Does the Agony of Defeat include Having a Heart Attack?

Can a fan be so caught up in World Cup soccer that they have a heart attack? Can watching your football team in a tough, hard-fought, closely contested Super Bowl lead to sudden cardiac arrest? There are well known triggers to major cardiac events, but are sporting events one of them?

Many studies have shown that there is an increased risk for a cardiac event immediately after a trigger or stressor occurs. Triggers can be physical, chemical, psychosocial or environmental. Stressors typically will increase the heart rate and blood pressure, increasing the oxygen demand of the heart and leading to a heart attack. Stressors can cause the heart arteries to spasm (the artery closes down, reducing blood flow to the heart). A trigger will result in the release of several stress hormones including catecholamines (adrenaline) and cortisol, in addition to inflammatory proteins and procoagulants (substances which increase blood clotting in a heart artery). In addition, stress reactions destabilize the electrical activity of the heart, which can lead to deadly irregular rhythms and sudden cardiac arrest.

One trigger is physical activity. In general physical activity protects against heart disease. However in patients who are sedentary, a sudden burst of physical activity can lead to acute cardiac events.  For example, consider someone who doesn’t exercise and who has to suddenly run for a bus on a hot humid day or who is out shoveling snow on a cold winter day. That person is at a higher risk for a heart attack than someone who exercises regularly. In fact studies have shown that the risk for a heart attack is 6 times higher in patients who exercise less than once per week, compared to patients who exercise 5 or more times per week.  Many studies have documented that specific physical activities, such as skiing, snow shoveling and sexual activity, can trigger acute heart events.

Caffeine, alcohol, cocaine, and cigarette smoke are all chemical triggers which can cause an acute heart attack, sudden cardiac arrest and stroke.  Caffeine and alcohol can cause these events if consumed in excess, or in greater than usual quantities, for example binge drinking. Patients who don’t regularly use these beverages are more susceptible than those whose consume moderate amounts. Cocaine and cigarette smoke may cause spasm of the heart arteries, cutting off oxygen to the heart muscle leading to heart attacks or malignant irregular heart rhythms. As opposed to caffeine and alcohol, even a single cigarette or snort of cocaine can lead to an acute cardiac event.

Environmental triggers include pollution and changes in temperature.  Many studies have shown an increased risk for acute cardiac events in areas of high pollution.  Heart patients are very susceptible to changes in temperature.  Usually the extremes of temperature, very cold or very hot, are a stressor for heart patients and can trigger an event, especially if combined with physical activity.

Psychosocial triggers include anger, depression, anxiety, work stress, natural disasters, war, and terrorist attacks.  Fits of anger result in the same bad physiological responses as a physical stressor. Patients who were angry, enraged, or furious face a two to nine times higher risk for a heart attack within hours of the episode. Acute episodes of anxiety or depression may trigger events as well. In patients who experienced an episode of severe emotional upset, the risk for a heart attack was 2.5 times higher within 24 hours. Work stress is well known to cause heart attacks.  For example, there is a six-fold increase in the risk for a heart attack within 24 hours of having a high-pressure deadline at work.

Natural disasters are certainly triggers which can precipitate an acute cardiac event. This was first described in a study that showed an excess of cardiac deaths in the days surrounding a major earthquake which struck Athens Greece in 1981.  There were no excess deaths from cancer or from other causes in the days after the earthquake.  These findings were confirmed in a study examining deaths after the Northridge earthquake, which struck the Los Angeles area in January 1994.  There was an excess of cardiac deaths in the six days following the earthquake with the death rate returning to baseline levels after one week. Most of the victims died or had chest pain within one hour of the initial tremor. Japanese researchers looked at heart attacks after the major earthquake and tsunami which struck in March 2011. They found that heart attacks increased from 9 per week before the disaster to 22 in the week following the catastrophe. The heart attack rate slowly declined to the baseline rate over the subsequent 6 weeks. Similar to earthquakes or tsunamis, a war or terrorist attack exposes an entire population to a stressful environment. Studies done after the September 11 2011 terrorist attack on the World Trade Center showed an increase in heart attacks and arrhythmias. In addition, it was shown that there was an increase in cardiac events far from New York City. All of these studies suggest that psychosocial stress, rather than the living conditions at the site of the disaster, precipitated these cardiac events in those who are vulnerable.  

