Category: Latest Articles

Covid-19 and Your Heart

written by Dr Lim Choon Pin

During this Covid-19 virus outbreak, many patients with chronic heart diseases may be worried about how their underlying heart conditions can be affected by the virus. While there is still much to be discovered about the short- and long-term effects the Covid-19 virus, here is a summary of what we know about the virus and the heart so far and how you can protect yourself.

Effects of Covid-19 on the heart

Patients who have a heart condition are at the same risk of catching the virus as any other person. The virus is spread by breathing in respiratory droplets in the air or touching your face, eyes or mouth after coming into contact with contaminated surfaces. Therefore, EVERYONE is at risk.
Patients with chronic heart conditions are at a higher risk of developing more severe forms of the infection if they do catch the virus.
The main organ that Covid-19 virus affects is the lungs. However, it can also cause damage to other organs. The virus can affect the heart in the following ways:
1. by causing inflammation of the heart muscles (myocarditis and pericarditis)
2. triggering abnormal heart rhythm (arrhythmias)
3. triggering heart failure symptoms
4. triggering a heart attack

This can happen even in people without pre-existing heart conditions.

ACE-inhibitors (e.g. Enalapril, Perindopril etc) and ARBs (e.g. Valsartan, Candesartan etc) are common medications used to treat hypertension, heart failure, heart attacks and kidney diseases. There are some debates that suggest that these medications could theoretically increase the risk infection by the Covid-19 virus; however, these same drugs may also protect from the severe form of illness. There is currently no convincing clinical evidence supporting these hypotheses, therefore many international professional bodies such as the World Health Organisation, American Heart Association, European Society of Hypertension and the Ministry of Health of Singapore have recommended patients should continue taking these medications in view of their beneficial effects for these chronic medical conditions.
Medications such as Hydroxychloroquine and Azithromycin are still unproven in the treatment of Covid-19. Moreover, they could also result in life-threatening arrhythmias, especially in patients with underlying heart disease. Therefore, you should not self-medicate with these unproven medications.
Vaccinations against influenza and pneumococcus are important for patients with heart disease. While they do not protect against Covid-19, it is still important to be current with these vaccinations as cardiac patients are still susceptible to these infections even during the Covid-19 outbreak.

You cannot prevent the effects of Covid-19 virus on your heart. However, you can do the following to protect yourself from catching the infection during this outbreak and keeping your heart healthy.

Practice good hygiene practices like:
1. Regular and thorough handwashing with soap, especially before eating or touching your face.
2. Avoid people who are sick.
3. Avoid crowded places. Go out only for essential activities.
4. Wear a mask when going outdoors.
5. Practise physical distancing. Stay at least one metre away from people around you when you are out.

2. Continue regular exercises 30 minutes a day for 5 days each week. Consider switching to indoor static exercises if you are unable to do walks alone or with a mask on in your neighbourhood.

3.Continue to eat a healthy diet. Do not binge on snacks and instant noodles when you are confined in your home.

4. You may consider delaying your reviews with your doctors if you feel completely well. Speak to your cardiologist whether it is safe to do so.

5. It is also important that you have enough supply of medications. Do not stop any cardiac medications without first consulting your doctor – this can potentially be harmful to you.

6. Do not delay seeing your doctor or going to the emergency department if you have symptoms such as worsening chest pain, palpitations, shortness of breath or fainting. While patients are recommended to avoid non-essential visits to the hospital, if you have any active heart-related symptoms, it is not safe to delay assessment. You can be assured that the hospitals will still be able to care for you safely during this period.

We hope that this information can enable all cardiac patients with the necessary information to tide through this difficult period.

Wishing all of you good health. Stay Home and Stay Safe!

From all of us at The Heart and Vascular Centre

April 8, 2020

COVID-19 Updates

As the situation of the pandemic is evolving, we will continue to update our health advisories according to Singapore government guidelines.

For more information on the coronavirus situation in Singapore, please visit the Ministry of Health website (click here).

Visitor and patient advisory

All patients and visitors to the Medical Centre are required to fill the visitor registration forms and health declaration form before entering. Every department, including the Radiology clinic (X-ray), Laboratory (for blood tests) and our clinics, will also require the patient and his/her caregiver to fill in health declaration forms.

