Thanksgiving Reflections

Happy Thanksgiving!

Thank you all for reading my blog.  I reflect back a year and consider what  blessings I am thankful for. This blog is one of them. It has provided me a good outlet for all the information I enjoy learning, sharing and teaching. So to the 11,ooo viewers to day, a very grateful thank you.

Choices in the care of your heart

Heart disease is challenging and frightful. Sometimes decisions are made very quickly regarding managing the disease process. Heart disease is a chronic condition that rears its ugly head over and over for many. As a heart patient  your best off having a good knowledge of the disease process and the choices of interventions.  Methods of intervention include:

  • Angioplasty (balloon opening of artery)
  • Cutting balloons and roto ruters
  • Stent
  • Drug eluting (coated) stent
  • Open heart surgery – Bypass Surgery
  • Treat medically with medicine and lifestyle
  • Enhanced Eternal Counter pulsation therapy
  • Left Ventricular Assistive Devices
  • Heart Transplant

Many of these decisions are based on the amount of heart tissue that is involved. If there is a large region with insufficient blood flow caused by numerous blocked vessels you most likely will be recommended to have bypass surgery. The general rule is if three vessels are involved you will most likely require surgery. You do have choices though, as the main blockage can be intervened on through stents and the other vessels can be addressed at a later time. We call this staged stents. The  cardiologist do not  recommend placing stents to both the right and the left side of the heart during the same intervention. They will treat the culprit, and then come back later for the others.  The decision tree also takes into account what other issues (co morbidities) a patient has. If  a patient has end stage renal disease or their kidneys were severely affected by the heart problem then the physician my want to avoid treatments that place a heavy burden on the kidneys such as angioplasty or stents. They may opt to treat medically until the kidneys have recovered if they can.

A single vessel blocked will more likely be treated with a stent. However the location of blockage can be very challenging. If the blockage is  where the artery separates to another branch – called an anastamosis  these are very difficult to deal with because a stent would block the flow to the other artery. Sometimes they require surgery, new technology in stents is coming and these may be able to be stented in the future.  Some vessels are too torturous – meaning twisty and turny to allow a stent to be placed. Again surgery, treat medically  or EECP therapy would be considered.

Small vessels are less likely to be treated with stents and more likely to be treated with medications.  Medication includes nitro, long acting nitro, calcium channel blocker, ace inhibitors, beta blockers and occasionally EECP.

Intervention is determined by how viable the heart muscle is. If the heart muscle was severely damaged due to a heart attack  and now scarred over – or remodeled, further intervention to that region is not likely to be of any help.

EECP – it is enhanced external counterpulsation therapy. The therapy consists of cuffs wrapped around legs, calves and buttocks. When the heart finishes pushing the blood flow out, the cuffs sequentially inflate to push the blood back up the heart. By doing this the heart is somewhat engorged with blood and forms collateral vessels. The treatment consists of one hour treatments 5 days a week for 7-9 weeks.  Most patients find their frequency and intensity of angina is greatly diminished. Many patients hold the benefits for 2-5 years, but others will require more frequent return treatments to hold the gains. It is usually covered by insurance such as Medicare if the angina is considered functionally limited or disabling.  For some people with very serious heart damage this improves the pumping ability of the remainder of the heart muscle, as it becomes stronger due to increased blood flow from collateral arteries. The EECP alone will not maintain the benefits, you must still keep physically active through exercise to maintain the benefits.  The treatment is non invasive.

LVAD is a left ventricular assistive device.  These are used when the heart cannot meet the demands any longer to adequately circulate the blood. For many this is now considered a destination therapy. This means they will not be a candidate for a heart transplant but will forever rely on the mechanical pump to circulate their blood. These are becoming more frequently used, and the mortality rates are decreasing with these pumps. If your health care provider is contemplating this route for you, I would strongly suggest you contact support groups of patients who already have LVADS here is a Facebook link to such a support group.  https://www.facebook.com/pages/LVAD-Recipients/207915222572308

Heart transplants are necessary when the damage is such that the heart cannot meet the needs. Often the patient is repeatedly hospitalized in congestive heart failure. They are disabled due to the heart condition.

The take home is know the procedures, research the pro’s and con’s of each. Don’t walk in to the physician’s office and simply take the first suggestion. Question the efficacy, ask the probability of success and what are the limitations, what can you expect in the future. Be active in your healthcare. Most inpatient nurses will tell you they witness too many incidents where the health care provider tells the patient and family if you don’t do this you will die. Thus the patient feels compelled to have the intervention performed. You have choices.

