Follow the Money

                                                                                   by Mary Knudson

I’ve been working for a couple of months on an in-depth article on personal defibrillators that are implanted beneath the skin of a person’s chest to shock a heart that starts shaking, thereby restoring its normal beating and preventing sudden death.  Discussing these defibrillators is extremely complex, which is why I am spending so much time on researching and writing the article intended to help patients and their families make an informed decision by learning the truth about the devices known as implantable cardioverter defibrillators (ICDs) -- the good and the bad, your life saved vs nothing happening or the accompanying risks and harm you may receive.  So when I heard that a new study would be presented at the annual scientific meeting this week of the Heart Rhythm Society, a professional organization of cardiologists and electrophysiologists who use cardiac devices in their patients, I made sure to get an advance copy of what would be presented and interview the lead author.

Potentially such a study would be of interest to physicians and to patients considering getting an ICD because it looked at all shocks the defibrillators gave the heart in patients who took part in the clinical trial, including those sent for life-threatening rhythms and in error.  For several reasons, I felt the study is not ready to report to the public.  It is only an abstract.  The full study has not yet been written, let alone published in a peer-reviewed journal or even accepted for publication.  Patients with defibrillators who received shocks were matched to only one other patient who was not shocked, but the two patients were not matched for what other illnesses or poor quality of health they had.  Yet they were matched to see who lived the longest and the study looked at death for all causes, not just heart-related. One critical question the study sought to answer was this:  Do the shocks themselves cause a shortened life (even if they temporarily save it) or is a shortened life the result of the types of heart rhythms a person experiences?

But the thing that really slapped me in the face and gave me pause was the exchange of money.  In all stories I write on drugs or medical devices, I have begun asking the sources I quote for any conflicts of interest they have with pharmaceutical companies that make these products and I list the conflicts within or at the end of the story.

This study was funded by Boston Scientific, a pharmaceutical company that makes defibrillators.  And all eight authors of the study from different medical centers had financial ties to Boston Scientific.  All of them?

Would I be surprised if the study found that it was not the defibrillator’s shock that shortened life?  In the few write-ups that I’ve seen on this study presented Thursday, the lead author is quoted as saying that not the shock, but rather the type of rhythm is what was associated with shortened life.  This study that was able to look at shocks sent for a variety of heart rhythms and for other reasons may be a valuable study.  But I can’t help wonder, both as a journalist and as a potential patient, if the study would have been designed differently and reached any different conclusions if no money exchanged hands between a company that makes defibrillators and the eight physicians who designed the study and wrote its conclusions.  I am not making any accusation here.  I simply am saying that I am made to feel uncomfortable by the financial association of the doctors and big pharma.  Why do doctors do this? Should organized medicine and university medical centers forbid doctors who have any financial ties to a company from participating in a clinical trial of a product that company makes?  Especially if the company is funding the clinical trial?  That would eliminate a lot of doctors.  But the tide is changing and some financial arrangements once commonplace between doctors and industry are no longer allowed at some major university medical centers and everything is under more scrutiny than before.  We were discussing this matter of conflicts of interest Tuesday in a university class I teach to doctors who want to write for the public.

Both doctors and journalists should be truth seekers, and seeking the truth is best done independently.  Would the public be able to trust my long-researched piece on the truth about defibrillators if it turned out that I am being paid to write press releases for one or more of the companies that make these defibrillators?  Or if I wrote speeches for executives of these companies?  Or if I served as a consultant to the companies on public relations?  As a journalist, I could not consider receiving money from groups I write about. Why should doctors be allowed to receive money from companies who make a product they are using on patients in a clinical trial that purports to provide answers to serious questions about the product?

As I was wrestling with this issue and whether to write about why I am not writing about that study, journalists with Pro Publica published several articles on their website and with USA Today on money ties between big pharma and the Heart Rhythm Society.  See  herehere, here and here

When I first began attending various cardiology organizations’ scientific meetings I was taken aback by the numbers of physician speakers who would begin their talks with a conflict of interest slide that stayed visible only for what seemed like one second before the speaker clicked to the next slide, visible just long enough for the audience to see there was a long list of financial ties to industry, but not long enough to read what they were.  The slides were there because the doctor organizations were requiring transparency.  But what was happening was not transparent because nobody could read what was on those slides.  How rare but heartening it was when a speaker began a talk by saying “I have no conflicts of interest.”  That is changing and more doctors are able to say they have no conflicts. But much more needs to change.

I was also amazed to see the large numbers of “non-official” scientific sessions sponsored by individual pharmaceutical companies and listed in the official scientific programs -- with leading cardiologists as presenters and well attended by conference goers -- that preceded the official program at these major cardiology meetings. What portion of these presentations used company slides and drove home company messages?  After seeing all this, I remember holding my breath as I asked the cardiologist I had invited to co-author a book with me about heart failure if he had any financial conflicts of interest with industry.  I felt that if he did have, I could not write the book with him.  How relieved I was when he said he did not.  

Pharmaceutical industry financial relationships with individual doctors and with organizations of doctors are important to the public welfare because these relationships can influence judgment and decisions, can influence what is said and not said in writing about medical products and in speaking to and advising patients.  And that is why these relationships are important to journalists who are servants of the public. 

As for my long-researched piece on defibrillators, I have found more studies to read and  a couple of new interviews to do.  I believe that this examination of the truth about defibrillators that I am writing for a well known magazine’s website will be worth reading, and once it is published there, I will reprint it here. 

What is Mitral Valve Regurgitation that led to Elizabeth Taylor’s Heart Failure?

                                                                 by Mary Knudson

I am saddened that Elizabeth Taylor died today of heart failure.  In his appreciation of her, film critic Roger Ebert said in the Chicago Sun-Times, “Of few deaths can it be said that they end an era, but hers does.” 

She is a star that many of us felt we knew.  She was a great actress and a woman of great beauty who was a hard working champion of people with AIDS and always seemed to be a determined person who knew herself. Yet she always had a vulnerable side.  So many marriages, so many illnesses, so many, many surgeries, over 40, I’ve read.  And then her heart problem developed.  Which leads me to talk a little about that problem, mitral valve leakage.

The heart's mitral valve

The heart has four chambers and four valves that open to let blood through to the next chamber of the heart and on out to the body and back.  The valves, acting as gates, then immediately close to prevent the blood from running back where it just came from. The mitral valve looks like a mouth with leaflets that look like lips that open and close.  When I saw it in action on an echocardiogram, a test that uses sound waves to show moving pictures of the heart, I thought it looked like a very sensuous mouth.  Each of the valves looks different.  But because it looks like a mouth, the mitral valve stands out.  Blood has just left the lungs carrying oxygen and arrives at the left atrium of the heart.  The mitral valve’s mouth opens to let the blood pour through into the left ventricle.  As the left ventricle contracts, the mitral valve closes and the aortic valve opens to allow blood to leave the heart and get out to the body. 

A mitral valve can start to leak.  This can range anywhere from a condition that is minor and does not need treatment to a serious problem that leads to a weakened heart and heart failure.  In Elizabeth Taylor’s case, it led to heart failure and her symptoms must have included difficulty breathing and fatigue.

I asked Edward K. Kasper, M.D., director of clinical cardiology at Johns Hopkins Hospital, to talk a little about what can go wrong with a mitral valve.  I should mention for disclosure that Ed is my cardiologist and co-authored with me the book Living Well with Heart Failure, the Misnamed, Misunderstood Condition:

A leaky mitral valve – mitral regurgitation, is common and has many causes. Most people tolerate a leaky valve well, but some need surgery to correct the leak. Repair is preferred to replacement. The MitraClip (which was used for Elizabeth Taylor) is a new technique to try and fix mitral regurgitation in the cath lab rather than in the operating room. There are no long-term comparison studies of this technique compared to standard OR repair – that I know of. Repair is currently the gold standard for those who have severe mitral regurgitation and symptoms of heart failure.  Outcomes are better including improvement in symptoms and survival in patients with repair rather than replacement.

What takes a person from a leaking mitral valve to heart failure?

The leakage back into the left atrium increases the pressure in the left atrium. This increased pressure in the left atrium is passed back to the lungs, causing fluid to leak into the lungs, leading to heart failure. With time, the demands of severe mitral regurgitation on the left ventricle will lead to a weakened left ventricle, a dilated cardiomyopathy (disease of the heart muscle). We try to prevent this by operating before it gets to that point.

Mitral regurgitation can also be a consequence of a dilated cardiomyopathy - the orifice of the mitral valve enlarges as the left ventricle enlarges. The leaflets of the mitral valve do not enlarge. Therefore, they no longer close correctly, leading to mitral regurgitation. 

It’s easy to see why anyone would want to opt for the Evalve MitraClip over open heart surgery.  The MitraClip is little different from a common test known as an angiogram in which a catheter is passed through the femoral vein in the groin up to the heart.  In this repair procedure, however, the catheter guides a clip to the mitral valve where the metal clip covered with polyester fabric is positioned over the leakage and brought down below the open flaps and back up, fastening the valve’s open leaflets together.  The manufacturer, Abbott, shows in a video here how blood still is able to pass through on either side of the fastening. 

Elizabeth Taylor got her MitraClip repair a year and a half ago, so it must have worked for awhile.  Then about six weeks ago she was hospitalized with heart failure at Cedars-Sinai Medical Center in Los Angeles where she died with her family at her bedside.  For more on mitral regurgitation, see this NIH site.

Heart failure has many other causes.  High blood pressure can damage the lining of blood vessels leading to deposits of cholesterol.  Coronary artery disease causes heart attacks.  A heart attack kills part of the heart muscle, forcing the rest of the heart to work harder and in doing so, get large and weak. Only about half the people who develop heart failure have a weak heart.  In another cause of heart failure, the left ventricle becomes stiff and the heart does not fill properly.  And in some heart failure, the heart itself is normal but connecting blood vessels are not or a valve may be too narrow.  In all of these cases, a person is said to have heart failure because the heart and vascular system are not able to provide the body with the blood and oxygen it needs. 


Sudden Death in Young Athletes

by Mary Knudson

John Mandrola MD is a cardiac electrophysiologist practicing in Louisville, Ky who blogs as Dr. John M.  Below is his insightful discussion about why cardiac screening may not be possible to prevent sudden death in young athletes.  Yet it is so distressing each time a young athlete falls dead during or after a game because he and his family did not know that he had a serious heart problem that could have been identified in a test.  For some heart defects, if only the family were aware of the defect, it would be appropriate for the young athlete to wear an implanted defibrillator that would save his life either through extra pacing as the disturbance began or through electric shocks if his heart suddenly went into a wild shaking known as ventricular fibrillation.  

I understand John’s concern about the high cost of making electrocardiograms and echocardiograms, heart tests that could pick up significant heart defects, a required part of a sports physical in schools and colleges.  Aside from the cost is the important issue that screening can pick up false positives and “shadows and innocent blips” that lead to further invasive testing.  Yet, I could see parents springing for these cardiac exams themselves, but then being very cautious about doing any further testing.

It is unforgivable not to have an automatic external defibrillator at all sporting events, close to the court or the field, and more than one athletic staff member trained to use it. Every minute counts when a person’s heart stops working.  Realizing what has happened, then calling an ambulance and waiting for the paramedics to arrive, may take up too much time to save a young athlete’s life.  When an athlete falls to the ground and is not moving, the trainer or other staffer should immediately have the defibrillator or crash cart ready so that the shocks could be applied to the athlete’s heart within one to two minutes. 

