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Cardiovascular disease
Heart and coronary conditions and care

General information about cardiovascular health or disease

What is cardiovascular disease? (American Heart Association, whose site provided the following:

Heart and blood vessel disease (also called heart disease) includes numerous problems, many of which are related to a process called atherosclerosis. A heart attack occurs when the blood flow to a part of the heart is blocked by a blood clot. If this clot cuts off the blood flow completely, the part of the heart muscle supplied by that artery begins to die. An ischemic stroke (the most common type of stroke) occurs when a blood vessel that feeds the brain gets blocked, usually from a blood clot. A hemorrhagic stroke occurs when a blood vessel within the brain bursts. This is most often caused by uncontrolled hypertension (high blood pressure).
---Top 10 Myths About Cardiovascular Disease
---What do your blood pressure numbers mean? Which ranges are healthy or unhealthy (print out the chart)
---What is cardiovascular disease?
Heart failure, sometimes called congestive heart failure, means the heart isn’t pumping
Arrhythmia refers to an abnormal heart rhythm. There are various types of arrhythmias. The heart can beat too slow, too fast or irregularly.
Bradycardia, or a heart rate that’s too slow, is when the heart rate is less than 60 beats per minute. Tachycardia, or a heart rate that’s too fast, refers to a heart rate of more than 100 beats per minute.
Heart valve problems: When heart valves don’t open enough to allow the blood to flow through as it should, a condition called stenosis results. When the heart valves don’t close properly and thus allow blood to leak through, it’s called regurgitation. If the valve leaflets bulge or prolapse back into the upper chamber, it’s a condition called prolapse. Discover more about the roles your heart valves play in healthy circulation.
---Why is health insurance important? The ACA allows qualifying individuals and families to receive financial assistance to help cover the cost of premiums. Known as the Health Insurance Premium Tax Credit, this subsidy helps people who need health insurance afford their coverage. Resources like HealthSherpa.com and Healthcare.gov can help you find out whether you are eligible for the tax credit.
---African Americans and heart disease
---Treatments and Tests: Answers by Heart Fact Sheets  and more.
Damar Hamlin’s Cardiac Arrest: What We Know and Don’t Know (Gina Kolata, NY Times, 1-3-23) In a freakish accident, a blow to his chest during a collision with a receiver on the opposing team sent his heart into an erratic rhythm known as an arrhythmia. an arrhythmia to occur, there has to be what Dr. Baggish called “a perfect storm” — the chest must be struck in a precise place at a precise moment while the heart is relaxing after squeezing out blood, and with the right amount of force....

     "Most documented incidents have occurred in baseball when a player has been struck in the chest by a ball, and it has also occurred in lacrosse and hockey. Chest protectors did not prevent the incidents in those sports. Dr. Baggish said he would not count on football pads either, saying that to his knowledge, “no commercially marketed pads for any sport guarantee complete protection.”

      There is just a 20-millisecond interval in the heart’s cycle when a strong blow can cause an arrhythmia....

     "The concern is whether, during those long minutes before Mr. Hamlin's heart rhythm returned, when his heart was not pumping normally, a lack of blood damaged his brain, heart experts said. If a patient in cardiac arrest does not recover right away, doctors will often induce a coma to give the brain a chance to rest, Dr. Mack said. Sometimes doctors also cool the brain to slow its metabolism while it recovers, using cooling blankets — which have coils that circulate chilled water — and headpieces."

     "Cardiac arrests differ from heart attacks, which are caused when an artery supplying blood to the heart is blocked, depriving the organ of blood. That can trigger an arrhythmia or even sudden death."
Cardiovascular Disease (The Cleveland Clinic) Excellent information, well-organized.What causes cardiovascular disease? What are cardiovascular disease risk factors? What are the symptoms of cardiovascular disease? of heart issues? of blockages in blood vessels throughout your body? What conditions are cardiovascular diseases? How is cardiovascular disease diagnosed? What tests might I have for cardiovascular disease? What tests might I have for cardiovascular disease? How can I prevent cardiovascular disease? 
Cardiovascular Disease (National Health Service, UK) Laid out in a way to show differences between (for example) angina (chest pain caused by restricted blood flow to the heart muscle), heart attacks (where the blood flow to the heart muscle is suddenly blocked), and heart failure (where the heart is unable to pump blood around the body properly).
Warning signs and symptoms of heart disease (Mount Sinai)
NIH Studies (National Heart, Lung, and Blood Institute, NHLBI) Studies to inform health care. For example: Study challenges “good” cholesterol’s role in universally predicting heart disease risk

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Cardiovascular health and illness
General information

What Is Coronary Heart Disease? National Heart, Lung, and Blood Institute, NHLBI)
Your Guide to Living Well With Heart Disease (free PDF, NHLBI) Excellent primer
The Heart.org (Medscape news & perspective, Cardiology)
Acetaminophen Is the Best Pain Reliever for Heart Patients (Orly Avitzur, Consumer Reports, 6-19-16) "Tylenol is a good choice for those needing relief from the physical pain caused by osteoarthritis in the joints or from headache pain and who also have heart troubles such as high blood pressure, heart failure, heart attacks, chest pain due to narrowed coronary arteries (angina), or stroke. Using acetaminophen is a much safer bet than most over-the-counter pain relievers like ibuprofen (Advil and generic) and naproxen (Aleve and generic)....That’s because acetaminophen is unlike other common, over-the-counter pain medications, like ibuprofen and naproxen, which can aggravate high blood pressure, and in turn raise a person's risk of having a heart attack. "
A Rural Doctor Gave Her All. Then Her Heart Broke. (Oliver Whang, NY Times, 9-19-22) 'Physicians suffer one of the highest burnout rates among professionals. Dr. Kimberly Becher, one of two family practitioners in Clay County, West Virginia, learned the hard way. In Clay County, there is no public transportation, no stoplight, no hospital. Most residents live in a food desert. And as one of only two family doctors in the county, Dr. Becher has an all-encompassing job....She began to run more, sometimes twice a day, for hours at a time, “raging down the road.” pandemic.

      "Tests soon revealed that she had a rare disease called takotsubo cardiomyopathy, which forces the tip of the heart’s left ventricle to stretch. Most cases occur in older women who have recently experienced some type of intense physical or emotional distress, like the loss of a loved one or a serious accident. It has gained a catchy moniker — broken heart syndrome — but its causes remain unknown. "In the hospital, Dr. Becher argued with the doctors as they tried to treat her. Her clinic’s answering service called her three times while she was being diagnosed; her husband, Mike Becher, had to take away her phone. She protested until she saw the medical imagery: a portion of her heart had been paralyzed, and her left ventricle had ballooned.

     "No one put me in this position. I applied to medical school, I sought a job in rural primary care and I poured my identity into it. Takotsubo's is typically caused by severe acute stress, something traumatic and abrupt. Mine was just from going to work every day and seemed super lame to me in the moment."'
Why Do People Drop Dead? Causes of Sudden Death (Dr. Mary Williams, CPR Certified, 8-23-17) Describes causes, risk factors, symptoms, and how to respond in an emergency (specifically for heart attack, stroke, pulmonary embolism, aortic rupture)
Heart Attack at 49—America’s Biggest Killer Makes a Deadly Comeback (Betsy McKay, Wall Street Journal, 6-21-19) Younger people, women and nonsmokers are more likely to be victims of the crisis in cardiovascular health, driven by skyrocketing obesity and diabetes.
Health topics (A-Z, National Heart, Lung and Blood Institute, NHLBI) Blood diseases and disorders; Heart and blood vessel diseases; Lung diseases; Obesity; Sleep disorders; Tests and procedures.

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State Laws Ban Surprise Medical Bills. She Got One for $227K And Fought Back. Even With Insurance, She Faced $227K In Medical Bills. What It Took To Get Answers. (JoNel Aleccia, KHN, 3-22-19) The first surprise was the massive heart attack, which struck as Debbie Moehnke waited in a Vancouver, Wash., medical clinic last summer. “She had an appointment because her feet were swollen real bad,” said Larry Moehnke, her husband. “But she got in there and it was like, ‘I can’t breathe, I can’t breathe!’” Her life suddenly at risk, the 59-year-old was rushed by ambulance, first to a local hospital, where she was stabilized, and then, the next day, to Oregon Health & Science University across the river in Portland for urgent cardiac care. She spent a month in the hospital, some of it in intensive care, before she was discharged home
     That’s when she got the next surprise: Bills totaling more than $454,000 for the medical miracle that saved her life. Of that stunning amount, officials said, she owed nearly $227,000 after her health insurance paid its part. Large “surprise bills” like the Moehnkes received have become a national epidemic outraging patients and politicians alike. Solutions have been elusive to date, even in a progressive state like Washington. Only later did the couple learn that she could have been transferred to an in-network hospital, potentially saving tens of thousands of dollars.

      While patients can generally avoid balance billing by staying in-network, a life-or-death emergency such as Debbie Moehnke’s can make that impossible. Also, many in-network hospitals often use out-of-network doctors, leaving patients vulnerable to surprise charges. As of December, 25 states had laws providing protection against balance bills, according to the Commonwealth Fund. Those laws take consumers out of the middle in billing disputes and force providers and insurers to negotiate directly for payment. With the help of Jared Walker, who runs Dollar for Portland , a nonprofit group, the couple applied for a medical charity care waiver, in itself a complicated process. OHSU officials granted the waiver, erasing the sky-high debt.
AP Cardiology Andrew Perry, MD, hosts a cardiology podcast for internists, residents and medical students.

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Defibrillators  Also known as Automated External Defibrillator (AED), Implantable Cardioverter Defibrillator (ICD), Wearable Cardioverter Defibrillator (WCD)  Essential for treating cardiac arrest.
Heart attack (Medline Plus information page)
Heart & Vascular Disease fact page (useful NHLBI links)
Cardiology's 10 Greatest Discoveries of the 20th Century (Nirav J. Mehta and Ijaz A. Khan, Texas Heart Institute Journal, on PMC, 2002) Electrocardiography, preventive cardiology and the Framingham Study, "lipid hypotheses" and atheriosclerosis, coronary care units,echocardiography, thrombolytic therapy, cardiac catheterization and coronary angiography, open-heart surgery, automatic implantable cardiac defibrillators, and coronary angioplasty.
A History of the Heart, That Most Vital of Organs (Randi Hutter Epstein, NY Times, 11-5-18). A review of Heart: A History by Sandeep Jauhar. "Most chapters launch with a riveting scene....We read about Werner Forssmann, who attempted one of the first cardiac catheterizations in 1929. He did it on himself. Forssmann threaded a thin tube through his arm until it pierced his right atrium. Colleagues called him a quack. Almost 30 years later, he won the Nobel Prize in Physiology or Medicine." Many advances in cardiac care got off to a rough start, and this history of the field is fascinating.

