Heart Disease & EECP in Europe
Additional Complications due to Aging!
I was 70 a couple of months ago - a wry milestone. Glad you've got there and a notice that you're getting older and that things are gradually not working as well as they did. About 4 weeks ago I had a 'big' operation to correct a slipped disc in the lumbar (Lower) section of my back.
I had seriously damaged the Achilles tendon in my left leg about a year ago - running for a bus! This took 6 months to repair and wasn't helped by my active part in building our new house - fortunately now finished - mostly. About the turn of the year I started to notice shooting pains in both legs when I walked and naturally put this down to side effects from the Achilles tendon repair - until the physiotherapist treating me said no - something else is happening - spinal stenosis. This is progressive compression of the spinal cord due to pressure from a slipped disc. He passed me on to a back specialist surgeon who confirmed the diagnosis and gave me the usual options - live with it and use painkillers, local injections or surgery, the last of which I chose. My judgment was that I was probably fit enough to withstand the operation with a reasonable chance of success - the surgeon gave me the odds as 85:15 on a successful outcome based on experience with what is now a 150 year old procedure.
This duly took place towards the end of July and I knew within 24 hours that it had been well done - the pains had gone and everything still appeared to work. The surgeon also told me the damage had nothing to do with the Achilles tendon problem - I was the unwitting victim of 20-30 years of self-inflicted damage of which I knew nothing. If you have no symptoms you just assume you can go on doing these things.
4 weeks later I hardly know that anything has even happened - except for the rather vigorous regime of daily exercises prescribed by the physio whom I see every couple of weeks (I should be doing them now). I no longer stumble and my daily walking is up to over 9000 paces again.
And what of the heart and blood pressure during all this? Not a tremor or whisper of a problem. My BP was 110/68 at the pre-assessment and got up as far as 137/80 immediately after the operation. The anaesthetist said he noticed nothing.
Indeed, over the last 6 months my BP has steadily declined, the average resting BP taken last thing in the evening (so, very benign but consistent conditions) has been 116/70 over the last 3 months. Indeed I wonder if my drug regime - still a full spectrum hypertension package - needs revision. A discussion with the GP next month.
In summary, hooray for EECP and the long-lasting effects of such a good treatment. I am a very lucky man, both with EECP and a well executed back surgery. Let's hope the luck persists
Update - February 2010
Just a short entry to report that everything is stable - no real changes. I am indeed very fortunate but EECP is still highly recommended
Update - July 2009
I was recently upbraided for not keeping my blog up to date, a stricture which I accept. However, there has been very little change since December 2008 - a very fortunate circumstance and a reinforcement of the powerful combination of EECP treatment, diet and exercise. My blood pressure is still recorded twice a day and the results stay in the 110-128 region, depending on what excesses I get up to.
Currently I am project manager on a house-build and this can get quite exciting at times and fatigue can play a real part - the more tired you are the more you are affected by adverse events. I have done a couple of foolish things such as carrying 25kg toilet bowls up the stairs 5 times in succession - this caused a minor flare-up of heartburn/angina which dispersed after a couple of hours. Other than that - nothing! I still keep up the drug regime with a change from Tarka to Olmesartan(an ARB) about 3 months ago, the result being a depression in systolic of 3-5mm.
One effect that is definitely becoming worse is that of short term memory. Whether that is the effect of advancing age (I am 69) or of the 20mg of statins (Lipitor) I take daily, is a moot point. Memory impairment is widely reported in the literature so I will have to monitor this. I have always had a good memory so the decay can be quiye upsetting at times. Reminds me once again of the Barry Cryer joke that Stannah (leading European manufacturer) have recently introduced a high speed stair lift to get you upstairs before you forget why you're going there. See www.spacedoc.net/board/viewtopic.php?t=830&postdays=0&postorder=asc&start=0 for a discussion of memory and other effects. The Spacedoc.net website has some excellent material showing how the conventional frontiers of medicine may not always be tackling medical issues in the right way.
