Heart Health

What's Harder on the Heart: Mental or Physical Stress?

Stephen T. Sinatra, M.D., F.A.C.C. — Tue, 21 Apr 2009 23:35:32 +0000

If you guessed "mental stress," you are right. While exercise stress tests on the treadmill can provoke transient heart symptoms, mental stress is much more demanding...and even debilitating...over the long run. And the two together can be devastating.
I recall a study some years ago where researchers evaluated 126 volunteer patients (112 men and 14 women) with a history of coronary artery disease. In a laboratory setting, the volunteers underwent a series of psychological stress tests including mental arithmetic, during which they were asked to perform a series of additions and calculations. Then they were asked to do public speaking, reading and a structured interview designed to provoke aggressiveness and irritation. After a 20-minute rest period, the subjects performed an exercise stress test on a bicycle.
Cardiovascular responses to the mental and physical stress tests were evaluated using sophisticated nuclear radiology techniques that measured motion abnormalities in the heart's left ventricle. During a two-to-five-year followup, 28 patients had at least one cardiac event ranging from new heart attacks, bypass surgery and angioplasty. Two patients suffered fatal cardiac events.
The researchers found that patients who had overreacted to mental stress had nearly three times the relative risk of having a cardiac event or dying compared to patients who did not exhibit cardiac vulnerability from mental stress. The findings also confirmed that exercise-induced diminution of cardiac blood flow was not as strong a predictor of subsequent cardiac events as poor response to mental stress. This suggests that mental stress is a much more accurate predictor of cardiac events than traditional exercise stress testing. This particular study strengthened my belief in the role that psychological stress plays in cardiac events--and which I was seeing on a pretty regular basis in my practice.
Some years ago, I gave a talk to the American Heart Association on stress and cardiovascular disease. One of the local chapter officers came up to me afterwards and said, "I really appreciated your lecture. Nothing provokes my angina like getting into a verbal confrontation with my 16-year-old son."
We typically associate only unpleasant or undesirable events (such as being layed off or losing a spouse) with stress, but happy or joyous events (such as the arrival of a new child or getting a promotion) can also be quite stressful.
Properly handled, neither type of stress usually escalates into a physical problem. But unhealthy responses to stress, or a prolonged stress reaction, like driving too fast, drinking, overworking, overeating and suppressing anger or grief,can stoke serious health consequences.
I have often used emotional healing techniques and short-term therapy sessions for cardiac patients. The goal is to help achieve relief from anxiety, obsession, depression, and unresolved feelings. Talking over a problem with someone you trust can help you find a satisfactory solution to distinguish between things that are "worth fighting for" from those that are less important.
Getting feedback and support from others, such as in group psychotherapy situations or with a private therapist, it is possible to gain new insights into yourself that can also put you on the road to physical healing or prevent trouble down the road. Mind/body medicine works wonders!

