Heart Attacks, Cholesterol, And You (book)

ACKNOWLEDGEMENT I would like to thank everyone who encouraged me to write this book. In particular, I owe a great deal to Rhonda, my wife, Vanessa and Kathleen, my daughters, and to Stephanie, my sister in England. The following have contributed in some way to this book. I thank them all. In alphabetical order, they are:Fiona Coote Andrea Demetrios The Heart Foundation Liverpool Public Hospital Bob and Liz O’Toole Prince Of Wales Private Hospital Kris and Peter Shead Adrian Small The nursing staff of the Prince of Wales Private Hospital Dr David Taylor Dr Hugh Wolfenden The first $5.00 of the profits from the sale of this book will be shared equally by The Heart Foundation, The Teddy Bear Fund, and the Victor Chang Institute. To the readers of this book who may be finding it difficult to come to terms with their own future, I can only hope that they might find in its contents something of personal use. It is only too easy to escape to one’s own island and avoid the reality of life today, however painful that may seem at the time. If there is just one paragraph in this book which lets you say, “yes! I can relate to that”, then I have succeeded in helping you ease the pain.

This book has a purchase price of $25.00 per copy. If you would like another copy please send a cheque or money order to the value of $25.00 plus $5.00 for postage and handling to Jeremy & Rhonda Hill, P.O.Box 101, Ermington, NSW 1700.

ISBN 0-646-36890-7 ALL RIGHTS RESERVED  COPYRIGHT JEREMY HILL 1999

INDEX

1

FAMILY HISTORY CAN COUNT HEART ATTACKS AND EMERGENCY FLIGHTS 6 YOUR HEART HEART DISEASE A GUIDE TO LOWERING YOUR CHOLESTEROL LIFE AFTER A HEART ATTACK TRUE FRIENDS GETTING TO YES, OR ACCEPTING THE INEVITABLE TIME FOR THE ANGIOGRAM LIVING WITH ANGINA HIGH BLOOD PRESSURE BY PASS SURGERY WHAT YOU PROBABLY WON’T BE TOLD SELECTING YOUR HOSPITAL THE WEEKS BEFORE “♥” DAY TRUSTING IN THE LORD (WHY ME?) ADMISSION TIME PRE SURGERY IN THE HOSPITAL INTENSIVE CARE WHATEVER HAPPENED TO PAIN RELIEF MAKING FRIENDS WITH YOUR PHYSIOTHERAPIST RECOVERY AND YOUR PERSONAL TEDDY BEAR PAIN AND DEPRESSION (LONG NIGHTS & STRANGE DREAMS) GOING HOME SO SOON ? (HAVE A TRIAL RUN) THE RETURN HOME MUM, WHY IS DAD SLEEPING IN MY BED ? EXERCISE THE FIRST WEEKS AFTER COMING HOME JEREMY’S HAVING A HEART ATTACK LETTERS GETTING HEART SMART AFTER HEART PROBLEMS 99 GOOD ONE - LINERS GLOSSARY

3 10 16 19 32 39 42 44 47 53 58 63 64 66 67 70 71 72 75 77 78 79 80 81 82 85 86 88 89 96 101 102

FAMILY HISTORY CAN COUNT

2

“When one man dies, one chapter is not torn out of the book, but translated into a better language”. John Donne (c. 1572-1631), English divine, metaphysical poet. Devotions upon Emergent Occasions, Meditation 17 (1624).

Heart disease is the single largest killer of adults in the Western World. According to the Australian Heart Foundation, heart disease kills over one thousand Australians a week, or one person every ten minutes. In one form or another at least one in three families is affected by someone in that family suffering from heart disease. One person in two over the age of fifty is at serious risk. Most of these adults are male, and probably the main family providers, so heart disease can have a critical effect on more than just the sufferer. Degeneration of the heart muscle and its arteries can take years and provide little or no symptoms, yet when a heart attack strikes it can eliminate a life as quickly as a head on car smash. My father died at fifty from a heart attack. Thirty years later I survived at forty eight. At the same time my father in law survived a ruptured main artery at eighty one. Things must be looking up ! On Saturday 25th January 1968 my father died in front of me, at the tender age of fifty. I was only seventeen. The day has been indelibly etched on my mind ever since. It was my mother’s forty sixth birthday. He died within seconds, and although I instinctively commenced resuscitation techniques and got him breathing again until the ambulance arrived, he probably was dead from the start. The issue for me for the next thirty years has been the anticipation that history would repeat itself. It nearly did. I had my first three heart attacks in the space of a week at the age of forty seven. There is no conclusive evidence to confirm that I have a hereditary cholesterol problem, however medical and scientific knowledge today has placed me in the high risk category. My father’s parents were in their late sixties when they died. My mother’s parents were also reasonably long lived. My father was a very active and fit man, yet he died at fifty and my mother died exactly ten years later at fifty six. My father spent four years from the age of eighteen in a German Prisoner of War camp during World War 2, and this must have seriously affected his general health. He was also, like many men of his era, a heavy smoker. He owned an electroplating factory, and five years before his death he fell headfirst into a cyanide effluent pit. This produced an unusual carcinogenic illness which was treated, not very successfully, by heavy doses of cortisone. Cortisone, administered this way, is now banned in many countries of the world as it has been found to destroy the human immune system. One month prior to his death he underwent a major medical examination, which he passed with flying colours. For this reason there was no requirement for an autopsy after he died. It is not entirely unusual for a medical examination to indicate excellent health, to be followed by a heart attack and sudden death, however, with increased public awareness today less people collapse in the street with no prior warning. When my father died, my mother reacted firstly by becoming very nervous, and then withdrawn. Due to her own death ten years later from a brain tumour, I am unfortunately unable to do much more than reflect on my own teenage observations of the ways in which she attempted to cope, and then try to understand them as best as I possibly can some thirty years later on, at a time when my own life was in serious jeopardy. What must it be like for a forty six year old woman who had endured World War 2 in her younger years, and who had married a man who maintained very rigid 3

