To save lives, this doctor is defying the orthodoxy
Having lunch with a medical professional could potentially It’s a matter of nerves. And that goes double when that doctor is a senior cardiologist on a mission to prevent more Australians from dying of heart attacks at an early age.
So as I browse the menu opposite Dr Stephen Fenton at the Centennial Homestead in Centennial Park, I’m already feeling a little judged.
Fenton’s has settled into the spot mostly for its heart-healthy menu, but I still need to shift my eyes from bacon, fries, and chorizo (mmm, chorizo) to something more likely to get the nod.
Happily, we both made it to the vegetarian nutrition bowl; This turned out to be both delicious and healthy. Sparkling water to drink. The days of eating chips, burgers and a cheeky chardie or two for lunch are now history and, as Fenton sees it, having just turned 74, it was never part of his story.
Probably the least judgmental doctor I have ever met, Fenton has been in the heart game for more than 40 years and has witnessed a remarkable period of advancement in cardiology. Our connection stems from my near-fatal heart attack last year, which was thankfully corrected by a stent surgery. Fiona Foo, the masked and gowned angel who operated on me, worked alongside Fenton and contacted us to discuss her work and her new book. 5 Channel Lifestyle.
Fenton, a talented amateur musician, begins by telling me about a gig he recently attended at the Lazybones venue in Marrickville. Before the main act, a 10-year-old boy was introduced and took to the microphone to sing and play guitar. Not your usual support act.
Later, his wife Helen learned the story from her pianist friend. “This 10-year-old boy lost his father three days ago,” Fenton says. “He had a sudden heart attack. And his father was 50 years old.”
This tragic scenario resonated deeply for Fenton. Without exact details, but in outline: a child, a father, a sudden heart attack and a family tragedy. Fenton’s father was just 45 years old when he had his first heart attack. The second, for the 65-year-old, proved fatal.
In Australia, someone dies from a heart attack every 90 minutes. This means 18 deaths and 18 families torn apart every day.
It is this quiet tragedy that prompted Fenton to write his book, in which he argues that despite extraordinary advances in cardiology, too many Australians are still assessed by population-based screening tools that he believes are blind, incomplete and often misleading.
Modern medicine can open clogged arteries, dissolve clots, insert stents, replace valves, transplant hearts, and rehabilitate people in countless other ways. But Fenton’s focus is now on what happens long before that threshold is reached.
And his message of disregarding orthodoxy on screening and testing is a controversial one, but at this late stage of his career he’s not looking to win any popularity contests with the establishment.
Fenton had a “pretty normal childhood” growing up in Brontë, playing football and being exposed to music (his mother was a classical pianist and his father a jazz musician).
But the event that was most sharply ingrained in his childhood memories was not musical. His father, a “typical Australian” born during the Depression, died during World War II. He had served in the Army during World War II and later worked in the textile business, primarily importing from Japan.
In 1962, when Fenton was 10 and his sister was three, 45-year-old Frank had a heart attack on the golf course.
They did what kids do when adults use scary words they don’t understand. “I remember my sister and I looking up the dictionary to find out what coronary thrombosis meant, because that’s what we were told,” Fenton says.
This was all before coronary care units, monitoring, and a host of interventions that now define cardiac medicine. The best the doctors could do for Frank was to immobilize him for weeks.
“They didn’t actually get any treatment,” Fenton says. “He probably had at least a 50 percent chance of not surviving, but he did.”
Then, 20 years later, when Fenton was a cardiology registrar himself, his father called with chest pain. He was taken to Royal Prince Alfred Hospital and suffered another heart attack at a time when clot-dissolving drugs, let alone stents, were part of routine care.
“They took him to emergency bypass surgery, but he died,” Fenton says. “He was 65. It was a tragedy for us, but I think I had at least 20 years, from the age of 10 to the age of 30. That was very precious.”
It would be easy to use Frank’s heart problems as the catalyst for young Fenton to pursue a career in medicine, but his entry into the field was more by chance than by design.
“In those days when I was leaving high school, there was a tug of war between medicine, law and architecture,” he says. “I studied medicine at the University of Sydney and in fourth year you go to hospital and that was fine. I was interested in cardiology but I didn’t really have a passion for it. But then fate played a part. My first term as a trainee I was randomly assigned to cardiology. I found it fascinating.”
