On Monday, I kept my appointment with Oriscello, a tanned, vigorous man of 47, who at 5:30 that morning had run his daily six miles in 43 minutes. The "national treasure" had received my records from Sheehan, and he proceeded to put my emotions through their paces with a 45-minute monologue. I had just sat down when he all but shouted, "Why did they do the thallium? I would have looked at that normal stress test and EKG and sent you out running. [I was delighted with his attitude.] But maybe it was divine intervention, because what they found was multiple perfusion deficits; the heart had cold areas. Then, when the radionuclide [the thallium] was allowed to recirculate, it was taken up by the heart muscle that had been cold. This means two things: a compromised blood supply to various areas of the heart ['Oh,' I said], but no heart muscle damage of any magnitude. ['Aha!'] If you had damage, the thallium would not have been picked up the second time around."
Oriscello held up the negative-like images called thallium tomograms that I'd spirited out of St. Vincent's. There were 20 or more pairs of little doughnut-like smudges that I'd assumed were cross sections of my coronary arteries but were actually two-dimensional "slices" of my heart. All of the doughnuts marked STRESS had blank, light or fuzzy areas. "See the lack of uptake here? And here?" Oriscello said as he pointed to them. But many of the doughnuts marked DELAY were solid. "And now it's picked up here," he said, pointing to the solid ones. "It's abnormal, Dan, and I don't know why. There are people who have a normal stress test—generally not to the level of yours—who can indeed have problems, but at least the EKG would be abnormal, even if they didn't have pain. However, there are strange things in this world. On the basis of what I see here, I'd have to say it was rather significant coronary artery disease.
"For some reason, someone then suggested that you have a Wall Motion Study, in which the radionuclide remains in the left ventricular chamber. One can watch as the heart contracts, ejects blood and then relaxes. Ordinarily, one sees a nice, uniform pattern of contraction, but in your case the study shows, according to the radiologist at St. Vincent's, that you have multiple areas of altered heart muscle contraction." That didn't sound as bad as "multiple perfusion deficits"; I was becoming a connoisseur of bad news. "So what do you believe?" Oriscello asked. "The thallium and Wall Motion, or the stress test/EKG and the fact that you feel fine and have been running for a long period of time?"
I said, "Another cardiologist told me, 'You've done an extraordinary amount of work in these tests. It's inconceivable that you have the disease described.' "
"No, it's not inconceivable," Oriscello said. "It's unlikely. Life is a bell-shaped curve. At one end is a group that can exercise interminably and feel nothing, yet has severe disease and abnormal tests. You may be at that end. You don't have the classic symptoms: the chest pain that comes and goes slowly, the EKG and stress-test changes, but you have two positive tests and you're a 46-year-old male."
"Even worse," I said, "someone said I almost certainly have coronary artery disease."
"Well, you could. That's what the angiogram would be done for, to rule it in or out."
What Oriscello wanted to leave me with came as a complete surprise. He said, "After I tell you what I think is going on here you're going to ask how I can justify telling you to go for an angiogram. Based on your history, your EKG and stress test, and having listened to your heart, I have to say that I think your coronary arteries are going to be totally normal. But Danny Boy, that's nice for me to say, but it's horse-feathers if you go out and do 10 miles and the next thing you know you wind up dead."
When I arrived home that day, my phone was ringing. It was respondent No. 3, Howard Bezoza, a specialist in preventive medicine and clinical nutrition. He started out in high gear: "From just the information you sent me, your anxieties are appropriate. There are definite Wall Motion abnormalities, and if I were you, I'd go for the angiogram."
Then Bezoza dropped a bomb. "Forty-six-year-old men with significant coronary disease do beautifully with surgical intervention."