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Other names: Simvastatin, Simvoget

LIVING A DYNAMIC, ACTIVE LIFE AFTER HEART ATTACK: LIGHT EXERCISE
Gone are the days of “no pain, no gain” and going for the “burn”. After scaring off most of the adult population by stressing the importance of all-out physical training programs, the scientific and medical communities have now come to the conclusion that it just doesn’t take very much at all to achieve cardiac fitness.
The fact of the matter is that for some individuals, just getting up off the couch to change the channel rather than using the remote control may get the heart rate up. No, I’m not exaggerating that one bit. Many men and women have done absolutely no exercise for years. For them, a walk needn’t even be brisk to increase the heart rate.
What we’re seeing today in the ever-expanding data coming out of research laboratories is that a performance fitness training rate isn’t the same as a cardiac fitness rate. That is to say, a young man or woman who’s training to compete in track and field contests will push the heart rate to 80 to 90 per cent of maximum for his or her age. But there’s no need to do that in order to achieve cardiac conditioning. Bringing your rate up to 60 or 70 per cent, in fact 60 to 70 per cent of a submaximal heart rate attained on the treadmill, will get you where you need to go for your heart’s fitness.
Dr Henry Miller, medical director of the Bowman Grey School of Medicine in Winston-Salem, North Carolina, goes even further. He conducted a study that found no difference in the recovery of heart attack patients whether they were on a low- or high-intensity exercise regimen. Dr Miller says, “You have to do something to increase the use of your muscles, to make your heart rate come up, but I don’t think there’s anything really magic about getting your heart rate up to 80 to 90 per cent of max.” He believes that even activities which will bring your heart rate up to 40 per cent will provide a healthful effect.
Dr Miller’s opinion is shared by Dr Arthur Leon, professor of epidemiology at the University of Minnesota. He reports that working in the garden and on the lawn, making home repairs, and even participating in sports such as golf, hunting and bowling all appear to reduce coronary risk.
Dr Leon bases his conclusions on an analysis of nearly 13,000 high-risk men who participated in the coronary prevention study known as the Multiple Risk Factor Intervention Trial, commonly referred to as the Mr Fit study. Individuals were divided into three groups: those whose activity level was termed “light” as defined as 15 minutes of light activity per day; moderate, defined as 47 minutes of light activity daily; and heavy, with 134 minutes of light activity each day.
Men in the moderate group showed a marked reduction in coronary heart disease compared with men whose activity level was defined as light. Interestingly, there was little added advantage in being the most active.
Dr Leon says that an average increase of about half an hour a day of “predominantly light and moderate physical activity” reduced by one-third the risk of heart disease, sudden death and heart attacks in this population of middle-aged men at high risk for coronary heart disease.
What kinds of activity was Dr Leon referring to? In order, the most popular activities in the groups studied were: lawn/garden (84%); walking (70%); home repairs (64%); water sports, mostly swimming (56%); other sports, notably bowling (52%); dancing (40%); biking (25%); and golf (25%). Only 12 pet cent reported themselves to be joggers.
What level of exertion do you have to reach to get the beneficial effects? In Dr Leon’s group, moderately active people averaged only about 6300 kilojoules a week of activity.
In Dr Ralph Paffenbarger’s study of Harvard alumni, research subjects who exercised enough to burn 8400 kilojoules a week were a third less likely to have died over the course of the ongoing study than those who got little or no exercise. In fact, those who did very heavy exercise, burning 14,700 kilojoules or more a week, had a higher death rate than those in the moderate-activity category.
The watchword is to take it easy, to start off slowly and surely. Dr Peter Raven, head of the department of physiology at Texas College of Osteopathic Medicine and the 1990 president of the American College of Sports Medicine (ACSM), says it should take 12 weeks to develop a good exercise program. “If you take that kind of time you’ll stop the injuries and the muscle soreness that often accompanies the beginning of any activity program.”
You’ll recall the study done in Dallas at the Institute for Aerobics Research in which both men and women benefited from an increase in physical activity. Subjects fell into one of five categories of fitness, from level one (virtually inactive, literally the couch potatoes), to level five (serious joggers and runners who put on 65 kilometres or so each week).
Not surprisingly, couch potatoes fared worst, with the highest rates of death from heart disease and other causes. As one left that group and entered the next level or two of light to moderate activity, death rates dropped precipitously. But, much to the surprise of the researchers and others who had long advocated a “the more the better” approach, those at the highest levels of fitness didn’t do much better than those moderately active individuals.
Dr Steven Blair was the principal investigator of the study, which was published in the Journal of the American Medical Association. He attended the 1990 meeting of the ACSM and put his feelings quite bluntly: “The public health message needs to swing a bit and we need to get people off their butts and up and moving, even if that just means getting them out for a 15- to 20-minute walk once or twice a day. I don’t care what their heart rate is! There is certainly evidence that that kind of light to moderate activity produces health benefits.”
But how does one define that level of activity? Dr Blair thinks that if one exercises hard enough to increase the breathing rate noticeably and?assuming that you’re not in a cold climate?you sweat a little, that’s hard enough.
Dr William Haskell, professor of medicine at Stanford University, supports this opinion. Speaking at a meeting of science writers I attended, he said that burning 1050-1260 kilojoules a day is sufficient to substantially reduce the risk of heart attack. That translates to a brisk 30- to 45-minute walk.
In fact, you don’t even have to do it all at one time. You can do that walk in short spurts of 10 minutes or so each. That means you can park your car a kilometre away from your appointment, walk to your destination, then walk back. Dr Haskell believes you can divide your day’s activities even further. You might want to do three or four 10-minute walks a day. Or you might prefer to do a little walking, a little gardening, a little work around the house, and then maybe a bicycle ride in the late afternoon. Another day it might be a swim. The important thing is to make that exercise a regular, routine part of your daily existence.
*77/85/2*

