New Light on Aortic Aneurysms - Mhsec.com

30 Pages·2004·3.55 MB·English

by  Tobias, Joanna

2004 Pulitzer Prize
A collection of Pulitzer Prize-winning articles by
Kevin Helliker &Thomas M. Burton
in the category of
Explanatory Reporting
Deadly Discrepancy:
New Light on Aortic Aneurysms
THE WALL STREET JOURNAL.
A few years ago, we set out to make Wall Street Journal
coverage of health—both as an industry and as a personal
concern of our readers—as authoritative, vital and engaging
as our coverage of business and technology. We’ve been
pleased to see this additional coverage valued by readers,
and we’re honored to see some of the best of it recognized
with journalism’s highest award.
Karen Elliott House
Publisher, The Wall Street Journal
THE WALL STREET JOURNAL.
Deadly Discrepancy:
New Light on Aortic Aneurysms
A collection of
Pulitzer Prize-winning
articles
by
Kevin Helliker Thomas M. Burton
in the category of
Explanatory Reporting
Cover designed by Joanna Tobias, Dow Jones Reference Services Dept.
THE WALL STREET JOURNAL.
2004 Pulitzer Prize
for
Explanatory Reporting
Deadly Discrepancy:
New Light on Aortic Aneurysms
by Kevin Helliker andThomas M.Burton
Battling the Bulge: Test for Aneuryms Might Save a Lot of Lives, Some Say
by Thomas M. Burton
January 13, 2003........................................................................................................................................................................................................................6
Fears Mount Over Dangers of Pumping Iron
by Kevin Helliker
March 13, 2003...........................................................................................................................................................................................................................8
A Time Bomb Near My Heart
by Kevin Helliker
April 22, 2003 ..........................................................................................................................................................................................................................10
How An Autopsy Could Save Your Life
by Kevin Helliker
June 3, 2003 .............................................................................................................................................................................................................................13
A Death Sentence You Can Avoid
by Kevin Helliker
June 10, 2003 .......................................................................................................................................................................................................................... 15
Denying Death No More
by Kevin Helliker
October 21, 2003................................................................................................................................................................................................................... 17
Knowledge Gap: Medical Ignorance Contributes to Toll from Aortic Illness
by Kevin Helliker and Thomas M. Burton
November 4, 2003................................................................................................................................................................................................................. 19
Health: Which Test Should You Get?
by Kevin Helliker
November 21, 2003.............................................................................................................................................................................................................. 23
Health Journal: A Mother’s Mission: When You Just Know the Doctors Are Wrong
by Kevin Helliker
December 23, 2003............................................................................................................................................................................................................... 24
The Surgery Your Doctor Shouldn’t Perform
by Thomas M. Burton
December 30, 2003............................................................................................................................................................................................................... 25
Paul E. Steiger
Managing Editor
THEWALLSTREETJOURNAL.
200 Liberty Street
New York, New York 10281
212.416.2327 Fax: [phone]
!
February 1, 2004
The Pulitzer Prize Board
Columbia University
709 Journalism
2950 Broadway
New York, NY 10027
To the Judges, Explanatory Reporting:
While the media focus on AIDS and certain cancers, an even more common killer is at large. Most doctors
don’t recognize its symptoms. Most patients don’t know they are at risk. And most of the 25,000 to 40,000
American deaths it will cause this year may be preventable.
The killer? The aortic aneurysm, a dangerous bulge in the body’s largest artery. When an aneurysm rup-
tures, it is almost always fatal. Conventional medical wisdom holds that aneurysms are rare and that little
can be done to prevent them. But as Wall Street Journal reporters Kevin Helliker and Thomas M. Burton
explain in this explosive, year-long investigation, the conventional wisdom is wrong on both counts – with
deadly results.
