John 1, Treadmill 0

I had a nice 30 minute workout on the treadmill tonight. Pulse up to 120 and felt good. Let's see if I can keep up with this and make my goal of a run on Christmas Day.

My minor surgical operation is healing up nicely and I get stitches out 12/11. Looking forward to that as well.

I'm not falling off the food wagon but maybe hanging off the side. I'm still getting lots of fiber but have slipped on the 5+ fruits over the last few days.

I shall try to do better!

More Heart Fun

On "Bad Friday", I had some plastic surgery to remove a couple of questionable skin blemishes - one on my forehead and one inside my ear. I don't know at this point if they were bad or not - I'll find out in a week or so.

During the prep for the surgery, the standard instruction was to lay off the Plavix, as it can lead to more bleeding during and after surgery. Given that I have stents, I couldn't do that. So I stayed on aspirin and Plavix.

The first couple of days after the surgery were a bit tough, but I'm getting back on my feet. I do have a couple of nasty looking scars that will scare the children for a few weeks.

I've also adapted to the change from Coreg to Atenolol, and I am happy to say I have most of my energy back. I have been getting some armchair exercise from our new Wii, but I intend to hit the treadmill soon to start working on getting some aerobic fitness back. I'd like to give myself a nice run outside for Christmas.

I Heart These Things

I am thankful for many things:

- Bruce, my guardian angel, who saved my sorry ass 6 weeks ago
- The EMT's and ER people who did their jobs very well
- The Cardiac specialists who also did their jobs well
- My family for their incredible support
- My friends and co-workers who provided great support during my recovery
- My church family who continually remind me that prayer is good for us
- My new PCP, cardiologist and others in the medical community who keep my sorry ass healthy
- The members of the HCHS Marching band family who offered their support during my recovery
- And for me just being here this fall. It might not have turned out that way had any one thing been different.

I have a bit of non-cardiac surgery tomorrow...should be even better after that.

Cheers,

John

Heart Doctor

This past Monday I had my first visit with my cardiologist. They took another EKG which still showed some residual damage from the heart attack. The cardiologist mentioned that the damage may reduce over time, but there may be some permanent damage. It will be more obvious in 3 or more months.

I also described my fatigue and he indicated the Coreg may be causing that. I'll be changing from that to Atenolol, another Beta Blocker, this week.

And, the cardiologist released me to start walking, and phasing into running again. I'll start with brisk walking once I can get my energy level back.

I'm staying pretty close to the diet, but I did travel this week and had some trouble getting completely healthy food whilst eating out. I did manage to have more salads than other food, and avoided the fried stuff.

So, recovery is under way and hopefully I'll be my normal bubbly self before too long!

Smoothie Operator

I got pretty "anal" on my last post about fiber (har). It's one of the key parameters I'm trying to balance in my new diet: Fiber, salt, fat. The rest will fall into place.

There are lots of good bread options loaded with fiber. Sandwich rounds are great. I'm staying away from plain pasta or white bread. The whole grain stuff has lots more flavor.

I'm also going heavy on the fruit, and decided to try out fruit smoothies. I never got into them because I thought the name was stupid. But they are a great way to get calcium and fruit.

I make them like this: Toss about a cup and a half of fresh and/or frozen fruit in the blender. If fresh, add some ice cubes. Add about a cup of skim milk and 1/4 cup or so of fat free vanilla yogurt.

Blend like hell for a minute or so and pour into a cup. Tastes really good. You get a lot of fiber and vitamins from the fruit and some calcium to boot.

Doctor Update!

I have an appointment tomorrow with my Primary Care Physician and a Cardiologist appointment on the 16th of November. Thanks to all for helping me get these under way!

Eat This - Heart Healthy Food Decisions

I promised a treatise on healthy eating. I have been reading a lot about this recently. There are great guides available, but a lot of confusion over the "truth". I'll show you some items that I think are pretty solid as they pertain to your cardiac health.

My discharge instructions told me to eat a high-fiber, low-fat, low-sodium diet. I'll do that to the extent that it's good to eat...beyond that, I know I'll fall off the wagon. So I'm all about health "with flavor"...I had some pretty bland crap in the hospital and I'm not looking to reproduce that experience again.

