The Heart Beat

By James Beckerman, MD, FACC

Former presidential candidate John Edwards has requested a postponement of his upcoming court dates because of a heart condition reportedly related to an abnormal heart rhythm. There is always more to the story, and more behind the story, but in this case, it’s important to clear up some misconceptions about abnormal heart rhythms, or arrhythmias.

There are as many different types of arrhythmias as there have been Republican front-runners in this year’s primary race. It becomes easier to understand them (arrhythmias that is) if we review a rough sketch of how electricity travels through the heart.

While all of the heart’s cells are capable of initiating a heartbeat, the task typically falls to a group of cells in the right upper chamber of the heart called the sinoatrial node. Electricity then passes south toward another group of cells called the atrioventricular node. The atrioventricular node is like a toll booth, which limits the number of electrical impulses that may proceed throughout the cells in the bottom chambers of the heart. This sums up the electrical pathways that result in a normal heartbeat.

But like in politics, anything can change. Cells can beat too quickly or too slowly, and they can even flip flop. Cells from the upper chambers of the heart can create too many electrical impulses, overwhelming the atrioventricular node and resulting in a fast, irregular heartbeat. Or cells from the bottom chamber can fire on their own, creating an erratic heart rhythm which can be dangerous or unstable.

As you can imagine, any irregularity in your heartbeat or any significant change in your heart rate can cause symptoms, although some asymptomatic people can be surprised to learn they have an arrhythmia. Some people describe their symptoms as palpitations, but they may also experience chest pain, shortness of breath, fatigue, or just a weird sensation. According to John Edwards’ representative, his abnormal heart rhythm may have been associated with a fainting episode. Certain types of arrhythmias may also increase the risk of stroke.

The most important steps in evaluating an abnormal heart rhythm include (1) making sure that the person having it is safe and (2) identifying the abnormal heart rhythm so that it can be treated appropriately. Treatments run the gamut from medications to manage the heart rate or rhythm to devices to prevent extremely slow or very fast heart rates and electrical procedures to shock the heart back into normal rhythm or even burn very small areas of heart tissue to stop the arrhythmia in its tracks. News reports suggest that John Edwards will be undergoing a procedure of some kind, but he has decided to keep the details of his diagnosis and his treatment plan between him and his doctors for the time being.

So it turns out that there is a lot that we still don’t know about John Edwards. But I guess we knew that already.

By James Beckerman, MD, FACC

Paula Deen is having quite a week.  Here’s the condensed version:

1) Paula Deen promotes a lifestyle associated with increased type 2 diabetes risk

2) Paula Deen develops diabetes.

3) Paula Deen endorses diabetes medication.

4) Everybody is talking about Paula Deen.

There is so much outrage and indignation in our tweets, blogs, and editorials as Paula Deen turns lemons into sweet, sweet lemonade. People are upset that she has not acknowledged — to their satisfaction — that bacon, egg and glazed donut burgers may have played some role in the development of her diabetes, or are frustrated that her pharmaceutical endorsement implies that a drug is the ideal solution to address a lifestyle problem.

But maybe we’re also upset because the joke is actually on us.

Paula Deen is not a role model for a healthy life, nor has she ever claimed to be. So why would we expect her to be one now? She is not a doctor with a financial interest in a drug company, nor is she a celebrity trainer endorsing diet pills. People have tuned in to her television shows for years not to learn how to eat more healthfully, but rather to escape into a world of sweets, salt, and fat.  But now this role model for excess has become a victim of her own success.

And so have we.

The more we watch her shows, buy her books, and follow her recipes, the more we expose ourselves to the same risks. But a big difference is that pharmaceutical companies and the media are not coming to our rescue with sponsorships, renewed publicity, and fresh opportunities for future income. We are left on the sidelines, holding our half-eaten bacon, egg and glazed donut burgers, somehow surprised by our collective stomach aches.

Paula Deen has turned our missteps into her success. She has promoted a lifestyle that has not only impacted her health, but has also impacted ours. And rather than feed us real solutions, she appears to be playing a new game.

And unfortunately, we’re probably going to play too.

By James Beckerman, MD, FACC

Happy New Year! And thanks to everyone for helping make 2011 so educational and inspiring in the WebMD Heart Disease Community. All of your posts, comments and insights are appreciated by everyone, especially me. I also value your feedback here on The Heart Beat blog, where I look forward to your posts and would love your input about interesting topics you would like me to cover in 2012.