Choices involve the above discussion, but also include risk factor modification every single day. Choose to exercise, choose to eat healthy, choose how to respond to stress, choose to take your medications,  choose to not smoke, choose to monitor blood sugar.

Bypass

Stent

Left Ventricular Assistive Device

 Enhanced External Counterpulsation Therapy

Know your Nitro and Save your life

Nitroglycerine  Facts

One thing that always surprised me in cardiac rehabilitation was the understanding of using Nitroglycerin (nitro). I think over the years I saw and heard every way imaginable to ensure nitro tablet wouldn’t work if needed. Or the other one is when patients would carry it for years and then not use it when it is most appropriate to use. The take home message is if you are having discomfort that you suspect is heart related use a nitro ASAP.

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How Nitro works:

Nitroglycerin  dilates blood vessels that supply the areas of the heart where there is not enough oxygen thereby delivering oxygen to the heart tissue that needs it most.  The dilation of  veins and arteries  reduces the amount of blood returning to the heart so that the heart does less work and requires less blood and oxygen. Dilation of the arteries  lowers the pressure in the arteries against which the heart must pump. As a consequence, the heart works less and requires less blood and oxygen.

How to store Nitro:

Here is the thing Nitro is a very volatile compound. It breaks down rapidly with light, heat, oxygen, time and exposure to plastic. It is packed in a glass vial because plastic will leach the active ingredient out of it and all you have left is the inert ingredients that hold the tablet together. Therefore don’t transfer it to a container that is plastic, don’t put a couple in a baggy and put them in your wallet. Yes it is a pain in the butt to carry the bottle everyday, but find a way, or use a metal nitro vial which you can wear around your neck.

Heat will break down the nitro tablets. If you carry your Nitro in your pants pocket every day the heat from your body will gradually make the nitro less potent.  What I teach patients is to take a good marker and write on the bottle the date three months from when they started to carry the bottle. That is when it should be considered to replace. Sometimes it can go six months, but if you look at the bottle…hold it up to the light, don’t open it…and the tablets are looking powdery or crumbled….then replace the bottle. If you leave them in your pocket and they go through the dryer…time to replace. If you leave them in your car and your car is 100* or more…replace the bottle. That was a common one…”I leave them in the glove box in my car.”  NO NO NO!

If you have opened the bottle you have exposed the tablets to oxygen. Oxygen breaks down the nitro. Once the bottle has been opened, label the bottle for six months from the time  you opened it. Replace the bottle at six months. A story I would frequently hear that would make me cringe would be when a patients loved one or child would say ” I poured a couple in a paper cup and have them in my cupboard in case they need one while at my house”…UHG!!!! Won’t work sorry!

The bottle is brown to prevent sunlight from destroying the tablets as well. Don’t transfer them to any other bottle, there is a reason they come this way.

When to use Nitro:

The most common mistake in using nitro is when patients would tell me the pain wasn’t bad enough to use it.  The instructions for nitro don’t say wait until the discomfort is 9 out of 10, the instructions are to use the nitro if you have heart symptoms that do not go away with rest.  This means any heart discomfort, no matter how minor if is present for 5 minutes, would indicate using the nitro.  If you wait until you are really in pain, you probably will have damage done to the heart. The point of this drug is to prevent the damage to the heart by improving the blood flow preventing damage from occurring.

  • Sit down
  • Place one tablet under the tongue – most people experience a burning or tingling feeling under the tongue, a headache, a flushed feeling….If you experience this you should always experience this, as this indicates your nitro is fresh.
  • Wait 5 minutes – if the symptoms resolved rest a bit then gradually become active again
  • If the symptoms persist use a second nitro table, again wait 5 minutes, if needed take a third 5 minutes later
  • If you took a third nitro and still have symptoms call 9-1-1.Try to do some deep relaxing breathing, and thinking try not to panic. It’s a good time to use those relaxations skills.
  • Chew an adult strength aspirin while you wait for paramedics

One discussion I frequently have with patients goes as follows: You may carry your nitro faithfully for years and never need it, but if and when you do need it, you want it to be fresh so it can work. On the other hand some will need to use occasional nitro. This isn’t a bad thing. Your physician prescribed it for a reason. Use it!!!! There are common times when people need one…Exposure to cold air, Exertion that is strenuous, Emotional Stress, and after Eating a large heavy meal. Where the medical community get concerned is if you are requiring 2-3 nitro to clear your symptoms, if you are having more frequent symptoms, or if your symptoms are coming on at rest or waking your from your sleep. The escalation in symptoms should be reported to your physician ASAP.

