Heart Of The Matter: Treating The Disease Instead Of The Person

by LEANA WEN

June 25, 201411:05 AM ET

Maria Fabrizio for NPR

A 56-year-old man is having lunch with his wife at a seafood restaurant just outside Boston when he develops crushing chest pain. He refuses an ambulance, so the man’s wife drives him to the ER.

What happens next says a lot about the difference that being a doctor or a patient can make in how one feels about the health care system.

First, how did the patient and his wife see the trip to the hospital?

When the man arrives in the ER, he is told to take off his shirt. He lies in the hallway, in pain, naked from the waist up. Strangers surround him. They don’t introduce themselves, and they talk over him, at each other.

Pagers ring and there’s a lot of beeping. Someone else must be really sick, he thinks; that must be why no one is paying attention.

After a few minutes, he signs some forms and finds himself being wheeled into an elevator. Masked figures enter. He feels a cool liquid flowing into his veins. The lights go out.

He wakes up hooked up to machines, uncertain what has happened. It takes several hours for the staff to find his wife, who is still waiting in the ER lobby and has no idea why her husband is in intensive care.

They are both surprised when they find out, two days later, that he’s had a heart attack. As soon as they get home, they file a complaint with the hospital about their terrible experience.

Now, how did the staff at the hospital see it?

A triage nurse greets the patient immediately upon his arrival and finds out that he has chest pain. Within three minutes, he gets an electrocardiogram that shows he is having a heart attack. The ER doctor activates the special heart attack pager, which immediately summons the emergency cardiology team.

The doctors and nurses arrive and bring the patient up to the catheterization suite. There, the attending cardiologist threads a catheter through an artery in his groin and pushes it all the way to his heart, where the doctor sees on an X-ray machine that a vessel is blocked. She inflates a small balloon in the catheter, opening the artery and restoring the flow of blood to the man’s heart.

All told, it took only 22 minutes from the time the man entered the hospital for the cardiology team to clear the blockage. The cardiology team is proud that they beat the national averagefor what they call door-to-balloon time by 42 minutes. The faster a blockage can be cleared, the better the odds are for a full recovery.

The patient gets well without complications. Two weeks later, he’s back at work and exercising again. The ER and cardiology teams consider the man’s case a resounding success.

Why then are there such different views of the same ER visit? Who’s right? The doctors who believe they delivered exemplary care, or the patient and his wife who feel he was treated badly?

As an emergency physician and advocate for my patients, I frequently hear clashing stories like these. When I review the cases, I find that the doctors and nurses are often surprised by the patient’s complaint because they did everything by the book and made no medical mistakes.

Indeed, in this case, every measure of sound medical care was met: prompt diagnosis, speedy and effective treatment and an uneventful, full recovery.

The objective measures that health care workers focus on are necessary, but they’re not enough by themselves. Every provider in this man’s case had good intentions and was working hard to respond to the medical emergency. But in their rush to open the blocked heart artery, they treated him as a disease to be cured, not a person to be cared for.

Would it have alleviated the patient’s anxiety for the doctors and nurses to introduce themselves, and to ask if he wanted his wife by his side? Would it have helped to assure him that all the activity was happening around him because everyone was trying to take care of him?

I think those simple courtesies would have made a difference.

These instructions aren’t on typical checklists for treatment of heart attack, yet they are part of caring for people as human beings. In modern medicine, we are fortunate to have incredible high-tech options available, but we must not forget the low-tech approaches that can improve communication and quality of care.

Patients and family members can also speak up when they are confused and scared. It’s possible that doctors explained what was happening, but not clearly enough.

What if the patient said he didn’t understand what was going on? What problems could have been avoided if the patient and his wife didn’t wait until after he was discharged to raise their concerns?

The two viewpoints of this ER visit end with one thing in common. Just as the providers were surprised by the patient’s complaint, the patient and his wife were taken aback when the team that I was part of presented them with their doctors’ point of view.

“We had no idea they were trying so hard,” the man said. “It’s too bad we didn’t know that at the time.”

Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. She is the author of“When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Care,” and founder of Who’s My Doctor, a project to encourage transparency in medicine.