As we embark on a new year, the Internet is full of commentary about resolutions and ideas about finally doing all those things that we resolve to accomplish each January. With publication of The Flex Diet earlier this year, I am often asked how I think about motivation — and resolutions in particular. I have recently become fascinated with some concepts explored by Tom Connellan in his book The 1% Solution for Work and Life. He believes that we have been approaching resolutions the wrong way. And I think he might be right.

What’s the purpose of a resolution, anyway? Most of us use resolutions to motivate ourselves to change our behaviors. But we know that about 25% of us will give up our resolutions a week from now, and only 10% of us will be sticking with our 2012 resolutions this time next year. So a skeptic might conclude that resolutions as motivators don’t really seem to stick.

So what’s the solution? Remember that while motivation in general can lead to accomplishments, it’s also the case that accomplishments themselves are actually great motivators. When people lose the first five pounds, they feel more excited about the next ten. When you run across the finish line, you want to sign up for the next race. When we experience success, we remember how good it feels. So the first idea is to use your accomplishments, no matter how small, to provide momentum along your journey, rather than just focusing on the big goal.

That’s not say that big goals aren’t good to have. I ran a marathon back in October, and that goal motivated me to run throughout the year (and even this morning!). But we can’t forget that big goals are made up of small stages and many small steps, both literally and figuratively. Rather than set yourself up for disappointment by focusing on how far you are from your big-picture goals, set yourself up to succeed by zeroing in on all the small steps and mini-accomplishments along the way. Going running one day a week is a success if you weren’t running at all. But it’s a failure if you only think about the larger goal of exercising every day. Think big, start small, and set yourself up to succeed.

Finally, let’s be real with ourselves. Change isn’t fun. Even positive change. It’s not fun to wake up an hour earlier to go for a run. It’s not fun to focus on aspects of your life that you would sometimes prefer to be mindless. It’s not fun (for me!) to order vegetables instead of fries on the side. But something interesting happens as you start making conscious changes. Better habits slowly get replaced. Conscious decisions become less conscious. Mindfulness turns into newer, healthier habits. And discomfort becomes more comfortable — and sometimes even fun. When you are at the starting line, prepare yourself for what lies ahead and don’t kid yourself that it will be effortless or that you can somehow beat the system by making positive change a completely positive experience. Many of us expect things to be easy, and we fail when we are reminded that they aren’t. Expect things to be challenging, but make this year different by embracing the challenge and recognizing that eventually, you can create new habits and a healthier lifestyle.

So there you have it. Use your accomplishments rather than lofty resolutions to motivate you. Set yourself up to succeed by thinking big, but focusing on smaller steps. And embrace change for what it really is: challenging, but exciting too.

Thanks again for being here — and have a happy, healthy 2012!

By James Beckerman, MD, FACC

My beeper went off at 4:30 this morning.

I was positioned at the edge of the bed, on my left side, my pager within easy reach so that I can silence its high pitched alert before it wakes my wife.

I called the emergency room and whispered into the phone, realizing that my four-year-old son had snuck into our bed. Cortisol surged. My heart rate went up. I moved quickly, but quietly. I slid out from under the covers, picked my scrubs and hoodie off the floor, and tip-toed out of my bedroom.

The music played loudly and cut into the fog as I drove. I opened the window and felt the cool air against my hand. I thought of my six-year-old, who likes to say that he lives in the clouds.

I complained to no one in particular. I was sad that I wouldn’t be able to help get my kids ready for school. I wondered how this will feel when I am old. Sometimes I see other vehicles on these early morning runs, and I wonder where they are going, and what their drivers are thinking about.

As I came down the hill, the fog lifted and street lights came into focus. I thought about my wife’s dad. I remembered performing chest compressions as a third-year medical student. I pictured the patient’s family in the waiting room.

I took the first parking spot I saw and wrapped myself in my white coat as I ran through the cold toward the automatic doors. Bright fluorescent lights and hard floors shone. I heard the sounds of morning breaking.

I pulled back the curtain.

By James Beckerman, MD, FACC

It’s that time of the year again…we’re just getting over the turkey and stuffing, and any day now we’ll be hit with latkes, eggnog and the dreaded fruit cake. And with these holiday treats come a barrage of advice on how to avoid gaining weight during the holiday season.