Messrs. Helliker and Burton uncovered the surprising prevalence of aneurysms, which in fact claim more
lives than AIDS each year and perhaps as many lives as breast and prostate cancers. They explain how a
simple screening process, using often inexpensive body scans, can easily detect aneurysms, which can then
be repaired before they do any harm. And they expose in disturbing, precise detail why these simple steps
haven’t been taken or disseminated by the medical community, which remains largely uneducated about
aortic disease. As the legendary heart surgeon Michael DeBakey, inventor of aortic aneurysm-replacement
surgery, told the reporters, “No physician can diagnose a condition he never thinks about.”
Messrs. Helliker and Burton lay bare the deadly discrepancy between available medical knowledge about
aortic aneurysms on the one hand and the ignorance of many front-line physicians on the other. They show
how thousands of deaths could be prevented. And their work already has saved lives.
While most people might associate aortic disease with the death this year of actor John Ritter, the Journal
reporters came to this important story in a more personal way. Mr. Helliker, the Journal’s 43-year-old
Chicago Bureau Chief and a triathlete, was diagnosed with an aortic aneurysm himself, discovered by
chance during a CT scan. Mr. Helliker, who helps oversee the Journal’s health coverage, had never
encountered in his extensive perusal of medical literature the fact that aneurysms could be detected – and
surgically removed – before they burst. A simple question struck Mr. Helliker as well as Mr. Burton: If
new-technology scans made possible the discovery of Mr. Helliker’s aortic aneurysm, why wasn’t the
medical profession seeking to find this killer in others?
The pursuit of that question led to more alarming ones. In the past two decades, Messrs. Helliker and
Burton learned, medical science has mastered the ability to detect and repair aneurysms in the aorta.
Scientists have also made tremendous progress in identifying people at high risk for aortic aneurysms. Yet
in reviewing the medical literature, Messrs. Helliker and Burton realized that the rate of misdiagnosis for
rupturing aortas hadn’t declined – and neither had the death rate. How could that be?
Finding experts who could shed light on that question wasn’t easy. No medical specialty is devoted to the
aorta. There are no patient advocacy groups, nor is there any patient literature. What was even more
difficult, the nation’s few aortic specialists were reluctant to go on the record with their criticism that the
medical profession has itself failed, and that thousands are dying because of medical ignorance. Finding
patients presented another challenge. The two reporters spent months researching medical literature,
combing through obituaries and interviewing survivors, ultimately turning up dozens of cases of medical
mishandlings of aortic aneurysms.
The result is a body of work so authoritative that many physicians have contacted Messrs. Helliker and
Burton seeking aortic advice. Their work persuaded federal death-statistic experts to concede that the
official number of aortic deaths – about 18,000 a year – was 40% too low, while aortic experts believe the
actual number may be more than twice as high. Their work was cited in a December article in the Journal
of the American Medical Association. “I’ve found better information in The Wall Street Journal than in the
medical literature,” said Peter Luttrip, a radiologist and aortic-aneurysm survivor.
The impact of these stories has been overwhelming. Many readers learned from the coverage something no
doctor ever told them – that they belonged to high-risk groups for aortic aneurysms. Numerous readers took
the Journal articles to their doctors to demand screens, and several found aneurysms as a result. Medical
societies are using the articles to seek Medicare funding for aneurysm screening. The cause has been taken
up by former Sen. Bob Dole, who cites the Journal in speeches asserting that medical ignorance is killing
people with aortic disease.
Ivan Lubash of Sudberry, Mass., was one of many readers who learned of an aneurysm thanks to the
coverage. As he wrote to the reporters: “I believe my reading the article and following up on it has saved
my life.”
The Wall Street Journal is proud to nominate this groundbreaking work by Kevin Helliker and Tom Burton
for the Pulitzer Prize for Explanatory Reporting.
