by Sally Pobojewski
photos by Martin Vloet

Just today alone, nearly 3,000 Americans will die from our nation's deadliest epidemic. This year, it will kill 8 million people worldwide — almost 1 million in the United States and 35,000 in Michigan. Since one in five Americans already has some form of the disease, its next victim could be you or someone you love.

If you think it's cancer, think again. America 's No. 1 killer is cardiovascular disease.

Heart attacks, stroke, high blood pressure, heart failure and other diseases of the heart and blood vessels claim more lives in the U.S. each year than cancer and the next four most-common causes of death combined.

The real tragedy, says Kim Eagle, M.D., the Albion Walter Hewlett Professor of Internal Medicine in the U-M Medical School, is that at least half of these deaths could be prevented.

"It's a nationwide problem, but especially serious in Michigan, where we are facing a growing epidemic of cardiovascular disease," Eagle says. "Death rates from coronary heart disease in Michigan are the 7th-highest in the country, and death rates from all forms of cardiovascular disease are the 13th-highest in the country."

"As the state's major public health care institution, the U-M Health System and physicians from the Medical School have an obligation to work with the public, our patients, their families and other institutions to try to solve Michigan's and the nation's No. 1 health problem," Eagle adds.

Kim Eagle

Kim Eagle is one of four Medical School physicians who have made a personal commitment of time, talent and energy to fight cardiovascular disease by accepting leadership responsibility for the University of Michigan's new Cardiovascular Center.

Being built on the site of the former Old Main Hospital, where U-M patients were treated from 1925 until 1986, the $199-million first phase of new construction for the Cardiovascular Center should be completed early in 2007. But even though a new building won't be ready for several years, the center's work has already begun.

As clinical director, Eagle is one of four co-leaders of the Cardiovascular Center. Its scientific director is David J. Pinsky, M.D., the J. Griswold Ruth, M.D., & Margery Hopkins Ruth Professor of Internal Medicine and chief of cardiovascular medicine in the U-M Health System. Richard L. Prager, M.D. (Residencies 1976, 1978), clinical professor of surgery, is director of cardiac surgery. And James C. Stanley (M.D. 1964, Residency 1970), professor of surgery and director of the Conrad Jobst Vascular Research Laboratory, is responsible for vascular surgery.

Working together upon the foundation of years of work by many in the U-M Health System, the four co-leaders are building a network of scientists, physicians and clinical specialists from many disciplines to conduct research, develop new treatments, train the next generation of physicians, and provide integrated clinical care for the entire spectrum of cardiovascular disease.

Departments and divisions participating in the center include Internal Medicine (Cardiovascular Medicine), Surgery (Adult and Pediatric Cardiac Surgery, Vascular Surgery), Radiology (Interventional), Anesthesiology (Adult and Pediatric Cardiac), Neurology (Stroke) and Nursing.

"We are all working together to achieve one common vision," Pinsky says. "We want to take disciplines that have been spread across the Medical School and the university and bring them together under one roof in an integrated effort to understand cardiovascular disease, discover new cures and apply that knowledge to the treatment of human disease."

Our own worst enemy

One reason for today's epidemic of cardiovascular disease is that we tend to take a healthy heart for granted. We assume that little 10-ounce ball of muscle in our chest will just keep beating 100,000 times each day — pumping the equivalent of 4,300 gallons of blood through our veins and arteries — no matter how we treat it.

We know a healthy heart needs exercise, but most Americans aren't even close to getting the recommended 30 minutes per day. We know junk food is bad for us, but the number of overweight and obese American adults and children continues to climb.

James Stanley

"In Michigan, we have a major problem with obesity," Eagle says." Michigan residents are less likely than people living in other states to exercise regularly. The trend in consumerism toward biggie-sizes of everything from french fries to soda pop is not subtle. It's killing us and it's killing our children."

This is why preventive cardiology with its emphasis on patient education and motivating people to make heart-healthy choices in diet and lifestyle will be an integral part of the new Cardiovascular Center 's program. "If we combine lifestyle changes with cholesterol-lowering drugs called statins, we can quickly lower high cholesterol levels and reduce the patient's immediate risk of a heart attack or stroke," says Eagle.

"The eventual goal is prevention, not therapy," agrees Stanley. "But that's not going to happen, unless we pay attention to the very early stages of the disease, which probably begin in childhood and adolescence."

What causes cardiovascular disease?

For a disease that kills nearly one million Americans every year, researchers know surprisingly little about how cardiovascular disease begins. Most of what we know was discovered within the last decade. For example, physicians used to think of atheriosclerosis, or blocked arteries, as a simple plumbing problem caused by a build-up of fatty cholesterol called plaque. Now they know that the process is far more complicated.

David Pinsky

"Over the last decade, we have learned that the factors contributing to this rapid accumulation of plaque in blood vessel walls are largely inflammatory," Pinsky explains. "Cholesterol is involved, too, but the cells responsible for the growth of plaque in arteries are largely inflammatory cells. It's the same process the body uses to heal an injury, but something goes wrong. As long as the plaque remains stable within the blood vessel wall, it's fine. But if something causes the plaque to rupture, it creates a surface on which blood tends to clot. You can go from a partial blockage to complete closure within a matter of minutes. The result is a heart attack or stroke."

"The blood vessel is an active participant in the process, not just a passive conduit for blood to flow through," Pinsky adds. "Endothelial cells lining the inside of blood vessels orchestrate the immune response and the formation of blood clots. We need more research to understand what changes the endothelial cells' response from a normal healing, protective mechanism to one that promotes inflammation and clotting."

According to Stanley, inflammation also is responsible for the development of aortic aneurysms — a ballooning or pouched-out area, similar to a hernia, which forms in the walls of major arteries carrying blood from the heart to the kidneys and lower body.

