Blog # 44 Andrew Siegel, M.D.
February is American Heart Month, so I put my heart into this narrative about this amazingly engineered, all-important organ that serves us tirelessly and relentlessly. Like our pet canines, this organ requires to be well fed, to be exercised, and to be given tender loving care. Be kind to it and it will return the favor big time.
Two hundred years ago, the following words on angina pectoris (chest pain from coronary artery occlusion) from John Warren, M.D. were published in the very first issue of the New England Journal of Medicine and Surgery:
The disease itself is excited more especially upon walking up hill,
and after a meal; that thus excited, it is accompanied with a sensation,
which threatens instant death if the motion is persisted in;
and that on stopping, the distress immediately abates, or altogether subsides.
Two centuries later, we are infinitely wiser regarding the diagnosis and management of heart disease, yet unfortunately this illness is more prevalent than ever. The saddest aspect of this is that coronary artery disease is largely a preventable and avoidable problem. Every day, many hearts are broken because of the premature and unnecessary demise of loved ones who succumb to cardiac disease. It is my heart’s desire that we become better caretakers of ourselves and avoid the 600,000 deaths to heart disease and 130,000 deaths to strokes that occur every year in the USA.
Cardiovascular disease (CVD), including heart disease and stroke, is the number one cause of death in the USA and other industrial countries. The only year since 1900 in which CVD was not the leading cause of death was in 1918, the year of the influenza pandemic. CVD is also the leading cause of death in every region of the world except for sub-Saharan Africa. The burden of CVD is increasing because of our longer life spans, continued tobacco use, physical inactivity, unhealthy food consumption, obesity, high blood pressure, elevated LDL cholesterol and prevalence of type 2-diabetes.
The following paragraph is a brief historical perspective of some of the important medical advances with respect to the management of heart disease. The 50-year cardiovascular Framingham study (1948-1998) linked high blood pressure and high cholesterol with angina and heart attacks and originated the novel concept that coronary artery disease and its complications could be prevented. The advent of the coronary care unit (CCU) vastly decreased the death rate of patients admitted with acute heart attacks by provided sophisticated monitoring with electrocardiograms, closed chest cardiac massage, and external defibrillation (using electric paddles to shock the heart back into a normal rhythm). Cardiac catheterization and coronary arteriography lead to the birth of cardiac surgery and coronary revascularization (coronary artery bypass). The field of interventional cardiology enabled balloon angioplasty revascularization of occluded coronary arteries without the need for cracking one’s chest open, using access through a thigh artery. Cardiac stents, initially metal and currently drug eluting, were developed to prevent coronary re-occlusion. Statin medications to lower LDL-cholesterol levels and many new and potent cardiac drugs have provided significant advances. Implantable pacemakers and implantable pacemaker-ventricular defibrillators have further improved the prognosis of those suffering with cardiovascular disease. Sophisticated tests including echocardiograms, treadmill tests, isotope stress tests, Holter monitoring, and computerized tomography of the heart are readily available to help pinpoint the precise cardiac diagnosis.
Despite all of the aforementioned incredible technological advances, coronary artery disease remains highly prevalent and is a major widow-maker and widower-maker. Why? It’s really very simple—those all-important, tiny blood vessels that provide the lifeline of blood flow of oxygen and nutrients to that vital organ that pumps our blood 24/7/365 get blocked with fatty plaques. With clogged coronary arteries, when increased demand is placed on our life-sustaining pump, not enough oxygen can get delivered through the compromised coronary arteries and we develop angina and possibly sustain damage to the heart muscle (a myocardial infarction or heart attack) or its electrical conduction system (an arrhythmia). Tragically, this compromise to our heart and blood vessels is too often self-induced through bad eating habits, physical inactivity, and the use of tobacco.
To quote the insightful and poetic Dr. David Katz who says it all:
“We are all offspring of predecessors who lived in a world where calories were relatively scarce and hard to get, and physical activity constant, arduous and unavoidable. We now live in a world where physical activity is scarce and hard to get, and calories constant, effortless and unavoidable.
