Fitness or Fatness? What to Focus on ?
-Dr Akshay Mehta
There is some good news for those huffing and puffing rolly pollies ! Fitness (aerobic or cardiovascular) appears to be more important thanweight loss when it comes to reducing overall death rates or deaths due to heart disease. Recent data from a large longitudinal study show that maintaining and improving physical-fitness levels (by increased physical activity) were associated with lower risks of all-cause andcardiovascular disease mortality, whereas changes in body-mass index(BMI) were not.
Data from the Aerobics Center Longitudinal Study, in 14 435 menwith an average follow-up of 11.4 years showed that men who maintainedtheir physical-fitness levels had a 30% and 27% lower risk of deathand cardiovascular death, respectively, when compared with men who lost fitness. Those who got into better shape from baseline had a 39% and 42% lower risk of death and cardiovascular mortality,respectively, when compared with those who lost fitness over the years. Cardiovascular fitness was measured by noting effort tolerance on an exercise treadmill as per a fixed protocol of speeds and inclinations. In contrast, changes in BMI status (calculated as a ratio of weight in Kg over height in meters squared) were not associated with mortality after accounting for other factors or 'confounders',including changes in fitness.
People think that weight gain is a bad thing, but in this studyfitness loss was associated with a higher risk of mortality regardless of weight change. The study thus concludes that if individuals can maintain or improve their fitness levels, they need to worry less about weight gain. Given the difficulty of reducing weight in some obese people,focusing on improving fitness instead, can have important clinical and public-health implications.
Wednesday, December 7, 2011
Wednesday, November 2, 2011
The 7 common myths about balloon angioplasty and stent implantation for coronary heart disease:
-- Dr Akshay Mehta
Myth No. 1. Angioplasty procedure ‘fails’ after a few years
The chances of recurrence of narrowing or “restenosis” after balloon angioplasty & stent implantation (“failure”) is less than 10% with the use of the new drug eluting (‘medicated’) stents and if at all this occurs, it is usually within a year or two. Beyond this period, the stent remains patent (open) in most cases and doesn’t ‘fail’. Most stents which have been implanted since more than 20 years have remained patent.
Myth No. 2. The balloon can burst in the coronary artery
Though possible, it is an extremely rare occurrence and can be tackled.
Myth No.3. The stent can slip or migrate from its position.
No, it never happens as it is embedded in the inner wall of the artery at high pressure.
Myth No. 4. One should always select ‘Medicated” (drug eluting) stents for implantation.
It is best to leave the choice of stent to the operating cardiologist. In certain cases, the apparent net advantages of a ‘medicated’ stent over a bare metal stent are minimal, so that a less expensive bare metal stent can be used in those cases.
Myth No. 5. One can stop medications after a few days once angioplasty has been done.
This is dangerous. After stent implantation, if blood thinners like aspirin and clopidogrel are stopped, the stent can get clotted and the resulting blockage can cause an ACUTE HEART ATTACK or DEATH. Hence aspirin, clopidogrel and cholesterol lowering statins should be continued non-stop under doctor’s guidance.
Myth No. 6. One has to restrict activities after angioplasty.
A few days’ rest may be advisable if the angioplasty is done for an acute condition like a heart attack or unstable angina. But eventually, gradually increasing activity under medical guidance is advisable. In fact, the chances of recurrence of disease or narrowing after angioplasty are reduced in people doing regular moderately vigorous exercise besides eating a prudent diet, taking medications properly and regular check ups and consultations.
Myth No. 7. Bypass surgery is always better than balloon angioplasty
No, both angioplasty and bypass surgery have their advantages and disadvantages and risks & benefits. It is important to discuss with your doctor how they apply to your situation and the best treatment option for you.
-- Dr Akshay Mehta
Myth No. 1. Angioplasty procedure ‘fails’ after a few years
The chances of recurrence of narrowing or “restenosis” after balloon angioplasty & stent implantation (“failure”) is less than 10% with the use of the new drug eluting (‘medicated’) stents and if at all this occurs, it is usually within a year or two. Beyond this period, the stent remains patent (open) in most cases and doesn’t ‘fail’. Most stents which have been implanted since more than 20 years have remained patent.
Myth No. 2. The balloon can burst in the coronary artery
Though possible, it is an extremely rare occurrence and can be tackled.
Myth No.3. The stent can slip or migrate from its position.
No, it never happens as it is embedded in the inner wall of the artery at high pressure.
Myth No. 4. One should always select ‘Medicated” (drug eluting) stents for implantation.
It is best to leave the choice of stent to the operating cardiologist. In certain cases, the apparent net advantages of a ‘medicated’ stent over a bare metal stent are minimal, so that a less expensive bare metal stent can be used in those cases.
Myth No. 5. One can stop medications after a few days once angioplasty has been done.
This is dangerous. After stent implantation, if blood thinners like aspirin and clopidogrel are stopped, the stent can get clotted and the resulting blockage can cause an ACUTE HEART ATTACK or DEATH. Hence aspirin, clopidogrel and cholesterol lowering statins should be continued non-stop under doctor’s guidance.
Myth No. 6. One has to restrict activities after angioplasty.
A few days’ rest may be advisable if the angioplasty is done for an acute condition like a heart attack or unstable angina. But eventually, gradually increasing activity under medical guidance is advisable. In fact, the chances of recurrence of disease or narrowing after angioplasty are reduced in people doing regular moderately vigorous exercise besides eating a prudent diet, taking medications properly and regular check ups and consultations.
Myth No. 7. Bypass surgery is always better than balloon angioplasty
No, both angioplasty and bypass surgery have their advantages and disadvantages and risks & benefits. It is important to discuss with your doctor how they apply to your situation and the best treatment option for you.
