The Heart Beat

By James Beckerman, MD, FACC

In my last post, I talked about the Dark Side of the Quantified Self — the possibility that becoming too focused on one’s own personal data may begin to diminish our individual real-life experiences and interactions. Mindfulness can be mind numbing if taken to an uncomfortable level. But for every Dark Side, I’m told, there has to be a Force for good. And in the case of the Quantified Self, I see the greatest potential for health improvement in the quiet collection of data that happens without our constant attention.

But don’t get rid of your pedometer quite yet. Pedometers, food diaries, and scales are definitely associated with positive changes in behavior, so we do recommend them as external triggers when we have trouble motivating ourselves on our own. But collecting data under the radar (with consent of course) and communicating it to the right people could potentially offer even more than a health course correction — it could save your life. I think that this is the future of the Quantified Self.

The AliveCor ECG device is an example of cool ideas to come. It’s simple and beautiful — an iPhone case that fits neatly on your phone. You gently press the phone to your chest and the phone automatically begins to record an electrocardiogram tracing which includes information about your heart rate and rhythm. It can even potentially diagnose a heart attack. The data could be sent automatically to a cardiologist who examines your heart’s data and can contact you with any concerns. I recently debuted the device on television and people are already asking when they will be available for sale. This simplicity of data collection, transfer, and health care provider response should be our goal.

So what’s the next step? Because ideally we wouldn’t need to find our iPhone when we develop an abnormal heart rhythm or a heart attack. Someone else would know about it and would be able to help us. Wouldn’t it be great to record this data on an ongoing basis and feed it to a databank which can analyze it and direct us to appropriate health interventions? Enter Everyheartbeat.org, a new platform that will help combine innovative sensors and your mobile phone to upload and track heart data — hopefully for millions of people. Researchers will have access to data to understand our hearts better, and clinicians will be able to give you a call if your heartbeat is irregular, too fast or too slow, or if there are signs of a heart attack. It’s amazing, and it’s really happening.

Would you want to upload your personal health data? Or does it sound too much like Big Doctor looking over your shoulder? It’s true — with big data comes great responsibility… So may the Force be with us.

By James Beckerman, MD, FACC

I admit it: I have a dysfunctional relationship with my running watch.

You may already have your own — or a similar device accessory that logs your calories, miles, steps, stairs, sleep, sitting, or even altitude. This year we’ve experienced an incredible increase in the ability and affordability of wearable technology that serves to quantify us, but it’s not a new phenomenon.

The earliest studies of pedometers demonstrated years ago that the mindfulness afforded by documentation tends to increase our overall activity levels. Fast forward to GPS locators, sophisticated accelerometers, and Bluetooth, which make it possible to develop surprisingly accurate algorithms that monitor where you go and what you are doing — with the goal of having you do more.

The next generation of gadgets will be able to dig even deeper, measuring your heart rhythm, blood pressure, blood sugar, and kidney function. Diabetics will be able to maintain their sugars at safer levels and triathletes will know when they should have their next energy drink. The quantified self is expanding rapidly.

But when does mindfulness actually become mind-numbing?

I had a chance to experience this first-hand a few weeks ago. For unclear reasons, my running watch stopped connecting with the USB port on my computer. I was unable to upload my runs for a few weeks. And in the world of connectivity, this means only one thing: my runs never happened. Because one thing I’ve learned about the quantified self is that if you can’t document it, then you can’t prove you did it. And if you can’t prove you did it, then those early mornings on the treadmill are somewhere in the ether — but unfortunately not in the Cloud.

It bothered me that I even cared. But I recognize this phenomenon as The Dark Side of the Quantified Self — there is a tendency to become so dependent on the secondary gain experienced by documenting our activities that our experience of the activity itself is tied to its documentation.

