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.
Should we be taking aspirin daily to prevent heart attacks and strokes?
Aspirin is a medication we have been using for over one hundred years. At a low dose, which averages between 40-100 mg a day, aspirin has been used in the last two to three decades primarily for the prevention of heart attacks and strokes.
We know that heart attacks and strokes can occur when cholesterol plaque in one of our major heart or brain arteries first develops, then matures (which can take decades!), and -- without warning -- becomes unstable and cracks. When it reaches this point, the blood flow over the unstable plaque recognizes the situation as “bleeding” or a “hole” in the artery. It tries to repair the situation by flowing very quickly to where it believes the problem is happening, and in the process can form a clot over the unstable plaque in less than one minute. So here we have a situation where a cholesterol plaque may only obstruct 10-20% of the opening (lumen) of a heart or brain artery. When this plaque becomes unstable, the blood forms a clot over it and within a minute there is a 100% obstruction of the blood flow. Because there is no blood flow through the artery, the cells start dying in a matter of 3 minutes for the brain and 30 minutes for the heart. This is how most heart attacks and strokes can occur.
A low dose of aspirin works by inhibiting the sticky cells in the blood, called platelets, from sticking together and forming a clot. However, at a high dose, aspirin also inhibits various enzymes and good cells. While a low dose would protect the arteries from clotting, a higher dose would not. This is why we have been using a low dose for the prevention of heart attacks and strokes. If too much aspirin is taken, it can cause bleeding, which has the reverse effect and can encourage clotting of the arteries.
Those who have had a heart attack or stroke are instructed to continue taking a low dose of aspirin every day for the rest of their lives. However, we must remember that science has no “last word”: it’s all based on the function of time and the evaluation of the available evidence.
So let’s say that the evidence from twenty years ago overwhelmingly supported using aspirin for the prevention of heart attacks and strokes -- not only for secondary prevention (meaning you’ve already had a heart attack or stroke and you’re taking it as a way to prevent this from happening again), but for primary prevention, which means you never had a heart attack or stroke, but you were deemed to be at a higher risk for suffering from one. This includes people with diabetes, smokers, those with high LDL or high blood pressure, a family history of heart disease, etc. For all of these people, we thought it made sense to give a low dose every day for the rest of their lives to prevent heart attacks or strokes from ever occurring in the first place.
A few months ago, science came forward and said that this is not correct. We have reevaluated the evidence, and in the modern era of medicine-- with better use of “statins” (Lipitor, Crestor, etc), medications that lower the LDL (bad cholesterol), and improved treatment of high blood pressure-- we don’t think the benefits of taking aspirin for primary prevention outweigh the risks. This is big news for patients and doctors!
Randomized trials and observations from the American College of Cardiology and the American Heart Association, which included tens of thousands of patients for years, have concluded that the use of aspirin is no longer appropriate for primary prevention of heart attacks and strokes -- except for those at very high risk (meaning those who have at least a 10% risk of developing heart attacks or strokes over the next ten years). The studies indicated that patients who have already had a heart attack or stroke should absolutely continue taking aspirin for secondary prevention. But for using aspirin for primary prevention, we have to really dive into the risk factors of the patient (age, family history, lifestyle, blood pressure level, cholesterol level) and determine if this is appropriate. Only if we evaluate these factors as being high, and the risk of bleeding from aspirin is low, then it is ok to use aspirin for primary prevention.
As with any kind of medication or regimen, please speak with your doctor before determining whether you should start or stop taking aspirin.
To your health!
Dr. Anthony
The Shocking 65 & Other "Sweet" Tales
Last week, while preparing for a presentation on wellness, I came along food labels for certain soft and energy drinks.
I must have read this type of information hundreds of times but it never stops shockingly amaze me to realize that they may contain up to 65 grams of sugar (or more) per 600 ml (20 oz)!
Now consider that the American Heart Association recommends no more than 25 grams of added sugar per day for women and no more than 37.5 gm of added sugars per day for men. So, if you just consumed 20 oz of a sugary beverage you’ve probably gulped in your added sugar allowance for an entire 2-day period!
And it is not just sugary beverages that contain a shocking amount of sugar, much more sugar that a health-conscious person could possibly afford. All of the so called “fast carbs” (high glycemic index carbohydrates) have lots of sugars that are quickly digested and absorbed from the stomach into the bloodstream. Fast carbs include not only sugary beverages, cookies, desserts, ice cream, baked goods and donuts but also added sugars found in low-fat yogurt and starches present in white bread, white pasta, white rice, white potatoes. If consumed daily or in large quantities, fast carbs are dangerous for our health because:
They have a great taste and texture that we cannot resist
Instead of keeping us full for several hours they promote hunger: the sugar-high leads to insulin-spike and then, 1.5-2 hours later, sugar-low, making us hungry and forcing us to eat again and again.
So, read the food labels and limit the amount of added sugar you have per day to no more than the equivalent of 6-9 teaspoons of table sugar. Avoid sugary beverages and be skeptical of “low-fat” yogurt. If you cannot entirely resist white bread, white pasta, white rice or white potatoes, consume them only in small amounts. If you are diabetic or obese, I highly recommend that you invest in a personal nutritionist. It will be one of the best investments you can make in your health journey!