Please note that each patient is allowed only ONE person to accompany him. All visitors are required to follow social isolation and infection prevention and control measures. These include:

Washing of hands with soap and water for at least 20 seconds, or applying at least 60% alcohol-based disinfection rub on hands before entry
Bringing of own mask and ensuring that the mask is worn at all times
Maintaining social distancing of at least 2 metres from the other patients and visitors
Not communicating and interacting with other patients or visitors

Anyone who has had travelled abroad within the last 14 days or had close contact with a confirmed COVID-19 patient will be denied entry to the medical centre and our clinics.

All non-essential visits such as consultations for health screening are to be deferred.

We are still able to render services to patients with the following conditions:

Unstable symptoms and emergency conditions such as breathlessness, heart attack etc
Chronic diseases with recent relapses and/or poor control, and medication refills
Procedures or surgeries required to prevent deterioration of the patient’s condition
Cancer chemotherapy echocardiography surveillance

Medication Refills

Local patients can come to our clinics to top up their medications. If delivery is preferred, please contact our clinic at 6735 3022 or 6694 0140 for more details. Please note that delivery fee is chargeable.

For International patients, we encourage you to obtain your medications for your local clinics and pharmacies. You can contact us via whatsapp +65 9664 0822 or +65 9236 1026 if you require prescriptions or further clarifications.

However, if delivery of medications from our clinic is preferred, do note that we use an outsourced delivery service, and the total charges will depend on your local taxation fees, delivery and administrative charges.

International patients

We are currently unable to accept new medical appointments for international patients due to local regulations that restrict short-term visitors from any country from entering Singapore.

Existing patients who require critical follow-ups or medical evaluation (approval is based on a case-by-case basis) may still come to Singapore. Their attending specialists can request for a waiver of the requirement to enter Singapore ONLY if ALL of the following criteria is fulfilled:

The patient has healthcare needs requiring specialist management that cannot be met in his/her home country AND
The patient is currently under the attending specialist’s active follow-up AND
The attending specialist certifies that delay in continuation of treatment will lead to serious, life-threatening adverse outcomes

If approved, a waiver approval letter will be sent to the patient. The patient is allowed to bring only 1 accompanying visitor to Singapore and upon arrival, the patient (and accompanying visitor) will need to serve a 14-day Stay Home Notice (SHN). For medical evacuation patients who require direct admission to the hospital, they may serve the 14-day SHN in the hospital but their accompanying visitor will need to serve the 14-day SHN in a separate residence as they are not allowed to enter our hospital.

Please contact the Parkway Regional Office in your home country for more information and assistance. Contact details for Parkway Regional Offices: https://www.mountelizabeth.com.sg/plan-your-visit/patient-assistance-centres

Please note that the above information are obtained from the following sites:

https://www.mountelizabeth.com.sg/novel-coronavirus-updates

https://www.moh.gov.sg/covid-19

https://www.gov.sg/features/covid-19

April 3, 2020

Planning for a Coronary Angioplasty Procedure

If you are being planned for a coronary angioplasty procedure, our cardiologist will first take your consent for procedure after explaining to you the risks that may be involved in the procedure.

Before your procedure, please inform our doctor and clinic staff what insurance policies you may have that could cover your outpatient clinic consultations and tests, and inpatient procedures. You could check with your insurance agent or HR (if corporate insurance) to find out about your coverage. For most corporate and personal insurance schemes, preauthorisation is usually required to obtain a Letter of Guarantee for the admission process, to ensure that your hospital stay and procedure costs will be covered. You can help by initating the request with your insurance agent or HR, after which we will do the necessary paper work and submit them to your insurance company for approval. The process for approval takes on average 3-5 working days.

Preadmission Tests

Before admission, you will be required to do some tests, including blood tests and an ECG. Other cardiac tests such as an echocardiography may also be done.

Admission and Procedure Day

On the day for the coronary angioplasty, you will need to register at the hospital’s admission office 2 hours before the time of the procedure. You will also be required to fast for 4 hours before the time of the procedure. You can still take your medications 4 hours before, or otherwise if advised by our cardiologist.

The admissions office will arrange a room for you where they will prepare you for the procedure. Nearer to the procedure time, you will be brought down to the cardiac catherisation laboratory where the angioplasty procedure will be performed. An angioplasty procedure usually takes approximately 1 to 2 hours time, depending on the complexitity of the procedure.

