Lown ForumHeart failure is often a misleading term, but knowing the causes, symptoms, and management strategies make it possible to maintain a good quality of life for many years.

T HE

2010

NUMBER

3

LOWN CARDIOVASCULAR RESEARCH FOUNDATION

Living with congestive heart failure: Facts and mythsShmuel Ravid, MD, MPH

Walking away heart failureJohn Bloom has been living with heart failure for 20 years, but that hasnt slowed him down. Despite his condition, John lives an active, healthy lifestyle traveling, walking, and spending time with his grandchildren. (Patient prole, page 8) stable CHF. A minority of CHF patients experience progressive and incessant symptoms resistant to conventional therapies and require advanced interventions such as a heart transplant or articial heart implantations performed in specialized centers. This group is beyond the scope of this review and is not discussed here.

The term congestive heart failure (CHF) refers to a constellation of symptoms, clinical ndings, and health consequences which stem from the inability of the heart to ll with or pump the necessary volume of blood required to sustain normal physiological processes. Although CHF is a serious medical condition, the term heart failure coined many years ago can be frightening and misleading to many patients. There are safe and eective treatment options that can improve the quality of life and longevity in the majority of CHF patients. It is estimated by the American Heart Association that in 2006 about 5.8 million Americans were aected by CHF. This number is expected to rise progressively in coming years, with about a half million new CHF cases annually. One reason for the increased prevalence of CHF is the development of eective therapies for the condition and improved patient survival. Aging of the population, particularly those with underlying cardiovascular conditions (such as hypertension, coronary artery disease, and valvular heart disease), who live longer but develop CHF later in life, plays a major role in the increased occurrence of new cases of CHF. For example, in the Framingham Heart Study, CHF aected 8 out of 1000 people aged 5059 years but around 72 out of 1000 people aged 80 or older. This article reviews the causes, symptoms, and types of CHF as well as the current therapies and management strategies. It focuses on outpatients with chronic and

Symptoms of heart failureBreathlessness, fatigue, and uid retention are the most common symptoms of CHF, and are also used to classify heart failure severity. Shortness of breath (dyspnea). Typically associated with physical eorts (such as the need to stop while walking), however shortness of breath can also occur when patients are at rest in advanced, uncontrolled CHF. For example, if a patient with uid overload is lying down, they can be breathless and will need to get up or elevate their upper body with several pillows. Fatigue and weakness. Fatigue and weakness are manifested by a low level of energy, being tired most of the time, or feeling exhausted after mild exertion. Fluid retention and weight gain. Fluid retention and weight gain is manifested primarily by swelling (edema) of the legs which may be painful and leave markings on the skin. This is more prominent at the end of the day after standing for long periods of time. Such uid buildup is absorbed better by elevating the legs. continued on page 6

We are grateful to the GrimshawGudewicz Foundation for their generous contributions that allow us to continue our work here at the Lown Foundation.

2

3 4 5

Presidents message Home care study update LCRF Board welcomes Breck Eagle Are calcium supplements harmful? Meet our stress and nuclear testing sta The rush to unnecessary interventions Know your meds

INSIDE

67 8 9 10 11 12

Living with heart failure (cont.) Patient prole: Walking away heart failure Launching the Lown Scholars program Losing ten pounds and keeping it o Louise Lown Heart Hero Award 2010 NewsBeat Winterizing: Be aware and prepared

2

LOW N

FO R U M

PRESIDENTS MESSAGE

The time of the seasonVikas Saini, MD, PresidentThe Lown Foundation and Group have been a Bostonarea institution for nearly 50 years. Dr. Lown tells me that the early years were no dierent than today technology and tests made money, seeing and talking to patients did not. Nobody thought he could make a go of it. Plus a change... Now after nearly half a century big changes are coming to our payment system. Massachusetts seems determined to move to a system of global payments where doctors and hospitals alike will be paid a xed amount to take care of their patients. The central rationale is to shift the burden of decisionmaking about the appropriateness of costly treatments away from insurance companies or the government and onto doctors. While some fear that this inevitably will lead to rationing, there are some important points to recognize. As Dr. Lown indicates out in this issue, there is an enormous amount of unnecessary testing and treatment in this country. The Institute of Medicine in its upcoming publication, The Healthcare Imperative: Lowering Costs and Improving Outcomes, identies several areas of excessive spending, which totals at least $750 billion annually. That would pay for a lot of prevention! All signs indicate that trends in Massachusetts will quickly spread nationally. Out of my recent conversations with the New America Foundation and others has come an idea: convening a conference of national leaders to draw attention to the responsibility of clinicians for providing leadership on the issue of unnecessary care. The physicians of the Lown Group are among those who would have an important voice in such a national conversation. We are also seeking to engage health plans locally and across the country with our rich experience in providing second opinions. Indeed, many of you may have come to the Lown Center because of that reputation. A physician who consults to cardiologists nationwide recently said to me, You guys are the gold standard for noninvasive care. You have been talking the talk and walking the walk for decades and the world nally seems to be catching up. When it comes to walking the walk, it is through your generous support that weve been able to tread the path of noninvasive care for so many years. By now you should have received our annual appeal for donations, and we hope you can continue to support us in our eorts. A happy and healthy holiday season to all of you and your families!

