Cardiovascular disease, Stress, Risk factors

The Campaign to Save a Million Hearts Is Stressed Out

By L. Terry Chappell

In 2012, the Centers for Disease Control (CDC) joined with major cardiovascular medical societies to attempt to save a million hearts over the ensuing five years. These groups targeted the risk factors of blood pressure elevation, high sodium consumption, inadequate exercise, cholesterol management with statin drugs, and smoking cessation (the so-called ABCs) and encouraged aspirin use when indicated to reduce emergency room visits and hospitalizations, myocardial infarctions, heart failure, strokes, and deaths due to cardiovascular events.¹ They omitted excessive stress as a risk factor.

During the last year of the five-year target, cardiovascular events accounted for 2.2 million hospitalizations and 415,480 deaths. Attempts to identify and modify the ABCs, were “frustratingly slow.” From 2011 to 2016, appropriate aspirin use actually decreased. No significant modifications occurred in blood pressure control or statin use (guidelines for BP control actually became more strict, and the use of statins applied to fewer people during the five-year period). Too much sodium continued. There were small but statistically significant improvements in both smoking cessation and exercise. In addition, high rates of diabetes, metabolic syndrome, and obesity persisted. Either the risk factors chosen for modification were inadequate or the efforts made to modify them were insufficient. The cardiology community chose the latter path. In 2017, another five-year program was established, attacking essentially the same risk factors that were targeted in the 2012 program. Again, excessive stress was not considered to be a major risk factor.

Cardiologist Robert Eliot warned us decades ago in his classic book, Is It Worth Dying For? (1989):

The major traditional risk factors—high blood pressure, high cholesterol, diabetes, obesity, and smoking—fail to explain approximately half of the worldwide cases of coronary heart disease. There is good reason to believe that stress is a major missing piece in this puzzle. Moreover, researchers are increasingly recognizing not only that stress is an independent contributor to heart disease, but also that it is closely interwoven with the five traditional risk factors. Controlling unnecessary stress may therefore be the single most important key to preventing heart attacks. Realizing this has led medical researchers to look beyond the heart and blood vessels to the brain.

In 2012, the International College of Integrative Medicine (ICIM) conducted a symposium, which predicted that the effort to save a million hearts was likely to fail because many prevention efforts that are recommended by alternative doctors were not included. Many alternative interventions relate to reduction of stress. The omission of excessive stress as a major risk factor must be recognized and dealt with. This includes anxiety, depression, post-traumatic stress (PTSD), and situational factors such as marital, health concerns, financial, work-related, and other forms of stress.

Many other factors increase cardiovascular risk. Any comprehensive program to reduce risk factors for cardiovascular events should include one of the most important factors of all, the appropriate management of stress. If stress is not addressed effectively, it has the potential to overcome all other risk factors, reduce performance of body functions, and result in major cardiac event(s). Avoiding control of stress as a major treatable risk factor in the Million Hearts program is a big reason why more hearts have not been saved thus far. This article explores ways to identify and manage stress for cardiovascular patients, as well as other patients, in an integrative outpatient practice.

Recognizing Stress as a Risk Factor

The first clue that stress is either a cause or a result for the presenting complaint is a thorough history and physical. The clinician must inquire about the quality and quantity of sleep. Sleep apnea is a common condition that can usually be addressed with a C-pap or other procedures. Depression can be linked to insomnia. Supplements such as SAMe, L-tryptophan, and GABA are useful treatments for depression-related insomnia. Melatonin is often employed to treat insomnia. If in doubt about depression, the PHQ-9 is a useful, quick questionnaire that is very helpful in the office. A score >4 might detect a problem that is not apparent in the early stages of depression. Frequent wakening is a clue from the history. The resulting reduction of rapid-eye movements interferes with the restorative function of sleep.

Recent evidence has shown that too much sleep can also be a risk factor for cardiovascular and all-cause mortality.² Patients who sleep too little or too much have been associated with diabetes mellitus, lower physical activity, depression, hypertension, and smoking.

Basic personality types uncover a patient’s response to stress. Type A tends to be aggressive and combative, a so-called “hot reactor,” while Type B is a more mellow “cold reactor.” Blood pressures and pulses of hot reactors rapidly increase in response to stress. Those who are Type A must develop ways to diffuse stressful situations, or they will become a powder-keg for coronary artery attacks.

