Depression and Heart Conditions

Depression is common in heart patients. Most studies show 2 out of 3 patients will experience depression. Does depression cause heart disease or does heart disease cause depression? Probably both. We all have ups and downs, however when one finds them overwhelming and debilitating it is time to get help. According to the National Institute for Mental Health the following are the symptoms of depression:

Signs and symptoms include:

• Persistent sad, anxious, or “empty” feelings
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Irritability, restlessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details, and making decisions
• Insomnia, early-morning wakefulness, or excessive sleeping
• Overeating, or appetite loss
• Thoughts of suicide, suicide attempts
• Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

One of the best things a person who is suffering from depression can do is to get daily exercise. Yet it is one of the hardest things to do when depressed. I would encourage patients to at a minimum schedule themselves 10 minutes per day of exercise. I know it is a very short duration, but it is a starting point. We build from there.  If you are a significant other of someone you suspect is depressed, don’t nag them to exercise, rather help them to engage in it. Offer to go for a walk, or go to the gym together.

For many suffering from depression winter can be especially difficult. The holidays may trigger episodes, a change in healthy eating habits to the holiday party foods, a change in exercise habits due to weather changes, getting out and socializing less due to weather, loss of loved ones,  and seasonal effective disorder can all be a catalyst for symptoms to worsen. If you note this contact your healthcare practitioner, consider counseling, increasing exercise, getting sunlight every day, and/or medications. It is important because if depression isn’t treated often heart disease worsens.

Seasonal affective disorder (SAD), which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy

 

http://www.nimh.nih.gov/health/publications/depression/what-is-depression.shtml

 

 

Heart disease patients who have anxiety have twice the risk of dying from any cause compared to those without anxiety, according to new research in the Journal of the American Heart Association.

Patients with both anxiety and depression have triple the risk of dying, researchers said.

Many studies have linked depression to an increased risk of death in heart disease patients. However, anxiety hasn’t received as much attention. Studies show that depression is about three times more common in heart attack patients. The American Heart Association recommends that heart patients be screened for depression and treated if necessary.

Depressed heart disease patients often also have anxiety, suggesting it may underlie the risk previously attributed solely to depression. It’s now time for anxiety to be considered as important as depression, and for it to be examined carefully.”

In the study, 934 heart disease patients, average age 62, completed a questionnaire measuring their level of anxiety and depression immediately before or after a cardiac catheterization procedure at Duke University Medical Center. Patients had anxiety if they scored 8 or higher on a scale composed of seven common characteristics of anxiety, with each item rated from 0 to 3 (range of possible scores: 0-21). Depression was measured using a similar scale composed of seven symptoms of depression.

Researchers, after accounting for age, congestive heart failure, kidney disease and other factors that affect death risk, found that 90 of the 934 patients experienced anxiety only, 65 experienced depression only and 99 suffered anxiety and depression. Among 133 patients who died during three years of follow-up, 55 had anxiety, depression or both. The majority of deaths (93 of 133) were heart-related.

Researchers measured anxiety and depression during cardiac catheterization because levels better reflected how patients normally handle stressful situations. Anxiety and depression each influence risk of death in unique ways. Anxiety, for example, increases activity of the sympathetic (adrenaline-producing) nervous system that controls blood pressure.

People who worry a lot are more likely to have difficulty sleeping and to develop high blood pressure. The link between depression and mortality is more related to behavioral risk factors. Depression results in lack of adherence to medical advice and treatments, along with behaviors like smoking and being sedentary.

Future studies should test strategies to manage anxiety alone and with depression in heart disease patients.

Anxiety reducing medications combined with stress management could improve outcome for patients with just anxiety, whereas patients with anxiety and depression may need a stronger intervention involving more frequent outpatient monitoring and incentives to improve adherence.

