The Winter Blues

The weather is getting colder. The days are shorter. People leave for work in the dark and come home in the dark.  Winter is here and with it comes an increase in heart disease and heart related deaths.  There are many reasons why winter weather worsens heart problems. Heart patients are under more stress at the extremes of temperatures. Cold weather increases the workload on the heart.  For example, it is harder to walk in 20 degrees with a biting wind than on a calm 70-degree day.  The cold may cause the heart arteries to spasm, reducing the blood flow to the heart resulting in chest pain or a heart attack. Wintertime brings an increase in flu and pneumonia. These respiratory infections put a significant strain on the heart and are the reason why the flu vaccine is recommended for all heart patients.  Another factor may be the colorfully named winter blues, or Seasonal Affective Disorder.

Seasonal affective disorder (SAD) is a type of depression triggered by the shorter days in winter. The depression eases during the summer months.  It is felt that shorter amounts of sunlight cause a chemical change in the brain. Melatonin, a hormone which is made when it is dark to aid in sleep, may also be involved. In the winter, people continue to make melatonin later in the day, as dawn comes later.  The melatonin can cause daytime sleepiness and fatigue.  In addition to a sleepy feeling and fatigue, SAD causes loss of interest in activities formerly enjoyed, social withdrawal, irritability, anxiety, decreased ability to focus and physical problems such as chest pain. SAD is different from major depression in that it causes people to eat more and gain weight. Patients with major depression have difficulty sleeping, a decreased appetite and weight loss.  SAD is treated with light therapy, either getting more sunlight or sitting in front of a light box.  Psychotherapy and antidepressants are also used.  In addition, patients with SAD should make an effort to be more social, exercise regularly, and avoid alcohol as it can make depression worse.

The relationship between depression and heart disease has mostly been studied in patients with major depression, but it likely applies to SAD patients as well. It has long been known that depression can lead to heart disease. Depression can decrease immunity and promote inflammation, conditions that can lead to plaque formation in heart arteries. In addition, depression increases certain hormones (catecholamines) which raise the blood pressure and heart rate, leading to heart disease. Lastly, depression is associated with poor lifestyle behaviors such as being sedentary, eating the wrong foods, smoking or alcohol use and not taking prescribed medications.  On the other hand, patients with heart disease are prone to develop depression.  After a heart attack, patients who become depressed are three times more likely to die than patients who do not have depression.  After open-heart surgery depression is quite common and is associated with worse outcomes.

The winter blues can manifest not only psychologically, but also physically.  The other winter blue happens when extremities turn blue in cold weather.  This is called Raynaud’s Phenomenon.  Raynaud’s typically affects the fingers, toes and the tips of the nose and ears.  It occurs when a trigger (cold or emotional stress) causes extreme spasm of the blood vessels to the extremity.  The blood flow is cut off causing the affected part to first turn white, then blue.  Often there is pain associated with the color changes. After about 15 to 20 minutes, the spasm subsides, the extremity turns bright red and there is a burning sensation as the blood flow returns.  Raynaud’s has two forms, a primary one where the cause is unknown and a secondary form which is due to another disease (for example lupus or scleroderma). The primary form occurs in about 4% of the population, is seen more with women than men and usually starts at a young age (15-30 years old).  The main treatment is avoidance of the cold and warming.  Local warming is with gloves or thick socks; systemic warming involves keeping the whole body warm with layers of clothing. In extreme cases, medications can be prescribed, such as calcium channel blockers or vasodilators.

Whether your winter blues are physical or emotional, one should make an effort to follow lifestyle behaviors that can help either condition. This includes regular exercise, as exercise is known to reduce depression.  In addition, exercise causes the small arteries in the hands and feet to dilate, increasing the blood flow to those areas. Smoking should be avoided as it worsens depression and causes the small arteries to spasm. Staying warm by snuggling under a blanket in front of a roaring fire is not a bad option for either of the winter blues.

Would a Trip to Mars be Bad for the Heart?

