to rest a little, but he wantec to finish the job, and before long he climbed back up, only to fee. the same discomfort again, this time more severe.

Now there didn’t seem to be any way around it. He wen: inside to tell his wife what he was experiencing. “Just let me lie down for a minute. I’ll be fine.” But no, she wouldn’t just let hin: lie down. Instead, she drove him to the local emergency room Events there moved fast. After the nurse took his blood pressure and listened to his chest, a doctor gave him a more thoroug.. physical examination. ”I’m sure you don’t enjoy all this fussin; over you, Mr. Samson, but we’ve got to do a couple of tests.”

First, there was an EKG-an electrocardiogram-that pre ~ vided a graphic display of each heartbeat. Then there were bloo tests, to determine if Alexander’s blood showed traces of tl. c enzymes released by the heart muscle during a heart attar. Finally, Mr. Samson was wheeled to the cardiac catheterizatie. lab, where a cardiologist inserted an intravenous (IV) tube in:
an artery in his left groin. “This way,” the doctor told him, “we G ~ct a picture of the arteries around the heart, to tell if they’re ?lugged up or not. It gives us a kind of roadmap of the arteries .hat feed the heart blood.”
“Oh my Jesus;’ Mr. Samson said. Despite his discomfort and
znxiety, he meant it. He’d been a machinist all his life, and these .iigh-tech gadgets and procedures impressed him.
They impressed his doctor in a different way. The tests :-cyealed that, although Mr. Samson hadn’t had a heart attack, the :”":1ajor arteries around his heart were blocked so seriously that he’d likely suffer a heart attack in the next few days if something wasn’t done to intervene. That heaviness in the chest and shortness of breath he’d been bothered by were early warning signs. His heart needed more blood than it was getting. Fortunately, in this case Mr. Samson and his wife had listened to the warning signs. Unfortunately, every day hundreds of African Americans die because they ignore these signs.

Recognizing the symptoms of CAD is the first step toward curing it. In Reverend Johnson’s case, these symptoms included:
•    Rapid pounding of his heart
•    Shortness of breath
•    Pain or pressure located in the center of his chest, sometimes spreading to the arms, back, or jaw
Other symptoms include:
•    Swelling of the legs
•    Fainting spells
•    Nausea and vomiting

But even before symptoms are apparent, there’s a way of anticipating them. Doctors call such signs risk factors–preconditions that make it likely that someone may have a heart attack. Here’s a list of risk factors, in a descending order of urgency (which doesn’t mean that any should be ignored):

1.    High cholesterol levels (In chapter 12 we talk about the distinction between “good” cholesterol [HDL] and “bad” cholesterol [LDL]. For the time being, when we say “cholesterol,” we mean bad cholesterol.)

3.    High fat content in diet (see chapters 12 and 13), which may lead to high cholesterol levels and to still another risk factor-that is,
4.    Excess weight and diabetes
5.    Smoking
6.    Advanced age
7.    Family history of heart disease
8.    Lack of exercise
9.    Excessive alcohol use

Look these over. Only two of the risk factors are totally beyond our control. We cannot avoid aging (except by the worse alternative), and we can’t unwrite our genetic makeup. We can watch what we eat, we can exercise, and thus lower our blood pressure, and we certainly can stop smoking or, even better, never begin. These aren’t lifestyle matters-they’re matters of life and death.
Before we discuss symptoms further in chapter 2, we want to say a few words about hypertension-high blood pressurebecause it’s the most dangerous risk factor, especially for African Americans. Elevated blood pressure, no matter how mildly elevated, is likely to result in coronary artery disease. It is one of the body’s early warning systems.

•    One in five males and females have some form of CVD .

•    One in three men can expect to develop some major cardiovascular disease before age sixty; the odds for women are one in 10.5.

More than 2,600 Americans die each day of CVD-an average of one death every 33 seconds.

•    CVD claims more lives each year than the next seven leading causes of death combined.

•    Since 1900, CVD has been the number one killer in the United States in every year but one (1918).

•    Currently, 69 million Americans suffer from cardiovascular disease.
•    This year, 1.5 million people will have heart attacks.

There will be 500,000 deaths among these 1.5 million people.

What happened to Reverend Johnson could obviously have happened to anyone-male or female, black or white. It happens to 2,600 Americans every day, one death every 33 seconds.

Statistics give us the context, but people are more interesting than numbers. So let’s take a closer look at what actually happened to Asa Johnson. If Reverend Johnson had seen a doctor in time, he would have learned that his pains, fatigue, and hard breathing pointed to angina. Angina is the body’s way of telling us that the heart isn’t getting the

blood it needs to function normally. And it’s marked by the kinds of discomfort Reverend Johnson suffered-that is, a feeling of heaviness, pressure, or pain in the chest, pain that sometimes spreads to the arms or neck or jaw, or radiates to the back.