views of marriage and the roles of men and women in that marriage, to have him cut down in his prime from heart disease so suddenly? While we were not a wealthy family, we were better off than many. Because my mother never handled the family finances, and devoted her entire married life to supporting her husband and two children she was totally unprepared for what was to follow. She would never have dreamed that after 23 years of marriage, and at such a young age (46), she would become a widow in such tragic circumstances. I remember clearly some of the members of her close circle of friends rallying round to offer support. One such, Pat Buck, who I still regard as almost a surrogate mother, arrived from London the day after my father died, with a knock on the door and a cooked chicken in hand. Only two years later she was to suffer the same anguish when her husband died from a sudden and massive heart attack while parking the car in the garage after returning from work. Their eldest son was my best friend, and yet neither of us has spoken to the other about our feelings at that time. When I ask myself this question today, I cannot find a logical or reasonable answer. It seemed to me, in the late 1960’s, that all of my mother’s friends had husbands who were suddenly dying from heart disease. What on earth was happening? I believe my mother reconstructed her own life emotionally by finding solace with the curate to her childhood family church. When she was a teenager she spent some years as a Sunday school teacher, and, although she had not had any contact with Philip Snow for thirty years, something inside her sub-conscious drove her to seek him out through the Anglican Church lists. By this time he was a Canon of Christchurch Cathedral in Oxford, and was responsible for a large parish in Chippenham, Wiltshire. He had remained unmarried, and when they met after so many years they quickly realised they should become married. In this way my mother overcame her grief of losing my father, and became able to terminate one chapter in her life and begin a fresh one on terms which were not personally threatening, but would soon become eventful and joyous. As a seventeen year old with no father I lost my way in the world, and moved from one job to the next, including a stint in the British Army. Eventually I realised that the only way I was going to be able to shake the “monkeys” off my back was to travel to some distant country where I might start life again. My choices were Canada, South Africa and Australia. I also even considered the British Police in Hong Kong. I have been a resident of Australia for twenty eight years now, and looking back on those years I can say that it probably took me at least five years to come to accept my father’s death, even though the memory of it still has never waned. I can remember feeling totally isolated after my father died. Of course, the “family” and my father’s business associates all attended the funeral and made all the right noises. At seventeen I was very good at keeping a British stiff upper lip. I was left to make all the funeral arrangements, as my mother was far too traumatised to deal with such issues. My sister was in her final year at medical school in London. We never talked about our feelings until I had my heart attacks thirty years later. Stephanie has now become a minister in the Anglican church and with her medical background has proved an ideal candidate to be allocated the hospitals in Oxford as her “parish”. I rather fancy she might be made a bishop one day !

4

When Stephanie and I did finally talk we discovered we had both experienced the same feelings as each other. I was living at home, and at seventeen had to try to take over the family business. She, at twenty one, had to return to university and finish her medical degree. We both remember feeling left out of things. When we walked into a room people changed the subject. I remember that any time a group of my friends started discussing death down at the pub on a Friday night, I would have to get up and leave the room. I became very resentful, and nobody offered to explain anything to me. Stephanie felt the same. In fact, as she has told me, only recently she experienced the same type of situation in her current role as hospital chaplain. She was counselling a family in hospital where one of the parents (quite young) was dying, and she suddenly realised that the teenage daughter was off to one side of the room, very quiet, but also clearly feeling very emotional, yet no-one was including her in the grief process. Stephanie immediately understood. She suddenly realised that nearly thirty years ago she had felt the same emotions as this lonely young girl.

HEART ATTACKS AND EMERGENCY FLIGHTS “Engulfed by fear and suspicion…… we try desperately to invent ways out, plan how to avoid the obvious danger that threatens us so terribly. Yet we’re not mistaken, that’s not the danger ahead.” C.P.Cavafy, Things Ended

5

It was Mother’s Day 1997, and I was being foolish. I was supposed to be in bed recovering from pneumonia. However, we had just moved into a new house in Sydney. The interest rates in Australia had halved in six months and suddenly I could afford to buy something better than a hovel for my family rather than continue to rent. We had just finished going through the trauma of losing everything fighting Bellingen Council near Coffs Harbour for a tourist permit to develop a commercial butterfly breeding centre. This was supposed to be our way to avoid the stress of city business life. Little did we imagine the stress we walked, or rather, ran towards ! Having moved into our new house in Sydney, I decided on the spur of the moment to concrete part of the driveway. It was Mother’s Day after all, and I was trying to be useful! I managed to mix three bags of concrete before I collapsed with what I considered to be a severe attack of asthma. The dust from the concrete was everywhere. The last bag of dried concrete I had mixed is still set hard as rock in the wheel barrow and is now a flower pot in the garden, known as “Jeremy’s Folly”. To make matters worse I had also concreted a lip around the garage entrance so Rhonda, my wife, was unable to get her car out to drive me to the local doctor. We eventually got my car out of the drive with me collapsed on the front seat and my eldest daughter becoming greener as the moments passed by. I remember feeling very miffed to discover, after arriving back home a week later, that there were car tyre tracks in my beautifully trowelled cement ! How could she ? Maybe she was too busy helping save my life to notice ! After my third heart attack I spent 5 days in intensive care at Liverpool public hospital denying the obvious. The ECG had been negative. The ultrasound was negative. The only positive result was the blood enzyme count. I spent eight hours in the emergency ward while the registrar dithered about admitting me. The man in the cubicle next to me had the same symptoms and they had only one bed in Intensive Care available. The decision to admit me came down to the issue that I spoke English and he didn’t. I would like to think he survived too. Two weeks after my initial heart attacks I went to Spain on business for ten days. This probably was not a good thing to attempt to do, but I was determined to fulfil my business obligations in Spain as well as visit my sister in England. The schedule was hectic and I started to get panic attacks in the middle of the night. My reduced confidence level combined with long days full of negotiations wore me out and I collapsed twice. On the first occasion I couldn’t catch my breath. On the second, I had pins and needles running through my entire body which felt like I was connected to the town power grid. I thought I was dying that time. In fact this sensation seemed at the time to be ten times worse than an actual heart attack. Being a long way from home in a foreign country I became so frightened that my brain started playing tricks on me. I later discovered to my cost that no insurance company will cover people for panic attacks during travel. For some reason best known to themselves they regard panic attacks as merely severe bouts of nerves. Having experienced these first hand I am quite certain in my own mind that they are not one and the same. Medical evidence today supports my view that panic attacks are a very real, and physical, illness. In my case the physical symptoms were many times worse than any angina or heart attacks I had experienced. While it may at times be difficult for insurance companies to tell the difference, surely the responsibility rests with them to determine the difference.

