The Widowmaker: Clarifying the Record for Our Patients

I’m a retired doctor who walks about 8 miles on some rural roads each morning. People sometimes stop to ask me medical questions. Some call me, “The Street Doctor.”

Last week, a 72-year-old man stopped to tell me about his heart condition. He said he had a stress test that was positive and then had a cardiac catheterization (cath), which showed a 99% blockage of the “widowmaker.” He said he had bypass surgery scheduled in 5 days.

I asked, “Are you having any symptoms?”

“No, he said, I feel fine. My primary care doctor thought I should have a stress test to check on things. Now they say I’m about to die.”

After a moment of hesitation, I said, “Well, you’re not really about to die.”

“Really? Then why did they say that?”

“It’s a long story. If you have surgery planned and you’re good with it, then you may not want to hear the long story.”

“No, I’d like to hear what you have to say,” he said.

“OK, I’ll stop by on my way back home. If you could get a copy of your cath report, that would help.”

When I got back to his house, he had the cath report. I looked at it. He had a 99% blockage of his proximal left anterior descending artery at a branch point.

I said, “Yes, that’s the artery they call the widowmaker, but in your case it’s not a widowmaker.”

“Why not?”

“It’s only a widowmaker — or maybe we should revise to also say widowermaker, as heart attacks don’t just happen in men — when it becomes suddenly blocked. You’ve been growing that 99% lesion for years.”

He looked confused.

I continued on, “There are two ways to block an artery in your heart. One way is with atherosclerosis, like you have. The other way is with a clot. The two things are very different. Atherosclerosis is a slow process, and though many think it is cholesterol plastered on the wall of arteries, there is much more to it. It is not just cholesterol but also cells, connective tissue, and calcium. Atherosclerosis is a kind of gradual growth; by itself, it does not cause a heart attack. But if that atherosclerotic blockage gets a tear on its surface, then a clot can form there, just like it does when you get a tear on your skin. It is that clot that causes the heart attack. But if a clot formed on your 99% lesion it wouldn’t kill you because you only have about a drop of blood going through there. The way a clot kills you is when you have a small atherosclerotic lesion in your artery, say about 20% blockage. If you have a 20% blockage then you have a lot of blood flowing through there and it is feeding your heart. If a clot suddenly forms at that site, taking the blockage from 20% to 100% in a matter of seconds, then that is what kills you. When a clot forms in the left anterior descending artery then it is often deadly. That is why it is called the widowmaker. But your 99% blockage is not a clot.”

“So, it’s the smaller blockages that are more deadly?” he said.

“Yes. The reason you don’t have any symptoms is because your heart has already done its own sort of bypass. That’s what it does when the blockage forms slowly. But if the lesion is small, then your heart has not bypassed it.”

He still looked confused.

I said, “Let me give you an example. Have you heard of Davy Jones, the lead singer for ‘The Monkees’?”

“Yeah.”

“When he was in his 60s he got a cardiac work-up, and his doctor told him he had the heart of at 25-year-old. He went on tour, and was doing just fine — until one day, his chest hurt. He thought it was indigestion or something minor, because he had been told his heart was fine. He sat in his truck waiting for the pain to pass. It didn’t, and he died from a heart attack. The reason his stress test was negative was likely because he didn’t have any major blockages. It appears he had a small blockage that tore, then a clot formed at that site, and it killed him. That’s how widowmaker heart attacks work.”

I paused for a moment to let the information sink in. Then I said, “There was a study done years ago, called the Coronary Artery Surgery Study (CASS), where they studied a lot of guys like you. In one group they did bypass surgery and in the other group they didn’t. Then they followed those guys for years to see if bypass surgery helped. In a guy like you, it didn’t.”

“Really? Then why do I hear about so many guys having bypasses?”

“Because we don’t always use the evidence. It’s counterintuitive that we spend a lot of money on medical studies and then don’t always go by the results, but that’s the way of medicine.”

“I guess money has something to do with that,” the man said.

“Yes, it does. But there’s more to it. People get emotional about health and illness. They want to believe that things work even when they don’t. Terms like the widowmaker play on emotions. People eat it up. Emotions eat at the fabric of medicine like termites eating on a house. They are hard to control.”

He laughed.

I said, “So that’s the story. But if your emotions tell you to have surgery then go for it.”

“I’ll talk to my doctor about it, but he said I really need it.”

He had bypass surgery 5 days later. The surgery went well.

But I still wonder, should we retire terms like “widowmaker” that patients don’t fully understand and lead to unnecessary interventions? Then again, if we did that for every condition, we might have a whole lot less to treat. Maybe that wouldn’t be so bad.

W. Robert Graham, MD, completed medical school and residency at UTHSC-Dallas (Parkland Hospital) and served as chief resident. Graham received an NIH fellowship at the Salk Institute for oncogene research in 1985. He was a professor of medicine at Baylor College of Medicine from 1998 through 2016. In retirement, he enjoys writing and ranching.

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