Slowly getting there, comments from our cardiac health innovators? http://bit.ly/100zip5

Sodium and fluid retention

How Sodium causes fluid retention

The job of the kidneys is to filter the excess sodium into the urine so that the body can get rid of it. Many with heart disease and diabetes kidneys cannot handle all the extra work. The kidneys become less efficient at filtering the blood stream. This causes excess sodium to enter the bloodstream. Sodium attracts water to it and effect known as being osmotic. Water follows the sodium  and is drawn into the bloodstream. Excessive salt keeps the circulatory volume higher than it should be, creating and increased pressure in the blood stream and pressing on the blood vessel walls. The stress of the pressure on the walls creates thickening and narrowing of the vessel, leaving less space for the fluid in the blood vessels and raising resistance.  The body then requires higher pressure to move blood to the organs. The heart has to pump against this high pressure system.

I equate it to trying to blow up one of those kids balloons that is turned into animal shapes. They are really tough to blow air into, your cheeks get really sore – this is the resistance of air, similar to the resistance pressure of blood in the arteries. If you stretch the balloon (relax the arteries) then there is less resistance in blowing up the balloon (filling the artery with blood). Twenty percent  of the blood pumped from the heart goes  first to the kidneys.  High blood pressure within the kidneys cause  damage to the heart and to the vascular system in the kidneys. Salt makes you thirsty so limit salty foods, especially if on a fluid restriction.

I once had a patient who lost 45 lbs simply from adhering to low sodium diet. He had a very weak heart with only 10% ejection fraction meaning very limited pumping ability. So a weak heart and sodium in the diet made him retain fluid more than most. He began to measure and count sodium with every meal for a few months and was shocked by how much sodium he consumed even though he thought he ate pretty healthy. By reading labels, doing the math every day and making changes such as eating out less, ordering special, reviewing his medication he lost the fluid and added years to his life, not to mention the improved quality of life with less shortness of breath and fatigue by easing the workload of the heart.

                      

According to the American Heart Association, eating more than the recommended 1500 milligrams a day puts you at direct risk of high blood pressure. Yet in America we consume an average of 3400 milligrams a day; more than twice what we should. While people with hypertension, heart and kidney disease are always advised by doctors to eat less salt, the AHA wants all of us to do this, whether or not our blood pressure is currently in the normal range. So if you are cooking or know the cook for pass this info on!

 

When holiday meal are  upon us  remind heart patients of being acutely aware of the sodium content in foods. The holiday meal contributes to many heart patients having increased symptoms of  high blood pressure, congestive heart failure, fluid retention, shortness of breath. The holiday meals  can be the culprit. Traditional foods like the turkey are often injected with  approximately 8% solution sodium to enhance moistness and flavor. If you read the ingredients you will often note: turkey broth, salt, sodium phosphates, sugar & flavoring. Then many a cook will soak the already salt injected turkey in a brine solution or salt it well, prior to cooking. The turkey alone gets many into trouble, then you add pre-packaged stuffing, broth, or use canned mushroom soups in casseroles. Did I mention the relish tray with pickled foods?

                                                        

A little extra salt in or on your holiday foods makes a difference.

1 teaspoon salt = 2131 mg sodium                                          1/2 teaspoon salt = 1066 mg sodium

1/4 teaspoon salt = 533 mg sodium                                        1/8 teaspoon salt = 266 mg sodium

75 mg—the average sodium content of 3 ounces fresh, unsalted beef, turkey, chicken, pork

240 mg sodium in 3 ounces self-basting frozen turkey, cooked (that’s without the gravy!)

580 mg sodium in 3 ounces frozen fully cooked baked turkey

820 mg sodium in 3 ounces honey baked ham

Bread is a major sodium contributor if you eat more than a couple of pieces a day unless you buy special low sodium bread. A slice (1 ounce) of loaf bread has 150 to 200 mg sodium—not including salted butter or other spreads or toppings. Consider using a bread maker to make a low sodium recipe.