The 7 Common Myths about Coronary Angiography
--Dr Akshay Mehta
Myth No.1 It is a risky procedure.
Fact : Although no invasive procedure is without risk, the risk of coronary angiography is very low (less than 1% chances of a major complication).
Myth No. 2. It is a painful procedure
Fact : Except for the pain of one local anesthetic injection (similar to the pain of a needle prick that one gets while giving blood for blood tests), it is a virtually painless procedure.
Myth No 3. It is done after making patient unconscious (under general anesthesia)
Fact : No, almost always it is under local anesthesia, by injecting a local anesthetic into the skin.
Myth No.4 . It cannot/should not be done immediately after a heart attack.
Fact : On the contrary, acute heart attack is one of the most important conditions where immediate angiography followed by immediate balloon angioplasty and stent implantation is highly beneficial, gratifying, effective and can prevent damage to a large part of the heart.
Myth No. 5. One has to take bed rest for a number of days after the procedure.
Fact : There is no need for this unless the underlying heart condition requires so. Angiography by itself does not necessitate more than a night’s rest
Myth No 6 If one undergoes angiography he/she should be also ready for immediate angioplasty or bypass surgery.
Fact : NO. If the patient’s condition is not acute or unstable, if the narrowing in the coronary artery is not critical or at a critical location, if the inconvenience of coming back again for angioplasty is acceptable and if there are other options for treatment (like bypass surgery or medications) that need consideration and discussion, the angioplasty or bypass surgery can be done later after a few days.
No 7. One has to stay in hospital overnight after the procedure.
Fact : Again no need, unless the procedure has been done late in the afternoon or evening, or insurance coverage rules requires a 24 hour stay. Usually after coronary angiography done through groin, about 8 to 10 hours rest in the hospital is sufficient. If done through the wrist, about 4 hours rest is enough.
--Dr Akshay Mehta
Myth No.1 It is a risky procedure.
Fact : Although no invasive procedure is without risk, the risk of coronary angiography is very low (less than 1% chances of a major complication).
Myth No. 2. It is a painful procedure
Fact : Except for the pain of one local anesthetic injection (similar to the pain of a needle prick that one gets while giving blood for blood tests), it is a virtually painless procedure.
Myth No 3. It is done after making patient unconscious (under general anesthesia)
Fact : No, almost always it is under local anesthesia, by injecting a local anesthetic into the skin.
Myth No.4 . It cannot/should not be done immediately after a heart attack.
Fact : On the contrary, acute heart attack is one of the most important conditions where immediate angiography followed by immediate balloon angioplasty and stent implantation is highly beneficial, gratifying, effective and can prevent damage to a large part of the heart.
Myth No. 5. One has to take bed rest for a number of days after the procedure.
Fact : There is no need for this unless the underlying heart condition requires so. Angiography by itself does not necessitate more than a night’s rest
Myth No 6 If one undergoes angiography he/she should be also ready for immediate angioplasty or bypass surgery.
Fact : NO. If the patient’s condition is not acute or unstable, if the narrowing in the coronary artery is not critical or at a critical location, if the inconvenience of coming back again for angioplasty is acceptable and if there are other options for treatment (like bypass surgery or medications) that need consideration and discussion, the angioplasty or bypass surgery can be done later after a few days.
No 7. One has to stay in hospital overnight after the procedure.
Fact : Again no need, unless the procedure has been done late in the afternoon or evening, or insurance coverage rules requires a 24 hour stay. Usually after coronary angiography done through groin, about 8 to 10 hours rest in the hospital is sufficient. If done through the wrist, about 4 hours rest is enough.
Do you have BP ? -Dr. Akshay Mehta
Yes, of course, all of us have BP (i.e. blood pressure).
All of us who are alive and kicking and have blood flowing in our arteries have BP.
Simply put, BP or blood pressure is the pressure or force exerted by the flowing blood on the walls of the arteries- the tubes that carry blood to all parts of the body from the heart. Every heartbeat consists of contraction and relaxation of the heart pump which sends a pressure wave throughout the arteries, much like the rising and falling waves of the sea.
The pressure wave generated at the time of contraction of the heart is the systolic pressure (the first or higher number usually mentioned in BP readings) and the pressure generated during the relaxation phase is called the diastolic pressure (the second or lower number in BP readings). So we all have BP with two numbers or readings: a higher (systolic) and a lower (diastolic) eg 140/90 (recorded as mm of mercury column ie Hg). However, some of us have high BP or hypertension which is a problem that needs attention
What is normal BP ?
It is the level of BP which is associated with least likelihood of producing complications in the future. From observations made over the years it has been seen that when the BP is consistently below 130 systolic and 80 diastolic, one has less chances of having complications related to BP.
What is high BP or hypertension?
When BP readings consistently remain above these desirable levels, it is called high BP or hypertension. Roughly one can say there is hypertension if the BP of a person on repeated and accurate measurements is above 140 mmHg systolic and/or 90 mmHg diastolic (i.e. 140/90). For diabetics and people with kidney failure, the limits are lower (130/80). For elderly people of say 75 years and above, the limits are more relaxed : about 150/90.
What is low BP? Is it dangerous?
Some people habitually have their BP at lower limits of normal i.e. 90/60 mm of Hg. So it is not abnormal or dangerous if this has been one’s usual BP and if it is not due to illness like shock, blood loss, dehydration, etc. or due to over medication.
Who are most likely to have hypertension ?
The following person have greater than average chances of having hypertension : diabetics, obese, people with kidney disease and people whose family members (parents or siblings) are known to have hypertension.
