Like the eminently quotable cardiologist Dr. John Mandrola once wrote on one of my favourite heart blogs:
“We urge patients to eat less, exercise more, and not to smoke. But when they don’t do these things, we still squish their blockages, burn their rogue electrical circuits, and implant lifesaving devices in their hearts.”
As a heart attack survivor, one of the Big Lessons for me has been that although my doctors can “squish, burn and implant” all they like, their heroic efforts do not address what originally caused this damage to my coronary arteries in the first place.
And we now know that most heart attacks are decades in the making. I didn’t suffer a myocardial infarction, for example, because I ate a piece of bacon or had a bad day at work.
And unfortunately, we are also used to looking at HEALTH CARE as DISEASE CARE.
That’s acute medicine for you. Get sick. See your doctor. Take the pills. Get better. Then say “Thank you!” to your brilliant doctor. See also: How To Be a “Good” Patient
But not so for cardiovascular disease – a chronic and progressive condition that doesn’t just go away because of the ‘stent cowboys’, as they are (only slightly jokingly) sometimes called in the cardiac biz.
When you’re a cardiologist with a toolbox full of squishing, burning and implantable hammers, perhaps it’s inevitable that every patient looks like a nail.
Last March, St. Paul, Minnesota physician Dr. Craig Bowron wrote a Huffington Post essay on this very subject called How We Treat Heart Disease Isn’t Good Enough. For example:
“Don’t get me wrong: stents can save lives. In certain heart attack situations, angioplasty and stenting has dropped short-term mortality rates from 13% to 3-5%; in other situations, it can prevent “after-shock” heart attacks and hospital re-admissions for angina.
“But treating a heart attack in the here-and-now is different from preventing one in the future, which stents don’t do very well. That’s because we’re lousy at picking which coronary blockages we should use them on, and also because stents don’t always stay open: they can slowly scar shut, or quickly clot off.
“As a cardiologist colleague of mine says: “We’ve created a new disease — the stent.”
“Of course we wish that stents worked better as preventive therapy for heart attacks. In fact, some interventional cardiologists wish so hard that they’ll go ahead and place a stent anyway. This practice is so common that it’s been given its own term, the “oculostenotic reflex” – meaning that if an interventional cardiologist sees a stenosis (a higher grade blockage), he or she will reflexively stent it.”
I’ve written here before about the landmark 2004 research* of Dr. Rainer Hambrecht in Germany. His work has suggested that patients with significant coronary artery blockages actually do better in longterm follow-up studies when they participate in regular exercise programs compared to having invasive cardiac procedures done to help revascularize those blocked arteries.
His 2004 study, published in the journal Circulation, showed that:
- nearly 90% of heart patients who rode bikes regularly were free of heart problems one year after they started their exercise regimen
- among patients who had an angioplasty instead, only 70% were problem-free after a year
Five years later, Dr. Hambrecht presented findings from additional follow-up research to the 2009 European Congress of Cardiology meetings in Barcelona, confirming his earlier results that regular exercise training is superior to angioplasty at preventing subsequent cardiovascular events. He said at the time:
“It’s difficult to convince people to exercise instead of having an angioplasty, but it works.”
In an interview with Heartwire, Dr. Hambrecht acknowledged that there are multiple forces working against a scenario in which regular exercise is prescribed instead of stenting.
“For one, patients are not motivated to take responsibility for improving their own cardiovascular health – even if it means better event-free survival.
“For another, encouraging exercising is financially less appealing for hospitals. That was my feeling – that hospitals were reluctant to participate in this study, because they derive revenue from revascularization procedures in their cath labs.”
Dr. Hambrecht also believes his research supports the call for cardiologists to take time between a diagnostic angiogram and any revascularization procedure in order to discuss lifestyle improvement options with the patient, rather than stenting every patient as part of their oculostenotic reflex.
His research also supports the call for cardiologists to refer all of their heart patients to attend cardiac rehabilitation programs after the fact, something that is not happening now.