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Aiming for blood pressure targets lower than 140/90 mmHg is not beneficial (Cochran review, 7-8-09) "Treating patients to lower than standard BP targets, ≤140-160/90-100 mmHg, does not reduce mortality or morbidity. Because guidelines are recommending even lower targets for diabetes mellitus and chronic renal disease, we are currently conducting systematic reviews in those groups of patients."
Oregon's only heart transplant program now stopped indefinitely (Molly Harbarger, Oregon Live, 8-31-18) "Oregon Health & Science University has placed its heart transplant program on hold indefinitely while leaders try to replace four cardiologists who announced their departures in the past few weeks....While the heart transplant surgeons are still at OHSU, there is now no one to follow up with new heart recipients. OHSU said Friday that all 20 patients on the wait list either have referrals to different hospitals, or have decided not to transfer. However, the suspension also touches patients who need follow-up care or evaluations from heart failure specialists."
When Evidence Says No, but Doctors Say Yes (David Epstein and Pro Publica, The Atlantic, Feb. 2017) Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. "Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died."
Links to important information on heart disease (NHLBI)
Resources for a healthy heart (PBS Take One Step Health Campaign)
Heart Disease (HealthLine)
How to Draw a Human Heart (Emon Hassan's short video about Laura Ferguson's art and anatomy class at NYU for medical students, faculty, and staff)

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A welcome side effect: Novartis anti-inflammatory may cut risk of lung cancer, study finds (Meghana Keshavan, STAT, 8-27-17) The "biologic drug canakinumab from Novartis (NVS) — which has thus far only been approved to treat a rare disease — lowered the incidence of cardiovascular complications by 15 percent" -- in line with the hypothesis that "by targeting an inflammatory pathway seen in heart disease, one could lower the risk for heart attack, stroke, and cardiovascular death." It also appears to reduce the risk of lung cancer. "The reason we have to be careful about this: It’s very exploratory, and needs to be confirmed. And while the biology is obviously very exciting and makes a lot of sense, it’s not yet clear how one would translate that into treatment algorithms for someone who already has lung cancer."
A bad heart and housemaid's knee (Pat McNees's story about Marian P. and a genetic disorder called sitosterolemia, in which the body absorbs abnormal amounts of plant cholesterol (sitosterol) and, unable to excrete it, deposits it in xanthomas and in the arteries, which leads to heart disease.
Heart diseases (also called cardiac diseases) (Medline Plus)
Calculate your risk of heart attack (Heart to Heart)
The NNT The Number Needed to Treat -- a tool to communicate benefit and harm that both patients and doctors can understand (traditionally, the number required to prevent one death). See also the Lancet article, Numbers needed to treat (needlessly?) by Peter Bogaty and James Brophy, suggesting that the NNT obscures the reality that many patients are treated without benefit. Figures on such questions as whether taking an aspirin prevents a heart attack (or does harm), whether beta blockers prevent myocardial infarction (or do harm), is the Mediterranean diet helpful after heart attack, do statin drugs given for five years (with or without known heart disease)help or harm health, in what ways? and so on.

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Answers to Questions About Heart Disease (Elizabeth Nabel, NY Times, 4-17-07)
Heart disease (many articles, from the New York Times)
Waltzing helps mend hearts (Marilynn Marchione, WaPo story)
Fresh Starts for Hearts (Krista Conger, Stanford Medicine, Spring 2014) "With a condition called dilated cardiomyopathy, in which the heart muscle weakens and begins to fail. Although some genetic mutations are known to be associated with the condition, the cause is often unknown. It affects about one child in every 100,000 in this country, and 40 percent of those with symptoms like Sierra’s either die or undergo a heart transplant within two years of diagnosis....But many experts believe better options are coming: They expect research on stem cells to bring about a revolution in care for heart disease patients."

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Pros and cons, ins and out, of various screenings, tests, treatments, habits

Abdominal Aortic Aneurysm: Screening (Recommendation Summary, U.S. Preventive Task Force) Who should and who needn't get screened.
FDA widening probe into heart drugs linked to cancer risk (Ed Silverman, STAT, 8-30-16) 'After learning an ingredient used to make a widely prescribed heart drug contained a substance linked to cancer, the Food and Drug Administration is now testing all drugs in that class for traces of the toxic material. The probe into angiotensin II receptor blockers is part of a widening investigation into a mystery over an impurity known as NDMA, which was found last month in generic valsartan blood pressure pills made by Zhejiang Huahai Pharmaceutical.,..The finding caused widespread concern and product recalls by several manufacturers as the FDA and regulators from other countries scrambled to determine how the substance found its way into the medicine. The FDA issued a statement saying it believes the problem occurred “through a specific sequence of steps in the manufacturing process,” but the agency is “still not 100 percent sure this is the root cause.” Due to the uncertainty, the FDA is “testing all the products in the ARB class to determine if they contain NDMA"...Numerous companies either manufacture or repackage these drugs, which are regularly used to combat high blood pressure and heart failure. As of now, they noted that more than half of all valsartan medicines that are on the market are being recalled. The episode underscores ongoing concerns about the quality of the pharmaceutical supply chain emanating from countries such as China and India that are large ingredients manufacturers, but have a history of inconsistent — some say inadequate — government oversight.' '[T]o put the risk into context: The agency estimated that if 8,000 people took the highest valsartan dose of 320 mg in a pill containing NDMA daily for four years — which is the amount of time the FDA believes the affected pill had been on the U.S. market — there may be one additional case of cancer over their lifetimes beyond the average cancer rate among Americans.'
The agency estimated that if 8,000 people took the highest valsartan dose of 320 mg in a pill containing NDMA daily for four years — which is the amount of time the FDA believes the affected pill had been on the U.S. market — there may be one additional case of cancer over their lifetimes beyond the average cancer rate among Americans.
Patients Facing Death Are Opting for a Lifesaving Heart Device — But at What Risk? (Daniel Chang and Holly K. Hacker, When Medical Devices Malfunction, KFF Health News, 12-19-23) The HeartMate 3 is considered the safest mechanical heart pump of its kind, but a federal database contains more than 4,500 reports in which the medical device may have caused or contributed to a patient’s death.
EKG Screening for College Athletes (Sandeep Jauhar, Opinion, NY Times, 1-26-16) "We should begin targeted screening of some groups of college athletes — starting with those in sports that recent research indicates pose a high cardiovascular risk, such as basketball and soccer."
One Big Stress Test (David Esselstrom, Pulse, 4-15-22) Back-to-back doctor’s appointments at Kaiser Permanente in Moreno Valley—she to talk about a puzzling lethargy that had been dogging her and I to talk about an odd chest pain that I thought a remnant of the flu I’d had in late January--lead to several ambulance rides from one facility to another, getting serious test after serious test, and a major surprise about the heart of the problem.
Giant study shows Apple Watch can spot heart rhythm changes — but it’s far from ‘medical-grade technology’ (Matthew Herper, STAT News, 3-16-19)
Should you fast before a cholesterol test? (Roni Caryn Rabin, Ask Well, NY Times, 5-24-16) ""Cholesterol levels change extremely slowly in response to food intake. That is why it is so difficult to get your cholesterol down by changing food habits."
When Evidence Says No, But Doctors Say Yes (David Epstein and ProPublica, The Atlantic, Feb. 2017) First, listen to the story with the happy ending; then listen to the one with the unhappy ending. What the patients in both stories had in common was that neither needed a stent. By dint of an inquiring mind and a smartphone, one escaped with his life intact. The greater concern is: How can a procedure so contraindicated by research be so common?Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments.
Boy who survived 90 minutes of CPR might change the way hospitals handle heart emergencies (Nicole Villalpando, Austin 360, 2-18-19) They continued CPR because 5-year-old Owen was an otherwise healthy child who lost his heart rate in front of them. They believed the CPR had been getting enough blood flow to the brain, and they had gotten his pulse back twice. An ECMO machine was on standby in another part of the hospital. "ECMO oxygenates the blood through the machine without the blood needing to go to the heart and lungs. It allows the heart and lungs time to possibly recover from whatever is making them not function. In Owen’s case, doctors think a virus attacked his heart. ECMO is not something that is typically used in an emergency room. There was only a slim chance that it would work on Owen. But it did.
Ankle-brachial index: Why it's done (Mayo Clinic)
Proteomics Might Have Saved My Mother’s Life. And It May Yet Save Mine. (Michael Behar, NY Times, 11-15-18) 'The 20,000 or so known proteins in each human body might soon be used as an early warning system for disease.... Proteomics, or the study of proteins, has long offered the ability to identify many biological processes.... Now, with the advent of more powerful computers and a form of artificial intelligence called machine learning, medical experts are imagining a future where proteomics will realize its power to tell us, to an incredible degree, what’s transpiring inside our bodies.... As the workhorses in the human body, proteins play a role in nearly all of its biological processes.... Researchers are now learning that diseases have their own unique proteomic patterns.... “Diagnostic medicine has always been about proteins,” says Philip Ma, Seer’s president and chief business officer. “All proteomics is allowing you to do is to look at them in bunches instead of one at a time.” ...Doctors won’t embrace the technology until they are sure that protein screenings provide reliable results, but improving reliability is largely contingent on widespread adoption....[It's still early days.] While allocating most resources to the big three — cancer, heart disease and diabetes — SomaLogic also is delving into realms that traditionally haven’t been studied with proteomics, such as smoking, social deprivation, excessive alcohol consumption and fitness.'
Ankle Brachial Index Exam for Peripheral Artery Disease (PAD) (American Heart Association). This YouTube video shows how to administer the test (for medical professionals) but you may realize a) that it takes time and b) you have never been given the test--as I hadn't). The American Heart Association recommends it for individuals 60 and above or who are suspected of PAD problems.
Paging Cardiology (Geoffrey Rubin, Pulse--voices from the heart of medicine, 12-9-16). Choices, as seen from the beginning doctor's viewpoint.
As Part of Choosing Wisely® Campaign, SCAI Issues List of Tests and Treatments to Avoid (Choosing Wisely, ABIM, 3-31-14)
Big Health Benefits to Small Weight Loss (Roni Caryn Rabin, Well, NY Times, 2-25-16) "Obese individuals who lose as little as 5 percent of their body weight can improve their metabolic function and reduce the risk of developing Type 2 diabetes and heart disease, a new study has found."
Taking a Daily Aspirin (Roni Caryn Rabin, Ask Well, NY Times, 5-6-16) "Adults ages 50 to 69 who are at high risk for heart attack or stroke should take a daily low-dose aspirin to prevent both heart attacks and strokes as well as colorectal cancer. That’s the latest advice from the United States Preventive Services Task Force...If you’ve ever had a gastrointestinal bleed or ulcer, you probably should not take aspirin.
Cardiac Rehab Improves Health, But Cost and Access Issues Complicate Success (Julie Appleby, Kaiser Health News, 8-31-16) In a medically supervised cardiac rehabilitation program you learn about exercise, diet and prescription drugs. "Despite evidence showing such programs substantially cut the risk of dying from another cardiac problem, improve quality of life and lower costs, fewer than one-third of patients whose conditions qualify for the rehab actually participate.... women and minorities, especially African Americans, have the lowest participation rates....Uninsured patients simply can’t afford cardiac rehab. And for those with some form of coverage, “the No. 1 barrier is the cost of the copayment, which is frustrating.”
The NNT The Number Needed to Treat -- a tool to communicate benefit and harm that both patients and doctors can understand (traditionally, the number required to prevent one death). See also the Lancet article, Numbers needed to treat (needlessly?) by Peter Bogaty and James Brophy, suggesting that the NNT obscures the reality that many patients are treated without benefit. Figures on such questions as whether taking an aspirin prevents a heart attack (or does harm), whether beta blockers prevent myocardial infarction (or do harm), is the Mediterranean diet helpful after heart attack, do statin drugs given for five years (with or without known heart disease)help or harm health, in what ways? and so on.
Hospital Chain Inquiry Cited Unnecessary Cardiac Work (Reed Abelson and Julie Creswell, NY Times Business, 8-6-12) Award-winning articles on how unnecessary — even dangerous — procedures were taking place at some HCA hospitals, driving up costs and increasing profits. HCA is the largest for-profit hospital chain in the United States. Implications of the piece: Borrowing money to pay dividends to investors, HCA turned partly to (sometimes unnecessary) cardiac care to fund its business needs.
Bright Review of VitaPulse. This "infomercial scam buster" discourages purchase of this supplement sold by Princeton Nutrients. In its review of Probiotics ("The Good, the Bad, and the UGLY"), it reminds consumers that probiotics are not regulated, so you should buy them in a store or online, and tells you what to watch for.
What Is Transesophageal Echocardiography? (NHLBI) TEE is a type of echocardiography (echo), a test that uses sound waves to create high-quality moving pictures of the heart and its blood vessels. Echo shows the size and shape of the heart and how well the heart chambers and valves are working.
Cardiac Imaging Tests Beget More Tests, but No Benefit (Michael O'Riordan, Medscape, 2-10-14). See Nonivasive heart imaging tests lead to invasive tests but not to better outcomes (Gary Schwitzer, HealthNewsReview, 2-22-14) Researchers found that "noninvasive cardiac imaging actually led to a lot of invasive tests. The hospitals that do more noninvasive imaging do more invasive angiography. But none of this results in better outcomes."

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CPR (cardiopulmonary resuscitation), yes or no?

Is it a heart attack or cardiac arrest--understand the difference!


A heart attack is a circulation problem.

Cardiac arrest is an electrical problem.

In a heart attack, the person might experience radiating pain, shortness of breath, feel faint or become sweaty. 

In cardiac arrest, the event will be sudden—the person's heart will stop and you will not be able to detect a pulse. They will also become faint unconscious and stop breathing.