Home care study updateLast year we announced our plans to implement a pilot study that explores how we might use technology to better serve our patients. The goal is to create a more comprehensive approach to care and deepen the communication that is at the heart of our philosophy. We also hope to help patients avoid unnecessary visits to the emergency room and answer those questions that inevitably arise between regular oce visits. Six months into Phase I of the study, 20 patients participate in regular telephone or evisits with their doctors. Whether a patient is in the comfort of their home or away on vacation, they enjoy Dr. Saini talks to a patient connecting with their doctors either over the phone or facetoface on their computers. Participants are reporting that the study is giving them peace of mind in knowing that another checkin is always only a few weeks away. The results from Phase I will help determine our goals for future studies with larger numbers of participants.

LCRF Board welcomes Breck EagleThe Lown Foundation welcomed J. Breckenridge Eagle to the Board of Directors in June 2010. Mr. Eagle earned his BA and MPH from Yale University and an MBA from the Harvard Business School. In his most recent position, he served as Chairman of Aspect Medical Systems, Inc. and was a member of the companys Executive Committee from 1996 through the companys sale to Covidien in November 2009. Prior to this, Mr. Eagle was the President of a private medical management company specializing in the development of primary care practices in New England. Before that he served as chief nancial ocer and general manager of The Health Data Institute, Inc., one of the rst companies to use cost and utilization data to underline the problems in the US healthcare system. He also worked in the healthcare consulting practice of the public accounting rm Ernst & Whinney, and in positions in nance and health services research at the Boston University Medical Center. He brings to us a particular interest in exploring models that can help the Lown Group realize the value we create for the system. His desire to have a signicant impact on healthcare practices in the US today is one we share, and we believe the Lown Foundation's chances of success are enhanced with his joining us.

LOW N

FO R U M

3

QUESTION FROM A PATIENTFred Mamuya, MD, PhD

Are calcium supplements really harmful?In the summer of 2010, a paper published in the respectable British Medical Journal, suggested taking supplemental calcium was associated with a 27% increased risk of heart attacks. The article received prominent play in the media, and we received numerous calls regarding the safety of calcium supplements. The most glaring shortcoming of this paper was that it reviewed patients taking only calcium supplements, and deliberately excluded patients taking calcium in combination with vitamin D. We know that vitamin D, vitamin K, magnesium, and other nutrients are all required for proper calcium absorption and metabolism; and to date no scientic studies have demonstrated harm when calcium is taken in combination with vitamin D. The current daily recommendations for calcium and vitamin D are 1200 mg and 800 IU respectively. Please be aware that calcium supplements can interfere with the absorption and action of many medications

including some antibiotics, iron supplements, medications to prevent bone loss (such as Fosamax), thyroid supplements, and some cardiac medications. Calcium supplements, especially calcium carbonate, may result in constipation, intestinal bloating, and excess gas. There is also a small associated potential risk of kidney stones, especially if you are also taking diuretics (water pills). Research has shown that calcium obtained through food does not seem to carry the same risk as supplements. If you recall from my last article regarding lifestyle changes and cardiovascular health, I believe one should try to eat real food, and not processed food or supplements. Moreover, none of the supplements appear to be particularly helpful to bone metabolism if you do not exercise regularly. Calcium, magnesium, and vitamin D can be readily obtained from foods items such as yogurt, sardines, and skim milk. Sunlight exposure to the hands, face, and arms for as little as 1030 minutes, 23 times weekly is helpful in producing enough vitamin D during the summer months. If you can, walk to your supermarket to buy the yogurt and sardines, and get a little exercise and extra vitamin D the oldfashioned way!

MEET THE LOWN CENTER STAFF

Stress and nuclear testing teamWhen visiting the Lown Center, your physician may request one or more noninvasive diagnostic tests for you. Some of these tests are performed by our stress and nuclear testing sta. ago. Originally from Fair Lawn, New Jersey, she has a BS in Kinesiology: Exercise Science from James Madison University. Sam is currently pursuing a MS in Clinical Exercise Physiology at Northeastern University. She is an experienced personal trainer, and is certied in advanced cardiac life support. Her favorite food is peanut butter. Nick Falter is an exercise physiologist who has been with the Lown Center since September 2009. Nick grew up in Franktown, Colorado and earned a BS in Biology with a concentration in anatomy from Colorado State University. A licensed EMT, Nick is also certied in ACE personal training, Advanced Cardiac Life Support, and EKG use and interpretation. Nick loves snowboarding, weightlifting, computer science, volunteering, Mexican food, and he can do an amazing Arnold Swartzenegger impression. Kathy Walton, RN is a registered cardiac nurse and supervises exercise testing here at the Lown Center. Born and raised in Boston, Kathy received her RN from Northeastern University and has been with the Lown Center for 11 years. Kathys puppy, a golden retriever named Oliver, keeps her active with regular long walks. She loves working here because the Lown sta and patients are like a big family.

