Opening the Heart and Opening the Arteries

1. Opening the Heart and Opening the Arteries Cardiovascular Disease – A Holistic Approach to Reducing the Risk

2. The typical talk on this subject: Cardiovascular Disease Prevention: Risk Factor Modification • Tobacco • Lipids – diet for a 15% drop, drugs for more, statins, fibrates, etc. • CRP – statins? • Aspirin, plavix, aggrenox, etc. • ACEI’s • Exercise

3. The “Green Medicine” talk on this subject: Cardiovascular Disease Prevention: Risk Factor Modification • Tobacco • Lipids – add in red yeast rice extract, CoQ10 with statins, etc. • CRP – some herbal anti-inflammatory combos • Other blood thinners (garlic, vitamin E, fish oil, etc.) • Exercise

4. This talk • A Whole Person talk on Heart Disease primary and secondary prevention • Mind-body Medicine and Heart Disease • Diet and Exercise changes • If time allows, the subject matter of the “green medicine talk” – natural medicines for treatment of specific risk factors

5. Basic Principles of Holistic Medicine • The Body is a Self-Healing Organism • If we remove toxic influences and provide basic needs, people will often get better • Unconditional Love is Life’s Most Powerful Healer • Do not underestimate the power of this factor (data to follow) • People behave as they do for good reasons: • Self-destructive behaviors are often coping mechanisms that have become meladaptive Even when looking at more concrete risk factors (diet, exercise), we find that in order to help patients adopt the lifestyle measures that provide for health of the body, we need to be watching out for the health of the mind and spirit

6. A Broader Approach to Cardiovascular Disease Prevention: Risk Factor Modification • Relaxation/Stress Reduction • Social Connection/Intimacy • Tobacco • Exercise • Diet • Lipids • Homocysteine and CRP • Fish oil

7. Sickness

8. Causes of Death Causes of death: Trauma is #1 age 1-44; Cardiovascular leads cancer

9. Causes of Death

10. Actual Causes of Death Source: McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207–12. (1990 data). Note: The percentages used in the figure are composite approximations derived from published scientific studies that attributed death to these causes.

11. Actual Causes of Death Physical inactivity and unhealthy eating are responsible for at least 300,000 preventable deaths each year. Only tobacco use causes more preventable deaths in the United States.

12. The Rules of Tacks 1. If you are sitting on a tack, it takes a lot of aspirin to make the pain go away. 2. If you are sitting on 2 tacks, removing one does not result in a 50% improvement in symptoms. (It still hurts to sit down.)

13. Healing the Heart:Further Broadening the Discussion • The heart is a metaphorically important organ as well as physiologically important • Interestingly, science is showing that caring for our metaphorical heart is important for the health of the physical one: • stress and isolation might be added to inactivity, poor diet, and tobacco as actual causes of this illness

14. The Essential 8 • Air and Breathing • Water and Moisture • Food and Supplements • Exercise and Rest • Play/Passion/Purpose • Gratitude/Prayer/Meditation • Intimacy & Connection • Forgiveness Body Mind Spirit

15. Mind and Spirit • The role of stress in heart disease: In 683 patients, there was a significant non-uniformity to the distribution of threatening arrhythmias, sudden death, and MIs, with the major peak on Mondays (p<.001) Peters RW et al. Circulation 1996; 94:1346

16. Stress A Definition

17. Stress • Homeostasis based definition: stress is the compromise of homeostasis: an imbalance that can lead to changes over time (as the physiological adaptation occurs) or dysfunction. • Adrenal-based definition. The state of adrenal activation stimulated by the influence or detection of an environmental challenge to the body's homeostatic mechanisms that cannot be accommodated within the normal metabolic scope of the animal. Rooted in the observations of adrenal hypertrophy (due to overactivity) in chronically stressed animals.

