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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Heart Patients and High Heat and Humidity

Summer time is here! Most of us welcome the heat, however heart patients have to be cautious. When the heat and humidity rise so does the incidents of heart problems. If the heart muscle has limited blood flow to its heart walls, when the heat gets up there the heart’s blood flow can become compromised. As the blood goes to the skin to cool the body, it may limit the amount it can provide its own muscle.  Most importantly high humidity appears to increase the incidence of acute myocardial infarction (AMI) or heart attack leading to death among the elderly.

The American Heart Association warns people about the effects of hot weather on their health. Extreme heat can cause dehydration, heat exhaustion and stroke. Add in high humidity and you can find a very dangerous situation. Warn seniors to limit outside activity when the temperature is above 70 degrees with humidity above 70%. With these conditions, the body’s natural cooling mechanisms are affected.

During hot summer months, outdoor activity such as exercise walking and gardening should be limited to cooler times of day in the early morning or in the evening. Seniors should also be encouraged to increase their water intake to compensate for fluid lost in hot weather. The American Heart Association suggests monitoring your weight by weighing your self in the morning after using the restroom. If your weight is down by two pounds or more you should increase the amount of water you drink. Avoid fluids with caffeine as they can increase fluid loss. Even if you are dieting and weight loss is expected you still need to drink plenty of water to stay healthy.

Remember, dehydration can lead to heat exhaustion which can lead to heat stroke. Heat stroke can kill, especially if you are an older adult with a health condition.

The symptoms of heat exhaustion include:

  • excessive heavy sweating
  • cold clammy skin
  • feeling dizzy or fainting
  • rapid weak pulse
  • muscle cramping
  • rapid shallow breathing
  • vomiting, nausea or both

I can’t emphasize enough the importance weighing self daily and listening to the bodies symptoms. Many patients who are predisposed to congestive heart failure do not tolerate the heat and humidity. By weighing yourself daily you can identify if there is a sudden spike in the weight. If you are holding fluid this is not the time to be physically active. If your weight is up 3-5 lbs do not exercise. Do not get into the habit of thinking that you should simply exercise more to take off the excess weight. Get into the habit of asking yourself does the weight mean I am holding fluid? Suspect fluid if your blood pressure is elevated, you notice increased swelling in legs, or belly, if you are more short of breath, or activity feels more strenuous. Avoid salty meals when the heat is on. Increased sodium intake makes you hold more fluid in the blood stream and with congestive heart failure that fluid backs up in the cardiovascular system working the heart extra hard. Stick to the fresh fruits and veggies, and a lemon aid.

When  patients come to exercise but are fatigued from the heat already, they shouldn’t exercise. I send them home or let them visit and enjoy the air conditioning.  No big deal if you miss a week or two due to a hot spell. You will get back to it. It is better to be safe than spend summer in the hospital or worse.

Keep in mind the air quality also gets worse when the heat and humidity are on. Poor air quality, air pollution is a known risk for increased heart attacks. If  you live in an area with lots of smog or pollution in the air, avoid doing strenuous activity outdoors as now you the additional risk added to the heat issues.

  • Exercise when the heat has broken or exercise very lightly in air conditioning.
  •  Try a slow walk or a light bike in a cool environment.
  • Cut your intensity and duration in half.
  • Drink your water.
  • Don’t overdress. I always laugh when on the hottest days people show up to exercise in their sweat suits.
  •  Get in the water and exercise or just walk in the water.
  • Practice relaxation and meditation instead of strenuous exercise.
  • Eat fruits and vegetables for potassium and magnesium.
  • Consider electrolyte replacement.
  • Cold wet washclothes at the pulse points – wrists, neck or forehead to cool the body

Heart disease medical terms to know

OK so you have recently been released from the hospital and there are a lot of new words you have heard thrown around. Lets talk about what these mean.

Myocardial infarction means heart attack.

heart attack occurs when blood flow to a part of your heart is blocked for a long enough time that part of the heart muscle is damaged or dies.

STEMI heart attack is a serious form of heart attack.

STEMI is the abbreviation for an “ST-elevation myocardial infarction.” A STEMI heart attack is identified by a test called an electrocardiogram (EKG or ECG) that records the electrical activity of your heart. If this test shows something called “ST-elevation,” you are having a STEMI heart attack. This type of heart attack is typically caused by complete obstruction of a coronary artery – an artery that delivers blood to the heart. A STEMI needs to be recognized quickly and is best treated by emergency angioplasty and stenting.

Non-STEMI  is a medical term for “non-ST-elevation myocardial infarction.”

