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 ? !! 

Bypass Surgery, Angioplasty or Medicines only ? Well , Let’s Call the Third Umpire !

Bypass Surgery,  Angioplasty or Medicines only ?

Well , Let’s Call the Third Umpire !

Many times, when I advise coronary angiography to a patient, one of the first questions posed by an anxious relative is: “After the angiogram will we have to be ready to undergo angioplasty immediately ?”

My usual answer is ‘NO’ if the patient is clinically stable and the disease not critical.

This answer is now vindicated by guidelines from various cardiology bodies as will be seen below. 

The field of cardiovascular medicine has seen great advances and at the same time burdened us with a wide variety of choices. On the one hand, the disease has become more and more complex with advanced age and associated conditions, with widely different expectations from patients (for example between a 91 year old and a 40 year old ) and widely different socio economic backgrounds, and on the other, an explosion of scientific information on newer and newer strategies of treatment.

Like the game of cricket, in some circumstances, the decision or choice is straightforward, for example, a patient with acute coronary syndrome (acute coronary problem-say, a heart attack) with an isolated single discrete narrowing of an artery, in whom angioplasty with stent implantation can be considered the treatment of choice with little or no disagreement, or a patient with significant angina, multiple coronary occlusions, and other severe complex disease in whom surgical revascularization is the treatment of choice.

Many patients, however, fit between these two extremes, and in this continuum, multiple considerations exist.

What method of treatment is best for such a patient ? A plethora of knowledge has accumulated about the relative merits of angioplasty versus surgical treatment versus “optimal medical therapy” alone, for such patients, and a potential danger exists of individual physician biases and ‘forcing’ one method of treatment.

That is the time, which is very often, that a third ‘umpire’ - A HEART TEAM is needed.

This multidisciplinary team, including an experienced cardiac surgeon, interventional cardiologist, and primary cardiologist/physician, working together with the present state of knowledge, as well as their individual experience can help to focus on specific patient considerations and fully inform the patient and family about the risks/benefits ratio of the various methods of treatment and help make choices.

By exploring the multiple options available and sharing them with patients and their families where applicable, more optimal shared decision making is achieved, along with a tailored recommendation for therapy for a more informed and engaged patient. The goal is that the patient and family be sufficiently educated about the alternatives available so that the best form of treatment can be selected rather than 'forcing' a method of treatment.

This team-based care –the ‘Heart Team Approach’ has now been strongly advocated by guidelines from various bodies such as  the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery as well as  American College of Cardiology and the American Heart Association.

Thus, whenever after a diagnostic angiogram, if the disease found is more complex than can be addressed easily in a straightforward manner or a potential exists for alternative methods of treatment such as angioplasty versus surgical treatment versus “optimal medical therapy” alone, the patient is taken off the table and the case discussed by the heart team followed by a discussion of the merits demerits of the various modalities of treatment with the patient and relatives.

 Of course, the above recommendation is mainly for stable patients whose condition may allow deferred decision making after the heart team meets and deliberates. For most acute, unstable or emergency patients the condition may not allow deferment of decision, which may have to be taken fast (within minutes) in the best interests of the patient. Thus in such patients ad-hoc angioplasty is the route usually recommended but rarely, emergency surgery.

Also, another point to remember is that both surgery and angioplasty do not exclude taking medicines. Modern cardiac medicines are the fundamental and integral part of all modalities of treatment, one of them being ONLY medicines.

While the age old adage ‘too many cooks spoil the broth’ does not apply here, ‘three heads are better than one’ applies very well – in Cricket and in Cardiology. 

                                                                                                                                - Dr Akshay Mehta

Flaxseed- good for BP:

Adding flaxseed to the diets of patients resulted in large drops in blood pressure (BP) of around 10 mm Hg systolic and 7 mm Hg diastolic after six months, according to the results of a double-blind, placebo-controlled study presented at the recent American Heart Association 2012 Scientific Sessions.