CPR is appropriate only for cardiac arrest. 

      ---Know the signs and save a life (UC Health)

Heart Attack, Cardiac Arrest, Heart Failure—What's the Difference? (Cedars-Sinai Staff) A clear explanation (here, in brief only):

     "During a heart attack, blood flow to the heart is blocked, often by a blood clot or a buildup of plaque in the arteries. Since the heart muscle needs oxygen to survive, when blood flow is blocked, the muscle begins to die. This is why heart attack sufferers need to be rushed into surgery to resolve the obstruction and restore blood flow....During a heart attack, you may feel pain in the middle of the chest that can spread to the back, jaw, or arms." You do NOT do CPR for a heart attack.

     "In cardiac arrest, the heart stops beating and needs to be restarted." Call 911 immediately. This is the only time when CPR is appropriate, and CPR should be followed immediately by defibrillation. Using CPR and an automated external defibrillator (AED) can improve the survival rate over CPR alone by 23%.) "Cardiac arrest can lead to death within minutes if not treated. Symptoms of cardiac arrest include dizziness, loss of consciousness, and shortness of breath. Within seconds of cardiac arrest, a person will become unresponsive and have trouble breathing."

      "Heart failure occurs when the heart muscle fails to pump as much blood as the body needs. It is usually a long-term, chronic condition, but it may come on suddenly."


• ****What Doctors Know About CPR Dr. Nathan Gray, a palliative care physician at Duke University School of Medicine, wrote and illustrated this excellent graphic piece about the realities of cardiopulmonary resuscitation, which is "must reading" before preparing an advance directive. On TV, chest compressions are enough to bring someone back to life. The truth is more complicated.
     "Only about 1 in 5 who receive CPR will leave the hospital alive. [Some assign even lower chances.]
     Only 1 in 10 elderly patients receiving CPR will be alive a year later.
     In real life, the ritual will save some, but for the majority who receive it, CPR will be their last experience. The chance of surviving cardiac arrest outside a hospital is slight, and that's ONLY with the rapid arrival of a team with an automated external defibrillator (AED).
     "And in the late stages of many illnesses, CPR success can be dismally rare. Odds of survival in illnesses like advanced cancer and organ failure may be less than 2 percent." Gray shows a Code Blue being called, the mechanics and impersonality of the process and the statistics showing how few people actually survive intact. “Until you witness it in person it can be hard to capture the inhumanity of our medical routine,” he writes. He urges the medical community to not let technology interfere with its humanity.' CPR "was never meant to be applied to everyone. CPR cannot reverse the process of normal death from organ failure, cancer, or dementia. In these situations, it can be terribly ineffective."

    "Rarely do TV dramas show the aftermath of broken bones, difficult recovery, and brain injury that can be left when CPR works."

• Nevertheless, I leave this note, just in case: How is CPR different for children and adults?
When administering CPR to adults, responders tilt the head back, pinch the nose shut, and provide two full breaths.
In the case of pediatric patients, the process remains similar, but the breaths are administered more gently, maintaining a ratio of 30 compressions to 2 breaths.

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The heart-stopping reality of cardiac arrest (Charlotte Huff, Mosaic, 8-13-19) Cardiac arrest is usually deadly, even it happens in well-equipped, well-staffed hospitals. Researchers are trying to understand how best to help more people survive and recover.
To Code or Not To Code - Considerations and Consequences (Alan C. Horowitz, Assistant Regional Counsel, HHS, PDF) This paper on the legal aspects and ramifications of performing - or withdrawing and withholding CPR-- addresses the reality that health care professionals do not always honor (or may not be aware of) a patient's DNR orders. They are more likely to heed Physician Orders for Life-Sustaining Treatment (POLST). See section on Physicians' or medical order for life sustaining treatment (known by different names in different states and abbreviated: MOLST, MOST, POLST, POST, COLST or TPOPP).

•  Among choices listed in documents about end-of-life wishes this often comes first:


The choices in Maryland are, if cardiac and/or pulmonary arrest occurs, whether to conduct CPR or not, if the patient's medical situation calls for it;  whether or not to intubate (DNI meaning Do Not Intubate); whether to provide  limited ventilatory support with CPAP or BiPAP (far less invasive), or whether simply to allow natural death to occur ("do not resuscitate," or DNR, and "do not intubate" or DNI).

     "The American Heart Association reports that conventional CPR can cause fracturing of ribs and/or the breastbone (sternum) in at least one third of cases. However, they also report that "the chance of surviving an out-of-hospital cardiac arrest is near zero for a victim who does not immediately receive high-quality chest compressions...followed by additional therapy within minutes."~ I've quoted from Everplans on the risks.

 • Advance Care Directives and the Person with Dementia (Fran Myers, founder and  executive director of Advance Care Advocate website) Read and follow the instructions for making multiple copies of a Do Not Resuscitate order. Without such an order, CPR will be started by the first responders if there is no pulse or breathing. It is the law. CPR is a very aggressive procedure. It is not often successful in the older patient and should not be done on anyone for whom a decision has been made to avoid it.

Videos On End-Of-Life Choices Ease Tough Conversation (Ina Jaffe, Shots, NPR, 3-29-15) It begins: "You're being shown this video because you have an illness that cannot be cured." Then, in an undramatic fashion, it shows what's involved in CPR, explains what it's like to be on a ventilator, and shows patients in an intensive care unit hooked up to multiple tubes. "You can see what's really going to be done to you," says Katakura. And you can decide not to have it done. The video explains that you can choose life-prolonging care, limited medical care, or comfort care.
The Trauma of Witnessing CPR (Amanda J. Calhoun, MedPage Today, 1-19-23) Nothing really prepares you for CPR, even if you're certified. "Real-life CPR is not light and glamorous like the movies may portray it. It's exhausting and forceful, violent even -- enough to break ribs opens in a new tab or window. The first time I did CPR, on a frail, elderly man who'd collapsed in the street, his chest gave way with a cracking sound that made me sick. Performing CPR is gut-wrenching and terrifying, and witnessing it is no better."

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End-Of-Life Advice: More Than 500,000 Chat On Medicare’s Dime (JoNel Aleccia, KHN, 8-14-17) The 90-year-old woman in the San Diego-area nursing home was quite clear, said Dr. Karl Steinberg. She didn’t want aggressive measures to prolong her life. If her heart stopped, she didn’t want CPR. But when Steinberg, a palliative care physician, relayed those wishes to the woman’s daughter, the younger woman would have none of it. ... Steinberg used an increasingly popular tool to resolve the impasse last month. He brought mother and daughter together for an advance-care planning session, an end-of-life consultation that’s now being paid for by Medicare. In 2016, the first year health care providers were allowed to bill for the service, nearly 575,000 Medicare beneficiaries took part in the conversations, new federal data obtained by Kaiser Health News show.

CPR, by Default (Paula Span, New Old Age, NY Times, 1-31-2020) When very old patients suffer cardiac arrest, doctors usually tried to revive them — even if they were already near death. Despite dismal survival rates — already reported in the medical literature, though probably not widely understood by the public — often health care professionals support resuscitation anyway. "Because do-not-resuscitate orders apply only in hospitals, states began adopting non-hospital D.N.R. policies in the 1990s. But there is a newer and more comprehensive document, covering a variety of health care choices beyond resuscitation and carrying legal weight in any setting, called a Polst" (short for “physician orders for life-sustaining treatment”), a MOLST – medical order for life-sustaining treatment, and several other terms, varying by state See section on Physicians' or medical order for life sustaining treatment (known by different names in different states and abbreviated: MOLST, MOST, POLST, POST, COLST or TPOPP)..

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Preventing or surviving myocardial infarction (MI, or heart attacks)

 A heart attack is a circulation problem.

Cardiac arrest is an electrical problem.

CPR is appropriate only for cardiac arrest.

What to do if someone is having a heart attack, whether it's you or someone else (Mayo Clinic)
Heart Failure: Causes and symptoms, diagnosis and treatment (Mayo Clinic)
The Major Differences Between a Heart Attack and Heart Failure (Michael Dreis, GoodRx Health, 7-14-21) Lots of good explanations on the GoodRx site.
Never Ignore These 11 Heart Symptoms

   1. Chest discomfort.

   2. Nausea, indigestion, heartburn, or stomach pain.

   3. Pain that spreads to the arm.

   4. Feeling dizzy or lightheaded.

   5. Throat or jaw pain.

   6. Getting easily exhausted.

   7. Snoring.

   8. Sweating.

   9. A cough that won't quit.

  10. Swollen legs, feet, and ankles.

  11. Irregular heart beat.
The heart-stopping reality of cardiac arrest (Charlotte Huff, Mosaic, 8-13-19) Cardiac arrests are usually deadly, even when they happen in well-equipped, well-staffed hospitals. So researchers are trying to understand how best to help more people survive and recover.
10 Ways to Lower Your Risk of Heart Failure (Amanda Gardner, WebMD, 6-8-21)

  1. Stay active

  2. Don't just sit there.

  3. Don't just sit there.

  4. Treat heart and other conditions.

  5. Don't smoke.

  6. Eat right.

  7. Limit alcohol.

  8. Lose weight if you need to.

  9. Limit stress.

 10. Get a good night's sleep. Ask your doctor about a CPAP device if you experience sleep apnea.
Bystander CPR in the COVID Era: Risk Too Low to Worry About (Nicole Lou, MedPage Today, 6-5-2020) Don't waste time putting on personal protective equipment (PPE), group suggests. Most important is rapid identification of cardiac arrest and immediately proceeding to chest compressions and use of a defibrillator.

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A Sea Change in Treating Heart Attacks (Gina Kolata, NY Times, 6-19-15). The death rate from coronary heart disease has dropped 38 percent in a decade. One reason is that hospitals rich and poor have streamlined emergency treatment. "The National Heart, Lung and Blood Institute, the primary federal agency that funds heart research, says this decline has been spurred by better control of cholesterol and blood pressure, reduced smoking rates, improved medical treatments — and faster care of people in the throes of a heart attack." Based on detailed analysis of the holdups in treating patients and a nationwide campaign led by the American College of Cardiology and the American Heart Association, "Hospitals across the country have adopted common-sense steps that include having paramedics transmit electrocardiogram readings directly from ambulances to emergency rooms and summoning medical teams with a single call that sets off all beepers at once."

       Also in this article: a clear explanation of how the heart works or fails to work. One letter to the editor also praised a broad-based effort to educate people on heart attack symptoms, so that more people know that you don’t have to have crushing chest pain to be experiencing a heart attack -- that less recognized symptoms like jaw and shoulder pain can be symptoms. Other stories in the Mending Hearts series:
---Putting Stents to the Test (Kolata, NY Times, 6-22-15)
---Medical Mysteries of the Heart (Editorial Board, NY Times, 7-3-15)
---New Alternatives to Statins Add to a Quandary on Cholesterol (Kolata, NY Times, 8-29-15)
---Blood Pressure, the Mystery Number (Kolata, NY Times, 6-23-15)
---Blood Pressure, a Reading With a Habit of Straying (Kolata, NY Times, 11-30-15)
---Data on Benefits of Lower Blood Pressure Brings Clarity for Doctors and Patients (Kolata, NY Times, 11-9-15)
---F.D.A. Approves Repatha, a Second Drug for Cholesterol in a Potent New Class (Kolata, NY Times, 8-27-15) See also FDA Approves Evolocumab (Repatha) to Prevent CV Events (Megan Brooks, Medscape, 12-1-17) "After priority review, the US Food and Drug Administration (FDA) has approved a supplemental application for evolocumab (Repatha, Amgen), making it the first proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor indicated to prevent MI, stroke, and coronary revascularization in adults with established cardiovascular disease (CVD). The FDA also approved evolocumab as an adjunct to diet, alone or in combination with other lipid-lowering therapies such as statins, for the treatment of adults with primary hyperlipidemia to reduce LDL cholesterol."
---Building a Better Valve (Kolata, NYTimes, 6-20-15) A new approach to replacing narrowed heart valves allows older, sicker, frailer patients to survive treatment.
---A New, Life-or-Death Approach to Funding Heart Research (Kolata, NY Times, 10-16-15)
Fact Check: NY Times Heart Disease Series Gets It Right-- Mostly ( Larry Husten, Forbes, 6-24-15)

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How Poetry Broke My Heart...Heart Attacks That Weren't Quite (Cortney Davis, Pulse, 5-27-22) There's much to discover about Takotsubo cardiomyopathy--why it happens mostly to women, why it resolves, what might trigger it again. The best advice is not to do what you were doing when you felt that first chest pain, that first hint of a broken heart.
Beware the Beer Belly (Nicholas Bakalar, Well, NY Times, 11-10-15) "It has been known for some time that having an “apple” shape increases the risk for disease and death. But the new study found that a man of normal B.M.I. with an abnormally large belly has an 87 percent higher risk for death than a man with the same B.M.I. but a normal waist-to-hip ratio. Pot-bellied women of normal B.M.I. have a 48 percent higher risk than women with normal B.M.I. and normal belly fat." Moreover, "“People with normal weight according to B.M.I. can’t be reassured that they don’t have any fat-related health issues,” said the senior author, Dr. Francisco Lopez-Jimenez, a professor of medicine at the Mayo Clinic. “Having a normal weight is not enough. It’s good only if the distribution of fat is healthy.
Time Is Muscle: Understanding Heart Attacks (NY Times graphic, 6-20-15) Graphic shows what a heart attack is, and how a heart attack is treated. In treating heart attacks, doctors often say that “time is muscle.” Quick diagnosis and treatment can save lives and reduce or prevent damage to the heart.