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DIETARY AND NUTRITIONAL FACTORS IN CIRCULATORY DISEASE: THE FRUIT FACTOR AND COMPLEX CARBOHYDRATES
Some people wanting to control cholesterol levels prefer to breakfast entirely on fruit. This is excellent provided fruits are washed, peeled or scrubbed to remove chemical sprays, or are (preferably) organically grown. Fruit should be taken apart from other foods, when digestion of them will be rapid and provide energy within half an hour of consumption.
Fruit juice should be taken pure and not too often as juice sources contain concentrated fruit sugars which can lead to excessive sugar consumption without the benefit of the fruit fibres ingested from whole fruit.
Complex Carbohydrates-These are very satisfying to eat as they do not disappear from the stomach too quickly leaving the eater hungry between meals. Brown rice is a wonder food, as is wholewheat pasta, the friend of those with arterial disease, provided the accompanying sauce is not rich and preferably not too meaty or fishy either. Buckwheat and couscous are two other grains worthy of dietary consideration.
Beans (lentils and pulses) require new cooking skills to be learned but have their definite dietary rewards. Some may find them indigestible, though, as they are a mixture of starch and protein. This brings us to a principle which stands all age groups in good stead but especially favours those who have reached middle age – food combining.
*76/104/2*

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ANGINA AND SELF-HELP: INVOLVING PROFESSIONAL PEOPLE
There is little doubt that involving professionals in the running of a support group is useful. Having professional people involved can give the group a higher profile and status in the eyes of people with angina and in those of the people involved in making decisions about giving grant aid. They may act as links with speakers you may wish to involve in the group and they may offer essential advice on topics that members will be asking questions about, for example, diet, exercise, medication and stress.
The key professional to involve in an angina support group is a sympathetic cardiologist. He/she may act as a recruitment agent for new members, may offer his/her skills by educating the group about their angina, and also may have access to other professionals and/or organizations the group may want to use.
If there is a psychologist available, he/she can also provide expertise on stress management, stopping smoking, training group organizers, individual therapy or counselling for those who may require it and can provide links with other professionals.
The third person it is helpful to involve is a physiotherapist, preferably one who has experience of cardiac rehabilitation. He/she can provide information on exercise and enhancing the self-management of fitness and angina in a safe and enjoyable way.
You might want to think about involving a dietitian, who can give advice on healthy eating, diet for reducing weight or high cholesterol. You may also want to involve a social worker or rehabilitation counsellor to advice on disability benefits or reemployment opportunities.
The extent to which you involve these other people will be a personal decision, but the main reason for doing so will be to help you build on your skills to manage your angina safely and expertly, thereby enhancing your quality of life.
There are many professional charity workers or voluntary body co-ordinators who will be happy to be consulted about organizing and co-ordinating (eg. National Council of Voluntary Organizations in London). Keeping a list of key people in the relevant organizations which, in Britain, include the Chest, Heart and Stroke Association and British Heart Foundation, is recommended. These people have access to nationwide communication networks which your organization can both contribute to and benefit from
*76/108/2*

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RISK FACTORS FOR CORONARY HEART DISEASE: OBESITY
Being overweight is a large (pun intended) problem in North American society. It is probably equally related to the relatively high-fat diets that we consume, and our lack of physical activity. Although being overweight is not in itself the most important risk factor for coronary disease, it is associated with a higher likelihood of diabetes, high blood pressure, less physical activity, and thus at least indirectly with a higher likelihood of coronary heart disease. In addition, being overweight impairs quality of life, since it makes it more difficult to perform pleasurable physical activities such as walking or traveling, and since patients’ self-image is improved by maintaining a normal weight. Achieving and maintaining a normal weight is a daunting and difficult task. We suggest to our patients that weight loss not be seen as an isolated goal in the process of cardiac recovery, but as part and parcel of increases in activity level, gradual but permanent changes in diet and modification of other risk factors. Slow, gradual weight loss is preferable to a sudden dramatic loss of weight, and this type of weight loss is more likely to be maintained in the long run.
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CARDIAC REHABILITATION AT HOME
While I strongly advocate a structured, medically supervised cardiac rehabilitation program, there are admittedly times when this is simply not possible for all patients. You may live in a remote area, too far from the nearest facility. You may lack the insurance or the financial ability to pay for such a program yourself. Whatever the reason you cannot enroll in a formal program, you owe it to yourself to engage in a home-based effort to the very best of your abilities.
Talk with your doctor about this. You’ll need to undergo a detailed physical examination including a treadmill exercise test to work out your personal exercise prescription. The physician will need to rule out severe myocardial ischaemia (whereby your heart is getting insufficient oxygen) and dysfunction of your left ventricle.
Ask whether you might be able to join an abbreviated supervised program for two to four weeks. This will get you started on the right course and will enable the health professionals to detect any difficulties and to answer your questions on a regular basis as they occur.
If working out at home, you’ll need to have your treadmill test updated on a regular basis to allow you to go on to the next level of exertion. There are also programs by which patients can attach their own electrodes to their chests and send the cardiac information over the phone by way of special equipment and a telephone modem.
As in medically supervised programs, keep your home activities to a low level at first. It’s far better to gradually increase your work load than to overdo it at the beginning. If at all possible, it’s best to work out on a number of different types of equipment. Vary your exercise as much as possible, both to utilise and condition all your body’s muscles and to maintain interest. Alternate walking, biking, swimming and gardening.
You may decide that you do want to buy or lease at least one piece of equipment to use at home. When the snow is flying, the rain is falling, or the temperatures are sinking or soaring, having a treadmill or an exercycle at home can be a real blessing.
The variety at your disposal is formidable, and I’d advise you to check out all your alternatives before making a decision. Many stores offer a lease or a rental with a purchase option. That way you can see if you’ll really use the equipment and decide if this is exactly what suits your needs.
In addition to exercise, spend some time doing gentle stretches during any activity session. To derive the greatest advantage of stretching in terms of increasing flexibility and preventing aches and strains, do a bit of warm-up exercise first. The ideal approach would be an easy 10-minute ride on a stationary exercycle, followed by about five to eight minutes of stretches, then on to another 35 minutes of aerobic activity, and finishing up with about five minutes of cool-down until your heart rate returns to its resting range.
By all means keep tabs on your heart rate. Take it before, during and after your exercise, and make certain that you don’t exceed your exercise prescription. This is definitely not the time to believe that if a little is good, then more must be better!
Keep an accurate log of your activities, marking the date, time, type of exercise, heart rates and comments. Share your diary with your doctor whenever you see him.
There’s no question that a structured, hospital-based program is more efficient in getting you started. But you can definitely achieve a successful recovery by way of a home-based approach. You’ll need more self discipline and motivation, but it can be done. Good luck!
Whether working in the hospital or at home, remember the story of the man in England way back in 1772 who achieved a remarkable recovery by sawing wood. We’ve come a long way since those days, and a long way since the time when heart patients were kept in bed. We know today that while doctors, cardiologists, surgeons and others in the health team can do much to get us off to a good start, in the long run it’s still up to us as individual patients to make total recovery a reality.
With every step you take, with every turn of the cycle pedals, with every stroke in the swimming pool, think of yourself as getting closer and closer to becoming a former heart patient!
*73/85/2*

