Issue No. 19
Healthy Minds, Healthy HeartsDate: January 17, 2013
Responding to a heart attack with the goal of renewal, not just recovery
Few things in life are as scary as a heart attack. And then, after surviving one, a person must take many steps to resume a normal life and, in most cases, a more healthy lifestyle. What can be just as surprising as the heart attack itself are the unexpected, nonphysical effects, which are equally threatening to one’s quality of life. Although these effects might make the road to full recovery somewhat bumpy, experts at Johns Hopkins are proving that life after a heart attack not only goes on, but it can get better.
Facing Down Challenges
“A heart attack is a major life change. All of a sudden, someone has a wake-up call and it’s as if, ‘I’m not healthy anymore,’” says Shellee E. Nolan, M.D., a Johns Hopkins cardiologist. “Patients perceive themselves as being ill, and so they start to think about their future and how long their life is going to be. Many feel depressed, defeated, weakened.”
Though some people develop depression, for most it’s anxiety that dominates their lives, largely in the form of worries about behaviors they believe might trigger another cardiac event, such as climbing stairs, having sex or drinking a glass of wine. So while they recover from an attack—attending rehabilitation and working to establish healthy habits—they struggle with the possibility of future heart problems.
Rehabilitation, too, is challenging. It can take several weeks to several months or more, and people’s day-to-day lives change so much as to be barely recognizable. Some cannot resume work right away, especially if they have physically demanding jobs or their employers insist on an extended leave. And strain on relationships with spouses and caregivers, who themselves frequently have questions and fears, may also hinder recovery.
For many individuals, however, time is of the utmost importance, as people learn about their health through the course of their recovery. Nolan calls this cardiac awareness.
“You don’t know whether the symptom you’re having is significant versus really nothing at all,” she says. “But with time, you learn what is a real concern or not a concern, and a lot of worries pass.”
Success Begets Success
Though it is said that time heals all wounds, what can people recovering from a cardiac event do to fast-track their success?
“To some extent, part of [recovery] comes just from asking your doctor about the different issues you’re facing, but this is where cardiac rehabilitation can also truly be beneficial,” says Stuart Russell, M.D., chief of heart failure and transplantation at the Johns Hopkins Heart and Vascular Institute. “You’re with people who are going through the same thing as what you’re going through, which is probably by far the best therapy.”
If heart health were for sale, cardiac rehabilitation would be considered one-stop shopping. It is designed primarily to help restore physical functioning by means of supervised exercise training. And the benefits don’t end there.
“It helps people cope with their illness in terms of dealing with stress and depression and improving quality of life,” says Kerry J. Stewart, Ed.D., director of clinical and research exercise physiology at Johns Hopkins Bayview Medical Center. “It also educates them about what lifestyle changes they may need to make, as people who have had some type of cardiac event are certainly at a high risk for having another one.”
Cardiac rehabilitation is considered a standard of care after heart attack, coronary artery bypass surgery and angioplasty (blood vessel repair), and both of Johns Hopkins’ cardiac rehabilitation programs, at Bayview Medical Center and at Green Spring Station, are certified by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). But just as important, research at Johns Hopkins has helped the AACVPR set the bar for excellence.
“We were involved in the first studies demonstrating that the use of resistance exercise is not only safe but also effective in people with heart problems; that has now become part of the standard of care,” Stewart explains. “We have also been a member of the American Heart Association’s writing committees that created the standards for cardiac rehabilitation.”
Along with exercise, cardiac rehabilitation at Johns Hopkins includes nutritional counseling, smoking cessation, stress reduction and basic education about topics such as medication adherence. And even when people don’t elect to pursue all options, Stewart observes, “by performing exercise where they are monitored and get feedback that says ‘you’re OK,’ people regain a level of confidence about their ability to do things, which in turn leads to them doing more when not in the program.”
Bill Fusting, one of Nolan’s patients, experienced a heart attack in January 2012 and, after placement of a stent (a mesh tube that will keep his artery open) and a brief hospitalization, was immediately referred to cardiac rehabilitation. Fusting was somewhat skeptical about how three days of exercise each week could make such a difference, but he trusted Nolan’s recommendation.
“She introduced me to the fine people at cardiac rehab, and I’m glad she did,” says Fusting, who saw improvements in his blood pressure, cholesterol levels, weight and mood shortly after starting the program. “Even now, sometimes I don’t want to go, but when I finish, I just feel so good,” he says. “It absolutely builds your confidence and clears your mind, which keeps you from worrying. And when you feel good, you can do more in life.”
Knowing Is Half the Battle
Just as exercise strengthens the mind as well as the body, education plays an important role in nonphysical healing. Optimal recovery from a heart attack is more likely when people understand why the event occurred and the nature and purpose of the treatment. Nolan says it’s more than just sharing facts; people also must be taught how to return to healthier lifestyles and avoid the habits that likely contributed to their problems in the first place. This is yet another way in which cardiac rehabilitation is beneficial, providing a form of self-care, as in Fusting’s case.
“He had this heart attack, but now he has embraced a new life, fully and happily,” Nolan says. “He has incorporated this new diet and this new exercise, and is just as robust now as before his heart attack—but just doing it differently.
“A lot of people end up embracing their situation with such vigor; it’s really quite amazing,” she adds. “People who were couch potatoes before and never paid much attention to their diet, and who maybe had this belief that they were invincible, they come out of this with a new appreciation for life and embrace the knowledge about how to keep themselves healthy.”
The Gender Conundrum
For decades, men were thought to suffer from heart disease and heart attacks more so than women. But, sadly, women have narrowed the gap, and cardiovascular disease is now the No. 1 killer of both genders. Hormonal and anatomical disparities between the sexes, however, mean some differences do exist. For instance, women generally report higher rates of depression after a heart attack than men—an unfortunate finding because depression increases the risk of mortality in heart disease and heart attacks. Whether this is attributable to women’s unique physiology is unclear, but Marlene Williams, M.D., director of the cardiac care unit at Johns Hopkins Bayview Medical Center, is trying to unravel the mystery, which could prove useful for preventing and treating depression in all heart attack patients.
Williams is looking to an increasingly popular area of cardiovascular research: blood platelets, and a particular protein stored within and used by platelets called brain-derived neurotrophic factor (BDNF). People who have depression also have lower levels of BDNF, and given that depression has a clear linkage to heart functioning, Williams is considering whether the protein is a potential culprit.
“If a depressed patient’s platelets can’t uptake and use BDNF, it circulates in their arteries, where it can contribute to plaque instability and rupture,” she says. “Maybe that is why there is an increased incidence of heart attacks in people who are depressed. But what we want to see now is whether there is a difference in the amount of platelet BDNF in men and women.”
Having recently received funding associated with the Marianne J. Legato Research Scholar Award in Gender-Specific Medicine, Williams and her colleagues will examine differences in platelet function and depression among men and women with and without heart disease.
With government research funding on the decline, studies in gender medicine have similarly shrunk, making this investigation all the more valuable for patients as well as for the field as a whole.
For more information on the study, including possible enrollment, call 410-550-5128.