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CDC: One-Fourth of Heart Attack and Stroke Deaths Preventable (Scott Hensley, Shots, Health News from NPR, 9-3-13)
Division for Heart Disease and Stroke Prevention (Centers for Disease Control and Prevention, CDC)
Interactive Atlas of Heart Disease and Stroke
My Telltale Heart (Robert G. Kaiser, Washington Post, 2-29-04) "It's a horror story, all right. One moment, your life is normal -- endless. The next, a surgeon saws open your chest, freezes your brain and scrambles to keep you alive, literally holding your heart. "
Depression Among Heart Attack Survivors Can Be Deadly, Yet Is Often Ignored (Liz Szabo, Kaiser Health News, 7-20-17) One in 5 heart attack patients suffers from severe depression, yet many get little or no treatment that could ease their suffering or save their lives.
Hearts Get 'Younger,' Even At Middle Age, With Exercise (Patti Neighmond, Morning Edition, NPR, 3-12-18) Think of the heart muscle as a rubber band, says sports cardiologist Ben Levine. "In the beginning, the rubber band is flexible and pliable. But put it in a drawer for 20 years and it will emerge dry and brittle. That's what happens to the heart and blood vessels," he says. And down the road, that sort of stiffness can get worse, he notes, leading to the breathlessness and other symptoms of heart failure." In a study that compared the effects of two years of exercise in middle-aged people who had been mostly sedentary but otherwise health. Among those who did mild exercise, the heart didn't change. Among those who did interval training— short bursts of high-intensity exercise followed by a few minutes of rest (4x4 intervals)— "their hearts processed oxygen more efficiently and were notably less stiff." They got stronger and fitter.
Study: Waltzing Helps Mend Hearts (Marilynne Marchione, AP, 11-12-06, in Wash Post) "proved to be just as effective as bicycle and treadmill training for improving exercise capacity in a study of 110 heart failure patients. Dancers also reported slightly more improvement in sleep, mood, and the ability to do hobbies, do housework and have sex than the others."
Heart attack risk rises after anger outbursts (Catharine Paddock, Medical News Today, 3-4-14) Harvard researchers who analyzed decades of evidence on links between anger and cardiovascular events, concluded that in the 2 hours following an outburst of anger, there is a higher risk of heart attack, stroke or other cardiovascular event.
Higher B.M.I. in Teenagers Tied to Heart Risks Later (Nicholas Bakalar, Ask Well, NY Times, 4-15-16)

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The Heart Disease Conundrum (Sandeep Jauhar, NY Times, 11-28-15) SOUTH ASIANS today account for more than half of the world’s cardiac patients. The NIH has started a Framingham-type study (Mediators of Atherosclerosis in South Asians Living in America, or Masala), enrolling about 900 South Asian men and women in two large metropolitan areas, the San Francisco Bay Area and Chicago. Researchers are focusing on novel risk factors, including malignant forms of cholesterol (previous research has suggested that South Asians may have smaller and denser cholesterol particles that are more prone to causing hardening of the arteries), as well as other social, cultural and genetic determinants.
10 Ways to Lower Cholesterol Without Statins (Charlotte Libov, NewsMax, 11-14-13)
Raising ‘good’ cholesterol doesn’t protect against heart disease after all, study finds ( Damian Garde, Stat News, 10-31-16) "HDL has been thought to lower cardiovascular risk by cleansing the bloodstream of “bad” cholesterol and scrubbing the inner walls of blood vessels, so your levels of HDL were thought to predict your risk of heart attack or stroke. But this new data suggests HDL may just be a fatty substance along for the ride." The study, published in the Journal of the American College of Cardiology, will sound familiar to the drug industry, which has repeatedly failed to design a pill that might improve patients’ lives by increasing HDL. “It’s not just [about] increasing HDL; it might be that only a specific population will respond to that increase positively.”

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Stroke (or cerebrovascular accident, CVA):

Causes, prevention, rehabilitation, and recovery

See also Transient ischemic attack (TIA)

Suspect a stroke is happening?


Ischemic strokes occur when blood flow to the brain is blocked (usually by a blood clot) and part of the brain becomes deprived of oxygen.
Hemorrhagic strokes occur when a weakened blood vessel ruptures. Two types of weakened blood vessels usually cause hemorrhagic stroke: aneurysms and arteriovenous malformations(AVMs). An aneurysm bursts, or a weakened blood vessel in the brain leaks into the brain.

What happens during a stroke? (Vaibhav Goswami, TedEd). Excellent short video illustrating and explaining what happens in a stroke and what to do (VERY QUICKLY: Call 911).
Spot a stroke F.A.S.T. (American Stroke Association and American Heart Association)
FACE drooping, ARM weakness, SPEECH difficulty, Time to call 911.
Face Drooping – Does one side of the face droop or is it numb? Ask the person to smile. Is the person's smile uneven?
Arm Weakness – Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
Speech Difficulty – Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence, like "The sky is blue." Is the sentence repeated correctly?
Time to call 9-1-1 – If someone shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get the person to the hospital immediately. Check the time so you'll know when the first symptoms appeared.


Beyond F.A.S.T. – Other Symptoms You Should Know
---Sudden NUMBNESS or weakness of face, arm, or leg, especially on one side of the body
---Sudden CONFUSION, trouble speaking or understanding speech
---Sudden TROUBLE SEEING in one or both eyes
---Sudden TROUBLE WALKING, dizziness, loss of balance or coordination
---Sudden SEVERE HEADACHE with no known cause.

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Stroke (NY State Dept of Health fact sheet). Reduce stroke risk by reducing risk factors: high blood pressure, carotid or coronary artery disease, atrial fibrillation (irregular heart beat), diabetes, tobacco use, and elevated levels of cholesterol, excessive alcohol use, and (risk factors that can't be changed:) prior transient ischemic accident (TIA) or previous stroke, age, genetic heritage/family history, race (African Americans are at much greater risk, partly because of high blood pressure, diabetes, and obesity). Fatty deposits in blood vessels cause the majority of stroke cases. High blood pressure is the leading cause of stroke, according to the American Stroke Association. "Stroke is more common in men than in women. In most age groups, more men than women will have a stroke in a given year. However, more than half of total stroke deaths occur in women. At all ages, more women than men die of stroke. Use of birth control pills and pregnancy pose special stroke risks for women."
Stroke: Treating blood clots in the brain goes from fast to faster to fastest (Mandy Erickson, Stanford Medicine, Summer 2019) “During a stroke, 1.9 million neurons die every minute. When we are able to administer tPA quickly, that translates into saved neurons, saved independence and saved health care costs.”

     The rapid stroke protocol at the bustling emergency department got its start at Stanford’s Clinical Excellence Research Center (CERC). Stanford’s new door-to-needle protocol was inspired by a stroke treatment innovation at Helsinki University Central Hospital; the CERC fellows uncovered it in a Scandinavian medical journal. In the Helsinki hospital, staff reduced their average time from nearly two hours to less than 20 minutes, largely by eliminating unnecessary steps and starting evaluations while stroke patients were traveling to the hospital.

     “There was a lot of resistance initially because we were changing people’s habits.” ...A little competition helped drive the numbers lower: The stroke team started issuing buttons that display the minutes it took from a patient’s arrival to the administration of tPA. If the door-to-needle time is impressive, under 30 minutes or so, stroke code team members pin them to their white coats and badge lanyards.     Must read if you are a potential stroke victim.

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Stroke, information about (National Institute of Neurological Disorders and Stroke, or NINDS).
Stroke warning signs and symptoms (American Stroke Association)
Stroke treatment (American Stroke Association)
Next Step Program (American Stroke Foundation) Aimed at maintaining and improving health, wellness, and participation for individuals who have moved beyond their stroke and wish to take their next steps in life. Targeted activities in four areas: Communication, Health Behaviors, Communication, Life After Stroke, and Physical Fitness.
Stroke (Medline Plus's informative site)
Patient Voices: Stroke (NY Times, 4-14-08) By temporarily severing the brain's blood supply and damaging the body's vital control centers, a stroke can change every aspect of the sufferer's life. Here, in their own words, are the stories of people coping with the aftermath of stroke.
NINDS clinical trial
What Is Stroke? (National STROKE Association)
Stroke (PubMedHealth fact sheet)
What happens during a stroke (Jacque Wilson, CNN, well illustrated, 2-17-13)
What Is Stroke? (National STROKE Association)
Stroke (NCBI)
Stroke Caregivers Handbook (Joyce Dreslin, StrokeSAFE, read online, or download the PDF
Recovery After Stroke: Coping with Emotions (National Stroke Association)
Recovering After Stroke (MedlinePlus)
Stroke Rehabilitation: What to Expect After a Stroke (WebMD)
Relationships; Families as Victims of Stroke (Georgia Dullea, NY Times, Style, 5-9-83)
Therapeutic Writing: Life Stories Punctuated by Healing (Carol Keegan, stroke survivor, Stroke Connection, Spring 2013)
Fact Sheet: Coping psychologically after a stroke (PubMed Health, 12-21-12)

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Men without caregivers at greater risk for nursing home placement following stroke (Liz Seegert, Covering Health, AHCJ, 11-29-17) Male stroke survivors over age 65 may be three times as likely to end up in a nursing home within five years if they lack a caregiver compared with those who have someone to assist them, according to a new study. A similar risk was not seen in female stroke survivors. The findings suggest that clinicians should remain aware of the critical role of caregivers in helping older adults remain independent.
Tell Me Everything You Don't Remember: The Stroke That Changed My Life by Christine Hyung-Oak Lee, whose story on Buzzfeed, I Had a Stroke at 33 (9-21-14) went viral. "On New Year's Eve 2007, a clot blocked one half of my brain from the other. My reality would never be the same again."
• The REGARDS Study (Reasons for Geographical and Racial Differences in Stroke, REGARDS study),sponsored by the National Institutes of Health (NIH), aims to better understand why Southerners and Black Americans have higher rates of stroke and related diseases, which affect brain health, than other Americans. By design, REGARDS has an oversampling of Black Americans and residents of the so-called “stroke belt” in the southeastern U.S. ― including Alabama, Arkansas, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina and Tennessee.   This national study focuses on learning more about the factors that increase a person's risk of having a stroke. Much to learn here.
My Invincible Summer (Diana Hardeman, Health Care in America, 12-22-16) "You’ve likely heard me describe my summer as a Netflix murder mystery set in a small town. In this series, I was the victim, the detective, and then the judge. The killer, as you know, was a stroke — my second stroke in the past three years. Luckily, it was just an attempted murder....I wanted to show you how painstaking every decision was, how necessary it is to be your own advocate, and how medicine can sometimes be a mystery."
Bad Year for Boars (Diana Hardeman, Medium, 12-30-13) "I’m a 30-year-old woman. I’m taller than your average girl, probably thinner than your average girl, and more active than your average girl. Yeah I run an ice cream business for a living, but like to think I’m healthier than your average girl, too. No prior medical history. Nothing....On day 3 we still didn't know the cause of the stroke."