Reprinted from the blog Dr. John M

A five-minute cardiac screen for athletes?

by John Mandrola MD

MARCH 5, 2011

It’s heart-wrenching when young athletes die of sudden cardiac death (SCD). This week, the death of Wes Leonard, a Michigan high school star athlete, was especially poignant since he collapsed right after hitting the game-winning shot.  This sort of tragedy occurs about one hundred times each year in America. That’s a lot of sadness.

The obvious question is: Could these deaths be prevented?

Let’s start with what actually happens.

Most cases of sudden death in young people occur as a result of either hypertrophic cardiomyopathy (HCM), an abnormal thickening of heart muscle, or long QT-Syndrome, a mostly inherited disease of the heart’s electrical system. Both HCM and Long-QT syndrome predispose the heart to ventricular fibrillation–electrical chaos of the pumping chamber of the heart. The adrenaline surges of athletic competition increase the odds of this chaos. Unfortunately, like heart disease often does, both these ailments can strike without warning.

Sudden death is sad enough by itself, but what makes it even worse for doctors (and patients) is that both these ailments are mostly detectable with two simple painless tests: the ECG and Echocardiogram (heart ultrasound).

Let’s get these kids ECGs and Echos then. Git-r-done, you might say.

On the surface the solution seems simple: implement universal cardiac screening of all young athletes. And you wouldn’t be alone in thinking this way. You could even boast the support of Dr Manny Alvarez of Fox News, and the entire country of Italy–where all athletes get ECGs and Echos before competing.

But America is not Italy and things aren’t as simple as Fox News likes to suggest.

There are three major flaws with Dr Manny’s simplistic proclamation that all (American) athletes should have pre-participation ECGs and Echocardiograms.

The Economic:

The estimated cost–in our current health care system–for adding an ECG and Echo to the sport’s exam is about $1000. That’s a bunch more than $19.99–the advertised price of the sports physical at my local grocery store’s walk-in clinic. Parents may be amendable to charging $19.99 to their credit card, but even when the safety of their teen is at stake, few can afford the current-day costs of ECGs and Echos.

Now, you could make the argument that 1000$ is ridiculously high. And you would own a valid point. But that argument goes to the heart of the healthcare debate.

Let’s consider this notion for a moment: I could listen to your teen’s heart, look at their ECG, place a hand-held ultrasound probe on their chest, and in a matter of five minutes I could clear them for competition. The ECG would exclude long-QT syndrome, and the Echo would exclude excessive thickening of the heart muscle. The reason why I could do this are threefold:

  1. My entire medical career revolves around understanding ECGs.
  2. I look at Echos nearly every day, and was schooled by one of its pioneers, Dr Harvey Feigenbaum.
  3. In general, I waffle a lot less than the average reader of subjective cardiac tests. (That trait might not be valuable at the Mayo Clinic, but it would be good for screening thousands of young people, who are normal 99.999% of the time.)

Ah, but that’s not how things work in our present health care model. Obviously.

You can’t just deliver quality care that easy. There’s got to be a certified technician and machine to do the studies–portable Echos will not work. Calling an Echo normal these days is totally insufficient, fraudulent even. There has to be a three page report documenting each section of the heart. And of course, I can’t officially read an Echo because I am not board-certified in Echocardiography, I am just board-certified in Cardiology and Electrophysiology.

It’s not just the high costs that make screening athletes problematic.

It’s the Math:

Why don’t the numbers support widespread cardiac screening of athletes?

Again, it isn’t as simple as Dr Manny suggests. He portrays ECGs and Echos as black and white, yes or no, high or low kinds of tests. That’s not even close to accurate. They are both highly subjective tests that require mastery of nuance, including the ability guts to call something “normal.”  When a young person’s life is at stake, shadows and innocent blips look much more sinister. Before guaranteeing the invincibility of a young athlete, doctors often see things on ECGs and Echos that “might be something.” Radiologists sometimes call these shadows “incidentalomas.”

That’s the rub with screening that Dr Manny omits. For every life saved by the screening test, there will be hundreds (perhaps thousands) of patients sent for more (and often highly invasive) testing. Doctors are not going to be wrong about sudden death in a young person. No way. No how. There will be more tests, not just because of defensive medicine, but also in the name of quality.

To the numbers: Rare diseases like HCM and Long-QT kill athletes at a frequency of about 0.01%. That’s the left side of the equation. On the right side of the equation are the risks of all the cardiac caths, electrophysiology (EP) studies and dye-requiring CT scans ordered as a result of the screening tests. Though an individual cardiac cath, EP-study or CT are low-risk, the cumulative risk of doing these on thousands of normal people surely approach the 0.01% chance of sudden death in an athlete. Said more simply, with made up numbers to make my point, if screening saves 50 of the 100 teens who die each year, but 50 die from complications that occur from chasing down incidentalomas, than it’s an expensive statistical wash.

The Reality of the Athletic Ethos:

The third major flaw with the idea that mandated cardiac screening will save lives is that making the diagnosis of heart disease doesn’t always equate to preventing sudden death. The athlete has to accept the treatment, which for them, like it was for Boston Celtic great Reggie Lewis, is often untenable.

Gosh, I wish we could save all the young athletes that die suddenly.

But the paradox of our present health care system is that awash in all its fury of available technology (the MRIs, the robots, the GPS-navigational-systems) is our inability to do simple things for the many.

That’s too bad.


P.S.: One thing that Dr Manny was spot on about was that more AEDs (Automatic External Defibrillator) in athletic arenas are surely a good thing. In the case of AEDs, there exists strong science to show that increasing their availability saves lives.


Baseball and Heart Health

Engaging in a sport as a player or as a robust fan is surely good for your heart health.  My favorite way to blow stress away and soar on summertime cottony cloud puffs of happiness is to watch a baseball game.

I share my passion for baseball in this Guest Blog post at PLoS Blogs.

An Open Letter to Bora Zivkovic on Baseball

By Mary Knudson

Posted: March 1, 2011

Dear Bora,

You said on Twitter that you have lived in the United States for 20 years and have never seen a baseball game and don’t know what the point of the game is.  With the 2011 spring training games now underway, I must respond.

I love baseball.  It seems as natural a part of my life as eating and writing.  Baseball makes me happy.  My team is the New York Yankees.  You notice I said MY team.  That’s how baseball fans feel about their teams.  The relationship is very personal.  I love the glorious remarkable history of the Yankees.  Lou Gehrig, Babe Ruth, Mickey Mantle, Yogi Berra, Whitey Ford, Casey Stengel, Catfish Hunter, Reggie Jackson, Thurman Munson.  I wish those names meant something to you.  Each player was a legend and together with the owner, managers, trainers and coaches, they built a legacy. The Yankees have had streaks of carrying on that legacy with modern players, winning championships and world series.  Baseball needs new heroes now who do amazing things, not for the huge salaries, but out of hard work for the love of the game.

Fans respect the giants of baseball for what they gave to the game and some of them we love for who they were as men.  On the wall of my exercise room is a large reproduction of a famous photograph of Lou Gehrig making his last appearance in Yankee Stadium after he learned he had the fatal paralyzing disease amyotrophic lateral sclerosis (ALS) that would later bear his name.  In his famous short speech to his fans who had packed the stadium, with his teammates lined up nearby on the field, knowing his fate, he still said: “Fans, for the past two weeks you have been reading about the bad break  I got. Yet today I consider myself the luckiest man on the face of this earth.”

Gehrig was the first “iron man”, playing 2,130 consecutive games over a span of 15 seasons between 1925 and 1939.  How many people go to work every work day over 15 years, never staying home sick?  During that time Gehrig had 17 hand fractures, back pain, and several different illnesses, but he played through it all.  His streak ended only because he developed ALS.  But his record was so strong it lasted 56 years before 

Photo: Michael O’Neill, SI

Cal Ripken, Jr., shortstop and third baseman for the Baltimore Orioles, another true “iron man” with an unyielding work ethic, broke it in 1995. Cal Ripken brought a special joy not just to Baltimore, but to all baseball fans, and won back their respect for baseball after the bitter 1994 strike.  I will always remember the standing ovations fans gave him in city after city his final year as a player, 2001. These were cities that belonged to the opposing teams the Orioles had come to play.  But the other teams’ fans showed their respect for Cal.

You never know when you watch a baseball game if you will be witnessing history.  Lou Gehrig was one of 15 players who have hit four home runs in one game!  Can you imagine the thrill of watching that happen? A home run comes when a batter lays the bat just right on the ball, just right, on the “sweet spot” of the bat, sending the ball rocketing out of the ballpark.  What ecstasy to watch in disbelief the fourth time a batter does that in the same game! How can you have any stresses in your own life on a day that happens?  Bobby Lowe of the Boston Beaneaters was the first to do it in 1894 and Carlos Delgado of the Toronto Blue Jays the last on September 25, 2003. Maybe it will happen again this year. You always hope to see something great in each game you watch.

Gehrig still holds the record for the most grand slams: 23.  A grand slam is a fan favorite.  Especially when it wins a game.  One by one your team’s players hit the ball without it being caught by the other team and they get on base.  In a grand slam the batter stands in the batter’s box (it’s not really a box, Bora) and his teammates are out there on all three of the bases: first base, second base, third base.  If the batter hits a home run, he and all three of his teammates get to run home for a grand slam, a total of 4 runs.  Pretty spectacular to hear the crack of the bat, see the ball ascend over the heads of the outfielders, you suck in your breath, praying please, please, and then shriek as the ball sails out of the ballpark.  “See ya!”, one announcer always punctuates a homer.  Lots of high fives at home plate and in the dugout.  If you’re at home watching, you’re on your feet whooping and hollering, doing high fives with your dog.  You don’t hold back.  There is no holding back in baseball.  Not for fans.  How good you feel, Bora!  This is real happiness.

The point of the game?  The point of the game is to win.  To get more runs than the other team.  To do that your pitcher needs to be better than the other team’s pitcher so that the other team doesn’t hit balls that turn into runs.  A pitcher can be so skilled and so powerful in the way he unleashes the ball, sending it hurtling sometimes 94, 95, 97 mph at the batter as a fastball, a slider, a curveball, a cutter, a changeup, that batter after batter can not get his bat on the ball.  And in some types of pitches it’s more the finesse with which the ball leaves the pitcher’s fingers than the speed that matters.  A battle of wits goes on between the pitcher and the batter, as the pitcher tries to stare down the batter and the catcher crouches behind the batter trying to influence what kind of pitch the pitcher throws. You’ll see the pitcher shake his head back and forth if a pitch the catcher is signaling is not what he wants to throw or nod yes if he agrees with it. The pitch is everything.  A team wins if its batters find a way to hit what the pitcher throws.

And those men in the infield and outfield who chase balls and lurch and dive for them are very important.  Some of the spectacular plays of baseball come from outfielders who leap higher than you think possible and snare a ball about to fly out of the ballpark or throw themselves horizontally after a ball, clutching it in one glove as their body slams brusingly to the ground.  Derek Jeter, Yankees shortstop and captain, has a signature twisting leap that always astonishes when he catches and then wheels in mid air and throws to first or second base for an out. Infielders often try for a double play, forcing runners out at both first and second base.

