Yet another exercise magic !

How an Active patient and an Astute physician “Abort” a heart attack !

Mr Parker is a 75 year old diabetic. He is always on the go. Wherever possible, whenever possible he avoids a vehicle or an elevator but walks and climbs besides doing his regular half hour walk every morning.

But one evening his long standing diabetes played spoil sport.  He started getting chest pain and hence went to his family physician. The doctor took his ECG, diagnosed a heart attack (technically termed ST elevation myocardial infarction) and packed him off to Nanavati hospital. (Fig 1 from attachment)

But before sending him, he did a wise thing. He gave him a soluble aspirin to chew and 4 tablets of  clopidogrel (another blood thinner like aspirin) to swallow.

By the time Mr Parker reached the hospital, his pain had subsided completely and the ECG reverted to normal (in medical terms- the elevated ST segments regressed to baseline). (Fig 2 from attachment)

This was because of the dissolution of the clot or thrombus which was occluding a coronary artery.  Usually it requires the intravenous injection of a clot buster (fibrinolytic drug) or emergency balloon angioplasty to dissolve or remove the clot and open the artery. In Mr Parker’s case it happened without any of these these remedies. It is very likely it came about due to the physical activity habit of the patient as well as the timely diagnosis with an ECG and administration of the blood thinners in correct dosage by the family doctor.

An angiogram that I did the next day confirmed our premise, and Mr Parker was referred for bypass surgery due to presence of multiple serious blocks in other arteries too.

Regular, moderate intensity  physical activity is known to stimulate body’s own “fibrinolytic” system- that is, the body’s ability to spontaneously dissolve unwanted clots.

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Although due to diabetes, Mr Parker had fat deposits and a threatened heart attack due to clot formation, the latter “melted”  due to a combination of his own vigorous fibrinolytic potential because of regular exercise and the blood thinners promptly given by the doctor after a quick diagnosis of ST elevation MI. Hence he did not suffer from much damage to his heart muscle. The bomb was diffused before it could explode !

A lesser known but important benefit of REGULAR MODERATE EXERCISE !

My 60 year old friend, a doctor himself,  has a daily habit of walking for half an hour in the morning. One day while walking he felt discomfort in his upper abdomen. He thought it was gas and continued walking. But the ‘gas’ did not go away and started spreading upwards in the chest as some tightness. He stopped, came home and took some antacids. Since he was alright through the day, he didn’t bother and went for a walk again the next morning when the symptom recurred. Now he felt something was amiss and went for a stress test which was mildly abnormal. That was when he consulted me.

Listening to his story, I promptly put him on medications (aspirin and statins) and did his coronary angiography the next day.  And what did it show ? ! It showed a 99% narrowing of a major artery (picture). This narrowing is called a “widow maker” because, if it occludes totally, it can cause a large heart attack or sudden death. Of course, we opened the narrowing with a balloon and stented it.

The moral of the story is that if our friend did not have a habit of walking regularly, he would not have had the warning symptoms and the narrowing in the artery would have worsened silently and announced itself suddenly with a large heart attack or even sudden death.

Hence a lesser known but probably the most important benefit of regular moderate intensity exercise like walking, swimming, aerobics, cycling etc is that coronary disease may be identified early before any of its devastating consequences  occurs.

To quote actor James Cagney again : “I try to dance at least once a day because I don’t want to take my heart by surprise!”

Seven Habits of Highly ‘Efficient’ Hearts :

Seven Habits of Highly ‘Efficient’  Hearts :

 A study published online January 30, 2012 in Circulation shows that individuals satisfying at least  five of seven conditions had a significantly lower risk of all-cause deaths and deaths from heart disease compared with individuals who met none of the measurable parameters

These components include four ideal health behaviors—not smoking, body-mass index (BMI) <25 kg="" m="" sup="">2

, physical activity at goal levels (at least 150 minutes of aerobic activity per week such as walking, running, swimming, dancing etc), and diet that includes three or more daily servings of fruits and vegetables—and three ideal health factors, including total cholesterol <200 and="" blood="" d.="" diastolic="" dl="" fasting="" glucose="" hg="" levels="" mg="" mm="" o:p="" plasma="" pressure="" systolic="">

After a median of 5.8 years of follow-up of  7622 adults, it was found that compared with individuals with no ideal health measures, those with five or more had a 78% lower risk of all-cause mortality and an 88% lower risk of death from diseases of the circulatory system.