Is hypertension due to mental tension?
There is no definite correlation between mental tension and hypertension although mental tension can precipitate hypertension in those who are predisposed to get it. There are many “tense” individuals who do not have hypertension and there are many “cool” guys who have hypertension.
What causes hypertension?
In more than 90% of hypertensives, the exact cause is not known. In the minority, the cause may be a kidney disorder, some hormonal disturbance or some other correctable disorder.
What are the symptoms of hypertension? How does one know one has hypertension?
In most people with hypertension, there are no symptoms. Some may have headache. The best way to know whether one is hypertensive is to get it checked repeatedly.
Why treat it if it does not produce any symptoms?
Untreated high BP can produce complications mainly due to abnormal changes in the arteries making them more susceptible to fat deposits and narrowing called atherosclerosis. This can lead to problems like coronary heart disease and brain stroke. Another complication is kidney failure. It is to prevent these complications that proper treatment and control of BP is required despite the fact that it does not cause symptoms or unusual sensations.
Are medicines the only treatment for high BP?
No. The first and most important treatment of hypertension is lifestyle modification, such as salt restricted diet, weight reduction, regular exercise, abstinence from smoking and alcohol etc. Then, if required, the doctor will prescribe medications over and above these lifestyle changes.
How long should one continue taking medicines? Can one stop them once the BP is under control?
Usually the BP rises again if medications are stopped, hence treatment should be continued as long as the doctor feels that reducing or stopping treatment will cause the BP to rise again. Which usually means life-long medications.
But of course there are exceptions. If the BP is only mildly elevated, and if one vigorously pursues changes in lifestyle as mentioned above, the BP may reduce and one may be able to avoid, reduce or even stop all medication.
Should one stop medications before going for a BP check up?
No. You should get your BP checked while you are taking the medicines. Only then will the doctor know the response and the need to modify the treatment
Should one stop medications if there are side effects?
Yes, but one must immediately inform the doctor who can adjust the medications without untoward harm.
What are the side effects of medicines? Can one take them for long time without harm? Will their effect wear off with time?
Most medicines for hypertension have negligible or benign side effects if prescribed and taken properly. One can take them for long term safely. However different people respond or react differently to different medicines. If any side effects are noticed, one should immediately report to the doctor. In almost all cases, a good alternative will be prescribed by the doctor.
Usually effectiveness of a drug does not wear off over time, but if it does, due to some cause, adjustment in medications will be done by the doctor.
What diet changes are required to control BP ?
The diet recommended for hypertension is one with low salt intake and an increase in fruits, green vegetables, cereals, pulses, and low fat dairy products.
What types of exercises are beneficial, and what types are harmful?
The exercises that are beneficial are the aerobic, isotonic type. Aerobic exercises are those in which the supply of oxygen and nutrients to the exercising muscles continuously meets the demands of the muscles. Isotonic exercises are those with more movement and less force. Examples of isotonic, aerobic exercise are brisk walking, slow running, swimming, cycling, etc.
Exercises that may be harmful are isometrics, requiring more force than movement. For example, weightlifting.
How frequently should BP be checked?
This depends on your age, your initial BP readings and your likelihood of having high BP in the future. Depending on these factors your doctor will guide you as to show how often you should get your BP checked. It may vary from once every week to once a year.
Should one measure BP at home? What is ambulatory BP measurement ?
In a few persons, BP is high only when taken in the doctor’s clinic or a hospital, but normal when taken at home. This is called “white coat hypertension” and is less of a risk than true hypertension. So, if accurately done, home BP is a good idea and is a true reflection of one’s BP and can be done at different times of the day. Ambulatory BP is automatic BP measurement at frequent intervals throughout 24 hours by an equipment tied to the patient’s arm. It gives an idea about BP levels also while asleep in the night. It can also reveal early morning rises in BP which are detrimental to health. Many times drug therapy can be better tailored to the BP levels by noting these variations throughout the day.
What other precautions should one take if one has hypertension?
Hypertension is one of the most important risk (causative) factors in the development of coronary artery diseases, and its harmful effect are magnified by the presence of other risk factors like smoking, diabetes, abnormal blood lipids (cholesterol), obesity and physical inactivity. Hence it is important to identify these other factors, with checkups if necessary, and reduce or eliminate them with proper lifestyle changes and medications. At the present time, proper lifestyle changes together with excellent medications available can almost totally prevent the complications of hypertension.
Yes, of course, all of us have BP (i.e. blood pressure).
All of us who are alive and kicking and have blood flowing in our arteries have BP.
Simply put, BP or blood pressure is the pressure or force exerted by the flowing blood on the walls of the arteries- the tubes that carry blood to all parts of the body from the heart. Every heartbeat consists of contraction and relaxation of the heart pump which sends a pressure wave throughout the arteries, much like the rising and falling waves of the sea.
The pressure wave generated at the time of contraction of the heart is the systolic pressure (the first or higher number usually mentioned in BP readings) and the pressure generated during the relaxation phase is called the diastolic pressure (the second or lower number in BP readings). So we all have BP with two numbers or readings: a higher (systolic) and a lower (diastolic) eg 140/90 (recorded as mm of mercury column ie Hg). However, some of us have high BP or hypertension which is a problem that needs attention
What is normal BP ?
It is the level of BP which is associated with least likelihood of producing complications in the future. From observations made over the years it has been seen that when the BP is consistently below 130 systolic and 80 diastolic, one has less chances of having complications related to BP.
What is high BP or hypertension?