During the angioplasty, local anesthesia will be administered to numb the area where a sheath (tube) will be inserted, usually at the radial artery (wrist) or less commonly at the femoral artery (groin). Our cardiologist then inserts a catheter (thin flexible tube) into the sheath and thread it towards the heart to perform the angioplasty. An x-ray camera is used to project images onto a screen to help our cardiologist guide the catheter to the heart artery.

When the catheter is properly positioned, our cardiologist injects a contrast dye (also called radiographic contrast agent) through the catheter into the heart and its arteries. Most people do not feel the dye injection. Rarely, some may feel a minor discomfort or a warm sensation, typically lasting only a few seconds, in their chest, and even more rarely, lightheadedness or nausea.

At the segment of the artery blockage (narrowing), a thin wire (called guidewire) is passed across the blockage. Next, a long, thin flexible tube (balloon catheter) with a small uninflated balloon at its tip is threaded through the catheter, over the guidewire and to where the artery is blocked. The balloon is inflated at the position of blockage. As the balloon inflates, it cracks and flattens the plaque against the wall of the artery. Some patients feel minor discomfort when it is inflated. Medication may also be given to some patients who experience more pain. A coronary artery stent is then put in place to hold up the artery walls, thus treating the blockage.

After the Procedure

After the angioplasty is performed, you will be monitored in the High-dependency unit or Coronary care unit for one night. The morning after, our cardiologist will assess your condition and prepare you for your discharge from hospital. After coronary angioplasty with stenting, you will require 2 types of blood thinning medications. We will also schedule a follow-up appointment in our clinic to review your condition after discharge.

For more information, please call our clinic at 6735 3022 or 66940140.

November 22, 2019

What is WATCHMAN LAA Device Closure?

What is WATCHMAN?

WATCHMAN LAA Device is FDA approved, an alternative to taking warfarin lifelong, for patients who are suffering from atrial fibrillation that is not due to heart valve problems, also known as non-valvular Afib.

It is a permanent implant that is done via a minimally invasive procedure, which can reduce the risk of stroke, without the risk of bleeding that can come with the long-term use of warfarin. It was found that left atrial appendage closure with WATCHMAN is as effective as warfarin in preventing strokes in patients with atrial fibrillation, and strokes in Watchman recipients are 55% less likely to be disabling, according to a meta-analysis of 5-year outcomes in the PREVAIL and PROTECT AF randomized trials.

This device therapy has addtional benefits over warfarin, such as significantly reduced risks of mortality, non–procedure-related major bleeding, and hemorrhagic stroke, Saibal Kar, MD, reported in presenting the results of the meta-analysis at the Transcatheter Cardiovascular Therapeutics annual educational meeting (TCT) in 2017.

How does WATCHMAN LAA Closure Device prevent Stroke?

In atrial fibrillation, the heart pumps irregularly and there is a tendency for blood to pool in a part of the heart chamber, called the left atrial appendage (LAA). As the blood pools, a clot may form, and when it escapes from the LAA and travel to the rest of the body, it can cut off the blood supply to the brain, resulting in a stroke. In patients with non-valvular Afib, more than 90% of stroke-causing clots that come from the heart are formed in the LAA.

The WATCHMAN LAA device fits right into the LAA, permanently closing it so as to prevent blood clots from escaping, thus reducing the risk of stroke.

How is the WATMAN LAA Device Implanted?

The device is implanted into the heart via a minimally invasive procedure. The doctor cuts a small hole in the leg vein and inserts a narrow tube, similar to the angioplasty when a stent is required. Using transesophageal echocardiography and Xray, the doctor guides the WATCHMAN into the left atrial appendage (LAA). The procedure is done under general anesthesia and takes about an hour. Patients commonly stay in the hospital overnight and leave the next day.

What to expect after the procedure?

After the procedure, the patients will require to continue their warfarin until the LAA is permanently closed off. Heart tissue will grow over the implant, which blocks out the blood clots, and to verify that this has happened, transesopheal echocardiography tests will be performed.

After than the patient will still require blood thinners, but those of a lower bleeding risk than warfarin.