Sincerely,
Paul E. Steiger
6 Reprinted from THE WALL STREET JOURNAL JANUARY 13, 2003
Battling the Bulge Doctors almost never inquire about a
family history of aneurysms, even though How It Works
Test for Aneurysms they have a strong familial link. They
draw minuscule research funding. And Aneurysms arise when a
while vast medical industries have grown thinning, weakening section
Might Save a Lot
up to detect ills such as prostate cancer of an artery wall balloons
and diabetes—with doctors routinely out to twice the artery’s
Of Lives, Some Say ordering tests and insurers routinely normal diameter. The
paying—doctors hardly ever suggest that most commonly deadly
a well patient take a simple test that of these occur in the
Artery Flaw Is Fixable if Found could detect countless repairable aortic aorta, the big vessel
aneurysms. It costs as little as $40 at stretching from the
And Often a Killer if Not, some centers. heart to the lower
“These deaths are basically pre- abdomen.
But Lacks a Constituency ventable if people just got themselves
screened,” says M. David Tilson, who has
Aorta
treated and researched aneurysms for
‘These Deaths Are Preventable’ more than a quarter-century and now
holds an endowed chair in surgery at
Columbia University. “Aneurysm disease
ByTHOMASM. BURTON
is one of the most neglected diseases in
Jo-Anne Coe took every medical test American history.” Kidney
Why this anomaly? An important rea-
recommended by doctors and was deter-
son is that aneurysms produce no large Normal Aneurysm
mined to stay healthy. At 69 years old,
aorta
she was working as an aide to former group of patients motivated to raise
Sen. Bob Dole while remodeling a Vir- awareness and funding. Most people with
ginia farmhouse. an aneurysm never have symptoms and
But on Sept. 27, while shopping for don’t know about it. If it bursts, they’re
kitchen cabinets, Ms. Coe felt an intense usually dead or disabled. In a third
pain in her back and went to an emer- scenario, where the aneurysm is found
gency room. Unlike chest pain, back pain and surgically repaired, patients aren’t A normal aorta is between 1.6 and 2.8
often isn’t regarded as urgent, so she likely to become activists. Most are essen- centimeters wide. If a spot gets as wide
waited 90 minutes to see a doctor. After tially cured, unlike the many people who as 5.5 centimeters, the risk of rupture
finding that blood was pouring into her live for years fighting cancer, AIDS or may be high enough to call for surgery.
body from a leaking aneurysm—a bal- heart disease.
looned section of a blood vessel—alarmed A rare exception is Bill Maples, who the screening but also monitoring of
doctors rushed her launched a support group and Web site aneurysms found, and surgery for some
into surgery. Dur- out of his home after having an aneurysm of them. To Rodney White, a surgery pro-
ing the operation, found and fixed. “We have no funding fessor at UCLA, “It’s a social dilemma
on her torn aorta, whatsoever,” says Dr. Maples, a retired because you can’t afford to screen every-
she died. college biology professor in Carrollton, body. But the argument for screening is
The popular im- Ga. stronger now [and] a lot of professional
pression is that an- A different obstacle prevents screening groups are advocates for screening.”
eurysms are like tests from becoming common and cov- Aneurysms arise when a thinning,
lightning: striking ered by insurance. Many insurers take weakening section of an artery wall bal-
rarely, suddenly their cue from Medicare, which doesn’t loons out. Such spots are considered
and unpredicta- aneurysms when they reach twice the
cover aneurysm screening. Now, how-
bly. In fact, the artery’s normal diameter. The deadliest
ever, a debate is stirring in medicine over
most lethal aneu- occur in the aorta, the big vessel stretch-
whether some groups of people with no
rysms, those on ing from the heart to the abdomen.
symptoms should be screened for
the aorta, develop They usually produce no symptoms.
slowly, are often K. Craig Kent aneurysms. K. Craig Kent, chief of vas- The majority never burst. But when they
easy to diagnose cular surgery at New York Presbyterian do, the patient dies about 90% of the time,
with an inexpensive ultrasound test, and Hospital-Cornell, did an economic often never reaching a hospital. By con-
can usually be treated. analysis concluding that ultrasound trast, when a large aortic aneurysm is
But most are never diagnosed, with the screening for abdominal aneurysms found and operated on, the survival rate
result that bursting aneurysms in the would be more economical, in terms of is typically 95% or better, depending on
abdomen and chest kill an estimated life-years saved, than mammography. In the hospital and where on the aorta the
18,000 Americans a year—more than an article last August in the journal aneurysm is.