6

Following my initial heart attacks I was supplied with Anginine tablets to take under the tongue. I was also told by mis-guided well-doers that I had better be lying down when I took them as they could give quite a “kick”. Naturally enough, since I still wasn’t totally convinced I could recognise true angina when I was having it, I spent the next twelve months avoiding at all costs taking a tablet which could so easily solve the problem. It was only during the final three months before the operation that I started taking Anginine on a regular basis in conjunction with walking. Initially I was able to walk seven kilometres, but my motivation waned with winter setting in, which made me somewhat less enthusiastic. Eventually, I was reduced to walking three or four kilometres on a weekend. I feel I must now provide a note of caution for what I am going to write next, particularly as I am not medically qualified to offer medical advice. Two weeks before my operation I was driving home by myself from the City, and had been sitting for most of the day. The medication I was on significantly reduces the blood pressure, and I now know that sitting in a car for a while lowers it even further. My blood pressure was by now dangerously low. I was feeling very anxious with the operation day drawing ever closer, and I experienced some sharp pain in my left shoulder. Without pausing to consider the consequences I slipped an Anginine tablet under my tongue and within a minute I started to feel very giddy. Fortunately, I was driving slowly in rush hour traffic, and managed to stop the car. As I did so I blacked out completely for a split second. If this had happened ten minutes later I would have been travelling too fast on the Motorway, with dire consequences. Nobody had bothered to warn me of these dangers. I delayed having my operation for some sixteen months from my first heart attack. I now know that my arteries are unusually narrow, and with the hereditary onset of cholesterol, I was living on borrowed time. Thank goodness I had quit smoking at the age of twenty. (After my operation I discovered than my arteries are only half normal thickness, so I was sitting on a time bomb). Many people I spoke to considered I was crazy to wait so long. They advised me to get on with it. My biggest hang up was convincing myself that I wasn’t going to die. I wasn’t ready for this to happen and I certainly wasn’t going to allow it to produce the same results as those which were experienced by my sister and I so many years earlier. Why should my children experience the same trauma as I did when I was their age ? It just wasn’t fair. In June 1998 I travelled alone to China and Hong Kong. I should never have gone, but at the time I felt I could cope. The first two days were in Shanghai and were fun. I went sight seeing. The highlight of Shanghai for me was the Chinese Acrobatic Troupe which tours the world. I have never experienced anything quite as special as these young acrobats. I then travelled to Qindao, which is north along the coast, half-way between Shanghai and Beijing. After an enjoyable dinner with my business hosts I went to bed but couldn’t sleep. I started to get panic attacks and tried to calm myself by sitting all night in the lobby in sight of the night staff reading a wonderful book about the Chinese Cultural Revolution, “Wild Swans”. The next day was all business and I felt very tired, but battled on. My hosts knew nothing of my battle with my subconscious. On the Monday evening I flew to Hong Kong, a journey of three odd hours. I was very unwell by the time the plane landed. I struggled through Customs and then collected

7

my bags. By some strange twist of fate I picked a baggage trolley with its brake locked on. I was in too silly a state by this time to realise what I was doing, but somehow I pushed that trolley the two hundred odd metres to the exit gate. I reckon it took me a full half hour. Not a single person (and there were plenty of airline staff around) offered me any assistance until I reached the taxi rank. A kind young American immediately spotted my distress and got me safely into a taxi and to the hotel. My friend was waiting for me at the hotel, in the centre of Hong Kong Island, right behind the new Convention Centre. I was whisked through check-in and installed in my room. Within ten minutes I started to feel better (typical angina symptoms of course, but was I going to take an Anginine? No! ). The next day was spent at a trade Expo I had wanted to attend. I felt rather tired, but OK. After a rather enjoyable dinner of Korean BBQ food with my associate I went back to my room and put in a couple of hours of work. By 11.00pm I was getting angina pains again, so I contacted a cousin of my brother in law who lives in Hong Kong, and he took me to a local hospital. One look at me by the Chinese doctor, and just after midnight I was admitted to hospital. There was considerable discussion by the hospital staff that I should pay a “cash” deposit of AUD$2000.00 before I could be admitted, and it took some time to convince them that at that time of night (1.00am at this stage!) their demands were absurd. I selected the cheapest general ward possible, as I had no travel medical insurance (no-one would give me any). I found out afterwards that all medical charges in private Hong Kong hospitals are usually valued pro-rata to the value of the bed selected. I had my blood taken twice for enzyme levels (a definitive indicator of a heart attack, and which cost AUD $300.00 each), and in the morning I was given a X-ray and a walking stress test which immediately produced angina, and a third beat in the rhythm. I was strongly counselled to stay in hospital for the time being. How could I ? The mounting hospital bill was becoming alarming. By noon it had reached AUD$2,200.00. The thought of the cost alone was likely to produce a heart attack. Thank goodness I had not chosen a private room. The bill would have been over AUD$10,000.00 per night ! To get on the next Qantas flight back to Sydney proved a major challenge. I enlisted the help of a church acquaintance who lived in Hong Kong, and he generously drove me around the Island to get the necessary medical clearances to fly. Qantas was still not satisfied and referred the whole case to Sydney for approval. This finally arrived and I was checked out of the hotel by the duty manager. I was on my way. Qantas were magnificent. I bypassed baggage check in, security and customs. I never touched my luggage once. I was put on board the flight first, upstairs, so there would not be many passengers close by. The pilot was given right of refusal to carry me, and he accepted the challenge. After a good meal I fell asleep, and woke up with angina pains an hour and a half out of Sydney. Naturally, I panicked. The cabin crew immediately cleared the upper deck of passengers and made a bed for me on the floor. I was hooked on to the automatic heart starter machine. This machine talks to the operators and tells them what is happening to the patient. If the patient’s heart changes significant rhythm or stops it automatically applies an electric shock. Qantas do not normally advertise the fact, but every international Qantas flight carries one of these machines and a staff member fully qualified in its use. I owe a huge debt of gratitude to Qantas for their concern and professionalism.