Studies on WATCHMAN LAA Device Closure

“This is not a first-line therapy. But we know there is a large number of patients who cannot tolerate long-term anticoagulation. And this is the ideal therapy for stroke prophylaxis in that group of patients,” according to Dr. Kar, director of interventional cardiac research at Cedars-Sinai Medical Center in Los Angeles.

The patient-level meta-analysis of 5-year outcomes included 1,114 patients with atrial fibrillation who were randomized 2:1 to the Watchman device or warfarin, with 4,343 patient-years of follow-up. This was a fairly high–stroke risk population, with CHA2DS2-VASc scores in the 3.6-3.9 range, and 40% of patients aged 75 years or more. At baseline, 23% of subjects had a history of stroke or transient ischemic attack.

At 5 years’ follow-up, the composite endpoint of all stroke or systemic embolism was the same in the two study arms. However, the rate of hemorrhagic stroke was 80% lower in the Watchman group, the risk of disabling or fatal stroke was reduced by 55%, the rate of cardiovascular or unexplained death was 41% lower, all-cause mortality was reduced by 27%, and postprocedure major bleeding was 52% less frequent in the device therapy group. All of these differences achieved statistical significance, the cardiologist reported at the meeting sponsored by the Cardiovascular Research Foundation.

In the PREVAIL trial, 92% of patients were able to stop taking warfarin just 45 days after the procedure, while 99% of patients were able to stop taking warfarin within 1 year after the procedure.

Please watch the following videos from Boston Scientific, to learn more about the WATCHMAN LAA device closure.

References:

Holmes DR Jr, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64(1):1-12.

https://www.mdedge.com/clinicalneurologynews/article/155532/stroke/watchman-device-prevails-stroke-prevention

https://www.watchman.com/en-us/resources.html

Images credits:

Boston Scientific

https://www.watchman.com/content/dam/watchman/downloads/download-center/WATCHMAN_DTP_Brochure.pdf

August 26, 2019

Left Ventricular Assist Device and How it works

What is a LVAD?

A left ventricular assist device (LVAD) is a mechanical pump implanted inside a patient’s chest to help the heart to pump blood around the body. It helps to bear the stress of the heart by circulating the blood to the rest of the body, allowing the heart to rest while other organ functions are sustained by the pump. The LVAD helps patients with advanced heart failure by relieving their symptoms such as shortness of breath and weakness, improving their exercise capacity and prolonging their survival.

How does the LVAD work?

The LVAD is implanted via an open heart surgery, with one end attached to the tip of the left ventricle (main pumping chamber of the heart) and the other end to the aorta (main artery of the body). Blood is pumped out of the left ventricle into the aorta by the LVAD. An insulated electrical cable (driveline) passes from the device, through the skin, to connect the pump to an external controller and electrical power source (two battery packs) outside of the patient’s body. The controller and battery packs are usually carried in a pouch that is slung on the shoulder or worn around the waist. The batteries are rechargeable.

Which patients require LVAD?

Patients with advanced heart failure have a poor quality of life and a one-year survival rate of less than 50%. Those who should consider an LVAD surgery include patients who have severely impaired left heart function AND:
a. have frequent disabling heart failure symptoms like breathlessness at rest or on mild exertion despite being treated with oral medications, OR
b. have frequent hospital admissions for heart failure, OR
c. have critically low blood pressure and require intravenous medications or mechanical devices to boost the blood pressure. These patients are usually confined to the Intensive Care Units (ICUs).

After a successful LVAD implantation, majority of patients experience markedly improved exercise capacity and reduced hospital readmissions. In Singapore, the 5-year survival rate of patients on LVAD support is more than 80%.
The LVAD can be implanted to temporarily support patients while they await a heart transplant (Bridge-to-Transplant) or as a permanent support (Destination Therapy).

Consult your cardiologist about LVAD if you continue to experience heart failure symptoms not controlled by your medications.

Here are some publications from Abbott, of the Momentum 3 Trial involving their Heartmate III LVAD, sharing from their website:

https://www.cardiovascular.abbott/us/en/momentum3publications.html

The MOMENTUM 3 (Multicenter Study of MagLev™ Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3™) investigational device exemption (IDE) clinical study was designed to evaluate the safety and effectiveness of HeartMate 3™ Left Ventricular Assist System (LVAS) by demonstrating non-inferiority to the HeartMate II™ LVAS when used for the treatment of advanced refractory left ventricular heart failure.