First, the good news: The average person who gains weight during the next six weeks will only put on about 0.8 pounds. Not so bad, right? It’s true that more overweight individuals may gain a bit more, but it tends to be much less than we’re led to believe.

But the not so good news? That 0.8 pounds sticks. Like, forever. It turns out that most Americans gain on average about a pound each year during their adult lives. But the fascinating part of it is that it seems to happen primarily during December. So it stands to reason that if we can hold off the holiday weight gain, we might have a shot at avoiding the upwards weight creep that seems to happen to almost everyone else you know.

So let’s focus on December, and worry about New Year’s resolutions in the New Year. Try these ten ideas on for size!

1. Weigh yourself every day from now through New Year’s Day.

2. Keep a food diary during the month of December.

3. Limit television/screen time for the whole family during school holidays.

4. Limit holiday snacks and treats to one a day.

5. Bring healthy food to potlucks and parties.

6. Fill your plate with veggies first.

7. Plan your alcohol intake ahead of time.

8. Don’t skip meals in anticipation of social/food events.

9. Lay off the sauces.

10. Go skinless and avoid processed meats.

Here’s to a happy, healthy holiday season for all. And if you have any strategies that have worked for you, please add them to the comments section below!

By James Beckerman, MD, FACC

Doctors don’t like to be told they may be wrong.

During my medical training and subsequent experience as a cardiologist in clinical practice, I find it striking how despite our track record of innovation and research, we as a profession are not too crazy about the threat of paradigm shifts, particularly when it comes to the definition of a “heart-healthy” diet.

Low in cholesterol. Low in saturated fat. Low in trans fats. Low in refined carbohydrates. Low in processed meats. And the list of lows goes on. When we look back upon the evolution of heart-healthy recommendations, some of our guiding principles are based more on common sense than on long-term research data, and more recent approaches — though sometimes more scientific — sometimes arise from the popular press as well as from scientists breaking from the “party line.”

How do we continue to advance our recommendations in accordance with science, yet avoid providing mixed messages to the public, let alone our physicians?

By now, you have probably heard about the American Journal of Hypertension meta-analysis of 167 studies that was published today. Its purpose was to estimate the effects of various levels of salt in our diets on various markers of cardiovascular risk, like high blood pressure, lipids, and some stress hormones. The conclusion was that despite a small reduction in blood pressure, a lower-salt diet was associated with a worsened lipid profile and higher levels of stress markers of future heart disease.

So what’s a salt-shaker to do?

I probably wouldn’t invest in a salt mine quite yet. While this study does ask some interesting questions, it is a meta-analysis as compared to a placebo controlled prospective study. This means that researchers combined the results of many very differently constructed research studies to form their results. The downside of this design is that some conclusions can occur as the result of chance. In general, we try to avoid making medical recommendations based upon this approach.

The other concern is that we still don’t have very good evidence for or against sodium with respect to its actual impact on heart attacks or other hard endpoints. We tend to measure its impact on risk factors instead, as they are easier to study.

However, I believe that it would be a mistake to ignore this research. I think that this study presents an opportunity for other scientists to create new proposals to readdress the low-salt diet question — and hopefully be able to draw additional conclusions. This report reignites the issue.  Sometimes we forget, but that’s a good thing in science. Even if it does sometimes make us feel uncomfortable.

By James Beckerman, MD, FACC

I’m talking about the media frenzy back in 2009 when President Obama met with Professor Henry Louis Gates and Police Sergeant James Crowley at the White House over beers in the aftermath of Mr. Crowley’s arrest of Mr. Gates at his home.  It was awkward, but President Obama declared its potential as a “teachable moment” for Americans to confront the state of our Union — or lack thereof — with regards to racial issues. But ultimately, this teachable moment was criticized as a lost learning opportunity for multiple reasons – one of which was that in the end, no one seemed willing to say that either party (Gates or Crowley) was truly responsible for what happened.  There was no real accountability.

This got me thinking about what facilitates a successful teachable moment in health care.  We use that phrase quite a bit to describe an interaction between a patient and the medical system in which an intervention (behavioral or medical) is most likely to stick.  This jibes with the popular definition of a teachable moment as described by Robert Havighurst in his 1952 book, Human Development and Education:

“A developmental task is a task which is learned at a specific point and which makes achievement of succeeding tasks possible. When the timing is right, the ability to learn a particular task will be possible. This is referred to as a ‘teachable moment.’ It is important to keep in mind that unless the time is right, learning will not occur.”