"These inflammatory changes appear to degrade the 'glue' that holds the artery wall together," Stanley says. If the aneurysm becomes large enough and weak enough, it will rupture, causing massive internal bleeding and often death.

"We are just beginning to understand the process, and much more research will be needed before the bits and pieces come together," Stanley adds. "But it's a very exciting time, because it appears that what we learn about degenerative changes in coronary arteries will be applicable to renal arteries or leg arteries, also. Very few institutions consider the entire vascular tree as one related system. But the bottom line is that cardiovascular disease begins in the blood vessel. If there's trouble in the blood vessel, then the heart will be in trouble, too."

Pinsky believes that greater understanding of the genes and molecular processes responsible for inflammatory changes in blood vessels could lead to major advances in clinical care for coronary heart disease and vascular disorders like aortic aneurysms. He is already recruiting new scientists to expand Medical School research into the basic mechanisms behind blood vessel inflammation — one of the Cardiovascular Center 's major research priorities.

The genetics of cardiovascular disease is another research priority, according to Pinsky. With the completion of the Human Genome Project, scientists now have coded instructions for all the genes in the human body, but they still know very little about what each gene does and how they interact.

Interactions between multiple mutated genes are responsible for a group of cardiac disorders called cardiomyopathies. People with this condition have an enlarged heart that cannot pump blood efficiently. As the heart continues to enlarge, it gets progressively weaker, until the patient dies from heart failure. Cardiac arrhythmias, or irregular heart beats, also caused by mutated genes, can lead to sudden heart failure and death — often in young people who appear to be in excellent health.

In addition to creating new knowledge about the workings of the heart and vascular system, genetics research has tremendous potential to improve the treatment of cardiovascular disease, especially in the field of pharmacogenetics. Scientists have discovered that people often have slightly different versions of the same genes called polymorphisms. Even variations as small as one unit of DNA can mean big differences in a person's risk of developing cardiovascular disease or their response to medication.

"My job is to bring together a critical mass of people to bridge the gap between basic and clinical science," Pinsky says. "To do that, we need to recruit people on both ends of the research spectrum — from geneticists and cell biologists studying fundamental mechanisms in the laboratory to physician-scientists trained to conduct clinical trials and take discoveries into the clinic.

"Our success as a cardiovascular center will depend on our ability to bring scientific discoveries into the clinical arena and clinical results back to the laboratory," Pinsky adds. "But no matter how good we are, research pays in ideas rather than dollars. We have a major philanthropic hurdle to overcome, if we are to continue making these advances. Philanthropy will drive the major research breakthroughs in cardiovascular disease in the next decade."

How do you heal a broken heart?

For decades, patients have been drawn to the U-M Health System by the reputation and skill of its physicians who pioneered innovative procedures to treat renal vascular hypertension, repair defective heart valves and aneurysms, perform coronary bypass surgery, and treat end-stage heart disease.

When the new Cardiovascular Center building opens in 2007, patients will receive the same superior clinical care they expect from U-M, but in a facility designed to make it more accessible and pleasant for patients and their families. The 350,000-square-foot facility will include operating rooms, patient rooms, clinics, classrooms and clinical laboratories. Specialized services and diagnostic facilities will be together in one place, enabling more patients to receive coordinated care from multidisciplinary teams.

Richard Prager

"The new building will be more welcoming, more comfortable, easier to access and much more efficient than our current facilities," says Richard Prager, director of cardiac surgery for the Cardiovascular Center. "We have great people here, caring people, but our clinics and specialists are scattered throughout the health system. It makes it more difficult to provide the level of integrated care our patients need and deserve.

"Whether you come to the Cardiovascular Center for complex surgery or a simple diagnostic procedure, our goal is to have you feel that we have created this entire culture around you to meet your needs and expectations," Prager says.

Since educating tomorrow's doctors is the primary mission of the Medical School, physicians affiliated with the Cardiovascular Center already are developing programs to teach integrated patient care by exposing medical students and residents specializing in cardiology or cardiac surgery to many different disciplines. Cardiology fellows work as members of the cardiac surgery team caring for patients in the Cardiothoracic ICU. Cardiac surgery residents learn the latest imaging techniques by working with the cardiac echocardiography team. Specialists in vascular surgery and vascular medicine see patients together in the same clinic.

"Residents and students get excellent training here now, but the Center's new building will be a model for tomorrow's medicine," says Prager. "What our students and house officers will see is an optimal communications system for diagnosis, decision-making and treatment, facilitated by a structure that makes it easier, and an intellectual commitment to designing and implementing the system that should be second-to-none."

"The traditional silos of surgery, internal medicine, radiology and vascular surgery are artificial," Eagle says. "It's all the same disease. The future of medical education will be more of a disease-based approach. The new building and our closer proximity to one another will make it possible to provide more opportunities for interdisciplinary education."

Today, the site of the new building for the Cardiovascular Center belongs to architects, construction workers, bulldozers and dump trucks. But the center's leaders are planning for the day in 2007 when the arrival of patients and physicians, staff and students will bring the building to life.

And, today, many of the people whose lives will be saved in the Cardiovascular Center may not even know that they have cardiovascular disease. Some of the scientists, who will spend hours in the center's laboratories searching for genes that control the ability of blood vessels to expand or contract, are still in college. And the physician who will discover tomorrow's treatment breakthrough is just beginning her first year of medical school.

All because of the Michigan effort and shared vision a broad team of physicians, researchers, nurses, technicians and administrators, working over a number of years and led now by four dedicated individuals, is taking into reality today.

Visit the Cardiovascular Center 's Web site at www.med.umich.edu/cvc.

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