Family physicians and other specialists have contributed to the opioid crisis in their attempts to relieve stress and pain.³ Family docs prescribe opioids more frequently than other physicians, but they rarely offer buprenorphine or naloxone to help prevent abuse. Physicians now sometimes find that treating an opioid addiction has become more difficult than treating an underlying cancer.

A heart rate variability (HRV) test is a good way to evaluate sympathetic and parasympathetic activity. Sufficient amounts of the latter are needed to deal with the sympathetic outflow that is encountered daily. A Max Pulse test contains a HRV assessment along with other cardiovascular functions. Especially when the patient reports late afternoon fatigue, a salivary cortisol test will detect exhausted adrenal function. A urine test for neurotransmitters is also available. However, one must be careful to do follow-up serial testing to interpret the relative effect of GI neurotransmitters. An important test is the adrenal stress index (ASI), which consists of salivary cortisol measurements throughout the day to detect adrenal exhaustion in response to stress.

Mark Hyman explains in his book, Ultra-Metabolism, why some people gain weight, even though they are under considerable stress.⁴ The opposite would be expected. What actually happens is that cortisol is excessively released from the adrenal glands, which reduces the body’s metabolism. Thus, calories are not burned off and fat accumulates. Each patient needs to find effective tools to deal with the stress encountered in his or her situation. Hyman also describes how food allergies, toxic foods such as sugar, and menopausal hormone changes all can drastically affect metabolism. Obesity, the metabolic syndrome, and diabetes can then develop into substantial risk factors for cardiovascular disease.

One must also keep in mind that stress can be beneficial.⁵ McDonigal and others have shown that short-term bursts of moderate stress during the day can improve alertness, cognitive function, performance, and memory. Growth of stem cells in the hippocampus and nerve cells in the brain are thereby enhanced. Good social support, establishing control of one’s situation, regular exercise, and the relaxation response are ways that regular stress can be utilized to reduce cardiovascular risk.

Goals for Treatment of Stress

Increased stress relates to many functions in the body. Treatment of those areas might reduce stress indirectly. Producing increased energy by improving mitochondrial function can reduce stress. Improved immunity and memory are often noticed. Various anti-aging measures for both treatment and prevention are useful, since most chronic illnesses relate to aging. Certainly, a primary successful outcome is improved longevity. Pain relief reduces stress. Detoxification cleanses the body. Strengthening ligaments and muscles with exercise and prolotherapy injections makes joint and body functions less stressful. Overall, improved performance of all body activities is a goal. Most body activities relate to stress in one form or another. Stress reduction should be a major goal for treatment of cardiovascular disease.

Therapies to Address Stress

Top-notch rehab centers employ health coaches to maximize the mind/body connection, especially with relaxation and biofeedback exercises. Such centers are aware that chronic anger increases blood pressure, makes strokes much more likely, and enlarges the heart. Excessive stress can act as glue that holds other risk factors together to create a greater risk. If a patient adds smoking to depression, for example, the risk triples. Constant stress in the workplace increases the viscosity of the blood. Inadequate family and social support in stressful situations can increase the death rate by three to fourfold. A successful health coach will emphasize lots of laughter, doing volunteer work, giving and receiving affection, a optimistic attitude, the relaxation response, and a religious faith as effective tools and skills. The American Heart Association offers added strategies (see Table 1) that might empower the mind over the body if practiced daily.

Benson described many positive techniques that he combined into the “relaxation response,” including meditation, progressive relaxation, prayer, visualization, yoga, music therapy, and breathing techniques. Practicing whatever works best for the patient on a regular basis enables him or her to achieve a state of relaxation that can counteract potentially harmful episodes of stress.

There are many therapies available that professionals use to protect patients from harmful effects of stress. The techniques listed below are often helpful. They change the body’s physiology in various ways to develop normal patterns, which can promote healing. Most of these therapies are not considered “proven” by the FDA due to the lack of large clinical trials. However, there is little doubt that patients who actively learn to manage excessive stress feel better, live longer, and function better, based on the experience of many trained clinicians. Much research needs to be done, but many tools are already in the hands of therapists. They are safe and often effective. Stress can be a massive factor in our lives. We need multiple therapies to help us succeed against a powerful enemy.