18. General Adaptation Syndrome (GAS) • The Response to Stress, in 3 Phases: • Alarm Reaction • Stage of Resistance • Stage of Exhaustion

19. Alarm Reaction: Fight-or-Flight • Evolutionary Role: escape from predator or acute physical danger

20. Alarm Reaction • Physiological changes: Adrenal hormones adrenaline (epinephrine) and norepinephrine • Metabolism increases • Heart rate increases • Blood Pressure increases • Breathing Rate increases • Muscle Tension increases

21. General Adaptation Syndrome (GAS) • The Response to Stress, in 3 Phases: • Alarm Reaction • Stage of Resistance • Stage of Exhaustion

22. Stage of Resistance • HPA (hypothalamo-pituitary-adrenal axis: Cortisol increases when stress becomes chronic • Block energy storage and help mobilize energy from storage sites • Increase cardiovascular tone • Inhibit anabolic processes such as growth, repair, reproduction and immunity

23. General Adaptation Syndrome (GAS) • The Response to Stress, in 3 Phases: • Alarm Reaction • Stage of Resistance • Stage of Exhaustion

24. Adrenal Exhaustion • Coping responses cannot sustain their response if stressor is sufficiently severe and prolonged • “Diseases of adaptation" may arise • Hypertension • Ulcers • Heart disease • Symptoms that disappeared during the stage of resistance may reappear • Death possible

25. Physical and Psychological Side Effects of Stress The body cannot distinguish physical danger from psychological threat For most modern stressors, the value of increased heart rate, increased muscle tone, etc. is less, and those changes are not utilized for physical exertion, leaving the organism aroused without a release (one part of the solution is cognitive therapy)

26. Maladaptive Symptoms with Acute Stress Hormones • Cold Hands and Feet • Palpitations • Diarrhea or Constipation • Decreased sleep

27. Maladaptive Changes with Chronic Stress • Worsened blood sugar control/increased insulin resistance • Increased visceral fat deposition (apple-shaped weight gain) • Increased inflammation • Decreased immunity

28. Documented Relationship of Illness to Chronic Stress • Susceptibility to the common cold correlates with psychological stress Psychological stress and susceptibility to the common coldS Cohen, DA Tyrrell, and AP Smith NEJM Volume 325:606-612 August 29, 1991. Number 9 Several potential stress-illness mediators, including smoking, alcohol consumption, exercise, diet, quality of sleep, white-cell counts, and total immunoglobulin levels, did not explain the association between stress and illness. Controls for personality variables (self-esteem, personal control, and introversion-extraversion) failed to alter findings. • Timing of heart attacks – as previously mentioned Many studies have shown an excess of cardiovascular events on Mondays. A relative trough has been seen on Saturdays and Sundays compared with the expected number of cases. Highest incidence is within the first three hours of waking on Monday morning. New Insights into the Mechanisms of Temporal Variation in the Incidence of Acute Coronary Syndromes Strike PC, Steptoe A, Clin. Cardiol. 26, 495–499 (2003)

29. Blaming or Taking Responsibility • Understanding the importance of stress in our medical conditions gives us the power to use stress management to decrease illness and change our experience of it • This concept should not be used to blame people for their illnesses

30. Mind-Body and Body-Mind Interactions in Chronic Illness

31. Hormonal Effects as described for cortisol Vasoreactive effects with adrenaline Sleep disruption causes multiple physiological effects (Shift work increases the risk of CHD by up to 50%. Scand J Work Environ Health. 1997 Aug;23(4):257-65) How Emotions and Stress Affect Disease Risk

32. How the Body Affects Emotions and Stress • Body tension is perceived as emotional by the brain • Pen demonstration • “I have so much to do” • Therefore, some simple physical relaxation techniques can help to alleviate mental/emotional stress • Abdominal Breathing

33. The Relaxation Response • Counterbalancing mechanism to the Fight-or-Flight Response • Metabolism decreases • Heart rate decreases • Blood Pressure decreases • Breathing Rate decreases • Muscle Tension decreases • May be consciously elicited • Generally needs to be practiced

34. Diaphragmatic Breathing Meditation Body Scan Mindfulness Repetitive exercise Repetitive prayer Progressive muscle relaxation Yoga Stretching Imagery (Music) Techniques Which Can Elicit the Relaxation Response

35. Common Elements of Techniques Used to Elicit the Relaxation Response • Focusing of attention through repetition of words or physical activity • Passive disregard of everyday thoughts when they occur, and return to the repetition

36. Benefits of the Relaxation Response • Immediate: • Getting through procedures and short-term stress • Long-term: • Used consistently, there are carry-over effects