To your health,
Dr. Anthony
Don’t just SIT there - it could be harmful to your health!
Sitting for a long period of time can be hazardous to your health. There are healthy alternatives to sitting, even if your job is traditionally a sedentary one. Many tips are available to keep you on your feet and healthy.
A Mayo Clinic report suggests that sitting for a significant period of time is not even offset by a few hours a week at the gym. More moving is necessary to keep your body burning calories. A study shows that sitting too much can actually cut your life short. The risk of diabetes increases, HDL cholesterol production lessens and enzymes that break down fat drop by up to 90-percent. Your blood pressure can also go up by sitting.
Sitting can be bad for your heart. While sitting, muscle burns less fat and blood moves more slowly to allow-in the long run- fatty acids to clog the heart. If you are hoping for the six pack abs, don’t sit for so long. The abdominal muscles are not engaged when sitting, and can also lead to poor posture. The curvature of the back can contribute to spine problems, strained neck and sore shoulders or back. Poor circulation in your legs can present a host of issues as well, from deep vein thrombosis (blood clots) to varicose veins to swollen ankles.
People who sit to watch TV or use handheld devices are in the same boat as those who sit to work. A study compared adults who watch more than 4 hours sitting in front of a TV with those who sat for only 2. Those who sat for the longer period of time showed a significant increased risk of events associated with cardiovascular disease. These data are also applicable to sitting in front of your computer or any kind of screen.
Sitting can be bad for your brain too. Movement pushes fresh oxygen and blood to the brain, releasing chemicals to help thought and mood. A “stale” brain can also cause clots to cause a stroke. The average US adult sits for 8 hours a day; high school students, although they sit less, they are also affected. A study found high school students who stood in class instead of sitting improved their test scores by 20 percent.
So what can you do to break up all this sitting? Here are some ideas for those who sit for work. Instead of a regular chair, opt for an exercise ball. The instability of the ball will keep you on the move and make for better ab muscles and hip flexors; using the ball may also alleviate back pain. But use caution - the ball needs to be properly inflated and your posture should not injure your lower back.
Another option is the treadmill desk. One study in 2011 found that those who used a treadmill desk reduced their hip and waist size by about 2 inches. A variable-height desk, a standing desk or an indo-board (a type of balancing board) are some other alternatives.
There are many easy options to get up and get moving. Take calls while standing, hold meetings while walking, get up and do a few laps around the office. Making the most of your lunch break can be helpful: gather a few co-workers and use half the break to eat and the other half to walk. If you sit when watching TV, use the commercial breaks to get up and move; I have my TV in front of my treadmill and I exercise the entire time I watch my favorite show. There are so many good solutions to break the vicious sitting cycle. You just have to remember to do it and be creative!
To your health!
Anthony Pothoulakis, MD, FACC
Is Skinny Really Healthy?
The obesity epidemic is real and has been for the last twenty-five years. Now it is spreading well outside the boundaries of developed nations. It brings along health concerns: type 2 diabetes, heart disease, stroke, and destroyed knee joints. There have been strong and concerted attempts to cure this epidemic and promote the image of a healthy, non-obese human body. But is becoming skinny at all costs the right answer?
Skinny or normal weight individuals who workout almost daily and eat right can also be suffering poor health. It is not unusual for normal or low to normal weight individuals, to have a very high LDL (the bad cholesterol) or high blood pressure. These conditions depend on heredity and aging as much as they do on lifestyle. Unfortunately, a great body is easier to see and detect than high LDL or high blood pressure. If one or both of those conditions has been a problem for years and goes undetected, it could destroy arteries and hearts beyond repair. Furthermore, many health conscious individuals who are thin, fit and eat healthy, have strong convictions against taking anything that is not natural; they are among the hardest to persuade that a pill might be medically necessary for them.
Muscular individuals may not appear skinny but are certainly healthy. If their muscle comes without belly fat, they are doubly healthy. First, they are spared of the toxic effects of belly fat. Second, muscle is metabolically wonderful. It will burn calories even when we are asleep and suck in excess fatty acids and blood sugar. Third, muscle is essential for exercise and later in life, for simply staying functional and able to walk. One caveat: lifting very heavy weights may raise the blood pressure to unsafe high levels and can destroy our aorta and heart, thus it is not recommended.
There are several conditions that can be even more destructive to our health than obesity.
Smoking is number one. The use of tobacco products, in any way or form, can destroy our arteries and cause heart attacks, stroke, heart failure and an assortment of cancers. Smoking can cause you to stop breathing, due to emphysema. This is irreversible. Since smoking reduces appetite, it is not unusual for smokers to have great figures. If these smokers could only see their insides. The ragged terrain of their arteries and their cancer cells in the making are not a trade off for a shapely body!
Trying to become skinny is not the “end all be all”. We know there are negative health consequences of anorexia and an extremely low body weight (a BMI below 18.5 or a waist circumference below 29 inches for men or 25 for women). In an all- out- war against the obesity epidemic and the ravages that come with it, we should see optimal body weight in the right perspective: desirable. Skinny is neither an absolute guarantee of health nor a goal in itself to be conquered at any cost or through any means. To your Health!