What patients with heart disease need to learn from cancer patients

Cardiologist Dr. Richard Fogoros has issued this blunt warning to those at risk for developing heart disease: “You need to change your life. If you don’t, you will suffer the consequences  – possibly decades earlier than is necessary.”

In his Heart Health Center column, he observed that most high-risk people end up making only half-hearted efforts to modify their heart attack risk.  And he blamed doctors for enabling this lack of personal accountability: “This may be related to the failure of primary care docs and cardiologists to stress to the patient the utter life-and-death importance of changing lifestyles.”

Instead, he says doctors say things like ‘You really should…” – when what they really ought to be clearly warning high risk patients is: “You MUST – or your children will be orphans!”

He then asked this question to his readers: “Is there any group of doctors who have succeeded in getting their patients to stop whatever they’re doing, and to suddenly focus every ounce of energy on regaining their health?”

Yes, he answers: it’s the oncologists.

Patients who are told they have cancer, he explains, often put everything in life on hold and steel themselves to do whatever is necessary (whether surgery, radiation, or chemotherapy, often painful, and often lasting for months or years) to attempt a cure.

This is the same attitude that people ought to adopt when told they are at high risk for cardiovascular disease, he warns:

After all, being told you are at high risk for a cardiac event is not all that much different than being told you have cancer. Heart disease is no less fatal, and the outcome no less dependent on your attitude and your active participation in doing what’s necessary.

If anything, you have a much better chance of favourably altering the ultimate outcome than the average patient with cancer.

Dr. Fogoros believes that the high-risk patients who are most successful are the ones who adopt a “change it all now” attitude – the ones who accept that a complete change in lifestyle is needed. They’ll stop smoking, adopt an exercise program, and change their diet all at once. And they do it by making risk factor modification the central organizing theme of their lives.

One day they’re a high-risk-lifestyle kind of person, and the next day they’re not. They take on all the modifiable risk factors at once – it becomes the chief focus of their lives until the new lifestyle is an ingrained habit (and they are a different person). It sounds tough, and it is. But it’s a matter of life and death — and it can be done. I have seen seen several of these patients achieve remarkable success.

I too have seen them. Yet alas I’ve seen far more of those who seem to utterly lack that “change it all now” attitude. These are the heart patients who don’t exercise as instructed, or don’t change the way they eat, or stop taking their medications, or don’t bother showing up at their Cardiac Rehabilitation programs, or keep smoking – and even start smoking again after being terrified into quitting by their initial heart attack.

A couple years ago, I wrote about Dr. Rainer Hambrecht of Bremen, Germany and his groundbreaking 2004 study suggesting that nearly 90% of heart patients who rode bikes regularly were free of heart problems one year after they started their exercise regimen. The astonishing thing about his research (published in the journal Circulation) was that among study patients who had coronary angioplasty performed instead of participating in ongoing regular physical exercise like cycling, fewer than 70% were problem-free after that year.

Think about this. What Dr. Hambrecht is suggesting, and what a five-year follow-up of his study subsequently confirmed, is that physical exercise is better than angioplasty for patients with stable coronary artery disease.  In fact, he made this sweeping claim to other cardiologists at last year’s European Society of Cardiology Congress in Stockholm: “Only exercise improves arterial function and slows the progression of heart disease.”

Dr. Hambrecht has gone so far as to describe standard heart treatments as just “palliative therapy,” while physical exercise actually has an impact on the underlying disease, adding: “I would be happy if I could convince everybody with coronary artery disease to participate in a moderate exercise program!”

And in 2009, Dr. Hambrecht presented new findings from a follow-up study to the 2009 European Congress of Cardiology meetings in Barcelona, confirming his earlier 2004 results that regular exercise training is superior to angioplasty at preventing subsequent cardiovascular events.  He said: “It’s difficult to convince people to exercise instead of having an angioplasty, but it works.”

So why are heart patients not jumping on our bikes en masse and cycling off to healthier futures? The stats are truly discouraging, such as:

  • Up to 80% of heart attack survivors return to previous unhealthy lifestyle patterns, according to Dr. Diana Hughes of the Long Island Psychiatric Society.
  • Half of all heart attack survivors who are smokers are being discharged from hospital still hooked, even though researchers show consistently that this decision to keep smoking doubles the chances of suffering a repeat heart attack.
  • The Minneapolis Heart Institute reported last year that even among patients with known coronary artery disease – 100% of whom should be taking daily aspirin to lower risk of future cardiac events – “only 70% of patients were actually doing so.”