One of the most recognized teachable moments in medicine involves the prescription of cholesterol-lowering medication. Studies show that compliance with statins is significantly higher in people prescribed them while in the hospital as compared to in the doctor’s office.  Turns out that a heart attack makes for a pretty captive audience.  We’re pretty good at teaching after the horse is already out of the barn.

But are there teachable moments in prevention? That proves to be much more elusive. But it’s my hope that by dissecting the teachable moment, we might be more likely to create environments in which they can occur. I have identified three components.

The first is Freedom. You need to be in a position to make choices before you can truly change your behavior. You need to live in a safe-enough neighborhood so that you can walk outside. Your kids need decent lunch options at school. You need to have time to be active and to put together a healthy meal. But most of all, you need to be aware that these choices do exist. I feel like we sometimes are in denial that we have choices. It’s true that there are societal, corporate, and even biological obstacles to making sustained changes in behavior, but we shouldn’t constantly use them as crutches. Instead, we should identify opportunities for change and make them more convenient.

The second component of the teachable moment is Accountability. Your choices need to matter.  To you.  To the people who care about you. But what about your employer? Your government? Here’s where it starts to get complicated. We seem to want our infrastructure to care about us (i.e. we want health insurance, and we want appropriate health regulations), but sometimes we don’t want them to care too much, especially when our privacy is involved.  But unless we are held accountable to some extent for the choices we make, our choices seem to matter less.  I want to believe that accountability to ourselves is all we need, but that seems a bit too optimistic.

Finally, there is Responsibility.  When you have freedom, and you are held accountable, something amazing happens. You start making better choices. You assume responsibility, and the best part is that you achieve results.  Responsibility is the key for individuals to make changes.

Think about your own situation. Are there things you’d like to do differently? Remember the choices you have. Remind yourself that you are accountable to yourself, to your family, and maybe to others for those choices. Taking responsibility is one of the unique opportunities you have to make a difference.

Freedom + Accountability = Responsibility.   F+A=R.

All this teaching is making me thirsty.

October 9 was a gray, chilly, and slightly misty morning in Portland, Oregon — basically, a perfect day for a marathon.

Over 12,000 of us ran, walked, and wheeled our way along the 26.2 mile route among throngs of community supporters, marathon volunteers, and even the occasional Occupy Portland protester. It was a wonderful, exhausting day.  I somehow managed to beat my previous PR by almost 20 minutes — I’m already planning the next adventure.

But my silver lining is overshadowed by gray.  As we were starting our race here on the West Coast, the Chicago Marathon was already well underway, albeit in warmer, sunnier conditions.  I was very sad to hear about the tragic death of Captain William Caviness, a 35-year-old father of two and firefighter running to raise money for burn victims.  He was an experienced runner, and a role model for his friends and colleagues.  My impression from the press coverage is that his death could not have been predicted or prevented.  My heart goes out to his family and his community.

As a cardiologist, I spend my days trying to spread the message that a healthy lifestyle is our best bet to prevent heart disease.  I do believe that what we do can truly impact who we are and how our lives can unfold.  But I am reminded that there is no perfect solution.  Many things are not within our control.  Despite my scientific training and my respect for the power of prevention, I also can get frustrated.  And angry.

Because sometimes, life just isn’t fair.

So it turns out that I’m running a marathon this weekend.

Call it peer pressure, or perhaps some navel-gazing around a “significant birthday” that I have in a few weeks. Either way, my wife convinced me about six months ago to run the Portland Marathon. In full disclosure, this wouldn’t be my first time flirting with shin splints — I have gone the distance three times before, although in three very different settings:

• Age 22: A friend and I dared each other to run the Boston Marathon on a Saturday night. We limped across the finish line the following Monday. Couldn’t walk for a week.
• Age 23: A friend dared me to run the Madrid Marathon while we were backpacking across Europe. I stopped for a glass of red wine at mile 23 (I was in Spain, right?). Couldn’t walk for two weeks.
• Age 29: My girlfriend (see “wife” above) dared me to run a flat marathon along the New Jersey shore. I trained a bit, and we crossed the finish line together. Walked her down the aisle the following year.

