Music, Inflammation and Holiday Stress

Can listening to music decrease inflammation and stress? Can music be beneficial to heart patients? To answer these questions, we have to understand inflammation and it role in heart disease.

What is inflammation?

Inflammation is the body’s protective response to a harmful agent.  The purpose of inflammation is to eliminate the initial cause of an injury to the body, clear out the dead cells caused by the injury and repair the damaged tissue.  The inflammatory process involves the vascular system, the immune system and specialized cells in the blood used to fight injury.  In addition, with inflammation, a variety of proteins are released to help break down a foreign body. Unfortunately, these proteins may also break down healthy tissue and increase the blood clotting ability of the body.  Acute inflammation occurs in response to specific injury, such as an infection by a virus or trauma to a body part.  This inflammatory response is quick and of a short duration. For example in a bacterial infection, the body sends cells to fight the bacteria, a fever is produced to help kill the bacteria, and there is swelling and redness in the area of the infection. Chronic inflammation occurs over years in a long running cycle of tissue destruction and healing. An example of chronic inflammation is rheumatoid arthritis.

Is heart disease an inflammatory process?

Atherosclerosis (plaque or blockage in the heart arteries) is now felt to be a type of chronic inflammatory process.  Inflammation has a key role in atherosclerosis, from the initiation of plaque, through the build up of blockage to the blood clotting that occurs with an acute heart attack. When the inner lining of the heart artery is damaged by high blood flow or biochemical stimuli (smoking, high blood pressure, diabetes or high cholesterol) it permits cholesterol and inflammatory cells to enter and be deposited in the wall of the artery, thus forming plaque. Once the body realizes that there is damage to the artery wall, more cholesterol and inflammatory cells are deposited to try to repair the damaged wall causing the plaque to grow over time.  Ultimately, the plaque starts to limit the blood flow through the artery, causing chest pain (angina) or the plaque breaks open stimulating blood clotting and an acute heart attack. The effect of inflammation can be measured via a simple blood test. Elevation in the inflammatory marker called C reactive protein (CRP) has been shown to increase the risk of heart artery disease.

How is inflammation in the heart arteries treated?

Aspirin is used to reduce the risk for a heart attack.  It does this by reducing the body’s ability to clot, but it is also a powerful anti-inflammatory agent. Interestingly, other popular anti-inflammatories such as ibuprofen (Motrin, Advil) and naprosyn (Aleve) don’t reduce the risk for a heart attack and may in fact increase the risk. They should not be used in place of aspirin to reduce heart risks.  The cholesterol lowering agents called statins have been shown to reduce the risk for heart attack and stroke. These medications lower total cholesterol and LDL (the bad cholesterol) and raise the good cholesterol (HDL). However there are many other medications which lower cholesterol, but have not been shown to reduce the risk of heart disease. It is felt that statins have anti-inflammatory properties. In patients with an elevated CRP treating with a statin reduces the risk for cardiac events by 50%. It is this anti-inflammatory effect, along with the cholesterol lowering properties, that gives statins their edge over other medications and their power to reduce heart attacks and stroke.  There are many non-pharmacologic therapies that are anti-inflammatory. These include foods such as fruits, vegetables and fish high in omega3 fatty acids.  Other anti-inflammatory therapies include exercise, yoga, meditation and music.

Is music anti-inflammatory? Can music be used as therapy?

Sounds in nature, such as a babbling brook or ocean waves on the shore, are known to be soothing and are promoted as a method to relax and to fall asleep.  Many musical pieces can produce the same sense of calmness.  When his biographer asked Steve Jobs, the inventor of ITunes, what music he listened to, the answer revealed the anti-inflammatory power of music.  Aside from songs by Bob Dylan and the Beatles, his favorites included a Gregorian chant, "Spiritus Domini" performed by Benedictine monks and the "Goldberg Variations", by J.S. Bach and performed by Glenn Gould.  The interview took place during Jobs third medical leave for treatment of pancreatic cancer. He felt the first piece was so calming it almost put him in a trance and the later he felt was deep and reflective. After listening to those pieces, Jobs insight is certainly supported.  The data supporting music therapy comes from diverse medical fields.  In patients with pregnancy or schizophrenia, listening to music provided clear-cut psychological benefits. In patients on respirators, music reduced the breathing rate and blood pressure.  Surgical patients who listen to music, even under general anesthesia, have less anxiety and less need for pain medication during recovery.  A large review of twenty-three trials with more than 1000 participants looked at music therapy in heart attack patients. It concluded that music reduced anxiety, heart rate, respiratory rate and blood pressure in these patients, suggesting a psychological relaxation response.