8

A medical emergency was declared, and the pilot put the jet into acceleration mode. The flight arrived thirty minutes early, probably much to the delight of the other passengers, who had no idea what was going on. I have a friend who is a Qantas Captain, and he told me that the pilots hate having people die on their flights. It messes up the paperwork! Customs and Immigration came on board and after answering a couple of basic questions and signing on the dotted line I was transferred to a waiting ambulance. As Rhonda was meeting me at the airport, and since I already knew what was the problem (I had all my Hong Kong reports with me), I persuaded the ambulance crew to release me on the condition Rhonda immediately drove me to see my cardiologist. My cardiologist took one look at my charts and shook his head. There were to be no more delays. If I did not act soon I would be dead by Christmas: a sobering thought indeed! I agreed to an angiogram the following month on the condition that he did the work himself. This meant I had to use a private hospital. I had been a member of Medibank Private for years and just assumed that I had some level of cover. The issue surely was more a case of what level of cover I could reasonably expect. While I had the top cover for medical and extras, I had selected the lowest cover for the hospital. Only when I booked my angiogram was I informed that this level of cover automatically excluded me from any heart surgery or investigations due to my bottom level hospital cover (all operations were covered on this rate EXCEPT for any tests or surgery relating to the heart). I argued my case with the State Manager, and to his credit he accepted my argument that Medibank Private’s brochure was not clear enough for people to properly understand. In fact, he asked six of his staff members if they understood why I was not covered for an angiogram and they all were unable to provide a clear answer. My status was upgraded to the next level after I agreed to pay the extra premium for this level backdated for twelve months, and then all was well. Large insurance companies have the right to insist that their customers understand what it is they are paying for. They also have a societal obligation to ensure that they provide a fair and just service. In my case I can say that Medibank Private met this obligation.

YOUR HEART But the LORD said to Samuel, “Do not look at his appearance or at the height of his stature, because I have refused him. For the LORD does not see as man sees; for man looks at the outward appearance, but the LORD looks at the heart.” 1Samuel 16:7

For thirty years the National Heart Foundation has supported research into heart disease, its causes, prevention, and treatment in Australia. This book uses information gained in that research. It tells you how your heart works, what can go wrong with it and what you can do to help avoid heart disease and keep your heart healthy. There is no total guarantee against heart disease but Australia has achieved a great drop in early deaths from this major cause of death and illness. I hope that advice in this book will help give you a healthy, long and enjoyable life. Your heart and how it works Your heart is a muscle which pumps blood to all parts of the body. The blood provides your body with the oxygen and nourishment it needs for energy and growth. The

9

blood also picks up waste products and gases, which leave the body through your kidneys and lungs. Your body contains about five litres of blood which pass through your heart every minute or so. But when necessary, as during exercise, your heart can pump up to four times that amount. Heartbeat rate At rest the heart beats 60-90 times a minute. In children it beats between 100 and 200 times. During a lifetime the heart will beat over a million times. When you are excited, ill or exercising your heart rate can rise sharply. This is natural. Size, shape and position Your heart is egg-shaped and about the size of a large fist. It lies in the front and middle of your chest behind your breastbone. The strong heart muscle is called the myocardium. Myo means muscle and cardio means heart. The heart’s chambers The heart has a right and a left side separated by a wall. Each side has a small collecting chamber called an atrium leading into a large pumping chamber called a ventricle. So there are four chambers in all - the left atrium and ventricle and the right atrium and ventricle. The left ventricle is larger and thicker because it has to pump over a greater distance and against much more pressure. The right side collects the ‘used up’ blood returning from the rest of the body and pumps it to the lungs for more oxygen. When it is recharged with oxygen the blood returns straight back to the left side of the heart which then pumps it out again to all parts of the body. To make sure the blood flows in the right direction, valves guard the entrance and exit of each of the four chambers. Circulation Your body has a network of vessels called arteries and veins to carry the blood pumped by your heart. Your heart and blood vessels together are called the circulatory system because they circulate blood to and from your heart. Arteries carry blood away from the heart; veins carry blood back to the heart from the rest of the body. Smaller branch arteries feed into even smaller blood vessels called capillaries which cannot be seen with the naked eye. Oxygen and nutrients pass into body tissues from the capillaries. The largest artery in your body is the aorta. It has branches which carry blood to your head, arms and legs and internal organs. The first branches of the aorta are the coronary arteries. These run back on to the surface of the heart itself to give the heart muscle its own blood supply. Phases of the heartbeat There are two parts to each heart beat. The first part, when the heart pumps, is called systole. The second part, when the heart relaxes so the chambers can refill with blood, is called diastole. Pulse Every time your heart beats there is a pulse wave of blood through your arteries. You can feel the pulse by placing two fingers over the artery at your wrist or on either side of your neck. Your pulse rate tells you how fast your heart is beating. What can go wrong As you can see, the heart and blood vessels are essential to good health - and to life itself. It is not surprising that when something goes wrong with the heart it can be serious - and even fatal. Heart and blood vessel disease is Australia’s No 1 killer. The premature deaths it causes - deaths under the age of 70 years - are five times the total road toll. What is heart disease?