(From left to right) Kathy, Ron, Nick, and Sam

Ron Currier is a nuclear cardiology technologist and has been working at the Lown Center since October 2005. He is originally from New Hampshire and earned his BS in Biology from Salem State University. Ron is a certied nuclear medicine technologist, radiologic technologist, and has his Massachusetts radiologic technologist license. Ron likes to kayak in the summer and cut and split wood in the winter. There's nothing more reassuring than a wellstacked pile of seasoned wood to begin the winter. Sam Esnaola is an exercise physiologist/stress technologist who joined the Lown Center just over a year

4

LOW N

FO R U M

The harm of unwarranted tests, procedures, and treatmentsBernard Lown, MDA Florida couple consulted me in the early 1970s. The wife, Marjorie, did all the talking. It was quite evident that her husband, Bill, was too disabled to provide a coherent story. The right half of his body was limp, his mouth sagged, he drooled, and his speech was an incomprehensible jabber. Marjorie, a youthfullooking woman in her 60s, stumbled over words in a hurried outpouring of staccato sentences. She was impatient to bring me quickly into the loop, as though I could oer a magical remedy for her disabled husband. Bill had been in vibrant good health. Two years earlier, having reached age 70, he retired and devoted much time to longneglected hobbies; preeminent among these was playing golf twice weekly with former business friends. One Friday morning Marjorie was taken aback to learn that Bill was heading for a cardiovascular checkup at a worldrenowned medical center that had recently established an outpost in Florida. Bill denied any symptoms. The reason he oered was that he had never had a heart checkup and the ood of advertisements from the new center made him realize that prevention was far preferable to coping with a heart attack or worse. He assured Marjorie that he would be back by lunchtime. When Bill had not returned by noon, Marjories anxiety mounted. She telephoned the medical center but was shuttled between prerecorded messages. At 2 p.m. she received a call to come immediately to the clinic. Full of dread, she arrived at the cardiologists oce. Her husband, normally outgoing, was silent and contemplative, and greeted her with a wan smile. The doctor explained that Bill had failed the exercise test, but was fortunate that there had been an opening in the catheterization laboratory, where he underwent an emergency angiogram. As the doctor had suspected, Bill had serious multivessel coronary artery disease. For Marjorie the afternoon is buried in a deep haze. She does remember the doctor saying, Your husband is living on borrowed time. The only remedy was to have emergency bypass coronary artery surgery. Marjorie pleaded with the doctor to arrange the operation as soon as possible. The doctor scheduled bypass surgery for the next morning. He again congratulated Bill on his good fortune, there being an opening in a tight surgical schedule. Everything went as planned except that intraoperatively Bill sustained a massive stroke. Deeply upset by her tale and knowing full well that there was no remedy to reverse the brain damage, I posed a question that was both insensitive and dumb. I asked, Why did you not seek a second opinion? She leaped from her chair, shouting, That is a stupid, stupid question, doctor. When your house is on re, you do not ask for a second opinion. You call the re department! She was absolutely right. The medical records of Bills clinic visit showed that he was able to exercise for ten minutes adhering to a standard treadmill protocol. The coronary angiogram showed only moderate multivessel narrowing. Both tests suggested a high likelihood of Bills reaching a relatively normal life expectancy. The rush to unnecessary interventions, as demonstrated by Bills tragic experience, is practiced on a colossal scale in the United States. I am persuaded that onethird of our gargantuan health care budget is consumed by overtreatment. An astronomic $900 billion annually is not only misspent, but far worse, much of it also does irreparable harm. Unfortunately, the focus of the national debate has been limited to the growing economic cost of health care. Much less attention is paid to the unnecessary emotional and physical pain, the avoidable complications, and even some deaths caused by mindless tests, procedures, and treatments. The medical journalist Shannon Brownlee brilliantly explores this issue at great depth and with riveting clarity in her 2008 book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. One of her examples is computerized tomographic imaging, the latest cash cow for hospitals and physicians. The number of CT scans over the past decade has increased from 40 million to 100 million annually. Beyond the economic cost, CT scanning exposes recipients to substantial radiation, as much as 100 to 500 times that of a conventional xray, depending on the parts of the body imaged. Radiation is a known carcinogen. As many as one in 80 persons tested could be at risk for cancer from a single CT scan. Furthermore, CT scanning, in common with other modern imaging technologies, opens a Pandoras box of ndings that frequently lead to further potentially injurious and costly interventions. One may ask what has happened with the timehonored medical principle, Primum non nocere (First, do no harm). Embodied in this principle is an appreciation that physicians, as fallible human beings, need to be guided by humility, restraint, and the wisdom to understand that even innocuous actions may lead to untoward consequences. Possessing less hubris diminishes the likelihood that physicians will inict injury when their actions are propelled by wholesome intentions.

LOW N

FO R U M

5

Know your meds: The importance of a written medication listHelene Glaser, RNA written medication list is a valuable tool for both the patient and the clinicians managing their care. When discussing medications, oftentimes we nd that patients are unaware of the details of their medications. An accurate medication list is an important component of any patients care. At the Lown Center we work closely with our patients to ensure that their list is updated, complete, and accessible. Medication lists are also important if emergency services are required. medications while you prepare for your exam. This will allow you to spend more time with your doctor. Also, carrying a written medication list on you is important in the event you need emergency services. It is a good idea to keep your medication list in your wallet because that is the rst place the emergency team will look for identication and the list will help them to appropriately treat your conditions.