Mars, the closest planet to the Earth, has always fascinated humans. From H.G Wells 1898 novel The War of the Worlds, to Orson Welles’ infamous 1938 radio broadcast about a Martian invasion, to Gustav Holst’s 1914 classical music piece Mars, the Bringer of War, to the 2015 Academy Award nominated film, The Martian mankind has long dreamed about Mars. Now NASA and private companies such as SpaceX, are beginning to plan trips to our nearest neighbor.  Mars is 140 million miles from the Earth and the trip would take about seven months. A typical mission would likely be two and a half years.  For comparison, the moon is 239,000 miles away and it takes about three days to reach it. There will be many obstacles and many risks to be overcome on a Mars mission. One of the issues is the health risk to the astronauts on a prolonged interplanetary journey.  How would a trip to Mars affect an astronaut’s heart? What lessons does that have for those here on Earth?

The biggest health hazard of a prolonged, multiyear space trip is radiation.  In space, the major cause of damaging radiation is high-energy galactic rays. These rays come from deep in space and are caused by supernova explosions and other phenomena. Radiation can penetrate the skin and travel through the body causing damage to DNA and to the mechanisms used to repair cells. These effects can lead to cancer.  Astronauts endure higher exposure to radiation in space than they do on Earth. On the space station, astronauts received ten times the radiation they would have been exposed to if they stayed on the ground.  On a two-year Mars mission, it is estimated they may have 100 times the exposure. Unfortunately, engineers still haven’t found a way to protect astronauts from galactic rays. On Earth, humans are protected from galactic rays by the Earth’s magnetic field and by the atmosphere, which deflects the high-energy radiation.  Under the Earth’s protective umbrella, people are exposed to a variety of sources of radiation. These include ultraviolet radiation from the sun (which is lower in energy than the deep galactic rays), radon, occupational exposure, small amounts of radiation from TVs and cell phones and radiation from medical procedures (the second most common source).

Excess radiation exposure, whether on Earth or in space, increases the risk for cancer, it can damage the nervous system and produce cataracts.  In addition, radiation can cause heart disease and can affect all three layers of the heart.  The effects of radiation on the heart have been studied in patients who have received high dose radiation therapy to the left side of the chest for various cancers (such as Hodgkin’s Lymphoma and breast cancer).  Many years after their cancer is cured, these patients manifest heart disease. When the outer protective layer of the heart, the pericardium, is damaged by radiation, it can become inflamed causing chest pain (pericarditis). Long-term radiation to the pericardium causes it to stiffen and compress the beating heart. Radiation can affect the inner layer of the heart producing damage to the heart valves. When damaged by radiation, the valves may not open as widely or may leak severely. With significant valve damage, open-heart surgery and valve replacement may be needed.  Lastly, radiation can affect the heart arteries, causing them narrow, reducing the blood flow and resulting in chest pain. Unlike atherosclerosis, which causes a discrete blockage in a heart artery, radiation damages long segments of the artery, making it more difficult to place stents or relieve chest pain with bypass surgery. Do galactic rays cause heart disease? The answer is unknown, but there is a clue when looking at astronauts’ health over time.  As a rule, astronauts are healthier than the general population as they are more fit and have access to high quality healthcare throughout their lives. However, the Apollo astronauts, the only humans who have been beyond the Earth’s protective magnetic field, have a higher rate of dying from heart disease compared to astronauts who have never flown in space.

Since most people won’t have to worry about galactic rays and one of the major causes of radiation on Earth is medical testing, what can be done to reduce a patient’s lifetime exposure to radiation?  Recently there has been a big push in the medical community to educate doctors about radiation risk. Campaigns touting the ALARA principle (As Low As Reasonably Achievable) and Appropriate Use criteria encourage doctors to choose wisely when ordering tests.   Patients should discuss the risks and benefits of radiologic procedures (for example, chest X Rays, CT scans) with their doctor and ask about alternatives without radiation risk such as ultrasound or MRI. Lastly, it might be prudent to forgo that trip to Mars.

Is Your Arthritis Medication Hurting your Heart?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are common medications, available over the counter as well as by prescription, used to relieve pain, reduce fever and decrease inflammation caused by arthritis, low back problems and soft tissue injury. There are many NSAIDs on the market including ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve), indomethacin (Indocin), diclofenac (Voltaren) and celecoxib (Celebrex).  NSAIDs have been around since the 1960’s and may be the most widely prescribed class of medications in the world. Along with their beneficial effects, NSAIDs have significant side effects including gastrointestinal bleeding, kidney problems and several adverse cardiac effects. What are the cardiac side effects and how important are they?