When BP readings consistently remain above these desirable levels, it is called high BP or hypertension. Roughly one can say there is hypertension if the BP of a person on repeated and accurate measurements is above 140 mmHg systolic and/or 90 mmHg diastolic (i.e. 140/90). For diabetics and people with kidney failure, the limits are lower (130/80). For elderly people of say 75 years and above, the limits are more relaxed : about 150/90.
What is low BP? Is it dangerous?
Some people habitually have their BP at lower limits of normal i.e. 90/60 mm of Hg. So it is not abnormal or dangerous if this has been one’s usual BP and if it is not due to illness like shock, blood loss, dehydration, etc. or due to over medication.
Who are most likely to have hypertension ?
The following person have greater than average chances of having hypertension : diabetics, obese, people with kidney disease and people whose family members (parents or siblings) are known to have hypertension.
Is hypertension due to mental tension?
There is no definite correlation between mental tension and hypertension although mental tension can precipitate hypertension in those who are predisposed to get it. There are many “tense” individuals who do not have hypertension and there are many “cool” guys who have hypertension.
What causes hypertension?
In more than 90% of hypertensives, the exact cause is not known. In the minority, the cause may be a kidney disorder, some hormonal disturbance or some other correctable disorder.
What are the symptoms of hypertension? How does one know one has hypertension?
In most people with hypertension, there are no symptoms. Some may have headache. The best way to know whether one is hypertensive is to get it checked repeatedly.
Why treat it if it does not produce any symptoms?
Untreated high BP can produce complications mainly due to abnormal changes in the arteries making them more susceptible to fat deposits and narrowing called atherosclerosis. This can lead to problems like coronary heart disease and brain stroke. Another complication is kidney failure. It is to prevent these complications that proper treatment and control of BP is required despite the fact that it does not cause symptoms or unusual sensations.
Are medicines the only treatment for high BP?
No. The first and most important treatment of hypertension is lifestyle modification, such as salt restricted diet, weight reduction, regular exercise, abstinence from smoking and alcohol etc. Then, if required, the doctor will prescribe medications over and above these lifestyle changes.
How long should one continue taking medicines? Can one stop them once the BP is under control?
Usually the BP rises again if medications are stopped, hence treatment should be continued as long as the doctor feels that reducing or stopping treatment will cause the BP to rise again. Which usually means life-long medications.
But of course there are exceptions. If the BP is only mildly elevated, and if one vigorously pursues changes in lifestyle as mentioned above, the BP may reduce and one may be able to avoid, reduce or even stop all medication.
Should one stop medications before going for a BP check up?
No. You should get your BP checked while you are taking the medicines. Only then will the doctor know the response and the need to modify the treatment
Should one stop medications if there are side effects?
Yes, but one must immediately inform the doctor who can adjust the medications without untoward harm.
What are the side effects of medicines? Can one take them for long time without harm? Will their effect wear off with time?
Most medicines for hypertension have negligible or benign side effects if prescribed and taken properly. One can take them for long term safely. However different people respond or react differently to different medicines. If any side effects are noticed, one should immediately report to the doctor. In almost all cases, a good alternative will be prescribed by the doctor.
Usually effectiveness of a drug does not wear off over time, but if it does, due to some cause, adjustment in medications will be done by the doctor.
What diet changes are required to control BP ?
The diet recommended for hypertension is one with low salt intake and an increase in fruits, green vegetables, cereals, pulses, and low fat dairy products.
What types of exercises are beneficial, and what types are harmful?
The exercises that are beneficial are the aerobic, isotonic type. Aerobic exercises are those in which the supply of oxygen and nutrients to the exercising muscles continuously meets the demands of the muscles. Isotonic exercises are those with more movement and less force. Examples of isotonic, aerobic exercise are brisk walking, slow running, swimming, cycling, etc.
Exercises that may be harmful are isometrics, requiring more force than movement. For example, weightlifting.
How frequently should BP be checked?
This depends on your age, your initial BP readings and your likelihood of having high BP in the future. Depending on these factors your doctor will guide you as to show how often you should get your BP checked. It may vary from once every week to once a year.
Should one measure BP at home? What is ambulatory BP measurement ?
In a few persons, BP is high only when taken in the doctor’s clinic or a hospital, but normal when taken at home. This is called “white coat hypertension” and is less of a risk than true hypertension. So, if accurately done, home BP is a good idea and is a true reflection of one’s BP and can be done at different times of the day. Ambulatory BP is automatic BP measurement at frequent intervals throughout 24 hours by an equipment tied to the patient’s arm. It gives an idea about BP levels also while asleep in the night. It can also reveal early morning rises in BP which are detrimental to health. Many times drug therapy can be better tailored to the BP levels by noting these variations throughout the day.
What other precautions should one take if one has hypertension?
Hypertension is one of the most important risk (causative) factors in the development of coronary artery diseases, and its harmful effect are magnified by the presence of other risk factors like smoking, diabetes, abnormal blood lipids (cholesterol), obesity and physical inactivity. Hence it is important to identify these other factors, with checkups if necessary, and reduce or eliminate them with proper lifestyle changes and medications. At the present time, proper lifestyle changes together with excellent medications available can almost totally prevent the complications of hypertension.
Can exercise kill ?
--Understanding the “Exercise Paradox”
- Dr Akshay Mehta MD, DM
(bindusar@rediffmail.com)
Not infrequently, we hear about persons suffering a heart attack and dying while or after working out on the treadmill in a gym or after intense exercise. Can exercise, which is supposed to prevent heart disease, itself cause a heart attack and kill?
Yes, an individual unaccustomed to vigorous exercise has about 50 to 100 times increased risk of having sudden
death or having a heart attack (acute myocardial infarction) after intense exertion, as compared with remaining at rest.