Source:  http://www.npr.org/blogs/health/2014/06/25/324005981/heart-of-the-matter-treating-the-disease-instead-of-the-person?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20140625

Delay in seeking medical attention for heart attack changes life

Don’t delay in seeking medical attention if you are concerned about a heart attack

Time is muscle if the heart is not getting the proper blood flow to the muscle, the muscle dies. The muscle is unable to repair itself and eventually that portion that dies is converted to scar tissue. Scar tissue is not flexible and doesn’t push the blood out of the chamber of the heart. If the blood is not pushed through the heart the amount circulating through the body is reduced. This can lead to serious heart related complications, including congestive heart failure, angina, shortness of breath and limited ability for physical activity.  This creates complications for many things including returning to work, or causing early retirement as the article above discusses.

Discomfort, squeezing, pressure, heaviness, aching…in the chest, between the shoulder blades, the neck, jaw or down the arms are the classic symptoms. If accompanied  by shortness of breath, nausea, profuse sweating the condition is all the more urgent. Chew up 325mg aspirin and call 911.

Exercising with heart disease

Start slow and add a little more over time. Make it feel  as if when finished feel like you could have done more easily. Begin exercising at this intensity for several sessions before making large increases in your intensity or effort required to be physically active. . Remember the whole goal is to adapt, and by doing so the body is changing how it responds. In the early recovery stage  the exercise prescription is very light. Do you know What exercise prescription is best for you?

Since exercise should be part of your everyday routine in order to make it a lifelong habit  injury avoidance is important to be aware of overuse signs and symptoms, to rest those muscles when needed.  Occasionally cardiovascular disease patients develop Peripheral Artery Disease and symptoms can present similarly to overuse. Pain should signal the body to be aware that something is going on.  Take some time to evaluate that pain, what happens with it, does it always come on at a certain time or point of the exercise or activity? How long does it take to go away? Can it be avoided while being active by another means for instance switching from walking to biking?  Make sure you communicate these findings with your healthcare practitioner as they could be signals of other health conditions related to heart disease and it’s recovery.

Some exercise and activity is better than none, so start slowly. Even a warmup is better than no exercise session here is why  warming up before strenuous activity helps your heart.

Don’t expect results overnight, but do take small steps each day. Move that blood around, push it through the muscles. Make the muscles use the oxygen in the blood  more efficiently. Exercise helps the the heart recover and stay strong.

You might not notice any big changes—especially in your weight—for a few weeks or even months. It is still good for your heart health! It is not all about weight loss. Forget the scale for a while. In fact many who initially start to exercise following hospitalization are  Sedentary at the start and will gain a couple of pounds. It is their muscles getting pumped up, holding and utilizing more blood flow. Generally the focus on how you feel.

 When not to exercise is if you are presenting with Signs and symptoms of heart problems. Exercise should be avoided if  if you are presenting with congestive heart failure, or are presently sick. When returning to exercise following illness 

Symptoms to be alert for include these.

What is the difference? Cardiac Arrest vs Heart Attack

Grocery shopping after a heart attack

Does this seem like a strange title? Well if you or a loved one has experienced a heart attack once back home the undertaking of grocery shopping can go from a one hour task to a two or three-hour task. This is common complaint heard in Cardiac Rehabilitation. Why? The task of determining which foods are to be avoided and what to replace them with takes a great deal of time. Reading the labels for fat and sodium content, determining  vitamin K sources,  or if the food contains grapefruit or others that could interact with medicines takes time. 

Shop the perimeter

Discharge instructions include following a heart healthy diet. For most that means eliminating much of the processed and  pre-packaged foods from the diet, as they are too high in saturated or trans fats, or too high in sodium. The best way to speed this process up is to try to shop the perimeter of the grocery store. Get your fresh fruits and veggies, stop by the butcher and select fresh-cut lean meats, get your low-fat dairy products,and purchase your baked goods that are whole grain, then be done. Eliminate the inner isles of the store (well other than the cleaning isle). The boxed foods are often high in saturated or trans fats because they replace butter. Butter goes rancid quickly and thus the products would have a short shelf life, so they substitute trans and saturated fats so the product can remain on the shelf for a year or more, although eating it reduces your shelf life 🙂

Vitamin K is an issue if you are discharged on the blood thinner Coumadin. While it is not necessary to eliminate vitamin K from the diet, it is important to get approximately the same dosage daily, to help avoid large swings in your INR rates. Try to eat the same portions of vitamin K each day. Many patients report they cannot eat foods with vitamin K, in fact we want them too, but we want them to understand the content and keep it similar from day-to-day. To learn more about Vitamin K and Coumadin click here