One of the grandest events in baseball is when a pitcher pitches a no-hitter.  Through nine innings, not a single man on the opposing team can get a hit. Either the batters are unable to connect the bat to ball or, if they do hit the ball, someone on the other team catches it.  No hits throughout an entire game of some three hours.  An amazing feat! If you are lucky enough to see one, Bora, it is an experience of a lifetime. It is the glory of baseball.

Fans feel baseball.  We are part of the game.  And we like to help manage the team.  In this pre-season time of year we worry about whether our team will be ready for the season.  I worry about what the starting lineup of pitchers will be for the Yankees who will add some new faces this year from youngsters coming up from the minor leagues.  I hope so much that A.J. Burnett who had a terrible season last year will make us proud as a starting pitcher.  I want to get to know the new pitching coach Larry Rothschild and feel content that I agree with his plan of action.  I feel the pain of distinguished veteran catcher Jorge Posada who will be 40 in August and learned that, barring some emergency, he will never again catch for the Yankees.  “I think I can still catch,” I heard him say in an interview.  He instead will be their designated hitter, a less involved role.  For all the emphasis on team and winning, a team nevertheless is made up of individual men who have feelings and pride, and it is hard to get older in baseball and relinquish leading roles.  A catcher helps direct a pitcher’s throws.  A DH just goes out and takes his turn at bat.

The Yankees will face outstanding competition in the American League East this season.  The Boston Red Sox who were held to low expectations by injuries last year could be a dangerous opponent this spring and the Phillies who snared Cliff Lee, a star pitcher the Yankees badly wanted, now have a starting lineup of pitchers that may be the best in baseball.  The Baltimore Orioles, under new leadership, were showing big improvement the end of last season and might surprise everybody.  There are great expectations for an exciting, suspenseful competitive season.

A baseball game squeezes many intense, anxious moments out of us.  You experience the game individually, willingly allowing what you see and hear and hope for to penetrate your senses and govern your soul.  Watching baseball is a take-no-prisoners commitment.  And yet it is also a spring and summertime and fall layback, informal, take-the-family group event where you eat and chat and join with thousands of others as you root for your team.  You can also enjoy baseball about as much by watching a good game on TV.  In fact, @Hudsonette recommends doing that before you go to your first game in person because you learn a lot by listening to savvy announcers call the game and explain what’s happening.

Some cool people on Twitter love baseball and send you some sage reasons why, if you give it a try, Bora, you will love it, too:

From @Hudsonette

1st Amendment lawyer, blogger

If you’re unfamiliar with baseball, it helps to watch a game while listening to great announcers, such as Vin Scully of the L.A. Dodgers, or Ken Singleton with the Yankees.  They will not only explain what just happened, which can be baffling because often several things are happening at once, but also the strategic choices and the moment to moment tension of competing interests involved in each pitch and each play.  It’s intricate, complex, dependent on individual skill choreographed with other teammates while battling the sun, wind, physical injuries, mental lapses, and the opponents’ own hidden stratagems.  It’s a game of statistics coupled with human grace.  There’s not much more beautiful than watching the great relief pitcher Mariano Rivera strike out a batter with his cut fastball, or the sound of a ball hit perfectly on the sweet spot of the wood, or the shortstop Derek Jeter appearing out of nowhere to make an intricate play that saves the game.  There’s no greater anguish than being a Cubs fan.  But above all, it’s fun to go to a game, even a minor league game, sit in the sunshine, eat what you want, say what you want very loudly, and get away completely from the troubles of the world.

Note:  There is an unwritten code to baseball that does not tolerate disrespect towards the other team such as public displays of exuberance (by the players, not the fans) if your team is way ahead.  See the Ten Unwritten Baseball Rules.  Some great baseball books: Moneyball, Veeck As in Wreck, Sadaharu Oh: A Zen Way of Baseball.

From @DeliaCabe

Writer, professor of magazine writing, blogger

My love affair with baseball starts with my grandfather, who came to this country from Puerto Rico because he wanted to be a bat boy for “los Yankees”. He watched the Yankees all his life.  He never did become a bat boy, but his love for the game became mine.

I don’t watch other sports. Baseball is different. No sport is as literary as baseball is. It’s a slow, evolving story that takes place over nine innings–no timers, no buzzers, no masks. The game begins with two protagonists, two pitchers, and goes from there.

Bora should see the Durham Bulls, since he lives near there! (He could also watch the movie. Here’s Susan Sarandon talking about making the movie movie.

From @garyschwitzer

Publisher, HealthNewsReview and blog

I can’t top  George Carlin .

From @Joe_Wallace

Author, Diamond Ruby, baseball-related historical novel

The historian Jacques Barzun once said, “Whoever wants to know the heart and mind of America had better learn baseball.” I don’t know if that’s true, but I definitely believe that the game–and, especially, its remarkable history–provides a window into the U.S.’s own past. From the Civil War (when baseball was used to knit the fractured nation) onward, every controversy, every struggle, has been reflected by the game. Race relations, women’s rights, political upheavals, cultural changes–they’re all here.

Baseball itself is a beautifully constructed cat-and-mouse game, filled with endlessly debatable strategy and tactics. In our noisy, fast-paced world, it can seem slow (and it’s certainly not for every taste), but like a great novel both the game and the long, unfolding season reward patience and close attention. Once you begin to understand, it can make you laugh out loud with pleasure…even when you’re past fifty, as I am, and not ten.

From @ivanoransky

Ivan Oransky, MD

Executive editor, Reuters Health

Embargo Watch

Retraction Watch

I fell in love with baseball as a five-year-old watching Reggie Jackson be the “straw that stirs the drink” and then hit three home runs in a single World Series game.

I love baseball enough that even though my wife has banished it to a sunroom, I have my very own bleacher seat from the old Yankee Stadium. Even she agrees, however, that spring training in Arizona is a perfect couples’ vacation: A spa, hiking, and a baseball game every day.

I love baseball because when I’m at a conference in Tampa and have nothing to do, I can go see someone hit the second of two majestic back-to-back walk-off home runs.

I love baseball because it has inspired a whole literary genre. And what other sport has inspired a book, Michael Lewis’ Moneyball, about the controversial genius of Bill James’ and Billy Beane’s data-mining?

Baseball is hardly perfect. It’s a deeply human enterprise. But the fact that it’s a long season every year means there’s a narrative that builds on itself and actually goes somewhere. Sort of like science.


Bora, if you still have any doubts about getting involved with baseball, feel the intense emotions immortalized in this poem that fans experience during a game.  Baseball is such a slice of life. Sometimes you win, sometimes you lose.  But as long as you believe they are trying, always you are one with your team.  You are a fan.


Casey at the Bat


A Ballad of the Republic, Sung in the Year 1888

The outlook wasn’t brilliant for the Mudville nine that day;
The score stood four to two with but one inning more to play.
And then when Cooney died at first, and Barrows did the same,
A sickly silence fell upon the patrons of the game.

A straggling few got up to go in deep despair. The rest
Clung to that hope which springs eternal in the human breast;
They thought if only Casey could but get a whack at that—
We’d put up even money now with Casey at the bat.

But Flynn preceded Casey, as did also Jimmy Blake,
And the former was a lulu and the latter was a cake;
So upon that stricken multitude grim melancholy sat,
For there seemed but little chance of Casey’s getting to the bat.

But Flynn let drive a single, to the wonderment of all,
And Blake, the much despised, tore the cover off the ball;
And when the dust had lifted, and men saw what had occurred,
There was Jimmy safe at second and Flynn a-hugging third.

Then from 5,000 throats and more there rose a lusty yell;
It rumbled through the valley, it rattled in the dell;
It knocked upon the mountain and recoiled upon the flat,
For Casey, mighty Casey, was advancing to the bat.

There was ease in Casey’s manner as he stepped into his place;
There was pride in Casey’s bearing and a smile on Casey’s face.
And when, responding to the cheers, he lightly doffed his hat,
No stranger in the crowd could doubt ’twas Casey at the bat.

Ten thousand eyes were on him as he rubbed his hands with dirt;
Five thousand tongues applauded when he wiped them on his shirt.
Then while the writhing pitcher ground the ball into his hip,
Defiance gleamed in Casey’s eye, a sneer curled Casey’s lip.

And now the leather-covered sphere came hurtling through the air,
And Casey stood a-watching it in haughty grandeur there.
Close by the sturdy batsman the ball unheeded sped—
“That ain’t my style,” said Casey. “Strike one,” the umpire said.

From the benches, black with people, there went up a muffled roar,
Like the beating of the storm-waves on a stern and distant shore.
“Kill him! Kill the umpire!” shouted some one on the stand;
And it’s likely they’d have killed him had not Casey raised his hand.

With a smile of Christian charity great Casey’s visage shone;
He stilled the rising tumult; he bade the game go on;
He signaled to the pitcher, and once more the spheroid flew;
But Casey still ignored it, and the umpire said, “Strike two.”

“Fraud!” cried the maddened thousands, and echo answered fraud;
But one scornful look from Casey and the audience was awed.
They saw his face grow stern and cold, they saw his muscles strain,
And they knew that Casey wouldn’t let that ball go by again.

The sneer is gone from Casey’s lip, his teeth are clinched in hate;
He pounds with cruel violence his bat upon the plate.
And now the pitcher holds the ball, and now he lets it go,
And now the air is shattered by the force of Casey’s blow.

Oh, somewhere in this favored land the sun is shining bright;
The band is playing somewhere, and somewhere hearts are light,
And somewhere men are laughing, and somewhere children shout;
But there is no joy in Mudville—mighty Casey has struck out.

Poetry Foundation

Guest Blogger Profile: MARY KNUDSON is the co-author of “Living Well with Heart Failure, the Misnamed, Misunderstood Condition”, a health blogger at HeartSense Blog, teaches writing at Johns Hopkins, loves books, baseball, and critters. She can be found on Twitter as @maryknudson

17 Responses to An Open Letter to Bora Zivkovic on Baseball

  1. Coturnix says:
    March 1, 2011 at 7:06 am

    Wow! Thank you so much! Anton promised to take me to a game in Durham very soon!


  1. Krystal D'Costa says:
    March 1, 2011 at 7:48 am

    Mary – This is a beautifully written post that captures the essence of the game perfectly–and I say this even though we are actually cross town rivals! Certainly an apt introduction for Bora or anyone else who wonders what this sport can mean to people.
    Baseball to me marks the coming of spring. I look forward to Spring Training every year, and every year–despite the previous season (many of which have admittedly hurt in recent years)–it represents a new beginning: a time to meet and try again, and tell a new story.
    The Mets recently moved to a new home, and I’m sharing a letter that Shea, our former home, wrote to the new stadium because I think it captures the sense of tradition and history that the game represents: http://newyork.mets.mlb.com/news/article.jsp?ymd=20090907&content_id=6839464&vkey=news_nym&fext=.jsp&c_id=nym


    1. Mary Knudson says:
      March 1, 2011 at 9:28 am

      I was both a Yankees fan and a Mets fan for years (how can that be, you ask?) but I felt like I knew both teams and really liked members of the Mets. But then the players I cared about and manager Bobby Valentine all left and I didn’t feel like I knew anyone at the Mets anymore and I quit caring about them. Glad you liked the baseball story and glad to have you share the letter! Thanks, Mary


  1. Franc says:
    March 1, 2011 at 8:32 am

    Dear Mary,
    I’m sure Bora was not writing his Twitter notice in disrespect of baseball or of any of the baseball’s fans. He is much to kind a person he would do that. But for somebody who was born in the Soccerland Europe, being myself from there, I can see how difficult is to understand the baseball idea and philosophy. And we from Europe are very curious why e. g. soccer is not so popular in America as it is in Europe?