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RISK FACTORS FOR CORONARY HEART DISEASE: DIET
The question of diet has received much discussion in both the scientific and the lay press. There are many books entirely devoted to diets or dietary advice for patients with heart disease, and it is not our intention to give an exhaustive review of the relationship between diet and heart disease.
In our view, attention to diet is an important component of the journey of recovery from heart disease. However, diet alone cannot cure and, for almost all patients, cannot reverse heart disease; we do not feel it is realistic to expect that any diet, however stringent, can by itself cure or reverse hardening of the arteries. This is especially true in the “real-life practices” that we see among our patients, most of whom do not have the time, resources and opportunity to follow the very particular and sometimes stringent diets occasionally advocated. Most North Americans find a very low fat diet unpalatable, and it is unrealistic to expect most patients to adhere strictly to a diet very different from the one they have been accustomed to for perhaps fifty or more years. Although a great deal of emphasis has been placed on reducing the amount of cholesterol in the diet, by avoiding red meats, eggs, whole milk and other cholesterol-rich foods, most of the cholesterol in the blood is manufactured by the liver and does not come from dietary sources. In addition, the best way to lower cholesterol in the blood is to limit the fat content of the diet, rather than limiting cholesterol alone.
An important aspect of paying attention to one’s diet is the opportunity for weight loss, which not only leads to a reduction in the risk of development or worsening of heart disease, but improves well-being, self-image and exercise tolerance. We feel that the best way to change one’s diet is to develop a different relationship with food, rather than to be excessively vigilant about the calorie and fat and cholesterol content of every bite or every meal. In general, the healthiest diets are the ones that are rich in fresh fruits and vegetables, bread or other grains, and skim or low-fat milk or milk products. These diets will include less meat than most North Americans regularly consume, and definitely less fat. In general, prepared foods (especially those served in fast-food restaurants), desserts and snack foods are high in fat and calories. The best example of a healthy diet is that taken by people in the Mediterranean region, and scientific studies have shown that this diet reduces coronary events. The Mediterranean diet primarily uses olive oil as its source of fat, and contains a lot of pasta, grains, fruits and vegetables, and fish, and relatively little meat and convenience foods.
From a practical perspective, limiting between-meal snacks, and cutting intake of meats and rich sauces (containing butter or oil), is a good start to a heart-healthy diet. It is important that diet be understood as a lifelong habit of healthy eating, and not as a temporary change in eating habits designed to lead to weight loss alone. Heart disease takes many decades to develop, as we stated before, and dietary changes cannot be expected to alter this process very quickly. In fact, it may take many years, or even longer, for the benefits of a change in diet to be observed.
Specific aspects of diet or dietary supplements deserve mention. Patients who eat fish more often appear to have a lower incidence of heart disease, especially those who eat fatty fish such as salmon. It is not clear if it is the fish itself that is protective, or whether these patients in general tend to have better diets. Fish-oil supplements, available in capsule form from health food stores, have been advocated by some to protect against heart disease, but in our opinion the evidence is inconclusive. We do not recommend fish-oil supplementation to our patients, although the risks are probably small. Vitamin E, present in vegetables (especially green vegetables) and other foods, is an antioxidant and may protect against heart disease. Again, the evidence for this is inconclusive, and large scientific studies are being conducted at this moment to see if vitamin E supplements can prevent the worsening of heart disease. Until the results of these studies are available, we do not generally recommend vitamin E, although the risks of taking it are probably quite small.
A great deal of research has been done on the effects of alcohol consumption on heart disease. Although no research study has ever truly compared alcohol as a “drug” and a “placebo” in the manner discussed above, it seems quite clear that individuals who drink moderate amounts of alcohol (generally defined as two or at most three standard drinks (a bottle of beer or a glass of wine) per day have a lower likelihood of developing heart disease than those who drink no alcohol or who drink higher amounts. Although there are theoretical reasons to believe that wine, especially red wine, may be more likely to be beneficial than other forms of alcohol, this is by no means clear from the research studies performed. Alcohol in any form is known to raise the level of “good cholesterol”, and this may be the mechanism of its benefit. We do not advocate taking alcohol as a medicine or a drug, but would certainly agree that moderate alcohol consumption is not dangerous, if this is a habit you already have. It is very clear that alcohol consumption, especially in excess, carries potential health risks, most especially the risk of impairment in operating motor vehicles, the possibility of liver disease, and the enormous social and economic costs of alcoholism. The advice about alcohol is therefore not to be taken lightly. Nevertheless, if you find a glass or two of wine or a beer with your meals or on social occasions to be pleasant, we advise that you continue this practice.
The question of the effect of caffeine on coronary heart disease is not entirely settled. Although there is much folklore surrounding the effects of caffeine, which can definitely cause jitteriness, palpitations and anxiety if taken in large quantities, there is no clear reason to believe that caffeine is dangerous for the heart. It is extremely difficult to disentangle the effects of coffee from other factors that may influence heart disease, since individuals who drink a lot of coffee may be more likely to be anxious, for example, more likely to smoke, and may be likely to have a different diet than non-coffee drinkers. It is prudent to avoid very large amounts of caffeine, but the occasional cup of coffee is very unlikely to be harmful.
*72/214/2*