Final Report of the Two-year Principal Outcomes in the MOMENTUM 3 Full Cohort

https://www.nejm.org/doi/full/10.1056/NEJMoa1900486

Mehra, M.R., Uriel, N., Naka, Y., Cleveland, J.C., Yuzefpolskaya, M., …Goldstein, D.J., for the MOMENTUM 3 Investigators. (2019). A Fully Magnetically Levitated Left Ventricular Assist Device – Final Report. N Engl J Med. https://www.doi.org/10.1056/NEJMoa1900486

The data from two-year followup of the MOMENTUM 3 full cohort demonstrates:

Clinical superiority of the HeartMate 3 LVAS when compared to the HeartMate II LVAS
Less frequent need for pump replacement with HeartMate 3 LVAS
Lower rate of stroke and disabling stroke with HeartMate 3 LVAS
Lower rate of gastrointestinal bleeding with HeartMate 3 LVAS

Other Publications:

2 Year Primary Outcomes in the MOMENTUM 3 Long-term Cohort

https://www.nejm.org/doi/full/10.1056/NEJMoa1800866

Quality of Life and Functional Capacity Outcomes at 6 months in the MOMENTUM 3 Short-term cohort

https://www.jhltonline.org/article/S1053-2498(17)32085-5/fulltext

August 26, 2019

Device Closure of PFO in Scuba divers with Decompression sickness

Suba diving is a popular sport in many countries. While the general risk of death or major injury during scuba diving is small (<0.001% per dive), one of the notable risks include decompression sickness.

Decompression sickness, also known as divers’ disease, is caused by nitrogen bubbles forming in the diver’s tissues during his ascent. These bubbles can form in or migrate to any part of the body, causing varied levels of symptoms, ranging from simple symptoms involving skin rashes and pain in the joints to more serious symptoms which can lead to paralysis or even death when the other organs such as the central nervous system (including brain), are involved.

The connection between Patent Foramen Ovale (PFO) and decompression sickness was first described in the 1980s. Foramen ovale is a hole between the top chambers of the heart in the fetus which is normally closed by a flap within the first breaths at birth. However, in about 27% of the adults, the flap does not seal the gap causing it to remain open (patent), hence allowing blood to travel from the right to the left heart chambers during occasions when the chest pressure is raised. In the event of decompression sickness in divers, the bubbles in the venous system can by pass the lungs where they were supposed to be filtered out, and travel directly to the arterial system through the PFO and left side of the heart. The arterial system includes arteries to the brain, spinal cord and heart. Blood formation in the arterial system also known as arterial gas embolism, is far more dangerous as it can result in blockage in the blood supply to the brain or spinal cord, leading to stroke or paralysis.

Currently, in most countries, routine screening for PFO in divers is not recommended. Suggested recommendations for divers with diagnosed PFO and a history of decompression sickness include cessation of diving, a conservative approach to diving, and PFO closure.

Transcatheter Device Closure of the PFO is the implantation of an occluder device across the PFO through a catheter (plastic tube) inserted via the leg vein in the groin. The device acts like a double-sided umbrella that opens on each side of the atrial wall between the top chambers of the heart to seal the PFO. This helps to eliminate the chance of arterial embolization, allowing the diver to return to unrestricted diving. It is a minimally invasive procedure, which can be performed with mild sedation, and takes less than one hour, with one night stay in the hospital. Most patients can return to normal activity in two days, but they must take anti-coagulation medication and blood thinners for three to six months. Other restrictions include: no elective dental care (such as cleanings) for three months, no contact sports for three months, and no heavy lifting for one week. After implantation, divers must abstain from the sport for three to six months.

Before proceeding to do the transcatheter PFO closure, the patient has to undergo a transthoracic echocardiogram or a heart scan, with an ‘agitated bubble saline study’ to see if there is any possible sign of PFO. After which, a transoesophageal echocardiogram (similar to a scope), will be performed to help confirm the diagnosis.