A large scale study recently reports on the positive effects of statin use. The results are summarised very well in a video by Professor Paul Ridker of Harvard University talking about the development of new lipid guidelines leading up to the forthcoming issue of the ATP IV set of guidelines. Check out www.theheart.org/article/961439.do - you may have to sign up to get access. The key point is that you have to not only control lipid levels but also inflammation, the level of C reactive protein (CRP) is very important. Prof Ridker also makes a very powerful case for the importance of regular exercise in the regime for control of cardiovascular disease. So I keep on with the statin treatment and level of exercise until I next see my cardiologist in September for a check-up.
Another factor that is being highlighted these days is the effect of proper levels of Vitamin D3. Most northern dwellers have abysmally low levels of D3 which is really a hormone rather than a vitamin and appears to play a vital role in many essential physiological processes. This has recently been discussed by Dr John Briffa in his excellent medical blog (www.drbriffa.com) and repays some study, especially as it may be a key intermediate in the transport of lipids in the bloodstream.
December 2008 Update
I am still in the very fortunate position of confirming this is a continuing success story - the data I recorded in June 2008 (below) is still essentially the same. No angina, a continuing improvement in stamina and resistance to fatigue and unexpected events. EECP has been, at least for me, a miracle.
I have to observe some disciplines, however, coming down to diet and exercise. Taking the exercise first, I try and walk an average of 8-9000 steps a day, but if I have a long day with up to 16000 steps, there is no effect except some aching muscles - and I feel a little well-used the day after. I am convinced that this regime has a major effect. I follow a moderate mediterranean syle diet, keeping the caffeine intake low. A caffeine shot does make a difference but it soon wears off. My weight varies little less than a kilo over the whole period.
I still follow a complete broad spectrum drug regime, ARB, CCB, beta blocker, statin, anti-coagulant, Omega 3 supplement. There have been no changes in this for the last 2 years and I am fortunate that I have no significant side effects.
I am quite frustrated, however, that the take-up of EECP in the National Health Service is still so slow. The pioneering work at Bradford is showing very good results and this needs publicising across the National Health Service as a cost-effective method of keeping a large population of CVD patients in a much better state than relying just on PCI, CABG and drug regime. Coupled with the essential lifestyle modifications, the economic benefits to the CVD population are potentially very large.
A new UK website (http://www.eecp.co.uk/) sets out the modern knowledge on EECP in a much better fashion than I have done in earlier entries in this blog, and I commend this to anyone wanting to follow up on the background to EECP, especially policy analysts in UK Primary Care Trusts - EECP will make a real difference to your budgets!
June 2008 Update - Something has happened!
The last post was at the end of February and the improvement noted there has continued, in fact to the stage where I am probably in a better state than I have been for several years. The graphic above shows the relationship between exercise amount - basically steps per day shown in light blue - and blood pressure (BP) tendency over the last 12 months. The red trace is the maximum daily systolic pressure and the dark blue trace is the average systolic pressure. All figures are averaged over a continuous 20 day moving period to iron out daily fluctuations and the BP difference is calculated by subtracting the average pressures for the whole of 2006.
Note the very large, and so far permanent, dip since the beginning of March, combined with the steady exercise regime since that time. Nothing like this has happened in a long while.
Having finished the EECP session in California at the beginning of February as noted before the BP did not really settle down although I felt considerably better. I decided about a week later to give up even decaffeinated drinks and bang! - within 2 weeks the BP had dropped by about 10mm. Since then there has been a steady although slow improvement in stamina and strength, effectively a slow healing process. This cannot be due just to EECP but possibly a virtuous circle effect of diet, exercise, medication and EECP all working together. It is still quite difficult to believe but it has been confirmed by a recent Bruce protocol stress test by my cardiologist who has booked me for another one in 6 months' time to see whether it keeps up.
The question is then - what is the secret? I suspect that there was a really persistent area of inflammation somewhere that has declined. In other words the chronic endothelial dysfunction that plagues me - and millions of others - has reduced a few percent and allowed the other improvements. Too early to say definitively but I live in hopes.