10

Heart disease usually means diseases of the heart and blood vessels. The medical term is cardiovascular diseases. They are by far the most common cause of death in Australia. Most of them result from a build-up of fatty deposits (atherosclerosis) in the inner lining of arteries. These deposits begin in childhood and by middle age or older can narrow the inside of the artery, reducing the blood flow. This can lead to angina or a heart attack. The main diseases of the heart and blood vessels are heart attack, angina and stroke. Heart attack and angina are types of coronary heart disease because they arise from problems of the coronary arteries. Heart attack Many thousands of Australians have heart attacks each year. Most recover and can return to a normal life, although a heart attack is certainly serious. A heart attack occurs when a narrowed coronary artery is suddenly blocked by a blood clot. Thus blood supplies to the heart are cut off and the affected part of the muscle can die if the blood flow cannot be restored by the emergency treatment. A heart attack is a lifethreatening medical emergency to be treated in hospital. Medical terms for heart attack are a coronary occlusion, coronary thrombosis, a coronary or myocardial infarction. Angina When the heart has to work harder it needs more blood. If a coronary artery is narrowed or partly blocked the blood supply may not be enough to meet the extra needs on the heart muscle. Pain or discomfort develops in the chest and can spread into the shoulder, arm or neck. This goes away in a few minutes with rest or tablets. Stroke A stroke occurs when the blood supply to part of the brain is cut off, usually by a blood clot but sometimes when a brain artery bursts. A stroke can paralyse part of the body and also affect speech and other brain functions. As with heart attacks, some strokes are mild but they can also be fatal. Putting it right Since the late 1960s there has been a sharp fall in heart disease death rates in Australia. This is due to better prevention and treatment. The Heart Foundation has also played a big role through its support of heart research and its public education programs. The treatment of heart disease and the outlook for patients are improving all the time. But heart attacks still kill many people and improved treatment does not mean the problem can be ‘cured’ after it develops. In fact, if you have heart disease following the healthy lifestyle steps in this book is even more important. Prevention ‘Risk factors’ are things that raise the risk of heart disease. They include: • smoking • high blood cholesterol • high blood pressure • overweight • lack of exercise • diabetes These can be reduced or avoided through lifestyle changes or medical treatment. The first three risk factors are the most important. There is not a lot you can do about some risk factors such as a family history of heart disease and juvenile onset diabetes. In these cases it is even more important to do something about those risk factors that can be reduced or avoided. Four steps to a healthier heart 1. Be a non-smoker 2. Eat a low-fat diet and know your cholesterol level

11

3. Keep a check on your blood pressure 4. Exercise regularly 1.

2.

3.

4.

Being a non-smoker Smoking is a major risk factor for heart disease and for many other diseases, including cancer. It doubles the risk of heart attack. There is no safe level of smoking. For women using the oral contraceptive pill smoking increases the heart risk by ten times. The good news is that it’s never too late to benefit from giving up. Eat a low-fat diet and watch your cholesterol level A diet that is high in saturated fat is the main cause of high blood cholesterol. Our bodies need cholesterol but too much in the blood can lead to the arteryblocking process (atherosclerosis) which leads to heart disease. Generally, the lower the cholesterol, the lower the heart risk. New research shows that you can slow and sometimes actually reverse the artery-blocking process by cholesterollowering and lifestyle changes. Overweight people tend to have higher blood cholesterol levels and higher blood pressure. Being overweight also tends to make existing heart problems worse. A low-fat diet and regular exercise can help keep your weight down and improve your blood-cholesterol level. A few people need medication as well to keep their cholesterol level down. Keep a check on your blood pressure High blood pressure means the pressure of the blood in the arteries is too high. Over time, this puts a strain on the heart because it has to work harder to pump blood around the body. High blood pressure also puts extra stress on the walls of the arteries. This makes the walls thicken and increases atherosclerosis. High blood pressure usually has no symptoms until it has caused serious damage. Ask your doctor to check your blood pressure. If you have high blood pressure your doctor will suggest your lose any extra weight, cut your alcohol to two drinks a day or less, start regular exercise and eat less salt. You may have to go on blood pressure-lowering tablets as well. Exercise regularly The more exercise you do the better for your heart and health generally. Regular moderate exercise such as walking brings almost the same benefits as more vigorous exercise but with much less risk of injury and other problems. Ask your doctor or local Heart Foundation office for advice, especially if you have been inactive and want to begin vigorous exercise.

Diagnosis and treatment Examples of diagnosis and treatment for heart disease are: Angiography: An x-ray and special dye are used to examine narrowing in the arteries in the heart. Angiography can also show how the heart is pumping and the heart valves are working. Angioplasty: This is a method used to open up a clogged coronary artery from inside the artery. A small flexible tube (catheter) is threaded up through an artery towards the heart until it reaches the narrowing in the coronary artery. A small balloon at the end of this tube expands to open out the narrowing and restore blood flow. Defibrillator: An emergency machine that shocks the heart back into normal beating if it suddenly stops. Drugs: Doctors now have a wide range of drugs to treat high blood pressure, high blood cholesterol, angina and other heart conditions.

12

ECG: Short for electrocardiogram, which measures the heart’s electrical beating pattern. Echocardiography: (see Ultrasound). Heart transplants: Since the 1980s heart transplants have been a way of treating some people with serious heart problems. Improved drug treatment for transplant patients means most now have an acceptable survival and quality of life. Pacemakers: Electrical devices which do the job of the heart’s natural heart beat pacemaker when it is affected by disease. Each year thousands of Australians have the small devices placed in their body to make the heart beat normally. Rehabilitation: Most heart patients can return to their normal lifestyle. Rehabilitation programs run through many hospitals help ensure a full recovery but patients will need advice from their doctor as well. Surgery: Modern surgery to bypass blocked coronary arteries and to correct other heart problems is giving thousands of Australians a new lease of life. Thrombolysis: Emergency drug treatment to dissolve a blood clot which is bringing on a heart attack. If given early enough it can reduce damage to the heart. It is being used more often but is not suitable for all people with heart attack. Ultrasound: Similar to sounding devices used by ships and submarines (SONAR) ultrasound helps doctors diagnose various heart conditions. Dealing with a heart attack Surviving a heart attack can often depend on speedy action. The symptoms Severe, crushing and continuous pain in the centre of the chest, often spreading to the arms or neck. It may also involve shortness of breath and nausea, sweating, faintness and weakness. Many people have different symptoms to each other. The obvious may not be necessarily obvious at the time. My only symptoms were shortness of breath which I attributed to acute asthma. What to do If someone nears you appears to be having a heart attack quick action may help save a life. 1. Recognise the attack. 2. Alert someone else - get them to contact the hospital or ambulance while you are helping the patient. 3. Give cardiopulmonary (heart-lung) resuscitation, if necessary. 4. Get the patient straight to the nearest major hospital - by ambulance if immediately available. Other heart problems As well as the main heart and blood vessel diseases there are a number of less common conditions. These include: Aneurysm: A weakening in the wall of a blood vessel or the heart. This causes the wall to balloon out. An aortic aneurysm affects the main artery from the heart (the aorta). It is usually caused by atherosclerosis. An aneurysm in the heart wall is usually caused by a severe heart attack which has damaged part of the wall. Arrhythmia: A disturbed rhythm of the heartbeat. It has various causes. Arrhythmias can be too slow, too fast, irregular or all of these. Some are serious. They can be treated by drugs and sometimes surgery. Some arrhythmias may need a pacemaker. Life-threatening arrhythmias may need emergency shock treatment (defibrillation) to restore the heart’s rhythm. Atrial fibrillation: An irregular heart beat caused when the collecting chambers (atria) do not contract as they should. Atrial fibrillation is common in the elderly. It is usually treated with drugs.