Keep a log of your nitro  use.  Put on your log, the date, what you were doing when the symptoms occurred, and how many nitro it took to clear the symptoms. When you have a followup appointment with either your cardiologist or your primary care physician present them with the log. Sometimes we are able to find a pattern, do your symptoms come on at a certain time of day? Thus we can probably adjust medication timing to prevent this. Do they come on with a certain level of exertion? We call this your angina threshold and we watch to see is the threshold improving or worsening. Often through exercise we can improve the angina threshold.

What about long acting nitro?

There are long acting nitroglycerin medications that slowly release nitro into your system throughout the day. These are usually taken during the hours you are up and active. Rarely are they used twice a day, as your body needs a period of time in which it is free of nitro, or else it gets to where the nitro doesn’t work as effectively. It is still ok to use the fast acting nitro if you are on this medication.

What about the headache from taking Nitro? 

Take a Tylenol.  The headache won’t kill you but the heart attack might.

Family history of heart issues, not just heart attacks

Risk factors for heart disease are well known when it comes to classic heart disease that causes heart attacks, however many families neglect to recognize that there are other heart conditions that can be genetic or familial meaning showing up in families.

These conditions can include:

  •  Hypertrophic Cardiomyopathy
  • Marfan Syndrome
  • Congenital Heart Disease
  • Familial Hypercholesterolemia
  • Blood Clotting Disorder
  • Sudden Cardiac Arrest/ Long QT syndrome
  • Aortic Dissection
  • Aortic Aneurysm
  • Valve disease

Early detection and management can be critical in each of these issues.

Modern medicine can help through use of medications, imaging of the heart structures, use of devices such as filters or implantable defibrillators to help prevent major problems from occurring. Families should make sure they communicate about issues as they can skip generations or show up in other siblings children. My own family has issues with Marfan Syndrome and Valve issues. Without knowing that someone could look at my family members and think they would be excellent in basketball or volleyball, however with this syndrome competitive vigorous exercise can be lethal. Problems such as Long QT syndrome can be addressed with medications and defibrillators and some are able to compete competitively.

By detecting early families can manage the issues that come with heart problems.

The problems include mentally accepting the issues, financial implications, health insurance, setting realistic goals, disability etc. I had a patient with Marfan Syndrome who turned down disability in his early 30′s before he really understood the serious implications of the disease. By the time he was in his 50′s he called himself the multimillion dollar man, as each surgery he needed could not be done locally and had to go to Cleveland Clinic or Mayo, and was very complicated given his condition. It wasn’t unusual for him to have a bill of over a million from each surgery. He was denied disability over and over again, because he turned it down early in life. Today we have lots of advocacy organizations for each heart condition to help address these issues. If families connect with these early education is a powerful tool and can arm themselves with current case law and resources to prevent such problems from occurring.

Sudden Cardiac Arrest Association. Click for home page.

http://www.suddencardiacarrest.org/aws/SCAA/pt/sp/home_page

Hypertrophic Cardiomyopathy Associationhttp://www.4hcm.org/

National Marfan Foundation - Homehttp://www.marfan.org/marfan/

Is my heart disease cured?

Many patients come through their heart procedures and feel they are cured. Unfortunately for most, heart disease is a chronic progressive disorder of the arteries in which deposits of cholesterol, calcium, and abnormal cells (that is, plaques) build up on the inner lining of the arteries.  Heart disease usually progressively deteriorates over time, whether due to normal bodily wear or lifestyle choices such as exercise or eating habits. This is a hard concept to grasp, and it doesn’t mean it is a death sentence either.

You can do everything right and still have further heart issues.