Endothelial dysfunction seems to be getting a lot more attention from the medics recently. It appears to be a pincer movement from several angles, not just conventional drug and intervention regimes:-
- EECP trials and results being more widely known
- Fundamental work to understand the physical and biochemical processes at play in the endothelium
- Effects of hormones and cholesterol transport mechanisms, in particular reverse cholesterol transport
- Flow mechanics studies
- Conventional intervention costs and their escalation
- Development of new and cheaper devices to measure endothelial funcion, e.g. Cardiatect
I believe a new paradigm approach is beginning to evolve in early detection and treatment of cardiovascular disease, of which EECP will be one of the constituents.
Finally, I commend the Yahoo EECP Group as a good source of new information on some of these trends.
Rye Harbour - UK
EECP for travellers and medical tourists
As the result of a comment on this blog I thought it would be helpful to other cardiovascular disese sufferers to put down some guidelines for people who were seeking EECP treatment in foreign countries, especially where the climate was more pleasant during a Northern winter - medical tourists. India is an obvious example where EECP provision has been both well developed and adverised on the web.My qualifications for doing this, besides being a CVD sufferer who has gained tremendous benefit from EECP, is that during my professional career I travelled and worked in many parts of the world. I have no experience in the Indian sub-continent and my EECP sessions have been in the UK (1) and the US (2). Nevertheless I hope that the following paragraphs, being a meld of my travel and EECP experiences, might be of help to others. These guidelines are only a first draft and would benefit a lot from input from others with complementary experience and more knowledge than mine. So please feel free to add your comments and see if we can't make these betterIntroductionThis document is intended as a guide to medical tourists seeking EECP treatment in countries such as India. If you are seeking EECP treatment, the inference is that you are suffering from cardiovascular disease and worse, that you are feeling unwell, perhaps in pain and less able to cope with the daily ups and downs of life. The advice is based on experience of having EECP treatment in various places, not in India particularly.EECP does not work for everybody and it has been mainly used for patients with chronic stable cardiovascular disease (CVD) where the cardiologists have run the gamut of conventional treatments. It is thus concentrated in cases of advanced CVD with significant levels of angina and impairment. From personal experience I gained great benefit from its use much earlier in the disease cycle – an enlightened cardiologist was the key in my case. Make sure at least that your cardiologist is aware of your intentions and has the opportunity to express his opinion and monitor your decision to proceed.General
1) Check carefully how far your travel insurance provides you with cover; what happens if, heaven forbid, you suffer a major emergency? Is the clinic you are attending equipped for coronary emergencies? Also check the length of time you can stay outside your home country – many insurances only provide 31 days in any one trip – which you will blow if you have a full 35 session course once a day.
2) Be aware that your legal rights to redress if something goes wrong will be governed by the laws of the country where you get treatment. EECP is a procedure with a small inherent risk of harm and so the overall risk is low. Therefore liability considerations should be a minor part of your decision to proceed, but do not expect these clinics to carry what you may regard as significant levels of liability insurance.
3) Make sure that your vaccinations are up to date for the country you are visiting.
4) The English and Americans are notoriously bad at speaking and understanding foreign languages - a great generalisation! Nevertheless good communication is important, especially when you're not feeling well or something is going wrong. Make sure therefore that you can communicate easily with the clinic and the people working there. If you need an interpreter, will they be available at short notice and at awkward times?
Travel & Accommodation
1) Get hold of a good guidebook for general background, e.g. Rough Guide
2) Be a lot more patient with the transport system, ideas of timing and punctuality can be very different.
3) If you can, agree prices for taxis and other transport before you get into them, unless they have official meters; be prepared to haggle!
4) Make a friend of the hotel manager and/or head porter; they can be immensely helpful avoiding local pitfalls. Be careful initially of local guides who try to sell their services to you; obtain independent verification if you can if they are any good.
5) Make very sure that your hotel room is comfortable and as quiet as possible; because of your condition and the treatment you may need a lot of rest. Having a room next to a busy road or with noisy neighbours is not a good idea!
6) Find out the local phone numbers of your country's consular service in the country you are visiting. They can usually provide information and help in emergencies, eg lost passports or visa problems. Also check the website of your home country's Foreign Service for travellers' advisories about the country you intend to visit.