Sorting out the "multiple personalities" of Cholesterol

Stephen T. Sinatra, M.D., F.A.C.C. — Thu, 05 Mar 2009 22:33:06 +0000

Glenda is one of my nurses. She approached me recently to ask about her cholesterol. She was concerned because her family doctor wanted to give her a prescription for Lipitor, the popular cholesterol-lowering drug. Her blood test results had come in, showing her total cholesterol at 271 and LDL at 165. By standard measures, those levels are considered "high."
Hold off on the prescription, I said to her, and recommended she take a new, more comprehensive lipid test now available to doctors. There are two of them to choose from: the VAP test (short for vertical auto profile), developed at the University of Alabama, Birmingham (UAB) Medical Center, and the Lipoprotein Particle Profile test offered by SpectraCell Laboratories in Houston.
These tests are a boon for doctors and not just cardiologists. I've been practicing cardiology for 35 years and have lived with the cholesterol-as-the-devil story that whole time. What you see and hear about cholesterol on TV and read in the newspapers is generally all nonsense. The "official" line about how high is your cholesterol is pretty much irrelevant. Numbers are misleading. Half the people who die from heart attacks have "normal" cholesterol levels.
To get a relevant picture of disease risk from your cholesterol, the standard lipid profile tests that most doctors perform really come up short. Just testing totals of cholesterol, high density lipoproteins (HDL), and low density lipoproteins (LDL) doesn't tell you enough. Such monitoring is probably only 40 percent accurate in predicting risk for heart attack. More information is needed if we are to utilize blood lipids as a reliable risk assessment. Thanks to medical science, we now have better tests that can break down the many components of cholesterol, and most importantly, single out the most dangerous fractions. You can now get a much more accurate picture of what may or may not be a cholesterol problem.
Here are just a few of the key readings these tests give you that the old test doesn't:
● Your LDL Components
Higher levels of LDL are considered to increase the risk of heart attack and necessitate treatment. But LDL, for the most part, is really a good guy-a sheep slapped with a wolf's reputation. Your basic cholesterol is none other than LDL-a fatty substance produced in the liver and wrapped in a protein coating that allows it to circulate in the bloodstream. It performs absolutely essential services in the body as a raw material. Enzymes convert it to vitamin D, steroid hormones (like estrogen, progesterone, testosterone, and cortisol), and the bile acids needed for digestion. LDL does have multiple personalities, however, and the new tests nicely identify who's who. LDL becomes dangerous when it is oxidized or overly present as a small dense particle as opposed to a larger, fluffy more "buoyant" particle.
● Your Lp(a) Level
The tests monitor a subtype of LDL called Lp(a). When this substance rises abnormally in the bloodstream, the result of a genetic flaw, it can increase the risk of heart attack up to 25 times. I consider it to be the most dangerous form of cholesterol, a highly inflammatory and thrombotic agent. There is no conventional medication for it Lp(a), but niacin (vitamin B3), high dose vitamin C, nattokinase (a supplement made from the Japanese soy dish natto), and fish oil will help neutralize it. I have seen many patients with normal cholesterol and high Lp(a) who have had coronary disease. Anybody with a family history of cardiovascular disease needs to check out their Lp(a) level.
● Your HDL Subtypes
A high level of HDL-the so-called good cholesterol-is generally associated with protection against heart attack. We now know that HDL is further classed into subtypes HDL1 and HDL2. Both reduce risk, and in the new tests, you get a measurement for both. The difference between the two: HDL2 is far superior to HDL1 in providing protection for the heart.
● IDL (Intermediate density lipoproteins)
This is a type of blood fat that represents an inherited independent risk factor for heart disease. I had never heard about this substance until recently, so even old dogs like me can learn new tricks.
● Triglycerides fractions
Previous blood tests give you a total triglyceride level, and anything above 180 is considered abnormal. With these tests, various triglycerides are singled out. The one to be concerned about is called VLDL3, the most inflammatory triglyceride, considered a prime indicator for coronary artery disease progression, insulin resistance, and type II diabetes. Triglycerides are fat globules in the bloodstream. In a concentrated form, they create the fatty "love handles" around your midsection.
To see how these tests can make a difference, let's return to my nurse, Glenda. The VAP test revealed her LDL mostly of the large, desirable particles. Her HDL fractions strongly favored the superior kind. Her IDL level was low, in the range where you want it. The test, however, showed her Lp(a) somewhat elevated. In reviewing her results, I felt the only thing needing improvement was Lp(a), so I recommended Glenda take some niacin, nattokinase, and fish oil.
If her regular doctor had put her on a statin drug, as he wanted to do to lower her cholesterol, the drug would have had more potential to do harm than good. Statins drive up Lp(a), and, of course, deplete the body of CoQ10, a natural substance produced in the body that is critical for cellular energy. It is this depletion that causes muscle pain, a common side effect with statins.
By way of example, here's another patient of mine who was helped by these tests. Dave had a history of heart disease. His results showed a high level of VLDL3 (the inflammatory triglyceride) and an excess of small dense LDL particles. His case warranted prescribing a potent anti-inflammatory medication like a statin. He had a threatening cholesterol profile and not just a vague count of total cholesterol.
You can readily see the major benefits from these advanced cholesterol tests just from these examples, and understand why I urge you to take advantage of them when you have a checkup. My hope is that these tests, as they become more and more popular, will put the brakes on the runaway statin prescribing mentality affecting doctors today who pull out the prescription pad at first sight of elevated cholesterol.
The bottom line: when your doctor talks about getting your cholesterol checked, ask for the VAP test, or the SpectraCell test. For more information on these tests, which are covered by Medicare and most health insurance plans, go to the following web sites: www.thevaptest.com, www.spectracell.com.

Protecting Your Health

Stephen T. Sinatra, M.D., F.A.C.C. — Sun, 11 Jan 2009 20:11:41 +0000

During the continuing economic turmoil, the plight of an 89-year-old Massachusetts man aired on TV's Good Morning America put the situation in a very poignant, personal framework.

Paul Camyre was unable to pay his heating and tax bills. "I've been around a long time," he said, "and I never saw anything like this." The World War II combat veteran was too proud to ask for help. Family members and friends didn't know of his dire straits. But Lady Luck appeared magically-somehow out of the blue-in the form of producers from the popular TV morning program. They filmed his plight. After the story was shown Mr. Camyre received a flood of money from generous Americans that enabled him to meet his financial challenges.

For most people there is no such luck falling into their laps and for many, savings, investments, and jobs have been wiped out. And for the unfortunate ones, Jimmy Buffett's 1999 song "There's Nothing Soft About Hard Times" seems to aptly describe the situation. There are, however, some actions each and everyone of us can and should do to soften the potential damage that hard times can exert on our health.

During the course of my decades in medical practice I have treated numerous patients who developed cardiac arrhythmias, high blood pressure, strokes and heart attacks as a result of stressful events in their lives, including finances gone sour. Stress comes a knocking in many shapes and forms and can be as deadly as a bullet unless we learn how to fortify ourselves.