Certainly what is good and soothing for one listener is cacophony to another listener. Everyone should find their own anti-inflammatory songs as music therapy has no side effects or risks, assuming of course that the decibel level is reasonable. So, after a day of battling the world and increasing your inflammatory markers, go home, slip on a pair of headphones, find some good relaxing music and engage in your own form of anti-inflammatory therapy. Perhaps sing or listen to some holiday tunes to reduce the stress and increase the enjoyment of the holiday season.

Hypertension Essentials

High blood pressure (hypertension) affects nearly 1 in 2 people worldwide between the ages of 35 and 70 years old.  Hypertension is a leading risk factor for stroke, heart attack, death and disability. Hypertension is often called the silent killer, as there usually aren’t any symptoms until an adverse event occurs. Here are some essential points on hypertension.

How is hypertension defined?

Unless the blood pressure is dangerously high (greater than 210/120) or a patient is having symptoms (a heart attack, stroke or congestive heart failure), hypertension should be diagnosed after two to three measurements about one to two weeks apart.  In Stage I hypertension the blood pressure readings average 140/90 or greater. In Stage II hypertension, the readings average greater than 160/90.

What causes hypertension?

In the vast majority of patients with hypertension, 90%, there is no cause for the high blood pressure. This is called primary or essential hypertension. In approximately 10% of patients, high blood pressure may be secondary to another process and can occur with kidney or adrenal disease, a narrowing of the aorta, sleep apnea or taking medications known to increase blood pressure. Secondary hypertension usually occurs in a patient who has not had previous hypertension and who is very young (under age 35) or very old (over age 70).  These patients should undergo further testing to see if there is a reversible cause for the hypertension.

What is white coat hypertension?

White coat hypertension is defined as a blood pressure greater than 140/90 in a doctor’s office, but normal at home.  White coat hypertension occurs in about 10% of patients.  In patients with white coat hypertension as well as many other patients with essential hypertension, it is important to get accurate blood pressure readings at home, with the patient relaxed, in their own environment.  This may be accomplished in two ways. One is with an ambulatory blood pressure monitor, a device given to a patient in a doctor’s office. The patient wears the monitor for 24 hours, blood pressure readings are taken every hour and averaged, both during the day and at night. The other method is to have a patient take readings with a blood pressure monitor, usually purchased at a local pharmacy. Arm or wrist cuffs are best. For optimal results, patients are advised to sit quietly for 15-20 minutes before taking a reading, the arm should be bared and supported on a table or arm chair, the cuff should be at the level of the heart and they should refrain from coffee or cigarette smoking for at least 30 minutes. If blood pressure readings are still elevated on home readings, then therapy should be initiated.

How do we treat hypertension?

The first line of treatment for hypertension is life style modification.  This includes weight loss (if overweight), limiting the sodium (salt) content in the diet, starting an aerobic exercise program, limiting alcohol consumption and getting the proper amount of sleep. These interventions may lower the blood pressure by 5 to 20 points.  The DASH (Dietary Approaches to Stop Hypertension) diet is recommended for patients with high blood pressure.  The DASH diet is high in fruits, vegetables and low fat diary products and low in saturated and total fats (http://health.usnews.com/best-diet/dash-diet?int=9ff509). The DASH diet has been shown to reduce blood pressure by 11 to 15 points in hypertensive patients.  Once it is felt that medications are necessary to lower the blood pressure, the doctor and the patient must collaborate. All hypertension medications work, but to achieve the proper blood pressure lowering, the patient must be able to tolerate the medications, side effects should be minimal and the regimen must be as simple as possible (the goal is to take medications once or at most twice per day).

What is resistant hypertension?

Resistant hypertension is a blood pressure greater than 140/90 despite taking three different blood pressure medications for more than one month. The most common cause is the patient not taking the medications or not taking them correctly. Other factors which can cause resistant hypertension is taking certain over the counter medications (such as ibuprofen, Advil, Motrin, Aleve, nasal decongestants),  taking steroids or other medications known to raise blood pressure, sleep apnea (stopping breathing during the sleep cycle, not allowing the body to get the proper rest), excess alcohol, or developing one of the secondary causes of hypertension.