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RISK FACTORS FOR CORONARY HEART DISEASE: DIABETES
Diabetes is a very common disorder that results from inability of the body to use sugar in the blood (the main form of sugar is called glucose), one of the main sources of energy for the body to perform its functions. Glucose from the blood enters muscles and other tissues under the influence of the hormone insulin, which comes from the pancreas gland. Diabetes is a condition in which the glucose in the blood cannot be taken up by muscles and other tissues, either because there is an insufficient amount of insulin released by the pancreas, or because the insulin that is available cannot work effectively.
Diabetes is commonly thought of as an illness in children or young individuals, who usually need insulin by injection one or several times daily, because their pancreas produces no insulin at all. This severe form of diabetes is fortunately relatively uncommon. Very much more common is another type, known as type II diabetes; patients with this type do not usually require insulin by injection, although they need to take drugs by mouth to lower their blood-sugar levels. This more common form of diabetes is a very major risk factor for coronary heart disease, and is closely related to obesity, or being overweight. A set of conditions, including excess weight, high blood pressure, diabetes, and high blood fats known as triglycerides, has been termed syndrome X. Patients with this syndrome are extremely prone to coronary heart disease, and the condition improves markedly with exercise, weight loss and a low-fat diet. Contrary to popular belief, for most diabetics the most important dietary advice is not to restrict sugar, but to maintain a normal weight and to limit fat intake. Many diabetics have only slightly elevated blood sugars, and may be unaware that they arc diabetic unless they are specifically tested.
*71/214/2*

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CARDIAC REHABILITATION: JOINING A STRUCTURED PROGRAM
Despite all the marvellous things that can be said about a formal cardiac rehabilitation program, the sad fact is that only a small percentage of patients take advantage of it. In fact, since the participation rate is so low, some critics have suggested getting rid of all such efforts! That’s like saying since antibiotics work only for those who take them when prescribed, that all those pills should be tossed out. Ridiculous.
Some have pointed to the high costs of a structured rehab program. The irony here is that no one argues against the use of physical therapy for recovery from broken bones and other orthopaedic injuries and surgery. Such programs are also expensive. But they work. In the case of cardiac rehabilitation programs, they work too. And they can save your life.
Unfortunately, not all physicians have read the documentation on effectiveness of such programs in the medical literature. Physicians who become involved with cardiac rehab programs will see the results: they’ll see their patients get better. When that happens, more doctors will recommend such programs.
Actually, doctors themselves benefit when their patients enter rehab. Such patients tend to ask fewer questions, since they have them answered during their sessions. They’re easier to work with since they’re better informed and better motivated, with a better attitude. And they have a better long-term prognosis.
Talk with your doctor about rehab programs at your hospital or in your area. Don’t let him tell you that taking a walk now and then is “just as good”. Demand your rights to have the best possible care, with the best possible outlook for the future. When you need a fine-tuned sports car to win the race, nothing else will do. Your doctor or the cardiology department at the hospital will have information on rehab programs in your community.
*72/85/2*

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DIETARY AND NUTRITIONAL FACTORS IN CIRCULATORY DISEASE: TRIGLYCERIDES
Some doctors believe that high levels of these in the blood are even more dangerous than high cholesterol levels, as an increased level of these make the blood more viscous and more likely to produce clots which might lodge in narrowed arteries. Although an important energy source, most people eat far too much of them. Two examples are cream and fat on meat.
A number of studies have confirmed the benefits of taking both kinds of EFAs as supplements to the diet. One interesting study by the Medical Research Council in Wales divided men who had already had a heart attack into three groups: one of which was asked to cut down on fat intake, the second to take a high-fibre diet, the third to eat (or take as supplements) oily fish regularly.
Although all three of these measures are known to reduce fat levels in the blood, a third fewer men died of a second heart attack in the fish group after two years than the other two.
*72/104/2*