While they may not be as serious as the STEMI heart attack, they are still heart attacks and result in heart muscle death. A non-STEMI heart attack does not show an elevated ST segment on an electrocardiogram.  A NSTEMI should also be recognized quickly and is best treated by medications and early angioplasty and stenting. The NSTEMI is usually diagnosed through blood work which is repeated several times. A patient who had suffered from a myocardial infarction would have an area of damaged heart muscle and so would have elevated cardiac troponin levels in the blood.

Ejection fraction is a measurement of the percentage of blood leaving your heart each time it contracts.

When the heart beats, the heart contracts and relaxes. When your heart contracts, it t of the pumping chamber (ventricles). When your heart relaxes, the chambers or ventricles refill with blood. No matter how forceful the contraction, it doesn’t empty all of the blood out of a ventricle. The term “ejection fraction” refers to the percentage of blood that’s pumped out of a filled ventricle with each heartbeat.

A normal LV ejection fraction is 55 to 70 percent. The ejection fraction may decrease if:

  • A heart attack has damaged the heart muscle such that it cannot forcefully contract
  • The valves of the heart are not working properly
  • Blood pressure has been uncontrolled  for a long period of time
  •  weakness of the heart muscle, such as dilated cardiomyopathy

Blood Pressure Measurement – things you might not know

How is your blood pressure measured? 

The blood flow to the arm is cut off, as the cuff slowly decreases the pressure the systolic – the top number is the pressure of the blood flowing through the arteries when the heart squeezes.

The bottom number  the diastolic is the pressure that remains in the vessel when the heart is relaxed.

Automatic cuff or manual cuff.

This was always an issue in cardiac rehabilitation. In my opinion automatic cuffs tended to read considerably higher than listening with our own ears. They might be fine while lying in a bed in the hospital, but in a busy outpatient facility I question their accuracy.  There are factors that can contribute including is the cuff over clothing, sitting still, not talking, feet square on floor. Even though these factors could be corrected often the readings were high.  Biomedical engineering would calibrate the machines regularly but the readings remained higher with automatic compared to manual. Patients were trained to instruct staff if the automatic cuff reading was unusual to compare it to a manual reading.

How about your home automatic cuff – how accurate is it?  Bring your cuff in to your next doctors appointment, and compare the two readings. There is always some variability but it shouldn’t be extreme. A common cause reading  may be off can be due to the size of the cuff.  There is a reference line on most cuffs as to where the end of the cuff should be. If the cuff is too small the readings will be high, if the cuff is too large the readings will be too low. For severely obese patients it isn’t uncommon to take a small cuff and read the pressure at the wrist instead of the arm. Many  frail thin people require a pediatric size cuff.

True Resting Blood Pressure – A true resting blood pressure is one where you have rested quietly for 5 minutes, feet flat on floor, shoulders square on chair, no caffeine or tobacco prior to measurement.  Activity will influence the blood pressure greatly. If you just rushed in to the office, had a long walk through the parking lot or up stairs your readings will be higher. Remember with blood pressure if it is taken 10 times in 10 minutes you will get 10 different results. What is being assessed is the average number your pressures are readings. If taken in the arm or the wrist the arm should be resting at the heart level.

Does the Time of Day Matter?  – Blood pressure is characteristically highest first thing in the morning, however with medication effects some people will peak later in the day as medications may be wearing down. Vary the times you measure it, get an understanding of the patterns that you run. Keep a log of your blood pressure, make sure to bring your log when you see your health care practitioner.

Should my pressure be taken in my Left arm or Right Arm?  Trick question. Use the arm the reads the highest. Not the lowest! Blockages that occur in the heart don’t just occur there, they can occur anywhere in the body. It isn’t unusual to have blockages in the arteries of the arms. Have your health care provider check both arms. Make sure they chart what arm they should measure your pressures in. I’ll bet at your next appointment they only check one arm, and never ask.  This can be a big problem for some people.

Is there a difference if taken in the wrist or the arm?  – It  doesn’t ‘matter the pressures should be similar. 

What about Leg Pressures? – As noted above, the pressure should be similar from legs to arms. However people with Peripheral Artery Disease – which is blockages in the arteries going to the legs will have a lower blood pressure in the legs. There is a measurement called an Ankle Brachial Index which measures the legs compared to the arms. If there is a big difference there should be additional testing done as these blockages often lead to poorly healing wounds, amputations, severe leg pain with walking.