37. Spirit • Meditation/Prayer/Gratitude • Intimacy and Connection • Forgiveness

38. Relaxation Practice and the Mind-Body - heart In 107 patients with ischemic heart disease, 38-month risk for cardiac events was 0.26 in those who had undergone sixteen 1.5-hour sessions of stress management cognitive education and relaxation training (p=.04) v. conventionally treated controls Blumenthal JA et al. Arch Intern Med 1997; 157:2213

39. Just for Comparison: • 4S trial – RR 0.67 after 5.4 years treatment with simvastatin Circulation. 1998;97:1453-1460 •  MIRACL Trial (higher risk patients, like the relaxation trial): RR 0.84 in 16 weeks on atorvastatin 80 mg vs. placebo JAMA. 2001;285:1711-1718 • LIPS – RR 0.78 after 3-4 years post PCI on fluvastatin 80 mg vs. placebo JAMA Vol. 287 No. 24, June 26, 2002 • EUROPA and HOPE trials show approximately 20% reduction in risk of events over 4 to 5 years of treatment with an ACEI Lancet 2003 Sep 6; Vol. 362 (9386), pp. 755-7

40. Religious Expression • Mortality – 39/52 studies – religious persons lived longer – 12/13 more recent (and more rigorous) studies found significantly longer survival, especially among those who were active in the religious community

41. Spirit • Meditation/Prayer/Gratitude • Intimacy and Connection • Forgiveness

42. Connection with Parents The Harvard Mastery of Stress Study 126 male Harvard students were asked questions regarding their relationship with their mothers and fathers. They were then followed for 35 years regarding their own development of health risks and illness. The key question was: Would you describe your relationship with your mother and father as: Very close Warm and friendly Tolerant Strained and cold

43. On follow up, 35 years later, the outcomes were as follows: • If relationship with Mother was: • Tolerant or strained - 91% had significant health issue • Close and Warm - 45% had significant health issue • If relationship with Father was: • Tolerant or strained - 82% had significant health issue • Warm and close - 50% • If relationship with both parents was: • Strained - 100% incidence of significant health risk • Warm and close - 47% had a significant health risk

44. Connection in Marriage Angina pectoris among 10,000 men II. Psychosocial and other risk factors as evidenced by a multivariate analysis of a five-year incidence study. Medalie, JH and U. Goldbourt, Am. J of Medicine, 1976, 60(6): 910-21 10,000 men were surveyed and followed for 5 years. The key outcome was the development of angina. Men with substantial risk factors for CAD (elevated cholesterol, age > 45, HTN, diabetes, EKG abnormalities) were 20 times more likely to develop angina than men without those risks. When asked, "Does your wife show you her love?“ men within the high-risk group who said, "Yes" had half the development of angina.

45. Social Connection The “Alameda County Study”– LF Berkman, LS Syme, L Breslow – multiple publications. 6,900 participants were surveyed and followed for 17 years. Key issues were contact with friends and relatives, church membership, membership in clubs or groups, and marriage.Those without close ties or frequent social contact had an overall death rate 3.1 times higher than those who did have these contacts. Social and community ties were more predictive than smoking (1.8), overeating, physical activity, etc. This has been confirmed in Sweden, Finland, Evans County Georgia and many other communities

46. Social Connection – Altruism • Tecumseh Community Health Study • Some social activities were more protective than others. Those who volunteered to help others at least once a week were 2 ½ times less likely to die during the 9-12 year study than those who never volunteered • Science 1988, 241:540-45

47. Social Connection – Altruism • Study of women with children – Major illness developed over a 30 year period in • 36% of women who were members of volunteer organizations • 52% of women who were not members of volunteer organizations Successful Aging, American Journal of Sociology, 1993, 97:1612

48. Connection & Heart Surgery Outcome U Texas study on people having heart surgery • Do you participate in organized social groups?Yes No Yes No • Do you draw strength from your religious or spiritual faith? Yes Yes No No Risk of dying 6 months later3% 9% 8% 22%

49. Intimacy Into-Me-See – An element of disclosure/trust Social support: simple ratings of feeling loved are more important than number and size of networks Someone special, whom you can lean on, to share feelings with, to confide in, to hold and comfort you

50. Pets • Having a pet: CAST trial which looked at flecainide and encainide • Death rate 1.1% of people who owned dogs 6.7% of people who did not own dogs • In one study, the effect of a dog on lowering blood pressure reactivity was greater than the presence of a good friend, since the friend was often perceived as being judgmental whereas the dog was not