13

Bacterial endocarditis: An infection on the heart’s valves. It occurs mainly in people whose heart valves are already damaged or who were born with a heart fault. Endocarditis can be caused by germs from infected teeth. That is why people with these conditions are given antibiotics before dental work. Drug addicts using unsterilised needles are also at risk. ‘Blue’ babies: Sometimes a heart fault at birth causes ‘blue’ (low in oxygen) blood from the right side of the heart to pass to the left side through the wall that separates the chambers. The blood bypasses the lungs and is pumped out to the tissues without getting the oxygen it needs. The baby looks blue, a condition known as cyanosis. Cardiac arrest: When the heart suddenly stops pumping. Cardiac arrest can arise from a heart attack or from an arrhythmia and needs immediate cardiopulmonary resuscitation. Cardiomyopathy: A disease which weakens the heart muscle so that it cannot pump strongly enough. The cause in most cases is unknown but it can result from infection or alcohol abuse. Most patients with cardiomyopathy can live near normal lives. Some types of the disease can be fatal. Serious cases can sometimes be treated by a heart transplant. Congestive heart failure is caused by the heart being too weak to pump blood through the body well enough. Blood ‘dams up’ behind the heart and fluid collects in the lungs and other body tissues (oedema). This can cause shortness of breath and swelling in the legs or ankles. Many heart problems, including heart attack, can lead to congestive heart failure, if not successfully treated. Treatment with drugs such as Digoxin or fluid tablets often allows patients to lead a normal life. Congenital heart disease: A heart defect present at birth. This might be in the form of arteries and veins connected to the wrong heart chamber, a hole in the heart’s dividing wall or the valves may develop incorrectly. These defects can usually be corrected with surgery. Heart block: A very slow heart beat. It is caused by a block or delay in the electrical message from the heart’s collecting chambers (atria) to the pumping chambers (ventricles). Normally the atria ‘drive’ the ventricles. When they do not do this in the normal way, the ventricles pump at their own slower rate. The condition is not common but occurs in the elderly. It can be serious. The cause may be a heart attack or problems with the heart’s electrical conducting system. Heart block may be successfully treated with a pacemaker. Heart failure: Heart failure has many causes, including a heart attack, high blood pressure or a damaged heart valve. It is usually serious but can be treated with drugs. Some people with heart failure receive a heart transplant. When heart failure causes swelling of the ankles and lung congestion, it is called congestive heart failure. Heart murmur: A murmuring sound heard with a stethoscope when listening to the heart. The sound may be normal but may also point to valve problems or other heart disease. High blood pressure: Also called hypertension. A major cause of heart disease. It may sometimes result from kidney disease but usually the cause is unclear. If it is not treated it can contribute to narrowing of the arteries and lead to heart attack and stroke. Hypertension: See High blood pressure. Pericarditis: An inflammation of the outer lining of the heart (pericardium), usually caused by a virus or an infection such as pneumonia. Treatment is mainly by curing its cause, often with antibiotics. Peripheral vascular disease: Blood vessel disease (atherosclerosis) affecting the legs. If the arteries to the legs are narrowed, the blood supply is reduced causing pain when

14

walking. Bad cases may cause gangrene. The single most important cause of peripheral vascular disease is cigarette smoking. Rheumatic heart disease: Now rare is Australia, it is caused by a childhood attack of rheumatic fever, which affects the heart valves. Modern surgery can repair damage to the valves or replace them. Tachycardia: When the heart beats too fast. Tachycardia may not be serious, but on the other hand it may indicate heart disease and need drug treatment to control it.

HEART DISEASE (HOW TO LOWER YOUR RISK) What causes heart disease ? You’re at more risk if you:• smoke • have high blood cholesterol • have high blood pressure • don’t exercise • are overweight The more of these, the bigger the risk you’re taking. Your risk is also greater if your parents had heart disease by their sixties. This is even more reason to fight the other risks. A few steps for health:• Be a non smoker • Eat less fat • Eat more fruit, vegetables, bread and cereals • Make exercise part of your day (walking is good) • Keep to a healthy weight • Get your doctor to check your blood pressure and cholesterol every few years Follow these steps and you’re much more likely to live a healthy and long life. More and more Australians are doing just this. What is cholesterol ? Cholesterol is a fatty substance. Although we need cholesterol in our bodies, too much of it in the bloodstream is a problem. Where does cholesterol come from ? All of us have cholesterol in our bloodstream. Some usually comes from food, but our body can make all the cholesterol it needs. A definition of cholesterol