You will find EECP difficult or impossible if you suffer diarrhoea and/or other types of food poisoning. There are lots of guides on Westerners being careful in hot countries - they seem to have more delicate constitutions! - but some general points may help.
1) Never drink water from a jug or tap, always bottled, unless vouched for by the hotel – and then still be careful! This also means no ice in drinks. Keep well hydrated but take advice if you are on a diuretic blood pressure medication. Beer is OK providing it is a good brand so it has been sterilized properly – but check that the bottle caps are clean. Draft beer from stainless steel barrels should similarly be OK if the glassware is clean. Be wary of fruit juice, milk, etc. unless it comes in Tetrapak-type packaging.
2) Hot drinks should use boiled water, hence tea and coffee OK. If caffeine is a blood pressure stimulant for you, perhaps take a supply of decaf teabags.
3) No salads, no fruit unless it can be peeled properly, e.g. bananas, oranges
4) Cooked meals only where you are reasonably happy with the conditions of preparation.
5) Be careful with bread, cakes, sweetmeats, Anything with exposed sugars or syrups is difficult.
6) Spiced dishes often disguise high salt loads – if you are sensitive to salt, then ask. The same is true of bread and baguettes, often these are made with up to 12 grams/kilo of salt. The European standard is 6 grams/day max.EECP treatment
The clinic will want to give you a fairly thorough medical examination before starting, if only to familiarize themselves with your case. It is immensely helpful for them to take as much information as your doctor and cardiologist will let you have. Ideally this should include:-
- Copy of prescription - CD of last angiography - X-rays of chest - Ultrasound data - Stress test history - Recent blood test results (do you know your total cholesterol, triglycerides, HDL,LDL, Total/HDL ratio?) - Blood pressure history - Copy of medical notes, if available
The clinic will probably want to do a stress test for themselves to assess your current state, as well as a 12 lead ECG check-up. They should also give you an ultrasound examination, if only to check that there is no danger of an aortic aneurysm from the EECP, happily a rare occurrence. They may also do a new blood test. They may also check your left ventricular ejection fraction (LVEF). If they have a sophisticated set-up, they may also do a nuclear SPECT imaging test to check heart muscle damage and LVEF. The costs of some of these tests may not be included in the price quoted to you and this may be where they increase the profitability of your case. However, all the data above is potentially very helpful.
The EECP sessions themselves are fairly innocuous. You have doubtless seen pictures of the equipment and you will get used to it very quickly. Initially you should have one session per day – it is possible to have 2 per day if your physical state allows you to do so. They should check your blood pressure before and after but this is not essential if you are reacting well. Keep taking your prescribed medication unless they suggest otherwise. Try not to drink too much before a session, you will then want to stop during the session for a pee!
They may start you off at 260mm inflation pressure but, if you do not feel uncomfortable, get it increased to 300mm (0.4MPa) ASAP. You should have a reasonably tight-fitting pair of longjohns without seams. These are to prevent chafing. They should be of cotton with a small amount of Lycra to make them expand over your skin. Unless they have specifically agreed to supply them, don't assume you can get hold of these locally, a sports shop at home may be best. You may suffer some abrasion chafing in any event, some talcum or zinc oxide cream usually helps but the clinic should be fairly expert at knowing what to do to alleviate the problem. Be suspicious of sheep wool pads and the like, they will certainly help to alleviate chafing problem but at the expense of absorbing a lot of the pneumatic energy you want to transfer into your leg arteries.
The objective of the treatment, is to enhance the flow into the coronary arteries and this is measured indirectly by a finger plethysmograph. They should check your readings every 15 minutes or so and adjust the inflation and deflation timing to optimize the peak and area under the curve. You should take a great interest in these results but do not be disappointed if you do not get a significant effect for the first 10 sessions or so; there may be some significant arterial and heart muscle stiffness to overcome. However, towards the end of the sessions you should be seeing ratio figures over 1.5 if you are lucky.
Make a friend of the operator, he/she will have some very useful background information. Also, if you are dissatisfied or otherwise feel you need to see the supervising cardiologist because you are unwell or making insufficient progress, then be insistent on seeing him quickly. Try and relax during the sessions by reading, listening to music or watching TV. They may even have CNN or BBC World Service!
