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From the Townsend Letter
May 2016

Head-On Collision Kills Millions Yearly
by John Parks Trowbridge, MD
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Congestive heart failure, an increasing problem in recent years, is a diagnosis encompassing a wide variety of cardiomyopathies, where the heart muscle itself is ailing and underperforming. In the year after initial diagnosis, more than a third of patients with conventional care are likely to die.15 A search for underlying conditions – hyperthyroidism, anemia, chronic tachycardia, and much more – is always essential. Many physicians-in-training learn the "basics" of emergent intervention: bed rest, diuretics, oxygen. Medication management has become intensely complicated, adapted to diverse presentations and evolving condition. In the old days – yes, I have enough gray hairs to state with certainty – we were taught to use digitalis preparations to improve heart contractility and, thus, ejection fraction. Unless acute infarction, rhythm alterations, rupture of a papillary muscle, valvular incompetence, or septal defect were discovered and required surgical intervention or other care, improved circulation dynamics usually resolved the episode in days. Restoring satisfactory heart function led to discharge home, usually with more medications.

A more recent technology is ECP (external counterpulsation), which uses pneumatic cuffs placed around the legs with inflation/deflation timed with the EKG rhythm, to decrease the afterload that the heart has to pump against, and increase the preload that fills the heart, increasing the cardiac output. Patients with more severe failure are candidates for an implantable defibrillator to reduce mortality associated with ventricular arrhythmias that are likely.

So what could possibly be wrong with this picture?

In the labor-relations field, blame is always directed at "management." And in this case, I squarely hold management responsible! Some find it reassuring that today's physicians rely on objective data – laboratory tests, imaging studies, published reports of treatments, and so on – to diagnose and "manage" patients. "Happily," such an approach rarely requires touching (examining!) the patient or even taking a detailed and illuminating history. (This would be an unwarranted sarcastic remark – but think back to recent doctor visits.) The next "objective" step is to write prescriptions. The patient on half a dozen "meds" might even receive instruction (counseling!) on their treatment program … then they're promptly sent home for a later return-to-office. (Remember: a patient on two or more prescriptions is already an "experiment," and results and adverse effects or interactions remain to be seen.)

What's wrong with this management? Doctors become skilled at ordering tests and writing prescriptions – listening to and examining patients have become lost arts, as has training in managing certain complex physiologic medications. Why? Because management is time consuming! You have to "fiddle" with dosages and respond to patient complaints and concerns. Who has time for those phone calls or extra test reports coming through? And insurance won't pay for extra ("unneeded"?) office visits that would make such management techniques more convenient for the physician. Management of digitalis is a classic example; too little doesn't work and the patient could die; too much is toxic and the patient could die. "Just right" is the "sweet spot" that has to be individually determined for each individual – and it changes over time. If a physician fails to understand or appreciate the complexities involved in effective prescribing of digitalis, he shies away from using it. Happily for "him," the "standards of care" now do little to encourage its use, instead favoring a beta blocker and/or a diuretic, or other recent cardiac/hypertension medications, despite rational arguments that have been advanced for continuing its usage.16,17 (See sidebar.)

Repeat episodes of congestive failure are taxing on body systems and lead to shorter survival times. So if digitalis isn't used as much by conventional physicians as would be desirable, why could it represent a dangerous or deadly clash of values? A large number of "alternative/integrative/complementary" physicians have practiced for dozens of years. They were trained to use digitalis. They actively manage various aspects of their patient's condition. They listen. They examine. They teach valuable tricks for home monitoring, such as daily weight, pulse, blood pressure, and assessment of dependent edema. They usually respond to patient concerns between office visits and readily adapt their treatments to changing circumstances. And many of them quite handily manage the use of digitalis to keep their patients out of congestive failure.

Window View, Bathtub Leak
Physician training encompasses a wide range of topics that need some degree of mastery. With the explosion of new drugs in the past several dozen years, younger doctors have even more to learn. Sadly, that might omit the finesse with which certain (often older) medications must be managed. First, you have to understand the mechanism of action and the degradation pathways. Second, you have to account for your patient's unique circumstances. Only then can you initiate and then manage the dose of certain medications.