If you don’t believe me, then check your Facebook account. You and your friends are posting updates, photos, links, and check-ins. Why? Because you really care if the kid who used to pick on you in high school reads some random Jezebel blog post, watches the ukulele duet of Zooey Deschanel and Joseph Gordon-Levitt, knows that you’re killing time at the Gas N’ Sip, and sifts through the fifty photos you posted from dinner last night? Nope. It’s because with status updates, there are “likes.” There are comments. There are shares. It’s because we are, unfortunately, judging our own tastes, experiences, and even (gulp) the cuteness of our kids based on whether our questionably curated group of friends thinks that they are as awesome as we do.

As we use similar technology to quantify ourselves, let’s be careful that we don’t fall into the same traps. Quantity doesn’t always mean quality, especially when it comes to the self.

Even as an early adopter of Facebook and Twitter, and especially as an advocate of mindfulness as a technique to improve health outcomes, I realize our collective tendency to lose the joy of a tasty meal in the hurry to input calories, or to mistake gamification for a true runner’s high.

Sometimes I just want to enjoy the moment for what it really is, not for its “significance” in defining who I supposedly am. I’m reminded of the observation by Socrates that the unexamined life is not worth living. Maybe so. But I’d still give him one heck of a deal on a slightly used running watch.

By James Beckerman, MD, FACC

Today, our obsession with celebrity combined with a 24-hour news cycle afforded by the internet and cable television make any tragic event seem worthy of further investigation. Like many people, I hear about the deaths of celebrities and feel empty. And curious. Because much in the same way that we are fascinated by the road that people take to achieve success, we are similarly captivated by the choices people make that lead to tragedy. We can learn from people’s good choices, and conversely we can learn from others’ mistakes.

For instance, smoking cigarettes may lead to chronic lung disease, which can be treated with steroids, which may impact the immune system, which can increase the risk of pneumonia. Chronic breathing problems may limit our ability to exercise. Steroids may worsen diabetes. In our effort to simplify a final moment, we uncover people’s inherent complexity.

For Whitney Houston, it was no different. Her autopsy report identified a 60% blockage in her right coronary artery and no evidence of a blood clot in the vessel or a heart attack. Toxicology testing showed cocaine, benzoylecgonine, cocaethylene, marijuana, alprazolam (Xanax), cyclobenzaprine (Flexeril), and diphenhydramine (Benadryl) in her system.

Substance abuse, and cocaine in particular, carry significant risk of the development of heart disease. Cocaine can impact the heart in three ways. The first is that the increased heart rate and high sympathetic tone can increase the risk of developing a cardiomyopathy. This is characterized by reduction in heart function and can be associated with symptoms of congestive heart failure like shortness of breath, fatigue, and swelling in the legs and ankles. Cardiomyopathies can also be associated with abnormal or dangerous heart rhythms.

The second way that cocaine can impact the heart is by promoting early-onset coronary artery disease, though the mechanism is not well understood. While some younger women like Whitney Houston may develop coronary disease, it is not as common in the absence of other significant risk factors like diabetes, high blood pressure, or abnormal cholesterol. It is possible that cocaine use might have contributed to the 60% stenosis noted in her right coronary artery. Her autopsy would suggest that, despite having coronary artery disease, she did not have a heart attack. There was no evidence of a ruptured atherosclerotic plaque or a clot at the site of her blockage to suggest an abrupt closure of the vessel. Additionally, inspection of the heart itself did not indicate any obviously damaged muscle, although earlier in a heart attack this might be more difficult to detect.

Finally, the possibly most life-threatening cardiac manifestation of cocaine use is abnormal heart rhythms, or arrhythmias. Using cocaine increases the possibility of developing dangerous heart rhythms that arise from the ventricle — the lower chamber of the heart. These can be associated with drops in blood pressure, decreased oxygen supply to the brain, and, eventually, death. Even if not deadly, an abnormal heart rhythm can cause a person to faint, and fainting while in a bathtub is clearly a life-threatening event.

While we may never know what exactly happened in the hotel room that day, Whitney Houston’s autopsy report reads, “Death was due to drowning due to effects of atherosclerotic heart disease and cocaine use. No foul play is suspected. The mode of death is accident.” Simply put, a tragic ending to a complex life.