And the harshly shocking reality is that encouraging exercising is financially less appealing for hospitals than doing expensive cardiac interventions, as Dr. Hambrecht observed: “That was my feeling, that hospitals were reluctant to participate in this study because they derive revenue from doing invasive cardiac procedures.”

Carolyn Thomas is a heart attack survivor who blogs at Heart Sisters.

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  • http://www.your-cancer-prevention-guide.com YourCancerPreventionGuide

    My father-in-law was diagnosed with myocardial infarction. Surgery was recommended but it was a 50-50 chance for him. He refused surgery and decided to change his lifestyle. He quit smoking and drinking and he started walking actively. He lived for another 10 years before succumbing to heart attack. Exercise offers protection against breast and colon cancers.

    • Anonymous

      Amazing story about your father-in-law. It seems there are few ailments that aggressive lifestyle improvements like his won’t help to address. 

      • http://www.your-cancer-prevention-guide.com YourCancerPreventionGuide

        He may not have lived longer but those 10 years were good enough as extension. Ih he chose surgery it wasn’t guaranteed that it would be a success . He could have died on the operating table. His decision to change his lifestyle helped in extending his life.

  • http://twitter.com/ButDocIHatePink Ann Silberman

    I am a Stage IV breast cancer patient, and as we like to say, there is no Stage V.  I know a lot about breast cancer and not much about heart disease.

    Because you said that most heart disease patients go back to “previous unhealthy lifestyle patterns” it makes me think there is a great difference between the two illnesses.  Few cancer patients have lifestyle related cancers.   

    I wonder if we cancer patients are able to change our lifestyle because our lifestyle didn’t cause our disease, and we aren’t as dependent on the habits that can happen that may cause or contribute to heart disease?  

    Yes, it’s true, alcohol may contribute to breast cancer (or may not) and obesity may do the same (or it may not).  But, nobody can say for sure that the cause of breast cancer is drinking and lack of exercise and it’s not that simple – it seems to be a constellation of things.  Or, anything, really. 

    Smoking certainly causes lung cancer and sun can cause skin cancer  - but I wonder how many smokers who have lung cancer really quit?  While it seems likely most with melanoma would stay away from the sun, I wonder how many with squamus cell will make serious lifestyle changes?

    I know many people who got cancer (including myself) who had healthy lifestyles to begin with.  I am slim, relatively active, I like my vegetables and wasn’t a heavy drinker.  Cancer just happened to me – who knows why – so it was easy for me to quit drinking entirely, for example.  I didn’t feel I needed it in any way – I wonder if somebody who has heart disease caused (at least in part) by a desire for high fat food feels more of a need for the comfort that diet can provide?  

    Cancer also has a very prominent place in our culture. Movies are made about it, months are dedicated to it.  The fear of cancer is great (as it should be) and unfortunately, I don’t think the fear of heart disease is quite there yet.

    Some of the treatment for cancer can be horrendous.  I’ve been on chemo for nearly two years, I’ve had my breast removed, I’ve had half my liver removed.  Not taking a baby aspirin or walking for 30 minutes a day in comparison seems laughable to me, but I have no motivation not to do it.  I don’t care about smoking or hamburgers or salt or drinking alcohol.

    Whatever the reason, let’s hope heart patients wise up.  My brother-in-law died after his third heart attack at only 50. He was obese and nobody could ever figure out why he didn’t stop eating fast-food, especially after #2. He had a wicked sense of humor and his son will always miss him.  It was a great loss.

    • Anonymous

      Thanks for your comment, Ann.  You might be surprised to learn that there are also many heart patients whose history sounds similar to yours: no risk factors, non-smoking, active lifestyles, eat their veggies, etc. I was a distance runner myself for 19 years before my own heart attack (but I DID have a serious condition called pre-eclampsia while pregnant with my first baby many years earlier – and studies now suggest a four-fold increase in subsequent heart attack risk for women with this and other pregnancy complications). 

      There’s an interesting discussion going on in response to this original article on my blog Heart Sisters – http://myheartsisters.org/2011/10/16/high-risk-for-heart-disease/  – in which cancer survivors speculate on the difference between heart pts and cancer pts, for example:  “…cancer is thought about in our society as something EXTERNAL to our
      “being” – reflected in our language – as an alien invader looking to
      destroy, does not belong and is to be driven out at all costs. Our heart is INTERNAL to our “being”. Our heart IS us, no threat there. Nothing to declare war against… ”

      Good luck to you, Ann.