    • Mary Knudson says:
      March 1, 2011 at 9:35 am

      Dear Franc,
      Of course Bora meant no disrespect for baseball! Everybody who knows Bora knows how incredibly helpful and kind he is. He is our leader in science blogging. I am grateful to know Bora and occasionally write for him and will be honored to be on a panel with him in April. He was having fun with our Twitter comments about baseball. But his comment gave me the idea for this story about why we love baseball and Brian Mossop graciously printed it.
      I fully understand how difficult it is to follow a game when you don’t know the rules. I find it boring to watch soccer or hockey because I don’t have any understanding of those games. I’ve had to learn about baseball over the years. And I keep learning.
      My letter to Bora was to encourage him to get to know baseball and was a vehicle for me to express some of the passion I am once again feeling as the 2011 season hovers. I love Bora. We all do. He is an incredible gem!


      • Franc says:
        March 1, 2011 at 11:55 am

        Dear Mary,
        I know that Bora doesn’t need an advocate, I only used the opportunity to enter the discussion on your really excellent and inspiring blog entry. And it’s my personal intention, when I go the next time to the States, that my American son-in-law will have to take me to watch a baseball game and I’ll do my best to try to enjoy it  . Another friend of mine, who also lived some 12 years in the States, actually agrees with Bora in not understanding the game. He describes the game as a bunch of middle aged, beer-bellied men who mostly just stand around, often scratch their crotches , throw things around, seem to threaten each other and the umpire with a big stick, all the time spitting disgusting goo on the ground, argue with the umpire and from time to time madly dash around like they stepped on a fireanthill. Please understand, these are my friends words and he is not known to mince words a lot! He likes, however, to quote Yogi Berra, and wishes to soften these here words with one of his quotes: »Little League baseball is a good thing because it keeps the parents off the streets and the kids out of the house«.


        1. Mary Knudson says:
          March 1, 2011 at 12:18 pm

          One thing I agree with your friend on is the spitting. I have considered writing an article on why do baseball players spit. I know some of them spit because they chew tobacco, a habit that is not only nasty to some, but also poses a risk of cancer. But I think that is now a minority of the spitters. Spitting somehow became part of baseball culture. Basketball player don’t spit. Football players don’t spit. Why do baseball players need to spit? I would think they would be concerned about sliding into base with their hand or diving for a ball and encountering the spitted product on the turf. How often, just as the camera goes in for a closeup of a player, he spits. Etiquette, please! There should be No Spitting in Baseball!!!


  1. David Dobbs says:
    March 1, 2011 at 8:53 am

    Bora at a baseball game. I REALLY WANT TO SEE IT. In fact, I’d like to be there.
    But just in case I don’t make that particular game, here’s my Foreigner-Goes-To-First-Baseball-Game joke.
    A Scot visits a friend in the States. Friend takes the Scot to a baseball game. Tries to explain the game as it goes along — how the batter tries to hit the ball, and if it he does, runs as fast as he can to get to first so he won’t be tagged or thrown out.
    Scot gets into it. He’s cheering, yelling the hitters down to first. It’s going pretty well when a batter in the second inning draws a walk. Batter drops the bat and starts to trot slowly to first base.
    The Scot, panicking, stands up and yells. “Run, mon, run! They’re going to tag you out!”
    “No, no, it’s okay,” says this American host, reassuring him. “He’s got four balls, so he gets to just walk.”
    The Scot looks thinks about this a minute, absorbs it, and yells, “Walk with pride, mon! Walk with pride!”
    One month to Opening Day.
    David Dobbs
    P, SS, 1B
    Montpelier Monties


  1. Joe Wallace says:
    March 1, 2011 at 9:13 am

    Thanks for asking me to contribute a “guest perspective” to this terrific post, Mary.
    I remember, when I was researching my first baseball-history book, walking into the Baseball Hall of Fame Library and thinking, “I’m being paid to do this!” What a pleasure to be surrounded by the game and its unforgettable figures.


  1. Steve Mirsky says:
    March 1, 2011 at 9:15 am

    Fav baseball joke. Elderly former Cy Young winner in nursing home is visited by an angel. Says to angel, is there baseball in heaven? Angel says, I have good news and bad news. Guy says, what’s good news? Angel says, there IS baseball in heaven, beautiful field, great players, terrific equipment. Guy says, what’s the bad news? Angel says, you’re pitching tomorrow.


  1. Mary Knudson says:
    March 1, 2011 at 9:41 am

    Thanks David Dobbs and Steve Mirsky for spicing up this baseball package with your baseball jokes! Anyone else have a baseball joke to contribute?


  1. Steve Mirsky says:
    March 1, 2011 at 10:38 am

    Mickey Mantle used to tell a joke on himself. He said that he had a dream that he died and got to the Pearly Gates and St. Peter said, “Mick, I’m afraid that you led such a sinful life that you didn’t make it in. But before you go, could you sign these six dozen baseballs?”


  1. James says:
    March 1, 2011 at 3:06 pm

    I have played baseball up until the last two years in Australia. I was a pitcher and first baseman (could never hit unfortunately) and played in the top division in South Australia as well as representing my state twice. As an Australian I think its easily one of the best sports, much better than dreary cricket, and can’t understand how you haven’t got into it already Bora!!!
    I loved this piece too, reminded me of why love the game so much. It’s just a shame there was so much Yankee love. You really want to go for a good team instead Bora, like the Red Sox 


  1. Mary Knudson says:
    March 1, 2011 at 9:13 pm

    Thank you, James. Comments from Red Sox fans are welcome. I could never love the Red Sox. It would go against my DNA. But what we all have in common is our love of baseball! I am so psyched for the long season to unfold. And I admit I’m curious to see how good the Sox are this season. We both need to worry about those Phillies.


    1. James says:
      March 1, 2011 at 10:09 pm

      I know. A postdoc who has recently returned to the lab has come back a Phillies fan. It’s so very depressing…

What New Pacemakers that Can Be Used with MRIs Mean for Consumers

by Mary Knudson

This was the Guest Blog post at Scientific American 2/16/11

This week Medtronic will begin shipping to hospitals in the United States the first pacemaker approved by the FDA as safe for most MRI scans.  For consumers, it is a significant step in what is expected to be a wave of new MRI-compatible implanted cardiac devices. 

But this is an example of one technology chasing another and the one being chased, the MRI scanner, is changing and is a step ahead of the new line of pacemakers.  The pacemaker approved for U.S. distribution is Medtronic’s first-generation pacemaker with certain limitations, while its second-generation MRI-compatible pacemaker is already in use in Europe where approval for medical devices is not as demanding as it is in the U.S.  So let’s check out what this is all about -- what it means now for current and future heart patients and where it may be headed.

We are all born with a natural pacemaker that directs our heart to beat 60 to 100 times a minute at rest.  The pacemaker is a little mass of muscle fibers the size and shape of an almond known medically as the sinoatrial node located in the right atrium, one of four chambers of the heart.  The natural pacemaker can last a lifetime.  Or it can become defective.  And even if it keeps working normally, some point may not function well along the electrical pathway from the pacemaker to the heart’s ventricles which contract to force blood out to the body.  

Millions of people in the world whose hearts beat too fast, too slow, or out of sync because their own pacemaker is not able to do the job right, follow their doctors’ recommendation to get an artificial pacemaker connected to their heart to direct its beating.  The battery-run pacemaker in a titanium or titanium alloy case the size of a small cell phone, (why can’t it be the size of an almond?) is implanted in the upper left chest, just under the skin, with one or two insulated wire leads connecting to the heart.  It can be programmed to run 24/7 or to only operate when the heart reaches a certain state of irregular beating.

With some rare exceptions, there are few drawbacks to having a pacemaker.  But you need to avoid powerful magnets.  No problem being around your microwave or computer and when you talk on a cell phone, just hold it on the opposite side of your body from the pacemaker. But it’s best not to walk through airport security scanners, and instead submit to a body search and hand-held scanner.  The biggest “no” that accompanied your pacemaker is to avoid any magnetic resonance imaging (MRI) exam. That may not have seemed like a problem at the time you agreed to get a pacemaker implanted.  But we never know what turn our health may take.  And there are many conditions for which doctors seek  to learn more through an MRI scan that uses a very strong magnet, radio frequencies and a computer to produce  images of soft tissue, bone, and blood vessels.  Because it produces such detailed images of soft tissue, it is frequently used for organs of the body such as liver, bowel, pancreas, kidneys, brain and spinal cord. The MRI, which does not require ionizing radiation, is also used in diagnosing and staging cancers and pinpointing heart problems.

But, only a few medical centers in the United States and maybe 10 worldwide have the ability to perform MRIs on patients with the pacemakers now in use. Most people wearing pacemakers who need an MRI have been unable to get one.  Pacemaker companies advise against it and the American Heart Association issued a statement in 2007 that discouraged doctors from performing MRIs on pacemaker patients unless the need for the MRI was compelling enough to warrant the risk of the exam.  Medicare will not pay for an MRI done on a patient who has a pacemaker.  There have been a few reported deaths of pacemaker patients who got an MRI and the risks include movement of the pacemaker and re-setting of the beating pattern. The wire leads are insulated except for the exposed metal tips that screw into the heart and under the tremendous vibrating of an MRI scanner that goes on for 30 minutes to an hour and a half during the course of an exam, the tips can heat up to the point that they can burn the flesh.

So getting a pacemaker that is safe to use during an MRI is a big deal for heart patients. “This is an important step in the right direction,” says Dr. Bruce Wilkoff, president-elect of the Heart Rhythm Society and Director of Cardiac Pacing and Tachyarrythmia Devices at the Cleveland Clinic.  Wilkoff was the primary investigator for the EnRhythm MRI clinical trial that was the basis for the FDA’s approval of the first U.S. MRI-compatible pacemaker and he presented the study’s findings to the FDA.  The study involved 464 patients in an international multicenter trial. Changes were made to the pacemaker, its leads, and the programming system, Wilkoff said, to address potential for interfering with the device’s pacing, overstimulating the patient, and overheating the tip of the leads.       

Revo’s Limitations

However, this Medtronic first-generation Revo MRI SureScan Pacing System  has some significant limitations.  

1.  The MRI-pacemaker is for new heart patients.  Patients who already have a pacemaker can not get this new model unless they undergo the risky procedure of having their old pacemaker completely removed. Usually, when it comes time to replace the battery in a pacemaker (about 5-7 years), the metal case containing battery and circuitry is detached from the leads, and a new model device is hooked up to the leads.  But doctors generally consider it too risky to remove the old leads from the heart for fear of tearing the heart or the veins through which the leads are inserted into the heart. Part of the design of the Revo pacemaker is its new leads and so they must be the leads that connect the pacemaker to the patient’s heart.

2.  Patients must have the Revo pacemaker implanted for 6 weeks before 

     receiving an MRI.