Skip the gravy! But if you must go for low or reduced sodium gravy instead of regular salted gravy which has more than 300 mg sodium for 1/4 cup.                                                                                                                                                              

Measurements and labels of sodium

•  1/4 teaspoon salt= 600 mg sodium
• 1/2 teaspoon salt= 1,200 mg sodium
• 3/4 teaspoon salt=1,800 mg sodium
• 1 teaspoon salt= 2,300 mg sodium
• 1 teaspoon baking soda =1,000 mg sodium

• Sodium-free: Less than 5 milligrams of sodium per serving
• Very low-sodium: 35 milligrams or less per serving
• Low-sodium: Less than 140 milligrams per serving
• Reduced sodium: Sodium level reduced by 25%
• Unsalted, no salt added, or without added salt: Made without the salt that’s normally used, but still contains the sodium that’s a natural part of the food itself.

Names for salt

• sodium alginate
• sodium ascorbate
• sodium bicarbonate (baking soda)
• sodium benzoate
• sodium caseinate
• sodium chloride
• sodium citrate
• sodium hydroxide
• sodium saccharin
• sodium stearoyl lactylate
• sodium sulfite
• disodium phosphate
• monosodium glutamate (MSG)
• trisodium phosphate
• Na

Some drugs contain high amounts of sodium.

Need an antacid after that holiday meal?  Watch out there is excess sodium there too. Carefully read the labels on all over-the-counter drugs. Look at the ingredient list and warning statement to see if the product has sodium. A statement of sodium content must be on labels of antacids that have 5 mg or more per dosage unit (tablet, teaspoon, etc.). Some companies are now producing low-sodium over-the-counter products. If in doubt, ask your healthcare practitioner or pharmacist if the drug is OK for you.

 

Heart Disease

End of Life Choices

For many with heart disease it is a battle to remain living, yet know you are dying from a diseased heart. Many don’t discuss with their healthcare practitioners the choices and decisions they have when it comes to fighting to stay alive or choosing to let go. Over my career I have watched many patients suffer trying numerous medical interventions and medications only to have a horrible quality of life. In the medical community we see patients literally beg their doctors to let them pass, and yet the physician urges them to fight on with the newest surgery or medication. These are issues that heart patients should be able to discuss with their families and health care providers early on, so everyone has a clear picture of your wishes.

When it comes to end of life you have choices

Your choices

• Stop treatment that prolongs your life. Instead, receive only treatment that focuses on your comfort and quality of life.

• Don’t stop treatment that prolongs your life.

Key points in making your decision

• If there is a good chance that your illness can be cured or managed, your doctor may advise you to first try available treatments. If these don’t work, then you might think about stopping treatment.

• If you stop treatment, you may still receive care that focuses on pain relief, comfort, and the quality of your life. This is called palliative care  or hospice care.

• A decision to stop treatment that keeps you alive doesn’t have to be permanent. You can always change your mind if your health starts to improve.

• Even though treatment focuses on helping you live longer, it may cause side effects that can greatly affect your quality of life and your ability to spend time with your family and friends.

• If you still have personal goals that you want to pursue, you may want treatment that keeps you alive long enough to achieve them.

Reasons to have life support:

•  You need life support because of an emergency that is not related to your illness.
•  Life support may help you return to your  normal activities.
•  Your quality of life is good and you have a sudden event that requires life support..
•  You could recover well from the event.

Reasons  not to have life support

• You have other long-term health problems that make it less likely that you will benefit from life support.
• The risks of life support outweigh the benefits.
• Life support will not help you return to your normal activities or to a level of activity you would like to have.
• You want a calm, peaceful death, and you do not want to spend the rest of your life on a ventilator

Physician Orders for Life Sustaining Treatment

I had a patient who wanted to die in cardiac rehabilitation. He expressed this wish often. He was adamant he did not want any life-sustaining treatment, however in rehab we were bound to comply with our standard of care which meant life-sustaining treatment, CPR and defibrillation until the patient was received in the hospital emergency room where his advanced directive were on file. This is the case in most hospital or outpatient settings, even EMS has an obligation to respond unless one has a POLST form visible in their house or on their person.   The only legal way for me to respect his wishes was for him to have a POLST form filled out and on file in the rehab department, and as a card he carried and a form posted in his home. What is POLST. It is an agreement made between  you and your physician about what life-sustaining treatment you with to have. To read more about this visit the link: http://www.ohsu.edu/polst/

Do you have an ICD?