AIDS or brain cancer, and four times as Surgery, Dr. Kent recommended that all Most deaths from aortic aneurysms
many as cervical cancer. Based partly on men over 60 be offered a quick ultrasound involve the abdomen, where they can be
estimates from doctors, deaths from all exam of the stomach. He also urges the detected by the inexpensive, and very
types of aneurysms, including cerebral, test for all women over 60 who have a accurate, ultrasound test. The rest of
aortic-aneurysm deaths—an estimated
equal prostate cancer’s toll and approach family history of aneurysms.
2,500 a year in the U.S.—occur where the
that of breast cancer.
‘Social Dilemma’ vessel runs through the chest. Spotting
Neglected Disease What such a policy might add to the these usually requires a CT scan, which
For all this, there is no national effort country’s surging medical bill is can cost as much as $800.
to find aneurysms before they rupture. unknown. The cost would include not only Cerebral aneurysms present a more
Reprinted from THE WALL STREET JOURNAL JANUARY 13, 2003 7
complicated case, because detecting them has tripled to about 200,000 a year. The
costs more and it’s not so clear which surge appears partly to reflect the greatly
Little-Known Killer
ones need surgery. But these, too, can be increased use of CTs, MRIs and the like,
deadly. They kill roughly 14,000 Ameri- Aneurysms are comparable to some high-profile to check for tumors or other conditions.
cans a year, estimates Gary Steinberg, killers, though not to the biggest, such as heart Relatively few scans are done simply to
chief of neurosurgery at Stanford Univer- disease, stroke and lung cancer. Estimated hunt for aneurysms.
sity Medical Center. annual deaths in U.S. Would insurers pay if tests to detect
The aneurysm toll actually may be
Breast cancer aneurysms were done to screen symptom-
much higher. In the absence of autopsies,
coroners tend to attribute sudden deaths 41,000 less patients, rather than to diagnose
Aneurysms* symptoms in individual cases? So far,
to cardiac failure. Each year in the U.S.,
about 450,000 sudden deaths, most of 32,000 insurers haven’t faced the issue. When
them unautopsied, are ascribed to car- Prostate cancer asked, some point to the added costs that
diac events. Dr. Kent says it’s likely a 31,500 would result from monitoring and sur-
substantial portion actually are due to AIDS gery, and say they haven’t been con-
burst aortic aneurysms. 14,500 vinced that screening would be broadly
High blood pressure raises the risk, Brain and nervous-system cancer effective.
both that an aneurysm will develop and 13,100 Some doctors also are reluctant to
that it will someday burst. Yet while doc- endorse widespread testing. Robert
Cervical cancer
tors routinely check blood pressure, and Zwolak, a vascular surgeon at Dartmouth
4,400
warn about heart risk, they rarely
Medical School, says, “We think we can
mention aneurysms. *Includes abdominal, thoracic and cerebral
identify a risk group for whom aortic
Meanwhile, doctors and fitness experts Note: Aneurysms and AIDS figures are for 2000;
aneurysm screening is appropriate, but
are increasingly preaching the benefits of others are 2001.
we need more substantiation.”