In the end, we are devoid of celebrity, or wealth, or struggles. We all die alone. And sadly, there is always more to our story.

By James Beckerman, MD, FACC

Millions of Americans will be traveling this week – some in search of sun, and others snow. And sadly, some people will experience injury or illness, or even worse. So this week I want to challenge you to do something that might save a life — maybe even yours — by joining other travelers to become an altruistic part of a crowdsourcing solution.

Crowdsourcing is a way people who don’t even know one another can solve problems together. Each individual can contribute to a solution by providing a small, unique part of the answer. All it takes is a smart phone and about a minute of your time.

The problem: Sudden cardiac arrest kills over 250,000 Americans every year; more than 95% of victims die before they reach the hospital. The definitive treatment for sudden cardiac arrest is defibrillation. But the risk of death or irreversible brain injury increases with every minute that passes before a bystander delivers that potentially lifesaving shock from an automated external defibrillator (AED). You might be able to access an AED quickly to help someone in a gym or school or in other familiar places. But what would you do if you were somewhere else? You’d call 911 and start CPR, but knowing where to find the nearest AED could significantly increase the likelihood of saving a life.

The solution: A group in the Netherlands has launched the website www.aed4.us as well as free iPhone and Android AED4 U.S. applications. This service enables you to add the location of any AED you see through either the website or via the GPS locator in your phone. By adding an AED location, you can contribute to an evolving worldwide map of AED locations along with thousands of other people. And by keeping the app on your phone, you will be able to locate the nearest AED if you find yourself in the position of needing to save a life. Even if you never need it, someone else will.

It can take a minute to save a life.  Not a bad way to start off a vacation.

For more information about crowdsourcing your health, watch Lucien Engelen talk about this technology, and join Dr. Beckerman on Twitter @jamesbeckerman to continue the conversation.

By James Beckerman, MD, FACC

“Go easy.”

The waiter raised his voice above the bluegrass band at the Salt Lick BBQ as he wished me a good time at Austin’s South by Southwest (SxSW) conference just a few days ago. An explosive marriage of music, film, and interactive (think tech/startups/social media) where strange bedfellows like Al Gore, Biz Stone, and Bruce Springsteen speak and perform before 30,000 fans wearing hipster glasses, personal WiFi hotspots, and ironic t-shirts.

Not your typical medical conference.

I sampled panels on digital health, social media and medicine, technology, and the arts. I made new friends from the WebMD family, and my Twitter feed became a human reality. Flying home from Austin to Portland, I found myself with three takeaways from South-by, and probably more to come.

1.      Location. Location. Location. In the past five years, we have experienced a surge of connectivity through Facebook, Twitter, and now Pinterest. But at this year’s SxSW, the buzz was all about Intro and Highlight — apps that use your social media profiles and leverage your smart phone’s GPS to introduce you to people around you before you have even met them. It’s too soon to say how this might impact healthcare, but I’m confident it will, especially as people are becoming more comfortable sharing their own health information (check out the new Facebook health feature or our WebMD communities if you don’t believe me). What would it be like if you knew that the person next to you on the bus had breast cancer too — and beat it? Or that the shopper in front of you in the grocery line is a neurologist searching for an Alzheimer’s cure and could share a research protocol with you that could change your mother’s life? This technology has only been available for weeks. Just wait.

2.      People respond to positives. One of my favorite sessions was a slightly less “medical” workshop led by actor Jeffrey Tambor from the show Arrested Development. He shared a directing “secret” used by all the greats from Kubrick to Scorsese: You get people to do their best by encouraging them. Doctors should pay attention. Our messaging as health care providers has become more punitive and less constructive. Patients can feel bullied sometimes, or made to feel guilty rather than inspired. We need to set our patients up to succeed without creating an inappropriate health ideal that sets them up to fail.