15

cho·les·ter·ol (ke-lès¹te-rôl´) A white, crystalline substance, C27H45OH, found in animal tissues and various foods, that is normally synthesised by the liver and is important as a constituent of cell membranes and a precursor to steroid hormones. Its level in the bloodstream can influence the pathogenesis of certain conditions, such as the development of atherosclerotic plaque and coronary artery disease. Cholesterol is a fat-related compound found in the tissues and blood plasma of vertebrates. A STEROID, cholesterol is found in large concentrations in the brain, spinal cord, and liver, and is a necessary component of cell membranes. It can be obtained from animal products in the diet or synthesised in the liver. Cholesterol is the major precursor of the synthesis of vitamin D and the various steroid HORMONES and can crystallise in the GALL BLADDER to form gallstones. In the blood, cholesterol travels with a protein in an organic compound called a lipoprotein. Lowdensity lipoproteins (LDLs) convey cholesterol from the liver to the body's tissues, and high-density lipoproteins (HDLs) convey cholesterol out of the blood stream for excretion. High levels of LDLs in the blood, or low levels of HDLs, are associated with an increased risk of heart disease; in atherosclerosis (see ARTERIOSCLEROSIS) deposits of cholesterol (mainly LDL cholesterol) accumulate inside blood vessels. Reducing consumption of foods containing cholesterol and saturated fat has been found to lower blood cholesterol levels; cholesterol levels can also be reduced with drugs (e.g., Lovastatin). The American Heritage Dictionary of the English Language,

What’s wrong with high blood cholesterol ? The higher your blood cholesterol level, the higher your risk of heart disease. High blood cholesterol is the main cause of a process which can gradually clog the blood vessels supplying the heart and other parts of the body. This can reduce the blood flow to the heart and lead to a heart attack. High blood cholesterol is one of the three main risk factors for heart disease. The other two are cigarette smoking and high blood pressure. Most people with high blood cholesterol feel perfectly well. They usually get no warning signs and the only way to find out if their level is high is to have it checked. Is “high” cholesterol always bad ? Yes, mostly. It’s true that some cholesterol called HDL is good, but it is only a small part of your total cholesterol level. What causes high blood cholesterol ? In most cases, diet does. The main thing which raises our cholesterol level is saturated fat. This is found mainly in animal foods such as meat and dairy products. Other types of fat are either polyunsaturated, as in many margarines and cooking oils, or monounsaturated, as in olive or canola oil and some margarines. If these fats replace saturated fat in the diet the blood cholesterol will fall. Cholesterol in foods can also raise blood cholesterol, but less than saturated fat does. Dietary cholesterol is found only in animal products, including full-cream dairy products, meat and eggs. Heredity certainly affects blood cholesterol and a few people will have a very high level of cholesterol no matter how good their diet. But most people can keep to desirable levels if they follow a healthy, varied diet which is lower in saturated fat. How can you help keep a healthy cholesterol level ? • Choose lean meat and eat fish more often • Remove visible fat from meat and the skin from chicken • Use lower fat dairy products, such as reduced fat or skim milk, cottage cheese, low fat yoghurt • Use polyunsaturated and mono-unsaturated oils and margarines 16

• Cut down on fatty fried foods, biscuits, cakes and pastries • Go easy on “fast foods”. Most have a high fat content • Use a non-stick frying pan. Limit use of fats to cook foods • Eat more fruit, vegetables, bread and cereal products The “diet” above is really a healthy eating pattern for all Australians. Who should have their cholesterol measured ? All adults should know their cholesterol level. Children don’t need to have their cholesterol measured unless there is a bad family history of heart disease. It is much better to have your cholesterol tested through your family doctor. This way, you can get balanced advise and your doctor can take other things into account, such as your blood pressure and smoking habits. Your doctor may also measure other blood fat, such as triglycerides. How is cholesterol measured ? A sample of blood is needed. This is usually taken from a vein in your arm, but new machines use a finger prick method and can give a result on the spot. If your first reading is high, you will have a further blood sample some days later to confirm the result. The second time you may have to go without food for eight to twelve hours beforehand so the blood sample can be tested for other fats related to cholesterol. What cholesterol levels are normal or high ? There are no hard and fast rules about what is high, but the following levels are a useful guide. • Desirable: Less than 5.5 mmol/litre (less than 4.5 mmol/litre for children) • Increased risk: 5.5-6.4 mmol/litre • High risk: 6.5 mmol/litre or more Having a “desirable level” of blood cholesterol is no guarantee you won’t get heart disease. But you will have a lower risk. Generally, the lower your blood cholesterol level the better. This is especially true for people with other risk factors or with heart disease. A blood cholesterol of 4.5mmol/ltre is better than one of 5.5mmol/litre. How often should you have your cholesterol measured ? If your last level was fine, check it through your doctor every two to five years. Check it with your doctor at least every if it has been high, if you have other risk factors, or if you or your family have a history of heart disease. What if your cholesterol is high ? Make extra efforts to follow the steps outlined above. Also keep to a healthy weight and make exercise a part of your day - walking is good. Don’t smoke, and ensure that you blood pressure is normal. If necessary, your doctor may help you cut down on fat by giving you information or referring you to a dietician. Some people also need medication to lower their cholesterol.

17

A GUIDE TO LOWERING YOUR CHOLESTEROL Everyone can benefit from the low fat advice in this section. However, if you have high blood cholesterol you will need to limit high cholesterol foods like eggs or offal, as well as fat. High cholesterol foods can be part of a healthy diet if you balance them with other low fat foods. This book’s strong recommendations to avoid high cholesterol foods don’t apply if your cholesterol is normal. Part 1: The basics Let’s start with the basics. What is cholesterol? Cholesterol is a fatty substance produced naturally by the body and found in our blood. It has many good uses. It’s only a problem when there’s too much of it in the blood. What’s wrong with high blood cholesterol? Too much cholesterol in the blood causes fatty deposits to build-up in blood vessels making it harder for blood to flow through. Sometimes major blood vessels can become totally blocked. The gradual blocking of blood vessels in the heart may lead to heart attack or stroke. What causes high blood cholesterol? The main causes are: • eating too much fat • being overweight • eating too much cholesterol. Family history also plays a part. If close family members have high blood cholesterol your chances are greater too. What should my blood cholesterol level be? The lower the better. Less than 5.5mmol/L is desirable. How can I lower it? The key is low fat eating. This book explains how. Part 2: Buying foods and preparing meals Eating to lower your blood cholesterol level is easier than you think. All the foods you need are at the local supermarket. It’s just a matter of knowing what foods to buy and 18