Can NSAIDs increase the risk for a heart attack? Heart attacks occur when a plaque in a heart artery ruptures, a blood clot is formed over the rupture and blood flow to the heart muscle is stopped. Plaque in a heart artery is comprised of cholesterol and inflammation is felt to play an important role in plaque build up. In fact, in addition to their usual properties, aspirin and statins are felt to lower the risk for a heart attack due to their anti-inflammatory effects.  Do the anti-inflammatory effects of NSAIDs provide the same protection against heart attacks? Unfortunately the answer is no.  Prior to 2004, NSAIDs were felt to be safe for heart patients. In 2004, the NSAID rofecoxib (Vioxx) was removed from the market due to its increased risk for heart attack and stroke, especially with prolonged use and at high doses.  After the withdrawal of Vioxx, a large study testing the heart risks of many NSAIDs was performed and recently concluded. The study found that all NSAIDs (including Naprosyn, which was thought to have acceptable cardiac safety) increased the risk for heart attack. The risk starts in the first week, is greatest in the first month of usage and is increased at high doses.  

Can NSAIDs increase blood pressure and cause swelling? If a patient goes to the doctor with new onset of swelling in the legs or with an increase in blood pressure, one of the first questions asked is whether the patient is taking an NSAID. NSAIDs mechanism of action is to reduce certain factors that result in inflammation. Unfortunately, those same factors have a good effect on kidney function. Reducing these factors leads to a reduction in the blood flow to the kidneys.  If the blood flow to the kidneys decreases, the kidneys feel the body is dehydrated and respond by retaining more sodium (salt) and water.  This leads to increased swelling and an increase in blood pressure. In addition, NSAIDs can block the effect of certain high blood pressure medications (ACE or ARBs), leading to hormonal activation and further retention of salt and water. Due to these effects, all NSAIDs have warnings on their labels stating that they may increase blood pressure or cause swelling.

Can NSAIDs cause congestive heart failure (CHF)? The link between NSAIDs and CHF has been known for more than 20 years. NSAIDs can cause CHF in several ways. NSAIDs can increase the blood pressure, increasing the workload of the heart. If there is a weakened heart for any reason, that extra workload can tip the heart into CHF.  In addition, if more salt and water is retained in a patient with a weak heart, the excess fluid accumulates in the lungs and CHF occurs.  In fact, the use of any NSAID was associated with a 19% increase in admission to the hospital for CHF.

All of this data does not imply that NSAIDs are bad drugs or drugs that should be avoided. On the other hand, NSAIDS are not harmless over the counter medications that can be taken without risk. Patients who are at a high risk for a heart attack, patients with CHF or high blood pressure perhaps should avoid NSAIDs or use them at the lowest possible dose and for a short period of time. Low risk patients should be able to take NSAIDs with appropriate caution.

Medicor Cardiology Donates AED to Flemington-Raritan Baseball Complex

Medicor Cardiology, part of Atlantic Medical Group with offices in Bridgewater and Hillsborough, has donated an Automatic External Defibrillator (AED) to the Flemington-Raritan Baseball Association for use at their baseball complex.

An AED is used to detect an irregular heart rhythm from the lower chambers of the heart, called ventricular fibrillation, the rhythm which causes Sudden Cardiac Arrest.  If this arrhythmia is found, the AED then provides a shock to the heart, a life saving treatment which aborts the arrhythmia.

Sudden cardiac arrest occurs in 450,000 people in the United States each year and is usually fatal.  It is most commonly caused by a heart attack, but it can occur if a projectile, such as a baseball, strikes the chest at just the right time in the heart cycle. With sudden cardiac arrest, the arrhythmia prevents the lower chambers of the heart, the ventricles, from pumping blood to the body. If no blood is being pumped to the brain, the victim passes out and collapses. If a patient suffers sudden cardiac arrest, the sooner the patient is shocked, the greater the chance of surviving. Fifty percent of victims of sudden cardiac arrest survive if shocked within two to three minutes, but only ten percent will live if the shock is more than ten minutes from the time of collapse.  Timing is everything and having an AED as close as possible to potential victims can be life saving.

On October 4 2017, Medicor Cardiology presented the AED to the Flemington-Raritan Baseball Association solidifying Medicor’s long-term commitment to the heart health of the Hunterdon and Somerset County communities.  Prior AED donations by Medicor include Bridgewater Baseball’s Prince Rogers Complex, Somerville Recreation’s Carol Pager Sports Complex and the Hillsborough Baseball League fields in Mountain View Park. The Flemington AED will be kept outside of the snack shack at the baseball complex.