    • http://www.your-cancer-prevention-guide.com YourCancerPreventionGuide

      My Dad died of lung cancer last year at the age of 83. He quit smoking when he was 35 but still he got lung cancer. His oncologist said his lungs had been scarred that even if he quit he still had lung cancer.
      You said you live healthy but still got breast cancer. Breast cancer runs in the family. It’s a risk that one can’t avoid.

      • Anonymous

        My own Dad died of lung cancer 33 years after smoking his last cigarette.  My theory: none of us is getting out of here alive.  Perhaps quitting gave him another 10 precious years he would never have enjoyed had he not quit decades earlier.  We’ll never know.

      • http://twitter.com/ButDocIHatePink Ann Silberman

        Wow, I hope your user name isn’t official for your work, “your cancer prevention guide” because it seems you don’t know very much..  Breast cancer may run in families, with the BRCA 1 or BRCA 2 genes.  However, in most families, there is no genetic component at all.  Even if you carry the BRCA gene there is still only a 60% chance you will get cancer, so it’s not a guarantee.  Breast cancer is just a crap shot.  Healthy, unhealthy, family genes, no family genes, skinny, fat, olympians, couch potatoes – they all get it and there is no way to stop it as of this date.

  • Anonymous

    Great article, message is spot on.

    As a side note, I was shocked to discover how many people with cancer will either “cheat” or worse, be blatantly non-compliant with treatment. It seems that Oncology docs (and nurses) don’t have all the answers either.

    • Anonymous

      @NewkNurse:disqus  - You’re obviously a radiological nurse. I refused a vaginal radium implant that was protocol because I knew it would harm my vaginal tissue. I was 26. I had stage 2b cancer. My radiologist gave me an extra week of radiation, which I took. Later I met a girl who let them do it, and she said it ruined her.  I am proud to say I was “blatantly non-compliant”.  It’s my life, not theirs. I am 54 now, I have always lived a healthy life-style, and my cancer was caused by a birth defect.

      You sound like one of those healthcare workers who have the attitude that everyone that gets sick is a “deadbeat”.

      You don’t have any vices, do you? I bet you squeak when you walk you’re so clean. Hogwash.

      • Anonymous

        I didn’t mean any offense. I’m actually not a radiological nurse, and I was not referring to individuals who make educated decisions about their own care. I was referring to patients who agree to a certain plan of care and then choose to deviate from that plan of care without notifying their provider. For example – I have worked with some older adolescents who openly admit to not taking certain treatments because they wanted to go out and party over the weekend, and alcohol is contraindicated. When asked if they want to stay on their regimen they say yes, but the decision to deviate is often repeated.

        These patients obviously do not represent all people with cancer, and to even these patients I mean no disrespect. They obviously have the right to make their own choices. I do have a pretty good idea of what chemo entails and I know why people may not want to take it.  But as a nurse (and as a provider, which I believe is the point of the above article), it can be frustrating when you don’t know how to help a person. 

        • Anonymous

          NewkNurse-Thanks for explaining yourself. 1. How to help a person, or a patient? Thought provoking, isn’t it. Since when did a patient cease to be a person? Never.

          Treat a patient like you would a child, rebellious adolescent, or compliant adult. If scared, comfort them. If rebellious, get in their face, and give them tough love. Tell them in no uncertain terms that if they don’t do what is best, they won’t benefit, and it will in the end, be their fault, and theirs alone. For the compliant adult, praise them for their willful obedience, and thank them on your behalf, because they do not have to do it. We are a free people in America (for now), we were created with a free will by our Creator, to freely choose right, or wrong.

          Like a commenters said: We will all die one day.  Some will die smoking, yet happy. Human beings are complex, each one different for many different reasons.

          I cannot help every person I meet.  Do the best that you can, as you have been trained, and rest in that.

    • Anonymous

      Thanks for your comment, NewkNurse.  It’s almost impossible to generalize – many patients will make choices  as you describe, but many don’t – and perhaps for some it doesn’t even matter much whether the Dx is cardiac or cancer. But until you’ve walked in our shoes facing such a devastating Dx, it may also be difficult to even begin to comprehend.

      Yale University, for example, is now recruiting 2,300 heart attack survivors for an online survey to help figure out the puzzling phenomenon of “treatment-seeking delay behaviour” seen in those suffering symptoms of severe heart attack. In fact, most of us will wait FOUR HOURS on average before deciding to seek medical help (despite the fact that medical care delivered within 60 minutes following initial onset of symptoms is considered optimal for best cardiac outcomes.  “Time equals muscle!”  No wonder many heart patients tend to ignore lifestyle makeover instructions – maybe it’s because we’ve already had lots of high drama practice with disbelief, denial, choosing to dismiss clear signs, not wanting to make a fuss or be a bother – many possibilities may be the culprits here.

