CHRONIC TONIC posts on Thursdays at 7 EST, it is a place to share stories, advice, and information and to connect with others with chronic health conditions and those who care for them. Our diarists will report on research, alternative treatments, clinical trials, and health insurance issues through personal stories. You are invited to share in comments (and note if you'd like to be a future diarist). In addition to our weekly diaries, please join us for ongoing conversations at the Kossacks Networking site.
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Already a member? Here is a direct link to today's discussion: Chronic Tonic: Chico David RN - Cardiac Health
Today’s Diary By: Chico David RN.
I was kindly invited to contribute a diary to this series from the somewhat different perspective of one who is not chronically ill, but who provides care to those who are. I’m going to focus on one chronic illness in particular: coronary artery disease. I’ll talk a little bit about the disease itself and some of the different ways in which it can progress and manifest itself. I’ll talk about some of my experiences with it as a cardiac rehabilitation nurse and the ways in which patients cope with the disease and then I’ll come back around to make a few connections to the kinds of issues that we talk about more on Dailykos: the intersections of health and wealth, illness and politics.
First, an introduction: I’ve been a registered nurse now since 1981 and spent nearly my whole career in a field called Cardiac Rehabilitation. We do education with patients in the hospital; teach them about the nature of their illness, the treatments they are receiving, how to care for themselves when they go home and how to reduce their risk for the future. We also run exercise classes for folks after hospital discharge. In those programs, people typically are with us for 3 months, but we do have a maintenance program where some have been attending over 20 years. So I get to see the entire spectrum, from folks who are newly diagnosed to people who have been living with their disease for many years.
Now let’s talk a bit about coronary artery disease (henceforth: CAD) The first big mental hurdle to get over is in thinking of it as a chronic disease, which it absolutely is. But it’s a chronic disease that manifests itself in very episodic ways. In between episodes, many people have quite extended periods – often several years – of feeling very well, which makes it easy to forget the chronic nature of the disease.
The coronary arteries are small arteries that supply blood to the heart muscle itself. It’s really intuitively strange: The heart pumps blood. Many liters of blood are being pumped through its chambers every hour. How can it run short of blood? But that blood is of no use to the heart itself. The heart depends for its nutrient supply only on what passes through the coronary arteries. We normally have 2 major coronaries: the right and the left, but the left branches so early into the Left Anterior Descending (LAD) and the Left Circumflex (Circ) that we talk of it as two arteries and speak therefore of three total. When we speak of coronary disease, we simply mean that the walls of the arteries have become thickened by fatty deposits that narrow the space in the center of the artery where the blood flows – the lumen – leading to various symptoms and complications.
CAD is the largest cause of death in North America and throughout the developed world. There are numerous other cardiac ailments, some fairly common, others pretty esoteric, but CAD is the big one in terms of numbers. We have made great strides in its treatment, but at the same time social and behavioral factors have conspired to increase its incidence – notably obesity and the consequent rise in Type II diabetes, a major risk factor for CAD. CAD often begins quite early in life, even in childhood. In both the Korean and Vietnam wars there were autopsy studies done on young men killed in battle – typically aged 19 -23 – that showed about 50% of them already had early stage coronary disease. However, through most of its natural history, CAD is asymptomatic – you don’t feel sick with it. This insidious progression helps to make it much more difficult to treat. First, it can be quite difficult to diagnose accurately in the early and middle stages. And even when it is diagnosed, it’s pretty hard to get people to make major changes in behavior and perhaps take expensive drugs to treat a problem that doesn’t make them feel ill.
Progression and symptoms of CAD
One of the interesting and troublesome features of CAD is that it presents and progresses in such different ways in different people. In our rehab classes it’s quite common to have people with the exact same underlying disease, but with personal experiences so different that they can scarcely believe they share the same illness. The easiest way to illustrate this is with a few scenarios:
Let’s imagine three patients: Mary, John and Bob. Each of them has developed coronary disease. Gradually over the years, their arteries have become more and more blocked. They are now all in their mid-fifties.