Come prepared How to make a medication listSteps for a simple, easytoread list: 1. Include the name, dose, frequency, and time of day taken for each medication. 2. When listing the dose, it is important that you indicate the size of the pill, rather than the milligram amount. For example, if you are breaking a Lasix pill in half, write Lasix 40MG pill rather than Lasix 20MG. Unless your physician understands how you arrive at that exact dosage mistakes can be made when relling a medication. 3. List how often and at what time of day each medication is taken. This is helpful especially if you are experiencing side eects. Often, the physician can adjust the time of day you take your medication to alleviate side eects rather than discontinuing the medication completely. Before your visit, you should: Check and update your list Include the date of when it was last checked Verify the dosage each time you receive a new rell List any overthecounter medications you are taking, such as Aspirin Indicate what time of day each medication is taken Be sure to include all new medications prescribed by any of your doctors

The Lown Centers medication cardThe Lown Center has designed a medication card that is benecial to our patients. The card can be folded in thirds in order to t conveniently in your wallet. Its yellow color makes it easy to nd, and theres a place for your physicians name and phone number. Be sure to ask for a medication card during your next visit to the Lown Center.

Why is a list important?Reviewing the medication list during your appointment allows your physician to know exactly what medications you are taking and if needed, he can accurately make any changes. We recommend that you carry a written medication list with you at all times. This written list can be reviewed in detail with the nurse or medical assistant and any discrepancies can be addressed before your physician sees you. Patients frequently come to their appointments without a list and explain to us that nothing has changed since their last visit, however, more often than not, this is not the case. Once we start reviewing their list of medications we nd that multiple changes have been made, many of which were made by another physician managing their care. During your visit at the Lown Center, it is our goal to have as much of your time spent with your physician as possible. Bringing a written uptodate medication list gives the nurse or medical assistant time to review your

A sample medication list

6

LOW N

FO R U M

Living with congestive heart failurecontinued from page 1

Shmuel Ravid, MD, MPH

Causes of heart failureWhile many factors can lead to CHF, a few common conditions are responsible for the majority of cases: 1. Weakness of the heart muscle due to a prior injury such as heart attacks from coronary artery disease, structurally abnormal heart muscle (cardiomyopathy), or long standing untreated hypertension (high blood pressure). These injuries result in the hearts impaired ability to pump blood (systolic CHF). 2. Stiness of the heart muscle (diastolic CHF) which is often the consequence of aging and hypertension, resulting in a reduction of the hearts output. 3. Faulty heart valves. 4. Heart rhythm abnormalities (such as untreated, fast atrial brillation). Heart failure severity is classied on the basis of the patients symptomatic status: Class I no symptoms Class II symptoms of HF with ordinary exertion Class III symptoms of HF with less than ordinary exertion Class IV symptoms of HF at rest

Treatment of heart failureEective treatments must be tailored to the individual patient with CHF. In addition to medical interventions directed at the underlying heart condition and alleviation of symptoms, nonmedical factors have to be taken into consideration. Important aspects to consider are the patients age, desired activity level, impact of intervention on quality of life, and the patients expectations and preferences. By collaborating with the medical managing team and actively participating in their own care, patients can signicantly improve their outcome. In older or more dependent patients, active participation by family members, friends, or paid health aides are potentially eective substitutes. Interventions to correct underlying conditions that facilitate CHF Adequate control of blood pressure cannot be emphasized enough as hypertension plays a key role in the development of CHF. Repairing or replacing faulty heart valves that facilitate CHF, when indicated and feasible. Revascularization procedures such as bypass surgery or stenting in selected patients with obstructive coronary artery disease where compromised circulation may precipitate progressive heart failure. Management and control of rhythm abnormalities such as atrial brillation. Implantation of pacemakers or debrillators in carefully selected patients with systolic heart failure in order to improve the pumping function of the heart and for preventing sudden arrhythmic death. Oxygen supplementation is very useful for symptomatic relief in selected patients with advanced CHF and reduced blood levels (saturation) of oxygen. Improving sleep quality and treatment of sleep disorders such as obstructive or central sleep apnea and nocturnal oxygen when indicated. Correction of underlying noncardiac conditions such as anemia, thyroid function, and other metabolic abnormalities. Vaccination against common infections that have the potential to exacerbate CHF, such as the u (annually) and pneumonia (pneumonia shot every 5 years).

Types of heart failureDepending on the mechanisms and the underlying heart condition causing CHF and the clinical manifestation, several types of heart failure are classied. Systolic heart failure. The heart can't contract vigorously, indicating a pumping problem, which results in lower blood output to the various organs. Diastolic heart failure (heart failure with normal ejection fraction). The heart can't relax or ll fully, indicating a lling problem that also results in lower blood output. Leftsided heart failure. Fluid may back up into the lungs, causing shortness of breath. Rightsided heart failure. Fluid may back up into the abdomen, legs, and feet, causing swelling. Rightsided CHF often is caused by leftsided heart failure. Chronic compensated CHF. Outpatients with heart failure who are stable and controlled by appropriate therapies.

A healthy lifestyle, including maintenance of optimal weight, regular exercise, low sodium intake, and not smoking, is mandatory for eective prevention.

