Dr John M

cardiac electrophysiologist, cyclist, learner

Let’s stop the unnecessary treatment of heart disease

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There are many reasons doctors suffer from burnout and compassion fatigue. One of the least-mentioned of these reasons is that much of what we do is so damn unnecessary. In the US, the land of excess everything, caregivers, especially cardiologists, spend most of our time treating human beings that didn’t need to have disease.

Let’s be clear and honest: Lifestyle-related disease is largely unnecessary.

These days, there is so much unnecessary disease that caregivers, especially cardiologists, rarely see it. We look past the obesity right to the cholesterol number and ECG. And then we pull out the prescription pad for the guideline-directed pills. Just typing that causes me angst.

A man gets referred for AF ablation for symptomatic AF. Indeed he has many AF episodes. But he also drinks alcohol excessively, weighs 300 pounds, and refuses to wear his sleep apnea mask. You refuse to do a $100,000 procedure and soon the reputation arrives: you are too conservative an ablationist. Mandrola won’t do procedures.

My interventional cardiology colleagues have it much worse. They are roused from sleep and family time to rush in and save people from mostly unnecessary heart attacks (MIs). One way to see the chorus of emergency PCI (percutaneous coronary intervention) treatment of acute MI is with awe. Another is with utter frustration–because in most cases it was unnecessary.

The study:

A recent population-based prospective study of Swedish men suggested almost four of five MIs in men could be preventable. (That’s not a typo.) Researchers from the Institute of Environmental Medicine in Stockholm Sweden followed 20, 721 men from 1997-2009. They specifically asked about five modifiable lifestyle behaviors: a healthy diet, moderate alcohol consumption, no smoking, being physically active and having no abdominal fat (waist circumference.) There were 1,361 cases of MI in the 11-year follow-up period.

Heartwire journalist Michael O’Riordan recaps the details of the study here on Medscape|Cardiology. The short story was that each of the five low-risk behaviors independently reduced the chance of having a heart attack. Not smoking was the strongest risk reducer. Men who combined all five behaviors were 86% less likely than those who had zero behaviors to have a heart attack.

The wake-up call:

I realize everyone knows lifestyle is important to prevent heart disease. It’s so obvious that we (patients and doctors) have grown numb to it. But pause for a moment and think about the finding that four of five heart attacks could be prevented with simple achievable lifestyle behaviors. That is something.

My electrophysiology colleague Dr. Prash Sanders (Adelaide Australia) stands in front of audiences of doctors and says risk factor modifications, such as weight loss and blood pressure control, are easy. The key word, he says, is motivation.

The challenge for caregivers, especially us cardiologists, is to stop suppressing the idea that heart disease can’t be prevented—that people won’t do it. The first definition of the noun motivation is the reason or reasons one has for acting or behaving in a particular way. That’s our job as caregivers.

My experience in the AF clinic in the past few years of lifestyle-enlightenment is that people can change. I’ve posted the lifestyle studies in the exam room. I discuss the biology of how lifestyle disease relates to the atria. I make the case that AF is (largely) unnecessary. I talk about atrial stretch and fibrosis, rotors and inflammation.

We can do the same with vascular disease and diabetes and high blood pressure. Being active, eating well, not smoking, and carrying less body fat work because they favorably affect oxidative stress, inflammation, endothelial function, insulin sensitivity and blood pressure. These are the reasons why people should eat less, move more and reduce their belt size. Reasons and expectations equal motivation.

The low-hanging fruit is right there. I say we reach up and grab it. Just thinking about doing fewer unnecessary things for unnecessary disease is soothing.

JMM

CW: That exercise has an upper limit makes perfect sense

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As a bike-racing heart doctor who practices in one of America’s least healthy states, it pains me to say anything against exercise. I spend a great deal of my typical office day cajoling Kentuckians to exercise more. Sometimes, I even prescribe daily exercise rather than a medicine!

“It’s OK to exercise every day that you eat,” I often say.

The simple triad of wellness is good movement, good food, and good sleep.

But…could exercise be like aspirin: one per day is good, but eight, not so much? Is it possible to exercise so much that our hearts break down?

The scientific data that looks at those who insist on running multiple marathons, cycling many centuries and swimming across channels (the so-called ultra-endurance athlete) looks consistently unsettling.