Mary begins to notice an occasional tight feeling in her chest with exercise. She gets short of breath more easily than in the past. Months pass and she notices the tight feeling is happening more often, particularly when she climbs stairs. It takes longer for the episodes to go away now. It worries her a bit, but the pain is not severe – just a dull tightness, so she thinks it can’t be too important. She’s seen lots of movies where heart patients clutch their chests dramatically, writhing in pain, and this doesn’t feel all that bad. After several months, she has a routine appointment with her Nurse Practitioner and happens to mention the tight feeling. Her NP questions her carefully about it, and decides to make an appointment for her to see a cardiologist. The cardiologist performs an exercise stress test – an EKG done while walking on a treadmill. In the 5th minute of the test, the tight feeling occurs and at the same time the Cardiologist sees typical changes in the electrocardiogram that are diagnostic for CAD. She stops the test and schedules a cardiac catheterization for later that week. The catheterization shows about an 85% blockage of the Right Coronary, and milder blockages of the other two. After a short discussion, the cardiologist performs an angioplasty – using a balloon to open the narrowed artery – and places a stent (a tiny wire mesh tube that holds the artery open and gives it a smoother shape. (Note: Studies have shown that patients with single vessel blockage do just as well with medical treatment as with stenting. In Canada, Mary would be treated medically and would have a similar life expectancy. In the US she is more likely to get the stent) Mary is kept in the hospital overnight and discharged in the morning. She is able to resume her normal activities in a few days, and has no further symptoms for the time being.
John is the same age as Mary and has had similar symptoms. He’s only had the symptoms for a couple of months, but they have worsened pretty dramatically. He has no health insurance, so he hasn’t seen a doctor. He did quit smoking, hoping it might help, but the episodes continue to be more frequent and severe. He hasn’t told his wife about it because he "doesn’t want to worry her". One evening, just after dinner, he gets an episode that is much worse than all the others. He feels like there is a great weight on his chest, it’s hard to breath, and he is sweating profusely. His wife notices immediately. He tries to make light of the episode, saying it must have been something he ate, but she can see he is in real distress and calls 911. In due course the ambulance arrives and he is hooked up to a monitor and to oxygen. He is given a nitroglycerin tablet under his tongue and then an aspirin to chew and swallow. The pain abates slightly, but is not gone. He is transported to the hospital, which has a cardiac catheterization lab. The catheterization shows a near-total blockage of his LAD, with severe narrowing in both the other arteries. He’s having a Myocardial Infarction (MI for short, or what most of us would call a "heart attack") An intra-aortic balloon pump is placed to help the blood flow to his heart and a surgical team is called to perform emergency cardiac bypass surgery. (Note: If he had only a single vessel badly diseased, like Mary, an angioplasty and stenting would have been the likely treatment, which is non-controversial in this situation. But with three arteries badly diseased, many cardiologists would consider surgery a better choice for most people.) Five days later, he is discharged from the hospital, with instructions on activity that will limit him quite a bit for a couple of months, including staying off work. He has no insurance, but does own his own home. The hospital is a non-profit institution and will write off a large portion of the bill and make payment arrangements for the rest. Because John has too much in assets to qualify for Medicaid, he is likely not to continue taking the prescribed medicines for cholesterol and high blood pressure or to keep follow-up appointments with the cardiologist. The stress of his financial situation may also contribute and 4 years later he will be back with two of his bypass grafts re-closed.
Bob is the same age as Mary and John. He is a bit overweight and his blood pressure is "a little high" but he stopped taking the medicine his doctor prescribed since he felt fine and didn’t think it made any difference. He has no clearly cardiac symptoms, but has complained of low energy lately. One afternoon he is out mowing the lawn and his wife hears the mower stop. When it has not resumed after several minutes, she looks out the window to see him face down on the lawn. She runs out to him and shakes him, but he does not respond. She returns to the house and calls 911. While waiting for the ambulance she attempts CPR, but he remains limp. When the paramedics arrive, they attempt resuscitation, but with no success. Bob is transported to the ER where he is pronounced dead after several more minutes of attempted resuscitation. (Note: when sudden cardiac death occurs in people younger than 35 it is usually due to inborn abnormalities. In people over 35, it is nearly always related to CAD. Depending on the study, as many as 60 percent of those suffering sudden cardiac death had no prior symptoms – or perhaps had symptoms they had not told anyone else about?)