Fast forward a decade (or more), and here I am contemplating the race this weekend, as well as my propensity to accept dares to run marathons. Fortunately, I am better trained. But I am also older. I can’t help but wear my cardiologist’s stethoscope now and again and wonder about the toll that this type of adventure takes upon a body – and a heart.

We know that abnormal heart rhythms are more likely in athletes who compete in endurance events. We also know that blood tests demonstrating evidence of microscopic heart damage and elevated markers of inflammation are abnormal in about half of runners following a marathon. And we have all heard about the tragedies of sudden death occurring in seemingly healthy individuals during a race.

But the good news is that these events are uncommon: on the order of 1 in 100,000 runners. And when we look more carefully at the autopsy data, we recognize that though the most common cause of sudden death in athletes under age 35 is hypertrophic cardiomyopathy, the most common cause in older individuals is, by far, coronary artery disease.

So if you’re older than 35 and are contemplating a marathon, a triathlon, or even a gym membership, do you need to see a cardiologist? Should you be screened in some fashion? Should you undergo an exercise treadmill test?

It depends. While a simple office-based exercise treadmill test has excellent prognostic value in people with symptoms such as chest pain or exertional shortness of breath, they are not as accurate in people who feel well. They may be abnormal in only about half of people with significant coronary artery disease, and a 10-minute test is unlikely to replicate the physical toll of a four-hour race. Not to mention the false positives that can lead to more expensive or invasive testing.

The other issue is about how heart attacks happen. The conventional wisdom is that a coronary artery blockage develops slowly over time, and ultimately blocks the vessel entirely, thereby causing a heart attack. But we now know that a heart attacks usually occur differently.

In about 70% of people having a heart attack, a previously milder blockage (less than 50%) suddenly becomes much more significant, usually due to the development of a blood clot at the site of a plaque rupture in the wall of the vessel. This sudden process can explain why people who previously had no symptoms can develop a heart attack. And the scary news is that their stress testing might have normal.

So what’s a weekend warrior to do? Take a look at yourself first. If you have a risk factor for a coronary artery disease – such as high blood pressure, abnormal cholesterol, or diabetes, make sure you are on top of it. Hopefully you aren’t contemplating crossing the finish line jones-ing for a cigarette. And if you do have a family history significant for coronary artery disease or sudden death — especially in younger individuals — you should let your doctor know. If you have any symptoms — like chest pain with exertion, shortness of breath, palpitations, or dizziness with exercise, please see your doctor and get cleared before the starting gun goes off.

Race events like marathons are a great way that we can motivate one another to adopt healthier lifestyles (even if it’s from a dare!). Let’s use these opportunities to reduce our own personal risk so that every race can be finished as safely as it begins.

Off to carb-load!

 Like many of you, I spent the better part of this week helping to get my kids ready for school.  New backpacks, shoes, and strategies for healthy lunches gave way to excitement and maybe even some nerves as we walked each of our little boys into their classrooms, reconnected with friends, and introduced ourselves to their teachers.  Was it as nostalgic for you as it was for me?

I’ve always loved the first day of school.  There’s something about the smell of the late summer air in the early morning… a fresh backpack… an unopened textbook — they signify new beginnings.  And despite all the fun we have during our less-structured summers, it’s always amazing how inspired we are by the first day of school.

Every first day presents a unique opportunity to reinvent, a possibility of rediscovery, and the challenge of genuinely new goals to set and maybe even achieve.  Even the most jaded kid can be inspired by a new beginning — by a first day.

So how can you recapture that nostalgia today, in a world where your job never really took a summer vacation, and you’ve been wearing the same old shoes for the past few years?  Is it possible to reinvent and rediscover?

I think so.  The key is finding those new goals to set… and maybe even achieve.  As the kids in your neighborhood start coming home with backpacks filled with books and art projects, maybe it’s time for all of us to invest in some self-starting by trying something new and getting creative about accomplishing some health goals in this new year.  

Find your starting line by seeing your doctor.  Buy a scale, and use it.  Keep a food diary for just a week, and be amazed at how an examined life is truly a healthier life.  

Assign yourself some homework, dig in, and please share your experiences with the rest of the WebMD Community.  We won’t be keeping score.