We like to cook, and eat. So I'm looking for ways to expand my culinary experience, getting healthier while tasting new and great stuff. I don't want to be bored and cheating with McNuggets in 6 months.

Much of this information is from the National Institute of Health Cookbook (and good guide to nutrition). This is a great online resource which includes basic nutritional guidance as well as a bunch of great recipes that I will be trying.

Calories and Basic Nutrition Requirements
1,600 calories—For young children (ages 2-6), women, and some older adults
2,200 calories—For older children, teenage girls, active women, and most men
2,800 calories—For teenage boys and active men
This puts me in the 2500 calorie per day range...kind of active and a man.

Basic Nutritional Intake Guidelines:
● Total fat .............No more than 30 percent of daily calories
● Saturated fat ......Less than 10 percent of daily calories
● Cholesterol .........Less than 300 milligrams per day
● Fiber ....................25–30 grams per day
● Protein ...............10–35 percent of daily calories
● Carbohydrates....45–65 percent of daily calories
● Sodium ...............No more than 2,400 milligrams per day

FIBER - Get Things Moving

I have spent a lot of time trying to get more fiber, from natural sources. The best sources for me are fresh fruits, vegetables, oatmeal and beans. I'm shying away from processed stuff like granola. I eat "sandwich rounds" which have 5g of fiber in each round. They are like a pita, but a bit more palatable.

There are two main types of fiber—soluble (also called “viscous”) and insoluble. While both have health benefits, only soluble fiber reduces the risk of heart disease. The difference between the types is how they go through the digestive tract.

Soluble fiber mixes with liquid and binds to fatty substances to help remove them from the body. Soluble fiber thus helps to lower cholesterol levels—thereby reducing the risk of heart disease. Good sources of soluble fiber are whole oats, barley, fruits, vegetables, and legumes (which include beans, peas, and lentils).

Insoluble fiber goes through the digestive tract largely undissolved. Also called “roughage,” insoluble fiber helps the colon function properly. Good sources of insoluble fiber are whole-grain
foods (such as wheat and corn bran), fruits (such as apples and pears with the skins), vegetables (such as green beans, cauliflower, and potatoes with the skins), and legumes.

As a rule, fruits have more soluble fiber and vegetables more insoluble fiber. You should try to eat 25–30 grams of total fiber each day. That should include at least 5–10 grams daily of soluble fiber.

I have found that not much processed American food has much fiber. You have to go looking for the stuff, unless you get your RDA of fruits and vegetables and beans.

FATS - Tasty but Oh So Bad?

I am OK without fried food. I like meat, but really like salads, vegetables and seafood, so I think I can do well in fat land. Here's what the book has to say:

Saturated fat. This fat is usually solid at room and refrigerator temperatures. It is found in greatest amounts in foods from animals, and increases cholesterol in the blood more than anything else in the diet. Keep your intake of saturated fat low.

Unsaturated fat. This fat is usually liquid at room and refrigerator temperatures. Unsaturated fats occur in vegetable oils, most nuts, olives, avocados, and fatty fish, such as salmon. There are types of unsaturated fat—monounsaturated and polyunsaturated. When used instead of saturated fat, monounsaturated and polyunsaturated fats help lower blood cholesterol levels.

Trans fatty acids. Foods high in trans fatty acids tend to raise blood cholesterol. These foods include those high in partially hydrogenated vegetable oils, such as many hard margarines and
shortenings.

My New Food Mission

So what does this mean? I'll put it in terms that I understand.

EAT MORE OF:
Oatmeal and high fiber breakfast cereals
Beans (yeah, look out!)
Fruits and Vegetables
Whole Grains - in Breads and Pastas
Oils - EVOO and its brethren
Seafood and lean meats
Vinegarette type dressings

GO LIGHT ON
Cheese and other dairy
Salty stuff, particularly snacks and any prepared side dish (rice, etc)

EAT LESS OF:
Fatty Meats...including chicken wings...damn!
Fried foods
Things made with butter, margarine
Refined starches (bread, plain pasta, sugary stuff)
Creamy dressings

The Food Pyramid

One area I have been noticing is the focus in the US on Meat and Dairy. The USDA Food Pyramid relies heavily on meat and dairy in the daily diet. This is largely owing to the heavy lobbies of the meat and dairy industries. Other cultures (and vegetarians in our country) have shown us that it's very healthy to avoid one or both of these categories and still be quite fit and get your nutrition. For example, I encourage you to check out the Mediterranean food pyramid - which deals very well with the types of food common in that area, and features very little dairy and meat. On average, other cultures may have no meat or dairy, other than a smattering of seafood, in the daily diet. Incidentally, the level of health is high in that area of the world. And a glass of wine is encouraged (well...not discouraged) with dinner!