LOW N

FO R U M

7

Congestive heart failure facts and ction: Know the truthFalseCHF is always a result of severe heart disease. The outcome of CHF is always grim and the quality of life is poor. Swelling of the legs is always a result of a severe underlying heart condition. Exercise and physical activities are prohibited in patients with CHF. Medications used in the treatment of CHF The goal of medications used in heart failure patients is to control symptoms, halt progression of the condition, and improve long term outcomes, which is accomplished by targeting the underlying mechanisms of CHF and related symptoms. These include medications that reduce uid overload and congestion, improve the pumping capacity of a weakened heart muscle, enhance eciency, and reduce the work load of the heart. Diuretics (water pills). Medications such as Lasix (furosemide), torsemide, spironolactone, hydrochlorothiazide, and Zaroxolyn (metolazone) are a mainstay of CHF symptoms treatment. They help to maintain adequate uid balance and alleviate edema, congestion, and breathlessness. Beta blockers. Medications such as Toprol (metoprolol) and Coreg (carvedilol) lower heart rate and blood pressure, prevent and control rhythm abnormalities, and improve the overall outcome in patients with CHF. These medications also improve symptoms and complications of coronary artery disease. Angiotensin inhibitors (ACEI) or blockers (ARBs). Medications such as lisinopril, enalapril, captopril, Diovan, Cozaar, and Avapro dilate blood vessels and consequently lower blood pressure, reduce the work load of the heart, and slow the progression of heart weakening and enlargement. Digitalis (digoxin). Digitalis improves the pumping function of the heart in systolic heart failure and reduces hospitalization by preventing CHF exacerbations. Nitrates (isosorbide). Nitrates dilate blood vessels, reduce pressure in the heart, and alleviate symptoms. They are especially useful in patients with underlying coronary artery disease.

TrueSevere heart disease is not present in about 50% of CHF patients (especially in older patients). Eective, safe treatments that improve outcomes are available for many CHF patients. Leg edema is very common and is frequently unrelated to CHF. Structured exercise, aerobic and strength training, is benecial to CHF patients. Lifestyle adjustments and monitoring in CHF patients There are several lifestyle adjustments that are just as important as medical interventions in improving the symptoms and outcomes of patients with CHF. Sodium restriction. Salt (sodium chloride) reduction cannot be emphasized enough with CHF patients. Sodium overload inevitably leads to volume (uid) retention and worsening of CHF. The goal is to consume as little sodium as possible. Sodium is an essential ingredient for food preservation; it is abundant in processed foods, restaurants, and takeout because it prolongs shelflife and enhances freshness. Daily weight. Daily weighing is a very useful tool to monitor the clinical status of CHF patients. Rapid weight gain or overnight weight uctuations of more than 23 lbs. are almost exclusively results from uid retention and allow for an early intervention (such as adjusting medications) before further deterioration of CHF occurs. Exercise and an active lifestyle. In contrast to past thinking, studies have shown that exercise training is benecial for patients with chronic, stable heart failure. It lessens symptoms, improves quality of life and exercise capacity, reduces hospitalization, and increases survival. These benets are additive to optimal medical care. Like in other medical and cardiovascular ailments, prevention of the condition in individuals at risk is the most eective way to reduce the occurrence of CHF. A healthy lifestyle, including maintenance of optimal weight, regular exercise, low sodium intake, and not smoking, is mandatory for eective prevention. The leading causes for CHF are hypertension and coronary artery disease, and optimal treatment and measures to control these conditions is essential.

8

LOW N

FO R U M

PATIENT PROFILE

Walking away heart failureA typical walk for John Bloom and his wife Nancy starts at their home on Beacon Street, down the Southwest Corridor Park, through Chinatown, and up the length of the Rose Kennedy Greenway to the North End. At this point in his life, John took stock of his situation. I didnt want to be an old man at a young age. Now twenty years after his quadruple bypass surgery and later development of heart failure symptoms, he is feeling better than ever. When I get up in the morning I feel like theres nothing I cant do that I want to do. With the support of his wife, John works hard to accommodate his active lifestyle to his medical needs. The key is to be involved in your care and trying to follow your doctors recommendations as close as possible and still have a life worth living. Adapting his routine to his health needs hasnt stopped John and Nancy from travelling the world to places like China, Turkey, Egypt, most of Europe, and meeting up with old friends in dierent parts of the US. And whether hes reading, walking, or spending time with his 5 children or 8 grandchildren, John credits much of his health, success, and happiness to Nancy. We share and enjoy every moment of retirement together. I dont let my health issues impede my way of life. Recently, on their rst cruise to Bermuda John took an extra water pill daily to adjust to the high levels of sodium found in cruise ship food. We had such a good time that we already booked another cruise for next year. You have to look ahead and keep a positive outlook.

John and Nancy Bloom on vacation

Walking hand in hand with Nancy is a daily part of Johns life, and so is managing his heart condition. Its been almost 20 years since his heart attack, and John believes attitude is everything. Im a positive person. Ive received many medical blows and Ive shaken them o and lived with them. Thats been my philosophy on life. Despite a history with chronic disease, Johns heart troubles took him by surprise. He was diagnosed with diabetes over 50 years ago and has since taken more than 45,000 insulin shots. Johns father, who was also diabetic, died of a heart attack, and his younger brother is going through the same pattern of heart problems as John. Yet for John, his troubles appeared seemingly out of nowhere. My heart problems snuck up on me in terms of my own awareness. At rst I thought I had a cold, and then I thought it was pneumonia, but the diagnosis established the remnants of a heart attack.