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New Research on Stroke Rehabilitation and Recovery (listen online to Diane Rehm show, WAMU-FM, host Susan Page, 9-26-13) or read transcript ). Guests Peter Turkeltaub, Alex Dromerick, and Audrey Holland. There are two kinds of strokes; one kind is a bleeding event in the brain; a blood vessel bursts and blood inside the brain causes damage; the more common kind is a blood clot that prevents blood flow to a portion of the brain, which, deprived of enough blood or oxygen, is damaged. The larger the stroke, the less likely you are to survive; you are also more likely to survive the second type, from a blood clot that prevents flow--get to an emergency room immediately! Excellent program--listen or read!
Hidden Stroke Victims: The Young (Anna Gorman, Kaiser Health News, 8-24-16) "The headaches were excruciating and wouldn’t go away. Her doctor said they were migraines. Then, one morning a few weeks later, Jamie Hancock stood up from the couch and discovered she couldn’t move the right side of her body. When she spoke, her speech was slurred." The 32-year-old was having a stroke.
My Beautiful Broken Brain (documentary, Netflix streaming) She was social, articulate, capable. Now she's relearning the alphabet. With her post-stroke brain, who will she become? The film details the experience of Dutch-French filmmaker Lotje Sodderland, after she suffers a hemorrhagic stroke and embarks on a journey of rehabilitation and recovery.
Resources for Caregivers of Stroke Survivors (Very Well)
CDC: One-Fourth Of Heart Attack And Stroke Deaths Preventable (Scott Hensley, Shots, Health News from NPR, 9-3-13)
Stroke Risk Scorecard
Stroke Prevention (National Stroke Association)
Researchers identify new genetic stroke risk factors (Liz Seegert, Covering Health, AHCJ, 4-5-18)
Men without caregivers at greater risk for nursing home placement following stroke (Liz Seegert, Covering Health, AHCJ, 11-29-17)
Nearly All Strokes Globally Have Avoidable Element (Gloria Rothenberg,Medpage Today 6-30-16) Behaviors, metabolic factors, and air pollution found key contributors. "Globally, stroke is almost entirely caused by modifiable risk factors, with air pollution emerging as a significant contributor....Potentially modifiable behaviors -- smoking, poor diet, and physical inactivity -- contributed to 74.2% of strokes...Metabolic factors -- high systolic blood pressure, high body mass index (BMI), high fasting plasma glucose, high total cholesterol, and low glomerular filtration rate -- were attributable for 72.4% ...The five risk factors associated with the strongest impact on disability-adjusted life years in developed countries were high systolic blood pressure, high BMI, diet low in fruits, diet low in vegetables, and smoking." And stop drinking sugary drinks! See Strokes Information Center (Medpage Today)

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Stroke rates appear to be rising steadily in young adults (Jia Naqvi, NY Times, 4-15-17) Although overall mortality rates from strokes have significantly decreased in last 50 years, hospitalization rates for stroke nearly doubled for men between ages 18 and 44, from 1995 through 2012. "The likelihood of having three or more of five common risk factors — diabetes, hypertension, lipid disorders, obesity and tobacco use — doubled in men and women hospitalized for acute ischemic strokes." Prescription: eat your fruits and veggies, be physically active, maintain a healthy weight, don't smoke!
Empathy is a long climb (Fred Clark, Patheos, 1-3-13) Senator Fred Kirk decided "to take a closer look at funding of the Illinois Medicaid program for those with have no income who suffer a stroke, he said. In general, a person on Medicaid in Illinois would be allowed 11 rehab visits, he said. “Had I been limited to that, I would have had no chance to recover like I did,” Kirk said [after suffering a stroke]. “So unlike before suffering the stroke, I’m much more focused on Medicaid and what my fellow citizens face.”
How serious is a mild narrowing of the carotid artery? (Heart Health, Harvard Health, 3-30-21) Even if it doesn't progress, mild narrowing is a sign of early blood vessel disease and calls for preventive measures. "The presence of atherosclerotic plaque in the carotid artery is a predictor for future risk of cardiovascular disease. But when the amount is not severe, the focus is on drug treatment, not surgery. Progression is associated with a number of factors, including diabetes and smoking. The initial amount of blockage is important, too. Cholesterol-lowering medications, aspirin, and blood pressure control (optimally less than 130/80 mm Hg) are recommended for all men with any significant carotid artery disease."
The Best News About Stroke Prevention...Chocolate (Heidi Moawad, MD, on VeryWell, 7-27-16). Both milk chocolate and dark chocolate (both made from cocoa) provide some protection against stroke; white chocolate does not contain the same cocoa element. Nor do foods made with "chocolate flavoring" and imitation chocolate, so read the label! In the study group, the highest amount of chocolate consumed was "the equivalent of eating between 10 chocolate chips per day up to one regular size chocolate bar, or a few snack size chocolate bars per day."
National Aphasia Association
Brain stimulation helps stroke recovery (Nick Collins, The Telegraph, UK 11-17-13) Early treatment with magnets could help stroke sufferers recover their ability to speak, according to a new study.
The gray beyond: A family copes after tragedy (Keith Alexander, Linda Davidson and Sandi Moynihan, Washington Post, 7-27-13) "Thomas “TC” Maslin easily reads to himself the local newspaper or latest issue of the Economist. Reading aloud a simple children’s book is another story.

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Jill Bolte Taylor's "My stroke of insight. Fascinating, informative, inspirational TED talk (video), partly about how the brain works. Taylor (whose brother has schizophrenia) got a research opportunity few brain scientists would wish for: She had a massive stroke, and watched as her brain functions -- motion, speech, self-awareness -- shut down one by one. You can also read her book: My Stroke of Insight: A Brain Scientist's Personal Journey (a story that provides hope for the brain-injured, not just those who have had a stroke, as this young brain scientist did)
After the Stroke by May Sarton. The poet's journal about recovering from a mild stroke when she is in her seventies.
The Diving Bell and the Butterfly: A Memoir of Life in Death by Jean-Dominique Bauby. Immobilized by a stroke, the narrator discovers the life of the unfettered imagination.
Remind Me Who I Am, Again by Linda Grant. About how her mother's vascular dementia (brought on by small strokes) exacerbates Grant's troubled relationship with the woman.

My Mother’s Stroke (Joyce Wadler, NY Times, 10-24-14) An 87-year-old woman’s carefully planned exit is knocked off course by a stroke.
My Mother’s Make-Believe Boyfriend (Joyce Wadler, NY Times, 4-21-16). "My mother’s brain has been melting since she had a stroke, and now the major territories include pastrami, kittens and a man in her nursing home. Hunks of her brain are gone, and she is still trying to gaslight her daughter...What do you do when your mother spends half her time on another planet, a snowbird of dementia?" Joyce Wadler's humor (I Was Misinformed) may help carry you through. See also Dealing With Ma’s Dementia, and That Trip Out West (Wadler, NY Times, 10-6-16)
Texas Tech Health Sciences Center’s STAR Program Offers Musical Therapy For Victims Of Aphasia (print and audio, Ariel Walden, KFYO News Talk, 7-25-13)
Oklahoma State University-Tulsa's aphasia camp is hearing kind words (Shannon Muchmore, Tulsa World, McClatchy-Tribune Information Services, 7-29-13)
Woman survives being 'locked in' after a stroke (MedStar National Rehabilitation Network). When she came to MedStar National Rehabilitation Hospital for therapy, she was in a ‘locked in’ state, meaning she could understand what you might be saying to her, but the words wouldn’t come out at all. Her rare ‘locked in’ state also affected all of her motor skills.
Fact Sheet: Coping psychologically after a stroke (PubMed Health, 12-21-12)
Children Don’t Have Strokes? Just Ask Jared (Jonathan Dienst, writing about his son, Jared, NY Times, 1-18-10)

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Act FAST. Time lost is brain lost. FAST is an acronym to help you remember and recognize the signs of stroke:
Face drooping– Does one side of the face droop or is it numb?
Arm weakness – can they raise both of their arms above their head? Does one arm drift downward?
Speech difficulty– is their speech slurred? are they hard to understand?
Time to call 9-1-1 and get them to the hospital immediately. Do not delay.

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Transient ischemic attack (TIA)


How to tell if you've had a ministroke
Common warning signs include sudden onset of:

Weakness, numbness or paralysis on one side of your body
Slurred speech or difficulty understanding others
Blindness in one or both eyes
Severe headache with no apparent cause
~Source: American Stroke Association


Adults who get shingles after 40 don't have an increased risk of stroke. But along with those who had shingles before 40, they do have a higher risk of heart attack and "transient ischemic attack" (TIA), sometimes called a mini-stroke, the study authors said."
Transient ischemic attack (TIA) (Mayo Clinic) "A transient ischemic attack (TIA) is a temporary period of symptoms similar to those of a stroke. A TIA usually lasts only a few minutes and doesn't cause permanent damage. Often called a ministroke, a transient ischemic attack may be a warning. About 1 in 3 people who have a transient ischemic attack will eventually have a stroke, with about half occurring within a year after the transient ischemic attack. A transient ischemic attack can serve as both a warning of a future stroke and an opportunity to prevent it....The signs and symptoms of a TIA resemble those found early in a stroke and may include sudden onset of:
---Weakness, numbness or paralysis in your face, arm or leg, typically on one side of your body
---Slurred or garbled speech or difficulty understanding others
---Blindness in one or both eyes or double vision
---Vertigo or loss of balance or coordination
TIA (Transient Ischemic Attack) (American Stroke Association) Some call it a mini-stroke, but it's really a major warning. Call 9-1-1. TIA is a temporary blockage of blood flow to the brain. Since it doesn’t cause permanent damage, it’s often ignored. But this is a big mistake. TIAs may signal a full-blown stroke ahead.
Stroke Struck (Michael De Rosa) What happens when it feels almost like you are having a stroke, enough to keep you in the hospital overnight....
Transient Ischemic Attack (TIA, Mini-Stroke) (Benjamin Wedro, MD, FACEP, FAAEM, eMedicineHealth). Good Q&A and a section with patient comments on the experience.
What are the causes of a ministroke? (HealthLine)

---Blood clots are the leading cause of ministrokes. Other common causes of this condition include:
---hypertension, or high blood pressure
---atherosclerosis, or narrowed arteries caused by plaque buildup, in or around the brain
---carotid artery disease, which occurs when the internal or external carotid artery of the brain is blocked (usually caused by atherosclerosis)
---high cholesterol.