Out of 110 patients, 58 were given milled flaxseed (30 g/day) in the form of bagels, muffins, and buns and the other 52 were given placebo products made from wheat with a similar flavor, for one year.

At 6 monthes, there was important decrease in SBP and DBP using flaxseed compared with placebo.

Flaxseed may reduce circulating cholesterol and trans-fatty acid levels. Also it has different components, including alpha-linolenic acid, enterolignans, and fiber, and all have been shown to decrease BP. Additionally it has antiatherogenic, anti-inflammatory, and antiarrhythmic effects.

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“Complete” Health Checkups : Are they complete? Are they useful ?

“Complete” Health Checkups :  Are they complete? Are they useful ?

There is a proliferation and plethora of health check up schemes offered by hospitals and clinics.

Conceptually, the expectation is they are very useful for making early detection of diseases and preventing their progression. Glaring examples are high blood pressure and diabetes which have no symptoms and can be only detected when measured as a routine.

However, an analysis of pooled results of nine trials involving 11,940 deaths has revealed the opposite. This recent Cochrane review (ref below and which was in the news recently) by Danish researchers lead by Lasse Krogsbøll has claimed that, “"We think it's unlikely that health checks reduce mortality to a degree where it would be beneficial," because in the analysis it was found that it did not lead to any substantial reduction in the deaths for instance from cancer and heart disease.

The reason for such findings could be that the health checkups are being utilized by the "worried well" segment of population- people who are usually fit and take an interest in their own health while unfortunately those who are at high risk of serious illness shy away from these regular checkups. Or it might be that genuine health problems are spotted at other times - when patients present with symptoms, to the physician. Following which the physicians generally do aggressively manage them and hence the results of regular health checkup do not seem to affect the statistics on deaths. Or it's possible that those getting the checkups were already well cared for by their regular doctor

A downside of general health checks is the problem of false positive and false negative test results.

The former (a test result which is falsely abnormal) may lead to unnecessary further testing or over treatment which may be harmful and anxiety development among the people.

The latter (a test result which is falsely ‘normal’, but actually the person has disease which is missed) may give a false sense of assurance and complacency. An example is a “normal” cardiac stress test and patient developing heart attack a few days or weeks later.

The again, if tests are normal but lifestyle is unhealthy, it could be dangerous. For example, a heavy smoker may get all his test results normal and hence may continue smoking. Sometimes all tests are done except the one relevant for that person. Hence the Cochrane reviewers mention that “public healthcare initiatives that are systematically offering general health checks should be resisted.”. “ The results don't imply that prevention is worthless”, Krogsboll said, “just that offering checkups to the general population of adults doesn't seem to add benefits.”

On the reverse, besides the examples of hypertension and diabetes alluded to above, there are ample examples of early detection of cancer and other diseases which lead to early treatment and prevention of progression of disease. Also, by providing an opportunity to both patients and physicians to contemplate and discuss potential risks, the check ups could also provide a vehicle through which patient worries can be more thoroughly addressed and methods to adopt preventive measures including lifestyle changes promoted.

So what is the way forward ?

As in many things in life, I think the middle way is the best. It helps to be selective.

1. Do a general health check if your doctor suggests or your organization requires it or if there is a suspicion that there may be a problem or if there is strong family history of a disease.
2. Add some more tests which are more relevant to a person if not included in the plan
3. Certain tests like routine & regular measurement of BP, blood sugar and lipid profile should be universally adopted, should start from age of 30 and done periodically in view of the high prevalence of coronary disease in our country especially in the young. Screening for breast cancer and cervical cancer in women and occult blood in stools are other examples. Hence the results of the Cochrane review does not imply that doctors should stop clinically motivated testing and preventive activities.
4. Remember the limitations of the tests. They are neither complete (no battery of tests can detect ALL the possible future abnormalities) nor 100% accurate. Don’t rely too heavily on test results or rush for further testing. The test results should be discussed with an independent consultant not related to the check up plans so as to take into consideration false positives and negative possibilities and the likelihood of disease in the person and to decide on the necessity of further testing or treatment
5. The most important role of life style should not be over shadowed by “health check ups”. One should remember that the test results could be normal, yet a person may develop disease due to faulty lifestyle or due to not doing important tests relevant to that person (not included in the check up plan). So a so called “complete medical check up” is no substitute to a healthy lifestyle consisting of regular aerobic exercise, prudent diet and avoidance of smoking.
6. How frequently should undergo “health checks” ( for example yearly ? every 2 years? every 5 years?)