Given that, in Canada, only one-third of patients are referred to rehabilitation after heart attack – and then only 20% of those actually attend – the University of Alberta’s Dr. Mark Haykowsky says the key to the best known outcomes is for patients to not only get referred to cardiac rehabilitation exercise programs, but to be referred early, participate, and stick with it. He adds:
“Exercise is a wonder drug that hasn’t been bottled.”
Dr. Chris Blanchard, a health psychologist at Dalhousie University in Halifax, studied 1,200 Maritimers to figure out why female survivors are up to 30% more likely to quit these cardiac rehab programs compared to men.
Out of a typical 20-session cardiac rehab program, Dr. Blanchard found that men will attend 80% of sessions, compared to women who will show up only 50-60% of the time. I saw this myself during my four months of supervised cardiac rehab. I was vastly outnumbered by men, and as the weeks went by, the other women gradually dropped out. And if these sessions are home-based, male adherence stays at around 80%, but that of women plummets to 30%. See also: Why Aren’t Women Heart Attack Survivors Showing Up for Cardiac Rehab?
Research from those like Drs. Hambrecht, Haykowsky and Blanchard also implies a clear need for accountability on the part of every heart patient who hears lifestyle improvement advice from their doctors – who often lament the reality that many patients seem to expect their cardiologists to do all the heavy lifting for them.
Regular exercise has also been found to reduce age-related changes in our cardiovascular function. Maximum oxygen uptake decreases as we age, but less so in physically active individuals. Left ventricular heart function (which is known to decline with age) also improves with exercise. And regular exercise helps keep arteries elastic, even in older people, which in turn may enhance blood flow and normal blood pressure. Sedentary people have a 35% greater risk of developing high blood pressure (hypertension) than athletic people do.
We already know the demonstrated link between physical activity and heart health. But we’re also seeing:
- strong links between pregnancy complications and subsequent heart attacks, usually years – even decades – later
- inflammation identified as the likely culprit in the rupturing of unstable or vulnerable coronary plaque
- mental illness affecting women’s hearts more than men’s (patients diagnosed with panic disorder, for example, have nearly double the risk of heart disease, while patients diagnosed with depression were at almost three times the risk compared to those without these diagnoses)
- heart patients leaving the Coronary Care Unit choosing to continue smoking – particularly deadly for women who are also taking birth control pills
- a woman’s risk of heart disease rising if she has poor oral hygiene
- less reliable cardiac diagnostic test results compared to male patients (for example, the American Journal of Cardiology reported that non-invasive exercise EKG diagnostic tests are generally considered 89% positive in men, but only 33% in women)
- higher risk for heart disease among women with a waist-to-hip ratio higher than 0-8 (the so-called apple-shaped body)
- not just a single independent risk factor, but a complex of interacting traits, acquired conditions and lifestyle variables that implicate various environmental, behavioral, psychological, physiological, social and genetic risk factors for heart disease
* Hambrecht R, Walther C, Möbius-Winkler S, et al. “Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial” – Circulation 2004; 109:1371-1378
- What Prevents Heart Disease “Better Than Any Drug”?
- Size Matters – But Not in Coronary Artery Blockages
- Why Aren’t Women Heart Attack Survivors Showing Up for Cardiac Rehab?
- Why Your Heart Needs Work – Not Rest – After a Heart Attack
- Physical Exercise vs the ‘Plumber’s Pipe’ Theory of Heart Disease
- Heart Healthy Weight: Secrets of the Always Slim
- Women’s Heart Health Advice: Walk Far, Walk Often
- Learning To Live With Heart Disease: The Fourth Stage of Heart Attack Recovery
- Your Health Care Decisions: Don’t Worry Your Pretty Little Head Over Them
- Say What? Do Patients Really Hear What Doctors Tell Them?
- The Ethical Nag articles called Cardiologists Accused Of Implanting Cardiac Stents That Weren’t Needed and Stent-Happy Docs on Notice in Maryland Health Care Fraud Debate