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Guns, and Less Butter

Not my title, actually.

Today's First Cardiac Rehab Session

Either they are being really cautious, or they don't know how to handle a case like mine, I'm not sure which.  They know that I have been doing 30-35 minutes a day on the treadmill -- so today they put on the EKG monitors, and had me do five minutes on the recumbent stationary bike, then five minutes on the stepper (without the arm part, because the stitches are still healing internally), then another five minutes on the recumbent stationary bike.  What a shock!  All my rhythms look good; my blood pressure a few minutes after the last exercise had dropped to 130/82.

Tonight, I did fifty minutes on the treadmill, much of it at 3.5 mph -- and I felt great at 3.5 mph.  In fact, the last couple of days I have found myself going up to 3.5 mph because I feel better at that speed than at 3.2 mph.

Heavy Drinking Before Motherhood Is Bad For You

And not just because it leads to "whoops!" moments.  From August 30, 2013 WXXI (an NPR affiliate):

The more alcohol young women drink before motherhood, the greater their risk of future breast cancer according to a new study published in the Journal of the National Cancer Institute.
The findings are based on a review of the health histories of 91,005 mothers enrolled in the Nurses’ Health Study II from 1989 to 2009....

They show that if a woman averages one drink per day between her first period and having her first child, she increases her risk of breast cancer by 11 percent, an average of two drinks per day means an increased risk of 22 percent and so on.

Obesity and Death Rates

From August 15, 2013 Los Angeles Times:

The death toll of the nation's obesity epidemic may be close to four times higher than has been widely believed, and all that excess weight could reverse the steady trend of lengthening life spans for a generation of younger Americans, new research warns.

Some 18.2% of premature deaths in the United States between 1986 and 2006 were associated with excess body mass, according to a team of sociologists led by a Columbia University demographer. That estimate, published online Thursday in the American Journal of Public Health, is far higher than the 5% toll widely cited by researchers.

The new figures do not reflect newly discovered facts about obesity's effects on health. Rather, they emerged after the researchers applied a finer-grained approach to examining obesity across the U.S. population.

Using historical survey data, the study authors toted up differences in excess weight status across different gender, ethnic and age groups. They combined that data with existing "mortality risk" statistics to estimate how many Americans over age 40 who died during that 20-year period did so because of weight-related causes.

This should not be any great surprise.  Extra weight means extra strain on the heart and joints, and obesity is seldom the result of simply eating too much high-protein food.  It's usually the result of gorging on fats and carbohydrates, which have all sorts of troublesome consequences in quantity.

Angiogram

The cardiologist talked to the radiologist, and because it was somewhat ambiguous as to whether there might be a cardiac artery that is blocked, or close, they are going to do an angiogram on the 24th.  If everything is working reasonably well, I'll be at work the next day.  If they find a blockage that requires a stent, I'll be in the hospital overnight.

There's about a 0.1 to 0.3% bad things happen rate to these, but I'm not obese, or diabetic, or with compromised kidney function, so I am not in the group that typically ends up in the dead category.

My Cardiologist Called

He is still waiting to talk to the radiologist, because there are some uncertain aspects to the written report he has received.  My ejection fraction (the amount of blood that is pumped out of your heart each beat) is 47%, which is below normal, and indicative of a problem.  There is evidence that one region at the back of my heart is damaged, and not getting blood supply. But the obvious blockage of cardiac arteries is not showing up.

I asked him if I had perhaps suffered a "silent" heart attack -- the kind that damage the heart but you don't know it.  He indicated that might be one explanation, and seemed to think that the evidence of damage might explain the left nerve branch blockage.  It doesn't sound like an immediately worrisome problem, but it does explain why I have been having breathing problems under severe conditions the last few years.

I see encouraging clinical trials like this, but this sounds like it is intended for people with much more serious ejection fraction problems than mine -- and at this point, the gains are pretty small.

On the other hand, there is this encouraging report of how high intensity aerobic conditioning exercise help to restore scar tissue to working status (the British Medical Journal abstract for the article is here):

Dr Richard Godfrey, a Senior Researcher within the Centre, suffered a heart attack in 2007 in the absence of any heart disease, resulting in 16% myocardial scar tissue. The cause was later found to be coagulopathy - a blood clotting disorder.

Dr Godfrey, who was formerly Chief Physiologist at the British Olympic Medical Centre, undertook 60 weeks of high intensity aerobic interval exercise, three times per week. Sessions involved six to 10 exercise intervals of 1 min hard alternating with 1 min easy, designed to take his heart rate just above 90% of maximum.

Cardiac MRI scans before during and after showed a 50% decrease in the amount of scar tissue in the heart - the first time that exercise has been shown to cause cardiac repair.