Fenton had entered the field at a moment of extraordinary change. Cardiology began to change. Coronary angiography was improving. Cardiac ultrasound came in primitive form. Fenton saw one of the first ultrasound machines and was amazed that a painless, radiation-free probe on the chest could reveal the movement of the heart.
“By today’s standards, these were completely primitive,” he says. “But I thought it was incredible.”
The bypass surgery was starting to take hold. Balloon angioplasty and stenting came. Pacemakers, defibrillators and powerful new drugs followed. The statin history, now so important for cardiovascular prevention, began to show decisive trial evidence in the 1990s.
What I experienced was the dramatic side of modern cardiology: When my own stent was inserted, the change was miraculous. Twelve months after my surgery, I plan to summit Mount Kilimanjaro. Before the surgery, I could barely walk up the stairs at home.
As Fenton gets older, he turns more to the much less dramatic job of keeping patients from reaching crisis point. His field now is prevention; the Holy Grail of medicine that promised huge returns for overstretched healthcare systems but never received the attention it deserved.
“This became more interesting as we started to prevent it,” Fenton says. “I see people transform and I know I changed course and prevented something from happening to them.”
But at the heart (pun intended) of this study to prevent heart attacks lies a major disappointment for Fenton. 5CH LifestyleIt’s a call to arms for the medical profession to redefine risk and test earlier, and it’s part of a lifestyle guide to help you avoid ending up in the heart ward or worse (spoiler alert: chorizo isn’t on the list of preferred foods).
Fenton argues that standard cardiovascular risk calculators used by front-line doctors are outdated and inadequate. It’s not saying that classic risk factors (blood pressure, cholesterol, diabetes, smoking, etc.) are irrelevant. Rather, his point is that they don’t matter only. Family history, women’s health factors such as inflammatory diseases, early menopause, preeclampsia and gestational diabetes, sleep apnea, stress, social isolation, depression, diet history and erectile dysfunction can change the picture.
Some of these are considered “risk-increasing” factors. But Fenton argues that the list is incomplete and poorly understood. He quotes a phrase from his hospital days: “Ask the orderly” question. As an intern at Sydney Hospital responsible for 30 or 40 patients, he would arrive early and ask the nurses who should be seen first. If they were busy, he would ask the doorman. “I’d say, ‘Who doesn’t look good, Bob?’ And he’d say, ‘Bed 17. You’d better take a look at that.’
What he means is not that janitors should practice medicine. Some things are obvious when someone bothers to look. “You don’t have to be Einstein or a super genius to know some of the things that happen,” he says. “So I call family history a question to ask the doorman.”
In his book, Fenton recommends a simple screening survey that is much broader than the population-based survey you are likely to encounter in your doctor’s office, which he considers inadequate and outdated. “These calculators have some utility in populations, but they’re not very accurate in individuals,” he says.
When you complete Fenton’s test, you come away with one score. If you score three or more, he recommends the Coronary Artery Calcium (CAC) test, which detects the level of plaque in the arteries, which is the root cause of a heart attack.
The results of noninvasive CAC, which he describes as a “mammogram of the heart,” determine whether further testing, medications such as statins, or even surgery are necessary.
Although no studies have tested Fenton’s full proposal, he says the evidence “strongly supports the claim that identifying individuals at higher risk and then treating the key drivers of risk can reduce the risk of cardiovascular events and heart attack by more than 50 percent.”
“Many primary prevention experts are ticking time bombs, some just a heartbeat away from a potentially fatal event,” he writes. “The best way to assess this risk is through the CAC score.”
He uses a horse racing analogy. How accurate would you be if you were trying to pick a winner and were only allowed to consider four things (jockey, trainer, form and breeding)? You ignore the track, weather, weight, barriers, obstacles and more.
“There are many ways to lose in a horse race,” he says. “But this is a horse race. It’s not good to make predictions when it comes to the main cause of death and the main cause of sudden death.”
All this talk of untimely death makes our lunch date feel a little somber, but as we sit in the sunshine and look out over Centennial Park, I can’t help but marvel at Fenton’s drive and his vision to reduce the pain and trauma of deaths from heart attacks.
“We still have a long way to go,” he says. “I used to rave about it at dinner parties, and then I stopped getting invited to dinner parties and I thought I should try to spread that message, so I wrote the book.”
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