Affairs Of The Heart
by Dr. Mo Lerner

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We are all just basically animals. We live our lives under the influence of basic instincts. Like all other living things we strive to procreate and survive. Then one day we are gone. I have thought a lot about these basic axioms of life lately.

Scientists believe that women, especially those with children, typically survive longer, even when stricken with a variety of ailments. Okay, that makes sense since matriarchs have to provide for future generations. But as we get older (whether male or female) and when reproductive potential wanes, it seems almost as though nature is trying to get rid of us. Various parts of our bodies begin to atrophy or deteriorate. Joints get brittle and sore and infections take longer to heal. Time itself seems to go by more quickly. It even becomes more difficult to fall asleep, stay asleep, and get a deep restful slumber. That's too bad. When times are tough, health deteriorates or pain and suffering seem to occupy much of a person's mind, most people find sanctuary in bed. During this quiet time in the dark when others are asleep, we find solace in reminiscing and fantasizing. Pleasant thoughts make the night easier.

Many people have called or written to me about what comforts them at night, when they are alone, afraid, or in pain. By far, their thoughts and fantasies involve loved ones. As a doctor who has watched a broad spectrum of pain and suffering over the years, it is clear that nothing affects people more than affairs of the heart. It is natural to hark back to lovers, friends, and especially those dreamy relationships and situations that "might have been."

NIGHT CALLERS

The other night I received three interesting phone calls. One woman from Germany had just seen the movie Fat Chance on television. The movie (also adapted for Arts and Entertainment network's Investigative Reports and titled A Matter of Fat), chronicled the struggles of a few large people in society. The woman (we'll call her Gretta for the sake of privacy) was moved by a scene in which I appeared discussing what most large people hesitate to reveal -- their innermost vulnerabilities. What can I say? The camera was unobtrusive and silent. My mood was somber and reflective. It is not that I am more sensitive than the other person. Or is it? Gretta felt that large people are more sensitive. She identified with my thoughts. It seems that years earlier, Gretta was in love with a very large man. His insecurities were so stifling that he could not accept the obvious love of this wonderful "thin" woman. Although she longed to spend her life with him, he let her slip away. She married another man. The larger love of her life apparently died in his early 30s. But even after many years of marriage to another man, even in recent widowhood, she never forgot about her large lover. She needed to tell me how wonderful large people are. She insisted that we must love ourselves despite others' disdain of our "large" size, health problems (if they exist), and social pariahism. Most importantly she said we had to let others love us.

The second call was from a large young woman who had sought me out some months earlier. She also saw that old movie. She was lonely and felt isolated. She had never heard of Dimensions, NAAFA, etc. After she plugged into these new resources her whole outlook changed. She called to tell me that just knowing that there were other large people like her opened new doors. She was bubbling over with enthusiasm for FAs and life in general.

UNDER THE KNIFE

The third call to me was more clinical in nature. It was from a large woman who was a trained health care professional who felt that she had to share her recent experience in surgery. Her relatively minor gynecological procedure turned into a nightmare. Despite having been advised of the increased risk of infection in large people, her surgeon decided to treat her conservatively and expectantly rather than proactively, so her abdomen became infected, requiring extensive drainage and antibiotics.

It was not her fault. She was conscientious. In the operating room she told all those present that she realized that there would likely be looks of contempt and derogatory comments like "how could she have let herself go." She reminded them that obesity is not automatically a lifestyle choice. She had not chosen to be harassed and humiliated all her life. She told them that she had gone through enough self deprecation for many years, she did not need their added scorn, especially not now as her life was on the line. She advised them of clinical precautions.

Large people undergoing surgery are indeed at higher risk of infection with Staphylococcus and Streptococcus, two organisms that are commonly present on skin. These bacteria are easily transmissible, even in the operating room and especially when extra hygienic prudence is not practiced by hospital staff. Extra measures mean that strong prophylactic antibiotics need to be given before and after the surgery and staff must take care to keep everything clean and sterile.

HEART DRUGS

My third caller also described interest in my last column about heart irregularities. Like many of you who responded, she too had extrasytoles. She had previously been prescribed certain medications to control these, but her gynecological problem, the surgery, and subsequent infections had altered her delicate metabolism. The heart rhythm problems exacerbated.

She wanted me to tell the medical establishment that large people have special needs and, especially prior to stressful periods like surgery, particular steps needed to be taken.

What about the medications for the heart? In my last column I discussed the irritability that occurs in regular muscle cells in the heart either because of infection, lack of oxygen, scarring, a surge of hormones, or an imbalance of bodily chemicals. Anyone with heart beat irregularities should have an EKG, A Stress Test, a Holter Monitor, and an Echocardiogram. If any of these tests reveal abnormalities, further sophisticated investigations may be required to delineate the problem and to decide on the best course of action. Under most circumstances, no anatomical abnormalities are found and drug treatment should be avoided.

Although some drugs will slow down or tame the fast or irregular heartbeats, they are not without side effects. People who have essentially normal hearts and occasional irregular beats of any configuration should not take medication. Some are blessed in that they are blissfully unaware of their irregular beats anyway. Most importantly, very few treatments have been shown to prolong life. On the other hand, if irregular heartbeats make people nervous or uncomfortable to the point that quality of life is affected, medications may be appropriate. In this column I will deal with some of the most common heart drugs used.