  • Anonymous

    Did nobody read the last paragraph? Dr. Hambrecht said that hospitals did not want to take part in exercise studies for cardiac intervention, because they derive revenue from doing invasive cardiac procedures.

    And we wonder why our Healthcare System is broken. Kudos to the doctor who was brave enough to state it, and the blogger who was brave enough to post it.

  • heartsurgeryguide.net/

    there clearly is a dichotomy in the perception of cancer and cardiac patients as to expectation from treatment. in general, cancer patients are more grateful for benefit rendered by care givers and foregiving of poorer outcomes as if the enemy “cancer” may be beyond at times human control. cardiac patients, despite having their own habits to blame as well as genes, expect painless, complication free and minimally invasive treatment of coronary disease and postoperative disregard for modifying their lifestyles. this is a generalization, but the zeitgeist we hear from these commentaries from a variety of people confirms my impression. clarly, long term benefit from coronary evascularization is determined as much by patient controllable modification of risk factors as much as the technical procedure itself. maybe if physicians and surgeons got paid to keep patients healthier and not perform piece work they would work harder to drive home this point to a rather self-destructive public

    • Anonymous

      My observation is that this difference might also be that cardiac patients don’t seem to ‘get’ that they now have a chronic and progressive disease diagnosis. If we all did, you’d imagine we’d be scared straight. Your comment about living healthier seems to be the point of Dr. Rainer Hambrecht’s work on this subject; in fact, he claims that a good exercise program is indeed superior to the technical procedures of revascularization like angioplasty/stenting. He’s not alone: according to another study of almost 500,000 cases published in July 2011 in the Journal of the American Medical Association that suggested only half of angioplasty procedures
      in non-emergency situations were clearly appropriate in the first place. Dr. Hambrecht would have likely prescribed three spins a week on the exercise bike instead!   But as you say, physicians and surgeons get paid to do medical interventions – not to do lifestyle counselling.

  • Michal Haran

    In the time of Hippocrates, it was recognized that every medical encounter has 3 components that will determine its success (or failure)-the physician, the patient and the disease itself. In modern medicine, we see more and more patients blaming their physicians, or physicians blaming their patients for failure (which is at times inevitable, since as much as we want, we are incapable of controlling many factors that will determine the outcome). We see less and less the combined efforts of physician and patient. Efforts that are life-long: at times require life style changes, at times require adherence to medications with their unwanted side effects, at times require unpleasant medical interventions and at times require coming to terms with relapse or worsening (even if both do everything possible to avoid it from happening). Many times physicians blame their patients for not adhering to a treatment plan, they themselves would never follow. Many times physicians cease their efforts because the patient is doing well enough (in their opinion), or because the patient is doing much worse (so why waste their time on fruitless efforts). Many times patients have unrealistic expectations (and therefore disappointment, anger and frustration) from the medical profession.  I believe that when there is good physician-patient relationship based on mutual trust and respect, and true understanding of each other’s abilities and limitations it significantly affects both the long-term outcome and the ability to adjust to the illness physically and emotionally .

    • Anonymous

      Valid points, Michal.  That seems to be an awful lot of blame and unrealistic expectations flying around in both directions. I wrote about something similar last year in “Heart Attack: Did You Bring This On Yourself?” – http://myheartsisters.org/2009/11/14/bring-this-on-yourself/  

      For example, try replacing the words “heart attack” with “surgical reconstruction for knee damage suffered while downhill skiing”. Would orthopedic surgeons expect that that they should only reconstruct sports-induced ligament injuries if the patient promises never to play that sport again?  You also raise a very good point about adjusting to an illness both “physically and emotionally”.  While cancer patients have ongoing ‘survivorship’ programs for support, heart patients have very little support once they are discharged from hospital (other than cardiac rehabilitation, which an appallingly low number of survivors, particularly women, even get their cardiologists’ referrals for – despite studies showing clearly superior outcomes  for those who register AND COMPLETE rehab).

  • http://twitter.com/dr_aletta Elvira G Aletta, PhD

    It drives me nuts when doctors are too subtle by half when it comes to giving their patients direction. I once had a doctor tell me I needed to “slow down” which I chose to interpret, “work six hour days instead of eight.” After I landed in the hospital she had the grace to apologize to me for being vague.

    Great article, Carolyn, for many, many reasons!

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