How Frequent should I  Measure my Blood Pressure? – In cardiac rehabilitation we measure blood pressure at rest – it isn’t safe to exercise if your blood pressure is greater than 170/100 at rest, as we know exercise elevates blood pressure and we don’t want blood pressure to exceed 220/110 as this is dangerous to the heart, brain and organs and can cause stroke or heart attacks to occur. If the blood pressure is too low 80/40 the pressure is usually considered too low to exercise. Exercise dilates the arteries and after exercise the pressure will be lower than entry. If lower than 80/40 most people will feel like they might pass out.

Blood pressure is measured during exercise. Large drops can indicate the heart isn’t tolerating the blood pressure, or excessively elevated blood pressure with exercise can signal poorly controlled and additional intervention might be needed. We compare weight-bearing exercise to non weight-bearing. Bearing one’s body weight with activity is generally harder on the heart.

Blood pressure is also measured after exercise. Exercise dilates the arteries and they stay dilated for a period of time afterwards, the heart rate slows down, and sometimes this causes the blood pressure to fall severely causing one to feel light-headed or possibly to pass out. For this reason it is recommended for all heart patients to perform a nice long cooldown, gradually slow the exercise, do some stretches, drink some water, slowly stroll around. This helps to keep the blood from pooling in the muscles that were being used and keep it circulating. If it does drop severely, lie down get your feet elevated, drink some water. If this happens frequently see your healthcare provider as your medications may require tweaking.

So how often should you check it at home? If it has been fairly stable measure it about once a week. If you are not feeling well, or had recent changes to your medication check once or twice a day. Every person will have occasional spikes or random variations in their blood pressure. Try not to be overly concerned if the number is elevated one day compared to another. So if you normally run 140/80 and today is  160/90 don’t worry.  Note that it is running higher and watch over next few days. Make sure you have taken your medications, review your diet to see if you had more sodium than recommended 1500 mg/day, as increased fluid volume from sodium is a frequent culprit. Did you eat out the day before? If it stays elevated for several days, contact your healthcare provider.   If the Blood Pressure readings are reading 220/110 see your healthcare provider immediately. 

There are several Blood Pressure Apps for iPhones, android devices. These are great. I think they are the future of health care. Some cuffs will download right to your app, others  require you to enter the data. Coming along with the urgent development of wireless technology, wireless devices have invaded the medical area with a wide range of capability. Not only improving the quality of life of patients and doctor-patient efficiency, wireless technology enables clinicians to monitor patients remotely and give them timely health information, reminders, and support – potentially extending the reach of health care by making it available anywhere, anytime.

Below are a few helpful links and resources:

An overview to measuring blood pressure at home. This is an overview of the benefits and resources. Lots of good information.

http://www.michigan.gov/documents/mdch/home_bp_328345_7.pdf

Public Information on  High Blood Pressure and Sodium. A website link and material from the National Institutes of Health with information in several languages on high blood pressure. Topics include, diet, sodium reduction, and risk factor advice to lower high blood pressure

http://ww.nhlbi.nih.gov/hbp/prevent/h_eating/h_eating.htm

“Salt matters. We must act, and act now.” A video featuring the CDC Director, Thomas R. Frieden, MD, MPH that discusses the importance of reducing salt and strategies for consumers to use in their effort to reduce it.  A Public Service Announcement – about 2 minutes

http://www.youtube.com/watch?v=k-YIO5lg9-w&feature=related%20v=k-YIO5lg9-w&feature=related&noredirect=1

Know the Facts About High Blood Pressure.  This  full-color, easy-to-read handout describes the risk factors,     prevention, diagnosis, and treatment of high blood pressure.

http://www.michigan.gov/documents/mdch/Know_the_Facts_About_High_Blood_Pressure_320302_7.pdf

Hot tub and Sauna Safety for Heart Conditions

This is a common question asked by people who have recently undergone a heart issue. It was always a tough one, as some people can and some people shouldn’t. There are a number of concerns for heart patients including elevated heart rates, dehydration, electrolyte depletion, blood pressure issues to be aware of. I have provided you with some education of the benefits and risk. If in doubt of course ask your health care practitioner.

 Vasodilatation –

Benefits: Both steam rooms and dry saunas cause the blood vessels in the skin to dilate, in part accounting for the warm glow appearance afterwards. The blood flow out of the heart increases by 2 or more times after a 10 to 15 minute steam room or sauna exposure.

Risks: However, the blood flow to the internal organs actually decreases, because so much blood is being directed to the skin instead. This can be a problem for those with coronary heart disease. If the heart has to decide where to pump the blood it sends it to the skin to cool the body, and for those with severe blockages the heart then cannot feed itself it’s own oxygenated blood, and then can give symptoms of angina.