 UPDATE: Obviously, I am going to check with my cardiologist before I start this, but there are advocates for what is called High Intensity Treadmill Training that seems to be related to the exercise program mentioned above.  It doesn't seem impossible that the body might be able to repair at least some levels of cardiac muscle damage through an aerobic exercise program like Dr. Godfrey used.

Nuclear Stress Test

The cardiologist referred to as an adenosine stress test; the person doing the scheduling called it a nuclear stress test.  The latter sounds so much more impressive, doesn't it?  I'm picturing a little mushroom cloud rising out of my chest while everyone runs away in terror.

UPDATE: I survived, but I will stay away from subways, airports, etc. for a while.  I have Technetium-99 flowing through my bloodstream!  I am a new superhero, Gamma Ray Man!

Aortic Valve Stenosis

I am learning so much about this subject!  It appears that a small percentage of the population has a bicupsid aortic valve (BAV) instead of the more common tricupsid form: 1-2% of the population.  But the majority of aortic valve stenosis (AVS) patients 15 to 65 have bicuspid aortic valves, and AVS appears on average two decades younger in BAVs.  It seems to have a similar mechanism to atherosclerosis in how it develops, with calcium deposits eventually stiffening and apparently destroying the valve.

There is a particular mutation associated with the disease, and that isn't surprising, because the BAV issue also seems to be inherited.

My cardiologist decided to do an adenosine stress test, instead of the more typical exercise stress test.  This article from 2001 gives a pretty clear explanation of why:

RESULTS Eight patients developed dizziness during exercise testing but made a rapid and spontaneous recovery. No other complications of exercise testing occurred. Survival curves, with or without the occurrence of end point events for the variables studied, showed significant differences for positive versus negative exercise testing (p = 0.0001) and aortic valve area < 0.7 cm² v⩾ 0.7 cm² (p = 0.0021). There was no relation between the end points and transaortic gradient (p = 0.6882). In multivariate analysis, a hazard ratio of 7.43 was calculated for patients with a positive versus a negative exercise stress test. Although asymptomatic in daily life, 6% of the patients (4/66) experienced sudden death; all these had a positive exercise test and an aortic valve area of ⩽ 0.6 cm².

Yes, 6% of the patients suffering sudden death is an argument against exercise stress testing, I would say.  (Note that it doesn't say that they died during the test, or because of the test, but no previous symptoms and die afterwards is not good.)

There seems to be some evidence that there is an inflammatory response relationship with aortic valve stenosis, and that may be why statins seem to delay (although not reverse) the increasing degradation.

I suspect that when I first started having problems breathing when exercising in cold weather about five years ago that this might have been an early sign that things were not going well with that valve.

Heard From The Cardiologist This Evening

The problem is the aortic valve is narrowed, which prevents the heart from pumping enough blood, and back pressure into the alevoli is what is causing the breathlessness.  The good news is that it isn't severe enough to require replacement immediately.  He explained that this is one of the few surgeries where getting older is an advantage, because the older you are, the longer bioprosthetic valves last.  Young people that need the aortic valve replaced get mechanical valves that last forever, but require them to take blood thinners for life.  He also indicated that the steady improvements in bioprosthetic valves mean that if I can put this off for a few more years, what they put in may actually be lifetime.

The downside is that this is an open your chest up surgery -- but there is a new procedure called Transcatheter Aortic Valve Replacement (TAVR) where they install the new aortic valve rather like the way that they do angiograms and angioplasty -- through an artery.  This sounds like it is roughly equivalent to replacing the valves in your engine by going up the tailpipe, through the exhaust manifold, and then through the open valve!  The downside of TAVR is that while they don't have to open up your chest, it is currently about three times more likely to cause a stroke than the traditional approach.  He also says that only about 10,000 of these TAVRs have been done so far, and he would feel more comfortable that the procedures and tools have been perfected when they reach the million operation mark.  Yet another advantage of being able to put off this operation.

In the meantime, he wants to do an adenosine stress test so that they can run radioactive dye through my heart and see which arteries seem to be blocked or restricted.  This is apparently a first step to figure out if you have blockages bad enough to justify the considerably more intrusive angiogram, which would lead perhaps to an angioplasty to clean out any blockages.  He doesn't have much hope that an arterial blockage is the cause of my left nerve branch block, but he admitted that it was possible that the electrical failure was caused by lack of blood supply.  At a minimum, it would be good to make sure that there are not any cardiac arteries that might suddenly preempt the need for aortic valve replacement in a few years.

It could be worse.  It could be better.  In the meantime, he encourages me to stay at the treadmill.  He doesn't believe that it could actually help the aortic valve narrowing, and he even finds it hard to imagine that the improvement that I am feeling on the breathlessness symptoms could be related to improved cardiovascular fitness, because the improvement is too quick.  But it won't hurt me, and the more fit I am, when surgery is required, the better I will recover.