3.      Be careful. I capped off the conference by attending a session called Surviving Technology. A cautionary tale in our pressured momentum toward ultimate connectivity, the speaker argued that we need to recognize that we can’t sacrifice quantity of associations for quality. No matter how cool the app, how many “friends” we think we have, or how much data we will ultimately share, nothing will replace a hug, a handshake, or looking someone in the eye. Don’t get me wrong — I strongly believe in the power of tech to improve our health — but I’m also proud to support the idea that the purest form of care will always happen at the bedside. In our efforts to leverage technology, we can never forget that are patients are people, not profiles.

So as the barbecue settles in our collective stomachs, and Sixth Street takes a breather until next spring, I leave Austin with a fresh perspective on continuing medical education:

Be present.

Be nice.

And go easy.

How do you see the future of technology and healthcare? Leave your comments and join Dr. Beckerman on Twitter @jamesbeckerman to continue the conversation.

By James Beckerman, MD, FACC

You are sitting in your doctor’s office, and after reviewing your laboratory tests, you hear what hundreds of millions have already been told:

“I think you should take a statin.”

So what’s your response? While some people are open to taking a cholesterol medication, others are not. So when I recommend a statin, I explain why. I describe the data that supports the use of statins to reduce the risk of heart attacks and strokes in higher risk individuals. I discuss what I perceive to be a benefit in lower risk people with significantly abnormal lipids. I mention the anti-inflammatory, anti-oxidant, and anti-clotting characteristics of statins which likely contribute to their benefit above and beyond their impact on your cholesterol levels. And despite some valid concerns regarding side effects, I also note that statins are likely the best studied medication in all of pharmaco-history. In the end, some take the prescription home, and others decide,

“I think I’ll work harder on diet and exercise.”

So fast forward to a world where Qnexa has been approved by the Food and Drug Administration — its expert panel gave it a thumbs up last week, so keep your eyes open for the television commercials any day now. Qnexa is a combination of phentermine and topiramate — an amphetamine and an anti-seizure medication with potential risks including elevated heart rate, fatigue, nausea, and increased risk of cleft deformities in children of pregnant women taking the drug. It was previously rejected because of concerns about these side effects and unknown longer term effects. But it will likely be approved because it is associated with loss of about 10% of total body weight. As with other obesity medications, the weight comes back if you stop the drug.

So there you sit in your doctor’s office, and after reviewing your weight and cardiovascular risk factors, you may soon hear what hundreds of millions will likely be told:

“I think you should take Qnexa.”

So what’s your response? Will you express concern about a medical therapy that was previously rejected because of safety concerns just two years ago? Will you wait for long-term data about its impact on blood pressure and stroke? Will you ask how it works, and wonder why a seizure medication is being used to help people lose weight? Will you take the prescription home, or will you decide,

“I think I’ll work harder on diet and exercise.”

I’ll be interested in your reaction. But if you go for the Qnexa, there might be a prescription for a statin waiting for you at the pharmacy too…

By James Beckerman, MD, FACC

Every year around this time it seems like we hear the same advice about dark chocolate, red wine, and the health benefits of romance. But as a father of young children, I thought I’d turn the conversation toward something that we can do as parents to show our kids how much we love them. I became inspired recently by a program in my community called Shape Up Across Oregon — and I bet if you look around you can find similar opportunities where you live.

Shape Up Across Oregon takes a simple idea and makes it fun. About ten years ago, members of the Oregon Governor’s Council on Physical Fitness and Sports created a free program to help elementary and middle school kids get more physical activity in a structured way. As you know, it’s getting tougher for kids to incorporate exercise in the school environment as budgets have forced physical fitness out of many schools. But it’s clear that there’s still a demand — Shape Up signed up over 88,000 kids last year, and it will hopefully see greater numbers this season.

The program is a cool mix of geography and exercise. Each child gets a map of the state of Oregon with a route divided into 45 segments, each of which represents 30 minutes of exercise. So the challenge for each kid is perform at least 30 minutes of physical activity every day to make their way across the state. Every kid receives a Certificate of Completion from the Governor, and all participants are eligible for prizes. And teachers can incorporate Shape Up into their curriculums at school. It’s very simple in concept, but also amazing what a little bit of structure and friendly competition can inspire. Similar ideas form the backbone of many successful employee wellness programs.