Can watching a sporting match trigger an acute cardiac event? The two arenas where this issue has been studied, World Cup soccer and the Super Bowl, involve football. A study was published in the New England Journal of Medicine comparing heart attacks among German fans during the 2006 World Cup tournament with cardiac emergencies in Germany at other times the same year.

The study showed that when the German team played, acute cardiac events were 2.6 times more likely to occur (3.2 times more likely in men, 1.8 times more likely in women). Interestingly, 47% of the victims had underlying heart disease and the risk rose during the knockout stage (when the stakes and the pressure are higher). Similarly, the risk for hospital admission for heart attack increased 25% in England on the day in 1998 that England lost to Argentina on a penalty shoot out. No excess admissions occurred for other diagnoses or on the days of England's other matches.

Is the Super Bowl a trigger for acute cardiac events? To answer this question, researchers examined death certificates in Los Angeles County for 2 weeks after the Rams Super Bowl loss in 1980. They found that heart related deaths increased 15% in men and 27% in women during that period.  A more recent study showed that cardiac deaths increased by 20% in Massachusetts following the Patriots loss to the Giants in the 2008 Super Bowl, as dramatic and intense a game as there has been in recent memory.

It seems that the psychosocial stress of watching a high stakes match can trigger an acute cardiac event. In addition, watching sporting matches is associated with adverse behaviors, such as cigarette smoking and binge drinking, which are triggers unto themselves. Clearly fans can get excited and succumb while watching their favorite sporting event, especially if they are male, have underlying heart disease, engaging in risky behavior and if it is a high-stress, pressure-packed event. So sit back and enjoy the game, but don't smoke, don't let the emotions of the game overwhelm you and take it easy on the beer.

How to Live to One Hundred

“Tell me doctor, how do I live to be one hundred years old?” This question was posed to me in a kitchen in a small village in the mountains of southern Greece. The year was 1988 and I was visiting Greece for the first time. I traveled with my cousin to our ancestral home, the village of Mavromati, where two of my grandparents and several aunts and uncles were born. The village was located on the side of a mountain, surrounded by olive groves and sheep pastures. We met my grandmother’s sister, my great aunt, who showed us the homes where my grandparents were born. We then hiked about 1000 feet down the side of the mountain to an archeological site where an ancient city was being unearthed.  My great aunt, who I guessed was about 80 years old, was quite spry, likely from the daily routine of walking with the sheep up and down the mountain. As we went back up the mountain to the village, I huffed and puffed as I tried to keep up with her. Back in her kitchen, we enjoyed a splendid meal of local fruits and vegetables, home made yogurt and fresh mountain water, obtained from the spring in the center of village a few feet from where we were sitting. She described her life in the village, surrounded by many family members and friends.  When she found out that I was a doctor, she asked me her famous question, “Tell me doctor, how do I live to be one hundred years old?” I looked around, noted her lifestyle, and replied to her, “Just keep doing what you are doing”

I returned to Greece in 2009 with my wife and our three children and of course our trip included a pilgrimage to the village. The village had changed, but the mountain spring in the village center was still providing water and I was able to find my great aunt’s house.  The house looked abandoned. In the village center the proprietor of  the coffee house told me that my great aunt had passed away a few months earlier, at the age of 98! I guess she followed my advice.