Today, in the NY Times, Gretchen Reynolds, beautifully ties together two human studies and one rat study that shed a light on the detrimental cardiac effects of ultra-exercise. Here’s a blog-length summary of the three studies she mentioned:

  1. In a very small study from Doha, Qatar, 12 lifelong veteran male endurance athletes underwent MRI scans of their hearts. Six of the twelve men showed evidence of heart scarring (fibrosis). Younger athletes, and regular people, in comparison, had no scar tissue.
  2. In a German study of 108 middle-aged marathon runners, the prevalence of heart (coronary) artery calcium deposits–a marker of blood-vessel disease–was markedly increased. This finding surprised investigators because “on paper” the marathoners were ‘healthier’ (Ed. note: there are now confirmatory trials showing that marathon runners are at increased risk for calcium deposits in the heart arteries.)
  3. Finally, Ms Reynolds tells us about yet another rat study— not just regular rats, but “Marathon Rats.” These were rats that could tolerate running for extended periods on a rat treadmill. (A grid on the back of the treadmill delivered a “small,” non-painful shock to “encourage” rats to run effectively.) The Canadian and Spanish researchers learned three things when they compared the over-trained rats to slacker rats: (1) The marathon rats developed scar in their hearts; (2) The over-trained rats were more susceptible to heart rhythm abnormalities; and (3) Scar tissue and arrhythmia susceptibility resolved after they stopped running.

Taken together, these three trials add to the increasingly large pool of evidence that links chronic physical (over)stress to heart disease. Things like:

  • The consistent reports of athletic middle-aged people who die suddenly at events like marathons and triathlons.
  • The strong association of endurance athletics and atrial fibrillation.
  • The fact that the number one cause of non-heart-attack-related (non-ischemic) heart muscle weakness is persistent revving of the heart rate—we medical people call this tachycardia-mediated cardiomyopathy.
  • Heart enzymes—the same ones released in a heart attack—rise after running marathons.

That all this science points to chronic exercise as maladaptive makes perfect sense to those of us who fancy the views of the famous 19th century British naturalist, Charles Darwin. For back in the day when human survival required hunting our own food, and avoiding becoming food for another species, the ability to twitch very rapidly, repeatedly, was far more desirable than the ability to drudge around for hours at ‘endurance’ pace. In other words, being able to run one fast mile was better than being able to run 26 slow ones. Those that were alert, fit and rested were more likely to keep their DNA going forward.

Go fast, rest, and be well.

Or, be an ultra-person. Just don’t count on being ultra-healthy.

JMM

P.S. How do you know how much exercise is too much?

That’s a tough one to answer quantitatively because all humans have different tolerances to inflammation. Remember not all the rats and endurance athletes showed heart scar. But as a general rule, if on Monday, the old guy pushing the IV pole down the hall is walking faster than you, it’s a good bet that you went a little too long on Saturday and Sunday.

Cycling Wednesday: The Three Rs

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This Wednesday, I’d like to talk about how rodents, relationships, and riding relate to intelligence and overall wellness.

This idea comes from a nicely written NY Times piece entitled, Does Loneliness Reduce the Benefits of Exercise?  Here, Ms Gretchen Reynolds reviews a few intriguing studies about how relationships may affect exercise, stress hormone levels and intelligence.

That combo caught my eye.

Anyone who pays attention to wellness knows that exercise produces more flexible arteries, more durable hearts and leaner body shapes.  These benefits are obvious, and honestly, sometimes a bit tiresome to write about.

To me, a far more interesting–and lesser known–benefit of regular exercise is that it might make us smarter.

Here’s where the rodents come into the story.  As was summarized in the NY Times piece, when researchers allowed rats and mice access to running wheels they observed (a) that they all ran, and (b) those rats that did run scored better on rodent IQ tests, and actually grew more brain cells.  This is a striking finding because nerve cells–unlike blood, GI and skin cells, which turnover rapidly–grow very slowly, if at all.

But that’s not the entire story.

The Princeton researchers wanted to know whether the rat’s social relationships could have measurable biologic effects.

It turns out that rodents—like humans—are quite social.  So social in fact, that in these trials the brain-growing effect of exercise was blunted when rodents lived alone.  Compared to rats and mice that lived in groups, those that were kept in isolation failed to grow new nerve cells in response to exercise.  And, importantly, isolated rats produced higher levels of stress hormones than those who lived in groups, even though both groups ran the same distance.

