Does Your Heart Pine For the Mountains?

While planning a trip to the Andes Mountains, I wondered about the effects of high altitudes on the heart.  Are high mountain elevations bad for the heart? Are there beneficial effects to the heart and exercise fitness for those living at high elevations?

With ascension to higher elevations, a variety of illnesses can occur, including acute altitude sickness, high altitude pulmonary edema (HAPE, fluid in the lungs, similar to congestive heart failure) and high altitude cerebral edema (HACE, swelling of the brain). High altitude is defined as 4,900 to 11,500 feet (for example: Mount Washington, White Mountains, New Hampshire), very high altitude is 11,500 to 18,000 feet (ex, Pikes Peak, Rocky Mountains, Colorado) and extremely high altitude is greater than 18,000 feet (ex, Mount McKinley, Alaska).  As altitude increases the available amount of oxygen progressively decreases until the "death zone" is reached at about 26,000 feet (for example at the summit of Mount Everest). In the death zone, the amount of oxygen is so low that life is not sustainable without the use of supplemental oxygen through oxygen tanks. In the body, the oxygen we breathe in is bound to hemoglobin, a compound found in red blood cells. The oxygen bound to hemoglobin is carried by the blood throughout the body and released for use.  At sea level, oxygen optimally saturates the hemoglobin. At high altitudes, the oxygen saturation of hemoglobin drops significantly, and the body feels "oxygen deprived". This would be similar to being trapped in a smoke filled room and not having enough oxygen to breathe. The body compensates for the lack of oxygen by increasing the breathing rate (hyperventilating), increasing the heart beat, increasing the amount of blood the heart pumps, producing more red blood cells and shunting blood away from nonessential functions (for example digestion is more difficult at high altitudes).

With rapid ascension from sea level to high elevations, acute altitude sickness may occur, especially for heights above 8000 feet. Symptoms include headache, nausea, vomiting, weakness, dizziness, swelling of the hands or feet, and shortness of breath with exertion. Acute altitude sickness symptoms are usually temporary and improve with hydration and as the person "gets used to" the elevation, a process called altitude acclimatization. Ascending slowly is the best way to prevent altitude sickness. Altitude acclimatization is routinely used by mountain climbers and includes ascending about 1000- 2000 feet at a time (once above 8000 feet) for several days and allowing the body to acclimatize to the lower levels of oxygen at the higher elevation. Once the body has adjusted to the new elevation, the process is repeated at progressively higher altitudes. For a climber attempting to reach the summit of Mount Everest, acclimatization can take several weeks.  In addition to acclimatization, other prophylactic measures include aspirin, ibuprofen or acetazolamide (a diuretic). 

High altitude pulmonary edema (HAPE) develops after two or more days at altitudes greater than 9000 feet. The risk increases with higher altitudes and faster ascent.  If left untreated, HAPE is fatal in 50% of cases. The symptoms include shortness of breath with exertion, dry cough, gurgling in the chest and pink frothy mucous. Despite symptoms similar to congestive heart failure from a weakened heart muscle, HAPE occurs due to high pressure in the lungs with leaking of fluid from the small vessels in the lungs into the lung tissue. Since the mechanism is different, it is treated differently than conventional congestive heart failure. Diuretics are not used, but oxygen and medications that reduce the pressure in the lungs are given. Immediate descent to lower altitudes is lifesaving. There appears to be a continuum from acute mountain sickness to HAPE to HACE and precautions to avoid acute mountain sickness reduce the risk of the more serious HAPE and HACE.

Patients with established heart disease need to be cautious at high elevations. Angina, chest pain due to heart artery disease, can worsen at altitude due to the increased demands on the heart. If a coronary stent is being planned, this should be done prior to travel. Patients with stable coronary artery disease and little or no angina with exertion at sea level can likely tolerate elevations to 8000 or 9000 feet.  Patients with congestive heart failure, unstable chest pain, pre-existing high pressure in the lungs or unstable rhythm diseases should not ascend to greater than 6000 feet. 

Can living at a high altitude be beneficial? Why do so many endurance athletes come from the mountainous countries of Kenya, Ethiopia, Uganda or countries in the Andes and Himalaya mountains? Why is the United States Olympic training facility located in the Rockies in Colorado Springs? The same effects the body goes through while acclimatizing to high altitudes occur in people who live at high elevations full time. Some of these effects are quite beneficial for heart performance and endurance athletics. For instance, the amount of blood the heart pumps with each beat is greater in those living at high attitudes. In addition, the body manufactures additional red blood cells to carry more oxygen (this is similar to “blood doping”, the method of cheating Lance Armstrong was accused of during his Tour de France wins).  Both of these adaptations have the same effect, to increase the amount of oxygen available to exercising muscles. So living at high elevations can give an edge in athletic performance.  However, training at high altitudes offsets these beneficial effects, essentially negating them, as athletes cannot train with same intensity at elevation that they can at sea level. That is why athletes, “live high and train low”; they live at elevation and do their training a lower attitudes.