Sudden deaths have been known to occur during or after intense exertion like running, sports etc. In young people, (below age 25 to 30 yrs) the usual reason is some structural or electrical defect in the heart since birth. Proper pre-entry or pre participation screening may help diagnose it.
However in people above age 30 years, it is usually due to underlying coronary artery disease or presence of fatty deposits lining the inside of coronary arteries also called atherosclerosis. During and after an intense and (usually unaccustomed) exertion, there is increased shear stress and mechanical strain on coronary arteries along with rise in stress hormones like epinephrine, norepinephrine. This may cause rupture of the surface of these fatty deposits (plaques). Simultaneously, at such times, there is activation of platelets- the blood cells which can clump together and initiate clot formation- at the site of the ruptured plaque in the coronary artery causing its acute occlusion leading to heart attack.
Also severe unaccustomed exertion can trigger a fatal rhythm disturbance – ventricular fibrillation, causing cardiac arrest, esp if there is already an underlying abnormality in the heart.
Then why do all the huffing and puffing? Let’s remain where we are- couch potatoes!!
Well, the key is the difference between sudden intense exertion and regular, moderate level exercise. (Regular means 4 to 5 times a week, all the year round. Moderate means at an intensity which maintains your heart rate at 60 to 80% of your maximum predicted heart rate- which is a figure you get by subtracting your age from 220).
In contrast to sudden, intense exercise, regular, moderate intensity exercise causes less stimulation of platelets and release of stress hormones. Also it stimulates the clot dissolving (fibrinolytic) property of blood. Hence plaque rupture and clot formation are less likely.
Regular exercise also promotes increased vagal tone leading to better electrical stability of the heart so that there is less chance of irregular heart rhythm which can lead to sudden cardiac arrest and sudden death.
Hence, even the transient high risk of heart attack or death during intense exertion can be reduced substantially by regular physical activity. Actually, there is an inverse relationship between this risk and the frequency of regular workout sessions. This means that the more regular and active you are, the lesser is your risk of heart attack or sudden death in situations where you have to exert a great deal and that too suddenly, like having to run for a train or a bus or to lift heavy luggage or to push a car.
Secondly, by remaining sedentary you are not immune to the risks of heart attack and sudden death. On the contrary you are more prone. Although up to 15% of all sudden deaths and heart attacks occur during or immediately after intense exercise, the vast majority of them occur while at rest or on ordinary daily activities like watching T.V., reading a newspaper etc. It is on such events that regular exercise has the greatest impact. Hence although there is a transient increase in risk during vigorous exercise, it is outweighed by decrease in risk at other times so that the overall risk is substantially lower in the habitually active than in sedentary individuals.
Regular aerobic exercise cuts down your probability of having a heart disease & heart attack substantially by
reducing most (risk) factors that increase your susceptibility to coronary heart disease like diabetes, hypertension, abnormal blood lipids (high LDL cholesterol and triglycerides and low HDL cholesterol), insulin resistance, obesity (esp. at the waist ie.- abdominal) and stress. Also, there is improvement in the function of endothelium (inner lining of coronary arteries). This leads to better capacity of coronary arteries to dilate or expand in times of need, along with lesser chance of developing blockage.
Finally, the risks of adverse events during or following exercise are mainly in sedentary and unfit individuals who have suddenly indulged in intense physical activity (or as in the person in the recent news article, who have abstained from regular exercise for a few weeks and are restarting). This is specially so in persons with multiple causative (risk) factors like family history of heart disease, smoking, hypertension, diabetes or abnormal lipids (cholesterol) or in persons with “silent” or hidden or undetected underlying heart disease.
Hence, this exercise related risk can be substantially reduced by screening for risk factors and for underlying heart disease and by gradual and careful entry into regular exercise programs.
Most importantly if one has been off regular exercise for more than a few weeks, it is crucial to re-enter very gradually as if he/she is starting it fresh.
So the answer to the question can exercise cause a sudden heart attack is :
Yes if the person has been sedentary (even for few weeks), has multiple risk factors like hypertension, diabetes etc or has underlying heart disease (hidden or known) and suddenly indulges in intense physical activity.
The answer is usually no if the person has been screened properly, has a gradual entry into an exercise program, has built up his stamina and endurance gradually and safely and is now used to doing regular vigorous exercise.
Exercise is like medicine : it works (as a preventive) only while it is taken regularly, loses its effect if stopped even for few weeks, and can have dangerous “side effects” if indulged in at high intensity suddenly after a gap of few weeks of rest.
No wonder, actor James Cagney says “I try to dance at least once a day because I don’t want to take my heart by surprise”.
--Understanding the “Exercise Paradox”
- Dr Akshay Mehta MD, DM
(bindusar@rediffmail.com)
Not infrequently, we hear about persons suffering a heart attack and dying while or after working out on the treadmill in a gym or after intense exercise. Can exercise, which is supposed to prevent heart disease, itself cause a heart attack and kill?
Yes, an individual unaccustomed to vigorous exercise has about 50 to 100 times increased risk of having sudden
death or having a heart attack (acute myocardial infarction) after intense exertion, as compared with remaining at rest.
Sudden deaths have been known to occur during or after intense exertion like running, sports etc. In young people, (below age 25 to 30 yrs) the usual reason is some structural or electrical defect in the heart since birth. Proper pre-entry or pre participation screening may help diagnose it.