Various nutrient IV therapies act synergistically with other techniques to lesson stress. High-dose nutrients such as the Super-immuno IV developed by Shrader might reduce stress and enhance normal function. IV Phosphatidyl choline with glutathione improves neurotransmitters. Serial measurements of urine neurotransmitters followed by amino acids by mouth can correct an imbalance of neurotransmitters. Mineral IVs, amino acids, high-dose vitamin C, magnesium by IV push, and variations of the famous Meyer’s cocktail all can improve performance. Nutrient adjuncts can convert harmful stress into managed stress.

Two other IV therapies might be utilized by alternative physicians to enhance normal function. EDTA chelation removes toxic metals and enhances circulation. A series of Nicotinamide Adenide Dinucleotide (NAD+) IVs were used initially to treat addictions and alcoholism, and now are also employed as a powerful tool to treat anxiety and depression.

Neuro-feedback detects abnormal brain waves and converts them into normal patterns. Many patients feel dramatically better after a series of this mini-electrical stimulation. Headaches, migraines, anxiety, depression, and PTSD all frequently respond with long-term benefit. The micro-current version of this therapy might be easier to use than earlier versions, while maintaining good results.

NanoVi Eng3 device reduces oxidative stress. It helps to make up for what you eat, what you breathe, and what you are exposed to. It reduces stress and inflammation as one ages by generating antioxidants. Increased performance commonly results.

Psychotherapy, otherwise known as talk therapy guided by a counselor, utilizes various techniques to treat anxiety, depression, and PTSD. Two of the most popular are cognitive behavioral therapy (CBT), which modifies harmful thought patterns to change moods and behaviors, and mindfulness therapy, which utilizes active listening and meditation. Hypnosis and self-hypnosis can also be utilized by trained clinicians.

Pulsed electromagnetic field (PEMF) is a series of targeted exercise of cell function. Tiny pulsations of magnetic fields stimulate healing, energy, and relaxation simultaneously. This is a powerful way to reduce pain and manage stress with lasting effects.

The Zona-plus device detects micro nerve patterns that lead to hypertension. Suggested isometric responses are relayed to the patient. Using these exercises relaxes the surrounding muscles, relieves tension, and reduces BP.

Stem cells injected into the nose has been modestly successful in improving memory. As memory improves, so does reduction of stress and quality of life.

Hyperbaric oxygen has been used extensively for wound healing. Treatment of wounds serves as a model for treating various inflammatory conditions and diseases in the body. Concentrated oxygen can improve impaired brain function resulting from strokes and PTSD. Autistic children often improve with HBOT.

The combination of ultraviolet light and ozone exposure to a large syringe of blood that is then re-injected into a vein can boost the immune system and increase energy. This improves performance of the circulatory and musculoskeletal systems and thus reduces stress. Ozone by itself can promote healing for many conditions.

Low dose immunity (LDI) is a very low-dose treatment to desensitize allergies and autoimmune problems over a period of time. As the patient feels better, harmful stress becomes much less of a factor. Food sensitivities can produce pain and stress. Shrader and Vincent were pioneers that taught LDA and LDI in conjunction with AAEM meetings.

Neural therapy by Klinghardt and pain neutralization by Kauffman are dramatic healing procedures that instantly relieve pain and increase parasympathetic activity to balance the “fight or flight” response. These techniques are taught in workshops and DVDs.

Acupuncture has been around for 5000 years and still works today. In the 1980s the electro-acuscope and myopulse machines were introduced for both pain and stress.

Low level lasers of various strengths and T.E.N.S. units treat around the areas of pain. The BioMat, the BEMER, and the InfraRed sauna are great for relaxation therapy. These devices can be purchased for home use.

Tenpenny sensitivity reduction (SRT–tapping), NAET, and the Emotional Freedom Technique (EFT) are treatments for allergies and stress. EFT is a technique you learn to use at home.

HeartMath offers a relatively inexpensive biofeedback device you can use at home to melt away harmful stress. This procedure was developed and recommended by conventional medicine.

Massage therapy is also an approved therapy. Chiropractic and osteopathic adjustments can be very useful.