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Atrial fibrillation, also called Afib or AF

Atrial Fibrillation: New Solutions for an Old Problem Andrea Cooley (DO, FACOS, board-certified cardiothoracic surgeon at the UT Health East Texas Cardiovascular Institute) presents a wonderfully clear explanation of how the heart works (or fails to), how atrial fibrillation (Afib) can lead to stroke, and what to do if you have Afib. An excellent illustrated  38-minute video explanation of how the heart works--or doesn't. 
Atrial fibrillation - Symptoms and causes (Mayo Clinic) Atrial fibrillation (A-fib) is an irregular and often very rapid heart rhythm (arrhythmia) that commonly causes poor blood flow and can lead to blood clots in the heart. A-fib increases the risk of stroke, heart failure and other heart-related complications.The heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles). This condition may have no symptoms, but when symptoms do appear they include palpitations, shortness of breath, and fatigue. Treatments include drugs, electrical shock (cardioversion), and minimally invasive surgery (ablation).
Atrial Fibrillation: Prevention, Treatment and Research (Johns Hopkins)

Valvular heart disease

Heart Valve Disease (National Heart, Lung and Blood Institute, illustrated) The heart has four valves: the tricuspid, pulmonary, mitral, and aortic valves. Birth defects, age-related changes, infections, or other conditions can cause one or more of your heart valves to not open fully or to let blood leak back into the heart chambers. This can make your heart work harder and affect its ability to pump blood. An excellent overview of what heart valve disease is, what else it's called, screening and prevention, signs, symptoms and complications, diagnosis, treatment, and living with the disease.
Novel technique reduces obstruction risk in heart valve replacement (National Heart, Lung and Blood Institute, 5-20-19)
NIH-developed technique prevents obstruction in heart valve replacement (National Heart, Lung and Blood Institute, 6-12-19) A novel technique has proven successful in preventing coronary artery obstruction during transcatheter aortic valve replacement (TAVR), a rare but often fatal complication. The BASILICA procedure shows successful results for some high-risk patients.
Mitral valve repair following heart attack may offer patients little to no benefit (National Heart, Lung and Blood Institute, 11-18-14) About one million Americans suffer heart attacks each year. Of these, about half are left with functional damage to the mitral valve due to the injury and changes to the heart muscle. This damage can result in leaks, causing a backflow of blood accompanied by symptoms such as shortness of breath, abnormal fatigue, and excess blood in the lungs. Doctors typically treat heart attack patients with this condition, called ischemic mitral regurgitation, by performing coronary artery bypass graft surgery, sometimes adding a procedure to repair the leaky mitral valve. Patients treated with both procedures versus the bypass graft alone showed no differences at one year in recovery from structural damage to the heart's left ventricle, nor in secondary measures such as heart failure, stroke, functional status or quality of life. These valves have tissue flaps that open and close with each heartbeat. The flaps make sure blood flows in the right direction through your heart's four chambers and to the rest of your body.
Living Healthy With Heart Valve Disease (Seconds Count, Society for Cardiovascular Angiography & Interventions, or SCAI) Heart valve disease often changes over time and can progress quickly with serious consequences. Early treatment of strep throat infection can reduce your chances of contracting rheumatic fever, which can cause your heart valves to thicken. Also, if you have heart valve disease and need to undergo surgical or dental procedures, talk to your doctor or dentist about taking antibiotics before the procedure.
Types of valve disease (Seconds Count, Society for Cardiovascular Angiography & Interventions, or SCAI) Acquired heart valve disease, Aortic Valve Disease (Aortic Valve Regurgitation, the tissue flaps don't close,which causes blood to leak back into the heart; Aortic Valve Stenosis; the tissue flaps don't open fully to allow enough blood to flow through); Mitral Valve Disease (again, MV regurgitation, where the tissue flaps don't close, and MV stenosis, when the mitral valve narrows); congenital valve disease; Tricuspid Atresia, Pulmonary Atresia, and Pulmonary Stenosis.
Treatment Options for Heart Valve Disease (Seconds Count)
Report of the NHLBI Working Group on Valvular Heart Disease (National Heart, Lung and Blood Institute, 11-14-05)
Tendyne: Mitral Valve Implant (95-second video-graphic shows how such an implant works--posted because my friend Sam had this done (and asked about pain on a scale of 1 to 10 said "40," which they didn't warn him about).

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Heart surgery

Open heart surgery, explained at MedlinePlus.
The Open Heart Companion: Preparation and Guidance for Open-Heart Surgery Recovery by Maggie Lichtenberg
Organ and tissue transplants. See also Donating your body or body parts
Recovering From Heart Surgery (For Heart Bypass, Heart Valve Surgery and other Open Heart Surgery Patients) (DVD, RecoverRite)
Opening My Heart: A Journey from Nurse to Patient and Back Again (about her own open heart surgery) by Tilda Shalof.
Heart surgery (overview, Texas Heart Institute)
At St. Luke’s in Houston, Patients Suffer as a Renowned Heart Transplant Program Loses Its Luster ( Charles Ornstein, ProPublica, and Mike Hixenbaugh, Houston Chronicle, 5-16-18) racking the Decline of a Historic Heart Transplant ProgramThe hospital and its legendary surgeon Denton Cooley performed some of the world’s first heart transplants back in the 1960s. In recent years, though, it has had some of the worst heart transplant outcomes in the country.
As Wait for New Heart Got Longer, Patient Grew Sicker (Mike Hixenbaugh, Houston Chronicle, and Charles Ornstein, ProPublica, 5-16-18) Baylor St. Luke’s in Houston was known for handling complex heart transplants. But when Travis Hogan was a patient there, he didn’t know that the program was undergoing a series of dramatic changes. He never got his heart.
Minimally invasive heart bypass surgery (Medline Plus)
What Is Coronary Artery Bypass Grafting? (National Heart, Lung, and Blood Institute, NHLBI)
Why Hospitals Need to Share Heart Surgery Success Rates (Catherine Roberts, Consumer Reports, 4-6-17) Consumers deserve full transparency about the performance of the hospitals they choose.
Cut to the Heart (PBS series on radical but promising new form of heart surgery)
• Nova has useful material online: Map of the Human Heart (images showing bloods flow path through the heart), Troubled Hearts (images, PBS, Nova)
DNA Links Deadly Germs, Tainted Heart Surgery Devices To German Factory (JoNel Aleccia, KHN News, 7-12-17) Heater-cooler devices made at the LivaNova PLC plant in Munich, Germany, were contaminated during production. Researchers also found that some hospital water systems and Maquet heater-coolers were contaminated, raising concerns about local contamination.
Treating a Sick Heart (PBS, Nova)
Narrating and imaging an aortic dissection (Edward Tufte)
Surgical corrective procedures for congenital heart disease (LearningRadiology)
The Richer You Are, the Better You May Do After Heart Surgery (Nicholas Bakalar, Well, NY Times, 10-20-15) They have found a relationship between income and survival, but that doesn't mean there is a causal effect.
More than half a million heart surgery patients at risk of deadly infection (Lena H. Sun, Washington Post, 10-13-16) "More than half a million patients who had open-heart surgery in the United States since 2012 could be at risk for a deadly bacterial infection linked to a device used during their operations, federal health officials said....The device in question is a piece of medical equipment known as a heater-cooler unit, an essential part of life-saving surgeries because they help keep a patient’s organs and circulating blood at a specific temperature during the operation....About 60 percent of these procedures use the German-made model that has been linked to the infections."
Heart Surgery, Unplugged (Jerome Groopman, New Yorker, 1-11-99). Making the coronary bypass safer, cheaper, and easier
Top-scoring hospitals for heart surgery in USA (Consumer Reports, June 2014)
Best Hospitals for Cardiology & Heart Surgery (U.S. News & World Report)
Mortality rates after surgery for congenital heart defects in children and surgeons' performance (J. Stark et al., Lancet, 18 March 2000.
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Heart disease in women

Heart Disease in Women (National Library of Medicine)
'Just A Little Heart Attack': PSA Sheds Light On The Number One Killer Of Women "While men often experience the "classic" symptom of chest pain, women's top symptoms are usually shortness of breath, weakness, fatigue, dizziness and nausea, according to the Harvard Medical School."
Anxiety in Women May Mask Heart Disease Symptoms, Researchers Say (HealthDay News, Medline Plus, 2-23-16) Women with an anxiety disorder may have less blood going to their heart when exercising, according to a new study -- and researchers suggest doctors may sometimes miss signs of heart disease in these women. ""If you're a woman and you say you're tired, short of breath, and really anxious about it, and you have no pre-existing heart disease, it's possible that doctors are confounding the two problems." Know the signs of a heart attack:
        The signs of a heart attack can be different for women than they are for men.
---Chest pain (heavy ache or pressure)
---Pain in your upper body (arms, neck, jaw, back or upper stomach)
---Shortness of breath
---Breaking out in a cold sweat
---Unusual or unexplained tiredness
---Feeling dizzy or light-headed
---Feeling sick to your stomach (nausea)

Heart health, women and the limits of exercise (Gretchen Reynolds, WaPo, 12-28-22) Sudden, unusual shortness of breath and profound fatigue are common among women experiencing a heart attack, as are chest pain or discomfort, upset stomach, and new pain in the back, neck or jaw.
More Evidence That Even 'Moderate' Exercise Helps Women's Hearts (HealthDay, 2-15-15) A few sweat-inducing workouts per week are enough to cut risks in middle age, study finds.

6 Symptoms of Women's Heart Attacks (Lisa Fields, WebMD -- symptoms for women often differ from symptoms for men, and more women die from heart attacks than from breast cancer).
Cardiac Rehab Improves Health, But Cost And Access Issues Complicate Success (Julie Appleby, Kaiser Health News, 8-31-16) In a medically supervised cardiac rehabilitation program you learn about exercise, diet and prescription drugs. "Despite evidence showing such programs substantially cut the risk of dying from another cardiac problem, improve quality of life and lower costs, fewer than one-third of patients whose conditions qualify for the rehab actually participate.... women and minorities, especially African Americans, have the lowest participation rates....Uninsured patients simply can’t afford cardiac rehab. And for those with some form of coverage, “the No. 1 barrier is the cost of the copayment, which is frustrating.”

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Managing cholesterol

(including 'The Statin Wars')

Get Your Cholesterol in Check (Knvul Sheikh, Well, NY Times, 1-31-24) It’s critical for preventing heart disease and other serious health problems. "Cholesterol gets a bad rap because there’s strong evidence linking higher levels to plaque buildup in the arteries and the hardening of blood vessel walls over time. In medical terms, this is called atherosclerosis. Eventually, the buildup can block blood flow to your heart, causing a heart attack. Pieces of plaque can also rupture and travel to other parts of your body, causing a stroke. Most people don’t have any symptoms until their arteries are already severely clogged. That’s why doctors look to cholesterol levels to catch and treat cardiovascular problems early."
Calculating (Measuring) Your Cholesterol Johns Hopkins' excellent explanation. "Cholesterol is a waxy substance that circulates through your body and takes part in some beneficial functions such as cell membrane health and brain function. Low-density lipoprotein (LDL) cholesterol is the garbage left behind after the beneficial cholesterol has been used....Cholesterol doesn’t float freely in the blood—it must be carried by lipoproteins, particles formed in the liver that are made of fat and protein. There are several types, including high-density lipoprotein (HDL), which helps remove cholesterol from the arteries and prevent fatty buildup..."
       "Not all LDL cholesterol is alike.  Nearly one in four people found to have LDL cholesterol in the “desirable” level through the traditional calculation method actually may have needed more aggressive treatment, according to a study at the Johns Hopkins University School of Medicine published in 2013 in the Journal of the American College of Cardiology. The newer way of calculating LDL cholesterol, which the same researchers reported in the Journal of the American Medical Association later that year, provides a more individual and accurate assessment of risks.
       The REGARDS study (2003-2007) was the first to find that lower HDL cholesterol levels only predicted increased cardiovascular disease risk for white adults. "It also expands on findings from other studies showing that high HDL cholesterol levels are not always associated with reduced cardiovascular events. The REGARDS analysis was the largest U.S. study to show that this was true for both Black and white adults, suggesting that higher than optimal amounts of “good” cholesterol may not provide cardiovascular benefits for either group."

