HOW TO HAVE A HEART ATTACK Coronaries aren't what they used to be. With new medicines and < surgical procedures, more executives not only survive but even wind up healthier and wiser than before.
By Brian O'Reilly REPORTER ASSOCIATE Sandra L. Kirsch

(FORTUNE Magazine) – I'LL NEVER GET a heart attack. Not me. Maybe that pasty-faced guy in sales who always looks so tired. And that blimp-in-a-suit who ate all the French fries at lunch today and had pie for dessert. He's doomed. Probably has veins full of Crisco. But me? Racquetball twice a week. Oooh -- what was that? Musta been that fancy veal at lunch. I mean, I've got the energy to jump on a plane for London one day, kick some butt, and be back in New York in time for the morning meeting the next day. Whoa. Shouldna had so much coffee. Major case of indigestion here. Where did my secretary put the Maalox? Scratch the surface of guys like us and down deep we're still cool college jocks who . . . Jeez, it's stuffy in here! Hard to breathe! In ten seconds those incompetents in building maintenance are gonna get hell from me. As soon as I can get this . . . incredibly . . . heavy . . . telephone receiver to my ear. Hmm. That's strange. The floor seems to be rushing toward my face . . . Punch the slow-motion button for a moment and contemplate our friend before he hits the carpet. He is one of 1.5 million Americans who will have a heart attack this year. Over 300,000 will die before reaching the hospital. For about half the people with heart disease, the first symptom of trouble will be the gripping, squeezing sensation of a heart attack already in progress. Coronaries and cardiovascular heart disease kill nearly as many people in the U.S. as all other illnesses combined. The odds of dying from an attack rise steadily with age (see chart), from a modest 18.7 per 100,000 for men 35 to 44, to 1,132 per 100,000 for men 75 to 84. But bad as they are -- and here's the news -- heart attacks are not the scourge they were a generation ago. The death rate has been dropping steadily since the mid-1960s, largely because people are smoking less and getting better medical care. The treatment of heart attacks has advanced far faster in the past ten years than most people realize. Luckily for our ailing, freeze- framed executive, new drugs and emergency medical procedures rarely available a decade ago can dramatically reduce the damage to his heart. A ZILLION QUESTIONS will soon be flying through our friend's mind. Will he make it? Why him? If he has to have surgery, what will it be like? Is his sex life over? Will he have to abolish all stress, put flowers in his hair, and talk like Mister Rogers to avoid another attack? Not least: Is this the end of his career? A common worry, that -- many men hide their heart conditions from their bosses, co-workers, and customers, fearing they will be shunted off the fast track or lose business. In fact, their medical condition rarely warrants such concern. The many doctors and patients interviewed for this story say that heart attack survivors are not nearly as damaged physically as they feared they might be. The wrenching transformations they undergo are more often emotional, psychological, and philosophical. ''I'll never be a quarterback for the New York Jets,'' mourned John Landi, 59, owner of a forest products company in North Carolina, when first told in 1980 that he'd had an attack. The experience can bring with it a dose of maturity, however. James Casey, 56, now a software marketing executive for Digital Equipment Corp. in Palo Alto, California, found himself uttering a prayer for serenity as he was wheeled in for bypass surgery seven years ago. He still says the prayer. Well, sometimes. ''I don't want to get too relaxed,'' he says. ''Heck. I'm in marketing.'' A heart attack occurs when any of the major arteries that supply the heart become so blocked that they are unable to carry enough blood to its tissue, which then dies. This is not to be confused with the condition angina pectoris, where those same arteries are narrowed and cannot deliver enough blood when the heart's workload is increased during exercise. Angina can cause severe pain when the arteries become spasmodic and clamp shut briefly, but it results in little or no lasting damage. As is now widely recognized, a high-fat diet is a big culprit in heart attacks and angina. It raises certain varieties of blood cholesterol, which contribute to atherosclerotic plaques, or buildups, in artery walls. But plaque is not just a glistening remnant of all the fat you've consumed over the years, piling up in some arterial nook like maple leaves in a gutter. It is extremely complicated stuff, often hard as rock. It develops at different rates from individual to individual, depending on everything from how much one smokes to how fast his blood clots. SYMPTOMS of a heart attack vary. Probably the most common is a deep discomfort, usually described as tightness, pressure, and aching. It can radiate down your arms and into your neck, jaw, ears, or even teeth. You probably are not having an attack if you feel a sharp, knifelike, or throbbing pain that lasts for only a few seconds. But clenching a fist over your sternum to describe the feeling is a warning sign. ''I've never had a heart attack,'' says one cardiologist, ''but I sense it's like that dull, painful ache you get from eating a lot of very cold ice cream too quickly.'' Sometimes, though, you don't feel a thing. Blaine Davis, a frequent jogger with a cholesterol level under 180, got an EKG as part of a routine physical early last year. Because the result was sharply different from previous