weightlifting, including for the elderly. Sources: National Center for Health Statistics; American
But “heavy weightlifting and heavy Cancer Society; interviews with physicians A huge British study provided some
last fall. After following 61,000 men aged
straining could worsen aneurysms,” says
Christopher K. Zarins, chief of vascular Screening for aneurysms on the aorta 65 to 74 for an average of four years, it
surgery at Stanford University Medical would be simpler, because these appear found a 42% drop in risk of death from ab-
Center. He suggests that people with in more distinct patterns. For instance, dominal aortic aneurysm among those
aneurysms use only light weights. 80% occur in men, and the odds rise with who had been screened. Their aneurysm
The National Institutes of Health will hypertension, smoking and arterioscle- death risk was 1.9 per 1,000, vs. 3.3 in the
spend $2.77 billion for research on AIDS rosis. others. “Screening can significantly
this year, along with $732 million on In addition, when this type of aneur- reduce mortality rates associated with
breast cancer and $408.3 million on pro- ysm is spotted, it’s easier to know if abdominal aortic aneurysms,” concluded
state cancer. The amount for abdominal surgery is needed, because the risk of the study, published Nov. 17 in The
aneurysms is just over $6 million. rupture increases with size. Normal Lancet, the British medical journal.
Some doctors say cerebral aneurysms, aortas range between 1.6 and 2.8 centime- A large new study is being organized
in particular, warrant more study. It is ters wide. Doctors say any sections wider
in the U.S. by the medical schools of
difficult to know which ones are likely to than four centimeters generally need to
Dartmouth, the University of Pennsyl-
burst, and it takes a $1,500 magnetic-reso- be watched closely. Many are stable, but
vania and the University of Pittsburgh.
nance or CT scan to find them. Despite when they start growing, alarms go off. If
the uncertainty, experts recommend the a spot gets as wide as 5.5 centimeters, the Initially it will measure the prevalence of
exams in a number of cases, such as risk of rupture may be high enough to call aneurysms; a later phase will check for a
persistent severe headaches and vision mortality benefit from screening.
for surgery. The death rate in surgery
problems. “There is reasonable emerging evi-
isn’t negligible but is much lower than
dence suggesting that it’s reasonable to
Devastated that from burst aneurysms.
screen men over 60” for abdominal aortic
Lois Porteous might have benefited. U.S. surgeons repair about 50,000 ab-
Suffering from severe headaches and a dominal aneurysms each year, typically aneurysm, “particularly if they have a
loss of peripheral vision on one side, she replacing the puffed-out area with a history of smoking, and anyone with a
was given headache medicine but no plastic or fabric tube. Some now use a first-degree relative with an aneurysm,”
scan. Last Jan. 30, the 58-year-old in less-invasive procedure that threads a says Jack L. Cronenwett, a study orga-
Zebulon, N.C., collapsed in her kitchen tubular device called a stent-graft into the nizer and chief of vascular surgery at
after an aneurysm behind her eye burst. bubble. Dartmouth. That would have included
She survived but needs 24-hour care. “It Over two decades, the number of intact Ms. Coe in Virginia: Her mother, too, had
just devastated her,” says a son, Michael. aortic aneurysms diagnosed in the U.S. an aortic aneurysm.
8 Reprinted from THE WALL STREET JOURNAL MARCH 13, 2003
Fears Mount surgeon, John Elefteriades of the Yale
University School of Medicine, that people
over 40 years old bench-press no more than
Over Dangers
half their body weight. Equally important is
breathing regularly during exercise to
Of Pumping Iron
minimize spikes in blood pressure.
Aneurysms aren’t the only concern for
heavy-weight lifters. Vascular experts say
Weight Lifting Craze Comes it can induce stroke, as well as dissection,
in which the inner lining of the aortic
Under Scrutiny by Doctors artery separates from the outer walls.