I always tell patients going through hard times to be strong and develop some thick skin because if not they will lose their health in addition to whatever losses they are dealing with-whether it's a marriage on the rocks, a beloved spouse who has died, or the loss of a job or a financial setback. I tell them to remember that their primary asset in life remains their health, and to treasure and safeguard it.

I would like to share with you some of the recommendations I have given to patients over the years to help them maintain health during periods of stress:

• Rally around your community, the supportive environment of family, friends, and religious and spiritual affiliations. Talk to those who know you and love you. You can better withstand stress than if you are alone.

• Be grateful for all that you have. Express gratitude on a regular basis. While watching an HBO miniseries on John Adams and life in early America, I was struck by the stark contrast of the lives of those people in comparison to ours. They were constantly threatened by death, disease, and the elements. They were tough. But they pulled through. Many of us in this age of convenience and abundance have become jaded and thin-skinned. Stop and take stock. Be grateful.

• Meditate. It's a great natural relaxing method that puts the brakes on speeding stress hormones. I have been doing Transcendental Meditation for years and it particularly serves me when my mind is running amok. There are many different forms of meditation, and, of course, prayer. Yoga and Tai-Chi are effective as well. Find something that works for you and do it regularly.

• Stress erodes health in many ways, major and minor. Nutritional supplements can help protect you.

--Vitamin C (at least 500-1,000 mg daily), a reliable protector of your adrenal glands that can become depleted from chronic stress;

--B complex nutrients, found in multi vitamin formulas, help protect your nervous system;

--Magnesium (400 mg), a critical mineral in many of the body's enzymatic reactions. It is depleted by stress;

--Fish oil (at least 1 gm) protects your arteries and helps prevent plaque eruption;

--White chestnut, a superb flower remedy available in health food stores. It helps calm fear and anxiety. Take 5 drops three times a day.

• Exercise. A brisk walk or workout takes your mind off problems.

• Play with a pet or a grandchild.

• Be available to others. We are all in this boat together. We all have our problems. Helping others is good for your emotions and your body. It makes you feel good about yourself. Psychologists call it the "server's high."

• Look for opportunities in a crisis time. Don't succumb to a victim mentality.

• Finally, put things into perspective: "Don't sweat the small stuff because it is all small stuff." I share that perfect piece of advice with patients all the time. I got it from Is It Worth Dying For?, a 1984 bestselling book written by Robert Eliot, a cardiologist at the University of Nebraska.

Eliot, while standing at a hospital podium in the mid-1970s and delivering a lecture on how to prevent heart attacks, suffered the very thing he was talking about: a heart attack. He was 44 years old at the time. He survived the event and made a full recovery. As he returned back to health he recognized that stress had brought him down and that he had to make dramatic lifestyle changes or else he was a goner. With a new lease on life, he went on to establish the Department of Preventive and Stress Medicine at the University of Nebraska Medical Center and became an outspoken advocate for productivity without self-destruction.

Eliot's examples serves us all well in these times. No matter what happens we need to ask ourselves: Is it worth dying for?

Happy, Healthy Holidays -- Without the Sugar

Stephen T. Sinatra, M.D., F.A.C.C. — Mon, 08 Dec 2008 19:36:25 +0000

Holiday time is here again, and typically a time we go collectively crazy for all things sweet, with temptation galore, for kids and adults alike, to overeat sugary empty calories.

Do you remember that popular song from years gone by: "Sugar in the morning, sugar in the evening, sugar at suppertime?" That aptly describes the bingeing opportunities that start with Thanksgiving and run through Jan. 1 and results in an average weight gain among American adults of anywhere from seven to ten pounds. The cause? Too many refined carbohydrates-and sugar is a carb-that become stored as fat if not sufficiently metabolized by insulin.

xcess dietary sugar raises the sugar level in your blood. In response, your body tries to control the sugar by releasing insulin, a pancreatic hormone. A rush of insulin brings your blood sugar level down, but the drop can leave you tired, irritable, and even depressed. Plus, excess insulin is the most potent inflammatory hormone, causing damage to arteries and contributing to atherosclerosis and heart disease.
The higher your blood sugar goes, the higher your insulin surges, and the faster you age. All of you. From the skin on the outside to pumping central, your heart, and all of the tissues in between.

Here are some suggestions to help you get through the holidays-and beyond:

1.Read labels! Most of the sugar you eat is hidden in or added to processed foods, drinks, desserts, and cereal bars-much of it labeled as high fructose corn syrup. This corn-based product sweetens up thousands of foods, from ketchup and tomato sauces to soft drinks, crackers, processed meats, and even so-called health food products. Researchers and medical professionals regard high fructose corn syrup as a toxic and inflammatory agent affecting obesity, diabetes, and heart disease. Take care to avoid these sneaky sugar products.
2.Steer clear of doughnuts and pastry. You get the sugar, plus damaging hydrogenated oil and processed, fiber-less flour.
3.Beware of sodas. They are liquid candy-the number one dietary source of added sugars. Studies connect them to weight gain and numerous nutritional deficiencies. For example, sodas rich in phosphates inactivate magnesium, a critical mineral for your health. And while I'm on the subject, watch out for sweetened trendy teas, energy drinks, and sports drinks. One popular brand of vitamin-infused water has more sugar per bottle than a Krispy Kreme doughnut!
4.If you need to sweeten any foods, add a little juice from oranges, grapes, pears, peaches, or other fruits. You can also use some shredded raw or dried apples, coconuts, raisins, or dates. Try sprinkling on cinnamon, cloves, or nutmeg. You also may want to experiment with stevia, an herbal supplement that millions of people use as a sweetener.
5. Eat several small meals, starting with breakfast, and include some protein at each sitting to keep you feeling satisfied. By eating little portions throughout the day, you will be less inclined to overload on party food.
6.As far as dessert is concerned, challenge your willpower. If you can't resist, take a couple of bites but no more.
7.If you have difficulties controlling sweets, check out the web site www.sugarshock.com. It's the work of veteran journalist Connie Bennett, who suffered dozens of debilitating symptoms for years until a doctor connected her malaise to overeating processed carbohydrates and sweets, particularly red licorice, chocolate, and hard candies. She changed her diet-and changed her life. She's all energy and enthusiasm now.
8.Limit alcohol intake. This includes wine, beer, and liquor. Many people don't realize that alcohol contains a large store of hidden sugar.

Remember, if you eat sugar all day long, you will just continue to crave it. So avoid it in the first place!

Lessons from Joe the Survivor

Stephen T. Sinatra, M.D., F.A.C.C. — Tue, 21 Oct 2008 22:36:12 +0000

One of the major stars (or distractions, not sure which) to emerge out of the raucous run-up to the 2008 elections was Joe the Plumber. In keeping with the Joe theme, I'd like to share my own Joe story with you. Call it Joe the Survivor.

Joe was about sixty when I first saw him in 1977. He was in bad shape for his age, with arteries so clogged that he lived on nitroglycerine to keep his angina at bay. His angiography results were disappointing to say the least-coronary arteries like rosary beads, which ruled out bypass surgery as a solution. Joe was a treatment nightmare, and his odds of living a long or comfortable life were slim.

The traditional treatment three decades ago was to limit Joe's symptoms by slashing the oxygen demand on his heart with medications such as beta blockers to hold down his heart rate and blood pressure. A pacemaker guaranteed we didn't drop his heart rate too low on drugs.

By 1980, Joe wanted to try intravenous chelation. When surgery isn't an option, some people do get symptom relief from this technique, so I agreed it was worth a try. Sixty treatments later, Joe's symptoms were much less.

As I became interested in nutritional medicine, I started Joe on a multi vitamin/ mineral and antioxidant formula, then CoQ10, an extraordinary antioxidant and vitamin-like substance, central to cellular energy production. The body produces CoQ10 but production declines with age.

In 1987 Joe had another angiogram. Amazingly, it showed that one of his arteries was no worse than it was ten years before, another artery was only slightly worse, and a third had actually improved. Moreover, all our efforts had helped him stabilize his symptoms, a pretty big accomplishment for a progressive disease like his. These results enabled me to feel secure about bumping up his supplements instead of falling back on the drugs when he became a little short of breath. We tried the amino acid L-carnitine to further boost his ATP production, then added fish oil to prevent clots.

ATP is short for adenosine triphosphate-the basic fuel of cells. Organs and tissues operate more optimally when the ATP tank is full. In the heart cells, L-carnitine and CoQ10 are biochemical agents that help keep the ATP level high and thus enhance pumping action. A stronger pump can make a difference for even the healthiest of us. We feel more energetic. But for anybody with angina, heart failure, hypertension, hypertrophy (an enlarged heart), arrhythmia, or any cardiac related concerns, a stronger pump means a much better quality of life as well

Joe is now in his nineties, and now taking D-ribose (another ATP contributor) and nattokinase, a natural clot busting enzyme derived from the fermented Japanese soy food called natto. He is also taking other supplements I have recommended. Despite his advancing age and cardiac condition, Joe's quality of life has actually gotten better with age.

Joe's progress is miraculous. Not only has he made it into his tenth decade against all odds, but he's in much better shape than most of his counterparts. But lest it sound like I'm taking credit for Joe's success, let me tell you the other ingredients for graceful aging for which Joe deserves total credit.

Joe's an exceptional patient with a positive attitude who walks two miles a day, follows a healthy diet, and has a strong spiritual life. To boot, he has a loving and supportive wife and strong friendships.

To me, Joe's story represents two important lessons. First, the power of integrative medicine-using the best conventional and alternative medicine can offer. Secondly, the power of personal responsibility. Joe wasn't healthy when he started with me, but he resisted the passive patient role, made a sustained effort, never gave up, and became healthier as he aged. He added years to his life and quality to those years, something we can all do. That's what healthy aging is all about.

Attitude and the Molecules of Longevity

Stephen T. Sinatra, M.D., F.A.C.C. — Fri, 26 Sep 2008 23:06:52 +0000

"What happens in the mind of man is always reflected in the disease of his body."