BETA BLOCKERS

If the primary pacemaker in the heart is firing too fast or if rogue pacemakers are trying to compete, causing too many extrasystoles, then something may need to be done. These cells act like sponges in a bucket of water, absorbing elements such as sodium and calcium too quickly, saturating themselves early and firing abnormally. A surge of Adrenaline that can occur with emotional excitement or physical stress of any kind, causes these sponges to saturate too quickly or too often. It does this by widening the holes in the sponges at places called Beta Receptors. Beta Blockers make the holes in the sponges smaller, thus slowing down saturation and the consequent irregular or fast rhythms. Of all the drugs available for this purpose, only Beta Blockers not only usually help, but are likely to actually prolong life in those with serious heart disease. Atenolol, Esmolol, Propranol, and Metoprolol are often beneficial but only if used very carefully in selected patients who really need them. As previously mentioned, for example, undergoing the stress of surgery may cause heart irregularities to exacerbate and be an indication for use of Beta Blockers.

SODIUM CHANNEL BLOCKERS

A specific class of drugs slows the influx of the element sodium into the sponge-like pacemakers. In a hospital under emergency conditions, intravenous drugs like Lidocaine and Procainamide are Sodium Channel Blockers that are used to slow down very rapid heart rhythms. They are often effective in the short term. Two other Sodium Blockers that were intended for long-term use, Flecainide and Ecainide, looked promising at first because they often had the desired effect of slowing down irregular rhythms. However, a large study conducted on thousands of people had to be stopped when it was found that candidates were often dying prematurely on these medicines. It appears that the drugs were, in effect, just masking irritable spots in the heart and were eventually proarrhythmic, i.e., causing these cryptic irregularities to burst forth with a fury.

FOXGLOVE

Digoxin, an ancient medicine from the Foxglove plant, has been used for centuries and was one of the first botanicals that truly had a profound effect on helping people with heart problems. You may recall from my last column, I spoke of Atrial Flutter and Atrial Fibrillation. These irregularities (which involve hyperexcitable cells in the top part of the heart) often occur in combination with two potentially dangerous scenarios. First of all, the heart action is not just irregular, it is too fast for the chambers to adequately fill or empty. Secondly, the heart is usually in failure as a pump. The latter circumstance is particularly problematic. In fact, most doctors agree that it doesn't matter how irregularly a heart is beating as long as it is pumping out at least 50% of its payload. However, once the chambers get flaccidly large and balloon-like, blood backs up in the body, causing lung congestion and ankle swelling. The interesting thing about Digoxin is that it not only slows down the rapid rate, it can also make the failing pump beat stronger and in some cases even help to convert the irregular rhythm back to normal. Nature is truly the best medicine cabinet in this case and, even in this day of high tech designer medications, Digoxin remains the gold standard for most patients with this problem.

CALCIUM CHANNEL BLOCKERS

Normally the heart has one pacemaker and a railroad of similar specialized cells that carry electrical messages quickly to the rest of the heart in anticipation of a contraction. These cells act like sponges with smaller than usual holes called Slow Calcium Channels. Rather than undergoing the rapid-fire action of regular heart muscle cells, these distinctive pacers take their time producing a rhythmic action that allows for regular beating several times a minute. However, when heart disease or the ravages of time cause the sponge holes to open wider, dangerous rapid and often irregular pacing results. Calcium Channel Blockers (Verapamil, Diltiazem) constitute a relatively new class of drugs that not only combat this problem by slowing the influx into the electrical sponges, they are also quite effective at decreasing the force of the heart's contractions. Therefore, some are used to lower high blood pressure as well as to slow down and often curb irregular rhythms.

POTASSIUM CHANNEL BLOCKERS AND OTHERS

Then there is what I call the "other" class of drugs whose mechanism of action varies and is complicated. Sotalol is a sort of Beta Blocker with a few extra properties that is used when other more traditional drugs in this group are not quite doing the trick.

Bretyllium causes a sudden initial Adrenaline rush in the body followed by a period of relative calm, slowing down irregular rhythms and decreasing blood pressure. When administered too quickly (intravenously) it can cause severe nausea and vomiting.

Amiodarone, although used successfully in Europe for years, remained on North American physicians' "cautious" list until recently. A very powerful antiarrhythmic agent, this drug has some very dangerous side effects. These include skin rashes, damage to nerves, liver toxicity, eye scars, and most seriously, Pulmonary Fibrosis (stiffening of the lungs). For this reason Amiodarone is used when people have serious heart beat irregularities that do not respond to other treatments. More recently, it has also been used by paramedics in an attempt to revive cardiac arrest victims.

NEW HORIZONS

For the sake of brevity I could not go into all of the drug, pacemaker, and even genetic treatments for heart problems that are either being developed or actually in clinical trials. Magnesium and Omega-3 (Fish) Oil Compounds are just two of many substances that are under investigation for their potential benefits.

Large people are often subject to cardiac problems but are usually treated with drugs and dosages that apply to the "thin" population. Since over 50% of Americans are now acknowledged by the NIH as being "overweight," it is time that we demand proportionately greater research for a common problem.

AFFAIRS OF THE HEART

When times are tough and we take stock of our achievements and indeed the meaning of life, perhaps it is that we are not just, after all, little animals running around with rudimentary instincts. I concur with Gretta and the many others who have shared their innermost thoughts with me on this subject. Perhaps what sets us apart from other species is our need to be needed, our love to be loved, and our hatred of being hated.

Do me a favor. If you are troubled and find peace (and perhaps even some well-deserved pleasure) in bed, dismiss any bad thoughts you may have tonight. Think about good times and good people. As Barbara Altman-Bruno (Dimensions columnist, author, and my friend) once told me, "Let your dreams be your guide."



Heretic Physician