My father was maintained on Lanoxin (trusted brand of digitalis) for the last 14 years of his life, staying out of congestive heart failure despite multiple health challenges. During his final course, his attending physicians refused to order Lanoxin – "We don't do that anymore." "But he's been stable for years, it works well for him." "No, we mostly use beta blockers and diuretics." "If you don't put him on Lanoxin, he'll likely slip into congestive failure in the next 4 or 5 days." And he did. Three separate times over 5 months. Their modern response was "admirable": he was urgently taken by ambulance from the "skilled nursing" (don't ask!) to the hospital in frank congestive failure (dyspnea, tachypnea, tachycardia, edema, elevated BNP, the whole show). And, of course, a man in his 90s must be entered into the standard treatment protocol that includes fourth-generation antibiotics "for pneumonia." "But … he doesn't have pneumonia." "Protocol requires him to be on presumptive treatment." "But …" It was a fruitless battle.

Lanoxin and Coumadin (brand of warfarin) share a common feature with regard to dosing for desired effect. The loading dose needs quickly to achieve a therapeutic level – not too low (below the bottom sill of a window) and not too high (above the horizontal part forming the top) but "just right," (enjoying the view through the window). A new factor then becomes central: maintenance dosing for "continued viewing through the window" needs to replace drug lost to metabolism or excretion ("leaking" out the bathtub drain, so the level eases down). A variety of factors – comorbidities, liver function, cholestyramine (Questran) for Lanoxin, "green" vegetables for Coumadin, and so on – influence the decline of drug level. Testing is easy for either drug … but the prescribing physician needs to manage the dosing, sometimes several times between office visits to achieve reliable levels. Some doctors are just too busy ("taking care of patients"), others simply aren't interested in making the extra effort, and maybe many (or most?) never understood the physiology, so they simply don't know how.

Not to mention numerous drug–drug interactions with Coumadin and Lanoxin, even by commonly prescribed items. Food choices matter as well: foods rich in vitamin K can reduce the anticoagulant effectiveness of Coumadin. These include beef liver, broccoli, brussels sprouts, cabbage, collard greens, endive, kale, lettuce, mustard greens, parsley, soybeans, spinach, Swiss chard, turnip greens, watercress, and other green leafy vegetables, and to a lesser extent asparagus, avocados, dill pickles, green peas, green tea, canola oil, margarine, mayonnaise, olive oil, and soybean oil, and even some vitamin products. Similar to impaired absorption by cholestyramine, Lanoxin levels can be reduced by high-bran/high-fiber foods, such as certain breakfast cereals.

Last but not least, there's the problem of the "protocols" or enforced "standards of care" often arriving by mail from large mail-order pharmacies. And, additionally, we are always coping with scanty insurance reimbursement for essential lab testing, "overly frequent" office visits, and prescribed drugs. Help me to understand: Exactly who is responsible for managing the patient?

One last note on the clash of values: integrative physicians might reach for medications but they'll also depend on adequate intake of magnesium and balance of potassium (both depleted by diuretics), and cardiac performance enhancers such as D-ribose, coenzyme Q10 and idebenone, pyridoxine (vitamin B6), cholecalciferol (vitamin D3), and iodine, to name a few. A number of herbs can be helpful as well: hawthorn, garlic, curcumin, bilberry, others. Increased vegetable intake (colored, often raw) along with reduction of sugar and starch intake have been shown since 1960 to be invaluable as well, especially with emphasis on low sodium, high potassium, and high water intake.18,19 Interestingly, "diastolic dysfunction" in heart failure is often documented on the EKG … and few physicians recognize that as a sign of intracellular magnesium deficiency.20

You're Driving Me Up the Wall!
Let's bust another myth; namely, that daily stresses drive blood pressures up. Sure, that can happen – especially with chronic magnesium deficiency – but many patients (and their physicians) misunderstand what stressors are and the simple nondrug techniques to better cope with them, such as easily learned and readily practiced meditation (not medication).21 Even worse, many physicians poorly appreciate the gradual worsening of mental and physical performance associated with aggressive control of blood pressure. The adult ideal, of course, is about 120/80 mm Hg. Elevations above 140/above 90 attract lots of attention and often lead to "the usual" medication programs. Patients come in with home pressures below 110/below 60 and are told by their cardiologist, "That's fantastic." But many of them awaken tired, are fatigued easily, have difficulty thinking clearly, and have little if any physical endurance.