Heart patients who have an ICD need to consider and  discuss the difficult issue of ICD deactivation as  clinical status worsens and death is near. Unfortunately, “clinicians and patients rarely engage in discussions about deactivating ICDs, and most devices remain active until death” and “most patients are not even aware that deactivation of the shocking function is an option.”

Palliative care relieves the symptoms of  disease, such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and difficulty sleeping. It helps you gain the strength to carry on with daily life. It improves your ability to tolerate medical treatments. And it helps you have more control over your care by better understanding your choices for treatment options. Including decision-making and coordinating of issues such as ICD deactivation.

The point of palliative care is to relieve suffering and provide the best possible quality of life for both you and your family.

Palliative and hospice care is often left for the very end of life. By initiating palliative care earlier it reduces emergency department visits and improve symptoms, which increases time at home and quality of life.

Palliative Care
Palliative care teams are made up of doctors, nurses, and other professional medical caregivers, often at the facility where a patient will first receive treatment. These individuals will administer or oversee most of the ongoing comfort-care patients receive. While palliative care can be administered in the home, it is most common to receive palliative care in an institution such as a hospital, extended care facility, or nursing home that is associated with a palliative care team. There are no time restrictions. Palliative care can be received by patients at any time, at any stage of illness whether it be terminal or not.

Hospice

Hospice programs far outnumber palliative care programs. Generally, once enrolled through a referral from the primary care physician, a patient’s hospice care program, which is overseen by a team of hospice professionals, is administered in the home. Hospice often relies upon the family caregiver, as well as a visiting hospice nurse. While hospice can provide round-the-clock care in a nursing home, a specially equipped hospice facility, or, on occasion, in a hospital, this is not the norm. You must generally be considered to be terminal or within six months of death to be eligible for most hospice programs or to receive hospice benefits from your insurance.

Our health care system faces the challenge of allocating limiting resources to an aging population. The focus is on solutions that improve patient quality of life while minimizing unnecessary expenses.  Integrating palliative care into the health care system at an earlier time helps quality of life and reduced cost associated with the disease process.

http://www.getpalliativecare.org/whatis/faq

http://www.caregiverslibrary.org/caregivers-resources/grp-end-of-life-issues/hsgrp-hospice/hospice-vs-palliative-care-article.aspx

Healthy eating tips for heart patients

After heart surgery most patients have a very poor appetite for the first three months.

The first month the medical advice is to eat anything. This isn’t a problem as the body needs extra fuel for healing, but in reality many don’t eat much because food doesn’t taste the same or smell the same. This is thought to be an effect from anesthesia. Most of the time is takes 1-3 months for the taste and appetite to come back to normal. After the first month, patients are instructed to eat a heart healthy diet. That can be a little vague, and different health care practitioners have conflicting ideas of what a heart healthy diet is. In my career it was challenging as one physician  might promote a Dean Ornish vegetarian diet, and the next might promote a Mediterranean  diet, or American Heart Association, Dash diet etc. There are common nutritional principles that all heart patients should try to adhere to.

 

Tip #1: Know your Caloric needs.

How many calories do you actually need every day? Here are a couple of resources that will help guide you:

• Calorie Calculator for Women and Men
•  holistic health tracker

Tip #2: Enjoy your food, but eat mindfully

Take the time to fully enjoy your food while you’re eating it (instead of just devouring everything on your plate). Pay attention to hunger and fullness cues before, during and after meals. Be mindful of them and use them to tell you when you’re should be full. Remember it takes about 20 minutes for the food you heave eaten to signal your brain if you are still hungry. For this reason eating slowly, and being aware of the quantity, rather than listening for your body to say it is full. It is ok not to finish everything on your plate.

#3: Avoid oversized portions.