-Scientist-humanist René Dubos

Attitude exerts a huge influence on health. Individuals who sustain optimism, instead of pessimism, and who express their emotions, are more likely to be healthier or overcome their afflictions. I've seen first hand that people do better who see their cups half full. Unfortunately, those who see their cups half empty are more likely to become victims, first emotionally, then physically. Then their health deteriorates accordingly.
I am reminded of one eighty-six-year-old Floridian with a bad heart, arthritis, and a hearing problem, who asked me at a recent seminar with my newsletter subscribers how he could make his cup fuller. At the time I was talking about the importance of positive attitude. "I want to make plans for the next thirty years," he said, with a laugh. Now that's what I would call filling up one's cup with optimism.
His attitude reminded me of a fascinating study I read several years ago done at the University of Kentucky. The researcher studied the medical histories and length of life of some two hundred nuns who had compiled handwritten autobiographies during the 1930s when they were in their early twenties. It turned out that those individuals who expressed strong positive emotions about life actually lived as much as ten years longer than pessimistic fellow nuns.
It is absolutely true that emotions become molecules inside the body that affect our physical well being or not-so well being.
The late Norman Cousins, a prominent political journalist, showed dramatically how laughter (along with plenty of vitamin C) could overcome disease-in his case, a debilitating collagen disorder called ankylosing spondilytis. He wrote about it in his bestselling 1979 book, Anatomy of an Illness.
Cousins also suffered from heart disease and died in 1990 of heart failure, ten years after being first diagnosed and years longer than his doctors had predicted he would live. After one heart attack, and as he was beingcarried into an emergency room on a stretcher, he announced his determination to overcome his physical challenges: "Gentlemen, I want you to know that you're looking at the darnedest healing machine that's ever been wheeled into this hospital."
In the 1990s, Lee Berk, a researcher at Loma Linda University who had been inspired by Cousins, demonstrated how laughter actually strengthened the immune system and protected patients following heart attacks. He did that by showing patients videos of their favorite sit-coms.
More than twenty years ago, I participated as an instructor in a psychotherapy training workshop. During the workshop we conducted an eye-opening experiment. We asked a group of forty-four male and female volunteers to discuss the most difficult issues-issues of sadness, bereavement, grief, and stress-in their lives. Afterward, we collected urine samples from them. I was amazed to find that the individuals who talked most freely about their problems, and it was primarily women, had fewer stress breakdown chemicals in their urine, and much less evidence of cardiovascular disease. It was just the opposite for the men. We men usually have a hard time crying, or expressing emotions as well as women, and one consequence is that we are more susceptible to heart disease.
This experiment provided the inspiration for Heartbreak & Heart Disease, a book I wrote in 1996, and recommend to patients because it contains lessons and stories that demonstrate how powerful a role the emotions can have in healing or harming the body.
Do tai-chi. Yoga. Meditate. Pray. Laugh a lot. Cry. Retire later in life. Volunteer your services. Get a dog or cat that gives you unconditional love. Follow your own personal passion. Do whatever it takes to stay optimistic, happy, and engaged in life. You'll be creating the molecules of longevity.

Marriage and Heart Health

Stephen T. Sinatra, M.D., F.A.C.C. — Mon, 01 Sep 2008 22:37:39 +0000

I have long believed that much of what we cardiologists treat relates to what goes on from the neck up-namely patient emotions. My book, Heartbreak & Heart Disease, which I wrote back in 1996, covers one aspect of the emotional equation.

Stress in the form of suppressed emotions-from heartbreak and overwhelming sadness to hostility and anger, heartbreak-can clog up your major arteries just as effectively as oxidized cholesterol, toxic metals, insulin, radiation, and sticky blood.

Many studies confirm this mind-body connection and the observations I have made for years in my own cardiology practice.

Stress is a killer, whether it comes from a job or a relationship. I've had many patients who worked at the wrong job for years and then had a heart attack. While staring up at the ceiling in intensive care they went through an almost religious catharsis as they realized that the stress of their work put them in the hospital. Likewise, I have had both men and women in intensive care make the same connection about a wrong marriage.

Sometimes it takes a heart attack to make people realize just how powerful stress can be. Some never get to act on their realization. Patients have confessed to me about the stress in their lives, whether it was a job or a marriage, and it eventually killed them. All the advice and medicine and supplements couldn't trump the power of stress.

The opposite of this, obviously, is a harmonious marriage and enjoyable work. Satisfaction protects the heart.

Research tells us the following, and I have certainly seen this at work in my practice:

Loneliness is a risk factor for heart disease.
Married people experience less cardiovascular disease than single people, however, a bad marriage can be disastrous to the heart.
One of the common denominators of longevity-as determined by surveys of people in their eighties and nineties-is a healthy marriage.

