by Carolyn Thomas ♥ @HeartSisters
Ponder this study the next time you are sitting on your toilet – particularly if you are already a heart patient. Most people spend a relatively short time per day in the bathroom (estimated at about 30-45 minutes total, much of that spent using the toilet) yet it appears that the bathroom is a location where sudden cardiac arrest occurs with disproportionately high frequency. According to Japanese researchers, about 8–10 per cent of all cardiac arrests occur in the bathroom.(1) . .
Both the toilet and the bathtub/shower are particularly unique when trying to resuscitate these heart patients, because they’re in such closed private spaces, and thus delayed because the collapse of the patient is rarely witnessed.
It turns out that the frequency of successful CPR resuscitation is slightly higher after a cardiac arrest happens while on the toilet compared to in the bathtub. Researchers suggest that patients are often drowned in the bathtub by the time rescue efforts are initiated. But in both scenarios, the longterm survival rate is low at only about 1 per cent.
The Japanese study investigated the cases of 907 cardiac arrest patients treated during a 4-year period, 11 per cent of whom sustained that cardiac arrest while on the toilet. The return of spontaneous circulation (ROSC) was achieved in 41 per cent of patients when CPR was attempted. However, the longterm survival rate following attempted CPR was still disturbingly low.
Given how closed and private the average household bathroom is compared to every other room in the home, how does a person having a cardiac arrest in a bathroom get discovered by others in time to be resuscitated? The Japanese researchers summarized the most common findings like this:
- in 62 per cent of the recorded cardiac arrests, concerned family members realized that the patient had stayed on the toilet “too long”, which led to their subsequent discovery that the person was in cardiac arrest.
- in 22 per cent of cardiac arrests, a loud sound caused by the patient’s collapse onto the floor of the bathroom prompted family members to investigate.
- in 10 per cent of cardiac arrests, the event occurred in the presence of caregivers because the patient had been dependent on caregiver help, requiring routine assistance to get on and off the toilet. (The only longterm cardiac arrest survivor in this study belonged to this group).
- the remaining patients (6 per cent) called or cried out for help while they were falling down, and were found on the floor by family members who had rushed to the bathroom.
None of the cardiac arrest patients studied by the Japanese researchers had an alarm call system available to them. Even if such alarm call systems had been available, however, researchers estimated that its help would be minimal because only a small fraction of patients would have been able to activate the alarm call system before they collapsed, unconscious.
The more I learned about cardiac arrests in the bathroom, the more I wondered, generally speaking, what people are doing just before experiencing a cardiac arrest? A previous study suggested this range of activities(2):
- the incidence of non-fatal cardiac arrest and sudden cardiac death was low while sleeping or resting or doing light work, and was high while using the toilet or doing sport or heavy work.
- the incidence of sudden cardiac death was also high even during moderate exertion, such as taking a bath, walking or cycling – and it was significantly higher than that in the group of non-fatal heart attacks.
- the incidence of non-fatal heart attacks was high while eating or drinking.
- many of the patients who suffered sudden cardiac death had past histories of cardiovascular disease, compared to those with non-fatal acute cardiac arrest.
It appears that there’s an overarching issue that may contribute to the “disproportionately high frequency” of sudden cardiac arrest happening in bathrooms. That issue is constipation.
A different team of Japanese researchers (and this focus on bowel movements seems particularly popular in Japan!) suggested that, because cardiovascular research often focuses on far more dramatic interventions, the association between constipation and cardiovascular disease is often overlooked by physicians.(2) In another large study published in the journal Atherosclerosis on over 3.3 million U.S. veterans, researchers tracked both constipation status and laxative use, following up over a nine-year period. They concluded that these factors were independently associated with higher risk of all-cause mortality (12 per cent) and both incident coronary heart disease (11 per cent) and ischemic stroke (19 per cent).(3)
Constipation is a common problem that affects millions of people worldwide, yet is usually perceived as a benign self-limited condition. But this can become a serious quality-of-life problem. It’s caused by a variety of factors, including a sedentary lifestyle, lack of fibre in the diet, dehydration, or certain medications. You may know this already if you’ve ever been prescribed opioids like morphine for pain. All opioids cause constipation, and the severity of constipation is not necessarily dependent on how high the opioid dose is. One of the palliative care physicians I used to work with frequently reminded us of the old adage: “The hand that writes the opioid scrip must also write the scrip for stool softeners!” In other words, prescribe medication for constipation at the same time as prescribing what causes it.
