An Overview of the EKG
The Electrocardiogram (EKG) has been an immensely useful and practical tool in cardiology for over 120 years. Its longevity is amazing if one considers how quickly new technological advances make older tests completely obsolete.
EKG Machines show the heart’s electrical activity, printing the “spikes” on paper for the doctor to read.
EKG provides a snapshot of the heart's electrical activity. Human heart is an amazing high-tech organ that does a lot more than simply pumping blood through our arteries. The heart cells that do this heavy-labor, mechanical work will not function unless there is an electricity current flowing through them. The part of the heart that creates electricity (out of nothing!) is called the sinus node and is located in one of the upper chambers of the heart (the right atrium). It then spreads to the rest of the heart, including the bottom chambers (the ventricles) where the “heavy lifting” and pumping of our heart occurs. In case the sinus node cannot function properly, other heart cells can take over the electrical production, although not quite as efficiently as the sinus node can. If none of the heart cells can create the needed electrical beat then a pacemaker may become necessary.
The EKG reveals the electrical activity in the heart, but why is this so important? What can the heart's electrical activity tell us about our health? It can first tell us whether the heart rhythm is normal or abnormal: is the rhythm too fast? Too slow? Are there any extra or skipped beats or is the rhythm completely erratic, like in atrial fibrillation? Beyond information about the heart’s rhythm, the EKG allows us to diagnose previous heart attacks or, indirectly, severely clogged heart arteries. If a large part of the heart has been damaged by a previous heart attack that part is electrically silent and shows up on the EKG. The pattern of the heart's electricity also changes in hearts that, because of clogged arteries, receive less oxygen. This is how the stress test (also referred to as a treadmill test) can help diagnose heart disease: by recording the EKG of a patient who walks briskly on a treadmill for a few minutes while attached to an EKG monitor, the EKG pattern reveals any serious oxygen shortage to a large part of the heart. Consider that at a normal, resting heart rate, an 80-90% blockage in the arteries is usually not obvious on the EKG as the demand of the resting heart for oxygen is so low that a 10-20% opening of the artery is plenty to allow things to proceed normally. However, if we stress the heart and ask it to do more, such a blockage prevents the heart from meeting the increased oxygen demand and this problem usually becomes obvious on the stress EKG.
EKG also gives useful clues when the chambers of the heart (atria or ventricles) become enlarged, thick or weak. And while the EKG may not be a very precise test and can’t give us an answer for everything, it can tell us that something is wrong and point towards the need for more detailed testing. Frequently an abnormal EKG becomes the indication for more specialized heart testing like ultrasound of the heart, nuclear cardiology, CT or MRI of the heart or even invasive direct visualization of the heart and its arteries. As the mechanical behavior of the heart changes when heart disease occurs, so does its electrical behavior. In this way we get early clues from the inexpensive, quick, practical EKG and doctors make a decision whether more expensive, complex and riskier tests are necessary. EKG has stood the test of time: invented in the early 20th century has made it well into the 21st century. It's easy to perform, it requires no needles, no pain, and no radiation -- making it very useful for patients and doctors alike.
Shared Decision Making
In an era where there are so many options in the medical field, having the opportunity for shared decision making is more important than ever. Shared decision making is when a doctor and patient decide together on what needs to be done next. This contrasts with the more traditional practice of medicine in the 19th and 20th centuries, where the health care providers had the knowledge and dictated to the patients and their families of what needed to be done. Shared decision making is important when more than one option is being presented and it’s not 100% clear on what needs to be done. In a more “clear cut” situation, the role of shared decision making is less pronounced. For example, a young person comes in with acute appendicitis. We know that if we don’t operate and remove the appendix quickly, it can burst, cause peritonitis and ultimately lead to death. We wouldn’t converse about it for an hour with the patient and his family; we would say that this is what needs to be done and this is what we are going to do. Another common case (that I have often experienced as a cardiologist) is when someone is having a heart attack. We know that it’s important to move quickly and take care of the situation, and giving a variety of options is not the best use of time.
In instances that have more than one option and are not as acute (or urgent), shared decision making is a very ethical option and practice with most physicians. Here’s an example of how this tends to play out: say we have a patient who comes in for an appointment. She feels fine, and has no symptoms of an impending heart attack or stroke, but is considered high risk. As a doctor, I offer the option of prescribing a statin (which lowers cholesterol). These medications have been widely used since the 1980s and have been credited for cutting the number of heart attacks in half. They have been very powerful and useful, but they need to be taken on a daily basis. While they are generally safe to use, it’s important to remember that there are no medications without side effects. Statins are not “muscle friendly”, and approximately 1 in 5 patients develops muscle aches while taking this medication. This is not life-threatening, but it can inhibit daily activities. It becomes a back and forth discussion that takes time and effort from both the patient and the doctor. Of course, it is much easier for a doctor to say “here is your prescription, take this daily and come back in two months so I can check your cholesterol levels”. But the approach where the physician invites the patient to make decisions together based on the patient’s comfort level can be extremely beneficial. On one hand, we want to educate the patient on what we think is best; but on the other hand, we want him to be able to follow through with that decision.