Is Oxygen Really Neccessary?

A 55-year-old man presents to the Emergency Room with crushing chest pain. He is diagnosed with an acute heart attack.  The nurse, following the American Heart Association Advanced Cardiovascular Life Support guidelines and out of habit, puts the patient on oxygen.  A football player comes off the field after a particularly grueling set of plays. He sits on the bench and puts on an oxygen mask. A patient with stable chest pain asks his doctor for oxygen to be used at home. Would oxygen be helpful in any of these scenarios? When is oxygen therapy useful and necessary?

Oxygen was discovered by Joseph Priestly in 1774 and is the second most abundant element in the air (after nitrogen).  Oxygen takes up 21% of the Earth’s atmosphere.  Oxygen is necessary for all of the functions of the body. As we breathe, the oxygen in the air is brought to tiny sacs in the lungs. In these lung sacs, oxygen is absorbed by the blood stream. In the blood stream, oxygen binds to the red blood cells. The oxygen, attached to red blood cells, travels through the lungs to the heart where it is pumped to the rest of the body. Oxygen is then extracted by the muscles and organs of the body to aid in metabolism.

Since oxygen is so essential to the body, how can we be sure we are getting enough? In medicine, the most common way to measure oxygen is with a pulse oximeter, an infrared device that provides the oxygen saturation in the blood. An oxygen saturation between 90% and 100% is normal while a saturation below 90% is considered low. Low oxygen saturation, or hypoxemia, causes shortness of breath, an increased heart rate and it can be very dangerous. To treat hypoxemia, oxygen therapy is delivered in a variety of ways. A nasal cannula has two prongs, which are placed in the nose, and gives extra oxygen. A facemask can provide higher dosages of oxygen, with concentrations up to 100% (ie, the gas in the mask is 100% oxygen versus the 21% oxygen present in the air).  Lastly, in extreme cases of hypoxemia and breathing distress, a tube is placed in the throat and the patient is placed on a respirator to help aid in process of breathing.

Oxygen has been a key treatment in cardiology for more than 100 years. In 1900, it was shown that oxygen could relieve chest pain, a finding that led to the routine use of oxygen in all heart patients. Over the years it has been found that oxygen therapy in patients with hypoxemia is undeniable but in patients with normal oxygen saturation the benefit is not as clear. In patients who are hypoxemic and have an acute heart attack or who are in congestive heart failure (CHF), with fluid filling their lungs, oxygen can be life saving. In cases with hypoxemia, oxygen therapy increases the oxygen saturation in the blood, decreases the resistance to blood flow in the lungs and eases the work of the heart by lowering the heart rate and blood pressure, thus reversing the body’s adaptation to a low saturation.

While the body has mechanisms to counter act low levels of oxygen in the blood, high levels of oxygen saturation is a man-made phenomenon caused by oxygen therapy. The body has no mechanism to handle this situation and in fact oxygen therapy can be damaging. There are two possible reasons for this. First, the red blood cells are nearly saturated with oxygen. Adding extra oxygen doesn’t increase the amount of oxygen delivered to the cells of the body. Secondly, excess oxygen can cause spasm or narrowing of the heart arteries, reducing blood flow to the heart. In CHF patients with normal oxygen saturation, high flow supplemental oxygen caused a decrease in the heart’s pumping capacity and increased the pressure in the lungs, causing worse outcomes. In heart attack patients with normal oxygen saturation, excess oxygen therapy can cause a reduction in flow to the heart arteries. Patients with oxygen therapy had larger heart attacks than those not given extra oxygen.  In a recent study of over 6000 patients with a heart attack and normal oxygen saturation, there was no change in the rate of death or recurrent heart attack with oxygen therapy.

Can oxygen be beneficial for the athlete? Can it be considered a performance-enhancing drug?  When supplemental oxygen was given to soccer players and other athletes, there was no demonstrated improvement in performance and no reduction in recovery time. On the athletic field, it is felt that oxygen may provide a placebo effect (an expectation of doing something good) without a real physiologic benefit. 

Oxygen clearly has a role and is life saving for those heart patients who have low oxygen saturation. For heart patients with normal oxygen levels, as well as football players and other athletes, supplemental oxygen likely has no benefit and can be harmful. Based on these findings, none of the patients in the scenarios would be candidates for supplemental oxygen.