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ANGINA AND SELF-HELP: BEGINNING A GROUP
The first step is to do some market research. Find out whether there will be enough interested people living in your area. This can be done by going along to your cardiologist’s outpatient clinic and asking the people who attend. Alternatively, you could ask your GP to put you in touch with other people on her/his list who have angina, or put a simple notice in the waiting room of your local surgery or in your local newspaper. Remember, at this stage you are just trying to find out how many people with angina want a group and how many would help to organize one.
Once you have ascertained there is a need for your group, then you can think about some practical arrangements. If you have not already done so, approach your cardiologist, discuss your ideas with her/him and solicit her/his support. More about this last point in the section on involving professionals on page 189.
Money
You will need some financial assistance for this project. Obviously, the more the better, but you can begin with just enough to pay for a room to be hired and to cover the costs of your attenders’ refreshments. Go to your local library and ask for the Charities’ Handbook. This is a list of all the registered charities in Britain, some of whom will donate small sums of money to getting a group started. (In other countries, ask your local library for a list of charities.)
Once you have a list of the appropriate charities, cost out your application for grant aid. Some useful things to consider are:
The cost of room per meeting,
Refreshments,
Publicity materials,
Organizers’ costs (telephone bills, stamps, letter paper, etc.),
Payment for speakers for the year,
Any necessary equipment purchase.
Most starter grants will cover these costs. However, you may wish to be a bit more ambitious and ask for writing materials, a typewriter, tape recorder or video recording machine to educate your participants. You may not get what you ask for but you may get some help towards the total cost.
It is advisable right from the very beginning to keep meticulous accounts. This will ensure that your sponsors are aware of where their money is being spent and it will help in the future running of the group and reapplication for grants.
Once you have been given a sum of money to start a group, you need to enlist the help of at least one other person and open an account to hold the money. Then begin to concentrate on advertising your group.
Going public
The first step is to let people know you exist. Contact local GPs, your cardiologist, local hospital coronary care units, other coronary support groups, put up notices in local shops and in your local newspaper. Maybe even contact local radio and/or television stations and ask if they are interested in doing an article on your group. When advertising yourself, bear in mind the following points:
Let people know the name of your group – avoid names such as ‘The Victims of . . .’, ‘. . . Sufferers’ or ‘. . . Cripples’. Consider – would you want to join a group which suggested hopelessness or inferiority? Be positive.
Give people the name of someone to contact and an address or telephone number – consider whether this contact person should be you. Bear in mind that you might be inundated with requests for information.
Make explicit the aim of your group – keep this simple, perhaps along the lines of ‘to offer support and education to people with angina about angina’.
Make it clear who the group is for, i.e. all people with heart disease? People with angina only? Families of people with angina?
Make your advertisement eye-catching, light and even amusing, but most of all make your main message clear and precise.
*72/108/2*

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Other names: Urispas

ANGINA AND SELF-HELP
This article concerns the main points of beginning and maintaining a support group. It gives you advice on how to select group leaders and gives a description of the key workers within the group. It covers the role of professional involvement and suggests why you should involve these people in the group. The experiences of the South Birmingham Angina Group, which has been running for three years, is discussed, its successes and failures, its aims and objectives, and a typical year in the Group’s life is charted.
Social support can act as a buffer to stress. Self-help groups are one form of this buffer. They allow people who are experiencing the disease to support others who might be newly diagnosed, or who might be experiencing greater difficulties. Another important function of a support group is that the members can concentrate on the things that they can do as opposed to the things that they can’t do. Support groups have proved popular for a number of health conditions and are at last being recognized by doctors as a necessary part of the complete management of an illness. Last, but not least, a theme which is emphasized throughout this book is that of the patient taking an active interest in the management of her/his condition. Support groups promote this sense of responsibility and self-reliance.
The following guidelines are based on three years’ experience of running a support group for patients with chronic stable angina, and hopefully will encourage more people to participate in a support group.
However, all support groups will be different because the people within them will be different, and each of the suggestions will have to be adapted to fit the group that you may be a member of.
Caution – group organizers at work!
One of the most important points about starting a support group of any kind, but particularly an angina support group, is to make sure that you, the organizers, have support! Having angina often means having to accept that you will have days where energy levels are low, so it is important to plan for these days and therefore reduce the frustration that this brings. If you intend to begin a support group, this will have to be considered and allowed for.
Forming a support group is tiring, often frustrating, sometimes hard work and time-consuming, but can be fun, very rewarding and gives some people a new lease of life. The advantages have to be weighed against the disadvantages before you begin; otherwise, if the group does not function well, the participants will experience having their hopes and expectations raised and then dashed and the organizers will experience a sense of failure.
*71/108/2*

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THE ELDERLY AND CARDIAC REHABILITATION
In its report on cardiac rehabilitation services, the US Department of Health and Human Services covers the benefits of rehab programs for the elderly. The conclusion is simple and straight to the point: “Although the absolute work capacity of the over 65 group was significantly lower than that reached by the younger groups, the magnitude of favorable change was equivalent.” And no additional risk due to greater age was found. The elderly patients benefit from early rehab in the same ways that younger individuals do; they experience enhanced functional capacity and improved psychological outlook.
A number of studies back up those conclusions. The effects of exercise training in 60- to 69-year-old patients with hypertension were studied by researchers at Washington University in St Louis. They found that both low- and moderate-intensity training lowered blood pressure.
Older patients who exercise have a brighter outlook both literally and figuratively. A Stanford University study demonstrated that older people who exercise have better thinking than those who don’t. Those who exercise regularly do the best when tested in the areas of vocabulary, memory, reaction time and reasoning. Those who exercised the most tended to regard their health as better and showed more satisfaction with their lives.
*71/85/2*

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DIETARY AND NUTRITIONAL FACTORS IN CIRCULATORY DISEASE: EFAS AND CHOLESTEROL
To eat fats in an attempt to reduce them may seem like a contradiction in terms but essential fatty acids (EFAs) are what is needed to restore the balance between HDL and LDL cholesterol: they contain omega 3 which helps to balance cholesterol in the blood. There are two groups of EFAs: the fish oil group which can be taken in tablet form (preferably not cod liver oil which as its name suggests, comes from the liver), and EFAs from seed oils such as sunflower, borage flax and evening primrose. (GLA is the name given to a refined extract of the vital component). Both should be taken and, since they are enriched forms of foods already found in nature, generous amounts are quite safe.
Cholesterol levels can also be lowered naturally by taking garlic and by taking one of the B group of vitamins, such as B3 or niacin which has been widely used in Europe for this purpose for almost four decades. Caution should be exercised, however, as in high doses certain forms of B3 have been seen to affect liver function and nutritional advice is needed.
One form of B3, inositol hexacotinate, is thought not to have these deleterious side effects, yet lowers cholesterol levels efficiently, whilst the inositol part of the compound protects the liver. This is achieved without any of the side effects of straight B3 or indeed of
cholesterol-lowering drugs.
*71/104/2*