What do people who live a long life, people from villages in Greece, from Japan, Switzerland and San Marino, have in common? Beyond having good genetics, there seem to be several recurring themes when the lives of nonagenarians and centenarians are researched. First, there is diet and exercise. Jack LaLanne, who passed away at age 96, said, “Exercise is king. Nutrition is queen. Put them together and you have a kingdom”.  Following a Mediterranean diet, which is rich in olive oil, fruits and vegetables, as well as fish, has been shown to decrease heart attacks, improve overall heart health and increase longevity. People who follow a Mediterranean diet can live up to 15 years longer compared to those who don’t. Diets high in tree nuts, like walnuts and almonds, can increase life span. Patients who ate three servings of nuts per week were less likely to have heart disease or cancer.   Fiber, especially fiber from grains, is important as well. Patients who met their daily recommended doses of fiber, 25 grams for women and 38 grams for men, had a lower risk of dying over a nine year period.  Diets high in omega-3 fatty acids, found in fish, can increase longevity by 2.2 years. Moderate alcohol consumption, such as one glass of red wine per day, can increase longevity as well. On the other hand, what foods should we avoid? Diets high in processed meats increase the risk for cancer and heart disease. Processed sugars and sugary drinks should be avoided due to the risk for diabetes and obesity. Lastly, how we eat seems to make a difference in how long we live. Cultures where emphasis is placed on preparing and cooking meals and where sitting and savoring the food rather than rushing through the meal as if it is another task are cultures with some of the best longevity data. For example, think French cuisine and the whole French dining experience.

Exercise is clearly another factor in longevity.  It has been shown that Olympic medalists and elite cyclists live longer. A recent study showed that Tour de France winners outlived their appropriately matched French counterparts. However, you don’t have to be a world-class athlete to live a long life. Moderate walking every day will increase lifespan by one and a half years while more vigorous walking will increase it by three years. A daily regimen of walking reduces the risk for heart attack, stroke, atrial fibrillation, colon cancer, hypertension, diabetes, depression, obesity and Alzheimer’s disease. Walking lowers total cholesterol levels, raises good cholesterol levels (HDL), maintains healthy bones and lowers stress levels. On the other hand, being sedentary is detrimental to health. For example, every hour of TV watching after the age of 25 can decrease life span by 22 minutes.

Another factor in living a long life includes getting the proper amount of sleep.  People who get less than six hours per night or more than nine hours tend to die younger than people who get seven to eight hours of sleep.  Just as important as the amount of sleep is the quality of sleep. Patients with obstructive sleep apnea are at increased risk for high blood pressure and heart disease. In addition, waking up naturally, ie waking up when one has had enough sleep and not with an alarm, improves the quality of sleep and adds to longevity.

Stress, or rather how a person perceives stress, is a factor in living a long life. Clearly a less stressful life is optimal, but resilience- the ability to cope with stress rather than being beaten down by stress, has been shown to improve longevity. Social support is a major factor as well in reducing stress and in improving longevity.  Having supportive friends and family can make life easier by providing emotional support, providing help when needed and giving a purpose to life.  When analyzed, people with adequate social relationships, including friends, family and community involvement, tended to live nearly four years longer than those without support. Often, the trifecta of socializing, food and exercise are bound together in cultures with longevity. Entire towns will be out walking before or after the evening meal and food is enjoyed over several hours, both being shared with others.

Lastly, people who marry, who have families, who have a pet, who laugh at least once per day, who are well educated, who are optimistic, who are generally “happy people” tend to live longer than those who do not possess these qualities.

It is easy to see how many of these factors for a long life are incorporated into life in a in a small, tightly knit community like my grandparent’s village, but these factors occur in many other places in Europe and throughout the world. So how does one live to one hundred years in the modern, western world? It may be impossible to incorporate all of these factors into our current life style, but with some effort, many of the ideals can be achieved. Alternatively, find yourself a nice Greek island.

            

New Advances in Atrial Fibrillation

Atrial fibrillation is a rapid, irregular heart rhythm in the upper chambers of the heart (the atria).  Instead of having a regular, coordinated beat, the atria are rapid and disorganized. When the atria are not beating in a coordinated fashion, the blood in these chambers does not drain effectively into the lower chambers of the heart (the ventricles). When blood is not draining well, it sits in the atria and can form a blood clot. A clot, or a small part of a clot, can break loose, go to the brain and cause a stroke. 