But other medications can cause constipation, too – including some anti-depressants, blood pressure medications in the calcium channel blocker family (e.g. Cardizem, Norvasc, Verapamil, Diltiazem) and even some allergy drugs (e.g. Benadryl). Read your drug label warnings for side effects like constipation; if they’re listed, ask your physician if alternative meds might be appropriate substituions. Consult also with your pharmacist (an often under-appreciated resource for heart patients).
Getting older is often blamed as a risk factor for both constipation and cardiovascular disease – but may not be for the reasons you might suspect. It’s not necessarily old age specifically – it may be the way older people are treated. Older patients with cardiovascular disease – especially when complicated with heart failure – are typically instructed to restrict their water intake, for example, and are also prescribed diuretic drugs, both of which can lead to dehydration and constipation.(4) If you’re familiar with chronic constipation, you know the mental stress associated with this condition – which may then be related to rising blood pressure. And in a study published in the American Journal of Medicine, researchers (not from Japan this time!) found that, during almost seven years of follow-up, post-menopausal women with frequent bouts of constipation had a 23% higher risk of a cardiovascular event than post-menopausal women with no history of constipation.(5)
Yet if you were raised in North America or Europe or any other first-world region, you may be unaware of a known culprit behind many constipation woes. Sitting on a modern toilet seat is behind most bowel-emptying problems – compared to the simple squatting posture that has been historically used worldwide before the invention of pedestal flush toilets a century ago.
Stephanie Watson, former Executive Editor of Harvard Women’s Health Watch, explained in her WebMD column:
“We’ve been going about our business in basically the same way since modern toilets were invented: sit, go, flush. The problem with sitting is that it keeps the kink in your lower bowel. That forces you to work harder to push out the poop. Squatting helps to straighten out your colon, giving the poop a straight route out. As a result, you can go more easily with far less straining.”
Until I started reading about the Japanese study, I had no idea that primary (simple) constipation is likely a consequence of “habitual bowel elimination on commonly used pedestal toilet seats. Squatting is the only natural defecation posture for human beings.” We now have squatting aid devices (like Squatty Potty, for example) for those suffering with chronic constipation, especially useful if you have joint or mobility issues. Or try just resting both feet up on a short foot stool to keep your knees above the level of your hips – which can also help to mimic a squatting posture.
As that first study from Japan concluded, “physicians caring for patients with cardiovascular disease should acknowledge constipation and related straining during bowel movements as an important cardiovascular risk, and pro-actively intervene to prevent it.”
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Inamasu J et al. “Cardiac arrest in the toilet: clinical characteristics and resuscitation profiles”. Environmental Health and Preventive Medicine. 2013 Mar;18(2):130-5
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Hayashi S et al. “Activity immediately before the onset of non-fatal myocardial infarction and sudden cardiac death.” Journal of the Japanese Circulation Society. 1996 Dec; 60(12):947-53.
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Keiichi Sumida et al. “Constipation and risk of death and cardiovascular events.” Atherosclerosis. Volume 281, February 2019, 114-120.
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Corella D et al. “Aging and cardiovascular diseases: the role of gene‐diet interactions.” Ageing Research Reviews. 2014; 18:53‐73
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Salmoirago‐Blotcher E et al. “Constipation and risk of cardiovascular disease among postmenopausal women.” American Journal of Medicine. 2011;124:714‐723
Image: Virgo Studios, Pixabay
Q: Should constipation be routinely considered as a cardiac risk factor?
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See also: Is sudden cardiac arrest the same thing as a heart attack? (Hint: NO, it isn’t!)
NOTE FROM CAROLYN: I wrote more about cardiac risk factors in my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local library or favourite bookshop (please support your neighbourhood independent booksellers!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
Heart Sisters 
Great article to make people aware that this is a real problem. Cardiologists need to ask their patients that question about constipation. They need to be the first line to prescribe stool softeners. Not all of them do that.
I remember an episode on the show The Sopranos where someone died on the toilet from a heart attack because of constipation. A bunch of us were laughing. Little did we know it is a real thing.
