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Five Lessons From My Heart Attack Patients

In only few months, I leave my clinic where I have been seeing patients with heart disease for the past three years. It was not until I started discussing with them the transition to a new cardiologist that I appreciated the unique relationship we have built.  It has only been few years since we first met in in the Emergency Department in the middle of the night as they were having a heart attack, but somehow this journey feels longer.  I witnessed their heart attacks change their lives in many different ways, as they learned to cope, recover and carry on in life with a story to tell. Being one of the characters in their stories, I learned five lessons about life that will stay with me.

 

1- You can make any terrible event a wake up call or the beginning of the end.

A big heart attack or sudden cardiac arrest is arguably the most terrible event one could experience. As my patients recovered from such an event and came to see me in clinic, I could tell that the event changed them, either to the better or to the worse. While some lost weight, started training regularly, left their high stress jobs, or decided to travel the world, others became even more sedentary, gained weight, and started lamenting their bad luck and “missed opportunity” for good health.  It was striking to observe those two trajectories of opposite directions. Like my heart attack patients, when you are faced with a terrible event in life, you can either use it as a wake up call to do better afterwards or fall off a ledge and spiral down. You decide your own fate.

 

2- A supporting family is worth all the medicine of the world.

One patient after another, it became clear to me that the presence of a supporting family member that cares for you during difficult times is worth the most state-of-the-art medicine. It is that person that ensures that your food is low in salt and has no butter, that you do your daily exercise and not miss your medication, that you come to your appointments and ask all the right questions, or that simply hold your hand and tell you it’s going to be okay when things turn sour.

 

3- You’re as old as you think you are.

I met a 90 year-old woman who had a big heart attack and went for the most aggressive therapies. A year later she still shows to my clinic fully groomed and cheerful telling me she picked up dancing and life could not be any better.  I also met a 50 year-old man who after a small heart attack gave up on enjoying life or hoping for better future and couldn’t be convinced otherwise.

 

4- Faith, hope, and courage are your best friends when you’re not in control.

When patients are waiting for a high risk surgery or intervention, they simply are not in control of their fate. I found that those that fared well had three unique characteristics. First, they had faith in themselves, their doctors, or God. Second, they always hoped for the best. Third, they had the courage to face a difficult reality when things don’t go as well.  Whenever you’re not in control, let faith, hope, and courage always be your best friends.

 

5- Write your best story today because you never know when it ends.

While I learned so much from the stories of those patients who made it to my clinic, many did not, and their stories ended in the hospital. As you go through life, live every day to the fullest and write your best story page by page, because you really never know when it ends.

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New Guidelines on the Most Effective, Most Accessible Health Intervention on the Planet Released at #AHA18

The new physical activity guidelines from DHHS were released, not coincidentally I suppose, on “Sneaker Day” at #AHA18. I walked up the 5th floor of McCormick place to hear Adm. Brett Giroir, MD, Assistant Secretary for Health present the update. I was excited to see this one, because I’m a lover of activity— running, yoga, strength training, dance, martial arts, hiking, swimming, etc. Activity makes me feel good, and I’ve seen the change in other people (friends, patients) who’ve become active. And because, as a clinician who works with underserved people, I love health promotion activities that are free.

I was curious to hear what the approach would be. Much of the “big news” at AHA is related to drug and intervention trials. Physical activity is a different kind of topic— one that isn’t necessarily the primary domain of many of the attendees. How would this group from HHS fit in? Giroir said, “Our overarching goal is to transform the current sick-care system into a health-promoting system.” Here, here! Not only is this intuitively appealing, but it better aligns with value-based payment systems that are coming down from on high. We’ve heard a lot about trying to align financial incentives in less perverse ways, so let’s keep a watchful eye on that. I like interventions that are free— but there’s a big machine out there that doesn’t agree, and it can be hard to get the same kind of traction.

So that said, what’s in the new guidelines? There aren’t big shifts in the actual recommendations, but there’s an important change in the messaging.

  • First, the guidelines address the need for activity in all people, including toddlers (for the first time), people with chronic illnesses, pregnant and post-partum women, and older adults. Message: activity matters for everybody.
  • The next key point is that all activity counts— it doesn’t need to be in designated sessions and it doesn’t matter if it’s just a few minutes at a time. The target numbers haven’t changed– but the message now includes that people should “move more and sit less” throughout the day, and any activity is better than none. As physical therapist Dr. Kelly Starrett says, the best position is the next position. This messaging also suggests that not only is activity healthful, but sedentary time is detrimental to health. It’s a two-sided coin, and it’s important to think of it that way. We’ve heard “sitting is the new smoking”– and the evidence here suggests that’s not off the mark. The key message is that activity that’s part of the day-to-day way we live is important to our health. I’ve said this a lot to patients, but it’s great to have the guidelines– and evidence– back it up. The recommendation to get activity throughout the day should strengthen support for programs that encourage movement in all kinds of contexts.
  • The last major theme is that activity is even better for us than we previously knew. Much of the evidence reviewed isn’t about what to do, or how, or even how much— but rather, that any and all activity is healthy in ways we hadn’t previously described and measured. Health benefits are immediate, and include lower anxiety, lower blood pressure, better sleep, and better insulin sensitivity. Long-term benefits include reduced cancer risks (including types for which the benefits were previously not described), better brain health, less weight gain, and fewer risky falls. For those with chronic illnesses, it can reduce pain, symptoms, and disease progression and improve cognition. It’s a testament to our physical activity research community (including lots of great work presented this week!) that we have all this data. Can we turn this data into action? We can’t do it exclusively in a clinical setting, despite our best intentions. We’ll need implementation studies. We’ll need CBPR. We’ll need policy advocacy.

 

Just 26% of men and 19% of women meet the current guidelines. The bar in these guidelines isn’t high. This tells me that we need to work on systems. Schools, workplaces, and public spaces are low-hanging fruit. Chapter 8 of the guidelines also touches on faith-based settings and mass media campaigns. Dan Buettner’s The Blue Zones is an example of a program that’s ahead of the curve, working with communities to tweak infrastructures and build social communities to keep activity in the fabric of life. Michelle Obama’s “Let’s Move” project took a stab at the public messaging approach. What else could we try? In a Viewpoint article for JAMA, Giroir & Wright make some systems suggestions, and also touch on the potential for wearable tech and workplace initiatives to move the needle. These are well-trodden paths, and we’re still waiting for strong evidence of efficacy. Personally, I’d like to see rules and norms encourage activity-friendly clothing and footwear in professional settings (#SneakerDay every day!?). Can we make it “OK” to stand for a bit when our tracking devices remind us that we’ve been sitting for an hour? Can we support activity with locker rooms at work? Better and more accessible training for healthcare workers on exercise prescription? More clarity on the roles and qualifications of fitness professionals? #AHA18 had a heart failure “Hackathon” this year to generate novel ideas– can we come up with some innovative ways to improve implementation of the cheapest, most effective treatment we have for poor health?

 

 

 

References:

U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd Edition. Washington, DC: U.S. Department of Health and Human Services; 2018.

Giroir BP & Wright D. (2018). Physical activity guidelines for health and prosperity in the United States.  JAMA, published online 11/12/18.