In health care, there is an increasing focus on reducing childhood obesity and creating a healthier family — WebMD just sponsored a town hall with Michelle Obama in order to discuss these very issues. The role of exercise can’t be underestimated. A research study recently found that maintaining physical fitness can reduce your lifelong risk of high blood pressure by 30%, your risk of high cholesterol by 30%, and your risk of metabolic syndrome by half. The goal of this program is to show kids that a healthier lifestyle can be fun and that it’s completely within their reach.

So check out www.shapeupacrossoregon.org and get inspired to find similar opportunities in your neighborhood. Or get together with other parents and create one yourselves.  Not quite as romantic as a nice dinner out, but that’s what dark chocolate and wine are for…

By James Beckerman, MD, FACC

Former presidential candidate John Edwards has requested a postponement of his upcoming court dates because of a heart condition reportedly related to an abnormal heart rhythm. There is always more to the story, and more behind the story, but in this case, it’s important to clear up some misconceptions about abnormal heart rhythms, or arrhythmias.

There are as many different types of arrhythmias as there have been Republican front-runners in this year’s primary race. It becomes easier to understand them (arrhythmias that is) if we review a rough sketch of how electricity travels through the heart.

While all of the heart’s cells are capable of initiating a heartbeat, the task typically falls to a group of cells in the right upper chamber of the heart called the sinoatrial node. Electricity then passes south toward another group of cells called the atrioventricular node. The atrioventricular node is like a toll booth, which limits the number of electrical impulses that may proceed throughout the cells in the bottom chambers of the heart. This sums up the electrical pathways that result in a normal heartbeat.

But like in politics, anything can change. Cells can beat too quickly or too slowly, and they can even flip flop. Cells from the upper chambers of the heart can create too many electrical impulses, overwhelming the atrioventricular node and resulting in a fast, irregular heartbeat. Or cells from the bottom chamber can fire on their own, creating an erratic heart rhythm which can be dangerous or unstable.

As you can imagine, any irregularity in your heartbeat or any significant change in your heart rate can cause symptoms, although some asymptomatic people can be surprised to learn they have an arrhythmia. Some people describe their symptoms as palpitations, but they may also experience chest pain, shortness of breath, fatigue, or just a weird sensation. According to John Edwards’ representative, his abnormal heart rhythm may have been associated with a fainting episode. Certain types of arrhythmias may also increase the risk of stroke.

The most important steps in evaluating an abnormal heart rhythm include (1) making sure that the person having it is safe and (2) identifying the abnormal heart rhythm so that it can be treated appropriately. Treatments run the gamut from medications to manage the heart rate or rhythm to devices to prevent extremely slow or very fast heart rates and electrical procedures to shock the heart back into normal rhythm or even burn very small areas of heart tissue to stop the arrhythmia in its tracks. News reports suggest that John Edwards will be undergoing a procedure of some kind, but he has decided to keep the details of his diagnosis and his treatment plan between him and his doctors for the time being.

So it turns out that there is a lot that we still don’t know about John Edwards. But I guess we knew that already.

By James Beckerman, MD, FACC

Paula Deen is having quite a week.  Here’s the condensed version:

1) Paula Deen promotes a lifestyle associated with increased type 2 diabetes risk

2) Paula Deen develops diabetes.

3) Paula Deen endorses diabetes medication.

4) Everybody is talking about Paula Deen.

There is so much outrage and indignation in our tweets, blogs, and editorials as Paula Deen turns lemons into sweet, sweet lemonade. People are upset that she has not acknowledged — to their satisfaction — that bacon, egg and glazed donut burgers may have played some role in the development of her diabetes, or are frustrated that her pharmaceutical endorsement implies that a drug is the ideal solution to address a lifestyle problem.

But maybe we’re also upset because the joke is actually on us.