3.  The Revo pacemaker requires a certain position of the patient inside the MRI tube so as to avoid most chest scans.  This is to prevent overheating the metal tips of the leads that are attached to the heart. So heart scans are forbidden with this first generation model.

 4.  And Owen Faris, senior scientific reviewer for the FDA, explains that the new pacemaker won’t work for all types of MRI scans and won’t work in all MRI scanners.  In his words:

In addition to the chest scan exclusion, there is a restriction on how much radio-frequency energy can be deposited into the body by the scanner. MRI scanners have two operating modes for most clinical applications. ‘Normal operating mode’ is how the scanner is normally programmed and that mode restricts the scanner to lower-energy scans (less than 2 Watts per kilogram). This is sufficient energy for most clinical MRI scans. However, for some patients and for certain scans, more power is needed. In those cases, the MRI scanner is placed in ‘First level control’ mode, which allows for greater energy deposition (up to 4 Watts per kilogram). For patients implanted with the REVO MRI pacemaker, those patients are not allowed to have these higher energy scans. 

MRIs for these patients are also restricted to only allow use of 1.5 tesla MRI systems. “Tesla” is a measure of the strength of the magnetic field.

5.  Medicare does not now pay for MRI scans on a patient who has a pacemaker.  Medtronic spokesperson Wendy Dougherty says that Medtronic will not speculate on whether Medicare will cover MRIs done on patients wearing the new Revo pacemaker.  The federal agency is considering a petition from a physician to cover MRIs done during an investigational study to determine the risk of MRIs involving pacemakers already in use.  During the comment period for this request, Medtronic asked Medicare to restrict MRI payment to patients wearing pacemakers approved by the FDA for use with MRIs.  Medicare's decision is due by March 1.  Patients on Medicare would be wise to check on whether Medicare will pay for their MRI before getting the test which costs between $1,600 and $3,500 at different medical centers and offices.

What to Expect for the Future?

Approximately 1.5 million Americans have cardiac pacemakers. Worldwide, 5 million people are implanted with a pacemaker or implantable cardioverter defibrillator (ICD) that shocks a chaotic shaking heart into normal working order. 

Europe, where approval process of medical devices is less strict than in the U.S., began using Advisa, the Medtronic second generation MRI-compatible pacemaker, early last year.  The Advisa has no restrictions on chest scans and Medtronic says this model is in clinical trials in the U.S.  

Cost of a pacemaker is $5,000 to $10,000 (just for the device, not counting the much larger charge by hospital and physicians for implanting it) and Medtronic says the Revo pacemaker will be in that range.  Tao Levy, Collins Stewart market analyst, says that the Revo will cost about $1,000 more than a standard pacemaker and will boost Medtronic’s revenue in the U.S. by $50 to $60 million.  Boston Scientific and St. Jude Medical are developing MRI-compatible pacemakers and other implanted devices and as other companies bring these products to market, the use is expected to grow.  

But “not over the near-term,” says Levy.   “In a recent survey of electrophysiologists (who put pacemakers into people), the expectation is that Medtronic’s MRI-conditional pacemaker would comprise around 20% of the pacemaker implants. So the vast majority will still be regular pacemakers. Over time this might change.”

“Expense and the need for proprietary leads and the coordination of personnel may prohibit widespread adoption,” says electrophysiologist Dr. Westby Fisher, clinical associate professor of medicine at University of Chicago’s Pritzker School of Medicine.  He is a member of the Speaker’s Bureau for both Medtronics and Boston Scientific.  “Monitoring in the MRI by EKG (an electrocardiogram of the heart) is required and not all MRI machines are equipped for this feature.”  Using a scanner that does not have EKG capability will call for scheduling a technician or a company representative to be present when the lengthy MRI test is performed, he says, which will mean “scheduling challenges due to logistics of having the right people in the right place at the right time.” 

The technology of pacemakers is chasing the technology of MRI scanners.  “Right now the issue is that Medtronic’s device is designed only for 1.5T powered MRI systems and there is a move to higher powered MRI machines (3T) for which the Revo is not indicated,” Levy says. The 3T MRI scanners produce clearer images in less time.

Nevertheless, cardiologists and electrophysiologists and market analysts think that MRI-safety will spread beyond standard pacemakers.  “I think eventually all implanted cardiac devices will be MRI compatible,”  says Dr. Henry Halperin, a Johns Hopkins professor of medicine who is Director of the Cardiology Bioengineering Laboratory.  Not that Hopkins is in any hurry.  It is one of the very few centers in the United States and in the world to run MRIs on patients with standard pacemakers and has done over 800 with no complications, Halperin says.  To accomplish this, he says they re-program the patient’s pacemaker into a “safe mode” so that the force of the MRI can’t make the pacemaker send out electrical impulses that are too fast or too slow, and they reduce the MRI scanner’s power by about half.  But he acknowledges that “there are still risks” and each decision to perform an MRI on a patient with a pacemaker comes down to this point:  “The risk of doing the scan vs the risk of not doing the scan.” That’s why Halperin says “All pacemakers should be MRI-compatible and I think they will be.”

“I expect MRI compatibility will become more commonplace in implantable cardiac devices and may become the standard,” agrees Dr. Thomas Callahan, an electrophysiologist at the Cleveland Clinic.  “A lot of people are hoping an MRI-compatible ICD will come along.” 

“That is the plan,” Levy says, both for ICDs and for a special kind of pacemaker used for cardiac resynchronization therapy (CRT) which resynchronizes a left ventricle that is not beating normally.  “But in order to be successful, they will need to avoid any disadvantages (like a stiffer lead) and not have restrictions that might be confusing (having an MRI-safe pacemaker, but not realizing that you are getting scanned in a more powerful machine than the pacemaker was originally tested in, designed for.”)

So, it seems, a good start, but there is lots of technical development to go.  Will  MRI-safe pacemakers eventually replace all other pacemakers? 

“Most likely,” says Wilkoff.  “But the transition will take up to 10 years or so.” 

Note:  A Medtronic spokesperson who initially said clinical trials for the Advisa pacemaker are underway in the U.S. now says, "Medtronic does not have any FDA-approved clinical trials in the U.S. for Advisa." 



HeartSense Helpathon: Sixth in a Series

Mini Exercises

(Beware of Sitting for Too Long at One Time)

by Mary Knudson

I can’t leave our discussion of exercise without talking about mini exercises throughout the day to counteract our terribly sedentary lifestyles.  I confess I sit far too long every day.  I, like Peter Janiszewski, have to make a plan to change that.  And so do you.  Almost all of us sit too long.  Think about it.  We sit at our computers to write, do research, communicate by e-mail, Twitter, Facebook and more, and play games.  We sit to eat.  We sit to read.  We sit driving in our cars and on other transportation. We sit to chat on the telephone and when friends come over to visit.  We sit to watch movies and TV shows.  I am a writer and so I sit a lot at the computer.  When I was writing the heart failure book with Edward Kasper, both of us considered investing in a stand-up desk  because, frankly, the part of your body you sit on for long times can start to go numb, and it is just not good for your circulation to sit for long periods.  But the health effects of being sedentary go farther.

Who is Peter Janiszewski, you may ask?  He is co-author with Travis Saunders of a delightfully written and highly informative and helpful blog called Obesity Panacea which you can find here at the PLoS (Public Library of Science) blogging network.  Please read their series of excellent blog posts about how sitting long periods harms your health and may cut short your life.  Break up your sitting pattern, they urge, by frequently getting up and doing mini exercises and other activities.  

This get-you-to-your-feet set of articles begins with a five-part series on sedentary physiology by Travis Saunders. In Part 1,Travis really got my attention with this simple fact: “sitting too much is not the same as exercising too little.”  He says he borrows this line from Marc Hamilton, one of the leading researchers in sedentary physiology.  But I heard it on Obesity Panacea. 

In Part 2, he reports that a study of over 17,000 Canadians found that “individuals who sat the most were roughly 50% more likely to die during the follow-up period than individuals who sat the least, even after controlling for age, smoking, and physical activity levels.”

In Part 3 Travis discusses the benefits of taking breaks from sitting.  He reports on another study that found The greater the number of breaks taken from sedentary behavior, the lower the waist circumference, body mass index, as well as blood lipids and glucose tolerance.”

Some readers responding to this popular series wondered how much sitting time was too much and whether it helped enough just to get up and go do some chore or whether you need to exercise every so often throughout the day.

Peter Janiszewski responded to his blogging partner with a not-to-be-missed post My Home-Based Mini-Exercise Regimen.  

“Essentially, I decided (completely arbitrarily) that I would do mini exercise breaks throughout my workday, with the daily goal of reaching 450 repetitions of whatever random movement popped into my head at each break.”

Peter got enormous reader response to that blog post and followed up by sharing suggestions from readers.  For instance, reader Dirk Hanson said this:  

“I’ve started arranging things in a way that requires me to bounce up from my desk at various intervals for 15 minute chore breaks–watering all the house plants, filling the bird feeders, vacuuming one room, making coffee, getting something out of the garage, taking a brief walk, whatever.”

I am so impressed with this fine blog and its authors.  Here, reprinted from their PLoS blog site, are bios for Travis and Peter.  Please visit them often. A good prescription for your health.

As for me, I will break up my long sitting periods.  But, I warn you, it’s hard to do, at least at first.  I want to turn now to finishing the syllabus for the spring writing course I teach.  But I would need to keep sitting here to do that and I can’t because now it’s time to get up and do marching exercises or use my leg press or go play with the dog or walk through the house looking at the ceilings to see if there are any cobwebs in the corners.  Jeez, I’ve got to work on the balance of all this. Up, down.  Concentrating, distraction.  Writing, not writing.  But, otherwise: Better health, not health?

Hey, it’s cheating to get up from sitting and go to the fridge.

About the Authors

Peter Janiszewski has a PhD in clinical exercise physiology. He's a medical writer/editor, a published obesity researcher, university lecturer, and an advocate of new media in scientific knowledge translation. You can connect with Peter on Twitter. For more information please visit his website.

Travis Saunders is a PhD student researching the relationship between sedentary time and chronic disease risk in children and youth. He is also a Certified Exercise Physiologist and competitive distance runner. You can connect with Travis on Twitter.


Heart Sense Helpathon: Fifth in a Series

Resistance Exercises to Strengthen and Build Endurance

by Mary Knudson

In earlier posts in this blog we have discussed stretching exercises, aerobic exercises such as walking, biking, and running, and balance exercises.  A fourth type of exercise that many people diagnosed with heart failure as well as those in good health can do safely is resistance exercises which build muscle endurance by challenging targeted muscles through a certain number of repetitions.   But be sure to avoid straining.  You are not the candidate to crouch and stand while hoisting heavy barbells over your head.  Before you start, look at these tables of contraindications established by the American Heart Association Science Advisory Committee which are at the end of this blog post.  I suggest you take them to your cardiologist and also show them to the rehabilitation specialist or trainer who will devise your exercise routine. Full article is in the medical journal Circulation here.

Usually you will start with one set of repetitions, then in future sessions go to two sets with a brief rest in between the two sets .  Some examples of resistance exercises:

  • knee extensions and hamstring curls done with weights strapped to your ankles
  • knee extensions and hamstring curls done sitting on a machine such as a home gym
  • lifting your hips up off a training table or a mat on the floor while squeezing a ball between your knees and again with a ball under your legs
  • lying down on a training table or mat and opening and closing your knees with an elastic theraband around your thighs for resistance
  • Rotating the trunk of your body and doing rowing exercises with resistance bands 
  • Squats and lunges are practical exercises that help prepare your body to get out of a chair or up off the floor.