Launching the Lown Scholars programOn November 5th, the Harvard School of Public Health (HSPH) celebrated the launch of the Bernard Lown Professorship and the Lown Scholars Program. Created from a fund made possible by Dr. Lowns generosity and that of his family, these programs will bring clinicians, scientists, nurses, and other health professionals from developing countries to Harvard to learn cardiovascular disease prevention and carry out research under outstanding professors. Program participants will receive training in many healthrelated elds as well as conduct research relevant to their home country. The rst Visiting Lown Professor, Dr. K. Srinath Reddy, inaugurated the event with a talk entitled: Global Cardiovascular Health Calls for Sustainable Development. Dr. Reddy is a leading gure in the developing world who has been a tireless advocate for prevention and public health while still remaining a clinician. He recently played a key role in the care of the Prime Minister of India as he underwent cardiac surgery. Dr. Reddy is the President of the Public Health Foundation of India, and has been involved in numerous large international studies on heart disease. The four initial Lown Scholars were also announced at the event: Dr. Shadi Kalantarian, Dr. Martin Lajous, Dr. Carlos Mendivil, and Dr. Marina Njelekela. The Scholars are involved in a variety of CVD projects including: estimating the burden of CVD in Iran; studying chronic disease in 100,000 teachers in Mexico; researching the impact of preventive dietary interventions on CVD in Columbia; and developing nutritional strategies that prevent CVD in people with HIV/AIDS in urban Tanzania. In Dr Lown's talk entitled Two Roads: One Destination, he reviewed his many decades of experience and shared his broad and deep vision of physicianship. He ended by issuing a passionate call for engagement by health professionals with the central questions facing humanity today, and insisting on nothing less than a New Renaissance.

LOW N

FO R U M

9

Losing ten pounds and keeping it oCharles M. Blatt, MD Following some basic rules of the road can go a long way in losing weight and staying healthy.My project to lose 10 pounds started a year ago this past March. My brother and I were skiing at Alta, Utah and got o the chair lift at 10,500 ft above sea level. Our much younger companions wanted to guide us to untouched powder snow about 800 ft higher. We took our skis o, hoisted them on our shoulders, and as we made our way one step at a time higher up the mountain, I found myself breathing harder. My brother noticed I was working hard and oered his analysis: He thought I was carrying an extra 10 pounds. Despite being uncomfortable to hear, I immediately realized he was right, and upon returning to Boston from this transforming ski holiday, I resolved to lose the 10 pounds. Determined to feel more condent and comfortable skiing, I adopted the following rule of the road. Avoid bread, pasta, potato, pastry and white rice avoid foods made with white our and white sugar. Why does this work? Turns out that 70% of our daily intake of calories comes from carbohydrates. Therefore if we reduce our intake of carbs, our calorie intake automatically drops. Losing 10 pounds doesnt have to be imposing or overbearing. In fact, there are some basic and simple guidelines to follow. Indeed, the simpler the guidelines, the easier they are to follow. Counting calories can become a dicult chore for many people, and most of us are unlikely to walk around with a scale or a calorie counting handbook. And so putting these guidelines into practical, daytoday use, my diet now consists of the following: Breakfast. I begin the day with a breakfast of whole grain shredded wheat cereal with skim milk, fresh fruit, black coee, and orange juice. In the winter, I switch from cold cereal to oatmeal. No muns, no bagels, no toast with my coee and juice. Lunch. Lunch is a salad of fresh vegetables, often with slices of fruit or a scoop of tuna sh. My dressing is olive oil and apple cider vinegar, and I sometimes add a fresh lemon and some pepper to further enhance the avor. Avoiding a daily sandwich removes 14 slices of bread half a loaf from the weekly calorie intake! Afternoon snack. Mid afternoon snack consists of raw, unsalted almonds, a piece of fruit, and a cup of tea (I like Earl Grey). This gives me the energy to nish the day at the oce without resorting to a candy bar or a cookie. Dinner. In our home, the evening meal is sh three or four days a week, chicken two days a week, and occasionally red meat. Side dishes include generous portions of broccoli, brussels sprouts, and squash. To wash it all down, Ill have a tall glass of water avored with fresh lemon or a sprig of fresh mint from the garden. You dont have to follow these guidelines absolutely every day all the time, but the key is that you follow them most of the time. On Sunday mornings Ill have a scrambled egg white omelet and a half a bagel. But only on Sundays! And if were invited to dinner, Ill eat what is served without feeling guilty. And of course I occasionally enjoy a piece of bread, a pastry, or a glass of wine, but I do so all within moderation and not on a daily basis.

Its not just eating healthy: ExerciseAn essential element to success is daily, moderate exercise. When it comes to exercise, dont burden yourself with two questions. The rst is: Am I going to exercise today? The second is: When am I going to exercise? The rst answer should always be yes, so you should not have to ask the question. The answer to the second is decided in advance according to what ts your schedule, but should then Dr. Blatt stays healthy hitting the slopes remain a routine part of your day. My favorite time to exercise is after work and before dinner, however, many people nd exercising in the morning better ts their schedule and temperament. The key is to nd a routine and follow it.