Wildly different stories – but all one disease process. We don’t know why CAD takes such very different paths in different people, but it does. That variability can be part of the problem, since many people know someone who had CAD and if their presentation is very different, they think it can’t be that. Now every one of these folks is a composite of many patients I have seen over the years. Some of them, I’ve seen hundreds with pretty similar stories.
Some random observations based on these stories:
- Cardiac pain – including that of a heart attack - does not have to feel very severe! Quite often, it’s just a dull pressure feeling, or some shortness of breath.
- What is it with us guys and our health? Over the years, I’ve talked to hundreds of men in the hospital with cardiac events, and I would bet that 80% had to be practically dragged in by their wives. Perhaps one of the reasons that married men have a longer life expectancy? Come on guys – admitting it hurts doesn’t make you less of a man.
- Persistent and sustained low energy might be a sign of heart disease. Most of the CAD patients I talk to tell me of a history of some months of just not having any zip.
- Bypass surgery does not cure CAD. Think of it as a way to buy time to change your life. The average life of a saphenous vein graft – the most common kind – is 7 years. Of course that says nothing about how long yours will last – averages are good for telling us about a thousand people, not much good for telling us about one person.
Now coming back to the theme of the series, I want to focus on the chronicity of the disease, and some of the more or less functional ways that people cope with that. And we might throw in a thought or two about how our society affects that.
When I talk to people in the hospital recovering from their first cardiac event - of whatever sort – one of my main themes with them is the chronic character of their disease. And one of their biggest challenges is to learn to think clearly about that.
I see people go wrong in two ways. One way is the person who thinks they are a cripple now, who lives in constant fear and is unable emotionally to return to normal activity. Not so many of those – it not in the cardiac personality. The other way, much more common, is the person who is determined to deny that something serious has happened or that they need to change anything. The person who ignores their risk factors, stops taking meds, misses medical appointments, continues smoking, etc. I’ll make a totally unscientific assertion just based on years of observation that the people in this group tend to have high levels of anger and hostility and I’d bet they are disproportionately Republican.
So I try to talk to people somewhat like this:
"You’ve had one event here and you will recover from this event. We expect very confidently that you will return to normal life, that you will go back to your job and be able to live well and return to all the activities you did before. But... You now know that you have coronary disease which just means you have a tendency to block your arteries in this way. And you will always have coronary disease. If you are smart about it – take your meds, follow-up regularly with your doctor and make the lifestyle changes you need to – diet, exercise, quitting smoking – then you will probably live out a normal lifespan with relatively few problems. If you don’t do those things, if you try to pretend that this was just a minor incident and you can forget about it and do everything the way you did before, then you’ll be back with more problems".
Of course, the reality is that even some of those who do everything right will be back with more problems – it really is a chronic disease, after all – but I want them to leave the hospital with the highest possible motivation to make changes. If they do come back with problems later, we’ll deal with that when it happens.
One final comment before I close is in the area of the kind of thing we talk more about here: the frustration of dealing with the US healthcare system. Working in cardiac care exposes the craziness of our "system" like nothing else. If you show up at the door of my hospital having a heart attack you will get the best of treatment without anyone asking about your finances or insurance status – that doesn’t mean the hospital won’t make strenuous efforts to collect in some way but finance won’t affect the emergent care you get even up to big ticket stuff like bypass surgery. However, you may very well leave the hospital with prescriptions for crucial meds that are vital to maintain your health – and that you have no way to pay for. One of my unofficial roles is often to point out to the doctor that the patient has limited resources and no or poor insurance, so they can take that into account in choosing what to prescribe. And if part of what caused your heart problem was diabetes or high blood pressure or another problem that requires quality long-term follow-up, you may not be able to get that. And I always wonder how many of the patients I see could have avoided major cardiac issues if they had access to decent preventive care.
This diary has already grown long and even though I have lots more to say – more than I would have thought when I started – I think I’ll stop here. If anyone wishes in the comments, I’d be happy to take questions on heart disease in general or its treatment or whatever. There’s a lot I don’t know, but after this many years, I’ve got a fair fund of knowledge I’m happy to share.
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