What is the goal of hypertension treatment? How low should the blood pressure go? The goal of treating high blood pressure is to reduce the risk for heart attack, congestive heart failure, stroke, kidney damage and death.  In 2014, the Eighth Joint National Committee issued recommendations based on the available medical literature. The goal for blood pressure control was less than 140/90 in patients under 60 years old and less than 150/90 in patients over 60 years old. The higher blood pressure target in older individuals recognized that these patients had a higher risk for complications with increasing medications, such as lightheadedness, dizziness, falls and fractures.  This month, the landmark SPRINT study was presented at the American Heart Association meeting. SPRINT is a trial which enrolled 9300 patients and compared two blood pressure goals, treating to under 140 and treating to under 120. The study was stopped early as the patients who were treated to under 120 had a significantly lower risk for congestive heart failure and cardiac death.  Those treated to under 120 were taking more medications and had a higher risk for low blood pressure, passing out and kidney injury.  While treating blood pressure to under 120 may be the new goal, certain caveats must be considered. The risks and benefits of taking more medications must be weighed on an individual basis. In addition, diabetic patients and patients with prior stroke were excluded from the SPRINT trial. Those patients should still be treated to a blood pressure under 140. Previous studies showed that diabetic patients had no benefit from further blood pressure reduction from 140 to 120. The SPRINT trial has generated a lot of controversy in the medical community. Most hypertension experts believe that the SPRINT trial will change, but not revolutionize, hypertension treatment. They don’t’ believe that the new goal for hypertension treatment should be lowered to 120 for all patients. However, in patients over 50 with a high risk for cardiovascular disease who have no diabetes or stroke, more aggressive blood pressure treatment is warranted.

Go Nuts for the Best Diet

What is the best diet for weight loss? What is the best diet for heart health? Many heart patients are obese and are looking for a good diet to lose weight. Certainly all heart patients would like to follow a diet that would help reduce their risk for further heart problems. What is the data on diets?

There are many different commercial diets available, all of which tout their ability to help people lose weight. There are, however, far fewer rigorous scientific trials studying the various diets.  In an ideal world, the best way to evaluate diets is to study one diet compared to another diet, however this is rarely done. Most diet studies compare patients on a diet to patients not on a diet. In a 2015 review in the Annals of Internal Medicine, the data on eleven weight loss programs were systemically reviewed. The eleven programs were: Weight Watchers, Jenny Craig, Nutrisystem, Health Management Resources (HMR), Medifast, OPTIFAST, Atkins, The Biggest Loser club, eDiets, Lose It!, and SlimFast. There were only 39 randomized, controlled trials available in the medical literature for review and even those had significant shortcomings such as limited duration, high rates of dropout, and poor adherence to the diet programs. It was felt that only two programs, Jenny Craig and Weight Watchers, were able to show weight loss at one year, and their results were only modest at best. Another recent review in the Journal of the American Medical Association showed that all diets produced weight loss at six months and one year compared to no diet at all. Weight loss at six months was greater than at one year, with wide variations (from 22 pounds with Atkins diet to 14 pounds for Jenny Craig). At one year, the variations were minor (from 14 pounds with Jenny Craig to 13 pounds for Weight Watchers). Lastly, the US News and World Report came out with their take on the best diets (http://health.usnews.com/best-diet). They did not use the scientific literature, but based their rankings on a panel of “nationally recognized experts in diet, nutrition and food psychology”.  This method is less rigorous and more prone to opinion and bias. Still, they concurred with the medical literature review ranking Weight Watchers number one and Jenny Craig number three for weight loss.

On the other hand, several diets specifically geared towards heart disease have a solid body of data. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fruits, vegetables, whole grains and low fat dairy products, while low in saturated and total fat content. The DASH diet has been shown to significantly reduce blood pressure in hypertensive patients.  Interestingly, US News and World Report ranked the DASH diet as their number one over all diet for 2015; the fifth year in a row it has been number one.