Atrial fibrillation is the most common heart rhythm disturbance with about 5.6 million diagnosed cases in the United States.  If left untreated, atrial fibrillation leads to stroke in 5 out of 100 people per year. Atrial fibrillation is treated with medications such as beta blockers, calcium channel blockers or digoxin to control the rapid heart rate. If doctors want to return a patient to a normal, regular rhythm then antiarrhythmic agents are used, often with cardioversion (shocking the heart back to normal rhythm).  To prevent blood clots and strokes, Coumadin (warfarin) has been prescribed for many decades. Coumadin will decrease the risk for stroke to less than 1 in 100 patients per year. Coumadin however is difficult to take, requiring frequent blood drawing to ensure that the blood is not “too thin” (leading to bleeding) or “too thick” (leading to stroke). In addition, eating green leafy foods will interfere with the level of blood thinning provided by Coumadin (green leafy foods have Vitamin K which reverses the effect of Coumadin). Many common medications interfere with Coumadin’s effect as well. Lastly, there is a significant risk for major bleeding on Coumadin, especially bleeding in the brain.

One recent break through in the management of atrial fibrillation came with the introduction of novel oral anticoagulants (NOACs).  These agents include Dabigatran (Pradaxa), Rivaroxaban (Xarelto) and Apixaban (Eliquis).  The NOACs are easier to take than Coumadin since there are no dietary restrictions. Their blood thinning effect is consistent, so blood drawing to test levels is not needed. In addition, they have been shown to reduce the risk of stroke to a greater degree than Coumadin and they are generally safer with lower risk for major bleeding and bleeding into the brain.  The major down side to the NOACs is that, to date, there is no antidote which can reverse the effect of these medications if a patient comes to the hospital with bleeding (there is an antidote for Coumadin).  Until a reversing agent becomes available, patents with bleeding on a NOAC are supported with blood transfusions, surgery and time (letting the medication wash out of the system).

Another recent innovation in the treatment of atrial fibrillation is catheter ablation. It is felt that atrial fibrillation is caused when tiny electrical wavelets are conducted from the pulmonary veins to the atria (pulmonary veins are vessels that carry oxygenated blood from the lungs to the heart).  Once in the atria, these wavelets perpetuate and cause the rapid chaotic rhythm.  Catheter ablation entails threading an electrical probe from the leg artery into the heart. The catheter is positioned at the inlet of the pulmonary veins into the atria and small areas of the heart tissue are burned, effectively causing a “circuit breaker”, the burned tissue stops the wavelets from reaching the atria. Catheter ablation has been successful in 84% of patients, allowing them to stop many of the medications, including blood thinners, they were taking to control atrial fibrillation.  Catheter ablation is generally recommended for symptomatic atrial fibrillation patients, especially if they have failed one or more antiarrhythmic agents.

Recently an association has been made between atrial fibrillation and obstructive sleep apnea.  Sleep apnea is a condition where patients stop breathing during the sleep cycle.  When they stop breathing the blood oxygen level decreases. When the oxygen level is low, patients are then aroused and gasp for breath. This cycle continues throughout the night. With frequent arousals, patients can’t enter the deepest phase of sleep, so the body does not get its proper rest. When the body can’t rest, it is perpetually aroused, there are excess catecholamines (adrenaline) and that may predispose to atrial fibrillation. When sleep apnea is successfully treated with a CPAP mask (to keep the airway open, stopping the drop in blood oxygen) episodes of atrial fibrillation are reduced.

It is becoming more apparent that atrial fibrillation is a disease related to life style and systemic disease. It has been known for years that atrial fibrillation can occur with binge drinking of alcohol (the so-called “holiday heart syndrome”).  Reducing alcohol intake can reduce episodes of atrial fibrillation. More recently, it has been shown that obesity is related to atrial fibrillation. Obesity can lead to diabetes, hypertension and sleep apnea, all factors in causing atrial fibrillation. Now, for the first time, it has been shown that obese patients who lost 10 per cent of their body weight achieved freedom from atrial fibrillation without the use of any medication or ablation. The more weight that was lost, the greater the freedom from atrial fibrillation.

Atrial fibrillation used to be thought of as a disease. Now we are beginning to see that the atria are a window on overall health and that atrial fibrillation is an exposure to an excess. Medications and procedures for atrial fibrillation can help manage the acute episode, but then the real work begins, as patients then must address life style issues such as alcohol intake and treating obesity and sleep apnea. Despite the new advances in pharmacology and surgery to treat atrial fibrillation, the future cure of atrial fibrillation will more likely come from identifying the life style causes and treating these causes.