I'll close with a quote from Michael Pollan, which summarizes his philosophy. 7 words to boil down your choices for healthy eating:

Eat Food. Not Too Much. Mostly Plants.

Other Links: New York Times article.

Getting Closer

A quick, non-ranting update:

I'm recovering well and keeping up with my medications. I have good stamina, although I am sleeping a good 8-9 hrs/night (and loving it). I called back one family practice and am confirmed for December start up. I have a lead on another and may get in there faster than the first.

I have had a couple of calls from friends who are in the health care industry in Erie who are sympathetic to my cause, and have provided great leads on speeding up the new patient process, and getting hooked up with a good cardiologist.

I'm staying on a good low-fat, high-fiber diet (with a little red wine in there), and feel pretty good at this. We're still pretty busy with band and some other stuff, but it's calming down starting next week. A later post, when I have time, will get into the whole food pyramid and America's love affair with meat and dairy.

Many thanks to those who sent good wishes and goodies. I really appreciate it!

One good outcome of this was that I was able to corral all of the ladies in my family and set up some outdoor photos this last weekend. This is the first outdoor set we have ever formally done...from my front yard!

Thanks ladies. I even smiled nice!

The Sargasso Sea of Medical Care

Warning: this is a Rant Post.

One of the first steps when we got back from the hospital was for me to schedule an appointment with a PCP and a Cardiac Specialist. One would THINK that would be a pretty easy process.

I thought I had a primary care physician. Years ago I had a checkup and follow-up exam at the PCP listed on my insurance card. The kids go there regularly. I had not personally gone in years. So I call this summer to get a checkup and they tell me that I have been away too long so they took me off of their list of active patients.

I was a bit confused, but I asked to get back ON the list. They'd have to talk to their people about that. They'll get back to me.

Two or three weeks later I call again...thinking simple administrative oversight. Same runaround. The say they will call back and never call. They don't want my business, or are simply incompetent in the area of patient retention.

So I pick another place to start up as a PCP, a new facility 2 miles from me, affiliated with a major local hospital. They will consider me as a new patient, but they need my medical records from old people. I call old people. "We destroyed your records".

Now I'm stuck in a hard place. Old guys not competent and won't take me anyway. New guys stubborn on medical records which don't exist.

So I call a NEW, new place. They need to ask the physician if they will take me, even though they say they are accepting new patients. Once more in a holding pattern...this one can take a week they say. I started the timer on Wednesday 10/21.

Meanwhile I call the leading cardiology practice in Erie to get set up with them...'cause I KNOW I have some issues there. They won't take me unless I get a referral from my PCP. Which I don't have, and don't exactly know when I will have.

So I am in medical limbo. No PCP, no specialist, no idea when I'll get either...and specific discharge instructions from the hospital to see both asap.

In reality, the only medical care I can get right now is to go to the ER. At least if I complain of chest pain they'll move me up the waiting line.

I know much of it is my own fault for not going for years...but this process of changing a PCP should not be this hard or time consuming.

Putting my Six Sigma hat on from my Black Belt days, I see a repeated breakdown in the practice's "transactional process" of new patient screening and acceptance. I don't know what their process requirements are (Critial To Quality characteristics, or CTQs). Usually it's cycle time, accuracy and maybe volume or capacity, and of course, customer satisfaction. If a business doesn't think about the process CTQs, they end up with a home grown process that optimizes some other parameter, such as the workload or satisfaction of the new patient administrator. As a customer/user of their process (regardless of whether they accept me, I'm input to the process), I am obviously not aware of their process CTQs, nor do I feel that the "normal" CTQs are being measured or considered.

I realize that the main processes in a practice are: Scheduling, Appointment/Care Delivery, Billing, Prescriptions, and Emergency, but Patient Onboarding is a key process as well. You miss this one and your practice will get a bad rep from those alienated or rejected, and your patient volume could come down.