If you use a machine such as a leg press, as I do, the resistance comes from the weights stacked on the leg press as, sitting down or lying on your back, you push a heavy bar down with your feet, until your knees are almost straightened out, and then bring your knees back up.  The amount of resistance is easy to control because you can add weights to the machine or take them off, making the pushing exercise more difficult or easier.  Typically you don’t have to physically lift weights onto the machine and take them back off.  The machine is made with a column of weights and you simply insert a metal pin into the weight level that is correct for you.

To determine the appropriate weight you should use in doing an exercise, the American Heart Association Science Advisory Committee says to first find out the maximum amount of weight you can push when doing that exercise.  Then take only a percentage of that maximum.  Starting out, that would be 30 percent to 40 percent for the upper body and 50 percent to 60 percent for the hips and legs.  “Most studies of previously sedentary adults with and without heart disease, including those with heart failure, reported training workloads of 50 percent to 80 percent” of  maximum weight the person could tolerate, the advisory committee reported. 

If you or your trainer or therapist have any doubts about your ability to test your maximum weight-bearing strength for an exercise, don’t do a test.  Just approximate your maximum based on what weight you comfortably handle, the committee advises. 

“For most people, if they can lift a weight 12 to 15 times before having to stop, that weight corresponds to about 50 percent of their maximum capacity,” says  Kerry J. Stewart Ed.D., director of clinical and research exercise physiology, Johns Hopkins University School of Medicine.  Dr. Stewart works with heart patients and is co-author of the guidelines for resistance training adopted in 2007 by the American Heart Association. 

It is very important for people with a heart problem to use the correct breathing pattern while doing resistance exercises. To avoid putting strain on your heart, exhale on the part of the exercise that takes exertion and inhale on the part that does not as you return to your normal position.

Times to Exhale

  • when you push the leg press down with your feet
  • when you push up from a squat
  • as you do an ab crunch
  • as you move your legs up in a leg curl
  • as you curl your arm upward in a bicep curl

By using this breathing pattern, instructs my trainer Randy Rocha, who is a certified athletic trainer and strength and conditioning coach,  you don’t build pressure.  He explains:  “That’s one of the biggest concerns with people with heart trouble -- that they’ll get on a machine and they’ll try to do a certain amount of weight and they’ll hold their breath and everything builds up inside, their blood pressure increases and that’s where they get into a lot of trouble and that’s why people with heart conditions may think that exercise is bad.”

Breathing correctly while doing strength training is not automatic with me.  I have to think about my breathing and remember when to exhale and when to inhale.  As I began doing resistance exercises, Randy continually prompted me to exhale when exerting myself, even though I was not aware of holding my breath.

Never hold your breath deliberately when straining.  But it may happen briefly.  “Some breath-holding is unavoidable,” Dr. Stewart says, “but try to avoid extended holding and strain.  Too much strain can raise the blood pressure to very high levels which puts unnecessary strain on the heart.” 

I hope you find you are healthy enough to engage in resistance exercises to build your strength and endurance.  I enjoy this strength training.  Please be sure to get your individual program structured at a heart rehabilitation center or by a certified trainer.

Recommendations for the Initial Prescription of Resistance Training

Resistance training should be performed 

  • in a rhythmical manner at a moderate-to-slow controlled speed, 
  • through a full range of motion, avoiding breath holding and straining (Valsalva maneuver) by exhaling during the contraction or exertion phase of the lift and inhaling during the relaxation phase, and 
  • alternating between upper and lower body work, to allow for adequate rest between exercises. 

The initial resistance or weight load should 

  • allow for, and be limited, to 8 to12 repetitions/set for healthy sedentary adults, or 10 to 15 repetitions at a low level of resistance, for example, <40% of 1 repetition maximum, for older (>50-60 years of age), more frail persons, or cardiac patients 
  • be limited to a single set, performed 2 days per week, and
  • involve the major muscle groups of the upper and lower extremities, eg, chest press, shoulder press, triceps extension, biceps curl, pull-down (upper back), lower back extension, abdominal crunch/curl-up, quadriceps extension or leg press, leg curls (hamstrings), and calf raise.

[Source:  American Heart Association Science Advisory, Resistance Exercise in Individuals With and Without Cardiovascular Disease:  2007 Update] 

Absolute and Relative Contraindications to Resistance Training 

Absolute Contraindications:

If you have any of these conditions, do not do resistance exercises:

       Unstable (Active) coronary heart disease. This means you are having symptoms of chest pain or shortness of breath even though you are on treatment.

        Decompensated heart failure. You are having symptoms of heart failure such as shortness of breath, fatigue, and fluid retention even though you are being treated for heart failure. 

         Uncontrolled arrhythmias

         Severe pulmonary hypertension (mean pulmonary arterial pressure >55 mmHg) 

         Severe and symptomatic aortic stenosis

         Acute myocarditis, endocarditis or pericarditis

         Uncontrolled high blood pressure (>180/110 mmHg). If your blood pressure is this high or higher, do not do resistance exercise until you get more treatment and your blood pressure falls below 160/100.  

       Aortic dissection

        Marfan syndrome

       Avoid high intensity resistance training (80 to 100% of 1-RM (one repetition maximum) if you have active proliferative retinopathy or moderate or worse non proliferative diabetic retinopathy. 


Relative Contraindications:

If you have any of these conditions, consult a doctor before participating in resistance exercise:

        Major risk factors for coronary heart disease (diabetes, smoking, high blood pressure, high cholesterol)   

         Diabetes at any age. If diabetes is controlled, resistance exercise is okay and even recommended by the American Diabetes Association.  

         Uncontrolled high blood pressure (>160/>100 mmHg). You can exercise if your blood pressure is below this level, even while taking medications to control blood pressure.

         Low functional capacity (<4 METs). Mets are a measurement of exercise capacity

         Musculoskeletal limitations – If the problem is so severe that it severely limits walking.

         Implanted pacemaker or defibrillator 

[Source: American Heart Association Science Advisory, Resistance Exercise in Individuals With and Without Cardiovascular Disease:  2007 Update] 

[Much of this post is excerpted from the book I co-authored with Edward K. Kasper, M.D., Living Well with Heart Failure, the Misnamed, Misunderstood Condition, chapter 13 “Exercise: How Much and What Kind?”  While the entire book was a collaboration, this particular chapter was one I researched and wrote because I was so involved with exercising.]

HeartSense Helpathon: Fourth in a Series

                                                             by Mary Knudson

I noticed on Twitter that Liz Scherer mentioned time and again that she was at the gym for her workout, even going in bad weather.  So I asked her to write about why and how she exercises for good health. Turns out she is even more dedicated than I thought.  Below is the guest post of a very determined woman who makes time for exercise daily because it is important.  In previous guest posts Jody Schoger inspired us with her passion for walking and cycling and Brian Mossop dazzled us with Why I Run.  Here Liz Scherer tells about her gym workout and explains that she just has to move every day.  Maybe something she inherited from her very active mom and dad? Are you like Liz or do you marvel at her story?                                  

                                       Move it or lose it: confessions of a junkie        

                                                              by Liz Scherer

Here’s a little known fact, even amongst my inner circle: I’m a junkie. And when I don’t get my daily fix, I lose my momentum, my emotional balance, my focus, my everything. 

As an aging, perimenopausal woman and a health writer/journalist, I’m well aware of the benefits of regular physical activity, including:

Significant improvements in metabolic and cardiovascular capacity 

Reductions in breast cancer risk, especially during menopause

Maintenance of normal weight as the metabolism slows

Better balance to counter bone loss, and along the same line, preservation of bone as estrogen begins to wane.

However, these benefits aside, it’s also personal; my activity regimen helps to keep the blues and life stressors at bay or, at the very least, temper them. Moreover, as an individual who’s been plagued with back and other joint issues most of her life, I know that movement keeps me upright.

Here’s another confession:

It’s in the genes.

I have yet to see any data that demonstrate that interest in exercise and physical activity is genetically based. Hence, as an “n=1” example, I’d like to offer the following hypothesis:

The need/desire to exercise is hard-wired at birth.

If true, this would provide a rationale for why I went from the gateway of jungle gyms to the harder stuff: gym workouts, running, biking, hiking and walking miles and miles and miles all over Manhattan. It would also explain why exercise doesn’t simply keep me alive and healthy, but it makes me feel vibrant and powerful. Moreover, every cell in my body craves it when I stay away for too long.

Physical activity. It’s my family’s genetic pool. Say what you will but one of the most vivid memories I have of my grandmother is her single-handedly moving a piece of furniture in her apartment, a piece that was at least twice her size and almost equivalent to her weight, and at the age of 87, no less.

My parents, currently 84 and 79, are also addicted. Back in the 70s, it was running and tennis; today, it’s horseback riding, exercise class, half-court basketball, tennis and golf, minutes on the BOSU, Qigong, you name it.  

For me, my routine is as varied as my interests. However, there are two constants:

A minimum of 50 minutes of cardio/aerobic activity daily.  Recent data  suggest that women need a minimum of 55 minutes daily of moderate intensity physical activity to maintain daily weight. I work out at a gym where I rely on a combination of the recumbent bike, elliptical, rowing machine or walking backwards on the treadmill. Not only is my aim to maintain a target heart rate but I also want to insure that I am hitting both lower and upper body areas during the course of my daily workout. In addition to metabolic boost, the goal is multifold: cardiovascular/aerobic conditioning, upper and lower body strengthening and core conditioning, all of which keep me healthy and upright. Of note, rowing has been a recent addition for me; not only does it work out my entire body, but it’s incredibly meditative and hence a stress buster and creativity enhancer.

An every-other-day weight/machine regimen as an add-on to aerobic activity. Due to time constraints, I tend to focus on either lower or upper body on these days but insure that I get both into my week. Of note, workouts should be individualized and take into account physical limitations, age and overall health. My workouts were developed by a trainer who understands the challenges of an aging body in conjunction with my physical therapist, who is also a physiologist and is responsible for helping me to eliminate much of the joint and back pain I am prone towards. Specifically, my weight/machine regimen is designed to strengthen my core, develop my upper back/shoulder strength and combat the middle-aged bulge that accompanies waning hormone levels in women. It includes free weights, the use of resistance bands, and Free Motion Cross-Cable machines that allow a customized program and smoother resistance. Importantly, I focus less on the overall weight I’m using for each machine and more on repetitions; this helps me to achieve fitness goals without overtaxing any area of my body. 

Whether you’re 25 or 35, 50, 70, or older, do yourself a favor: move. Physical activity is addiction that’s not only good for you, it’s also bound to make you feel good and can help keep you feeling good for the rest of your life. The one rule of thumb is to make sure that your healthcare practitioner supports whatever physical activity that you decide to engage in and that you work with a knowledgeable team of trainers and physiologists who can individualize programs.

Yes, I am a junkie and I come from a long-line of junkies. I don’t need a pusher because I push myself every single day.  Kick the habit? Not a chance!