Be patientDont expect to lose your 10 pounds in one week or even in one month. You may start to see your scale show a drop in a pound or two after two or three weeks. After three months it is likely that youll have lost 10 pounds! Of course, you have to be honest with yourself and avoid those ingrained habits like stopping at candy bowls and sampling. Losing these pounds will provide reinforcement to continue eating well and then the routine becomes sustained and enjoyable. Eighteen months after that ski trip, Ive maintained a weight that is 1012 pounds lighter and I now have no trouble nding that untouched powder snow.

10

LOW N

FO R U M

Argentina antitobacco program receives Louise Lown Heart Hero AwardBenn Grover; Sandy Burkhardt, ProCorOlavarra: Tobacco Free City, a cityrun tobacco advocacy, education, and support program, was presented with the globallyrecognized Louise Lown Heart Hero Award on October 5th from ProCor. Olavarra, a city of 120,000 people 350km south of Buenos Aires, faces an uphill battle in its ght against tobacco: Argentina has the second highest smoking Students participate in education program prevalence in all of Central and South America. According to local health data, onethird of adults in Olavarra use tobacco and almost half of the mortality rate is attributed to chronic diseases such as hypertension, stroke, and cancer. However, that hasnt stopped the eorts of a dedicated community and its leaders in reducing the local impact of tobacco. Under the direction of this program, the overall adult smoking prevalence in Olavarra decreased by 18% over four years and cardiovascular diseaserelated visits at local hospitals dropped by onethird. Dr. Carlos Joulie, chair of the Public Health department at the University of Salvador, presented the award to Mayor Jos Eseverri and program sta on behalf of ProCor and Dr. Lown, founder and chair of ProCor. As mayor, Im proud to carry forward a policy that is a pioneer in our province and widely supported by our community, Eseverri said. This award distinguishes us as the city we want to be modern, friendly, and providing people a good quality of life. Started in 2004, Olavarra: Tobacco Free City works with many local stakeholders schools, health professionals, businesses, community groups, politicians, and the public to train health workers, educate students and teachers, engage in community activities, and garner support for public smoking bans. As a result of these eorts, Olavarra is now 100% tobacco free in bars, restaurants, most major shopping centers, and in cars whenever a child is present; hundreds of health workers, teachers, and students have received tobaccorelated education and training; and eight tobacco health centers have been established throughout the city. As a sign of their success, the ban on smoking in enclosed places was supported by 90% of Olavarras citizens.

Everything we have said and lived in Olavarra is the result of a team eort, with the commitment of all social institutions, schools, health personnel, politicians, and the community.I think that the main strength of the program is community participation, said Dr. Fernando Verra, president of the Argentinean Society of Tobacco Sciences. Its amazing to see how social and academic institutions, shopping centers, health clinics, the media, unions, etc. are working together. According to Ral Pitarque, the programs director, the motivation behind the program is clear. This is an opportunity to convey to society and our children that smoking is not normal, that it is not a minor defect and that it is a serious problem of individual and community health, Pitarque said. Those working in health, we strongly believe that the endeavor to control the use of tobacco is a very important contribution to the health of our neighbors. Csar A. Di Giano, president of the Argentinean Union Against Tobacco, said whenever his organization wants to show how communities can be successful ghting tobacco, he mentions Olavarra. We believe that the main strength of the tobacco control program is its continuity in time and the commitment from many institutions, Di Giano said. Everything we have said and lived in Olavarra is the result of a team Program advertisement eort, with the commitment of all social institutions, schools, health personnel, politicians, and the community. The annual Louise Lown Heart Hero Award recognizes innovative, preventive approaches to cardiovascular health in developing countries. It was established in 2007 by Dr. Lown to honor his wife, Louise, and her lifelong commitment to the rights and wellbeing of others as a social worker, activist, and writer. For more information about the Olavarra: Tobacco Free City program or the Louise Lown Heart Hero Award, visit www.procor.org.

LOW N

FO R U M

1 1

LOWN CARDIOVASCULAR CENTER

Thank you for your supportThe Lown Cardiovascular Research Foundation promotes cardiac care that advocates prevention over costly, invasive treatments and restores the relationship between doctor and patient. Your financial support allows us to continue our work and carry our heart health message to local, national, and global audiences. We are greatly appreciative of any donation you are able to make. You can donate online at our website (www.lownfoundation.org) or mail your donation in the enclosed envelope to 21 Longwood Avenue, Brookline, MA 02446. Please make checks payable to Lown Cardiovascular Research Foundation.

NewsBeatDr. Fred Mamuya was a guest speaker at the Woburn Senior Center on August 25, where he discussed second opinions and alternatives to surgery. On August 29, Dr. Vikas Saini presented an abstract titled Twelve year allcause mortality with optimal medical management of chronic CAD at the European Society of Cardiology Congress in Stockholm, Sweden. The ESC Congress is currently the largest international cardiovascular meeting in the world. In September, Dr. Tom Graboys was interviewed by Joan Brunwasser from OpEdNews where he discussed his memoir, Life in the Balance, and spoke about his personal journey from cardiologist to patient with Parkinson's disease and Lewy body dementia. A complete transcript of the interview is available at FutureHealth.org. Also, as part of Lewy Body Dementia Awareness Week, Dr. Graboys gave a well attended presentation followed by a book signing at Southgate at Shrewsbury on October 13. LCRF Board Member, Dr. Barbara Roberts participated in the rst annual conference of the Women's Health Council of Rhode Island on October 14. The topic was violence against women as a risk factor for chronic disease. During the month of October, Dr. Saini was a guest lecturer at the Cambridge Senior Center and the Weston Council on Aging, where he discussed stress and the heart, and second opinions. A portrait of Dr. Lown painted by Stephen Coit was unveiled at the Lown Scholars Program and Lown Visiting Professorship launch event on November 5 at the Harvard School of Public Health. The portrait was presented to Dean Frenk by Dr. Saini and Nassib Chamoun, Chairman of the Foundations Board of Directors. The Foundation welcomed two interns during the Fall. Sandy Burkhardt received a BA in Integrative Public Relations and Interpersonal and Public Communication from Central Michigan Univeristy. Currently pursuing her MA in Health Communication at Emerson College, Sandy also works in an assisted living home as an activities assistant. Anna Shum received her BA in English from Colby College, and is currently pursuing her MA in Health Communication at Emerson College. Anna is certied in both kettlebells and Zhealth, a neuromuscular training protocol. She teaches an exercise class that combines these practices and aims to redene the workout.