Learn what is the true portion size of the food you are eating. If you are going to overeat eat a larger portion of vegetables. Try using a smaller plate, bowl and glass.  When you’re eating out, try splitting a dish or take home part of your meal.

Tip #4: Foods to eat more often.

 These are all the foods you know are good for you: fruits, vegetables, whole grains, low-fat dairy, etc. Make them the basis for meals and snacks. Try getting 2 cups of veggies, 1.5 cups of fruit and 3 servings of low-fat dairy or lean protein each day.

Tip #5: Decrease the unhealthy foods in the diet

Foods high in solid fats, added sugars, and salt (e.g. cakes, cookies, ice cream, pizza, fast food, sweetened drinks, etc.) should be cut back in the diet. Try to avoid these as part of your daily meal intake.

Tip #6: Hydrate with healthy fluids

Drink water, sparkling water mixed with a splash of juice, tea, or sparkling water instead of high calorie drinks. High calorie drinks include soda, alcoholic beverages, juices, energy drinks and sports drinks. If you are on a fluid limitation, poor the recommended amount of fluid in a container and use it to help you visualize the amount of liquid you should have each day.

Tip #7: Pay attention to added sodium in foods

 Read the labels and choose the lower sodium option for breads, canned goods, and soups. Choose packaged products with labels like “low sodium,” “no salt added,” or “reduced sodium.” Fresh, foods have the least sodium. If it comes from a box, a can, or is ready to eat, it is probably loaded in sodium. Water added usually means sodium added, this is common in poultry. 1500 mgs a day is the recommended amount for heart patients. I had one patient that lost 45 lbs, simply by tracking sodium and adhering to recommendations, it has so far saved him from the disabling CHF symptoms he was experiencing.

Sodium sources are not only food! The medicine cabinet is often an unrecognized source of sodium. Many prescription and non-prescription drugs, such as antacids, ibuprofen, sleep aids, heartburn relievers and cold medicines, have large amounts of sodium. Some antacids have upwards of 250 mg of sodium per tablet. Before taking any medication, it’s always best to consult a doctor, especially if you’re watching your sodium intake for health purposes.  

Most people are unaware of the amount of sodium that comes from our tap water. It varies significantly from state to state, but the public health department in any area should be able to provide information on the exact amount of sodium in the water. Even if a home employs a water-softening system, there’s still a certain amount of sodium in the drinking water, since many of these units use sodium as a softening agent. The amount is solely dependent on the type of system installed and the hardness of the water in that area. Bottled waters, especially mineral waters, can also contain significant amounts of sodium.

Tip #8: Keep your dairy low-fat 

Drinking whole milk is the equivalent of 3 pats of butter, 2% is 2 pats of butter, 1% is one pat of butter. And low-fat cheese is a good substitute for full-fat cheese, but if you are going to use regular cheese, try using a smaller quantity.

 

Tip #9: Get healthy fats in your diet every day

 When you’re cooking, choose oils high in monounsaturated fats like olive or canola oil. These are better choices, but don’t use large amounts, as oil is high in calories. A pump oil spray is a good way of adding a little oil and avoiding chemicals. Avoid products containing trans fats. Read the labels and avoid hydrogenated oil or shortening or partially hydrogenated oils. This is the same as eating shortening.

Tip #10: Get out of  your comfort zone

Many people won’t try new or unusual foods. They are stuck in a rut of eating the same foods, because it is what they know and like. Try new foods regularly. Especially try different vegetables. If you always cook your foods a certain way, challenge yourself, try sauteing, steaming, fresh, juicing, combining with other foods, adding nuts or seeds to foods.

Tip #11: Know your issues

Some heart patients have to be very aware of vitamin Kin diet, if they are on coumadin. Keep your intake of foods rich in vitamin K about the same each day. For example, you may plan to eat only ½ cup of these foods per day. If you like these foods and eat them often, you can eat more, but be consistent. It is a common misconception for patients to think they have to avoid foods rich in Vitamin K, it is more important however to get these in the diet, but as mentioned be consistent and get the same amount each day.