The physiology usually is not difficult to understand. Arteries and tiny arterioles have muscular and elastic layers, both of which slightly resist expansion when impacted by the bolus of blood pulsing through during systole. By returning to their preferred "no tension" baseline state during the pause of diastole, they contribute "just a bit more" to distal tissue perfusion. Not merely the brain but all other organs as well depend upon a basal volume and pressure of flow to meet their survival needs, with an increased level obviously needed to perform functions. When one is lying down, the heart is pumping blood "horizontally," with little effort. Any upright position, especially standing, imposes a gravitational load on the now-vertical columns of blood, requiring more "punch" (stronger contractility, even a more rapid pulse and greater ejection fraction) by the heart. Beta blockers, diuretics, and other blood pressure medications can impair physiologic reflexes and thereby severely limit cardiac responses to increased demand. Simply stated, many alternative practitioners are mindful of fine-tuning control, sometimes allowing systolic pressures to reach or breach 150 and diastolic to reach 95. Those higher levels, so long as tolerated without cardiac strain or peripheral distress, have only a marginally increased risk of infarct, aneurysm, or hemorrhage – but the beneficial effect on patient comfort cannot be underestimated.

So what is the collision with conventional care? Desirable cardiovascular conditioning becomes achievable only when a patient can tolerate (even enjoy) a tailored and graduated exercise program. Obviously, hardened vessels (arteriosclerosis) or flow-limiting blockage by plaque (atherosclerosis) reduce the younger-age contribution of arteriolar distension and resistance, so the heart by itself must work harder for any result. Integrative physicians will reach for medications as needed – but they'll also depend again on minerals and vitamins, dietary factors, and herbs for cardiac support, as noted above.

Before we exit the "stress highway," reflect on the oft-forgotten work of Canadian experimental surgeon Hans Selye, MD, who first characterized the phenomenon of "stress" within the body. Studies on doctors-in-training showed work-pressure can lead to a surge in white blood cells, which apparently clump and promote clot formation that reduces distal blood flow. This finding led to experiments with mice that placed under chronic stress conditions, associated with higher levels of noradrenaline. The results show that mice developing atherosclerosis in their arteries make plaques that very closely resemble those known to be most at risk of rupturing and causing heart attacks or strokes in humans.22 (Relax, pull over, take time to smell the roses?)

A Duke University study of 6000 white patients with a history of heart disease – two-thirds of them men – showed 13% had a simple genetic mutation (one base-pair in one gene coding for the serotonin receptor) that led them to overreact to stress. They found double normal circulating cortisol levels and a 38% greater risk for heart disease and early death.23 There you have the scientific future of health enhancement for each individual patient: the better your map, the more you'll enjoy the trip, and the easier to get to your destination.

Keep on Truckin'
Our autonomic (automatic) functions are reliably monotonous or unconsciously responsive to changing conditions. Pulse is usually so "straight and steady" that rarely is someone aware of his heartbeat – until it seems to be jerking or racing along or pounding hard. Arrhythmias are frustrating disturbances, and some can create dangerous or fatal problems. Atrial fibrillation – seemingly much more frequently seen than in past years, now affecting more than 2 million Americans – is especially troublesome. Advances in electrophysiology and cardioversion have rapidly ushered in the new and often effective specialty of interventional cardiology. Sadly, some patients remain stubbornly out of rhythm control or easily or frequently relapse. Antiarrhythmic medications sometimes have troublesome side effects and are no guarantee of normalized rhythm. Alternative physicians are keenly aware of the critical contribution of minerals and vitamins, dietary factors, and herbs for cardiac support, as noted above.

Perhaps of greatest concern is the prospect of arrhythmia-related coagulation, with the very real likelihood of resultant myocardial infarcts (heart attacks), transient ischemic attacks or frank cerebrovascular accidents, optic nerve or retinal infarcts leading to vision degeneration, kidney failure (possibly obstruction of renal artery flow, creating a Goldblatt kidney that leads to ischemic renin–angiotensin–aldosterone system-mediated hypertension), mesenteric ischemia or infarct, peripheral ischemia and even gangrene. The list is ominous – and survival is squarely challenged by any of these pathological blood clots. Although related to different mechanisms in the post-capillary circulation, deep vein thrombosis (DVT) and pulmonary embolism (PE) are similarly calamitous.

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