One fascinating study in 2006 caught my eye along these very lines. It shed specific light on the dynamics within marriages and how they affect heart health. It was conducted by Tim Smith, a University of Utah psychologist. In his study, Smith recruited one hundred and fifty healthy married couples-most of them in their sixties. None of the participants had a history of cardiovascular disease.

Each couple was interviewed by psychology graduate students and videotaped. The interview was based on a topic the couples chose-such as money, in-laws, children, vacations, and household duties-that caused disagreement in their marriage. The husband and wife then discussed the chosen topic, facing each other, while the camera rolled.

The research team assigned values to the comments indicating the extent to which they were friendly versus hostile, and submissive versus dominant or controlling.

For example, comments like, "You can be so stupid sometimes" or "you're too negative all the time," were rated hostile and dominant. Another dominant or controlling comment would be, "I don't want you to do that; I want you to do this."

According to Smith, some of the discussions were calm and peaceful, but in some cases, quite hostile, even prompting the interviewer to recommend counseling.

The researchers assumed that a couple's behavior during the discussion was like the microcosm of the macrocosm-a snapshot of long-term pattern of behavior, and that probably a marital spat in front of researchers likely represented a muted rendition of what really went on at home.

Two days after these sessions, all participants underwent a special CT scan of the chest in which doctors used a standard scale to score each person's level of coronary artery calcification, an indicator of plaque buildup in the arteries to the heart. Even though none of the atherosclerosis revealed by the scans amounted to a medical emergency, some of the scores were actually high enough to place the individuals at high risk of a coronary event.

The findings were summarized thusly:

The more hostile the wives' comments during the discussion, the greater the extent of calcification of the arteries. Particularly high levels of calcification were found in "women who behaved in a hostile and unfriendly way and who were interacting with husbands who were also hostile and unfriendly."
The extent to which either wives or husbands acted in a dominant or controlling manner was unrelated to the severity of calcification in the wives.
The extent to which wives or husbands spoke with hostility had no relationship to the severity in the husbands.
Husbands who displayed more dominance or controlling behavior-or whose wives displayed such behavior-were more likely than other men to have more severe calcification.

Smith concluded that either being controlling or being married to someone who is controlling is enough to promote atherosclerosis in men. In couples where there was not a struggle for control, those men had much lower levels of atherosclerosis.

Smith felt that hostility during marital disputes was bad for women's hearts, while controlling behavior during marital disputes was bad for men's hearts.

"Disagreements are an unavoidable fact of relationships," he said. "But the way we talk during disagreements gives us an opportunity to do something healthy." For spouses concerned about each other, avoid both hostility and controlling behavior during disagreements, he adds.

Fascinating information. Obviously, this is not impeccable science. We don't know other things going on in the lives of these people that could be contributing to calcification, but the study nevertheless sheds some light on how the dynamics of husbands and wives plays out on the stage of cardiovascular disease.

In any case, the bottom line is still the same. Stress has the potential to kill. It is interesting that the more hostile the wives' comments the greater the level of calcification. Many patients of mine have been shocked to hear that they have coronary calcification even though their other risk factors are in good shape.

They want to know, "How did I get this?"
The answer to them is another question: "How much stress do you have in your life?" I've been doing these scans for years. I've had many people with really no physical risk factors for cardiovascular disease but who still have calcification of the arteries just on the basis of stress alone.

Psychological stress causes release of stress hormones-cortisol, adrenalin, epinephrine-and these chemical substances can oxidize cholesterol and make it inflammatory. And then calcium gets laid on as part of the inflammatory process.

The control and dominance issues in this study were fascinating and reminded me of animal experiments in which weaker animals developed atherosclerosis when dominant animals were placed in their presence. In these experiments, mice and hamsters became frightened, excessively vigilant, and then deathly sick after dominant tree shrews were introduced.

Can the same thing happen in a marital relationship? This study was the first time I have seen this evidence in humans. So dominance or control-whether you are shelling it out or receiving it- can be harmful to one heart or the other. In any case, the body is producing stress chemicals and somebody's arteries are suffering as a result.

Anger and Your Heart

Stephen T. Sinatra, M.D., F.A.C.C. — Mon, 18 Aug 2008 20:35:40 +0000

To me, anger is like the Achilles heel of the cardiovascular system, a trigger for serious problems, including a heart attack. Your blood vessels constrict and your blood pressure rises. The electrical currents to your heart become unstable. If you have arterial plaque, anger is like throwing a match into a can of gasoline. The plaque can rupture and the resulting clots kill you. Anger can also affect your ability to heal normally after surgery.

Two patient stories demonstrate the potential impact of anger.

Patient No. 1 was an attorney who had his new car scratched from one end to another by a teenage punk with a key. When he first saw the damage, the man got so angry that he had a heart attack on the spot. He was still livid when I saw him later in the emergency room. I had to calm him down and remind him that his car wasn't worth the price of his life.