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RISK FACTORS FOR CORONARY HEART DISEASE: CHOLESTEROL
There are many excellent resources for patients and families to find out about cholesterol, and its importance in heart disease. We provide only a very brief summary here. Cholesterol is a natural substance found in the blood and body tissues, which is necessary for the body’s normal functioning. Most of the cholesterol in the blood is manufactured by the liver, and does not come directly from the diet. However, a diet high in fats, particularly so-called saturated fats (found in animal products, whole milk or butter, and certain plant oils) leads to a higher cholesterol level in the blood since more is manufactured by the liver. Since cholesterol is a form of fat, and since it doesn’t mix with the water in the blood, much as oil and vinegar do not readily mix in a salad dressing, cholesterol is transported or ferried around in the blood in transport modules called lipoproteins. Cholesterol packaged in low-density lipoproteins is so-called bad cholesterol, since it is this type of transport module that carries the cholesterol to blood vessel walls, where it may settle, ultimately causing and contributing to hardening of the arteries. To simplify, cholesterol packaged in high-density lipoproteins is more likely to be carried away from blood vessel walls, and thus this carrier transport can ferry cholesterol away from blood vessels where it does the most damage. High-density lipoproteins are thus “good cholesterol.”
There is now very clear scientific evidence that the higher the blood cholesterol, the greater the risk of developing coronary heart disease. The level of blood cholesterol in a given person is largely genetically determined, but can be slightly to moderately altered by diet. However, even with the most stringent diet, blood cholesterol can usually not be lowered by much more than about 20 percent.
Recent scientific studies have shown that patients with high cholesterol, or even so-called normal cholesterol (that is, at the average for Western society), can reduce their risk of heart attack or death by taking cholesterol-lowering drugs known as statins. Although it seems less artificial to modify the diet in order to lower cholesterol, there should be no shame or guilt attached to taking a drug to lower cholesterol, especially when such drugs are undoubtedly effective and rarely cause side effects. It should be remembered that taking cholesterol-lowering drugs is not a license to eat high-fat foods; rather, such drugs should be part of a treatment program that includes a sensible low-fat diet and exercise.
How does cholesterol wreak havoc in the arteries?
Although we are not entirely certain how it happens, cholesterol is probably deposited inside the cells lining the artery walls, called endothelial cells, where they can go through a chemical process known as oxidation and become irritants that stimulate the blood vessel walls to essentially form a scar. This scarring includes deposits of extra muscle cells, scar cells (fibrous tissue) and calcium. Although “hardening of the arteries” eventually leads to precisely what the term implies?rock-hard and stonelike blockages of the arteries?initially this process involves soft, fatty deposits inside blood vessel walls that are prone to tear or rupture, leading to clot formation and a rapid increase in the severity of blockage. This is probably why cholesterol lowering, especially the marked cholesterol lowering that can be achieved with drugs, can lead to very rapid diminishing of the risk of heart attack or death, although the deposits themselves may have been building up for years or decades. The important conclusion from recent research studies is that it is never too late to lower your cholesterol, and that the benefits can be seen quite quickly once treatment is started. All patients with a history of coronary heart disease should have their cholesterol measured, and treated to lower the cholesterol level in the blood if it is too high. The more risk factors a patient has, the more important it becomes to achieve and maintain an ideal cholesterol level.
*70/214/2*

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DIETARY AND NUTRITIONAL FACTORS IN CIRCULATORY DISEASE: HDL, LDL, AND LIPOPROTEIN A
To understand why, it is necessary to look at what happens in the body when fats are ingested. Fats in the body are converted into cholesterol (some remain as triglycerides and the level of these in the blood is equally as indicative of likely arterial disease as is a cholesterol level of over six, of which more later).
Cholesterol, being a fat, is insoluble in a water-based solution such as blood, so to be carried about in the bloodstream it has to be enveloped in a water-soluble protein overcoat, known as a lipoprotein (lipo=fat). There are two main divisions of these: high density lipoproteins (HDLs) and low density lipoproteins (LDLs).
LDLs are deployed by the body to transport cholesterol from the liver to parts of the body where it is needed. HDLs carry excess cholesterol back to the liver, but their primary function is to scavenge excess cholesterol which is left in potentially health-damaging places, such as the artery walls, and transport it back to the liver to be broken down and excreted.
Problems arise when there is a shortage of HDLs to facilitate this cleansing process and, lo and behold, we find that the average western diet is fearfully lacking in foods which facilitate the supply of HDLs like fatty fish, such as mackerel, sardines, herrings, and to a lesser extent tuna and salmon and river trout.
The British diet used to include plentiful supplies of such cheap fish as herrings which were once served fresh: now they’re more likely to be canned which affects their efficacy somewhat. Also they have fallen out of favour with the rise of convenience foods and frozen foods for microwave purposes.
There are two levels quoted in blood test results; look for one for HDL and one for LDL. It is ideal if the HDL figure is over 20 per cent of the total.
Other dietary measures for reducing cholesterol include eating less dairy products, fewer eggs (less than four a week) and less shellfish, as well as less meat, except for extremely lean poultry and game.
Eating less saturated fat means being aware of foods in which fat is a hidden or not so hidden constituent, such as sausages, luncheon meat, hamburgers, ice cream, cheese, dairy-based
products, cakes and biscuits, etc. and doing away with them before they do away with you! Making this single change will go a long way towards improving arterial symptoms and health in general.
Processed foods contain the worst kind of fat – known in the trade as hydrogenated. These are designed to prolong the shelf-life of food by, quite literally ‘holding food together’. Unfortunately, because they are not natural fats they are very poorly digested and may end up not just bonding food but bonding to the walls of arteries. Avoiding them could go a long way towards avoiding fatty deposits.
Despite this caveat in respect to processed fats, the taking of some fatty acids in the diet is essential.
*70/104/2*