Although there are no consensus criteria for PFO closure in divers currently, several studies have established that the incidence of PFO is two to six times greater in divers who experience a neurological decompression; and that catheter-based PFO closure is shown to lead to complete elimination of arterial bubbles after simulated dives, suggesting that PFO closure in continuing divers have a relevance in preventing symptomatic (major decompression sickness) and asymptomatic (ischaemic brain lesions) neurological events. There is a small risk of complications with PFO closure which should be discussed with the cardiologist.

Sources:

http://www.alertdiver.com/294

https://heart.bmj.com/content/97/23/1932.long

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220018/

https://en.wikipedia.org/wiki/Decompression_sickness

Primary Transcatheter Patent Foramen Ovale Closure Is Effective in Improving Migraine in Patients With High-Risk Anatomic and Functional Characteristics for Paradoxical Embolism

https://link.springer.com/article/10.1007/s12471-018-1153-x

March 26, 2019

TAVI/ TAVR now shown to be Equal or Better than Open Heart Surgery

During the latest American College of Cardiology (ACC) 68th Annual Scientific Session held in New Orleans, LA, on March 2019, data presented demonstrated strong evidence that Transcatheter Aortic Valve Implantation (TAVI/ TAVR) is non-inferior or even better than open-heart surgery for aortic valve replacement for low-risk patients with aortic stenosis. Two studies, PARTNER 3 and the Evolut TAVR in Low-Risk Patients trial were presented.

The PARTNER 3 trial exceeded noninferiority expectations, with investigators reporting that treatment with the balloon-expandable Sapien 3 transcatheter heart valve (Edwards Lifesciences) was better than surgery for the prevention of death, stroke, and rehospitalization at 1 year, the study’s primary endpoint.

In the Evolut Low-Risk trial, which tested the self-expanding CoreValve, Evolut R, and Evolut PRO (Medtronic) valves in a low-risk patient population, the 24-month estimated incidence of death or disabling stroke was similar in the TAVR and surgical arms, meeting the definition of statistical noninferiority but not superiority.

Michael Reardon, MD (Houston Methodist DeBakey Heart and Vascular Center, TX), the co-principal investigator of the Evolut Low-Risk TAVR trial and cardiac surgeon, said TAVI/ TAVR should be the preferred strategy across the entire risk spectrum of patients. When discussing treatment options in low-risk patients with severe aortic stenosis, unless he mentions the benefits of TAVI/ TAVR, “I have not truly given informed consent,” he added.

The results of the trials were said to change the landscape of treatment for severe aortic stenosis.

From a patient’s perspective, only one-third of the TAVR patients from the trial underwent general anesthesia and very few were taken to the intensive care unit after the procedure. TAVR patients were hospitalized for shorter periods after valve replacement and the vast majority were discharged home or to self-care. “In the first 30 days, they have almost complete recovery to normal functional status,” said Martin Leon, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), one of the lead PARTNER 3 investigators. All of this, said Leon, “is very powerful from the standpoint of a new therapy for low-risk patients.”

“If you had a TAVR, you’re going to be out of the hospital in less than half the time as surgery patients and more likely to go directly home,” said Reardon. “The hemodynamics are what we’ve come to see in all the randomized trials with the supra-annular valve, that is single-digit mean gradients and [effective orifice areas] that are 2 [cm2] or above.”

Both trials are now published in the New England Journal of Medicine following an embargo break ahead of the ACC presentation.

The Heart and Vascular Centre performs TAVI with Edwards Sapien S3 valve, Corevalve Evolut R and Evolut Pro, along with a FDA approved Cerebral Protection Device for stroke prevention during the procedure.

Sources:

https://www.tctmd.com/news-acc-2019-low-risk-trials-cement-role-tavr-alongside-or-place-surgery

ACC 2019: Evolut TAVI as good as surgery for low-risk patients

November 6, 2018

Is your job stress bad for your heart?

By Dr Paul Chiam
Published on Ezyhealth on April 2015

Work stress can do a real job on your ticker

It is commonly accepted that work stress can affect our cardiovascular health. You’re probably familiar with the phrase “worked to death”!

Various kinds of jobs create different types of stress, and whether the stress becomes harmful depends on the individual – some people cope much better than others.

Some individuals even thrive as the stress drives them to work harder and improve work performance! So is job stress actually bad for your heart?

What is a stressful job?