I predict that the practice I find that can screen and accept me immediately is the one in town that actually has a support staff that is competent, and has a set of "onboarding" processes that were thought out with the intention of minimizing the waste associated with starting new patients.

Here's my advice to medical practices in Erie: Know your customer base, both those you have accepted and those who apply. Spend a bit of time to define the common processes and what should be important to the customer during those processes. Little things like telling them how long it may take for screening, and regular updates will go a long way to improving your reputation and making the processes better from the customers' eyes. And gather some data during the process - how many inquiries per week, how many turn into applications, how long each application took through various stages of the process, how many you accept, how long until first appointment. Basic stuff that you can collect and analyze with little effort. Having a standard process with standard measurements will let you know how you are doing.

And here's my advice to medical consumers: Know your PCP. Make sure they think you're still alive and haven't shredded your medical records. Give them feedback on which processes work well and which don't.

Oh, and don't try to live with a heart attack if you live in Erie. Better to do that in a small town in Ohio, where they still know how to care for you.

Hills of Pills

I took no medication before the Heart Attack. Once in a blue moon I'd take Ibuprofin but that was it. I took a daily multivitamin for guys my age. I took pills a lot as a kid and since college, was never on a prescription.

Well, now I get to take lots of pills. I figured I'd write them down here so I don't forget, and so people have some idea of the mechanism behind cardiac medications.

In no particular order, we have:

Carvedilol (brand name Coreg).
Dosage prescribed: One pill twice daily. Dose 6.25mg
Carvedilol is a nonselective β-adrenergic blocking agent with α1-blocking activity. That means that it is a beta blocker with alpha blocking abilities as well.

Beta blockers counteract the stimulatory effects of adrenaline (epinephrine) on beta receptors, found in many tissues of the body including the nervous system and heart. When beta receptors are stimulated, the heart beats faster and harder and the blood vessels constrict, resulting in an elevation of blood pressure. If the coronary arteries are narrowed by atherosclerosis, the increased burden on the heart can cause inadequate oxygen delivery to the heart muscle, leading to the chest pain and other symptoms like I had on Saturday.

Beta blockers act by suppressing these impulses and lead to a slowing of the pulse rate and a reduction in blood pressure. They are prescribed as treatments for high blood pressure and have been shown to improve survival when administered following a heart attack.

The most common side effects are drowsiness and fatigue, along with dizziness and weakness. Dryness of the mouth, eyes, and skin may occur, and those taking beta blockers may develop cold hands and feet. Sleep disturbances and a decreased sex drive are less common but possible side effects of beta blockers. Wheezing is also a less common but potentially significant side effect of beta blockers, and for this reason, they are often not prescribed for people with asthma. Other serious side effects are rare.

Simvastatin (brand name Zocor)
Dosage prescribed: 40mg, once per day
Zocor is a lipid-lowering agent. They lower cholesterol by inhibiting the enzyme HMG-CoA reductase, which is the rate-limiting enzyme of the mevalonate pathway of cholesterol synthesis. Inhibition of this enzyme in the liver results in decreased cholesterol synthesis as well as increased synthesis of LDL receptors, resulting in an increased clearance of low-density lipoprotein (LDL) from the bloodstream. The first results can be seen after one week of use and the effect is maximal after four to six weeks.

These drugs are made from by products of the fermentation of a fungus.

Statins are generally well-tolerated and have only two major side effects that occur relatively rarely: raised liver enzymes and skeletal muscle pain and/or damage.

Clopidogrel (brand name Plavix)
75mg 2/day initially, then 1/day after 2 weeks
Clopidogrel is an oral antiplatelet agent to inhibit blood clots. It works by irreversibly inhibiting a receptor called P2Y₁₂. It inhibits platelet aggregation (clumping).

I was told that this is the most important drug for those with stents, as the body will try to stick things on the stent and this drug will reduce the impact of that activity.

Some interesting commercial information on this drug: It's nearly $6/pill as it is in exclusive north american production by the patent owner, Bristol-Myers Squibb. It is sold in nearly 110 countries, with sales of US$5.9 billion in 2005.

In 2006, generic clopidogrel was briefly marketed by a Canadian generic pharmaceutical company before a court order halted further production. The court ruled that Bristol-Myers Squibb's patent was valid and provided protection until November 2011.

