Doctor's Heart Series Chapter 2: Stress and Heart Disease

When stress happens, we have a choice either live with it or do something about it.

A Day in Doctors life …

It was just another day after finishing hospital and office rounds (doctor seeing patients) and answering a few calls from the patients and their families. Finally, I settled down and started to document in the EHR. EHR(Electronic health records) is written with each patient visit. Medicare (US Govt subsidized insurance for age over 65 yrs) converted paper charts to Electronic health records in 2014 and was mandated all the documentation is done thru Electronic health records. My average census is 16 - 20 patients; due to time constraints, I bring work home. When the rest of America is spending time with families and kids, most medical professionals (playing catch up with the days’ work). Most evenings, busy writing patient notes and interruptions are the norms; sometimes, finishing work could be midnight or later. The following day, start early and continue with hospital rounds, then go to the medical office and repeat. The current system is stacked against the smaller practices like myself. Hence hard work is tremendous to sustain and establish a practice. It is tough to be a solo practitioner as the odds are against you as governed by new medical laws, and remuneration is lower for a single practitioner as insurance companies negotiate better rates for larger groups. Hence, after training, many physicians join bigger groups and corporations to avoid dealing with complicated systems and difficulty getting coverage.

After working as the solo practitioner for more than 3 years, running a business and making it successful has its own merits at the cost of health. Every other doctor in the US has some kind of stress and burnout (burn out means feeling empty and mentally exhausted, devoid of motivation). Currently, other professions too have to deal with this undue ongoing stress at work.

Most of the job market is driven by performance-based metrics, deliver or being fired. The system has created this vicious cycle, especially in the US, as the technology is ever-changing. Most of our handsets are more powerful than laptops a few years ago. This comes with tremendous costs on individual health. There is no demarcation between work and personal time; personal time suffers(happened with me). Due to the pandemic, many jobs have turned to work from home(physical inactivity and less social interaction).

Everyone deals with stress differently. The stress affects everybody, from the kindergartner throwing tantrums to the isolated centenarian. People under stress experience mental and physical symptoms, such as irritability, anger, fatigue, muscle pain, digestive troubles, and difficulty sleeping.

Effects of Chronic Stress on Brain and Body (Courtesy Career Smart Learning)

What is stress?

The stress mechanism is very complex (involves the brain, autonomic nervous system, and the endocrine system, with associated metabolic, inflammatory, and hemostatic abnormalities medically speaking). Stress is a feeling of emotional or physical pressure. It can come from any event or thought that makes you feel frustrated, angry, or nervous. Stress is your body's reaction to a challenge or demand.

We interact with the environment, people, places, etc., many times a day based on the external stimulus perceived. Based on the threat, the body goes into flight or fight mode. It starts the Hypothalmic-Pituitary-Adrenal axis(sympathetic nervous system directs the body's rapid involuntary response to dangerous or stressful situations- cannot avoid medical jargon), a set of hormones released, causing elevated blood sugar, blood pressure, and heart rate, putting undue stress on the heart. It lasts until the stimuli are present; once the threat has been disabled, the activity turns off. This is the body’s natural protective mechanism, like an alarm system in the house. When the external stressor(something that causes state of strain or tension) becomes more persistent, causing a plethora of problems leading to causing coronary artery endothelial injury puts disproportionate effect on heart causing Acute Myocardial Infarction or Heart Attack.

Mild stressors are essential and are short-lived, like during the roller coaster ride and giving a speech, etc. However, when stressors become significant can cause detrimental effects to the body. For example, studies have shown that substantial short-term stressors such as earthquakes, hurricanes, loss of loved ones, etc., can cause severe stress and have increased heart attack events and even death.

The mechanism of chronic stress has been significantly studied in the last few decades. Studies showed mental stress with substantial levels of blood pressure elevations and coronary artery vasoconstriction( Increased pressure in coronaries), especially in Coronary artery disease patients causing ischemia (decreased oxygen supply to the heart), leading to a heart attack. Studies showed in the patients using the defibrillator showing the mental stress were more significant abnormal rhythm compared to controls. This study shows the importance of mental focus and heart condition. Another interesting ailment caused by stress is called Broken heart Syndrome (Takotsubo syndrome).

Broken Heart Syndrome(Takotsubo Syndrome)…

The name "Takotsubo" comes from the Japanese word takotsubo, "octopus trap," because the left ventricle of the heart takes on a shape resembling trap; it was observed that the condition that led to Apical(left heart) stunning from major stress or significant event in the patient life. This, after being followed for a few months, has ultimately returned to normal.