Last Night's Treadmill Experience

It seems that the more exercise I get on the treadmill, the less serious the breathlessness symptoms become.  I spent 65 minutes on the treadmill last night, and the breathlessness problem was of a shorter interval at each speed than the previous night.  I ended up at 3.1 mph, with no real problem.

I am really beginning to wonder if whatever this problem is can be attributed to the prolonged high blood pressure spike caused by the kidney stone, surgery, and recovery.  Perhaps I can exercise my way back to health.

Echocardiogram Today

It was really fascinating.  I've seen ultrasounds done, but on body parts that don't move (like gall bladders).  This is the first time that I have seen one being done on a part in motion.  The resolution isn't spectacularly high, limited, I would assume, by the frequency that they are using, but there is still enough detail to see valves opening and closing, and Doppler shifting enables the device to color blood flowing one direction blue and the other direction red.  The technician was also measuring chamber volume minima and maxima.

I could see my mitral valve, and it looks like it was closing and opening properly.  I could see my aortal valve, although it didn't look like it was completely closing.  (The cardiologist had indicated Tuesday that he wasn't sure if the squeak was mitral valve or aortal valve.)

The technician, of course, could not tell me anything.  But I did ask her when I would hear back from the doctor, hours or days?  "Early next week."

"If you saw something really serious, would it be early next week before I heard from him?"

"No, it would be hours."

I guess that I am not too worried.  The other interesting sign is that while the breathlessness that was bothering after the kidney stone surgery is still present, it seems to be declining.  On Sunday, I was spent 80 minutes on the treadmill, starting at 2.0 mph, and working my up to 2.7 mph.  At each level, I was breathless for a few minutes... then it went away.  Last night, I treadmilled for 80 minutes, starting at 2.0 mph, but getting up to 3.0 mph by the end.  Again, I had some breathing problems at each speed, but they did not last very long.

High blood pressure can be a cause of chronic aortic valve regurgitation.  While I have struggled with high blood pressure in the past, it was not a recent problem until I ended up in the emergency room with the kidney stone.  I find myself wondering if the high blood pressure brought on by the pain and anxiety might have done some damage -- and the exercise since then is helping.

Throws Up Hands in Disgust

Omega-3 fatty acids are supposed to reduce your risk of heart disease, right?  My cardiologist agrees, so I started taking one of these fish oil supplements.  (After a traumatic experience with a fish as a small child, I have a hard time eating fish that I can recognize as fish.)  But this article from July 10, 2013 NBC News reports that a recent survey finds that high doses of omega-3 fatty acids increases the risk of prostate cancer.

But a startling study shows men who have the highest levels of these compounds – the kinds found in fish but not in vegetable sources -- have a higher risk of prostate cancer. Men with the very highest levels had a 71 percent higher risk of high-grade prostate cancer – the kind most likely to spread and kill, they report in the Journal of the National Cancer Institute.

It might be a sign that popping a pill is not only possibly a waste of money – it might be downright dangerous. And eating fish too often might be, also.

“These fish oil supplements in which some men getting mega, mega doses…in our opinion that is probably a little bit dangerous,” said Theodore Brasky of Ohio State University Medical Center, who worked on the study with a team from the Fred Hutchinson Cancer Research Center in Seattle.

Even worse, the article goes on to report that even the supposed benefits for heart disease may turn out to be overrated:

But the researchers point out that recent studies have shown taking extra omega-3 has little effect on heart disease – including a study published in the New England Journal of Medicine in May. 

That article is pretty interesting -- it describes a study where people at high risk for heart disease, but who were being aggressively treated:

They had not suffered a heart attack but were at high risk of having one because of diabetes, high blood pressure, high cholesterol, smoking, obesity or other conditions. Most already were taking cholesterol-lowering statins, aspirin and other medicines to lower their chances of heart problems.

 And yet the fish oil supplements were no more effective than placebos in reducing hospitalization for heart disease.  And fish oil supplement makers paid for this study.  (I bet they wish that they hadn't.)  What is fascinating to me is that the article quotes an expert who essentially argues that people who eat high fish diets are probably more focused on good health anyway, and that supplements aren't effective alternatives to healthy eating:

"People who choose to eat more fish are more likely to eat heart healthier diets and engage in more physical activity," and studies testing the benefit of supplements may not be able to completely adjust for differences like these, said Alice Lichtenstein, director of the cardiovascular nutrition lab at Tufts University in Boston.

I have a brother-in-law who is skinny, backpacks, bicycles, eats a diet that seems positively hippie compared to me -- and just had surgery for prostate cancer, which appeared quite unexpectedly in his late 50s.  I have read that people who are skinny are more prone to cancers, and those who are overweight are more prone to heart disease.  Perhaps all we are doing is picking different poisons? 

Kidney Stone Article at PJMedia

"How To Avoid Very Painful Kidney Stones"