       "A National Institutes of Health-supported study found that high-density lipoprotein (HDL) cholesterol, often called the “good cholesterol,” may not be as effective as scientists once believed in uniformly predicting cardiovascular disease risk among adults of different racial and ethnic backgrounds. See also Cholesterol: 5 Truths to Know (also Johns Hopkins)
Statins vs. supplements: New study finds one is 'vastly superior' to cut cholesterol (Allison Aubrey, Shots, Health News from NPR, 11-6-22) "What we found was that rosuvastatin lowered LDL cholesterol by almost 38% and that was vastly superior to placebo and any of the six supplements studied in the trial," study author Luke Laffin, M.D. of the Cleveland Clinic's Heart, Vascular & Thoracic Institute told NPR. He says this level of reduction is enough to lower the risk of heart attacks and strokes. The findings are published in the Journal of the American College of Cardiology.
SAMSON Pins Most Muscle Pain Experienced With Statins on the Nocebo Effect (John Mandrola, MD, Medscape, 11-15-2020) In blinded randomized controlled trials (RCTs), people taking statins have almost the same rates of minor adverse effects as those taking placebo. One explanation is the nocebo effect—when a negative expectation produces a negative outcome. "A novel randomized trial taking on a vexing issue around one of the world's most commonly prescribed medications has concluded that frequently intolerable statin side effects, such as muscle weakness or pain, are almost entirely a nocebo effect, the placebo effect's darker cousin. "The many patients who report such symptoms while taking statins are indeed probably feeling them, but they are a result of taking the pills rather than any pharmacologic effects, conclude researchers based on their 60-patient study, Self-Assessment Method for Statin Side-effects or Nocebo (SAMSON)."
2 Studies Back Guidelines for Wider Use of Statins (Andrew Pollack, NY Times, 7-14-15). See Health News Review of article (rating 5 stars out of 5) But read on.
Am I heading for a heart attack? (Dan Roberts, The Independent UK, 4-18-11). Roberts weighs the evidence-based pros and cons of taking statins when his cholesterol is high. (Scoring for cholesterol is different in Canada and the UK than in the U.S., so cholesterol numbers here might confuse U.S. readers)
The statin wars expose 2 factions in medicine (Saurabh Jha, Kevin MD, 9-30-16) The latest fight between orthodoxy and free inquiry is about the benefits and harms of statins for primary prevention, with various factions arguing about whether the benefits are real, the harms are exaggerated, etc. Both sides are right, neither is wrong, yet both are wrong. Is the role of medicine to heal the sick or to stop people from being sick? Neither question is easy to answer.
More People Should Get Statins, Report Says (Maggie Fox, NBC, 7-14-15) . See Health News Review (4 stars of 5). "NBC did a better job than the Times in answering the question about risks. NBC wrote that statins “can damage muscle in 5 to 15 percent of patients. In 2012, the Food and Drug Administration updated labeling on statins to include warnings about confusion and memory loss, elevated blood sugar leading to Type 2 diabetes, and muscle weakness.” This is a nice addition to the overall coverage of the new statin studies and a step we wish more reporters had taken."
Controversy Over Statins for Older Patients (in their 70s and 80s--Judith Graham, NY Ties, 10-22-13) There is "scarce scientific evidence supporting the use of statins by 70- or 80-year-olds without pre-existing cardiovascular disease," according to a study by AMDA, a professional group representing physicians working in nursing homes. Some doctors disagree, but "There is evidence of harm linked to statin use in seniors... including muscle aches, liver toxicity and gastrointestinal distress; growing evidence of impaired memory and a heightened risk of diabetes; and some evidence of an increased risk of cancer."

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Hypertension, blood pressure, and stress

Hypertension and cardiovascular disease (World Heart Federation)
Drug Test Spurs Frank Talk Between Hypertension Patients And Doctors (Blake Farmer, Nashville Public Radio and NPR, 4-18-18) There’s an irony at the heart of the treatment of high blood pressure. The malady itself often has no symptoms, yet the medicines to treat it — and to prevent a stroke or heart attack later — can make people feel crummy....Research shows roughly half of patients don’t take their high blood pressure medicine as they should, even though heart disease is the leading cause of death in America. For many unfortunate people, their first symptom of high blood pressure is a catastrophic cardiac event. That’s why hypertension is called the “silent killer.” A drug test is now available that can flag whether a patient is actually taking the prescribed medication.

Don’t Let New Blood Pressure Guidelines Raise Yours (H. Gilbert Welch, OpEd, NY Times, 11-15-17) "The new recommendation is principally in response to the results of a large, federally funded study called Sprint that was published in 2015 in The New England Journal of Medicine....The primary finding was that the lower target led to a 25 percent reduction in cardiovascular events — the combined rate of heart attacks, strokes, heart failures and cardiovascular deaths. [Etc.] Oh, and did I mention that to be eligible for Sprint, participants were required to be at higher-than-average risk for cardiovascular events?"
Take That Scary Hypertension News With a Grain of Salt (Faye Flam, Bloomberg, 11-17-17)
3 Things to Know About the Sprint Blood Pressure Trial (Harlan M. Krumholz, blog, NY Times, 11-9-15) “If you are age 50 or older, with a top blood pressure number between 130 and 180 ([as] measured in the study) and are either age 75 or older or have a high risk of stroke or heart or kidney disease, then you have a new option to consider.”
What the New Blood Pressure Guidelines Mean for You (Hallie Levine, Consumer Reports, 11-13-17) 'The percentage of Americans with high blood pressure jumped from 32 percent to 46 percent today, when the American Heart Association and the American College of Cardiology issued new guidelines for the condition. But that doesn't mean that all those people suddenly need to be on blood pressure medication, our experts say....“We now know that a blood pressure level between 130-139/80-89 doubles your risk of cardiovascular complications such as a heart attack compared to people whose blood pressure is under 120/80,” says Paul Whelton, M.D., lead author of the guidelines. That’s because damage to blood vessels begins as soon as blood pressure is elevated. For most people who find themselves in that range, however, changes in diet and exercise routine—not drugs—are what's needed to bring those numbers back down to normal.' Read this article!
Data on Benefits of Lower Blood Pressure Brings Clarity for Doctors and Patients (Gina Kolata NY Times, 11-9-15) Driving systolic blood pressure to levels far below what current guidelines recommend — less than 120 instead of 140 or 150 millimeters of mercury — can save lives and prevent heart disease and strokes. Prescribing drugs to lower hypertension can save lives and prevent heart failure. That study answers the questions posed in Blood Pressure, the Mystery Number (Gina Kolata, NY Times, 6-22-15) However, read the following:
Drugs Not Always Best for Mild High Blood Pressure? (Veronica Hackethal, MD, Medscape Medical News, 9-24-14) and read this, too:
Aiming for blood pressure targets lower than 140/90 mmHg is not beneficial (Arguedas JA, Perez MI, Wright JM. Cochrane report (evidence-based medicine), 7-8-09). Treating patients to lower than standard BP targets, ≤140-160/90-100 mmHg, does not reduce mortality or morbidity. Because guidelines are recommending even lower targets for diabetes mellitus and chronic renal disease, we are currently conducting systematic reviews in those groups of patients.
Blood pressure lowering drugs reduce stroke and heart attack in elderly people with hypertension (Musini VM, Tejani AM, Bassett K, Wright JM. Cochrane abstract. "Treating healthy persons (60 years or older) with moderate to severe systolic and/or diastolic hypertension reduces all cause mortality and cardiovascular morbidity and mortality. The decrease in all cause mortality was limited to persons 60 to 80 years of age."
The Economics & Politics of Drugs for Mild Hypertension (David Cundiff, co-author of the Cochrane systematic review, “Pharmacotherapy for Mild Hypertension, for HealthNewsReview, 11-4-13) "The Cochrane Collaboration’s Hypertension Group published a systematic review of drug treatment for mild hypertension in August 2012 showing no evidence that drugs benefit patients while about 11% have side effects severe enough to stop treatment. As coauthor of that review, I will comment on the economics, politics, regulatory intrigue, financial conflicts, and subsequent media coverage involved."

Why we're hardwired to hate uncertainty (Marc Lewis, The Guardian, 4-4-16) A new study shows that uncertainity is even more stressful than knowing something bad is definitely going to happen. But you can learn to live with it ‘There’s good evidence that gamblers are hooked, not by sure wins but by lucky wins, unpredictable good fortune.’

Making Art Will Lower Your Stress Level (Tom Jacobs, Pacific Standard, 6-16-16) A new study shows that even a short burst of creative activity can lower stress levels, Turn off cable news and start molding some clay.

The Best Exercise to Reduce Blood Pressure (Gretchen Reynolds, Ask Well, NY Times, 9-18-15) The "best way to fight hypertension may be to divvy up your workout into bite-size pieces. In a 2012 study by Dr. Gaesser, three 10-minute walks spread throughout the day were better at preventing subsequent spikes in blood pressure — which can indicate worsening blood pressure control — than one 30-minute walk....'Exercise intensity does not appear to play any significant role' in helping people control blood pressure, Dr. Gaesser says. Movement is what matters. So go for a stroll a few times during the day or simply stand up more often to develop healthier blood pressure."

Health experts have figured out how much time you should sit each day (Brigid Schulte, Wash Post, 6-2-15) According to a journal of sports medicine, "Americans should begin to stand, move and take breaks for at least two out of eight hours at work. Then, Americans should gradually work up to spending at least half of your eight-hour work day in what researchers call these 'light-intensity activities.'"

One Thing I Taught Our National Management Team: How to Do Squares (Christa Bedwin, LinkedIn, 1-14-16) A breathing exercise. The ritual or distraction of the counting is part of the calming effect.

Lower Blood Pressure Guidelines Could Be ‘Lifesaving,’ Federal Study Says (Gina Kolata, NY Times, 9-11-15) How low should blood pressure go? The answer: way lower than the current guidelines. Below 120 is the number to shoot for. One of three adults have high blood pressure, and half of those being treated for it still have systolic pressures over 140. The results of a major study make "below 120" supersede the old goal of "below 140" suggested in a June 22 article: Blood Pressure, the Mystery Number (Gina Kolata, NY Times, 6-22-15)

What a Compelling Blood Pressure Finding Means for Patients (Gina Kolata, NY Times, 9-11-15) The government stopped a blood pressure study a year early because the results were so clear: You're better off with BP below 120. "The nearly 90 approved [blood pressure] drugs fall into four main categories: drugs like diuretics that reduce blood volume by increasing water excretion, ones like calcium channel blockers that make blood vessels expand, ones like angiotensin receptor blockers that block hormones that make blood vessels constrict, and ones like beta blockers that slow the heart. Many patients in the study took two or three or even more of these drugs."
What Barbershops Can Teach About Delivering Health Care (Aaron E. Carroll, NY Times, 5-21-18) One reason that an experiment to reduce high blood pressure in a high-risk population succeeded is that it adapted its approach to encourage trust. "Heart disease is the most common killer of men in the United States, and high blood pressure is one of the greatest risk factors for heart disease. Despite knowing this for some time, we have had a hard time getting patients to comply with recommendations and medications. A recent study shows that the means of communication may be as important as the message itself, maybe even more so. Also, it suggests that health care need not take place in a doctor’s office — or be provided by a physician — to be effective."
A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops (Ronald G. Victor et al, NEJM, 3-12-18) Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood-pressure reduction when coupled with medication management in barbershops by specialty-trained pharmacists.
Blood Pressure Fluctuations May Signal Risk (Nicholas Balabar, NY Times, 7-30-15) Large variations in blood pressure readings from one doctor’s appointment to another are associated with and appear to be a big risk factor for cardiovascular disease and death.

High Blood Pressure Medications (RxList.com), by type of medication. Click on name of medication to find side effects. Diuretics (increase urination which reduces sodium and fluid in the body); beta blockers (lower blood pressure by acting directly on the heart); Ace inhibitors (angiotensin-converting enzyme (ACE) inhibitors decrease the production of angiotensin (a hormone that causes blood vessels to narrow) and, in turn, that helps lower blood pressure; Angiotensin II receptor blockers ( prevent angiotensin from binding to receptors on the blood vessels, which helps lower blood pressure); calcium channel blockers (lower blood pressure by relaxing blood vessels and reducing heart rate); and so on (click on numbers at top to get to them) -- with alpha blockers, alpha-2 receptor agonists, central agonists, Peripheral adrenergic inhibitors, and vasodilators.