Generic clopidogrel is also produced by several pharmaceutical companies in India at significantly lower retail prices, up to 1/30th of the price. Counterfeit Plavix is in circulation, as with many popular medicines.

So, this is a medication that is highly useful and expensive, so there's lots of shady and illegal duplication going on. At least in late 2011 the drug price will go down as legal generic manufacture may be permitted.

Adverse effects include hemorrhage.

Aspirin
Dosage prescribed: 325mg, once per day

Aspirin also known as acetylsalicylic acid, is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. Aspirin also has an antiplatelet effect by inhibiting the production of thromboxane, which under normal circumstances binds platelet molecules together to repair damaged blood vessels. This is why aspirin is used in long-term, low doses to prevent heart attacks, strokes, and blood clot formation in people at high risk for developing blood clots. It has also been established that low doses of aspirin may be given immediately after a heart attack to reduce the risk of another heart attack or of the death of cardiac tissue.

The main undesirable side effects of aspirin are gastrointestinal ulcers, stomach bleeding, and tinnitus, especially in higher doses.

Today, aspirin is one of the most widely used medications in the world, with an estimated 40,000 tonnes of it being consumed each year.

Glyceryl trinitrate (brand name Nitrostat)
Dosage prescribed: One tablet only as needed for chest pain

Glyceryl trinitrate (GTN) is an alternate name for the chemical nitroglycerine, which has been used to treat angina and heart failure since at least 1870. Despite this, the mechanism of nitric oxide (NO) generation from GTN and the metabolic consequences of this bioactivation are still not entirely understood. In medical circles it is often referred to as "nitro."

This is the same substance as the explosive, but in very tiny quantities. I had a couple of these on Saturday - one in the ambulance, and another sometime during the ER or Cath Lab adventure.

So...now I take a cholesterol reducer, two anti-clotting drugs, and a beta blocker, and I have my "emergency pills". I'm still not sure how I feel about all of this, but if these reduce the potential for a recurrent of the symptoms, I will gladly take them!

What, pray tell, is a Stent?

Here's a nice, boring description of the procedure that brought me home.

Not long after my second "reboot" in the ER, the Cardiac Surgeon was explaining treatment options to my wife and daughter. The Left Anterior Descending artery (LAD) was blocked and needed to be opened up. He discussed that there is a nonzero chance of complications, but that the procedure was important to start quickly. We all agreed that the current situation was not desirable, and told them to proceed.

So they prepped me in the ER (shaving - youch!) and sent me to the Cath Lab, which is where they perform Angioplasty and insert the stents.

They enter the artery at the groin and thread a tube inside the artery to reach the right spot near the heart. They insert dye into the tube to make the contrast stand out more on the screen (GE Medical Systems equipment). I could turn my head and watch the video of the tube moving and various things, but I didn't really know what they were doing. It took a team of three to make it all happen - one on the "steering wheel", another supporting him (operating the air line and dye I think), and a third to grab the needed parts.

Reboot number three happened in the lab. I don't know why, but it was before the procedure had been completed. Probably because the pipe was still clogged.

I did some reading on the whole procedure, called Coronary Angioplasty. Here's a great explanation of the procedure. Basically after the tube reaches the destination, they inflate a balloon which pushes against the arterial walls and opens up a passage through the plaque or other blockage. Once that's done, they insert a stent (a metal matrix), which is expanded by the balloon and, once in place, holds the arterial walls open.

I got three stents installed during my session. Here's a photo of a stent very similar to those inserted into my artery last Saturday:
You can see that it is a hollow matrix or scaffold made of stainless steel, and once inflated by the balloon, holds its shape. This one is also coated with a specific drug that is used to discourage rejection. It's called a "drug-eluting stent". For the first 120 days, it will secrete a drug to keep from accumulating stuff on its surface. Mine are brand name Promus, made by Boston Scientific. Hmm, I wonder if I can get a "Powered by Promus" T-shirt? Not many people would get it - it would be considered an inside joke - pun intended.

This whole session from arrival in the lab to leaving, seemed like maybe an hour. Once they removed the tube, they had to put a pressure dressing on the insertion site to keep from bleeding. I had that on for several hours and was instructed to not move my leg for about 12 hours after the procedure. Bleeding risks are increased after a heart attack, because I had lots of clot-reduction drugs in my system.