Paula Deen is not a role model for a healthy life, nor has she ever claimed to be. So why would we expect her to be one now? She is not a doctor with a financial interest in a drug company, nor is she a celebrity trainer endorsing diet pills. People have tuned in to her television shows for years not to learn how to eat more healthfully, but rather to escape into a world of sweets, salt, and fat.  But now this role model for excess has become a victim of her own success.

And so have we.

The more we watch her shows, buy her books, and follow her recipes, the more we expose ourselves to the same risks. But a big difference is that pharmaceutical companies and the media are not coming to our rescue with sponsorships, renewed publicity, and fresh opportunities for future income. We are left on the sidelines, holding our half-eaten bacon, egg and glazed donut burgers, somehow surprised by our collective stomach aches.

Paula Deen has turned our missteps into her success. She has promoted a lifestyle that has not only impacted her health, but has also impacted ours. And rather than feed us real solutions, she appears to be playing a new game.

And unfortunately, we’re probably going to play too.

By James Beckerman, MD, FACC

Happy New Year! And thanks to everyone for helping make 2011 so educational and inspiring in the WebMD Heart Disease Community. All of your posts, comments and insights are appreciated by everyone, especially me. I also value your feedback here on The Heart Beat blog, where I look forward to your posts and would love your input about interesting topics you would like me to cover in 2012.

As we embark on a new year, the Internet is full of commentary about resolutions and ideas about finally doing all those things that we resolve to accomplish each January. With publication of The Flex Diet earlier this year, I am often asked how I think about motivation — and resolutions in particular. I have recently become fascinated with some concepts explored by Tom Connellan in his book The 1% Solution for Work and Life. He believes that we have been approaching resolutions the wrong way. And I think he might be right.

What’s the purpose of a resolution, anyway? Most of us use resolutions to motivate ourselves to change our behaviors. But we know that about 25% of us will give up our resolutions a week from now, and only 10% of us will be sticking with our 2012 resolutions this time next year. So a skeptic might conclude that resolutions as motivators don’t really seem to stick.

So what’s the solution? Remember that while motivation in general can lead to accomplishments, it’s also the case that accomplishments themselves are actually great motivators. When people lose the first five pounds, they feel more excited about the next ten. When you run across the finish line, you want to sign up for the next race. When we experience success, we remember how good it feels. So the first idea is to use your accomplishments, no matter how small, to provide momentum along your journey, rather than just focusing on the big goal.

That’s not say that big goals aren’t good to have. I ran a marathon back in October, and that goal motivated me to run throughout the year (and even this morning!). But we can’t forget that big goals are made up of small stages and many small steps, both literally and figuratively. Rather than set yourself up for disappointment by focusing on how far you are from your big-picture goals, set yourself up to succeed by zeroing in on all the small steps and mini-accomplishments along the way. Going running one day a week is a success if you weren’t running at all. But it’s a failure if you only think about the larger goal of exercising every day. Think big, start small, and set yourself up to succeed.

Finally, let’s be real with ourselves. Change isn’t fun. Even positive change. It’s not fun to wake up an hour earlier to go for a run. It’s not fun to focus on aspects of your life that you would sometimes prefer to be mindless. It’s not fun (for me!) to order vegetables instead of fries on the side. But something interesting happens as you start making conscious changes. Better habits slowly get replaced. Conscious decisions become less conscious. Mindfulness turns into newer, healthier habits. And discomfort becomes more comfortable — and sometimes even fun. When you are at the starting line, prepare yourself for what lies ahead and don’t kid yourself that it will be effortless or that you can somehow beat the system by making positive change a completely positive experience. Many of us expect things to be easy, and we fail when we are reminded that they aren’t. Expect things to be challenging, but make this year different by embracing the challenge and recognizing that eventually, you can create new habits and a healthier lifestyle.

So there you have it. Use your accomplishments rather than lofty resolutions to motivate you. Set yourself up to succeed by thinking big, but focusing on smaller steps. And embrace change for what it really is: challenging, but exciting too.

Thanks again for being here — and have a happy, healthy 2012!