Medical Matters Muiris HoustonThe recent report from the Heartwatch programme illustrates how effective a targeted prevention scheme can be in reducing risk factors in people with existing coronary heart disease. Heartwatch, which is available to patients in 20 per cent of general practices in the State, is estimated to have prevented 81 deaths in the first two years of its operation.
People who have had a heart attack or a coronary bypass procedure have their risk factors for heart disease proactively managed by GPs, practice nurses, dieticians and other staff.
Among participants, cholesterol levels were reduced by 53 per cent, while blood pressure readings improved by up to 45 per cent. Smoking levels dropped by 26 per cent. These are highly significant reductions in the three major risk factors for coronary disease. As well as saving lives, changes of this magnitude undoubtedly prevented future heart attacks and strokes.
However, there was little or no improvement in exercise levels and markers for obesity such as waist circumference and body mass index. This reflects international experience and shows that lifestyle factors can be difficult to modify.
Recently published research, carried out by the departments of general practice at the National University of Ireland Galway and University College Cork, throws light on what patients with heart disease think of their disease and its treatment. Published in the Journal of Family Practice, the research is based on in-depth interviews with heart disease patients in the west of Ireland.
Heart disease was characterised by interviewees as an illness which now allows people to carry on a normal life. "I had a bypass and a pacemaker put in there last July. But I'm fine, I'm getting on. It's a thing you can live with by comparison to cancer now," was a typical quote.
The effectiveness of treatment in combating heart disease was identified as a key influence in patients' attitudes to cardiac illness. Bypass operations and stent procedures were seen as a way of securing their future if the disease got worse. "You know there is something there that can be done for you eventually," a male patient noted.
Some interesting views emerged when patients were asked to reflect on the causes of heart disease. "Many were of the opinion that medical knowledge does not fully explain the implications of lifestyle on heart disease at an individual level. Such a view seems to help lessen the burden of individual responsibility," the authors say.
These interpretations of the causes of heart problems were reflected in patients' attitudes to recommended lifestyle changes. Lifestyle decisions were made based on personal experiences rather than professional advice.
While it is encouraging to note a positive attitude to living with heart disease, part of this was based on the understanding that they were "cured" by medication and did not need to make lifestyle changes. This contradicts the medical view of heart disease as a chronic illness where secondary prevention of complications is vital.
Clearly, people's behaviour after they have a heart attack is based on a complex interaction of beliefs and attitudes to heart disease. And who's to say that patients haven't hit the nail on the head when they conclude that medical knowledge does not have all the answers when it comes to understanding heart disease at an individual level?
In her book, The Heart Speaks, US cardiologist Mimi Guarneri asks that we consider other layers of the heart: "The mental heart, affected by hostility, stress and depression; the emotional heart that could be crushed by loss; the intelligent heart that has a nervous system of its own and communicates with the brain."
Guarneri refers to research showing the role that pets play in the survival of heart patients. A study of patients discharged from a coronary care unit found that those with pets had a far higher chance of survival. In fact, four times more patients without pets died within the first year.
Almost half of cases of coronary disease cannot be linked to risk factors such as family history, smoking, blood pressure and obesity. Even cholesterol levels are part of a more complex picture, with the landmark Framingham study finding that 80 per cent of people who had a heart attack had the same cholesterol levels as those who did not.
Proponents of an integrated approach to cardiac health say we must consider issues such as emotions and grief. Although such hazy areas are hard to measure, by addressing them in individual patients, hearts "broken" by loneliness and depression could be healed.
Dr Muiris Houston is pleased to hear from readers, but regrets he cannot answer individual medical queries.
mhouston@irish-times.ie