Angina results from what most of us call hardening of the arteries, and what doctors call arteriosclerosis, or, more simply, coronary artery disease or just plain coronary disease. It’s not very different from the kind of plumbing problem you might experience at home when the water flow in the pipe slows or is interrupted by calcium buildup or something th rt sticks at a bend in the pipe.

In the human body, what clogs the arteries isn’t only calcium but also fat deposits. When these clogs or blockages occur in the arteries that feed the heart, because the supply of oxygen to the heart is restricted, symptoms of angina will occur. Like every other organ in the body, the heart needs blood in order to function properly. If the supply of oxygen-rich blood fails, the heart will fail. That failure may be mild or severe, but if the condition that led to the problem isn’t addressed, the heart will become less and less able to do its job, and the symptoms of angina will eventually result in a heart attack.

A heart attack occurs when small or large parts of the heart muscle die because they aren’t receiving nourishment. In extreme cases, like Reverend Johnson’s, the entire heart is affected, and the result is death.

TO BEGIN, WE MUST present some unpleasant but essential facts:

•    Coronary artery disease is the number one killer of African Americans.
•    African American men develop coronary artery disease
earlier than white men.
•    African American men with coronary artery disease are
more likely to die than white American men who suffer
from the same disease.
•    African American women with coronary artery disease
are more likely to die than white women who suffer from
the same disease.

•  African American smokers with coronary disease are at
higher risk of death than white American smokers with
coronary disease.

•    African Americans who stop smoking or control their blood pressure decrease their risk of death from coronary artery disease.
•    The more you know about coronary artery disease, the better the chances that you and your loved ones won’t be killed by it.

Not only is coronary artery disease-also known as cardiovascular disease, or CVD-the leading killer in America but if you’re African American the odds are one and a half times greater that you suffer from high blood pressure (or hypertension)-one of the leading risk factors contributing to CVD.
It doesn’t have to be this way. A lot of heart disease is pre
ventable and a lot of it is correctable. It can be stopped, or
mended, before you suffer a heart

attack that ‘will hospitalize you, and, in some cases, kill you. The fact is, what you know won’t kill you, and what you don’t, will.

Now that you’re with us, we’d like to tell you a story.
Though Reverend Asa Johnson had felt poorly for months, he hadn’t had much time to think about it. Church membership was falling off and he’d been working twice as hard as ever to turn that around. Worse, for all his efforts there hadn’t been much improvement, and some of the members were beginning to blame him.

Through all this Reverend Johnson was troubled by shortness of breath and frequent heaviness in the middle of his chest. Or he’d feel a nagging pain there that spread to his arms or sometimes to his back, and the pain didn’t seem to have any connection with what he’d been doing. Sometimes his breath came so hard he wanted to take to his bed. But when these symptoms came, he’d sigh and continue with what he was doing. “At sixtynine years old,” he’d say to himself, “a man’s got to expect a few aches and pains. Anyway, I’m a strong black man and a child of the King.” As for fatigue, well, he was working hard, but he was working for the Lord, as he’d always done and always would do. This was his life’s purpose. For twenty-five years he’d fought with all his heart for the church he served. He couldn’t afford to slow down now.
And, after all, he’d taken good care of himself all his life, he never smoked or drank, and he liked to boast, truthfully, that he’d never been sick a day in his life. Yes, he didn’t have time for much exercise and he’d put on a few pounds and, yes, his wife thought that he didn’t look well and wanted him to see his doctor. But he shook off her insistence, though with his usual patience. Sure, he would go in for an examination, he promised her over coffee one Tuesday morning-he’d go just as soon as he got this trouble at the church settled. She shook her head and said nothing. His health worried her, but he’d never been a man you could talk much sense into about such things.
The next day Reverend Johnson met with his board of directors and the Deacons of his church, hoping that together they could agree on the plan to increase membership that he’d been up several nights thinking and worrying about. So strong was this hope that just before the meeting Reverend Johnson had whis pered to himself: “Jesus, stay with me.” But twenty minutes into the meeting some of the deacons were fidgeting uneasily. The reverend looked sick. Once he bit his lip, as if he were fighting to keep something back, and his breathing became more and more difficult. Then, as Reverend Johnson, with obvious effort, came to the end of an eloquent appeal for his plan, suddenly and without a sound he fell hard to the floor, unconscious.

He died forty-five minutes later in the emergency room of the community hospital. He’d suffered a massive heart attack.