The Heart Attack occurred around 5:30 on Saturday. By 7:30 PM I was recovering from the Cath Lab procedure and was actually on my feet standing on Sunday morning.

I now carry a card that describes the location and nature of the stents. They will be there forever. The card describes what medical people should do in the event that they need to do an MRI, as the stents are metal and might be impacted by the strong magnetic fields of an MRI.

So, here's to the medical and scientific community that can put a man's heart back in order in 2 hours, and have him walking a day later!

There was no white light

It's still crystal clear. We were at a marching band competition in Massillon Ohio, nearly 3 hours from our house. I was hanging out on the top of a hill, waiting for band awards to end and the marching band to come over for dinner. We had pizza, soda, fruit and other snacks for the kids and support team, and I was the guy guarding the chow and the picnic grove.

As I walked down the hill toward the car, it came over me. Right in the middle of my chest. It wasn't bone-crushing hurt, but enough that I couldn't think of anything else. Panic and troubled breathing. I tried to sit down, lay down, nothing worked. I thought it was maybe a bad case of heartburn from our lunch, but something told me this was more serious.

I popped open the cell and called Bruce. He's another band helper (Pit Dad) and we had just traded numbers not 2 hours earlier. He answered and I told him I was having chest pains and could he get over to the picnic area. Not 30 seconds later I see him barreling down the hill like a fullback. He took one look and called 911. He found a couple aspirin which I took, and set me beside a tree.

It could not have been more than 2 minutes until the first responders arrived. They quickly put a portable EKG on my chest, and started the interview process. Maybe 3 minutes later the ambulance arrived and off we went to the local Affinity hospital ER. On the way, the guys gave me a Nitro tablet and started the IV. By the time the ambulance pulled up at the hospital, much of the pain had gone away.

Once we hit the ER, things moved very quickly. A hundred questions: No, I didn't take cocaine. No, I don't smoke. Another IV started in the right arm. The specialists were pointing at the first remote EKG strip, and they could tell exactly where the problem was. Something about an artery.

Lots of noise and confusion. Then: nothing.

Absolutely nothing.

Like someone turned off all the lights, sound and sensation.

No white lights, no out of body, just nothing.

Then: all the switches came back on at once: hearing, vision, sensation. I had no idea where I was for a bit, not accustomed to seeing ceiling tiles and faces. Then it came back to me and I realized where I was...but not what had happened. I thought I had passed out.

It was a bit more than that. I am told I flatlined twice in the ER, within about 5 minutes of each other. That team knew exactly what to do, and to my great gratitude, did it well. I still have some tender spots from the paddles, but I'm really not complaining.

I don't know why it happened to me. I'm 46. I'm pretty healthy, slightly overweight, and I run 10 miles a week. I'm a blood donor and have strong vitals. I don't have a strong family history of heart disease. But my artery plugged up and the result was a heart attack and 3 cardiac arrests in one day.

This is obviously a significant life event. Other than the three "reboots" and the discomfort of the treatment and recovery, I don't feel all that different. But that by itself is the miracle. How a heart can be restarted and the body and brain picks up and can keep going is truly amazing. It is possible because I was in a place and with people who could treat me as soon as it happened. Had I not been in the hospital when my heart stopped, it would have been much worse. My brain and heart did not suffer for lack of Oxygen for very long, so I had even my short term memory after I came back.

But I know things will change. I have an injured heart. I will have limits where there were none before. I have to back off on some of the stuff I do. I have to get my affairs in order: a will and more. Time to grow up I guess.

I'm home. I can't thank enough the medical professionals, close friends, family, clergy and co-workers who offered support and concern for my family. It was a very rough few days, more I think for my wife and daughters and family than for me. Believe me, I thank each of you for caring.

I don't know where this blog will go. It's more for my own good to document my thoughts and journey into cardiac recovery than for any other purpose. If you find it to be useful, or if it persuades you to get a checkup or change a lifestyle, then it will be good for more than my personal therapy.

Here's a photo that I asked my wife to take of me today, as I was released from the hospital. Note the Halloween decorations in the yard off to the right. That wasn't intentional, but I'm real glad to be standing in front of the fake graveyard at this point.