The Stethoscope

The stethoscope is a device that doctors can use to listen to the internal sounds of a patient’s body. It was invented in 1816 by Rene Laennec in France and the first American stethoscope was patented in 1882 by William Ford. The basic structure of the stethoscope hasn’t changed much since its original invention. The head of the stethoscope has a diaphragm, which transmits sound when it is applied to a patient’s skin. From the head of the stethoscope there is a plastic tube, which conducts the sound. The doctor listens to the sound through two earpieces.  

Before advanced medical imaging, before modern medications and advances in surgery, the physical examination and the stethoscope were the only ways for doctors to diagnose and follow heart disease. A patient’s pulse was examined and characterized. A doctor would auscultate the heart and analyze each sound, click and heart murmur. Each murmur was further characterized by putting a patient through maneuvers such as squatting, deep breathing, standing and leg raising. This helped determine the cause of the heart murmur. These physical examination techniques are still taught in medical school today.  Since there wasn’t any other way to diagnose a patient and only a few therapeutic options to discuss, the doctor spent quite a lot of time doing the physical examination.

The stethoscope of today is quite similar to the original models. The acoustics have improved, but it remains an analog device. Electronic stethoscopes have been developed which improve the acoustics, and give the ability to amplify, record, and download the heart sounds to a computer.  Most doctors still carry the old analog device, but the newer stethoscopes as well as hand held ultrasound devices (which give both acoustic and visual images of the heart) are being used more and more. Despite the improvements in technology, it has been shown that doctors’ ability to diagnose heart murmurs by physical examination is getting worse over time. Younger doctors and medical students cannot identify murmurs as well as older physicians. There are several reasons for this. Despite the fact that physical examination techniques are still taught and tested in medical school and in training, there is far less emphasis on developing these skills. In addition, in the typical patient encounter, there is much less time to do as extensive an evaluation as in the past. Lastly, with medical imaging such as echocardiography so readily available, there is less reliance on the stethoscope since an ultrasound of the heart can give a better, more accurate diagnosis. In fact, in some medical circles, the physical examination is felt to be a dinosaur and worthless in the diagnosis and treatment of the modern patient.

I still carry and use an analog stethoscope. It is around my neck from the time I leave the house until I return home, often more than 12 hours per day. On days off and on vacation, I feel naked without my stethoscope. My stethoscope requires some maintenance (I clean and disinfect it regularly), but it is always available and ready to use. It is never down due to a power outage or because of a hardware failure. I never have to upgrade its software.   I listen to every patient I see with my stethoscope. I can tell if a patient’s lungs are filling with fluid or if there is a new or changing heart murmur. I can tell if the heart rhythm is regular or not. Most importantly, it brings me close to the patient and gives me a physical connection to them. There is still great value in that.

Exercise as Medicine

Diet and exercise have long been touted as a way to reverse heart disease. Can exercise be as good as medications for heart disease?

Everyone understands medications. A pill is prescribed in a fixed dose and taken at a specified time.  How can exercise be prescribed? How can we “dose” exercise? One way to “dose” exercise is by measuring the intensity of exercise using the metabolic equivalent, or MET, level. The MET is an estimate of the amount of oxygen used by the body during physical activity. One MET is the energy the body uses while sitting quietly at rest. The harder you work, the higher the MET. An activity that burns 3 to 6 METs is considered moderate, while one that burns more than 6 METs is vigorous. Walking is great exercise. For example, walking on level ground at 2.5 mph requires 3 METs, backpacking is 7 METs and climbing hills with a heavy pack uses 9 METs. Tables are available that outline the METs for various activities.

A person who wants to start an exercise program should be given an exercise prescription by their doctor. This prescription should have the frequency of exercise (typically 3-5 times per week), the intensity (usually moderate or 6 METs), the time per session (20-30 minutes), the target heart rate and the type of exercise. The target heart rate can be easily calculated by the formula: (220-age) x 0.85.

What type of exercise is best? The answer is the one you will actually do. If you like an exercise, then you will be more likely to follow through with it. One does not need to spend lots of money on gym memberships to gain the benefit of exercise. Walking is an excellent exercise which is easy to do, requires no extra equipment, is generally safe to do, is easy on the joints and has the lowest drop out rate.