Grapefruit, blood oranges are a couple of items that effect the potency of medications and should be avoided at all cost. Statin – cholesterol lowering medications in particular are effected. Know what items contain grapefruit juice and avoid these. For more information about heart medication that interact with grapefruit click here

Sodium is in just about everything in the middle shelves. It is the preservative which again allows for the long shelf life. Avoid foods with 800 milligrams or more per serving. Remember the 1500 milligram daily goal shouldn’t be exceeded. Again if buying fresh foods and not processed is the easiest way to adhere to the guidelines. Learn more about sodium

It gets easier, and takes less time after a while. You learn what brands are best, and where to find them. You try new foods and decide what you like. Some hospitals have grocery store tours with dietitians to help you learn what is marketing and what is healthy.

Common marketing issues where you think you are purchasing healthy foods but are not

Ground turkey. Everyone comes to rehabilitation and tells me they had ground turkey burgers. I challenge them to go back and look at the percentage of fat in the ground turkey. Most of it contains 80% protein 20% fat, that is the same as most hamburger contains. It would be better to eat ground sirloin of 90% protein and 10% fat. Better yet, learn to make bean burgers – super easy to make and much better and less expensive as the pre- packaged bean burgers. Another one that I chuckle at is the milk choices. Patients come in proud they are no longer drinking whole milk, and report they are at 2%. Well I educate them to consider a glass of whole milk is about equal to three restaurant size pats of butter, 2% would equal 2 pats of butter, 1% equals 1, skim equals no saturated fat. Green labels also don’t mean. Peanut butter – read the labels it may say no trans fats, but contains partially hydrogenated oils…hmmmm….not a good choice. Select the peanut butter that is natural the kind that you must stir the oil into the peanut butter. Many foods are labeled trans fat-free, as if it were a recent change to make it healthier, when in fact they never contained trans fats.

A funny story one time I had a very young woman with serious heart disease proudly announce she made a good selection when she picked chicken gravy over beef….missing the point that gravy is fat and salt completely.

Heart Rates: Why are they important to know?

 There are many things that can affect the heart rate and are important to consider if you are a heart patient. Heart rate vary as the body’s need to absorb oxygen and excrete carbon dioxide changes, such as during, exercise or physical activity, sleep or illness. The normal human heart rate is between 60-80 beats per minute at rest.

 

Slow Heart rates

Exercise implications of a low heart rate can indicate a problem when the heart rate does not increase sufficiently with exertion, creating increased fatigue, shortness of breath, exercise intolerance, or EKG changes.  It is important  for heart patients to observe how the heart rate responds to exercise. Does it increase and by how much? 

Medications known as beta blockers frequently lower resting heart rates to upper 40-60 range. That isn’t always considered a problem. If there are no symptoms of compromise such as shortness of breath, chest discomfort, fainting, overwhelming fatigue or cognitive changes and the treatment is tolerated, there is not usually concern. When the rates start to get into the low 40’s there is  more concern. When you sleep the heart rate usually drops another 10 beats per minute, and heart rates in the 30’s are not able to adequately get enough circulating oxygen in the bloodstream to nourish the organs. You might not notice it thus might be found in sleep studies, or if on remote monitoring with holter monitor studies.

If you are on beta blockers the the heart rates are quiet a bit lower than traditional heart rate posters. Many people  on beta blockers have a very blunted heart rate response to activity. On beta blockers your heart rate ranges are usually set 10-20 points lower than the traditional age predicted heart rate ranges or are often prescribed at 50 -70% of age predicted values (see chart below). This doesn’t mean you don’t get the benefits from exercise. The benefits are not directly linked to the heart rates. Exercise conditions the muscles to be efficient at utilizing the oxygenated blood and  thus takes demand off the heart to work harder to provide the blood flow to the working muscle. So the heart doesn’t have to pump as fast.  Think of the muscles as a secondary pump that extracts the oxygen and pushes the blood back to the lungs for re oxygenation.