Shared decision making is a wonderful thing. It’s what patients deserve, but it takes time and a good attitude from both the patient and the physician. It takes the realization from the patient that there are no easy fixes in medicine and that prevention is the first line of defense. Does your doctor practice shared decision making? If you’re not sure, have a discussion with her and find what fits your needs the best.
To your health!
Dr. Anthony
Start Your New Year's Resolution Now!
Do you remember January 1st, 2016….seems like a distant memory now. Remember the New Year’s resolutions you made? Have you kept them? Most people would say - no, I gave up on it about March (maybe May if you were “good”)! Well, it is never too late to start again!
The struggle to lose weight, quit smoking, eat healthy and exercise is a lifelong one. It is not hundred meters dash; it’s a marathon. So, setbacks are to be expected and need to be dealt with in a pragmatic way, without overreacting or completely abandoning your efforts to become a healthier person.
Don’t let the calendar dictate your promises or your failures. As your health and personal well-being should be at the top of your list of most important things in your life, you need to be determined to stand up after every fall and never accept defeat. Sometimes, all you need is that little push to get you going again. If, for example, you used to eat unhealthy every day of the week, aim at a healthy Tuesday; that’s a real progress. Once you conquer this first step you can add another day, allowing yourself your old-style unhealthy binge on the rest of the week. Capitalizing on your positive psychology of eating healthy on certain days, it is very likely that, over time, you will be able to eat healthy most days of the week. One healthy day is better than none! There is a quarter of the year left, enough time to prove you can really improve to yourself and achieve your initial goal.
Let’s talk about diet: if you can only eat five or more portions of fruits and vegetables a day and cut out sugar (especially sugary soda), even if you also eat some junk food, you have made a big step forward. Then, try to eat lean meat and the good fats (olive oil, fish, nuts), and prefer fresh non-GMO foods over processed food. Control your calorie intake, as too many of the bad carbs or even the good fats, can lead to belly fat or abdobesity. This can lead to a whole host of problems down the road (diabetes, heart attacks, stroke, to mention but a few).
Also, take advantage of your “wellness” visits to your primary care doctor. Most plans require no copay for these visits. If you have not made that doctor’s appointment that you meant to do- do it now! Many insurance companies have a flex fund or HSA account where money is put aside, and if you don't use it, often you lose it. So put that money to use and make your health a priority. A wellness visit can unmask a high blood pressure or cholesterol, prediabetes or diabetes and start you on the right path towards health.
Exercise usually ranks high on New Year’s resolutions. With summer, and vacation and work and kids and,and, and….well you see where this is going. It is easy to fall off the workout wagon. But climb back on. Pretend the calendar says 1/1 again! Get to the gym, grab a friend or your spouse and start a walking routine (and light weight training every other day-muscles improve your metabolism), check around to find home exercise equipment that someone ELSE is now selling after buying it last Christmas! Make their loss your gain. Consider buying a standing or a treadmill desk and use it at work. It is a waste of precious time and opportunity if we spend all our working hours sitting; we get the “sitting disease’, as many scientists now call it-contributing to obesity, muscle wasting, diabetes, high blood pressure and more.
If your resolution was to stop smoking and you haven’t ... please consider stopping now. There are several smoking cessation tools, including groups and/or medication to help. Ask your doctor to help you quitting. Be aware, though, that if you are not really determined to quit, no nicotine patches or gums, no Wellbutrin and no Chantix will get the job done.
Make today your “new year” day and get in gear! If you do this, by December 31st, you will not need to make as many resolutions.
To your health!
Dr. Anthony
Please HELP! What do I do about my Belly Fat?
Excessive belly fat (a waistline over 40 inches in men or over 35 inches in women) can destroy your metabolism and damage your arteries. It is also an early sign that you may be on your way to becoming diabetic, developing high blood pressure and, later, heart attacks or stroke. It also increases your chances of colon and breast cancer and Alzheimer’s disease. So what do you do?
Given the importance of belly fat, it is natural for people to try to get more information by googling it. If you google “belly fat” you may be directed to websites with advertisement for pills, supplements, shakes and drinks that “guarantee” you will lose belly fat. Should you believe them? Like most health-related issues, there are no easy fixes for abdobesity (excess belly fat); if they existed there would have not been as many people with a big belly walking around. But, in order to be fair about the web, one can find credible sites from reputable hospitals like Cleveland and Mayo Clinic, professional medical organizations like the American Diabetes Association and the American Heart Association or recommendations from professionals like physicians, registered nurses, registered dieticians or exercise physiologists. None of these credible websites will ever claim that you can lose your excess belly fat in a few weeks and keep it off for the rest of your life with a minimum effort.