Once a person has their exercise prescription and begins their exercise program, what kind of health benefits can they expect?  A daily regimen of walking reduces the risk for heart attack, stroke, atrial fibrillation, colon cancer, hypertension, diabetes, depression, obesity and Alzheimer’s disease. Walking lowers total cholesterol levels, raises good cholesterol levels (HDL), maintains healthy bones and lowers stress levels. Walking can even help you live longer (one and one half more years for walking daily at 3 METs). More strenuous daily activity can extend your life by three years.

Despite all of the benefits of exercise and government campaigns to promote physical activity, many people remain sedentary. One way to promote and sustain walking behaviors is through walking groups. Walking groups are short walks scheduled weekly or monthly. Walking groups, especially those targeted at older adults, have supportive effects that encourage adherence and positive attitudes toward physical activity, companionship and a shared experience of wellness, providing both physical and psychological health benefits. Walk with a Doc (www.walkwithadoc.org) is a national walking group where local physicians walk side by side with their patients.  The informal setting makes participants comfortable interacting with their doctor, questions or health topics can be discussed while walking and, most importantly, patients witness their physicians practicing what they preach. A Walk with a Doc walking group has been established in the central New Jersey area. The first walk will take place in the Bridgewater Commons Mall on Saturday February 28 2015 at 8:30 AM. The meeting place for the walk is the mall’s food court. For future walks look for information on www.medicor.com.

So to help your heart, start walking today. For the best benefit, take a walk for 30 to 60 minutes each day. Alternatively you can join us at Walk with a Doc. If you really want to challenge yourself, take a hike.

There was a case in New Jersey this week where a 16 year old catcher died from commotio cordis. He was at baseball practice and was struck in the chest by a ball, causing SCD. This case is important due to three factors. One, the player was wearing a chest protector, which obviously didn't absorb the energy of the ball. Second, the accident took place in a school gym, not out on a baseball diamond. There was no mention of an AED being used and apparently the family is questioning whether one was available at the gym. Third, NJ legislators introduced a bill in 2008 that would require all public schools, recreation facilities and youth camps to have an AED. The bill has not been adopted, but it is time to get it passed as at least one life potentially would have been saved.

A busy weekend in sports and cardiology

2 items from the weekend caught my attention:
1) A high school football player in Oregon had sudden cardiac arrest. He was saved by a cardiac nurse who was in the stands, saw him collapse and, presumably, did CPR. He was diagnosed with an anomalous coronary artery and had successful heart surgery.
Anomalous origin of a coronary artery is a condition one is born with. It is a leading cause of cardiac arrest (approximately 20% of cases). There are many different coronary anomalies. The ones associated with cardiac arrest involve either the left anterior descending coronary or the right coronary arising from the opposite coronary cusp from normal. The artery then courses in between the aorta and the main pulmonary artery. Cardiac arrest can occur when the artery is compressed, causing ischemia (lack of blood flow) and either a heart attack or an irregular rhythm. Fortunately, the football player survived and had corrective surgery.
http://www.kgw.com/news/local/HS-football-player-prepares-for-heart-surgery-103283964.html
2) Michigan State's football coach, Mark Dantonio, suffered a heart attack hours after making an incredible call, faking a field goal, in overtime, to score a touchdown and win a big game against Notre Dame. Several hours after the game, the coach had chest pain and went to the hospital. He was taken to the cath lab, found to have blockage and a stent was placed.
We have known for years that stress can precipitate heart problems, including a heart attack or sudden cardiac arrest.  Stress will trigger a "fight or flight" response in the body, releasing adrenaline and cortisol. These hormones will increase the heart rate, increase blood pressure and make the body more prone to blood clotting. These responses may have been helpful in the jungle when we need to fight an enemy or a wild animal. but they are detrimental if someone has underlying heart disease. The hormones may constrict  a blocked heart artery, the increased heart rate and blood pressure increase the heart's demand for oxygen, which may not be met by a blocked artery and the propensity to clot can lead to a blood clot within a blocked heart artery. All of this may lead to a heart attack, followed by sudden cardiac arrest.
http://sports.espn.go.com/ncf/news/story?id=5592217 
Fortunately both cases turned out OK.