Atherosclerosis is the process that gives rise to the fatty plaques in our arterial walls that compromise blood flow to our organs. Atherosclerosisis a chronic arterial inflammation that develops slowly, gradually and progressively over many years. It happens in response to the biological effects of risk factors. It begins with changes in the endothelial cells, the unique cells that line arteries. When subjected to these risk factors, endothelial cells change their permeability and allow white blood cells and LDL cholesterol entrance into the cells. The risk factors include the following:
- high blood pressure within the arteries
- oxidative stress from free radicals (highly reactive molecules known as free radicals are created as a consequence of how our body reacts with oxygen; these interact with other molecules within cells and cause oxidative damage)
- biochemical stimuli (chemicals from tobacco, high levels of bad fats like LDL cholesterol in the blood, food toxins)
- inflammatory factors
The presence of white blood cells and LDL cholesterol within the endothelial cells gives rise to a cascade of chemical reactions that causes proliferation of both endothelial and smooth muscle cells and the formation of plaques. Plaques lead to symptoms by restricting flow through the arteries involved, or alternatively, by provoking clotting that interrupts blood flow. If the plaque ruptures, more clotting will occur at the site of the disruption, perpetuating the restricted flow, and additionally, the ruptured plaque can travel and jam other blood vessels. LDL cholesterol is clearly a major culprit and atherosclerosis occurs in direct proportion to LDL levels.
Occlusion of the coronary arteries is a big deal because damage of the blood flow to the heart—the most important organ in our body—is a major concern. However, it is important to know that the process of atherosclerosis is by no means unique to the heart—it is just that the effects of atherosclerosis on the heart—including angina, heart attacks, arrhythmias and death—are ever so dramatic. It is critical to realize that if you have atherosclerosis in your coronary arteries, you can bet you have it in every artery in the body—including the aorta and those arteries providing blood to the brain, kidneys, intestines, legs, genitals, etc. This can give rise to strokes or transient ischemic attacks, kidney disease, pain in the abdomen after meals, pain in the legs when walking, sexual dysfunction, etc. Suffice it to say that intact blood flow to transport oxygen and nutrients to every cell in our body is our lifeline and we don’t want it compromised.
It is nothing short of wonderful that the medical fields of cardiology and cardiovascular surgery have become so evolved and sophisticated and that we have the medical and surgical resources to manage CVD so well. Countless lives and loved ones have been saved from premature deaths. That being the case, I must make an appeal from the bottom of my heart for preventive and pre-emptive measures that can keep the disease away and the cardiac team at bay. Nature and nurture have roles in CVD and we can’t do a thing about the genetic blueprint that we inherited from our parents that can predispose us to CVD, but we do have incredible power to shape our health destiny with our lifestyle. In my heart of hearts, I can assure you the truth and the validity of the following statement: Genes load the gun, but lifestyle pulls the trigger. Even if genetics has been unkind to you, you have the authority and choice to pull the trigger, keep your finger on the trigger, or withdraw your finger from the trigger.
Prostate cancer is the number one cancer in men and one that I spend a great deal of my time managing and treating. Can you guess what the leading cause of death is in prostate cancer patients? If your answer was prostate cancer, you are wrong. The leading cause of death in men with prostate cancer is CVD. After CVD, cancer happens to be the second leading cause of death in the USA and in most developed countries. Most of our knowledge regarding lifestyle and dietary change for CVD prevention applies to cancer prevention as well. One of the most dramatic reductions in both CVD and cancer has been through smoking cessation. A heart-healthy diet and lifestyle will contribute to health improvements in every part of our human anatomy, whether it is the heart, colon, prostate or genitals.
As individuals, we must take responsibility for our health and make every effort towards maximizing our fitness and well-being. We are the stewards of our own health destiny—no one else is. Yes, we have physicians, sophisticated diagnostic tests, medications and surgery to help us when things go south, but simply by being smart and living a healthy lifestyle, we can avoid personal grief and the grief of our families.
Please take the following advice to heart:
Pearls to keep your heart ** healthy:
- No smoking or tobacco
- Maintain a healthy weight
- Eat a healthy diet: nutrient-dense, non-processed, whole foods; lean protein including seafood which is abundant in heart-healthy omega-3 fats; eat meat and dairy sparingly (use fat-free dairy products); fruits, vegetables and legumes; nuts and seeds; whole-grain carbohydrates
- Exercise daily: walking is great, but try to get some exercise that makes you sweat, breathe hard and gets your heart pumping. Exercise is all about adaptation. Our hearts and bodies are remarkably adaptable to the “stresses” that we place upon them, whether they be vigorous exercise or sitting on the couch.
- See a medical doctor for periodic health check-ups: don’t take better care of your car than you do of yourself!
- Minimize and manage stress
- Know your blood pressure and cholesterol levels and maintain them at healthy levels
** And every other organ in your body as well.
Andrew Siegel, M.D.
Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food