Besides suggesting an almost 90% lower risk of developing heart disease by having all the healthy parameters, an important fallout of the study is that having these parameters also resulted in  reduced mortality due to other causes and improvement of overall health of the population.

Don’t buy the ‘label’, don’t believe the ‘number’ !

“If you label me, you negate me !”  — Søren Kierkegaard

Vineet is a 38 year old gentleman who visits me regularly for a condition called “dilated cardiomyopathy”. A normal heart pumps about 55 to 60 % of blood contained in it with every heart beat. In other words, normal “ejection fraction” is 55 to 60 %. Vineet’s EF was only 15 % as judged on a 2D Echo exam.

With medications and encouragement to gradually increase physical activity over the year, he is better and symptom- free with his usual activities.

After about a year of treatment, at one such consultation, his wife wanted to ask two questions which had been bothering her since a year. One: will his ejection fraction remain 15 % for ever? And more important, two : Can the family take him on a holiday, say, a hill station ?

I said, of course the EF can improve , and yes he can definitely go on a holiday with care about exerting himself etc.  Before I could ask why she was asking these questions now, she said :

Our first consultant said, EF will never improve, there is no medicine for this and that he should be always confined to the house.

We doctors often are overzealous inn believing and conveying textbook statistics to patients, we forget that what may be true for a thin majority of patients with a typical disease, doesn’t  hold true for ALL patients, that the beauty of medicine and life in general lies in all its variability and unpredictability.

Patients are handed over reports which mention a number, say EF of 15%, or a coronary narrowing of 90 % or that your knee joint is severely worn etc. Studies have shown that the condition of the patient deteriorates after hearing such numbers and labels, such is the power of words from a doctor. However, many patients live for decades with a 90 % blockage in a coronary artery and many patients carry on without pain in the knees despite the x-ray findings.

By suggesting not to believe in the numbers, my purpose is to convey that numbers and labels do not automatically decide the future. True, they are accurate, they make the correct diagnosis, but not necessarily the prognosis. They are useful for the physician to plan treatment and guide therapy, but not to sit on judgment and pronounce the final verdict.

Those patients who have the tenacity and wisdom to not buy completely into the labels and numbers but believe in a force of nature beyond themselves and the healing properties of their own bodies, do well despite all apparent odds.

Listen to the wise words of Sir William Osler uttered as back as 1892 :

“If it were not for the great variability among individuals, medicine might as well have been a science, and not an art” !

NB : By the way, the latest Echo of Vineet shows he has now an EF of 30 %  !! And he recently made a wonderful trip abroad with his family !!

Four scourges of modern life: 

Obvious but easily missed  

-         Dr Akshay Mehta

Smoking, stress, too much alcohol, lack of physical exercise and improper diet are well known health hazards of modern life. However, there are four other dangers of modern life that are obvious and very common but hardly paid attention to. These are :

1. Sitting too much
2. Sleeping too less or too much
3. Not using public transport
4. Not eating proper breakfast

1 Sitting too much :

One of the banes of modern life is prolonged sitting: whether it is with the TV or the computer or the car. Recent research shows that the more time people spend sitting, the greater their risk of diabetes, cardiovascular events, and death. In the people above age 60 it also raises the possibility of early disability.

In a recent Australian study of 222,500 Australian adults for about three years, it was found that compared to people who spent less than four hours per day sitting, the odds of dying were 15% higher for people who sat for at least eight hours 40% higher for people who sat for 11 or more hours a day. This effect was independent of body weight or regular leisure time exercise. Thus, being lean or getting 30 minutes of physical activity five times a week is no insurance against chronic disease if we sit for long hours in the day.

Keeping sitting time to less than three hours a day might make us live an extra two years. And cutting TV viewing -- which most of us do while sitting -- to less than two hours every day might extend life by almost 1.4 years.

When we sit, our muscles are not used, and we quickly become more insulin resistant and can utilize glucose less efficiently. Studies have shown that people who sit after eating have 24% higher glucose levels than people who walk very slowly after a meal.

For people susceptible to develop diabetes. It might be especially important to avoid prolonged sitting.

Thus, a healthy balance between sitting, standing and walking or other physical activities is what is required. Following steps can be taken to avoid prolonged sitting : Drinking enough water so that you have to pee four times a day, standing up, stretching and walking around a little bit every hour or so,  standing up while on the phone or having  a stand up meeting, doing desk or computer work in standing position sometime etc. etc. An organization in Japan has an alarm bell every hour reminding the staff to stand up and stretch a few minutes.