Commonly prescribed Beta Blockers are usedd to treat the following conditions

• HTN  is Hyperension
• Angina =Chest Discomfort
• Arrhy=arrhythmia or irregular heart rhythm
• MI = Myocardial Infarction meaning heart attack
• CHF = Congestive Heart Failure – Shortness of breath and fluid retention in abdomen, legs, weakness of the heart, low ejection fraction

• Acebutolol -Sectral
• Atenolol – Tenormin
• Betaxolol – Kerlone
• Bisoprolol – Zebeta, also sold as Ziac
• Carteolol -Cartrol
• Carvedilol -Coreg
• Labetalol – Normodyne, also sold as Trandate
• Metoprolol – Lopressor, also sold as Toprol
• Nadolol – Corgard
• Penbutolol – Levatol
• Propranolol – Inderal, Inderal LA
• Timolol – Blocadren

This is a question for you and your healthcare professional. What should my target heart rate range be at given my being on beta blockers? It is up to you to determine how you will measure and track your rates. Here are some methods and tools to monitor. 

 

 

To monitor the heart rate you should  measure the rate for 60 second to determine the rate. It is also useful to note if it is regular. Fitness plays a role here. The more fit you are the lower the resting heart rate. If the heart is efficient and the muscle are strong there is less demand for the heart to go faster to meet the supply and demand of the muscles. Most symptoms of this are shortness of breath, fatigue, exercise intolerance. Then exercise is progressed more on tolerance than by the goal of getting the heart rate elevated to a higher percentage but a rate between 50 and 85% of age predicted target heart rate range.

Exercise  elevates the heart rate. How high is too high?

Most frequently the Karvonen target heart rate is method to determine the age adjusted threshold which is 220  – minus age = Maximal Heart Rate range at which one should not try to achieve when exercising a heart that has had  cardiovascular health issues. A percentage between these ranges is often prescribed by your healthcare practitioner. It is a range!!!! Not an I have to hit the top of this to benefit my heart range. The goal is to be somewhere in that range, we all have good days and bad especially when struggling with heart issues.

If you are in the low end of the range that is just as good as the upper end when it comes to exercise, and there are times when the upper range is too high and it is better to be in the lower range. Again there is an art versus  science of target heart rate ranges the best advise is  be active at a level for which you are  free of symptoms, yet the effort feels fairly light to somewhat hard and does not feel physically hard to perform for several minutes.

Some heart patients  may find a fast resting heart rate if medications are off, or if complications are developing such as the heart rhythm abnormalities or changes.  If the rate is faster than normal and in the recommended exercise levels when resting do not exercise instead contact your healthcare provider ASAP. 

Wall motion, blood pressure, heart rhythm, exercise intolerance, pacemaker or ICD programming must be discussed to really understand the extent of your target heart rates for exercise. Because of such complexity, initially starting to increase activity on a regular basis that elevates the heart rates some and remaining free of symptoms, being able to talk while exercising is an important assessment tool of how well one is tolerating exercise. Make sure to include this discussion at your cardiology or primary care appointment. Discuss safe heart rate ranges for activity, and how your medications and heart condition will influence it. What are your medical concerns?  Heart patients are not instructed to exercise at age predicted maximum heart rate ranges.

Below  is a standard chart your healthcare staff  uses to prescribes a ranges for safe activity. For heart patients there may be ranges where there are ischemic changes meaning there is a change in the EKG noted while in  Cardiac Rehabilitation or with stress testing. Theoretically one could monitor their own  for issues through use of the new Ipod apps for heart rhythm monitoring, or small handheld electronic devices like those shown above. Most exercise is initially prescribed light following a heart issue and gradually increased to meet daily living needs including work, physical, and activity/exercise needs.

Age	Maximum HR	50 percent	75 percent	85 percent
20	200	100	150	170
25	195	98	146	166
30	190	95	142	161
35	185	93	138	157
40	180	90	135	153
45	175	88	131	149
50	170	85	127	144
55	165	83	123	140
60	160	80	120	136
65	155	78	116	132
70	150	75	113	127
75	145	72	108	123
80	140	70	104	119
85	135	68	101	115

If you have cardiovascular issues such as  angina, poor heart wall motion due to the injury to the heart  from a heart attack or cardiomopathy, inadequate blood pressure responses, EKG electrical changes, then the target heart rate ranges are established by your physician to a safe level. This target heart rate range is your individual level based on your medications, your heart issues, and your fitness goals.

Most rehabilitation of the heart is done in lighter zones initially, then progresses gradually too higher heart rates to meet daily living needs including work, physical, and activity/exercise needs. Many are able to do high levels of physical exertion when trained including returning to jogging, cross country skiing, or strenuous job requirements. Rehabilitation programs are beginning to work select patients to higher target heart rate ranges with interval training. Sometimes the art of exercise prescription outweighs the science of it when balancing a complex medical history of cardiovascular disease.