So if you are lucky enough to live at a high elevation, start training at sea level; you could become an Olympic star. If you are visiting the mountains, take precautions and enjoy the views.

Alcohol and the Heart

Can a drink a day keep the cardiologist away? Does alcohol decrease the risk for heart attack and cardiac death or is it harmful to the heart?

Before tackling this question, some definitions are in order. Moderate drinking is defined as two or less drinks per day for men and one or less for women.  A drink is 12 ounces of regular beer or 5 ounces of wine or 1.5 ounces of spirits.

In large studies looking at alcohol and cardiac mortality there appears to be a J shaped curve. Patients with moderate alcohol consumption were at the bottom of the curve (the lowest mortality) with 16% reduction in deaths for men and 12% reduction for women compared to nondrinkers. Nondrinkers had an intermediate mortality rate. Patients with heavy alcohol use, greater than 4 drinks per day, had the highest mortality. The possible heart protective effect of alcohol was even given a name, “the French Paradox”, based on the observation that people in France have low levels of heart disease despite diets high in saturated fat.  In 1991, 60 Minutes aired a show on the paradox, and it was suggested that the high French intake of alcohol, particularly red wine, was responsible for the effect and the lower cardiac mortality. After the show, red wine consumption in the US increased by 44%.

How does alcohol decrease cardiac disease?  While the answer to this question is still not known, it had been theorized that resveratrol, an antioxidant found in the skin of grapes, was the mechanism. Resveratrol, which is found in red wine, is purported to have anti-inflammatory properties and to increase longevity. However, it has been found that the amount of resveratrol in wine is rather low and cannot explain any protective benefits.  Alcohol itself, it seems, may provide benefit by increasing HDL (“good cholesterol”) and decreasing inflammation.  Alcohol, especially after meals, increases insulin sensitivity and sugar metabolism, keeping weight down and diabetes risk low.  On the other hand, heavy alcohol consumption can cause liver disease and cancer as well as having adverse effects on the heart, such as hypertension (elevated blood pressure), atrial fibrillation (an irregular rhythm from the upper chambers of the heart), congestive heart failure and stroke.

Alcohol is a well-known heart toxin. In patients who drink and are susceptible, alcohol can weaken the heart muscle (a condition called cardiomyopathy), decreasing the heart’s pumping ability and causing congestive heart failure, with fluid filling up in the lungs and leading to shortness of breath.  If the heart’s ability to pump blood continues to worsen, the body is deprived of oxygen, several organ systems fail (for example the kidneys stop working) and death follows. In extreme cases, alcoholic cardiomyopathy can lead to heart transplantation. Fortunately abstaining from alcohol once the diagnosis is made can lead to recovery of the function of the heart muscle.  The amount of alcohol needed to cause cardiomyopathy is not known. Women need lower amounts than men and the same consumption in one person may cause no adverse effect while in another person it may cause heart failure. Alcohol is implicated in atrial fibrillation as well. Atrial fibrillation is dangerous in that it can lead to heart failure or blood clots and stroke. Drinking less than 2 drinks per day was not associated with an increased risk for atrial fibrillation. However, for those who drink more than two per day, the risk of atrial fibrillation increases 8% for each drink above two. The more alcohol consumed, the greater the risk for atrial fibrillation. In addition, binge drinking can lead to atrial fibrillation, a phenomenon termed “Holiday Heart Syndrome”  (due to excess consumption of alcohol on weekends or on holidays).  Lastly, for some people, even moderate alcohol consumption can be dangerous, including patients on blood thinners or those with uncontrolled high blood pressure.

Clearly, alcohol is a double-edged sword and the scientific community is still split over whether it is beneficial or not.  There are several factors to keep in mind regarding the data on alcohol’s cardiac protective effects. In almost all of the studies, patients are asked about their alcohol consumption rather than having it measured. This certainly can lead to inaccurate data, as many people will not be truthful about their alcohol use.  It is not known whether moderate drinking is truly protective or whether it is a marker of a healthy lifestyle (moderate drinkers tend to have better over all health, watch a better diet and exercise more than heavy drinkers).  It had been thought that wine was better than other types drinks, however, it seems that the type of alcoholic beverage is less important than the amount and pattern of usage.  In addition, more recent data has shown that the death rates between moderate drinkers and nondrinkers are not that different. In fact, it has been suggested that no amount of alcohol is safe for the heart.

What then is the recommendation for alcohol use? No health agency or major medical group recommends drinking for health purposes. The American Heart Association suggests that if you don’t drink, then don’t start. If you choose to drink alcohol, do so in moderation, without binge drinking. Further, if your moderate drinking is wine with meals, then the benefit seems to be the greatest.

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.