Dr John M

cardiac electrophysiologist, cyclist, learner

Fixing the heart rhythm is but just one chapter…

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The heart’s resilience and fixability is striking.  That is, compared to the frailty of other components of the birthday-ravaged body.  We cardiologists are advantaged by the attention heart disease garners in the minds of patients.  We get priority over the polyp, or the bulging disc.

But should we?

He is an older man living a simple happy life with his cane. There were other medical issues resulting in life on a fine line.  Healthiness for the older is like a narrow exposed trail, with danger lurking on either side, and just the smallest bobble creates a potential disaster.

He had the dreaded ventricular tachycardia (VT) for years. Even though it only raised the heart rate to 120 beats per minute, it scared everyone because of its name–like the friendly old black lab with the loud deep bark. Atrial fibrillation, atrial flutter or other benign SVTs go faster, but VT always elicits more fright.    

The rapid heart rate traversed through tiny channels of living heart tissue inside a scar from a distant heart attack.  It caused him symptoms that were troublesome, but even worse were the side effects from the ineffective rhythm medicines.

Assess and decide: it was time.  It was fun searching out those serpentine-like channels, which created a mosaic of electrical squiggles.  “Wow, that was an amazing electrogram.”  High watts were passed through the saline-irrigated catheter tip.  The tachycardia vanished immediately.  Huge grin!

However.  But.  Not so fast.  This triumph was months ago. The arrhythmia is gone, and the toxic medicines are no longer needed.  Unfortunately, there have been four unrelated hospitalizations since:  pneumonia, urinary tract infection, exacerbation of kidney failure, and then fluid excess.  He is arrhythmia free, but miserable in his wheelchair.  “I am so weak.  I am trying so hard.”

“You heart is good,” I add.

“I know, but I am so weak.”

Chapter 2:

He has intermittent atrial fibrillation.  He is older, also with a cane and a life on that same narrow trail.  His generic four dollar per month rhythm medicines work.  The heart is resilient.  Ah, but that dreaded little colon polyp that could not be snipped with the scope.  Surgery.  It could be cancer.

The surgeon is one of our cities best.  The anesthesia, or all the other factors–bed-rest, immobility, pain, pain-meds, ileus, atrial fib from withholding oral meds, or a combination of all the above–results in weeks in the hospital.  Finally the discharge.  The urinary catheter was pulled and urine will not come.  Sadness ensued.  The heart was rhythmic again as he is back on his generic medicine–that works.

Now a urinary catheter was in place for weeks.  A bag was taped to the leg. That little baby colon polyp.  More urologic surgery is needed.  Office based “procedures” done with rigid catheters through the aged urethra were required.  A little tear drops out from his eye as he tells me of the wide awake urologic procedure.  The heart is good. That dreaded polyp. It was benign.

The heart ticks on, sometimes almost infinitely.  The singular focus required to eliminate pathologic squiggles from the heart sometimes blinds us to the other stories of the aging human body.

Heart disease frightens the most, but often proves easiest to fix.

JMM

In today’s medical world, is it possible to die of old age?

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He is 93 and has numerous medical problems, most of which involved aging blood vessels, as well as multiple orthopedic issues, including compression fractures and diffuse arthritis. The bony issues have resulted in a severely compromised mobility of late.

Despite ongoing treatment with both aspirin and clopidogrel, he presents after numerous hours of focal neurologic symptoms.  A CT scan shows no evidence of bleeding and the diagnosis is a major stroke in a 93 year old who is already taking two anti-platelet medicines.  The issue is what to do next?  Reportedly, a rhythm strip somewhere shows atrial fibrillation and so heparin is given in addition to the two other blood thinning drugs.  It was clear that this case was destined to end poorly–“rock and a hard place” comes to mind.

The next day brought a worsening of mental status and another CT scan showed bleeding in the brain.  Soon, he drifted off into an unrelenting sleep, and passed away that same day.

Much discussion centered around the question of adding a third blood thinner in a 93 year old with a stroke.  The discussion was detailed and rigorous, and studies were cited. Important tenets of acute stroke care were learned and a medical education continued.  However, what struck my brain more than the medical details was a distant childhood memory.

I was a little boy, and the memories have much fog and a face is barely seen.  He was my great grandfather who lived with my grandparents in the home next to mine.  Four generations lived within a baseball throw.  He was very old and grumpy and always sat in the same chair next to the Fridgidaire.  Little else is recalled except the coffee can under his saggy bed upstairs.  My grandmother, Nellie, emptied it each morning and now after many years of observing the elderly, I understand the difficulties in nocturnal ambulation to the only downstairs bathroom when in your ninth decade of life.

One day after school a commotion happened next door and soon an ambulance came.  “Naunoo,” as he was known to the children had a stroke and died very soon in the hospital.

I was told he died of “old age.”  Before the era of anti-platelet drugs, CT scans, MRI and angiography one could die of old age.

In modern day medicine, since there is so much to see on scans and many tools to treat, we often forget that humans are mortal and the body eventually loses.  The CT scan revealed bleeding in the brain, but the inciting event was a large stroke in a very old man, who likely was destined to live in a nursing home for the remainder of his life had he not passed.

With so many trees sometimes the forest is difficult to see.

JMM

Clues to longevity. More obviousness…

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To live long, there are many guidelines and much to avoid.  There is now published data suggesting boredom is a risk for an earlier death.

One who is engaged in health reads the litany of things that are detrimental to our existence, and it seems impossible to believe that average lifespans are rising.  There are the obvious toxins like trans-fats, smoking, high fructose corn syrup and the pancreas-stressing flesh of the pig.   There are lesser known life shorteners like immobility, meanness, not having a pet or enough sex and possibly even EMF from electrical devices.

Now we have boredom as a risk.  UK researchers describe in the International Journal of Epidemiology -a journal slightly less prestigious than the New England Journal – that boredom was associated with an increased risk of an earlier death.

More obviousness makes it to print.

For sure, the aging process is inevitable, but it can be slowed and many do so.  Exercising the body gets most of the press, but activity of the mind and maintaining a sense of worth or purpose, remains a consistently observed trait of the healthy person of any age.   In other words, not being bored.

Fairly soon, all common sense advice will have a link to a journal article somewhere.  

At least, it would seem on the surface, boredom should prove less daunting a problem to treat than danish eating.  Macbooks, bicycles, books, gardens and Polar Bear plunges are just a few of the therapeutic tools available to overcome this newly discovered risk to longevity.

JMM