Most studies concur that jobs become stressful in situations where the worker feels that he or she has little or no control. Let’s say you have a highly demanding job. If you have minimal power to make decisions about your daily tasks, that makes it a lot more stressful than if you have some control. If you love your job and enjoy what you’re doing, then putting in long hours is not going to have too much impact.

How stressful a job is also depends on the personality of the individual and his co-workers. Persons with hostile personalities face more job stress and are at higher risk of a cardiovascular event. Jobs that require sudden intense bursts such as firefighters may also place more stress on the workers.

The Stats on Job Stress and Your Heart

A large British study of over 10000 white collar workers over a 12-year period found that people who felt stressed at work were 68% more likely to die of heart disease, suffer a non-fatal heart attack or have exertional chest pain (angina).
Another British study of over 6000 civil servants found that overtime work of three to four hours a day was associated with a 1.5 times increased risk of heart disease, independent of other risk factors.
Researchers in South Korea found that increasing numbers of hours worked per week correlated with increased heart disease. Compared to those who worked 31 to 40 hours a week, workers putting in 61 to 70 hours a week had a 42% increased likelihood of developing coronary heart disease; those working 71 to 80 hours a week had a 63% increased likelihood; while those working more than 80 hours a week had a 94% increased likelihood.

Although these statistics look alarming, they must be considered in the context of other risk factors that can contribute to heart disease. In an analysis of 13 studies pooled together, job strain was found to contribute to 3.4% of heart attacks; conversely, smoking alone accounted for 36% and physical inactivity for 12% of heart attacks! So though job stress can indeed increase heart disease, the overall burden on heart disease is small.

How does one’s job affect the heart?

Job stress can affect the heart arteries directly by causing mild vasoconstriction (artery narrowing). Stress causes blood pressure to rise, and blood platelets (a group of cells that promote blood clotting) to become stickier. These changes have been associated with increased risk of heart attacks.

Job stress and long work hours can also result in poor sleep, a lack of physical exercise, increased smoking (to cope with the stress!) and in some people, heavy alcohol intake and binge eating, resulting in weight gain (which predisposes them to diabetes and heart disease).

Working at odd hours and shift work can also result in sleep deprivation. This can lead to high blood pressure, weight gain and increased levels of a stress hormone called cortisol (this hormone increases blood pressure and blood sugar), raising the risk of heart disease.

What can one do to reduce job stress?

It may not always be possible to reduce job stress in a fast-paced competitive society like ours, and it certainly is not an easy thing to do in any case. However, there are some things we can do to help mitigate job stress.

Regular exercise – Take short breaks where possible and move around. Even walking around is better than sitting at the desk all day. Schedule regular exercise on a weekly basis, ideally at least three times a week for 20 to 30 minutes each time. Exercise helps take our minds off work.
Relax – Learning how to relax can be beneficial to one’s overall health. Picking up a new hobby takes the mind off work and helps relaxation.

In many situations, we cannot reduce the job stress that we face. We can help ourselves, however, by getting regular exercise, not smoking, adhering to a sensible diet, and screening for and controlling cardiovascular risk factors for heart disease such as diabetes, high blood pressure and high cholesterol.

November 6, 2018

Screening for Cardiovascular Diseases

Screening for cardiovascular diseases

By Dr Paul Chiam
Published on Medical Grapevine on October 2015

The aims of cardiovascular screening are to identify cardiac or vascular disease and detect cardiovascular risk factors in asymptomatic or “well” patients.

Screening starts with a thorough history and physical examination, and simple laboratory investigations. Other tests may also be performed when necessary according to the patient’s risk profile.

The tests that we choose should be cost effective, reproducible and accurate, and that the diseases being screened should be serious with early detection leading to a better outcome.

However as no test is 100% sensitive nor specific, false positive results may paradoxically increase costs due to the need for further tests and create unnecessary anxiety, whereas false negative results may confer a false sense of security to the patient.

Thus screening should be evidence based and should result in a change in lifestyle leading to improved outcomes.

Screening for cardiovascular risk factors and cardiovascular disease

The screening usually starts with a detailed history and physical examination. They are part of the initial consultation, and do not involve additional cost or risk to the patient. A cardiovascular risk profile (eg 10-year risk of cardiovascular event – high, moderate, low risk) can be estimated using the Framingham risk score calculator (cvdrisk.nhlbi.nih.gov) or the HeartScore risk calculator (escol.escardio.org/Heartscore/calc.aspx?model=europelow). These have been shown to predict likelihood of future events and can serve as an impetus for behavioural change.