EKGs, his doctor instructed him to be tested on a treadmill. He made an appointment for the following day. A minute after the treadmill started, the doctor told him to stop. ''She didn't even want me to go home,'' says Davis, 56, a vice president at AT&T in Basking Ridge, New Jersey. ''I was incredulous.'' Blood tests and an angiogram, a procedure where a dye is used to make a moving picture of blood flow through the coronary arteries, revealed that he'd had a silent heart attack sometime in the previous six months. A small portion of his heart was damaged, and one artery was 99% blocked, another 95% shut. Davis had a triple bypass three days later. The key to surviving a heart attack is to get to the hospital quickly. ''Time is muscle -- heart muscle,'' says Mazen Kamen, a New York City cardiologist. A coronary artery has to be blocked for several hours before significant amounts of tissue begin to die. New clot-dissolving drugs such as streptokinase and t-PA have made most emergency rooms vastly better at stopping the spreading damage from heart attacks. Clot dissolvers often begin to take effect in half an hour. ''You can actually see the drugs work,'' says Dr. Gary Stiles, head of cardiology at Duke University Medical Center. ''You can see blood flow returning to the coronary arteries on X-rays.'' But to do the most good, clot dissolvers must be administered within two hours of an attack. After six hours, much of the damage has been done. If chest pain strikes, an otherwise healthy executive who gets to the hospital quickly doesn't have to be scared to death. About 75 times in 100, the pain will be something other than heart trouble, says Dr. Robert Califf, a cardiologist and epidemiologist at Duke. Of the 25 cardiac cases, 17 will be angina -- that painful shortage of blood to the heart. Only eight will be heart attacks, also known as myocardial infarction or coronary thrombosis. Among those eight victims, seven will survive. % AND NOT JUST to sit in the park feeding pigeons. One of the most encouraging developments in the treatment of heart disease is that so many former patients can resume near-normal lives. It wasn't always that way. Says Dr. Califf: ''Twenty-five years ago people were lucky to survive heart attacks. Those who did were put to bed for a month. Most men retired from their jobs. There was no running, no sex. The doctor would say, 'Take it easy,' and some people spent the rest of their lives on the sofa.'' Why are things so different today? Several reasons. Those clot dissolvers greatly reduce damage to the heart. Balloon angioplasty, which opens clogged arteries, and bypass surgery, both relatively rare and risky a decade ago, can eliminate the pain and shortness of breath that used to cripple many people. And drugs and implantable devices reduce the irregular heartbeat condition known as arrhythmia.

Still, don't be surprised if your love life suffers for a while after an attack or surgery. Depression frequently sets in -- it usually lasts only a few months -- but heart attacks sometimes trigger discouraging thoughts about one's entire life, accomplishments, and friendships. You won't be swashbuckling through the boudoir with that on your mind. You may also think you will kill yourself with your lust, or your spouse may think she will kill you with hers. Fear not. Although you are undoubtedly a barnburner in the sack, the average middle- age married man expends only five calories per minute during sex. If you can walk up two flights of stairs without pain, you will probably be okay. Beware of extracurricular romps, though, says Mary Ellen McCann, a nurse who runs a sexual and emotional health counseling service for cardiac patients in New York City. In a Japanese study of 5,559 cases of sudden death, only 18 fatal heart attacks occurred during sex, but 75% of deaths by sex happened with partners from outside the bonds of marriage. Medication may also affect your love life. Commonly used heart drugs can cause impotence. A class of drugs called beta blockers, the most prominent of which is Inderal, may decrease sexual drive. Many doctors don't inquire about such problems, and many patients don't speak up. Do. You can usually be switched to another drug. PSYCHIC DAMAGE may be harder to treat. Depression about careers is common. Many people wrongheadedly see themselves as ''damaged goods'' after a heart attack. Says McCann: ''They fear that their career path is blocked, that they can't move to another company because word is out on the grapevine, or that they can't handle the stress of making it in a new job.'' Valentin Fuster, recently made head of cardiology at Massachusetts General Hospital and for years a prominent New York cardiologist, says high-level corporate executives have particularly strong emotional reactions to heart attacks. ''The executive is, by definition, in control of himself and many others, and that gives him a sense of security. At the moment of the attack, he learns he is vulnerable.'' Two common reactions occur about half the time, says Fuster: complete denial or going to pieces. The deniers insist they are fine -- that they are too busy to meet with doctors; they then fling themselves into a busier than ever schedule. The others become hopelessly dependent on the doctor, calling several times a day. Wiser executives, Fuster says, develop balance. ''The moment they are vulnerable, they recognize that most of the time they will be okay, but that this is an opportunity to make some changes. They ask whether they could have avoided this. That maturity is not easy for a person into control, but it often leads to very meaningful changes.''