A simple point is to check whether the EECP room itself is well ventilated. EECP systems are fitted with a fair size blower unit that itself generates considerable heat. The room can get very warm if the heat is not properly dissipated, making the patient feel uncomfortable.
You will certainly feel tired both with the sessions and the heat; however, you should aim to get into a good exercise regime every day, the extent of which will depend on your physical condition. If you can walk reasonably well then this is excellent exercise. The ideal would be an average of 8-10000 steps per day (if you do not have a pedometer, buy one and check your progress. The only decent reliable one in my experience is the Omron Walking Style II (HJ-113), the rest stop working after a few months for one reason or another. If a swimming pool is available then a gentle session is very good. Fatigue is a real enemy, however, and it is a difficult balancing act between being well enough for the EECP session and getting a good level of exercise. Therefore, give in to your tiredness and rest as far as possible.
At the end of the treatment course the clinic may well give you an equivalent set of tests and hopefully you will get some really encouraging results.
February 2008 Update - Effects of Decaffeinated Drinks
I should note (see previous post)that I have not drunk any significant amount of caffeinated drinks in the last couple of years and stuck to decaffeinated coffee and tea. I began to get a little bit concerned that EECP was producing the results after the course was completed - and so I cut out any decaffeinated drinks as well.
This graphic (up to 25th February) shows what has happened since the end of the EECP course and eliminating any decaffeinated drinks. The course finished on 5th February and the blue line shows that average SBP was still running about 140. A week later I gave up the decaffeinated drinks - and the blue line marched from 140 to near 120 in a week. This effect has persisted right up to date - long may it continue! At the same time I have been able to increase the amount I can walk each day - so hopefully improving the overall level of fitness.
The ship's doctor's strictures about eating and drinking too much have also worked out well - I came back to the UK a couple of weeks ago 300 grammes lighter than when we departed in December. I still drink only a couple of glasses of wine a day and, if anything, I drank less on the ship.
There is a definite relationship between the amount of exercise - too much probably causes some aggravation of inflammatory patches - and blood pressure in my case. I would dearly like some better insight into how these relationships work. Excessive salt and decaffeinated drinks may also play some part but I am sure that other factors have effects that, at present, I do not understand.
Data update for Nov2007 - Feb 2008
I hope this graphic is not too confusing. It is a time series plot of my systolic (SBP) and diastolic blood pressures (DBP) for the period Nov 2007 to the end of January 2008. These are measured using a Microlife recording unit that takes 3 readings and then averages them. Readings are normally twice a day in the morning and evening and are taken sitting up with legs horizontal after 2 - 3 minutes rest.
The vivid purple line is the daily pedometer reading, an attempt to measure the daily physical effort. The red line is the maximum SBP on any one day and the blue line is a running average of the previous 5 days' figures - to get some idea of the trends.
you can see that all through November there has been a steady increase in SBP even though the physical effort is reducing - that is until we started our holiday at the beginning of december, boarding a cruise liner in Barcelona and then taking 10 days to sail to Boston. I was feeling pretty good at the beginning of the voyage and spent quite lot of time walking on the exercise deck, a 610 metre circuit. This effort is reflected in the pedometer readings, followed a couple of days later with a real jump in maximum SBP, making me feel much worse - to the extent of eventually checking in with the ship's doctor. He did a quick examination and said the basic pump was OK and the variations were due probably to:-
- Change of food and eating too much
- Possible increased salt and/or spices load hidden in exotic dishes
- Changed emotional state
- Drinking more
Also I was getting older (nearly 68) and not so resilient as before. I was more worried about aggravating plaques, increased inflammatory patches, etc., but of course he could not answer that, not having the right equipment on board.
We landed and then flew to California to stay with some friends, but the increase in average SBP was still a worry - I didn't feel brilliant. I found a local practice in California that had an EECP unit and, having been checked out by their cardiologist, started in on a course of EECP on 10th January, the third in 20 months. This was organised for 2 sessions a day with an interval over lunch of about 2 hours during which I spent some time in coffee bars, etc. You will note that the average SBP did not reduce, even though I felt better and was able to do a lot more walking.