When patients struggle with this, I point out doing everything right may be why they survived, as approximately 50% of people do not survive their first heart attack.    It is so important for each person to know their body’s signs and symptoms and not ignore them. We don’t really know what makes coronary artery disease aggressive, there seems to be several factors. These factors include inflammation, c- reactive proteins, genetics, lifestyle to name a few. Some patients will have multiple issues for years requiring frequent interventions and then be fine for many years before having another issue. On average coronary artery bypass  grafts  10 years out will be 50% blocked. Some patients will go 20-30 years before needing another intervention, yet others may not even go a week or month before having symptoms. Thirty percent of open heart surgery patients will continue to have angina symptoms after surgery. The drug eluding stents have  much lower rates of re-stenosis than the bare metal stents which average 25-30% restenosis rates, but in both cases the vessels often continue to develop blockages in other locations in the artery. If the bare metal stents are going to re-stenos the usually do so in the first 3-6 months.  It is vital to stay on the platelet inhibitors – Plavix (clopidogrel) as prescribed to prevent complications.

Photo: According to a recent study based on government nutritional data, we're coming up short in terms of eating a variety of fruit and vegetable colors. For instance, 78 percent don't get enough red. How to work in all those colorful vegetables: http://ow.ly/bxoS1

Accepting the fact that you will have further heart disease is important.

Be on the lookout for new symptoms, for changes in energy patterns, note if you are becoming less active due to fatigue. Keep your risk factors in the best control possible. Try to get blood pressure, blood sugar, cholesterol numbers to national guidelines. Exercise regularly. Eat a rainbow of color in fresh fruits and vegetables each day. Don’t let stress effect your health, manage your stress as best as possible, consider counseling.  Don’t live in fear, live life to its fullest!!

Play hard.         Enjoy your families.

 Embrace life.          Do something rewarding every day.

Laugh.     Mentor others.   Love

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Stress – Tools to help you Cope

When you get overwhelmed by the stresses that life throws at you how do you cope? Many people find they just don’t have good coping skills. They tend to obsess on the problem,  let it effect their mood and interactions for the entire day, or turn to alcohol or tobacco as a coping mechanism.

Stress is normal we will all encounter major stress. What I teach is to plan for how you are going to respond.  Will you let this stress effect your health? Will you allow it the ability to raise your blood pressure, to give you waves of anxiety? Will you breathe short and shallow?   Will your heart race?  Will you carry emotional burden all day?

Stress management is something many don’t give enough time or thought to. I like to look at it as a tool box full of different tools. If you never have used the tools in this box the chances are you won’t know how to use them when you really need them. For that reason stress management is something that is practiced. Kind of like child birth and Lamaze in order for that to work you need to practice.

Some of the initial tools to learn include:

Being in the present - if you are reflecting on past events – take a time out and be in the present. What around you is positive, is it the sunshine, the breeze, family, friends, a flower, a pet, a companion, a song…take the time to be in the present. Sure the past comes back, but if it is too much to bear and you can tell it is effecting your health be in the present.

Breathe - sounds like a cliche right? Well it isn’t. When we experience a major stress we often breath short and shallow only filling the top most portion of our lungs. Take a few deep cleansing breathes. Make your belly extend out when you breath in.  This is a great one to practice and use when you experience a health stress. If you are lying in the ER freaking out about what is happening and feeling powerless, use the breath. Focus on nothing more than taking a breathe in through your nose, feel the air as it travels down into your chest. Try and make it feel like you are bringing the breathe right down to your pelvis.Then slowly exhale out through your mouth. Listen to the sound, feel the cool air go in, and the warm air come out                                                                                    

Imaging  - This one is my favorite for when those stressors haunt me at night and I can’t sleep. Where are you peaceful? For me it’s at the beach. What do you see? What do you feel – warm, cold, a breeze, the warm sand, the cool sand below? What do you smell? What do you hear – the waves lapping the shore, the birds, children laughing.  Sure at first you hear the clock ticking and the voices in your head pulling you away from your peaceful place, but the more you practice this the better you are at tuning them out. Initially just stop and acknowledge the things breaking you away, but then go back to your peaceful spot. This is a great one to practice during medical procedures, it helps to keep your heart rate, blood pressure and respiration rate lower, and gives you a sense of control.  

Exercise -  This is a great form of stress management if you go about it right. Some people feel the need to work out like a mad man. This isn’t so good. When you do this the exercise creates a physical stress response, chances are your body already is responding physically to the other stress. Examples are your blood pressure tends to run higher, your heart rate and respirations are higher. Then you are going to exercise and drive these up even further.  This means you could be burning the candle at both ends. It is far better to take it a little easier than you would for a normal workout, maybe go a little longer, but keep the intensity backed down just slightly. Hit the weights afterwards, try some yoga stretches after – the yoga breath would be quite helpful as well. And while you exercise don’t focus on the stress or finding a solution. Be in the present, focus on the positives.

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