Though the precise way that loneliness blunts the brain-boosting benefit of exercise is not known, it’s reasonable to speculate that the inflammation-lowering effects of exercise gets countered by the stress of isolation.

Obviously, humans are far more complicated creatures than rodents.   Unlike our four-legged relatives, we humans don’t just hop on exercise wheels simply because they are available.  If we did, there wouldn’t be an obesity epidemic.

This distinctly human decision of whether to partake in regular exercise was the subject of another of Ms Reynold’s cited studies.  In this 8000 patient human exercise study, researchers from the famed Cooper Clinic in Texas provocatively suggested that marriage may worsen physical fitness.  They reported that single women who stayed single retained more fitness than those who married.  And recently divorced men reaped the largest gains in fitness.  These findings come as no surprise to competitive cyclists. There’s nothing like a good marriage to slow down a cycling cyborg.

All this science speaks to me at four levels:

As a heart doctor, I hear the message that healthy relationships foster wellness, and this benefit is likely mediated by lower levels of stress.  I witness this everyday, and it’s comforting when science confirms the observed.

As a fan of education, I find it striking that in the face of mounting evidence that regular exercise boosts brain power schools are curtailing regular gym classes.  Hello.

As a regular exerciser, I like the idea that my habit might make me smarter.  Too bad spinning that bike wheel didn’t make sentences flow any smoother.

As a bike racer, I love it when one of my more talented competitors gets married, and stays married.

JMM

Just because the rigors of endurance athletics may be inflammatory doesn’t mean it isn’t fun…

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A patient asks, “Doc, do you ride your bike to prevent heart disease.”

I reply, “Heck no, I am hoping to live long enough to get heart disease.”
The non-athletic patient looks quizzically at me as if trying to decipher what I mean, or whether I am serious.  Too long a story, so we move on to the medical problem at hand.
For too numerous reasons to drone on about, it is clear that bike racing does not promote longevity.  Take the results of the sudden decelerations that are ubiquitous to bike racing as a representative example.
I received many thoughtful comments, and specific questions on the cautionary note story. This week, on rides populated with many middle age riders, comments suggested my words are anti-exercise.
On the contrary, I am absolutely, totally, completely (however many adverbs in Thesarus.com there are) convinced that exercise is essential for good health.  Inactivity is akin to a slow growing cancer that degrades one over years.  You probably cannot read this in the Geriatrics literature, but I believe the single most important thing an older person can do for their well being is move–bunches.
There is a difference though, in daily exercise, and training.  I, like many others, love the sensations and camaraderie of bike racing (or swimming, running or nordic skiing.)  Like all other competitive sports, bike racing requires a lifestyle in which a rigorous formatted training program is essential. Herein is the catch.
Training for the rigors of racing requires extraordinary amounts, and intensities of exercise–or at least that is how most racers think and act. The amazing drive that bisects the fairway, perpetually rising till the ball leaves the limits of your vision, keeps golfers engaged in the pursuit of perfection.  Racers in pursuit of similar perfection will always think that the perfect training plan will guarantee success.  It just is this way.  And it likely always will be.
However, just because science is confirming that said mandated training is not healthier, does not mean I am against it.
I am for knowledge.  In medicine, all therapeutic decisions are like “Ys” in a road–left or right.  Us doctors are tasked with clarifying the pros and cons of each path, so that an educated patient can choose wisely.
My purpose in writing on the paradoxically increased incidence of arrhythmias and coronary calcium in athletes, is not to discourage training for endurance sports, but rather to point out that those who repetitively push their bodies to extraordinary wattage outputs–over many years–are not likely preventing disease.  Rather, these endorphin producing behaviors are–in some cases–promoting chronic inflammation which accelerates the aging process.  It’s ok, just know.
How much exercise?
Patients often ask how much exercise is enough. Who knows for sure?  There are the mind-numbing encyclopedic guidelines from many committees of experts, or the Thoreau-like simple rules from a master of the obvious who was trained in the evolutionary biology classes of a liberal arts college.
So, I tell “normal,” non-racer patients my simple rules for exercise…
Exercise should be daily, or almost daily.  It’s ok to exercise each day you eat.

Exercise should make you breathe hard enough so you can’t read a magazine simultaneously.

Exercise should be fun enough to be sustainable.

Exercise should give more life-force to you than it takes away.
JMM