In my book Abdobesity, I explain the seriousness of the belly fat and show how it is damaging our body’s metabolism and arteries’ health. As opposed to fat under the skin or around our hips (which is metabolically innocent), belly fat is directly wired to the liver, our chief metabolic factory. Under the constant negative influence of the belly fat, our liver is turned into a production line of chemical poisons that induce inflammation all over our body and promote cholesterol plaque development in our arteries; along with the other risk factors (smoking, high blood pressure, high LDL, diabetes, aging and family history) these cholesterol artery plaques mature overtime and they may become unstable as unpredictably as an earthquake. If this happens a heart attack, a stroke or sudden death follow with little or no warning. This is why a healthy lifestyle and early and aggressive treatment (with medications, if necessary) of high blood pressure, high LDL cholesterol or diabetes are so important; to effectively protect our artery health, however, they must be implemented as early in life as possible.
Don’t let abdobesity (excess belly fat) and the catastrophes that may follow it irreversibly damage your health and ruin your life. Espouse the elements of a healthy lifestyle; monitor your blood pressure, blood sugar and cholesterol; and nurture a close relationship with your primary care physician. Start by measuring your waist; if your numbers are in the red, don’t wait; take action. And, if you ever find your daily battle against abdobesity difficult or impossible, think of those who need you and believe in you: how will they be affected if your health takes a turn for the worse?
To your health!
Dr. Anthony
Fitness Trackers … Are they worth it?
The newest rage in fitness is the fitness tracker. They range in price from around $30.00 to several hundred dollars. Do they work? Are they worth the money? And what exactly are they “tracking”?
The fitness tracker is a wearable device that will track everything from your steps, your sleep, your heart rate, blood pressure or oxygen level and even your sweat. It may reveal that you need to “step it up” (pun intended) or that you are on track to your fitness goals. It is available in app form as well and/or will work in conjunction with an app or your smart device. For most people, it is a reminder that you need to do more, and to some a surprise, that they have not been doing enough!
The fitness trackers are usually in the form of a band (usually worn on your wrist, ankle or neck) and they track your progress. One brand will light up to show your progress, another will display a red move bar after one hour of inactivity acting like a personal coach. A sweat tracking wearable is attached to the skin of your leg.
Shape magazine reported a recent survey by the NPD Group showed 58 percent of women who were asked intend to buy one of these devices. The most sought after features: counting calories and tracking the number of steps taken in a day.
I believe that the most important benefit of a fitness tracker is that it signals your determination to be directly involved in your own health and to start monitoring it. This is a much bigger step than most people would think. A great example is the number of steps you take in a day; taking at least 10,00 steps a day means that you meet or exceed the minimum exercise requirements of 150 minutes per week, an important milestone in healthy living. The 10,000 steps a day is also part of the “Step Diet”, a relatively straightford combination of physical activity and diet to help you lose weight. Exercise can also help you reduce your blood pressure (which can also be monitored by some wearables) and, thus, reduce the chances of heart attack, stroke and kidney disease.
Tracking your fitness is valuable; it can bring you back to reality. Maybe walking down the hall for that cup of coffee at work is not walking enough even though you pat yourself on the back for getting up and moving. Fitness trackers or apps can be the extra kick in the pants to help get you on the right path, but only YOU can make the changes you need.
There are a few issues that come along with the benefits of the fitness trackers. One is that they are not always very accurate. They can miss the number of steps you took and can tell you that you did not get enough sleep even if you did. Their data may also be too much to handle and can cause some confusion. There are technical improvements on the way that can improve the accuracy of these devices. And you don’t have to get caught up in the entire amount of information the tracker is telling you. You body, body weight and waist circumference, are good indicators of your health report card and complements the information from your wearable.
In Abdobesity, I write that “diagnosis is extremely important in medical care because it reveals the seriousness of the illness and suggests those treatments that are most likely to help the sick person.” While a tracker or app or device cannot diagnose a problem, they may be able to indicate if there is an issue with something such as blood pressure, blood oxygen levels, etc. If this is the case, discuss it with your physician. Your doctor can delve deeper to uncover what the issue is and what can be done to help with the problem at hand.
As always, be your own health advocate. Choose wisely. A fitness tracker is definitely an important step forward, but you may not need to pay too much for all the bells and whistles. Use your wearable to keep you in check, get moving or “coach” you to a healthy lifestyle. Just don’t rely on it as the end-all-be-all to good health.
To your health!
Dr. Anthony