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ANGINA AND YOUR DIET: BUT HOW DO I CHANGE MY DIET?
You may find that in order to improve your diet you will need to change the eating habits of the people who live with you. To succeed, everyone will need to be involved in making the decisions and everyone will need to be motivated. Probably the best way of tackling the problem is for you all to work through the chapter and then compare the answers you have all given. This way you can come up with a ‘house plan’. Alternatively, they can suggest changes they might like to try from the list of good eating tactics in order to improve their diet.
Remember that any changes you decide to make will have to be practical and right for your circumstances if they are going to last.
It is advisable to make a few dietary changes which you can stick to for life, rather than making several dietary changes for a few months, which then become a chore so the whole new diet is then in danger of being abandoned.
A solution would not be, in the case of a busy family, all to decide to have different evening meals. Even if everyone was prepared to do their own cooking, it would get very expensive and very messy in the kitchen! You may also be more tempted to snack if you see another person eating, even if you only sit down for a chat, having eaten earlier.
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SAFETY OF CARDIAC REHABILITATION
Unfortunately, not all patients are physically able to participate in cardiac rehabilitation. Among the contraindications are congestive heart failure that is uncontrolled, severe damage to the heart muscle with resultant ventricular incapacitation, unstable angina pectoris, thrombophlebitis, severe arrhythmias, and uncontrolled hypertension.
The most complete review of the safety of cardiac rehabilitation was published in a position paper by the American Association of Cardiovascular and Pulmonary Rehabilitation in 1990. The data were collected from 167 programs throughout the United States and involved more than 51,000 patients who exercised for more than two million hours between 1980 and 1984. The rate of complications was one cardiac arrest per 111,996 hours, one heart attack per 293,900 hours, and one fatality per 783,976 hours of prescribed, supervised exercise. The authors attribute this high rate of safety to proper patient evaluations, education, careful exercise prescription, appropriate use of ECG monitoring, well-trained personnel and rapid handling of emergencies. In other words, the safety of a structured, formal program is, by its very nature, much better than would be expected if the patients were on their own.
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KEY PHYSICAL HEART ISSUES: MEDICAL RESEARCH
Just about everything we know in modern medical science is the result of research, usually performed over many years by many individuals in different countries. Modern medicine is vastly different from traditional sciences, such as physics and chemistry, and from other disciplines, such as philosophy. Whereas in these areas individual thinkers or scientists make important observations which may be subsequently observed to be true or not true over time, in modern medical science, developments occur “bit by bit” in an unpredictable pattern, and are very rarely the result of one great mental leap made by one individual. For example, the development of “clot busters,” an extraordinarily important event in the treatment of patients with acute heart attack, and one that is undoubtedly associated with dramatic patient benefit, was the result of decades of research by many different individuals in many different disciplines (including studies of blood clotting; biochemical studies of the drugs; understanding of the relationship between the clotting system, blood vessel wall, and various physical stresses). Clot busters, like all other current treatments, were finally proven to be effective in controlled clinical trials, which are extensive tests of a particular medication or treatment done in patients with the disease in question.
Patients with heart disease and the general lay public are these days bombarded with information about treatments or substances which are alleged to be beneficial in treating heart disease. These include vitamins, diet, drugs, treatments such as chelation therapy, as well as more traditional treatments such as bypass surgery and angioplasty. Although any of these treatments can in theory be effective, and it is natural that patients will be drawn to the simplest, cheapest and least complicated of these therapies, we can unfortunately not be assured that any of these treatments is truly effective until it is properly tested. For medical researchers, such proper testing requires that the treatment in question be compared to some other treatment, usually a placebo (an inactive substance), thus allowing an unambiguous comparison of the test treatment to no treatment in order to eliminate any biases, which are inevitable when human beings, with all of their expectations and frailties, judge human health or disease. Almost all trials need to be double-blind; in other words, neither the caregivers nor the patient is aware of the nature of the treatment he or she is receiving. In practice, this means that a very large group of patients with the disease in question?in our particular example, an acute heart attack?had to be given either the active clot-busting agent or a placebo, and the patients and their doctors and nurses did not know which was actually being administered to any given individual. Patients were all monitored very closely, and at the end of some time period, such as one or two months, the results were compared. In this way, it was proven beyond doubt that patients who had received clot busters lived longer and had less heart damage than those who had not received them. It is important to emphasize that, in the absence of such rigorously performed and very expensive and time-consuming research studies, we can never be really sure whether or not a treatment is truly effective. This is true in almost all situations, unless an illness is usually fatal in the absence of treatment (e.g., appendicitis or severe pneumonia). Since most patients with heart disease recover to some extent even without treatment, such blinded studies are absolutely essential if true benefit from a particular treatment is to be proven.
Therapies which are now universally accepted as being beneficial, such as ASA, beta blockers after heart attack, and treatments to lower blood pressure in patients with high blood pressure, have all been verified to be effective in such clinical trials. Refinement in drug therapy of course continues and has even accelerated in recent years. There are thus many new clot-busting agents available for testing, or new treatments for high blood pressure, which potentially promise to be more effective, safer, or simpler to take and use. Each of these needs to be compared to some standard treatment, usually the currently available therapy in general clinical use. Patients with almost any form of heart disease may be approached to participate in such clinical trials. The usual process is that a patient is identified as having the particular illness or characteristics ideally suited for the testing of a new treatment or procedure. Patients will then be approached to participate in such research trials, and it will be stressed that their participation is entirely voluntary.
Although many patients or their families have justifiable reservations about being an experimental subject, or a “guinea pig,” participating in these studies may give you a chance to receive a new, potentially more effective or safer treatment. You will also have the less obvious but important benefit of being monitored and cared for by a team of very expert individuals. Perhaps not surprisingly, patients in such clinical trials, even if they receive the inactive substance, or placebo, generally have better outcomes than apparently comparable patients who are not part of clinical trials. There is of course no guarantee that the experimental treatment will be effective, nor even that it will be safe. All treatments unfortunately carry some risk of causing harm, whether they are experimental or not; simply, the risk from experimental therapies is less well known although it may not necessarily be higher. For example, plain old ASA can often cause irritation of the stomach lining, and even bleeding ulcers in the stomach, potentially with serious consequences. The fact that these traditional side effects are known and understood does not make them less serious.
The other reason that patients may wish to participate in clinical trials is the knowledge that such tests are the only way to establish the effectiveness of new treatments or procedures, which can potentially be of great benefit to future patients with the illness. In this way, patients who participate in such trials are helping fellow patients have full access to potentially life-saving treatments in future years.
In practice, patients approached for participation in clinical trials will be given information about the study (the trial), including a consent form, which details all of the study procedures, potential risks and potential benefits. Participation in any such research study is voluntary, and patients should never be coerced overtly, or subtly, to consent. Patients also need to know that they can withdraw from studies at any time if they change their mind about participation. Many patients, however, find that the reasons to participate outweigh the reasons not to, and the medical profession has been fortunate in having outstanding cooperation from patients in performing this kind of research. As a result, there have been a number of gigantic studies in the past decade involving many tens of thousands of patients, which has allowed cardiologists and other doctors to be much more confident than they otherwise could have been in their assessment of the efficacy of certain treatments.
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ANGINA AND YOUR DIET: OBESITY
First, being overweight places more stress on the heart, which is not a good idea if you suffer from angina. Second, if you are overweight you stimulate cholesterol production and therefore your blood cholesterol levels tend to be higher, also not a good idea.
If you do need to lose weight:
don’t bother about calorie counting – this is too complicated.
eat plenty of vegetables, fruit and wholegrain foods.
cut down on fats and sugars
take regular exercise. You will burn off calories doing the exercise but, more importantly, you reset your ‘ticking over rate’ and generally burn up more calories throughout the day. It takes more calories to keep a fit body ticking over. Hence, the fitter the body, the easier it is to lose weight.
only weigh yourself once a week, preferably at the same time each week and on the same scales. Aim for an average weight loss of 1-2 lbs (0.5-1 kg) each week.
If you find it difficult to cut out certain foods here are a few tips that may help you:
Eat slowly – this makes meals last longer and you may feel fuller.
Reduce tempting situations for food and eating.
Only keep food in the kitchen or pantry.
Keep food away from the table. Do not put a whole loaf of bread on the table, just the slices you wish to eat.
Avoid passing by a particular shop if you are likely to see foods that may tempt you.
Remember, if you don’t buy the food and it is not in the house you can’t eat it.
Only eat at the kitchen/dining table, not directly from the fridge or cupboards.
Try not to eat when you are doing other things, e.g. watching television or reading.
Have regular meals, particularly breakfast and do not skip meals or you may get too hungry and binge.
Have a stock of low-calorie and healthy, filling foods such as fruit and fresh vegetables to hand if you get hungry. It is better than bingeing on cakes or ice cream.
It is not easy to lose weight. The most important thing is not to go on any crash diets but to adjust to a healthy lifestyle and watch your weight come down gradually.
*69/108/2*