Charles Kaplan spied a telephone jack on the wall of the intensive care unit where he was recovering from a heart attack last year. Kaplan, now 49 and the owner of a Los Angeles company that makes auditorium chairs, was terrified his customers would find out about his condition and switch to another supplier. He persuaded a nurse to give him a phone so he could make calls to his company, urging work crews not to slacken the pace. Says he: ''A head nurse walked in on me and let out a shriek.'' Kaplan had convinced himself he was indispensable, and in a bad way he was. ''I never delegated, never let anyone else in the company deal with customers. I felt I had to solve every problem that came up.'' As soon as he got home, he set up more phones and routinely called customers, pretending nothing had happened. He learned, though, that his supervisors could solve most problems as well as he could. A longtime friend and hitherto silent partner in the business discovered he could deal with customers effectively too. Finally, a few months ago, Kaplan told customers about the attack. ''Virtually all of them told me they would have stuck by me,'' he says. ''The customers who wouldn't were the ones who would have gone off anyway.'' Now he shakes his head at people who behave the way he did. ''I've got one guy who is convinced his career will be over if we don't get some chairs in next week. I shrug. There is absolutely nothing we can do. He's going to have a heart attack. I won't.'' Every year some 200,000 people with heart disease undergo a procedure called balloon angioplasty. A tube about the thickness of a pencil lead is threaded through an artery from the groin to the heart. The tube is tracked on monitors to the center of the blockage. Then the tip of the tube is inflated to crack the plaque and push it outward. The patient is sedated but conscious. The procedure can be uncomfortable -- much like a bout of angina -- and in one- third of cases, the arteries become blocked again in six months. But the effect is usually dramatic: Long-clogged arteries open up. ABOUT 300,000 times a year, heart patients have more dramatic intervention: bypass surgery. Here a vein or artery from elsewhere in the body is grafted onto the heart, bypassing a blockage and restoring blood flow. Bypass surgery is controversial. At an average cost of $39,800 per procedure, it is one of the most expensive in medicine. Dr. C. Noel Bairey, head of cardiac rehabilitation at Cedars Sinai Medical Center in Los Angeles, says studies indicate that half the people who have bypass surgery would do as well with drugs and lifestyle changes. ''Everybody has this idea that bypass works and nothing else does,'' she says. Dr. Robert Jones sprints up the stairs two at a time to the locker rooms outside the cardiac surgery center at Duke University Medical Center. It is 7:32 A.M. Jones is two minutes behind schedule, and that kind of imprecision bothers him. He changes rapidly into green surgical garb and strides into the operating room. The patient is out cold on a table, surrounded by a half-dozen doctors, nurses, and mountains of machinery. Jones calls up a movie of the patient's heart, points out blockages, and backs the film up several times to study a particular section. The incision is swift and bloodless. The arc from an electric cauterizing knife seals the cut, which exposes the bone at the center of the rib cage. Jones makes a deeper cut at the top of the abdomen and quickly runs a shiny, stainless-steel jigsaw the length of the patient's chest, severing the bone. He makes it look easy. A metal clamp pulls the rib cage up and back, exposing a decidedly unromantic, yellowish thing the size of a fist. Like most hearts, it is covered with fat, which helps protect it. Another surgeon makes an incision in the patient's calf to retrieve a vein for two of the three bypasses. After about an hour, Jones has two lengths of vein and a chest artery ready to attach to the heart. The vein from the calf was too small, so the team removed one from the thigh. The heart, which has kept beating all along, is stopped, and blood is routed to the heart-lung machine. Jones gently cuts through thin tissue on the surface of the heart, exposes an artery, makes a quarter-inch opening on it, and stitches the new vein into place. He repeats the procedure on two other arteries. Eventually he inserts two spatula-shape devices on either side of the heart to give it an electric shock. It begins beating rhythmically. Jones is pleased. Other doctors finish up, while he leaves to talk with the patient's family. You can vary the odds of having a heart attack, but you cannot do away with the threat entirely. Besides, even if all heart disease were eliminated, the average American would live only 3 1/2 years longer. But while most of us cannot add ten or 20 years to our life spans by living on berries and running marathons, many people are at far greater risk than others from heart disease and would benefit enormously from early medical attention and changes in lifestyle. ''Choose your parents well, be young, and be female,'' one cardiologist advises on the best way to avoid a coronary. If you find that hard to arrange, quit smoking. Or try changing your cholesterol level. The average American has a cholesterol of 210 to 220 mg per deciliter of blood. About 40% of the middle-age population has a level below 200, which is considered relatively safe. A person with very high, but not uncommonly high, blood cholesterol of 300 has nearly three times the risk of fatal heart disease as someone with 200. Your mix of cholesterols can matter a great