The Mediterranean diet (http://dietamediterranea.com/en/nutrition/) has become the standard for heart healthy eating, showing reduction in heart disease, stroke, cancer and Alzheimer’s disease and lowering the risk for cardiovascular death. It is a plant-based diet with high intake of olive oil, fruit, nuts, whole grains, moderate intake of fish, poultry and wine and low consumption of red meat and sweets. The Mediterranean diet has not been around for very long. It was first described in the 1950’s in Southern Europe and it is actually a result of post-World War II impoverishment and food restrictions. Despite being born from poverty it is rich in benefits.  It has been studied in primary prevention (preventing patients who do not have heart disease from having a heart attack or stroke) and in secondary prevention (preventing patients who have had heart disease from having another event).  It has been studied in over 100,000 patients. In people who do not have disease, those who follow a Mediterranean diet have a 47% lower risk for developing heart disease. In patients who have had a heart attack, those on the diet lowered their risk of dying from heart disease by 50-70%. The Mediterranean diet isn’t just a diet, but a way of life. In addition to the food content, it is emphasized that the food be savored, that meals be shared with friends and family and daily physical activity be a part of the lifestyle.

Nuts, specifically tree nuts such as walnuts, almonds and hazelnuts, are an integral component of the Mediterranean diet and are high in unsaturated fatty acids, fiber, vitamins and minerals. A recent study of nuts showed that nut consumption of 30 grams (about a handful) per day several times per week decreased the chance of dying from heart disease and cancer. It also lowered the risk for diabetes, obesity, hypertension and inflammatory disease.

So the clear winners are the Mediterranean diet for best overall heart health and the DASH diet for hypertension. Both of these diets are well supported by data and recommendations from the American College of Cardiology. Unfortunately, there is no clear winner for the best diet for weight loss as the data is not as strong.  To find out which weight loss diet is right for you, you must first change the concept of a diet, something you go on and then come off. Instead of going on a diet, you should try to achieve a balanced lifestyle with food consumption that is livable and good for the long term. Therefore the likely answer for the best diet for weight loss is similar to, “What is the best exercise” (Answer, the exercise that you like to do and will stick with).  So pick a diet that suits your tastes best and one that fits your lifestyle and budget. Once you have picked your diet and your exercise regimen, stay with it for the long haul. Just remember to reward yourself with a tasty treat. How about a handful of almonds?

Commotion in the Heart

On a warm spring night, a twelve-year-old pitcher toes the rubber in a Little League baseball game. His team is playing their in-town rivals in an intense game with many friends and family looking on. The batter, one of the best and biggest on the opposing team, awaits the pitch. The count is two balls, one strike; a hitter’s count. The pitcher winds and delivers a fastball down the middle of the plate. There is a loud “ping” followed by a dull thud. The baseball was rocketed by the trampoline effect of the batter’s aluminum bat and it struck the pitcher in the left side of the chest.  Coaches and parents rush to the mound. The pitcher, gets up, dusts himself off, proclaiming he is fine. The adults leave for the sidelines. As the pitcher returns to the rubber, he collapses, in full cardiac arrest.

What happened to this young pitcher?  He is a victim of commotio cordis, “commotion in the heart”. Commotio cordis was first described in 1857 and is defined as a blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. Commotio cordis is the second leading cause of sudden death in young athletes. Sudden cardiac arrest can occur in young athletes if a projectile, such as a baseball, strikes the chest at just the right time in the heart cycle. The projectile’s energy is transmitted to the heart, disrupting the normal heart rhythm, causing sudden cardiac arrest and collapse of the athlete. The vulnerable period for a projectile striking the heart is only about 10 to 15 milliseconds long and represents one percent of the total heart cycle. Children and young adolescents are at greatest risk for commotio cordis because they have compliant chest walls that transmit the energy of the projectile to the heart.  Commotio cordis most commonly occurs in youth baseball, but it can also happen in lacrosse, hockey, football and soccer. It can also happen during boxing or karate after a blow to the chest or after a collision between sports participants.

The treatment for commotio cordis is prompt defibrillation, an electric shock to the heart that restores the heart to normal rhythm. The shock is usually provided by an Automatic External Defibrillator (AED), a small portable device that is brought to the victim’s side. Unless the arrhythmia is treated promptly, commotio cordis is almost always fatal.  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.

In recent years AEDs have become widespread.  AEDs have been used by bystanders to treat sudden cardiac arrest in airports, schools, casinos, stadiums, businesses, fitness centers and many other venues where there are large public gatherings.  With the recognition of sudden cardiac arrest in young athletes and after cases of commotio cordis have been reported, AEDs are now being placed in youth sporting facilities.  Community organizations and businesses are encouraged to buy an AED for the area’s sports venues.  An AED is not very expensive, typically costing about $1000, and the cost is equal to buying an outfield sign for three to five years.

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.