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DIETARY AND NUTRITIONAL FACTORS IN CIRCULATORY DISEASE: DIET AND ARTERIAL FAT DEPOSITS
For some time now it has been thought that fatty deposits seen in artery walls from about the age of 10 are the result of grossly excessive fat intakes characterized by western diets. (For example, the British diet contains no less than 42 per cent fat. Why? Because fat is cheap, fat is tasty, fat is satisfying as it remains in the stomach for longer than starches and proteins, giving a sense of fullness. Needless to say hidden fats in foods and their equally well-hidden additive chemicals, which improve taste and shelf-life further, remain one of the commercial scandals of our
day – together with the vast array of foods containing hidden sugar and salt. These have educated western palates into tastes which are extremely bad for health.)
But fat consumption is not tied up so straightforwardly with cholesterol levels in the blood (known to be tied to heart disease) as was originally thought. Recent research has shown that it is the type of fat consumed rather than (within reason) the quantity, which is connected to both the incidence of coronary thrombosis (clots) and coronary atherosclerosis.
Fat falls into three main categories: saturated, as found in meat, eggs, and dairy products; polyunsaturated, found in most vegetable oils used in cooking and in margarine, and
mono-unsaturated, found in foods such as avocados and olives.
Originally it was thought that people with heart and arterial disease should lower the level of all types of fats in the diet, reducing the proportion to no more than 20 per cent. This makes for a rather unpalatable diet, but on the principle of needs must, many people were advised to follow it.
Nutritional expert Dr Melvyn Werbach suggests that while evidence is irrefutable that the eating of saturated fats is tied to the incidence both of coronary atheroma and coronary thrombosis, the practice of simply reducing or substituting polyunsaturated fats in the diet as many do – such as substituting margarine instead of butter – doesn’t always work. However, transferring the fat content of the diet to mono-unsaturates does protect one from the above conditions, even if fat intake rises to a more palatable 35 per cent of the diet.
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