However in people above age 30 years, it is usually due to underlying coronary artery disease or presence of fatty deposits lining the inside of coronary arteries also called atherosclerosis. During and after an intense and (usually unaccustomed) exertion, there is increased shear stress and mechanical strain on coronary arteries along with rise in stress hormones like epinephrine, norepinephrine. This may cause rupture of the surface of these fatty deposits (plaques). Simultaneously, at such times, there is activation of platelets- the blood cells which can clump together and initiate clot formation- at the site of the ruptured plaque in the coronary artery causing its acute occlusion leading to heart attack.
Also severe unaccustomed exertion can trigger a fatal rhythm disturbance – ventricular fibrillation, causing cardiac arrest, esp if there is already an underlying abnormality in the heart.
Then why do all the huffing and puffing? Let’s remain where we are- couch potatoes!!
Well, the key is the difference between sudden intense exertion and regular, moderate level exercise. (Regular means 4 to 5 times a week, all the year round. Moderate means at an intensity which maintains your heart rate at 60 to 80% of your maximum predicted heart rate- which is a figure you get by subtracting your age from 220).
In contrast to sudden, intense exercise, regular, moderate intensity exercise causes less stimulation of platelets and release of stress hormones. Also it stimulates the clot dissolving (fibrinolytic) property of blood. Hence plaque rupture and clot formation are less likely.
Regular exercise also promotes increased vagal tone leading to better electrical stability of the heart so that there is less chance of irregular heart rhythm which can lead to sudden cardiac arrest and sudden death.
Hence, even the transient high risk of heart attack or death during intense exertion can be reduced substantially by regular physical activity. Actually, there is an inverse relationship between this risk and the frequency of regular workout sessions. This means that the more regular and active you are, the lesser is your risk of heart attack or sudden death in situations where you have to exert a great deal and that too suddenly, like having to run for a train or a bus or to lift heavy luggage or to push a car.
Secondly, by remaining sedentary you are not immune to the risks of heart attack and sudden death. On the contrary you are more prone. Although up to 15% of all sudden deaths and heart attacks occur during or immediately after intense exercise, the vast majority of them occur while at rest or on ordinary daily activities like watching T.V., reading a newspaper etc. It is on such events that regular exercise has the greatest impact. Hence although there is a transient increase in risk during vigorous exercise, it is outweighed by decrease in risk at other times so that the overall risk is substantially lower in the habitually active than in sedentary individuals.
Regular aerobic exercise cuts down your probability of having a heart disease & heart attack substantially by
reducing most (risk) factors that increase your susceptibility to coronary heart disease like diabetes, hypertension, abnormal blood lipids (high LDL cholesterol and triglycerides and low HDL cholesterol), insulin resistance, obesity (esp. at the waist ie.- abdominal) and stress. Also, there is improvement in the function of endothelium (inner lining of coronary arteries). This leads to better capacity of coronary arteries to dilate or expand in times of need, along with lesser chance of developing blockage.
Finally, the risks of adverse events during or following exercise are mainly in sedentary and unfit individuals who have suddenly indulged in intense physical activity (or as in the person in the recent news article, who have abstained from regular exercise for a few weeks and are restarting). This is specially so in persons with multiple causative (risk) factors like family history of heart disease, smoking, hypertension, diabetes or abnormal lipids (cholesterol) or in persons with “silent” or hidden or undetected underlying heart disease.
Hence, this exercise related risk can be substantially reduced by screening for risk factors and for underlying heart disease and by gradual and careful entry into regular exercise programs.
Most importantly if one has been off regular exercise for more than a few weeks, it is crucial to re-enter very gradually as if he/she is starting it fresh.
So the answer to the question can exercise cause a sudden heart attack is :
Yes if the person has been sedentary (even for few weeks), has multiple risk factors like hypertension, diabetes etc or has underlying heart disease (hidden or known) and suddenly indulges in intense physical activity.
The answer is usually no if the person has been screened properly, has a gradual entry into an exercise program, has built up his stamina and endurance gradually and safely and is now used to doing regular vigorous exercise.
Exercise is like medicine : it works (as a preventive) only while it is taken regularly, loses its effect if stopped even for few weeks, and can have dangerous “side effects” if indulged in at high intensity suddenly after a gap of few weeks of rest.
No wonder, actor James Cagney says “I try to dance at least once a day because I don’t want to take my heart by surprise”.
“Doc, is my chest pain an impending heart attack ?”
Myths & facts related to pain related to heart attack
-- Dr Akshay Mehta
Myth No. 1. The chest pain of heart attack always occurs in the left side of chest.
Fact : The chest pain of heart attack can occur in the center of the chest, the left side or the right side. In fact it can occur anywhere from the level of our ears down to the navel. That means it can occur in the jaws, neck, throat, back, shoulders, arms and upper abdomen besides the chest. It occurs in different places in different people.
Myth no. 2. The chest pain due to heart attack is severe, piercing and comes suddenly- like a bolt from the blue.
Fact: Most heart attacks start as mild discomfort in the center of the chest (over an
area, the size of your palm) or on either side or both sides of the chest that increases
in a few minutes, and continues for more than 15 to 20 minutes, or that goes away
in few minutes and comes back again. Most commonly it feels like uncomfortable
pressure, squeezing, fullness or tightness. Sometimes it is a feeling of “gas”, lump,
indigestion or burning in chest like “acidity”. The feeling is different in different
people.
Myth No. 3. Pain in the right arm is not due to heart attack, only left arm pain is important.
Fact : As mentioned earlier, pain or discomfort can occur anywhere in or around the chest, or in either arm or shoulder. Discomfort occurs at different places in different people.
Myth No. 4 Women have the same symptoms of heart attack as men.