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Hello Michelle – I was a huge Sopranos fan for years and I too remember that episode. It’s common to make crude jokes about stories like these – but they are indeed real. I was just reading about the death of Elvis Presley: a PBS report suggested he was found unconscious, lying face down on the floor of the master suite bathroom in his Memphis mansion, Graceland.
Two pathologists, Drs. Noel Florredo and Eric Muirhead, participated in his autopsy and concluded that they’d found evidence of severe and chronic constipation, and “Toxicology reports found that Elvis’ blood contained high levels of opiates (Dilaudid, Percodan, Demerol, codeine).”
Their conclusion: “He had likely been straining very hard to have a bowel movement — a maneuver that put a great amount of pressure on his heart and aorta. He probably died of a massive heart attack and collapsed onto the floor.”
Not a laughing matter at all, but a tragically painful way to die. 😦
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My mother-in-law lay semi-conscious on the bathroom floor for more than 24 hours until I called my daughter to go check on her. She was then hospitalized.
Reading this I understand how lucky she was to survive. Thanks for highlighting the connection between constipation and heart problems.
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Hello Pat – Your poor mother-in-law, lying helplessly on the bathroom floor all that time. She was indeed lucky to have survived, and also lucky that your daughter arrived in time for her to get urgent help!
Take care, stay cool. . . ♥
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Oh and 1 magnesium bisglycinate tablet a day does wonders in keeping things “soft” and also significantly reduced my heart “flutters” post bypass.
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I had to look this one up, Lori! Turns out many people apparently take this supplement to help them sleep better at night as well – two benefits for the price of one. BUT. . . As in all supplements, best to start low, go slow as the body adapts to this new chemical. Common potential side effects, not surprisingly, are diarrhea, nausea or stomach cramps. Ironically, “extremely high intake can lead to an irregular heartbeat and potentially a cardiac arrest!”
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Thanks Carolyn, my Cardiologist said there is no evidence that magnesium helps with pvc’s (premature ventricular contractions) – but he admitted all his patients tell him it makes a big difference for them.
I originally took magnesium bisglycinate to soften my stools and noticed 2 days later that my pvc’s were SIGNIFICANTLY diminished, and have been ever since. Could be coincidental but I had so many flutters before that I don’t want to stop taking it, and am over the moon that this preparation of magnesium has significantly improved my quality of life.
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Thanks for that feedback, Lori. It’s hard to argue with all those patients who report the same “big difference” improvements, isn’t it? In 2020, the University of British Columbia was recruiting participants for a study called “Oral Magnesium Supplementation in Athletes With Premature Ventricular Contractions or Premature Atrial Contractions”. The lead author is cardiologist Dr. James McKinney.
I’m not sure if the study is still ongoing, or if results have been published yet – but here’s the basic clinical trials study info, FYI – in case you were interested in following up. https://clinicaltrials.gov/study/NCT04186728
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Thanks Carolyn -I will check out this study
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Awesome article with new information that will be extremely helpful. I had serious constipation starting 6 months before my bypass operation and thought it was because of menopause, but now I think it was a signal from my body that not all was well. Took a long time to get back to normal.
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Hi Lori – I’m not a physician, but I suspect that “serious constipation” is likely an important signal to us that something is very wrong. No wonder you blamed menopause! We know that changing hormones during menopause can mean more water is reabsorbed back into our bloodstream – which can lead to constipation, increased gas and bloating. Lots of fun! But no matter the cause, best to try to get on top of early symptoms sooner rather than later.
One of my high school friends suffered with painful chronic constipation for all the years I knew her, and somehow she just learned to suffer – but as you say, by then it takes a long time to get back to normal after that kind of damage.
Take care – stay cool out there! ♥
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I thought that it was that the strain of constipation had an effect on the vagus nerve, which can have an effect on heart attacks/cardiac arrest and strokes.
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Hi Jeanette – that vagus nerve does seem to be involved! It’s a long and important cranial nerve (starting in the brain stem and supplying all the organs of the chest and abdomen). Nutritionist Anna Sampson calls it the “super highway of information between your brain and your gut” because it affects downward movement (motility) of food and waste by stimulating the muscles of the small and large intestine to push all of it through the digestive tract.
My understanding is that constipation starts first (for any of the reasons mentioned in this post – dehydration, lack of exercise, medications, etc.) and the reaction to feeling constipated (pushing and straining) comes next. As in most bodily functions, preventing constipation is generally much easier than trying to fix it once things go sideways – or the condition becomes chronic. Some studies suggest that the constipation/cardiac relationship may also involve intestinal micro-organisms (which have been studied as possible cardiac risk factors because they can raise blood pressure) more than straining does.