      This depends on the risk profile of the person and the results of first test.  Not everyone requires an annual medical check up. For example certain professions like pilots on whom many lives depend, require annual checks even though first check up is entirely normal.

So do you want to go for a general health check up ? Go ahead, but tread slowly, with eyes, ears and mind open.

Young hearts in India-Not so Young !

Young hearts in India –not so young !

 A few days ago, I was invited to release at a press conference, results of a study carried out over the last 4 years by the research team of Saffolalife, a not- for- profit organization and "Via Media"  along with Indian market research bureau. They collected data from about 1,200,000 people who responded to their site. When a person logs in to this site, he/she has to enter his/her own data about weight, height, recent cholesterol, BP and sugar values etc. From these values, as per the Framingham Risk Score and a logarithm, the person’s heart age is calculated. If this age of his/her heart is greater than his/her actual age, the person is said to be at risk for getting coronary heart disease in future.

 Using this information and analyzing it, they came to the conclusion that about 70% of men, in age groups 30 to 60 were having their heart ages greater than their actual ages, ie they were at higher than average risk of getting coronary heart disease. In case of females about 60% were at risk. The major factors increasing their risk were low levels of the “good” HDL cholesterol and increased Body Mass Index (BMI) –in other words- obesity. What was most alarming was that the younger lot was equally at risk as the older people, in fact in the age group 40-44, the risk is 80%. Most of the causation lies with our lifestyle of eating and lack of physical activity. All this got a good and prominent press coverage the next day in most of the city’s prominent newspapers.

 Although the study suffers from the disadvantage of a selected sample (only those who log in to the site) and that of self reporting, its strength lies in the large numbers involved. This strength will increase all the more with passage of years as the numbers increase. Another area of strength is the simplicity of its methodology. In addition, it conforms to our experience in clinical practice in that we do see many patients in the 30 to 50 age group coming with severe coronary artery disease.

 The very fact that someone has thought to do such a study on a pan India scale is commendable.

 Of course, some refinements can be brought about, such as addition of waist hip ratios for one. It is now known that obesity by itself is not that important a risk as abdominal obesity which can properly be quantified by the waist circumference and its relation to the hip circumference. (Normal waist to hip ratio is 0.9). There are many people who appear misleadingly lean but have a high or abnormal waist to hip ratio. The exact method to measure hip and waist circumference will have to be described. The other factors to add would be family history of premature heart disease ( heart disease below 55 in a male first relative or below 65 in a female first relative), hs CRP measurement, fasting triglycerides (TG) and non HDL cholesterol if TG are above 200 etc.

 The study highlights why preventive efforts are so important. In a country where the incidence of coronary heart disease is high and increasing, (2 to 4 times the western developed nations), where the young are disproportionately more affected than the western counterparts, where the disease is already severe when first diagnosed and above all, where most of the times, the medical expenses of treatment is not covered by third party reimbursements, prevention is so very important. Add to this the enigma of sudden coronary deaths where there is NO TIME available for treatment. And there is ample proof of the benefit of preventive measures . .Deaths due to heart disease in the west have reduced by more than 50% in last few decades and a major cause of this reduction is risk factor management (with life style changes and medications) besides the high tech treatment methods.

 Thus, prevention is the key to this epidemic of heart disease and it is estimated that more than 80% of heart disease is preventable.

 Studies such as this one are the first step in that direction.

 Dr Akshay Mehta