People with hard-to-control hypertension (high blood pressure) may experience worsening blood pressure in response to heat exposure. In addition, many blood pressure medications interfere with the normal response of the body to heat exposure.

 Analgesia –
Benefits: Heat has long been recognized as beneficial for folks with fibromyalgia, arthritis and other painful conditions.

Risks: If heat exposure is extreme, excessively prolonged, or if the individual has underlying irritation of the skin, heat can cause the equivalent of a sunburn, or thermal burn. In addition, steam exposure may be a concern if you have had recent surgery (particularly if sutures are still in place) or if you have an open or infected wound. Do not go in a steam room or sauna if you have open wounds.

Diaphoresis (sweating)
Benefits:  The average person will sweat about a pint during a 15 minute session in a sauna, depending on the person’s acclimatization to heat exposure. This has theoretical benefits for cleansing skin pores and some people believe sweating helps clear toxins from the body. This is not well proven and in many instances, is simply not true. In general, people with documented toxicant accumulation in their bodies benefit from specific medical treatment directed at the specific toxicants, rather than sweating. In addition, many of the toxicants of concern these days, for example: pesticides and many metals, asbestos, are not cleared very well through the sweat.

Risks:  The effect of both wet and dry heat to increase fluid loss from the body can also be a problem, particularly if you are already somewhat dehydrated (e.g. after heavy exercise with inadequate fluid replacement or in response to the diuretic effects of caffeine, beverage alcohol, and medications (diuretics). Too much fluid loss can lead to electrolyte imbalance, heart arrhythmias, blood pressure changes, heart rate range changes, light headedness, and fainting.

Dehydration can be a problem in people who have blood vessel blockages to the brain and the heart  The body lacks enough water to fill he blood vessels. Low fluid volume means lower blood pressure. A dehydrated person feels weak and dizzy especially when standing.

Some individuals experience an increase in their migraine headaches in response to dehydration.
There are a number of other medications that can affect the body’s normal response to heat either by inhibiting sweating or by otherwise interfering with the normal physiology, for example, some medications used for psychiatric conditions like schizophrenia. Use of stimulant medications for conditions like ADD or excessive sleeping also increases the health risks from heat exposure.

Dehydration also is dangerous on the kidneys, they will decrease the output of urine and low blood pressure with dehydration can damage the kidneys.

 Calorie Burn:
Benefits: Although exposure to heat increases energy consumption and thereby increases calorie burn, for example, up to 300 to 400 Kcal during a 20 to 30 minute sauna bath, thus helping to promote weight loss, there are clearly more healthful alternatives available, i.e. EXERCISE .

Risks:  Individuals who have been cautioned to restrict exercise intensity by health care providers should be aware that the effects of heat are similar to those of exercise for increasing heart rate. Increasing energy consumption through increased work of the heart can be a concern for people with coronary heart disease, congestive heart failure, valvular heart disease or heart rhythm problems (arrhythmias).

Recommendations:

1- Avoid beverage alcohol and excessive caffeine intake and medications that may impair sweating or increase the health risks from heat exposure.

2- Stay in no more than 15 to 20 minutes at a time.

3- Cool down gradually after use. Avoid going rapidly from a hot to a cold environment, e.g. sauna cold shower as this increases the physiologic stress on the body considerably.

4- Drink 2 to 4 glasses of cool water after each session.


5- Don’t take a sauna or steam bath if you are ill, and if you find yourself feeling unwell while in a steam room or sauna, head for the door.

6- Ask your health care provider for advice and recommendations, if you have any concerns about potential health risks from steam room or sauna use.

HEALTH BENEFITS AND RISKS ASSOCIATED WITH USE OF
STEAM ROOMS AND SAUNAS, Doug Linz MD, Medical Director, TriHealth
Pavilion http://tinyurl.com/7bhlj5u

 If you take a blood thinner (such as Plavix) or blood pressure meds, the heat of a hot tub can combine with the medications to cause you to become dizzy, nauseated or even faint.

When you go in a hot tub, the heated water causes your blood vessels to dilate. In turn, blood pressure drops. If it falls too low, you can pass out.

It may be okay for short periods.

If you are able to carry out moderate exercise without symptoms such as chest pain or shortness of breath, you should be able to tolerate a sauna or soak in the hot tub.

When you get into cold water blood vessels constrict. Any sudden change in temperature leads to a considerable increase in the heart’s workload so moving back and forth between cold water baths and saunas or hot tubs is not a good idea.