Liz Scherer is a digital copywriter, medical & health writer/journalist, blogger, consultant, strategist and women’s health advocate. In addition to writing about midlife and menopause on her blog, Flashfree, she is a regular contributor to womengrowbusiness.com and an occasional contributor to disruptivewomen.net and savvyauntie.com.  She also sits on Social Media Advisory Boards for HealthJustice CT and the Council for Responsible Nutrition’s Life…Supplemented campaign. Liz is a member of the National Association of Science Writers and the Association for Health Care Journalists. Follow Liz on TwitterLinkedInAmplify or Quora. 

Cardiologists comment on Heart Failure Death Statistics blog post

                                                          By Mary Knudson

Some of my HeartSense blog posts are picked up and published on CardioExchange, a social network run by the New England Journal of Medicine which, as I write this, has 2,572 members.  The site was established as a safe environment for cardiologists to exchange views candidly and learn of breaking cardiovascular news quickly. I thank CardioExchange for extending an invitation to me, a journalist, to join its site and for finding some of my posts worth their time to read.  I learned yesterday that the  public can see blog posts at the site but can not see comments.  And so with permission from Harlan Krumholz, editor of CardioExchange, I reprint comments made to my post “Heart Failure Death Statistics: Don’t believe what you read on the internet”.  I reprint only those comments made by doctors who also gave me permission to publish their comments here.  

Some commenters agreed that there are glaringly wrong statistics about life expectancy with heart failure on the internet and some expressed strong beliefs about the need to pursue prevention of heart disease.  

To read the blog post that drew these responses, please scroll down to the post titled “Heart Failure Death Statistics”. 

Below are comments reprinted from CardioExchange:

Mark Dayer, PhD MRCP Physician, Taunton, , GB
Competing interests: none

I could not agree more. I now have to advise patients to be a little wary of the statistics quoted on many reputable websites. Although mortality for patients with intractable and unstable symptoms remains high, for many the annual mortality is much lower. I would hope that organisations such as Kaiser Permanente which collect a lot of data on patients electronically will be able to answer this question in time. In the UK more and more hospitals are routinely collecting data on all heart failure admissions and mortality data will follow from this.
December 13, 2010 

Mary Knudson, Health Journalist Other, Silver Spring, MD
Competing interests: none

So glad to hear you say this. Thank you for telling patients that much of the time heart failure is not what it sounds like and that life expectancy for people with heart failure is increasing. I recognize that mortality remains high for patients with intractable symptoms, and for some others there is the possibility of sudden death. But I wish all reputable websites would take the responsibility of publishing prognosis statistics they can gather from experienced cardiologists who see many heart failure patients or else just not address the subject at all. What is not right is to frighten newly diagnosed patients who are seeking information about their condition and read these terribly outdated death statistics. 

I applaud what the UK hospitals are doing. I wish in the U.S. we could create a national registry or a huge prospective study in which information is collected uniformly and patients’ doctors would give out the information on cause of death for the registry rather than have a a third party try to ascertain from death certificates who died of heart failure. In addition to accurate death rates of people dying from heart failure itself and those experiencing sudden death, we could learn what medical regimens those who died were on and see if there is a pattern of people dying who didn’t get the best treatments. We not only want to know how many people die of heart failure. We want to know why they die. We could also gather a trove of genetic data that one day could be very helpful.
Thank you very much for commenting.

December 13, 2010

Richard Kones, MD PhD Physician, Houston, TX
Competing interests: none

The larger issue here is that misinformation is rampant on the web. Of the two studies I came across recently, the accuracy, reliability and overall validity of most was horrifyingly low. I believe there is an unavoidable delay in translation of findings, and even more difficulty in getting the information out… I certainly do not fault the HFSA, since I am a member and fiercely loyal, but inadequate funding is likely responsible for lack of updates. 

There is always a balance between divulging a truthful poor prognosis to patients and their families, and reluctance to overwhelm them with such despondency that it paralyzes and prevents partnership to help fight the illness.
My other point is that usually the media and reporting is woefully inadequate, largely lacking in perspective. So thanks, Mary, for your good work.
December 20, 2010

Barry M. Massie, BA (Harvard), MD (Columbia P&S) Physician, San Francisco, CA
Competing interests: none

I remember talking to Mary Knudson some time ago. I made the point that there is no one mortality rate for heart failure patients. Patients hospitalized for their first episode of heart failure have a poor prognosis, especially if it is caused by a myocardial infarction, and the 50% 50-60% year mortality rates reported from the Framingham study in the late 1990s were astonishing. As noted by other commentators, these deaths often are not caused by heart failure or even related to cardiovascular disease. In a follow-up study from Framingham published in 2002, however, there was a these rates had declined by 31% and 32% in men and women, respectively. Most of this improvement occurred between 1980 and 2000 and probably reflected the impact of ACE inhibitor and beta-blocker therapy. 

But numbers don’t tell the whole story. Framingham MA, a relatively homogenous, middle income town is not reflective of the United States. Nor is Olmstead County MN, mentioned by Ms. Knudson. By and large, residents of these communities have good access to health care. Another source of statistics is the data generated from large clinical trials. Compared to epidemiological studies, these patients uniformly have a much better prognosis. Why? They are carefully selected for the absence of other serious comorbid conditions and for their adherence to treatment. Their follow-up in the trial is frequent and rigorous. In these, mortality rates often fall below 5-8%/year, even in the control groups.

Despite what impresses me as a dramatic improvement in the outcomes of heart failure patients in the more than 30 years I have worked in this field, we still have a long way to go. Unfortunately, the attention focuses on the dramatic treatments that make it to TV—transplants, left ventricular assist devices, implantable defibrillators, stem cells. Yes, these work, but the costs are high, and the numbers of appropriate candidates for these are relatively small and will remain limited.

Hence, my plea would be that we shift our focus to prevention. Heart failure is relatively easy to prevent but will take a shift in our behavior. Early detection and effective treatment of hypertension can prevent up to 50% of all new heart failure cases. Prevention of heart attacks with changes in diet, life style, and smoking cessation will prevent another large number of heart failure cases. Changing diets can have a similar effect. 
A decrease of 1 to 3 grams of daily salt would save more lives than all of these high-tech interventions taken together

Those of us who work in the field and keep up with the basic research advances in our understanding of the potential mechanisms causing heart failure and novel treatment targets are aware of the large number of potential therapies that have not been developed because the large pharmaceutical companies prefer to develop “me-too” drugs where the path to approval is more straightforward and the risk is less. Research is risky, but marketing works. In the end, they seem more interested in winning the marketing war than investing in “finding the cure”.  

Using the usual sports adages, if we want to win the war on heart failure, we have to invest. We need to change behaviors, emphasize prevention, and build on the great success of the decades of neurohormonal directed interventions with novel and complementary approaches. 

This should be the role of the NHLBI. It needs to invest on the next generation of novel therapies, perhaps in partnership with industry. It should use its prestige and resources to educate the public. As a recent seminal analysis by Bibbins-Domingo in the February 18 issue of the NEJM demonstrated, just a moderate reduction in salt intake (largely driven by intake of processed foods and fast food restaurants) would have a major impact on cardiovascular outcomes including heart failure. It would be much more cost-effective and save many more lives if we direct our research toward the prevention of heart failure or early diagnosis and modification of the process in its early stages. Wouldn’t this be a wiser way forward investing enormous resources on developing high tech interventions for the tip of the iceberg of patients with advanced heart failure? 

January 1, 2011 

Mary Knudson, Health Journalist
Competing interests: none

Thank you Richard Kones and Barry Massie for your thoughtful replies to my post about heart failure statistics. The reason I care so deeply about bad information on heart failure, especially outdated bad predictors of life expectancy, is that I have felt the fright it causes to read this bad information when you are affected and you don’t know enough to realize that it is bad information. I want to save others this experience.

You and I are in tune in trying to promote prevention of heart failure, Dr. Massie. As we start a new year I yesterday published the third in a series of posts on my HeartSense blog dealing with prevention. The first several posts are about exercise and then I will move to nutrition, starting with the deadliness of sodium. If any of you would like to contribute comments to the sodium post or any other heart failure prevention topic, will you please contact me? Also I would welcome a guest blog post on preventing heart failure or any one aspect of that.

As a journalist and as a person who had heart failure, you have my attention. You are the second significant leader in the field of heart disease, Dr. Massie, to tell me that heart failure would be easy to prevent. Daniel Levy, director of the Framingham Heart Study, said of heart failure: “in the majority of cases, it is preventable.”

But preventing heart failure must go beyond urging people to take personal responsibility for lifestyle changes. I would hope that the cardiology community will launch a take-no-prisoners campaign to drastically limit the sodium content in processed foods and restaurant and takeout food.
Thank you very much. I look forward to talking with you again.
January 2, 2011 

Stephen Fleet, MD Physician, Peabody, MA
Competing interests: none

There is an old adage that the way to a long life is to have a chronic disease and take care of it. Many people with CHF live for a long time, particularly if some of the underlying factors can be corrected. It is a very heterogeneous group so alarming web statistics should be taken with a “grain of salt”–so to speak.
January 2, 2011

Richard Kones, MD PhD Physician, Houston, TX
Competing interests: none

These remarks are insightful indeed, and speak to several issues. Mary Knudson correctly points out that inaccurate older information, especially on sites of medical organizations should be updated, since they not only have professional functions and readers, but offer public information and hence operate in the public trust. The responsibility of such a site is significant. She further suggests that pooling data in a national registry would provide valuable current information.

The history of HF and coronary syndrome treatment is instructive. In the days when I made house calls moonlighting as a resident, acute HF, then known as pulmonary edema, was treated with mercurial diuretics IV, rotating tourniquets, and morphine. Similarly, a confirmed MI was treated with a months’ bed rest as an inpatient, creating an open market on VTE! While this sounds embarrassing to me now, what will be said about our current treatments 75 years hence? Most likely, I suspect, equally barbaric and misdirected.

Thereafter, ventricular mechanics during ischemia and HF became better understood, with Braunwald, Sonnenblick, Parmley, Jay Cohn and many others as major contributors.

I brought up the extent of misinformation on the internet, which is a real concern. There are several forms: outright deception for sales, errors which are egregious in number or impact, significant omissions, simple inaccuracies, or carelessness. However, given Google’s commercial orientation, the nonacademic entries usually get prioritized, leaving the extent of misinformation horrendous. I suspect there is a huge population that relies on web-based info for self-treatment of serious diseases. Put the two together and the potential for untold harm exists. There are patients buying colon cleanse kits to treat nearly every known codable illness, from acute appendicitis to MIs to brain tumors, which can only result in tragedy.

Then there are investigational techniques. The unreliability of death certificate diagnoses, and screening, unique study populations, and run-in periods common in large clinical trials make one question the applicability of results, however generated, to real-life practice, and the ability to generalize. Tell someone nowadays that a meta-analysis is not gospel or law, and they recoil in horror.

I could not agree more with Dr Massie, who himself has made significant contributions over the years. Prevention is a proven, cost-effective, and preferred method of handling chronic disease, but particularly in CVD, where the incubation period occurs over decades, and the common causes in risk factors are widespread. Yet as Gerald Berenson MD (Bogalusa Heart Study) has said, prevention is a “hard sell.” Prevention trumps drugs, invasive procedures, devices, and surgery hands down in every way, yet continues to be ignored. It is not flashy in the sense that transplants, ICDs, LVADs, and stem cell research are, as Dr Massie mentioned above. We need to stop looking at the smoke and mirrors, but more at the big picture, and where the present inexorable increase in CV risk burden is leading. Flash, image, and marketing are more important in our society, not old stand-bys that may work better, at a fraction of the cost, without side effects, and are more humanitarian.