Take care, stay cool out there. . . ♥
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I actually was in ICU once and had been given the medication Ranexa for angina which didn’t do anything for me, but caused an impaction. They let me get up to go to the bathroom and when I “pushed”, four nurses came running as my heart rate on the monitors increased greatly.
They made me go back to bed with milk of magnesia and I passed the baby the next morning. Fun times!
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Hello Jennifer – wow, that must have been a stupendous “PUSH” to get four nurses running! An impacted bowel sounds awful, doesn’t it? Some of the studies I saw mentioned things like “if an enema alone doesn’t do the trick, the stool must be broken up and removed by hand…” I had to have a wee lie-down after I read that!
Constipation is a known side effect of Ranexa! Those nurses may not have needed to come running had you been given a laxative prescription at the same time you took the Ranexa!
Take care – stay cool. . . .♥
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Well, I’ll never have a bath again!
I learned that straining is a culprit when I had an aneurysm in my ascending thoracic aorta. Between diagnosis and surgery, the surgeon told me not to strain on the toilet AND – here’s another important straining source – when weightlifting. (He mentioned this after I told him I work with free weights three times per week. I still do, being careful to breath rhythmically through the repetitions.) He also told me to keep this in mind after surgery because the site of the aneurysm repair would always be somewhat fragile. And speaking of stools … your readership may also be interested in this: when using a pedestal toilet, prop your feet up on a small footstool. This straightens out that kink in the lower bowel. I started this last summer and it works like a charm! What a topic – so much fun! – and actually quite important.
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Hi Deborah! This topic is indeed enough to make us feel weird about any locked door in the house! (I replaced my bathtub with an oversized shower years ago, so at least I don’t have to worry about drowning in the tub anymore!!)
I thought the research findings that “only a small fraction of patients would have been able to activate the alarm call system before they collapsed, unconscious” were frightening (although the life of my own mother-in-law was saved when she fell off the back porch while adding bird seed to the porch feeder during a bad snow storm; her medical alarm necklace automatically sent a warning call based on the impact of her falling. The ambulance was there within 11 minutes – she would have frozen to death for sure had she not had that alarm necklace on!)
Good reminder about straining during weightlifting! In cardiac rehab, we were also told not to lift heavy weights over our heads, too. Just NO STRAINING allowed – if patients are straining to lift free weights, that is too much weight to lift.
And thanks for the reminder about bringing a small stool into the bathroom to keep our colons un-kinked! Who knew there was so much to learn about pooping?
Take care, stay cool out there. . . ♥
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As a former cardiac nurse, I would certainly agree with the study about a disproportionate number of cardiac arrests in the bathroom. It seems to have to do with using the Valsala maneuver as we bear down or strain. People who are post-heart attack are advised to keep their bowels soft.
And if you do have heart disease, let family know to check on you if you’re in the bathroom too long and to leave the bathroom door unlocked.
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Hello Connie – it definitely seems that bearing down/straining is a trouble-maker here (and that’s not even counting the issue with constipation-related hemorrhoids – linked to not only increased straining during bowel movements, but also pressure due to being overweight and/or pregnant (which I learned all about after the birth of my first baby! OUCH!)
Great advice about unlocking the bathroom door and reminding family to check in on you! It’s easy for family members to get busy with other stuff and “forget” that you’re alone in the bathroom. If family isn’t around (or if you live alone) I’d suggest bringing your phone into the room with you JUST IN CASE as a matter of routine!
I agree 100% that ALL cardiac patients *should* be advised about the importance of avoiding bearing down/straining – but realistically I wonder how often or even IF this is regularly done before hospital discharge? I’ve been discharged twice after trips to the cath lab – and not once was this topic mentioned at all by any of the CCU staff.
Take care, stay cool. . . . ♥
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Live and learn, Carolyn!
Great that you bring this “heavy” matter to our attention. Thank you!
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Hello Maxine – what “moved” me about this topic was that so much of the published research in medical journals is from Japanese researchers. And – weird fact! – the demographic in Japan that is most likely to suffer chronic constipation is actually young women in their 20s!
So much I’d never thought about before!
Take care. . . stay cool. . . ♥
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