Fact : Women are more likely than men to have “atypical” or “non classical” symptoms like nausea, vomiting, fatigue, “gas”, “indigestion”, neck pain, shortness of breath, upper abdominal or back or jaw pain etc. instead of the classical pain described above. This can be misleading and can cause delay in taking prompt action. Hence, heart attack in women is more likely to be missed or diagnosed late.
Myth no. 5. Chest pain due to heart attack always occurs with severe sweating and vomiting.
Fact : Although many heart attacks occur with shortness of breath, breaking out in a cold sweat, nausea or lightheadedness, not all heart attacks are associated with these signs.
Myth no. 6. The pulse rate and blood pressure (BP) during heart attack are always abnormal.
Fact : Although some heart attacks are associated low or high BP , fast or slow heart (pulse) rates, in many heart attacks the heart rate and BP are normal.
Myth no. 7. Burning in the center of the chest is always due to acidity.
Fact : In some people, heart attack pain causes burning in chest similar to “acidity”, and it may be difficult to distinguish between the two. However if the “heart burn” or “acidity” occurs early morning without food or in the middle of night waking up the person from sleep, or if it radiates to back or arms or increases on exertion, it is very likely due to heart disease.
Myth no. 8.: A heart attack never gives a prior warning.
Fact : Many heart attacks are preceded by transient chest discomfort lasting few
minutes called angina (see below) few hours or days before the heart attack. Prompt
recognition and proper treatment of this warning signal could have avoided the heart
attack
Myth No 9 Constant or recurring sharp piercing pain like poking of pins and needles could be due to angina- a warning signal of heart disease.
Fact : Angina is transient chest discomfort due to coronary heart disease and lasts few minutes. It consists of discomfort or heaviness/tightness in center of chest or on either side that is provoked by exertion or emotional stress and relieved by rest and/or nitroglycerin. Sharp, poking pain over a localized (finger tip sized) area, especially just under the left nipple area, which continues for hours or days is not angina disease and is usually due to anxiety..
Myth No 10 When there is discomfort in chest likely to be a heart attack, one should call home a doctor to take an ECG.
No. Minutes matter! One can’t waste more than a few minutes if the pain is even ‘suspected’ to be due to a heart attack. Calling a well equipped cardiac ambulance is the fastest way to get lifesaving treatment if needed. If the ambulance can’t come home in a few minutes, it is best to reach the nearest ICCU where an ECG can be taken and prompt diagnosis made and treatment started. One can be taken in a car, taxi or even an autorickshaw. Remember, reaching hospital within minutes or an hour of chest pain and receiving clot dissolving drugs or emergency balloon angioplasty may mean the difference between life and death and may mean saving the heart muscle from extensive damage.
Myths & facts related to pain related to heart attack
-- Dr Akshay Mehta
Myth No. 1. The chest pain of heart attack always occurs in the left side of chest.
Fact : The chest pain of heart attack can occur in the center of the chest, the left side or the right side. In fact it can occur anywhere from the level of our ears down to the navel. That means it can occur in the jaws, neck, throat, back, shoulders, arms and upper abdomen besides the chest. It occurs in different places in different people.
Myth no. 2. The chest pain due to heart attack is severe, piercing and comes suddenly- like a bolt from the blue.
Fact: Most heart attacks start as mild discomfort in the center of the chest (over an
area, the size of your palm) or on either side or both sides of the chest that increases
in a few minutes, and continues for more than 15 to 20 minutes, or that goes away
in few minutes and comes back again. Most commonly it feels like uncomfortable
pressure, squeezing, fullness or tightness. Sometimes it is a feeling of “gas”, lump,
indigestion or burning in chest like “acidity”. The feeling is different in different
people.
Myth No. 3. Pain in the right arm is not due to heart attack, only left arm pain is important.
Fact : As mentioned earlier, pain or discomfort can occur anywhere in or around the chest, or in either arm or shoulder. Discomfort occurs at different places in different people.
Myth No. 4 Women have the same symptoms of heart attack as men.
Fact : Women are more likely than men to have “atypical” or “non classical” symptoms like nausea, vomiting, fatigue, “gas”, “indigestion”, neck pain, shortness of breath, upper abdominal or back or jaw pain etc. instead of the classical pain described above. This can be misleading and can cause delay in taking prompt action. Hence, heart attack in women is more likely to be missed or diagnosed late.
Myth no. 5. Chest pain due to heart attack always occurs with severe sweating and vomiting.
Fact : Although many heart attacks occur with shortness of breath, breaking out in a cold sweat, nausea or lightheadedness, not all heart attacks are associated with these signs.
Myth no. 6. The pulse rate and blood pressure (BP) during heart attack are always abnormal.
Fact : Although some heart attacks are associated low or high BP , fast or slow heart (pulse) rates, in many heart attacks the heart rate and BP are normal.
Myth no. 7. Burning in the center of the chest is always due to acidity.
Fact : In some people, heart attack pain causes burning in chest similar to “acidity”, and it may be difficult to distinguish between the two. However if the “heart burn” or “acidity” occurs early morning without food or in the middle of night waking up the person from sleep, or if it radiates to back or arms or increases on exertion, it is very likely due to heart disease.
Myth no. 8.: A heart attack never gives a prior warning.
Fact : Many heart attacks are preceded by transient chest discomfort lasting few
minutes called angina (see below) few hours or days before the heart attack. Prompt
recognition and proper treatment of this warning signal could have avoided the heart
attack
Myth No 9 Constant or recurring sharp piercing pain like poking of pins and needles could be due to angina- a warning signal of heart disease.