Heavy-weight lifting can spike blood
Concerned About Health Risks pressure to dangerous heights. In max-
imum-effort lifting, which pits a partici-
pant against the most weight he can hoist
ByKEVINHELLIKER one time, studies have shown that blood
A pressure rises to as high as 370/360 from
S A FITNESS TRAINERand health
a resting rate of 130/80. Conventional blood-
fanatic, Michael Logan knew that
pressure monitors can’t even measure
weight lifting could strengthen his
levels above 300. “At that level, nobody
bones and protect his heart.
would be surprised if you had a stroke,”
What he didn’t know was that it could be
lethal. Mr. Logan had a bulge in his siaalyisst Farta tnhze MOecshssenrelir, Ca lhinyipce Frtoeunnsdioanti osnpe icn- mages
pthriamt abruyl gaert,e royr, athnee uaroyrstam. ,K wnoowulledd ghea voef New Orleans. Getty I
John Robertson witnessed just such an
prompted doctors to allow only light-weight Overload:
event one day when he was lifting weights
lifting. But like the vast majority of people
as a medical student. Lifting beside Dr. Heavy-weight lifting can trigger
with aneurysms, Mr. Logan didn’t know he
Robertson was a fellow medical student
had one. strokes and aneurysms.
who suddenly keeled over backward. A
So he continued heavy-weight lifting—
vessel in his brain had ruptured. He was
until an aortic aneurysm killed him last
rushed to the hospital, and survived.
June at age 46. “It’s very surprising that Dissection typically occurs in older adults,
“During the time that you’re lifting, the
something he did for his health might or those who have a family history or who
pressure on the artery wall is intense,”
have hurt him,” says Mike Logan, the suffer from a syndrome called Marfan’s dis-
says Dr. Robertson, chief of thoracic and
late Chicago trainer’s son. ease. Yet Dr. Elefteriades has treated two
cardiovascular surgery at St. John’s
In a nation obsessed with looks and fit- Health Center in Santa Monica, Calif. young dissection victims who had none of
ness, weight lifting is the latest workout Doctors have long suspected that the the traditional risk factors but who were
craze. Recent studies have shown that steep blood-pressure spikes arising from heavy-weight lifters. Similarly, a study
lifting can lower blood pressure, combat heavy-weight lifting could trigger rup- conducted at Los Angeles County Harbor-
diabetes and strengthen bones. Bookstore tures of already weakened vessels. Now, UCLA Medical Center profiled four men
shelves are teeming with new fitness
suspicion is growing that such lifting can (aged 22, 34, 37 and 57) who entered the
tomes touting weight lifting. Over the
damage healthy vessels. Yale’s Dr. Eleft- emergency room suffering dissection—all
three years ended in 2001, participation in
eriades has shown in a lab experiment heavy-weight lifters. Steriod use may
weight lifting in the U.S. has risen 12%—
that intense pressure can induce dissec- increase the risk.
while aerobic exercise declined 2%, ac-
tion, often requiring emergency open- One option for anyone over 60 or with a
cording to American Sports Data Inc.
heart surgery. family history of aneurysms or dissection
Now, however, a small but growing
number of researchers are raising con-
cerns about the safety of lifting heavy
weights. Such lifting can trigger strokes Pumping Iron Safely
and aneurysms, and perhaps even cause The safest way to lift weights may also be the easiest.
a highly fatal arterial disease called dis-
section, believe doctors at prominent
Go Light Breathe Rest
health centers such as Yale University
Start out with a weight The key to keeping down After 15 repetitions, take a
School of Medicine and the Stanford
that seems ridiculously your blood pressure is 30-second break. By your
University Medical Center.
easy. Lift and bring down regular breathing: Exhale fourth set of 15, you might be
Aneurysms alone kill 32,000 Americans
in a smooth, unhurried as you lift, inhale as you surprised at how heavy that
a year, making them as big a killer as
motion. return the weight. weight has begun to feel.
prostate cancer, and a more common kil-
ler than brain cancer or AIDS. Especially
vulnerable to aneurysm and other arte-
rial conditions are senior citizens—a
group that has been urged to take advan- inh
tage of the bone-strengthening effects of ale
weight lifting. 2 lbs. exhale
Aneurysm experts express little con-
cern about moderate to light-weight
lifting. Some define light as an amount Two 20-minute sessions a week (or even one) of this style of lifting can add muscle tone,
that can be lifted 60 times, in four sets of lower your blood pressure and strengthen your bones.
15. A leading aneurysm research and