Less than 3% of our health budget is allocated to prevention. Cardiovascular prevention, despite the higher mortality rates from CVD, is actually afforded less attention for preventive monitoring by guidelines and grant committees than are cancer and HIV.

The benefits of prevention are not new, but have been known for over 30 years. However, if one simplistically asks average people whether they would prefer to change their lifestyle or when faced with angina, have stents implanted, they will overwhelmingly choose the stents. This choice tells the tale. Not only in health, but elsewhere, personal responsibility is on the wane, not on the upswing. Roots here are societal, not medical, although socially, wherever possible, they are medicalized as a denial mechanism for political and personal reasons.

Mary Knudson, Health Journalist
Competing interests: none

Wow! Mercurial diuretics, rotating tourniquets, and morphine! That is unbelievable.
But it is also unbelievable that we eat the foods we do, isn’t it. Another strong voice for prevention of heart disease. Thank you. I’m glad that CardioExchange exists to have these stimulating discussions. But the public needs to hear your voices. The public doesn’t hear you in this forum.

Will the community of cardiologists, perhaps in partnership with the American Medical Association which has money and lobbyists, please launch a public campaign to stress both personal and corporate responsibility for nutritional and other lifestyle changes? This would need to go beyond polite ads about benefits of eating right. Your campaign needs to squarely place sodium and trans fats in the same danger zone with cigarettes and house fires and drunk driving. Are you going to challenge food manufacturers and fast food chains and Congress? Are you going to collectively put to work the knowledge that you have from your training and your years of experience watching patients struggle with disease and die and go out there and change the eating habits of America and beyond? 

Are you going to get angry about the state of our food and our eating habits and say so in full-page newspaper and magazine and internet statements and on talk shows and in congressional hearings and in posters placed in community barbershops and stores and churches and honkey tonk bars? Are you going to get pastors talking about personal and corporate responsibility to health and get singers singing about it and television programs writing it into their scripts?

What are you going to do, doctors?

January 4, 2011

Heart Sense Helpathon: Third in a Series


                                                 Exercising Basics: Getting Started  

                                                                                      by Mary Knudson

In the previous two guest posts on exercise, Jody Schoger and Brian Mossop inspired us with their stories of building and sustaining a rigorous exercise program.  Both promised that if you exercise regularly, you will never want to go back to being a couch potato. Exercise makes you feel better and has many healthy benefits.  For those of us who have experienced heart failure, the main reasons to exercise are to strengthen our hearts and the muscles in our legs, arms and core of our bodies.

But the idea of walking, running, or biking for miles if you are unsteady on your feet or still get fatigued easily, may seem out of the question.  So let’s talk about how to get started and what types of exercise to do.  Please be sure to get your doctor’s approval before you begin exercising.  Much of the following is excerpted from Chapter 13 “Exercise:  How Much and What Kind” in Living Well with Heart Failure, the Misnamed, Misunderstood Condition the book I co-authored with Edward K. Kasper MD.  While the entire book was a collaboration, the exercise chapter was one I researched and wrote and the main references are listed below.  

If you are not already exercising regularly, why not start today.  Let’s make 2011 a year we build our strength and fitness.


Why Exercise?

To keep from turning into a statue; gain more freedom of movement; ease your heart’s workload; strengthen your core body, legs, arms, heart, and lungs; and become more active.  A main symptom of heart failure is an inability to exercise for long, or even do normal activities such as walking or bathing without feeling fatigued or short of breath.  Heart failure doesn’t just affect your heart.  It also affects many of the muscles in your body, and muscle weakness is often most noticeable in your legs. 

At least three things contribute to your muscle weakness:  As your heart labors to send oxygen to your body, your skeletal muscles receive less oxygen, certain damaging chemical changes occur, and using the muscles makes them tire easily.  Your symptoms of heart failure – your general fatigue, shortness of breath, and muscle fatigue --  often lead to your becoming less active.    Randy Rocha, strength and conditioning coach who has worked with me, explains that with inactivity, as can happen when people first develop heart failure or have moderate to severe heart failure,  muscle tightening and muscle atrophy set in.  “You atrophy so much that you don’t have the strength to get from Point A to Point B,” he says. “Not only is everything atrophying, everything’s tightening up and it’s slowly getting tighter and tighter.”  Then when you try to get up from a chair or off the toilet or walk up stairs or even walk on a flat surface, your shrunken muscles can’t meet the demands you ask of them.  So you may find yourself hobbling along, stopping to rest your hands on the back of a chair or leaning against a wall.  Not the shape you want to be in?  Regular stretching and strengthening exercises will help you get up more naturally and walk more normally with better posture for longer periods. 

Most heart failure occurs in people who are over 55 and so, aside from your heart failure, you also may have gotten out of shape, overweight, and have some arthritis, diabetes, or other medical problems.  I was fortunate enough to get through my bout with heart failure and come out with a heart that is working normally.  But separately from heart failure, I’ve developed a neuromuscular problem that makes walking challenging.  Like me, you may have multiple reasons to exercise. When you plan your exercise routine, treat your heart failure, but also take care of your whole body’s needs.  Besides gaining the ability to be more active and do more things, benefits from exercising include lower blood pressure and improved ability of the blood vessels to expand and contract.

Types of Exercise

If your doctor says you are healthy enough to exercise and have no particular exercise restrictions, choose a combination of these four types of exercise:

1.  Stretching exercises will isolate individual muscles, lengthen them, and keep them and your joints flexible.

2.  Aerobic exercise, also called cardiovascular exercise, such as biking, walking, or running will build the heart’s endurance and improve muscle function in your legs and arms, depending on the exercise you do. 

3.  If you are strong enough, balance exercises such as standing on a balance board or wobble board will improve your body’s awareness in space.  

4.  Resistance exercises or strength training can strengthen muscles throughout your body, increase muscle endurance, and improve balance and posture.  Increasing muscle endurance can increase the body’s ability to burn fat throughout the day.

We will discuss stretching, aerobic, and balance exercises in this post and save resistance exercises for the next one because there is much to understand about how to safely do resistance exercises.

If you still have an active heart condition, the safest and most effective way to start your exercise program is to learn exactly what to do at a cardiovascular rehabilitation program or exercise center.  If your heart problem is resolved or if you don’t have a heart condition and are exercising to be healthy, you may want to go to a sports therapy center to learn how to build your personal exercise program.  Please get instruction in how to do stretching exercises.  Once you’ve learned what to do, you can work out on your own at home or you may choose to make regular visits to an exercise center.

These are some basic questions to ask a therapist or trainer:    

What exercises should I do?

In what order should I do them?  

How long should each exercise last? (How many repetitions?)

How frequently should I do each exercise?  (More than once a day?  Every day?  Two or three days a week?)

How long do I need to rest between exercises or between exercise sessions?  The right workout/rest ratio is important for people with active heart failure.  Start with short exercises and progress as you get stronger.

How will I know when to progress to more intensity with my exercises?

Stretching exercises. Before doing your stretching exercises, ride your stationary bike or walk for five minutes.  After a short warmup, you will get more benefit from stretching your muscles.  Stretching your calf muscles in your lower leg, your quadriceps -- the major muscles in the front of the thigh, and hamstrings in the back of the thigh is important for walking well and not tiring easily.  Stretching the muscles surrounding the hips – glutes, hamstrings, and iliotibial band -- can help reduce back pain and improve posture.  You will hold each stretch for 20 to 30 seconds. 

Aerobic (cardiovascular) exercise. Examples are biking outdoors or riding a stationary bike, walking outdoors or on a treadmill, running or jogging, and using an elliptical trainer. These exercises, which you’ll spend the most time at, get your heart rate up. They also burn fat and help you lose weight. A recent study found that aerobic exercise helps remodel an enlarged left ventricle to a more normal size.

Walking 20 to 30 minutes a day is a great aerobic exercise if you can manage it.  You may want to have a regular time each day to walk outside with a friend.  Walking in a grocery store is a good way to get started.  If you need some support when you walk, pushing a grocery cart acts as a great walker on wheels. 

If walking is difficult for you because your legs are weak, your balance is not as good as it used to be and you may fall, your knees are painful, or it’s too hot, too cold or even icy out or the air quality is poor, there are aerobic exercises that you can do at home.  Riding a stationary bike is a good one.  Stationary bicycles and elliptical trainers are non-impact machines because there’s no pounding on the ankles, knees, hip joints, or the spine. 

You can monitor your heart rate by wearing a heart rate monitor.  Some exercise machines have built-in heart rate monitors. You can also use the old-fashioned, low-tech method of counting your heart rate at your pulse.  Your target heart rate for aerobic exercise should be set by your doctor or an exercise specialist who communicates with your doctor. Your rate will relate to your medical condition and the type of shape you’re in.

Biking requires a lot of lower extremity strength, especially the quadriceps.  As you exercise targeted muscles, the heart sends blood and therefore oxygen to that muscle group.  Aerobic exercise also decreases your resting heart rate and your blood pressure.  Exercising your heart challenges it which helps it do a lot better when it’s not challenged.

Balance exercises.  Exercises such as standing on a balance board or wobble board are important because balance plays a role in stability and strength.  If you don’t have good balance, something needs to assist you.  You’re going to focus more and use muscles a lot harder than a person who has good balance, or you will hold on to something such as a cane, a crutch, or a walker to take the stress off.  Randy says that, unless you have an injury, if you use a walking aid, what you are doing is making up for your lack of balance and strength. 

If you use a balance board or wobble board, please place it very close to a railing or other sturdy structure that you can grip to keep from falling.  You should also place the board on a rubber mat or rubber floor to help keep the board from slipping.

You can do balance exercises without using a balance board or wobble board.  Stand close to something you can hold onto such as a railing or the back of a sturdy chair in case you start to fall.  Try standing on one foot, standing on one or both feet with your eyes closed (but hold on to something or have someone stand next to you if you close your eyes), or practice marching, lifting one leg at a time, eyes open.

Start with short exercises and build to longer ones. Just get started.  Do a little each day and I think you’ll want to do more.  


  1. Kerry J. Stewart Ed.D, Director of Clinical and Research Exercise Physiology, Johns Hopkins University School of Medicine.
  2. Randy W. Rocha, Director of Sports Medicine, Metro Orthopedics and Sports Therapy Centers, Maryland.
  3. American Heart Association Science Advisory, Resistance Exercises in Individuals with and without Cardiovascular Disease: 2007 Update.
  4. ExTraMATCH. “Exercise Training Meta-Analysis of Trials in Patients with Chronic Heart Failure,” British Medical Journal 328 (2004): 189.
  5. Stewart, K.J. “Cardiac Rehabilitation Following Percutaneous Revascularization, Heart Transplant, Heart Valve Surgery, and for Chronic Heart Failure.” CHEST 123 (2003): 2104-2111.
  6. HF-ACTION.  “Efficacy and Safety of Exercise Training in Patients with Chronic Heart Failure,” JAMA 301(2009): 1439-1450. 


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