Oral supplements that are especially helpful for stress include the following:

• Combination of l-tryptophan and melatonin for sleep problems and depression;

• d-Ribose, CoQ10, l- carnitine, Mg, taurine for cardiac strength (recommended by Sinatra, Roberts, Whitaker);

• Vitamins D3, K2, tocotrienols;

• Antioxidants such as vitamins A, C, E, selenium, and glutathione to quench free radicals;

• Peptides, amino acids;

• Adrenal glandulars, along with pantothenic acid, for stress and fatigue;

• Oral supplements for stress (valerian, passaflora, SAMe, others);

• Alpha lipoic acid orally for detoxification (helps remove toxic metals);

• Fish oils and nattokinase to reduce platelet adhesiveness;

• Strong multivitamin (usually requires 4-6 pills a day);

• Magnesium (the anti-stress mineral), perhaps the most important nutrient to treat and prevent coronary artery disease;

• Anti-yeast/ program/ ketogenic diet (Trowbridge), DASH, or Mediterranean diet;

• Essential oils, CBD, and hemp oils; and

• Homeopathics.

Conclusion

Every clinician who treats cardiovascular disease should have multiple modalities at his or her disposal to deal with stress. These measures should include some form of relaxation response. The modalities chosen must be used regularly and supported by the entire office staff. Casual suggestions rarely are effective. Relapses are common. Different patients respond to different entities. Maintenance is required to be sure that treatments are continued.

Keep in mind that small amounts of controlled stress are beneficial to the body, as long as they are managed carefully. Chronic uncontrolled stress is a major risk factor that must be dealt with and treated effectively. Stress management should be made a priority, along with diet, exercise, smoking cessation, BP control, and chelation of metals. Financial considerations must be addressed. Everyone, especially those with cardiac risk factors, should actively deal with excessive stress. Otherwise, many will fall short in their efforts to avoid damage to their hearts. Stress is a powerful risk factor that affects the body in many different ways.

References

1. Wright JS, Wall HK, Richey MD. Million hearts 2022 small steps are needed for cardiovascular disease prevention. JAMA 2018;320:1857-1858.

2. Khan H, et.al. Sleep duration and risk of fatal coronary heart disease, sudden cardiac death, cancer death, and all-cause mortality. Am J Med 2018;131:1499-1505.

3. Kowalchuk A, De Grubb MM, Zoorob R. Preparations for treating opioid use disorder in the office. Fam Pract Man 2018;25:21-26.

4. Hyman M. Ultra-Metabolism. New York, NY: Schribner;2006.

5. McDonigal K. The science of compassion. http://kellymcdonigal.com (on-line courses). Stanford university continuing studies, Fall 2018 (accessed December 11, 2018).

6. Sinatra ST, Roberts JC. Reverse heart disease now. Hoboken, NJ: John Wiley & sons; 2007.

SIDEBAR

The American Heart Association Recommendations for Reducing Stress

The American Heart Association offers an array of strategies for reducing stress, particularly if you have cardiovascular disease. They include the following:

• Talk with family, friends, clergy, or other trusted advisors about your concerns and stresses, and ask for their support.

• Learn to accept things you cannot change. You don’t have to solve all of life’s problems.

• Count to ten before answering or responding when you feel angry.

• Don’t use smoking, drinking, overeating, drugs, or caffeine to cope with stress. They make things worse.

• Look for the good in situations instead of the bad.

• Exercise regularly. Do something you enjoy. Check with your doctor to determine what activity level is right for you.

• Be an animal caregiver. Elderly individuals with animal companions make fewer visits to doctors than non-owners and do much better following heart attacks. They have lower blood pressure.

• Think about what might upset you and try to avoid it. Avoid people who bother you. Try to avoid rush hour traffic.

• Plan productive solutions to problems. Seek clear limits on how much you will do for family members.

• Learn to say no. Don’t promise too much. Give yourself enough time to get things done.

• Join a support group—maybe for people with heart disease, for women, for men, for retired persons, or some other group with which you identify.

• Practice altruism. By giving we don’t necessarily mean money, but kind deeds that help the lives of others.

From Reverse Heart Disease Now by Sinatra and Roberts⁶

BIO

Terry Chappell, MD, is a 1969 graduate of University of Michigan Medical School, board-certified in family medicine. He has served as president of both ACAM and ICIM. He has published widely, often in the Townsend Letter. Dr. Chappell continues to practice medicine in Bluffton, Ohio. He has no financial disclosures or conflicts of interest.

Correspondence:

terrychappell@healthcelebration.com

419-358-4627

Fax 419-358-1855