Subsequent tests such as the electrocardiogram (ECG) and chest x-ray (CXR) can help further stratify the risk profile of the patient. Apart from the ECG and CXR, the fasting glucose and fasting lipid profile are amongst the most useful screening tests. These tests, together with the office blood pressure, will detect the 3 common risk factors for cardiovascular disease as a significant proportion of the population may have silent diabetes mellitus, hypertension or dyslipidemia. Early detection and treatment (lifestyle or drugs) are likely to have an impact on future event rates as demonstrated in the primary prevention trials (eg. West of Scotland Coronary Prevention Study (WOSCOPS), Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) and STOP-NIDDM trial). WOSCOPs showed that primary prevention with pravastatin reduced myocardial infarction (MI) and death from cardiovascular causes in men with hypercholesterolemia compared to placebo. ASCOT showed that treatment of hypertension with amlodipine and perindopril significantly reduced all-cause and cardiovascular mortality and strokes. STOP-NIDDM demonstrated that arcarbose could reduce progression of impaired glucose tolerance to overt Type 2 diabetes as compared with placebo. More recently, a lifestyle-intervention program or metformin have been shown in a major study performed by the Diabetes Prevention Program Research Group to reduce the progression of glucose intolerance to overt diabetes.

The NCEP guidelines which are endorsed by the American Heart Association, recommends a fasting lipid profile in all adults aged 20 years or older, and if optimal, every 5 years subsequently. If the results are sub-optimal, the fasting lipid profile should be repeated at earlier intervals. At the same time, the fasting glucose level can also be performed. The Ministry of Health, Singapore strongly recommends a fasting lipid profile at age 40 years (or younger in those with comorbidities or family history).

Silent peripheral vascular disease has been shown to confer a poorer long term outcome as these patients usually have multiple risk factors and/or heart disease. Asking for a history of claudication and palpation of the foot pulses are simple and effective methods of screening for peripheral artery disease.

Use of stress testing and imaging in cardiovascular screening

The treadmill ECG stress test (TMX) is a test that can be easily performed and is most useful for patients in the moderate risk category with atypical chest pain or patients who have a high cardiovascular risk profile. With a sensitivity and specificity of 70% at best, the TMX is not useful in low risk patients as it does not alter the low pre-test probability of heart disease. However, most patients presenting for cardiovascular health screening would want a TMX performed. The main utility is that it has been shown that patients with a normal result and good exercise capacity (Bruce protocol stage 3 or more) have a good long term prognosis and a low yearly cardiovascular event rate.

More recently, the CT heart scan derived coronary calcium score has been shown to be a predictor of future cardiovascular events since the calcium score is a reflection of the coronary plaque burden. The calcium score has become recommended by certain scientific societies for use in cardiovascular screening, and when combined with the TMX, gives added prognostic value.

In contradistinction, the CT coronary angiography is not recommended for use in screening as it entails a higher radiation dose, a need for intravenous contrast administration and the possibility of false negative and false positive results due to the limitations in the technology.

In patients whom silent peripheral vascular (artery) disease is suspected, an ultrasound Doppler of the lower extremity arterial system is a test that is safe and easy to perform and is fairly accurate.

Screening in the endurance or competitive athlete

This group of patients often present for screening. One knows too well of the rare incidences when a seemingly fit and healthy athlete suddenly collapses and dies. Though it is a rare occurrence, it is shocking and devastating. Common causes of sudden death in young athletes would include cardiomyopathies (in particular, hypertrophic cardiomyopathy), long QT syndromes and other arrhythmic/ conduction disorders, congenital anomalous course of the coronary arteries and silent ischaemic heart disease.

In general, competitive and endurance athletes should have at least an ECG performed before embarking on such activities. In selected patients, a TMX and echocardiogram may also be considered.

Conclusion

Regular cardiovascular screening may identify risk factors and preventive measures such as adopting healthy lifestyle habits can be carried out to minimise subsequent disease. With early detection and proper medical treatment, cardiovascular disease can be treated or even prevented.