The most common stressors with heart disease are Living single, Social Isolation, Depression and hopelessness, Childhood Socioeconomic status, Childhood abuse, Work-life stress, Marital problems, death of a child, or care of a sick spouse. Depressive symptoms have been associated with the risk of sudden death and Heart Attack. Meta-analytic reviews show that patients with chronic heart disease or other chronic conditions have a significantly worse prognosis if they experience social isolation. An INTERHEART study found that ‘permanent’ stress at work was associated with over twice the odds of MI(Heart attack) compared with those reporting no pressure at work.

South Asian and Heart Disease…

The presence of heart disease in South Asians is well documented. However, the mechanisms are poorly understood. Some point towards genetics and others lifestyle. The data from community surveys in 10 countries showed a more than the twofold increased risk of heart disease among those who reported 3 or more childhood adversities (poor socioeconomic status, childhood sexual abuse, parental substance use, parental illness, etc.) compared with those reporting none. A study published in South Asian Indian city showed significant changes in cholesterol between 13-18 year adolescents. 38 % of teens showed elevated cholesterol levels, pointing towards early screening for cholesterol for younger populations.

Heart health appears directly related to adversity in childhood based on some studies. Most South Asians are under tremendous stress hardships during their childhood and teen years. It’s eye-opening to see the data in this part of the world. Heart disease affects 10 - 15 yrs earlier than other ethnic counterparts. Screening younger kids for cholesterol probably sheds some light on the problem of early accelerated atherosclerosis(plaque buildup) and heart attack in 30 and 40 yrs olds; however, more aggressive research is needed to better understand and treat it.

Self-assessment questionnaire for stress designed by people sense from Australia.

Solutions…

Identifying stressors in life…

Identifying the presence of stress will put me on the path to tackle stress. I have attached a sample quick questionnaire if any one is interested to check for themselves. If the scores are moderate or higher possibly discussing stress with their health care provider is the first step. Whether it's workplace stress, anxiety or depression. Seek help and counseling when appropriate. The associated causes of stress are not to be undermined as they can lead to alcoholism, substance use, etc. resulting in severe morbidity and even death.

Mindfulness…

Studies show MBSR(mindfulness-based stress reduction) is moderately effective in reducing stress, depression, anxiety, and distress and improving quality of life. Mindfulness meditation improves focus and clarity of thought and improves energy. I have tried few sessions and interested in making it routine. Please check out the detailed MBSR instruction attached below. Whatever platform one chooses sticking to it is the key (I think we can spare 15 min of phone time a day).

Mindfulness-based stress reduction

According to the study, when all meditation forms were analyzed together, meditation reduced inflammatory markers and hemodynamic parameters (cortisol, C - reactive protein, blood pressure, heart rate, triglycerides Etc). Overall, I do believe meditation and its benefits has sustained millennia in eastern civilization and scientific studies are finally catching up.

Sleep…

The ability to disconnect and having restful sleep. Studies have shown that having 7- 8 hours of sleep reduces burnout and stress; one biggest change I have done since my heart event is the sleep.

 Social support…

The social support is essential at workplace, one study highlights the importance of support from colleagues and supervisors at the workplace, which may help reduce job stress and improve mental well-being. Frequent workplace social gatherings and outings help tremendously and decrease job stress.

Time management …

Time management is essential in delineating work time Vs. Personal time. I would prefer the 8-8-8 rule (work less than 8 hrs, individual and family time of 8 hrs and 8 hrs for sleep). This gives enough time from work, investing in physical health and well-being, and improving diet by cooking more at home.

Tsimane tribe from Bolivia showed to have healthiest hearts, out of more than 700 people (lancet) studied underwent coronary calcium scoring(plaque buildup in coronary arteries), none of the calcium built in the group below 45 years of age (compare 25% in the US). They had more carbohydrates in their diets but were physically active. Good social gatherings and small groups have a better outlook on life and stress-free living.

Conclusion…

Stress is something everyone constantly tackles; there are no shortcuts to stress. Everyone has to go through the stress. The question is how one can navigate and understand stress. Stress cannot play its entirety for heart disease and death but is definitely one of the significant players in disease morbidity and mortality. If we can understand the nature of stress, it gets better to deal with it. A few things can be pursued to improve stress-free lives and personal well-being. Countries that are happier and have less heart disease enjoy and balance work and family. 

Suman Manchireddy MD FACP FHM

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