The Therapeutic Science Of Adult Coloring Books: How This Childhood Pastime Helps Adults Relieve Stress (Dana Dovey, Medical Daily, 10-8-15)
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Evidence-based cardiovascular care

Easy Does It (Tracie White, Stanford Medicine, Article 6, Spring 2014) Aortic valve replacement without surgery gains ground. In the first year after FDA approval in late 2011, about 7,000 U.S. patients with severe aortic stenosis were treated with transcatheter valve replacement (TAVR). TAVR has emerged from the trend over the past three decades toward less invasive heart treatments — catheter-based procedures instead of open-chest surgery. It's not for everyone.
Improving Evidence-Based Care for Heart Failure Patients (Gregg Fonarow, Medscape, 11-9-16)
Choosing Wisely (Coronary Care)
'Green' Mediterranean Diet Linked to Aortic Stiffness Reversal (Crystal Phend, MedPage Today, 4-17-23) All healthy diets helped, but the green Mediterranean diet had the biggest impact in post hoc trial analysis. The "green" version of the Mediterranean diet added consumption of 3-4 cups of green tea and a shake made of Wolffia globosa (Mankai, a high-protein aquatic plant also known as duckweed) each day, along with avoidance of processed red meat.  Beef, pork and other red meats are okay for the heart, but not hot dogs, bacon, cold cuts, and other processed meat.
As Part of Choosing Wisely® Campaign, SCAI Issues List of Tests and Treatments to Avoid (Choosing Wisely, ABIM, 3-31-14)
Translating Evidence into Clinical Practice: Cardio Care (Evidence-Based Practice Network, NursingCenter.com) Links to articles about specific evidence-based practices
Heart attack risk rises after anger outbursts (Catharine Paddock, Medical News Today, 3-4-14) Harvard researchers who analyzed decades of evidence on links between anger and cardiovascular events, concluded that in the 2 hours following an outburst of anger, there is a higher risk of heart attack, stroke or other cardiovascular event.
Low-Risk Trials Cement a Role for TAVR Alongside—or in Place of—Surgery (Michael O'Riordan, tctMD/the heart beat, 3-17-19) Hotly anticipated new randomized clinical trials testing transcatheter aortic valve replacement in low-risk patients, for whom surgery is standard, provide strong evidence that TAVR has earned its rightful place in this patient population.
Both trials, presented during a late-breaking clinical trials session Sunday at the American College of Cardiology (ACC) 2019 Scientific Session, sh"owed at the very least that TAVR is equivalent to surgery in the treatment of low-risk patients with aortic stenosis....The PARTNER 3 trial, however, exceeded noninferiority expectations, with investigators reporting that treatment with the balloon-expandable Sapien 3 transcatheter heart valve (Edwards Lifesciences) was better than surgery for the prevention of death, stroke, and rehospitalization at 1 year, the study’s primary endpoint."
The Proof: Why Evidence-Based Medicine Improves Cardiac Care (Lisa Fratt, Cardiovascular Business, 1-1-08) "Take for example the common scenario of acute myocardial infarction (AMI) detection. Physicians can vary in the marker level used to launch the AMI order set, resulting in variability or delays in treatment. A standard cutoff—one derived from evidence-based data—levels the playing field. Another common process prone to human error is administration of aspirin and beta blockers at admission. Appropriate administration of meds is linked to positive outcomes, but the full regimen requires a precisely timed mix of medication. A standard order set helps ensure compliance and boosts patient outcomes. Such changes not only improve clinical care but also can boost the bottom line by eliminating duplicative and unnecessary tests."
The role of cardiac registries in evidence-based medicine (European Heart Journal, 1-10-10)
Fish Oil and Vitamin D Pills No Guard Against Cancer or Serious Heart Trouble (Liz Szabo, KHN, 11-10-18) A widely anticipated study has concluded that neither vitamin D nor fish oil supplements prevent cancer or serious heart-related problems in healthy older people, according to research presented at the American Heart Association Scientific Sessions. Researchers defined serious heart problems as the combined rate of heart attacks, stroke and heart-related deaths. The study also suggests there’s no reason for people to undergo routine blood tests for vitamin D. (Vitamin D testing has become a huge business for commercial labs — and an enormous expense for taxpayers.) But Manson's team also found no serious side effects from taking either fish oil or vitamin D supplements. When researchers singled out heart attacks — rather than the rate of all serious heart problems combined — they saw that fish oil appeared to reduce heart attacks by 28 percent, Manson said. As for vitamin D, it appeared to reduce cancer deaths — although not cancer diagnoses — by 25 percent. (Slicing the data into smaller segments — with fewer patients in each group — can produce unreliable results. The links between fish oil and heart attacks — and vitamin D and cancer death — could be due to chance, Kramer said.) Experts agree that vitamin D is important for bone health. Consumers who want to reduce their risk of cancer and heart disease can follow other proven strategies. “People should continue to focus on known factors to reduce cancer and heart disease: Eat right, exercise, don’t smoke, control high blood pressure, take a statin if you are high risk,” said Dr. Alex Krist, a professor of family medicine and population health at Virginia Commonwealth University.)
What's the relationship between diabetes and dementia? (Andrew E. Budson, MD, Harvard Health Publishing, 7-12-21) Due to increasing rates of obesity, inactivity, and an aging population, type 2 diabetes is more prevalent in our society than ever before.     

         Particularly troubling is that type 2 diabetes is now being seen frequently in children, due to their obesity and inactivity. It has been known for many years that type 2 diabetes increases your risk for strokes and heart disease. More recent studies have shown that diabetes also increases your risk of dementia. The earlier you develop diabetes, the greater your risk is for developing dementia.
    Reduce your risk of diabetes and dementia:
    Engage in aerobic exercise at least 30 minutes each day, five days each week.
    Eat a Mediterranean-style menu of foods.
    Maintain a healthy body weight.
    Treat high blood pressure.
    Treat high cholesterol.
    Don't smoke.

     "Lastly, social activities, a positive attitude, learning new things, and music can all help your brain work at its best and reduce your risk of dementia."
Evidence-Based Medicine on Coronary Care (MDLinx, which sorts, ranks, and summarizes medical news articles and journals for easy and accessible viewing)
Evidence-based medicine, generally (Writers and Editors site)

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Eminence-based medicine

"Eminence based medicine—The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as 'making the same mistakes with increasing confidence over an impressive number of years.' The eminent physician's white hair and balding pate are called the 'halo' effect." from Seven alternatives to evidence based medicine (David Isaacs and Dominic Fitzgerald, BMJ, 1999; 319 doi: http://dx.doi.org/10.1136/bmj.319.7225.1618) (The other six: Vehemence based medicine, Eloquence based medicine, Providence based medicine, Diffidence based medicine, Nervousness based medicine, and Confidence based Medicine. The latter is restricted to surgeons.)
The Big Dirty Secret Every Doctor Knows (Larry Husten, Medpage Today, 8-2-16) The culture of medicine rewards the hubris of eminence and actively punishes or offers subtle disincentives to anyone who question this process. " I've been told by several cardiologists that large portions of the Maryland cardiology community had been aware for years that Mark Midei implanted stents in patients who didn't need them. No one said anything."
When Evidence Says No, But Doctors Say Yes (David Epstein, ProPublica, 2-22-17) Years after research contradicts common practices, patients continue to demand them and doctors continue to deliver. The result is an epidemic of unnecessary and unhelpful treatment. The RightCare Alliance is a collaboration between health-care professionals and community groups that seeks to counter a trend: increasing medical costs without increasing patient benefits. As Dr. David L. Brown put it, RightCare is “bringing medicine back into balance, where everybody gets the treatment they need, and nobody gets the treatment they don’t need.” And the stent procedure was a classic example of the latter. In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” (Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure.) [Emphasis added.]
Pioneering Interventional Cardiologist Defends Unorthodox Practices (Larry Husten, CardioBrief, 8-1-16) –Bernhard Meier explains why he seals plaques and thinks PFO closure is ‘the best procedure in interventional cardiology.’
Interventional Cardiology and the Rejection of Science (Larry Husten, CardioBrief, 7-22-16) Prominent interventional cardiologist Bernhard Meier (University Hospital of Bern, Switzerland) says clinical trials are slowing progress. "In their eagerness to embrace a glorious future of ever more spectacular technology-based advances, interventional cardiology— a subspecialty never exactly known for caution, patience, or self reflection— is poised to reject science, evidence-based medicine, and randomized controlled trials. "Generating and publishing evidence is a tedious job," writes Meier one of the top interventional cardiologists in the world, in the European Heart Journal. “Waiting for the results of randomized trials may preclude patients from an apparently good thing while the trials are ongoing.” "The problem, it should be unnecessary to point out," writes Husten, "is that what often seems like “an apparently good thing” turns out, after careful scrutiny with good evidence, to be not good at all, and perhaps even harmful."
Eminence Based Medicine and Cardiac Surgery (Larry Husten, CardioBrief, 7-26-16) Did a top surgeon perform a nonrandomized, semi-prospective, historically controlled clinical trial without IRB approval or patient consent? (One comment: "Among the many well deserved criticisms, I will say it is refreshing to know the surgeon rejected his own hypothesis.")
NEJM Blasts “Crusade,” Omits that Its Former Editor Launched It (Michael Millenson, The Health Care Blog, 1-19-18) 'What Rosenbaum fails to mention is that the policy consensus she seeks to puncture – that the sheer magnitude of wasted dollars in U.S. health care offers “the promise of a solution without trade-offs” – originated in the speeches, articles and editorials of the late Dr. Arnold Relman, the New England Journal’s editor from 1977 to 1991....The “30 percent” waste figure came from Relman, and others (including the Institute for Healthcare Improvement, employer groups, policymakers and Dartmouth) took it from there.'
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Books and other resources about
heart, stroke, and other cardiovascular disease

Knocking on Heaven's Door: The Path to a Better Way of Death by Katy Butler is an important book to read if you are, or are caring for, a patient with heart disease. Through the story of her father, and with final chapters that provide concise practical advice, she provides "a map through the labyrinth" of a health care system that is geared more to saving lives (no matter the cost and extended suffering) than to helping people die a good death, when death is inevitable. In her father's case, a pacemaker was installed when he was in the early stages of dementia, without fully informing the family about what that meant, or consulting about what he wanted, and it kept him alive long past when he would have wanted to die the natural death that would have come, without it. Full of essential knowledge and practical explanations in the final two chapters.
Cri de Coeur (Naderge Pierre, Pulse: Voices from the Heart of Medicine, 10-27-17) A surgical resident learns after a tense heart surgery experience that her own heart is in trouble.
• Martha Weinman Lear's memoir, Heart-Sounds: The Story of Love and Loss "Martha has done a remarkable job balancing her love story with Hal, her desperate, angry struggle to save him, along with tough, specific reportage on the medical profession. . . . What a sense Martha has for anecdote, for character, for time and place . . . for life.” —Patricia Bosworth (about heart disease, among other things)
The Sanctuary of Illness: A Memoir of Heart Disease by Thomas Larson. ''This powerful book conveys one man's struggle fighting heart disease. Thomas Larson describes multiple heart attacks, interventions, and his decision to try to change his fate with a plant-based diet. His example and dramatic rebound are truly inspiring.'' --Neal Barnard, M.D.¸ featured in the film, ''Forks Over Knives.''
Childhood Disrupted: How Your Biography Becomes Your Biology, and How You Can Heal by Donna Jackson Nakazawa. How childhood trauma, adversity, and stress affect our physical and emotional health as adults--and are linked to adult illnesses such as heart disease, autoimmune disease, and cancer--and how to heal).
At the Will of the Body: Reflections on Illness by Arthur Frank (explores what illness can teach us about life, drawing on his experience having a heart attack and cancer)
Death: Living to Talk about It by Brian M. Hayden. "For over twenty-years I have found myself on the verge of death and fought to stay alive. My heart attack in 1989 marked the beginning of a life and death struggle that has lasted more than twenty-years. I have been in hospice, and my family told I had three weeks to live. I was on a heart transplant list, but was removed because they said I was too sick to survive surgery."
My Father’s Heart: A Son’s Journey by Steve McKee (a tender memoir about suburban life in York, PA and Buffalo, NY -- in the 1960s, in every sense a “family history,” shedding light on heart disease, especially as inherited in families). Check out Steve McKee’s blog, too.
The Open Heart Companion: Preparation and Guidance for Open-Heart Surgery Recovery by Maggie Lichtenberg
Go To Guides (Mended Heart), Free: Download or read free online: Unerstanding and Managing Chronic Heart Failure, Why You Should Be Tested for High Cholesterol and FH (FH is Familial hypercholesterolemia (a genetic disorder in which LDL cholesterol is present in very high levels from birth), The GoToGuide on Valve Disease, and/or The GoToGuide on Heart Attacks.
Back to Life After a Heart Crisis: A Doctor and His Wife Share Their 8 Step Cardiac Comeback Plan by Marc Wallack and Jamie Colby
Recovering From Heart Surgery (For Heart Bypass, Heart Valve Surgery and other Open Heart Surgery Patients) (DVD, RecoverRite)
Remind Me Who I Am, Again by Linda Grant. About how her mother's vascular dementia (brought on by small strokes) exacerbates Grant's troubled relationship with the woman.
After the Stroke (the poet May Sarton’s journal about recovering from a mild stroke when she is in her seventies)
A Change of Heart: A Conversation with Dick Cheney (Stanford Medicine, Spring 2014). Cheney’s first heart attack occurred when he was 37, a young man running for the U.S. House of Representatives in Wyoming. After a fifth heart attack, in 2010, he did the research and sought a transplant. Read about it and what he learned in his book Heart: An American Medical Odyssey

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