deal. One variety, high-density lipoprotein (HDL), is good; it seems to carry more dangerous types of cholesterol away from artery walls and to the liver for elimination. Pay attention to the ratio of total cholesterol to the good, high-density stuff; it should be at least 4.6 to 1, meaning that HDLs make up 22% of the total. Dr. Sherry Jackson, an expert in cholesterol at New York City's Columbia Presbyterian Hospital, says exercise and a diet rich in monounsaturated fats like olive or canola oil may increase the HDL ratio. Saturated fats, such as those found in red meat, and cholesterol-rich foods like cheese increase a dangerous variety of blood cholesterol known as low-density lipoprotein (LDL). There is some evidence that getting your total cholesterol level below 150 and the dangerous LDLs under 90 can, over several years, actually reverse existing blockages. How the body handles saturated fats and cholesterol depends a lot on genes. Heredity contributes in other, less well understood ways too. For example, the tendency of arteries to develop tiny faults that let plaques grow may be passed from one generation to another. If one of your parents had a heart attack or heart trouble before age 55, take it as a warning that your odds of having similar trouble are sharply higher than those for the rest of the population and that cigarettes, elevated cholesterol, and the like are especially dangerous. THE ROLES that personality and stress play in heart disease, while hard to measure, appear to be significant. Job stress alone is not the problem -- 85% of people think their jobs are stressful, says Dr. Mark Hlatky, a Stanford cardiologist. The bigger worries are anger, impatience, aggravation, and irascibility -- all attributes of the Type A personality Dr. Meyer Friedman, a San Francisco cardiologist, identified more than 40 years ago. Working hard because you genuinely love what you do is okay, Friedman says. It's the insecure executive frantically trying to prove himself who is in trouble. Dr. Redford Williams, a leading researcher on stress and illness at Duke, says explosive anger and ''cynical mistrust of others'' are deadly traits in anyone. He followed up on a group of more than 4,000 college students who had taken personality tests in the 1960s. He found that those who scored high in hostility were more likely to smoke, drink, and eat too much today. They also had a higher total cholesterol to HDL ratio, a powerful predictor of who will get heart disease. WALKING in Connecticut with his wife late last year, Tom McDonnell found himself repeatedly asking her if she wanted to catch her breath. For six months, says McDonnell, 49, ''I'd felt like someone was digging a heel into my chest when I walked.'' Nonetheless, he was planning to spend three months golfing with his brother in Scotland before starting a new job with Cable & Wireless, a British telephone company, in New York. After days of prodding from his wife, he went to the doctor. < When the doctor refused to let him go golfing, McDonnell finally suspected he had a problem. The doctor arranged an angiogram. ''He showed me what it's supposed to look like,'' says McDonnell, ''and then he showed me mine. He said, 'Oops, no blood flowing down that artery. Oops, nothing going down that one either. Your heart is getting 30% of what it should.' '' McDonnell didn't have a heart attack, but a week after the angiogram he had triple bypass surgery.

Dr. Kamen, who advises a large New York City bank on cardiac cases, says only a small percent of managers there go on disability after a heart attack; about 30% curtail some job activities. One of the most common changes: cutting back on frequent international travel, since interruptions in daily sleep patterns can be stressful. Doctors can make a precise analysis of your condition and calculate the odds of a recurrence: An otherwise healthy person who has had a mild heart attack stands only a 5% chance of having another one in a year. If a well-meaning boss tries to protect you with a cushy but dead- end job when you return to work, speak up. If necessary, says Fuster, have your cardiologist meet with your boss to discuss exactly what you can do. Trying to reduce stress simply by changing jobs is rarely successful. Executives who chuck it all and buy a commercial fishing boat in the Florida Keys don't impress Duke's Dr. Stiles. ''In no time they're trying to organize the largest fishing fleet, or racing out to get a bigger catch than anybody else.'' Learning to delegate and to put one's job into perspective are what really cut stress, says Dr. Andrew Littman, head of cardiac rehabilitation at Massachusetts General Hospital. Virtually every executive interviewed for this article said he had reduced the stress in his life and was a better manager for it. Says Casey at Digital: ''I get better results without being tough.'' Davis at AT&T cut out 20-hour round trips to Europe. He hardly sounds mellow, but says he watches for stress ''like a hawk.'' HEART ATTACKS are painful and frightening. But don't live in mortal fear of them. With a little luck and foresight, you may never have one. If you do, get to the hospital, and once you know you're going to make it, be philosophical. Treat the attack as a telegram from the gods urging you to change the way you live. A heart attack won't be the best thing that ever happened to you, but it might not be the worst, either.


CHART: NOT AVAILABLE CREDIT: FORTUNE CHART/SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS CAPTION: RISKS RISE WITH AGE Coronaries and cardiovascular disease kill nearly as many Americans as all other illnesses.