Educational opportunitiesInterested in hosting a lecture on a heart health topic by one of our physicians at your worksite or community organization? Please contact Jessica at jgottsegen@partners.org or 6177321318.

Receiving the ForumIf you would prefer to receive the Lown Forum by email, send your full name and email address to info@lownfoundation.org.Board of Directors Nassib Chamoun Chairman of the Board Vikas Saini, MD President Bernard Lown, MD Chairman Emeritus Thomas B. Graboys, MD President Emeritus Patricia Aslanis Charles M. Blatt, MD Joseph Brain, SD Janet Johnson Bullard J. Breckenridge Eagle Carole Anne McLeod C. Bruce Metzler Barbara H. Roberts, MD Ronald Shaich Robert F. Weis Advisory Board Martha Crowninshield Herbert Engelhardt Edward Finkelstein William E. Ford Renee Gelman, MD Barbara Greenberg Milton Lown John R. Monsky Jerey I. Sussman David L. Weltman CONTACT US Lown Cardiovascular Research Foundation 21 Longwood Avenue Brookline, MA 02446 (617) 7321318 info@lownfoundation.org www.lownfoundation.org www.procor.org Lown Cardiovascular Center Brian Z. Bilchik, MD Charles M. Blatt, MD Wilfred Mamuya, MD, PhD Shmuel Ravid, MD, MPH Vikas Saini, MD Lown Forum Editorial Sta Jessica Gottsegen Benn Grover Claudia Kenney

2010 Lown Foundation

Printed on recycled paper with soy based ink.

Lown Cardiovascular Research Foundation 21 Longwood Avenue Brookline, Massachusetts 024465239

Nonprofit Org. US Postage PAID Boston, MA Permit No. 53936

12

LOW N

FO R U M

Winterizing: Be aware and preparedBrian Bilchik, MDWinter months can be hazardous for your heart health. In fact, there is some evidence of a higher incidence of cardiovascular events in the winter. At the Lown Center, we are very aware of these higher risks as well as the obstacles to maintaining good heart health during the winter months. Let me explain the reasons why there are more cardiovascular events during the winter season: Weather. Cold weather causes blood vessels to constrict and this can increase blood pressure. In addition, blood may be more likely to clot, and this can be exacerbated by dehydration. Cold, dry air and dry heat increase the likelihood of dehydration, and people are less likely to take in enough uids when the weather is cold. Stress and depression. We know that stress plays a role in cardiovascular events, and winter stress can be explained by several coincidental issues. Short days, long nights, lack of sunlight, and end of the year stressors such as family, nances, holidays, and isolation can all contribute to mood changes, depression, and heightened stress. Food. The food we eat is dierent during the winter months. We tend to look for comfort foods that are salt loaded and high in energydense carbohydrates. Exercise. People tend to exercise less during the winter. Energy levels are lower and the shorter days and longer nights add to fatigue and diminished motivation. However, we also tend to overexert ourselves at times when it is most dangerous such as shoveling early in the morning after a snowstorm. Many people add an exercise routine or gym membership to their New Years resolutions, but there is a tendency to do too much too quickly rather than gradual, consistent exercise.Infections. Viral illnesses, like the u, may add to the risk of cardiac events. This is thought to be related to inammation, which makes our blood vessels more vulnerable to cholesterol plaque rupture, causing blood clots to then form in blood vessels. Despite the strain the winter months can put on your heart, there are some easy, eective steps you can take to winterize your heart health.

Be preparedHave an exercise plan and stick to it. Your exercise routine should be consistent, and it can help you prepare for the winters physical stressors such as shoveling. Please refer to Dr. Blatts article on losing ten pounds and the importance of an exercise routine (page 9). Be active socially. Socialize around an activity like dancing, walking, biking, or going to the gym. Dont meet to eat, that is, your social activity should not be solely focused on food. Be aware of your calorie (energy) intake. Portion size, salt intake, and dehydration are all factors that can lead to poor heart health. Monitor your winter weight and your winter blood pressure. Avoid excessive alcohol consumption. This can create additional burdens to your heart health, because of its impact on depression, lack of energy and motivation, sleep interruption, and dehydration. Dont ignore your symptoms. A pain in the arm or chest while shoveling may not be a muscle strain. If you notice an unusual symptom or soreness, its a good idea to check in with your doctor.