Patient No. 2 was a Korean War veteran. He had bypass surgery and it so happened that when he opened his eyes after the operation he saw an Oriental face in front of him. One of his surgeons was a Chinese doctor. The reality of a Chinese doctor infuriated the patient, who still harbored vivid memories, twenty-five years after the war, of fighting the North Koreans and their Chinese allies. The resentment and emotions were so intense that they affected his healing. It took nine months for the chest incision from the operation to heal. Normally it takes a month. I worked with him psychotherapeutically for months to defuse his anger. His eventual physical healing depended on his emotional healing.

After I became a cardiologist I studied psychotherapy because of my interest in the mind/body connection. I always ask my heart patients about their emotions prior to an angina episode or heart attack. Many have said they had an outburst of anger prior to the event.

Although he wasn't a patient of mine, I will never forget the conversation I had with a cardiologist who was a top official of the American Heart Association. He told me that the thing that aggravated his own angina problem the most was anytime he got into a heated argument with his teenage son.

In the 1990s, Murray Mittelman, M.D., of the Institute for Prevention of Cardiovascular Diseases at Harvard, conducted a series of studies on anger and its effect on the heart. His research identified anger as a common trigger of heart attack and life-threatening arrhythmias. "The scope of the problem is sizeable-at least 36,000 (2.4% of 1.5 million) heart attacks are precipitated annually in the U.S. by anger," he said at the time.

Here's the moral of this short mind body story and a tip I tell my heart patients all the time. The minute you get angry over something the immediate thing that should come into your mind is this: Is this upset or argument worth dying for?

Lessons to Learn from Tim Russert's Death

Stephen T. Sinatra, M.D., F.A.C.C. — Fri, 01 Aug 2008 17:29:27 +0000

I was deeply saddened when I heard about the sudden death of Tim Russert, the host of TV's popular "Meet the Press." He was 58, at the top of his career, when an arterial plaque ruptured. A resultant blood clot apparently caused ventricular fibrillation, a wild arrhythmia that effectively stopped the normal pumping activity of his heart muscle-a classical and deadly scenario in cardiovascular disease. Russert had asymptomatic coronary disease that was under control with medication and exercise, his doctor said.

This headline death carries multiple messages for all of us. It brings attention to one of the most insidious realities in cardiology. Ninety percent of the time, people with coronary artery disease are asymptomatic. And 50 percent of the time, the very first symptom is sudden death. Some 300,000 Americans die of sudden cardiac arrest each year without knowing they have heart disease. Russert was conscientious about his health. He knew he had heart disease, was being treated for it, but it still didn't help him.
If a patient complains of typical symptoms like jaw or chest pain, we can jump on those clues, do the tests, and start treatment aimed at stabilizing plaque and preventing a heart attack. At least we have a chance to head off a disaster. Sometimes we may only be able to delay it.
Russert's death reminds us all of our vulnerability in the fast-paced nature of our society. In his case, it looked like he had just taken an overnight flight from Europe and was busy working the day he died. Modern life is full of ups and downs, and stress and pressure that affect the heart in a way that most people, even doctors, don't fully appreciate. Stress kills, accelerating arterial disease and its most powerful risk factors: blood pressure, heart rhythm disturbances, insulin resistance, the tendency to clot, smoking, alcohol, drug use, and insomnia. On top of that, our arteries are besieged by mercury, lead, sugar, bacteria, and other damaging inflammatory agents.
Russert's death evoked multiple flashbacks to my days as a young cardiologist when I lived in fear of patients dropping dead while I treated them. I saw it happened too many times: a truck driver stressed by traffic and delivery deadlines, a businessman who couldn't take the pressure anymore, a person fired from a job, somebody going through a nasty divorce, and even my own father who died in my arms from sudden cardiac death. I've seen many life dramas end in the emergency room or my office. They are the most devastating situation that occurs in medicine.
Years ago in this pressure cooker situation I rapidly became aware of my own vulnerability. and I started popping aspirin. I remember one high-level attorney I was treating in my office who was having an acute heart attack. He refused to go to the emergency room. I said I would drive him myself. It was only a short three-minute ride. Reflexively, I pulled out an aspirin and started chewing it.
"Why are you doing that?" he said.
"Because I am afraid I am going to have a heart attack dealing with you," I answered.
He got the message. He saw that I was serious, that he could really die, so he relented. I drove him to the emergency room and we had a happy ending.
More than fifteen years ago I learned about fish oil, which became the main weapon in my anti-plaque program. Fish oil protects against sudden cardiac death, as was first discovered by Danish researchers back in the 1970s. They found that Greenland Eskimos had a low incidence of heart attacks compared to Westerners. The Danes linked the hardiness of Eskimo hearts to a diet with abundant fish oil, which they felt had potential anti-atherosclerotic benefits. This original study inspired more than 4,500 scientific investigations of fish oil on metabolism and health, and resulted in repeated confirmation of cardiovascular benefits.
One of the most impressive studies was the famous GISSI prevention trial in Italy during the 1990s. In this study, researchers monitored more than eleven thousand highly vulnerable patients who had suffered a recent heart attack. They found that the patients who took a 1 gram supplement of fish oil daily had a dramatic decrease in sudden death of more than 40 percent compared to non-supplemented patients. These results are rendered even more extraordinary by the fact that all the patients in the study were being treated with standard medication and, in general, eating a protective Mediterranean diet.
When you ingest fish oil it gets within the structure of any arterial plaque within three days, making the plaque much less prone to rupture. Fish oil reduces inflammation, improves the variability of the heart rate, and makes the blood less sticky. Those are all cardiology goals.
I don't know if Tim Russert took fish oil. I do know that a lot of doctors fail to recommend fish oil to their patients despite all the research. Last year a survey was conducted among Washington State family physicians to determine their prescribing frequency of fish oil supplements as a form of prevention against heart disease. Fully 99 percent of them agreed on the importance of nutrition in preventing cardiovascular disease and 57 percent knew of fish oil's effectiveness, but only 17 percent prescribed it to any significant degree! That's a serious disconnect, and a tragic one in my opinion.
If there is one thing I consistently rely on for my cardiac patients, it is adding fish oil to their plaque stabilization and prevention program. It can make the difference between life and death! Preventively, everybody on the planet should be getting some fish oil-at least one gram a day through the diet (good quality fish like wild salmon) or a supplement. For existing heart disease I recommend 2 grams.

