25 years, the first ‘deposits’ begin to appear on the walls of the coronary arteries (arteries that supply the heart muscles themselves with blood). At this stage, it’s not a big problem, but it lays the foundation for a very serious condition: arteriosclerosis, sometimes called ‘hardening of the arteries’. It is the number-one cause of the world’s most-common killers: heart attacks and strokes. Deposits of fatty plaques on the walls of the blood vessels will continue to build up, getting thicker and thicker and restricting the flow of blood until, in a worst-case scenario, a vessel eventually becomes completely blocked (like a water pipe with limescale).
When this happens to the coronary arteries, small or even larger sections of the heart muscle are left with an insufficient supply of nutrients and oxygen, and they begin to change. This is the infamous heart attack. Undersupplied areas of muscle transform into a kind of scar tissue that no longer contributes to the beating action of the heart. And, as we all know, a team is only as strong as its weakest member. The result is that the heart loses both strength and stamina.
At this point in a play, drama theorists speak of a ‘delaying factor’ in the plot, when the pace of the story slows down as the final denouement approaches. In the case of heart-attack patients, the role of delaying factor is played by medicine. To delay, or, even better, avert the oncoming catastrophe, doctors can prescribe medication, insert catheters (thin plastic tubes) into the coronary arteries, and try to alter the patient’s life circumstances to take some pressure off the heart and thus minimise the risk of another heart attack.
Act Five: the (c)old heart
Chest pain. Irregular heartbeat. A listen to the chest with a stethoscope shows it is no longer beating with its regular ba-boom, ba-boom, ba-boom rhythm. Now, it sounds more like ba … boom, ba-ba-boom, boom, ba-boom. Difficulty breathing and weakness set in. After beating without a break for almost a century, the heart is now significantly weaker. It’s been through a lot. For some, it may be experiencing its second or third attack. It pumps ever less powerfully and, in a final act of valour, it gathers all its resources and tries to work faster. But in the end, all is in vain. The heart is no longer able to work properly; it twitches uncontrollably for a brief while and eventually becomes still. And then that’s it: curtains.
This is the inescapable end to the drama. Predictable, but nonetheless tragic. Although all of our hearts will eventually stop, the time before this happens need not be dramatic. On the contrary, a hale and hearty life is more reminiscent of a comedy than a tragedy. The heart still ends up still, but at least its owner has laughed a lot and spent the time in a fulfilled way.
The good news is that anyone can take preventive measures to make sure the time when their heart stops beating comes as late as possible. And, at best, without cardiovascular disease ruining our existence before it does.
The first step towards this goal is keeping a sense of humour. Life can sometimes be an extremely serious business, but everything is easier when you’re smiling. You could try laughter yoga. Or just search ‘quadruplet babies laughing’ on YouTube.
It’s not only hypochondriacs who interpret trivial symptoms as the harbingers of death-bringing illness. No one is completely free of this crippling habit — not you, not me, not any of us. But the great thing is that, as a rule, human beings are basically healthy creatures. And that’s true of the heart, too. When some part of our body feels strange, it’s usually not due to a rare disease that will carry us off in a matter of hours, but due to something completely harmless. True to my favourite saying: ‘If you hear hoof beats, think horses, not zebras.’ So there is nothing standing in the way of personal happiness and physical health. But, still, I sometimes like to listen carefully to my heart.
Medics and Money before Midnight
I lie in bed and listen to my own heart hard at work. It’s beating a little harder than normal because I swam a few lengths before going to bed. Looking at my alarm clock, I count 19 beats in 15 seconds. I do the math: four times 19, or 19 times two times two. Or two times 38, equalling 76 beats a minute. I look down at my chest and watch it pulsating with each beat of my heart.
As a doctor-to-be, I have my stethoscope at hand. I listen to my chest. Ba-boom, ba-boom, ba-boom, ba-boom, ba-boom. I’ve just celebrated by 25th birthday. That means my heart has already beaten around 900 million times during my lifetime. Faithfully and dependably fulfilling its duty of keeping me alive. Thank you, dear heart, for doing that monotonous job for me.
But listening a little more carefully, it becomes clear that the work of the heart is not quite so monotonous after all. It does not simply go boom, boom, boom, boom like the bass from the speakers of your stereo system or boombox. In fact, a heartbeat consists of more than just the simple contraction of the entire organ. It is a precisely timed and coordinated operation of the muscles of the atria and the ventricles, as well as the opening and closing of the heart’s valves.
First, the atria contract and press blood into the ventricles. This process can’t normally be heard through a stethoscope. A short time after, normally about 150 milliseconds, the ventricles contract, transporting the blood into the lungs and eventually the rest of the body. That contraction of the ventricle muscles is what causes the ‘ba-’. The subsequent ‘boom’ isn’t caused by the heart muscle itself, however, but by the closing of the semilunar valves of the aorta and the pulmonary artery. I place the stethoscope on another part of my chest. The sound changes. A little further up, and it changes again. I could happily spend hours just moving my stethoscope around.
What particularly fascinates me on this evening are the sounds made by the valves of my heart. They make sure that the blood travelling through our heart always moves in one direction and doesn’t suddenly go into reverse gear. As we have seen, anatomists identify four valves, two of which are atrioventricular (the mitral and tricuspid valves) and two of which are semilunar.* Always alternating, they open and close, creating specific sounds that can be attributed to each valve. Medics distinguish between four heart sounds, although only two can be heard through a stethoscope.
The first of these heart sounds is caused by the contraction of the ventricular muscles. It is sometimes called S1 by medics. The second, higher-pitched sound is shorter in duration than the first and is somewhat sharper and louder. Known as S2, this sound is caused by the closing of the two semilunar valves. During inhalation, it can change and split into two components if the aortic valve closes a little earlier than the pulmonary valve.
As any parent or teacher will confirm, children and teenagers make more noise than adults — and the same is true of their hearts. The third and fourth heart sounds can’t be heard through a stethoscope in a healthy adult, but they can sometimes be picked up in younger people. The third sound (S3) is heard when the left ventricle of the heart is filled with blood. It is normal in pre-adulthood. When it occurs in older patients, it can be a sign of problems. More precisely, it can indicate a problem with the mitral valve between the left ventricle and the left atrium,* an abnormal increase in the size of the ventricular cavity,† or cardiac insufficiency ( failure of the heart to work hard enough). And if the amount of blood remaining in the ventricle when it refills is too great, the new lot of blood will slosh against the old and this will also cause a sound.
The fourth sound (S4) results from the contraction of the atria. If it’s heard in adults, it can be an indication of high blood pressure, a thickening of the muscle of the ventricular wall, an obstruction in the left ventricular outflow tract, or — more rarely — a narrowing, or stenosis, of the aortic valve. It is generally followed immediately by the first heart sound.
Hearing all this with a stethoscope is a true art. Some doctors have such a finely tuned ear that they can hear not only the tiniest changes in the sounds of the heart, but also microtumours in the lungs. This involves placing the stethoscope
