On a daily basis I engage with patients on the choice making of using medications versus "I'd rather do it on my own with more exercise and better eating". It is hard for most people to accomplish this. Most of us know what we need to do and we just don't do it to the extent that we need to.
This essay is based on a lecture that I gave at a regional symposium for the National Lipid Association as well as at Hoag hospital.
It covers most of the themes that we live life by. There is definitely hard core advice about the things we should do, but it also embraces a very real perspective about many of the themes that impact us.
I hope you enjoy this presentation. Part 1 deals with the really tough stuff!
There was a paper presented in 1976, in the New England Journal of Medicine by my mentor, Dr. Bernard Lown about a case of recurrent ventricular fibrillation (which is the heart rhythm abnormality that causes sudden cardiac death) in the absence of coronary artery disease. It was a case study of a 39 year old man who experienced collapse with ventricular fibrillation on 2 occasions: the first at home in the midst of an intense emotional situation, and the other when in the hospital during sleep. He was successfully resuscitated with CPR and defibrillation. In the hospital, all heart testing including angiography was normal. There was no evidence of structural heart disease. Extensive psychiatric and psychological interaction, sleep EEG, and cardiac monitoring were carried out.
Lown wrote, "He was defensive and covertly hostile and denied being depressed or angry, but his lifestyle pattern was one of controlled aggression." When he went through intense psychological interviews, he was outwardly calm but on the heart monitor he would develop increasing ventricular premature beats, and runs of ventricular tachycardia. (bad heart rhythm disturbances) The second cardiac arrest occurred during sleep and the EEG showed that dreams were taking place.
This was before the era of implantable defibrillators, and the management of this person was complicated, involving both heart rhythm medications, as well as ongoing psychotherapy, and the use of meditation.
I was a Lown Fellow from 1980 to 1982 at Harvard School of Public Health and Brigham and Women's Hospital, and met this man who was alive and well 6 years later.
The research that was done before and during my Fellowship was about the impact of psychological factors and autonomic nervous system issues that could trigger life threatening ventricular arrhythmia. Of 117 patients we saw who had ventricular fibrillation, we identified 25 (21%) who had a discrete psychological trigger that provoked their arrhythmia. (Certain psychological stressors were used during interviewing that consisted of the methodology).
Three conditions appeared to be operating to provoke the ventricular arrhythmia:
1. A certain degree of electrical instability of the heart ( a tendency to provoke arrhythmia).
2. The presence of a psychological state intense enough to invade daily life; low grade depression and a sense of entrapment in life without possible exit.
3. Occurrence within 24 hours preceding the life- threatening arrhythmia of a highly meaningful psychological event that was judged as a precipitation up to the rhythm disorder.
In 15 of the "trigger" patients, the psychological event occurred less than 1 hour before the onset of the arrhythmia. In 17 of the 25, the major emotion was intense anger.
The purpose of the above story is to highlight some of the forces that all people have to struggle with to varying degrees: The really dark and troubling things such as depression, sadness, regret, loneliness, entrapment, unresolved conflict, anger...all of which play a role in your physical health.
A study published in 1974 by RH Rahe assessed significant life changes into "life change unit weights" and assessed the stories of 1279 survivors of heart attacks and another 226 people who had sudden death. Issues such as bereavement, loss of job status, divorce, imprisonment: all had very significant increased incidence of heart attack and death in the first 6 month of these events versus those who did not have these issues: a difference of 12.2% vs. 1.2%.
Education plays a significant role in heart attacks and mortality: Mortality after heart attack was 33% over 3 years in men with less than 9 years of education vs. 9% over 3 years in men who had attended college for at least 1 year. (1973 data, before angioplasty and stents)
To make sense of this, there are the issues of lifestyle risk factors:
Poor dietary habits
An interplay as well of psychological issues, education, career, marriage and relationships... All the life stressors!
These factors lead to overweight bodies, high blood pressure, cholesterol (lipid) issues, diabetes, metabolic problems, endothelial dysfunction, inflammation, thrombosis, leading to subclinical arterial disease (atherosclerosis). This physiologic turmoil leads to a degradation in the artery walls of your heart, and the arteries going up and into the brain. Eventually and at times unpredictably, clinical events can occur such as coronary events, heart attacks, arrhythmias, heart failure, stroke, cognitive decline, and death.
This is the end of PART 1. I wanted to touch upon the sad and bleak stuff which is the stuff that all humans have to live with and deal with to varying degrees. It's much of these emotions and entrapments and behavior patterns that have people stuck in their "same old patterns", making it difficult for so many to "break out" and change their style of behavior let alone their inner world struggles.
PART 2 AND PART 3 will present information and discussion of how to solve some of these prevalent risk issues.