Other’s need to be more aware of the potassium or protein contents of foods.  Certain diseases (e.g., kidney disease and gastrointestinal disease with vomiting and diarrhea) and drugs, especially diuretics (‘water pills’), remove potassium from the body. Potassium supplements are taken to replace potassium losses and prevent potassium deficiency. If you can meet with a dietitian to help you understand what the sources of these nutrients are. If you can’t meet with a dietitian do your research, but don’t ignore the recommendations as many can be life threatening if not adhered to.

http://www.cdc.gov/salt/pdfs/Salt-tistics.

http://www.vaughns-1-pagers.com/food/vitamin-k-foods.htm

 http://www.livestrong.com/article/10349-identify-sources-sodium/#ixzz27lT6ptHG

A lesson about the heart: Cardiac Output

Here is some information that is useful to know. It is a little in-depth when it comes to heart function, but I believe education is power and/or a sense of control when it comes to managing a chronic disease.  The more you know, the better you can work with your health care provider to help to manage it. 

Why are certain tests performed? An example is an echo is often performed 3-6 months following a heart attack. This allows the heart time for recovery and remodeling, and gives the healthcare provider a good idea of your cardiac output. Is your ejection fraction diminished, is the stroke volume lower thus decreasing the output? Is the cardiac output lower because the heart chamber is stretched, and weaker – inotropic effect, or due to medications? Does this place additional risk to you? When the ejection fraction is below 30% the risk for arrhythmia increases, thus precautionary measures such as Implanted Cardiac Defibrillators become an issue. Or vise versa if the heart function improved back to safe levels since the event there may no longer be the need, or those wearing external defibrillator vests may no longer be necessary.

The following came from Jewels of Clinical Medicine

What Is Cardiac Output?
Cardiac output is defined as the amount of blood pumped by the ventricles, the lower chambers of the heart, in one minute. Two factors determine cardiac output: stroke volume and heart rate. The equation used is: heart rate x stroke volume = cardiac output. A normal adult heart will have a cardiac output of approximately 4.7 litre( 5 quart) of blood per minute. Exercise will increase cardiac output, since it increases heart rate.

Heart rate
• The number of times the heart beats in one minute is the heart rate. In adults, the average heart rate is 60 to 100 beats per minute. Heart rates are usually higher in children and women. Differences in gender, size, age and fitness can affect the heart rate, as can some medications and conditions. Very fit people have lower resting heart rates. Heart rates increase when people are upset or excited.

Stroke Volume
• Stroke volume is the amount of blood pumped by the ventricles with each heartbeat. An average resting stroke volume is about 2 ounces (60 to 80 milliliters) per beat. Usually only 65 percent of the blood is pumped out of the ventricles during each beat. This is the normal ejection fraction value. Starling’s law of the heart and the inotropic effect are two things that can alter the force of the contraction, causing more of the blood to be expelled with each beat.

Starling’s Law of the Heart
• Starling’s law depends on the amount of stretch in the cardiac muscle fibers. If there is an increase in the volume of the blood pumped into the heart, that increase causes the ventricle to stretch, which in turn increases the force of contraction and the cardiac output. If less blood volume enters the heart, the ventricle does not stretch as much, the contraction is less forceful, and the cardiac output is decreased. This is important to ensure that the heart pumps out only what it receives at a given time.

Inotropic Effect
• If the strength of the contraction is increased without increasing the stretch of the cardiac fibers, cardiac output will be increased. Certain hormones and medications can cause this to happen. Sympathetic nerve stimulation of the heart, for example when a person is scared or excited, is another mechanism of the inotropic effect. Some drugs may also cause a negative inotropic effect and will decrease the cardiac output, which can lead to heart failure. It is extremely important to closely monitor the usage of any medication that has a negative inotropic effect on the heart.

Interesting Fact
• The amount of blood pumping though the body of the average adult is about 5 liters. That is equivalent to the average cardiac output. That means that the heart pumps the total amount of blood in the body every minute.

Heart Disease Health Centre- Dr.Yaseer SK