Fact : Angina is transient chest discomfort due to coronary heart disease and lasts few minutes. It consists of discomfort or heaviness/tightness in center of chest or on either side that is provoked by exertion or emotional stress and relieved by rest and/or nitroglycerin. Sharp, poking pain over a localized (finger tip sized) area, especially just under the left nipple area, which continues for hours or days is not angina disease and is usually due to anxiety..
Myth No 10 When there is discomfort in chest likely to be a heart attack, one should call home a doctor to take an ECG.
No. Minutes matter! One can’t waste more than a few minutes if the pain is even ‘suspected’ to be due to a heart attack. Calling a well equipped cardiac ambulance is the fastest way to get lifesaving treatment if needed. If the ambulance can’t come home in a few minutes, it is best to reach the nearest ICCU where an ECG can be taken and prompt diagnosis made and treatment started. One can be taken in a car, taxi or even an autorickshaw. Remember, reaching hospital within minutes or an hour of chest pain and receiving clot dissolving drugs or emergency balloon angioplasty may mean the difference between life and death and may mean saving the heart muscle from extensive damage.
Monday, October 10, 2011
My Golf Geeta in Goa
Wife and I are on a week end holiday at the Taj Exotica in Goa. Among the many activities happening at the place, the one which I always wanted to do but never got a chance to do was to learn and play golf. There is a 9 hole golf course in the hotel where you can learn and play golf with a coach for an hour. So I book an hour and start my golf lessons with my coach Johnson D’silva.
First, the basics. The stance, the grip, the feet, the swing etc. Most important of all, he tells me to keep my eyes on the ball. I start with the big shot called the T shot in which you swing the club and hit the ball a hundred yards away to reach as near the first hole (our first destination) as possible.
As I hit my first swing, I looked to the sky to see where the ball went. It went nowhere. It was peacefully perched like Lord Ganesh on the T, untouched.and unfazed. Ofcourse I had swung the club in air and had completely missed the ball.
My second swing grazed the ground and the grass a bit too much and managed to push the ball a few yards.
That is when my guru swung into giving me a sound advice, which I later thought was the key to good golf, and good living. He said, Sir, you are taking your eyes off the ball at the last minute as you are too anxious to see where your ball is going, whether it is going to the desired destination. Please forget where it is going, forget the result. Just keep your eyes on the ball and swing to the best of your ability. The result will take care of itself.
It immediately struck a note in me ! How familiar ! I thought. In the next few shots it was amazing to see how he would catch me taking my eyes off the ball even for a fraction of a second to see how I was doing or how the result was.My best shots, the best connections between the club and the ball were when my eyes were only on the ball and I let the swing take care of itself.
How familiar it was to the advice my father used to give me in my student days, when I struggled to get a good result. He used to place his hands on my shoulder and gently tell me to do the best I can and forget about the result. Of course, my best results were when I did forget about the result.
And the same is true now as I attempt to treat my patients. Being over anxious to see the result, I stress myself too much, whereas doing my best and leaving the rest helps me treat them better.
The same was true when I was treating my ailing father, who in his last days could not even turn sides while in bed, what to talk about bowels and urine. ‘Thinking’ about his condition stressed me no end, but when I confronted his state and ‘acted’ to the best of my ability to comfort him, there was great peace in my heart.
Finally, the same is true about Christ’s message of love (especially your enemy), which I think is the epitome of selfless action, action without regard to the result. It is where I think Christ meets Krishna.
So, whether it is working or painting, singing or ‘swinging’, the Geeta law permeates our lives - whether we realize it or not- and brings forth the beauty of life.
Just the way it did during my golf lesson that day. Thank you Mr. Johnson !...
First, the basics. The stance, the grip, the feet, the swing etc. Most important of all, he tells me to keep my eyes on the ball. I start with the big shot called the T shot in which you swing the club and hit the ball a hundred yards away to reach as near the first hole (our first destination) as possible.
As I hit my first swing, I looked to the sky to see where the ball went. It went nowhere. It was peacefully perched like Lord Ganesh on the T, untouched.and unfazed. Ofcourse I had swung the club in air and had completely missed the ball.
My second swing grazed the ground and the grass a bit too much and managed to push the ball a few yards.
That is when my guru swung into giving me a sound advice, which I later thought was the key to good golf, and good living. He said, Sir, you are taking your eyes off the ball at the last minute as you are too anxious to see where your ball is going, whether it is going to the desired destination. Please forget where it is going, forget the result. Just keep your eyes on the ball and swing to the best of your ability. The result will take care of itself.
It immediately struck a note in me ! How familiar ! I thought. In the next few shots it was amazing to see how he would catch me taking my eyes off the ball even for a fraction of a second to see how I was doing or how the result was.My best shots, the best connections between the club and the ball were when my eyes were only on the ball and I let the swing take care of itself.
How familiar it was to the advice my father used to give me in my student days, when I struggled to get a good result. He used to place his hands on my shoulder and gently tell me to do the best I can and forget about the result. Of course, my best results were when I did forget about the result.
And the same is true now as I attempt to treat my patients. Being over anxious to see the result, I stress myself too much, whereas doing my best and leaving the rest helps me treat them better.
The same was true when I was treating my ailing father, who in his last days could not even turn sides while in bed, what to talk about bowels and urine. ‘Thinking’ about his condition stressed me no end, but when I confronted his state and ‘acted’ to the best of my ability to comfort him, there was great peace in my heart.
Finally, the same is true about Christ’s message of love (especially your enemy), which I think is the epitome of selfless action, action without regard to the result. It is where I think Christ meets Krishna.
So, whether it is working or painting, singing or ‘swinging’, the Geeta law permeates our lives - whether we realize it or not- and brings forth the beauty of life.
Just the way it did during my golf lesson that day. Thank you Mr. Johnson !...
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