Combining Conventional Medicine and Natural Healing=Healthier Hearts

Stephen T. Sinatra, M.D., F.A.C.C. — Thu, 17 Jul 2008 22:40:45 +0000

I'm very excited to have the opportunity to blog on the Psychology Today web site. It's a great match for me as a cardiologist who has long seen a close connection between cardiovascular health and the emotions. The blog will allow me to reach out to a new audience of health-minded readers and introduce the powerful integrative approach to cardiology that I believe can revolutionize the practice of cardiology and put a major dent in heart disease, the leading disease killer in the industrialized world.

Over more than thirty years of medical practice I've treated countless cardiac emergencies involving people only a heartbeat away from death. I've rushed into middle-of-the-night crises to perform medical heroics and I've even slept in hospital beds next to critical patients. Within a few short years of being a cardiac savoir to so many people, my ego began to inflate. I became pompous and unrealistically over-confident about my ability to make a difference.

Time, however, is a great ego vaccine. And in time, I got humble, as a result of repeatedly seeing the same patients at those emergency room doors in crisis after crisis despite all my best efforts. I finally "got it." I might be able to rescue people from the brink, but I was clueless about how to keep them healthy so they wouldn't have to go through it all over again. I could get the heart back on track. I just couldn't heal it.
In 1978, I had a career-altering conversation with an amazing Dutch petroleum chemist named Jacob Rinse who'd managed to "cure" his arterial disease, so he claimed, with lecithin, vitamin E, magnesium, and other nutrients. I was led to him by a patient, and did she ever alter the course of my career by suggesting I speak to him! At first his claims seemed preposterous, but thankfully I kept listening. I soon realized that Rinse knew more about the chemistry of heart disease than I did!

The conversation aroused my curiosity and touched that still, subconscious place inside of me that knew I needed to "think outside the box." Slowly, I began looking beyond the limitations of my drug-and surgery-oriented medical training to improve the arterial health of patients and address the underlying causes of their heart disease.

After several years of investigating the connection between toxic stress, emotions, and the heart, my attention expanded to include the bright new world of nutrition and the therapeutic promise of vitamins and minerals. My research turned up ever-increasing evidence and wind in my sails that pushed me into a new direction unknown to most cardiologists.
Slowly I started recommending supplements, starting with vitamins E and C and lecithin. Then I started talking up exercise and diet to patients with renewed enthusiasm. I soon observed speedier recoveries and dramatically improved health, often among the sickest patients for whom I had run out of all conventional options. I quickly became a believer, and for decades now I've been using an ever-growing arsenal of nutraceuticals in my medical practice-such as fish oil, CoQ10, carnitine, magnesium, and ribose-as a core strategy for achieving optimum cardiovascular health. Integration means using the best of both conventional medicine and natural healing. I bank on both to benefit my patients the most. To me that's smart medicine.

The results have been fantastic. I was once the top patient admitter to my hospital-and proud of it. Now, I rarely admit a patient to the hospital. Instead, I have learned how to keep my patients healthy and maximize the production of energy in their hard working (as in: around the clock, no time off) heart cells and throughout the body.

I lecture a good deal-to both lay people and doctors-about how to use conventional and natural healing for preventing and reversing arterial inflammation, the big hit man of cardiovascular disease. I take odds with the current cholesterol obsession and strongly believe there are much more troubling risk factors to consider than cholesterol, which is, by the way, an essential substance in the body's normal operations. Your sex hormones, for instance, are made from cholesterol. Instead of worrying about some cholesterol number that may mean very little, I believe we should be really concerned about the excess dietary sugar we eat, getting our stress under control, and getting enough physical activity.
In the coming blogs I will share the exciting concepts of integrative cardiology as well as practical recommendations-and in the process hopefully expand your cardiac consciousness.