2. Sleeping too little or too much :

When and how much we sleep is just as important as what we eat or how much we exercise, according to studies. Sleeping too little or too much can lead to health effects like obesity, diabetes, hypertension, heart disease, stroke and mental distress. Optimal sleep for an adult is 7 to 9 hours. Thus if you suffer from sleep deprivation or are getting up without being refreshed it is time to manage sleep better. Following steps may help:

SLEEP SCHEDULE: make one and religiously follow it. Consistent timing of going to bed reinforces the body’s sleep- wake schedule.

COROLLARY: in 15 mins if you cant sleep, go ahead do a relaxing chore and return back to bed when exhausted.

EAT EARLY DINNER and SLEEP EARLY (about 10 pm) : Make use of your own body’s “sleeping hormone”- melatonin, to get good sleep. Levels of this hormone rise after 9 pm and are maximal about 10 pm (assuming sunset at 7 pm)

AVOID STIMULANTS such as nicotine, caffeine and alcohol which will affect the quality of sleep. Eating too much or staying hungry may also disrupt sleep patterns

BED TIME RITUAL: developing it may work as a signal to the body for winding down.

CREATE AMBIENCE: cool, dark and quiet surroundings may help get a better sleep. Pillow mattress, comfortable temperature may contribute too.

LIMIT DAYTIME NAPS: sleeping too much in day affects nighttime sleep in both quality and duration.

REGULAR PHYSICAL ACTIVITY: promotes better sleep. However schedule it away from bedtime.

MANAGE STRESS: if your plate is too full, learn to delegate, organize and prioritize. Leaving worries before making it to bed for managing them the next day will equip us to handle them better.

PRACTICE REGULAR MEDITATION : This is a good stress buster inasmuch as most stress is due to our responses to the environment which is much better and mindful if you practice meditation regularly.

CONSULT your doctor if you need help.

3. Not using public transport or cycling to work

A recent study  published in September 2013 issue of the American Journal of Preventive Medicine states that use of public transport or even better - cycling to work instead of using private transport - is linked with lower risk of developing diabetes and hypertension. Previous studies have associated “active travel” to work with reduction in obesity

Results of the nationally representative survey of UK residents, called Understanding Society, from 2009 to 2011, analyzed in 2012, showed that those who walked to work had a 40% lower risk for diabetes and a 17% lower risk for hypertension than those who used private transport. And even just using public transport lowered the risk for diabetes by 18%.

Reductions in overweight or obesity were also significant, with a 15% reduction among those using public transport as against those who used private transport, a 20% reduction was seen in those who walked to work, and a 37% lower risk for those who cycled.

The best outcomes were seen in those who cycled to work, followed by those who walked and modest but considerable advantage was even seen amongst those who used public transport.

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Thus not only should people be encouraged to build physical activity into their everyday life like commuting to work, but also governments should be proactive in providing good  infrastructure which can support “active travel.”.

4. Not eating proper breakfast :

A recent study, conducted by Harvard School of Public Health (HSPH) and published on July 22, 2013, in “Circulation”, the American Heart Association journal, says that skipping breakfast raises the risk of heart attack by 27%.

Those who eat breakfast feel less hungry later in the day, thus breakfast makes it easier to avoid overeating.  While those who skip breakfast feel gluttonous later and are tempted to reach for a quick fix — such as vending machine candy or doughnuts, or oily snacks available near or at the office. Further the prolonged fasting which is the result of skipping breakfast may stimulate body's insulin response, resulting in excess storage of fat and consequent weight gain. Hence those who skip breakfast have a higher risk of obesity, metabolic syndrome  high blood pressure, high cholesterol, and diabetes and resultant higher probability for heart diseases

Also, eating breakfast provides energy which may stimulate an individual for further physical activity. A healthy breakfast refuels the body and replenishes the glycogen stores that supply our muscles with immediate energy. While those who skip breakfast are low on energy and have decreased physical activity.

Breakfast also encourages one to make healthy choices all day. Those who consume healthy breakfast regularly, tend to eat a healthier overall diet, paying attention to nutrition and low fats. Those who skip breakfast, are more likely to skip fruits and vegetables the rest of the day, too.

Breakfast is the most important meal of the day. No wonder it has been said “"Eat breakfast like a king, lunch like a prince and dinner like a pauper!"

So while writing the above piece, I got up four times from my chair and stretched a few minutes each time, am going to sleep early and well for about 7 hours, will have a good breakfast tomorrow morning and will be off to the hospital a few kilometers away, on my feet !!

What about you ? !!