Check with your doctor or health clinic to be on the safe side.

http://www.smart-heart-living.com/heart-disease-questions.html#hottub

Building the chest and back muscles after open heart surgery

Once you have your weight restrictions from bypass surgery lifted (and your physician’s permission)  it is time to build back the muscles you lost from surgery.

The muscles are weak from the limited lifting for the last 3 or more months. It is important to go slow and to balance the muscles. In previous posts I write about the importance of posture and stretching after open heart surgery to prevent or manage pain.  https://rehabilitateyourheart.wordpress.com/2012/05/21/stretching-your-upper-body-following-open-heart-surgery-12/

The muscles of the chest and back balance one another.

Muscles work like a pulley system, if one group is shortened the other is lengthened. By strengthening the chest muscles the opposing muscles of the back are lengthened. Therefore the back should be worked just as much as the chest to maintain a balance. A common issue is many only train their chest, neglecting the back and this sets the stage for shoulder, neck and back problems down the road. By strengthening both you create a balance to the muscles.

There are many ways one can work the muscles including free weights, dumbbells, resistive bands, or the bodies own resistance – such as push ups. . It is important to start out light. You may have had a 10-20 lb lifting restriction for some time. It is not graduated up but simply lifted.  Therefore don’t start with really heavy weights. Work your way up. Start with a few exercises, see how your body feels the next day. You shouldn’t experience days of pain from the first few workouts, you should be able to tell you worked the muscles but not be suffering.  Don’t overdo it!

Remember it is approximately one full year of healing following surgery.

The bone is knit together but to rebuild the strength, decrease the inflammation and allowing the nerves to heal it takes a full year.  Some precautions to note – if you feel any shifting, cracking or popping of the sternum stop. Try again in a month or two, or modify the movement to avoid the shifting. If you cannot move it without the shifting contact your surgeon.

Breathing with weight training is vital. 

Exhale on exertion. This means when you are pushing the weight away from your body breath out. When you are returning the weight to your body breath in. It is extremely important to your heart’s health not to hold your breath.  Holding your breath increases the blood pressure, strains the heart, and for some people can make them light-headed or pass out. Not good when you have weights in your hands to pass out!  This breathing technique should be used with all of your strenuous physical activities or lifting, pushing, or carrying.

The following images of exercises address the key muscle groups lost from open heart surgery. Start with a light weight – it may be 10 lbs in each hand or it might be 5 lbs, everyone is different but you will appreciate starting with light weights as we expect a little soreness initially. See what works for you. The initial goal is to do many repetitions, gradually build up the amount of weight over time. Try doing each exercise 10 times, if it is easy then next time add a little more weight. If it is difficult, try less weight next time. It is recommended you start with 10-15 repetitions of each exercise, and do it in 1-2 sets the first week or two. You can gradually add in more sets of the 10-15 repetitions. Don’t work the muscles every day, try for 2-3 times per week. The muscles need recovery time.

Chest muscles – note the elbows of the lady in the second picture, this is an example of good technique. Don’t let the elbows come lower than the shoulders as it puts a lot of stress on the the sternum and shoulders, and you don’t want to be hurting the next day. Breathe out as you lift the weight up. Don’t hold your breathe!

Shoulder muscles – note only lift the weights to 90* lifting higher than this tends to irritate the shoulders. Be aware to use your muscles not the swinging of your body for momentum. Lift the weight to a slow count of 1 -2, then lower it even slower a slow count of 1-2-3-4. Remember breath out as you lift the weight up.

These are standing fly’s, the knees are bent to support the lower back’s natural curves and prevent injury.                                                                                                                          

Back exercises – standing row. This works the muscles between the shoulder blades.  When doing exercises bent over remember to come back up gradually, as many heart patients experience dizziness when bent over. Again remember to BREATHE!  If you don’t have weights there are resistive bands that can be used. They can be found at your physical therapy centers, medical supply stores or fitness stores. They come in a variety of strengths, remember start light. Make sure you control the band or weight and that it doesn’t control you.                                                                                                                                                                                                                                                                                                               

Weight machines are good. Here is an example of working both the chest and the back. I love lat pull downs and seated rows. Typically I will have patients work these for 1-2 weeks before I introduce the chest press, as the back is far more neglected than the chest muscles in our day to day use.  Below are ways of doing the upper back using resistive bands.                                                                                                                                                                                                                                                                                   

I know some of you  are impatient about getting back to push ups. I generally start patients with push ups against a wall initially, gradually moving feet further back. When through the initial muscle soreness, have good breathing techniques then have them begin floor push ups.