how to put them together to make healthy meals. The main points to remember about eating to lower blood cholesterol are: • eat less fatty food, especially if it’s high in saturated fat • eat more bread, cereals, vegetables, fruits and legumes (dried peas, beans, lentils) • eat fewer high cholesterol foods • keep to a healthy weight. Down with fat The cholesterol story is really all about fat. Fats in food are a mixture of three different types known as saturated, mono-saturated and polyunsaturated fats. A fat is usually named after the type present in the greatest amount. For example, the fat in butter is mainly saturated fat. The main fat in polyunsaturated margarine is polyunsaturated. The different types of fat have different effects on blood cholesterol levels. Saturated fats are the bad ones. They raise blood cholesterol and should be avoided where possible. Meat fat, full cream dairy products and many processed foods such as pastries and biscuits are full of them. Animal fats are mainly saturated. Some fats that come from plant foods are also saturated. Vegetable fats and oils used in processed foods or commercial cooking are usually saturated fats. Mono-unsaturated fats don’t raise blood cholesterol levels. They can actually help lower them if your meals are low in saturated fat. Some oils and margarines, avocado, nuts and seeds contain mono-unsaturated fats. Like all fats, mono-unsaturates are high in calories and should be enjoyed in small amounts. Polyunsaturated fats can also help lower blood cholesterol if your meals are low in saturated fat. Some oils and margarines, nuts and seeds contain polyunsaturated fats. Polyunsaturated fats are high in calories too so keep them to small amounts. Too much fat, especially saturated fat, raises blood cholesterol. A guide to fat in food If you want to lower blood cholesterol levels it’s important to limit saturated fats as much as possible: • trim fat from meat and poultry • choose low fat dairy foods • use polyunsaturated or mono-unsaturated margarine and oils instead of butter and solid frying fats • limit pastries, cakes and biscuits. This will lower the amount of fat, especially saturated fat you eat and will help lower your blood cholesterol level.

19

Get that weight off! Being overweight tends to raise blood cholesterol levels. If you’re carrying a few extra kilos around the middle it’s very important to lose weight. This can be done by eating low fat meals, limiting sugar and alcohol and enjoying regular physical activity. This table will give you an idea of whether your weight is desirable for your height. It can be used by both men and women over the age of 18 years. How do you shape up? Table of acceptable weights-for-height HEIGHT BODY WEIGHT (WITHOUT SHOES) (IN LIGHT CLOTHING WITHOUT SHOES) (cm) (ft in) (kg) 142 144 146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182 184 186 188 190 192 194 196 198 200 Source: Dietary Services

4 8 40-50 4 9 41-52 4 9 43-53 4 10 44-55 4 11 45-56 5 0 46-58 5 1 47-59 5 1 49-61 5 2 50-62 5 3 51-64 5 4 52-66 5 5 54-67 5 5 55-69 5 6 56-71 5 7 58-72 5 8 59-74 5 9 61-76 5 9 62-77 5 10 63-79 5 11 65-81 6 0 66-83 6 0 68-85 6 1 69-86 6 2 71-88 6 3 72-90 6 4 74-92 6 5 75-94 6 5 77-96 6 6 78-98 6 7 80-100 Guidelines for Australian Commonwealth Department of Health & Community

More carbohydrate, please 20

Cutting down on fatty foods may put quite a hole in your daily meals. Carbohydrate foods can help fill this gap. They include: • bread • breakfast cereals, oats, porridge, untoasted muesli • pasta, rice, barley • fruit and vegetables • legumes, e.g. kidney beans, baked beans, lentils. Carbohydrate foods are low in fat and may be high in dietary fibre which can help lower blood cholesterol. More carbohydrate means less room for fats. Eat and enjoy! Fewer high cholesterol foods Cholesterol is found in some foods and eating these may raise your blood cholesterol level, especially if you’re eating lots of saturated fat as well. This may not happen to everyone but it can have a large effect in some people. Cholesterol is found only in animal foods. If you have high blood cholesterol it’s important to limit those foods which are high in cholesterol as well as high in fat. Foods which are high in cholesterol: • brains, liver, kidneys and other offal food (except tripe) • egg yolk (no more than two a week) • caviar • scampi, calamari, squid, octopus (maximum one serve a week). If your cholesterol is normal you can enjoy these foods a little more often. Many people are confused about eggs. If your blood cholesterol is normal, one egg a day is fine. Plant foods such as avocados, nuts, vegetable oils, grains, fruit and vegetables don’t have any cholesterol. Other Foods Some foods will not increase your blood cholesterol level but some people may need to go easy on them. These include: Sugars and confectionery These are high in sugar but won’t raise blood cholesterol levels and may be eaten in small amounts. If you’re trying to lose weight or have high triglycerides it’s best to limit the following: • sugar (table, brown, icing, raw) • glucose, lactose, fructose • jam, marmalade, honey, molasses • boiled sweets, marshmallow, licorice • jelly, jellied sweets • regular soft drink/cordials, flavoured mineral water Salty foods, condiments and miscellaneous These won’t raise blood cholesterol levels but they’re high in salt. If you have high blood pressure it’s best to go easy on them. If you’re on a low salt diet ask your dietician for advice. Some of the following high salt foods come in reduced salt forms: • salt, vegetable salt, rock salt, garlic, salt, onion salt • meat paste, fish paste • tomato paste • commercial sauces, e.g. oyster, black bean sauces • tomato sauce, BBQ, soy, Worcestershire, Tabasco • powdered sauce mixes

21

• salad dressings • pickles, e.g. gherkins, pickled onions, chutney • olives • soup powders and boosters, tinned soups • packet seasonings • stock cubes • lean bacon, lean ham • breakfast cereals, e.g. cornflakes. Confused about food labels? Food labels can be confusing. Knowing which processed foods are good choices isn’t always easy and food labels often make a food sound healthier than it really is. Here’s a guide to help you through the shopping maze. What must appear on a food label? All food labels should include: • the name and address of the manufacturer or distributor - useful if you want to write to them for extra information • a packaging or ‘use by’ date if the food has a shelf life less than two years • a list of ingredients with the main ingredient by weight listed first and the smallest listed last. The amount of each ingredient does not have to be given. Look out for fat in ‘disguise’. Other words for fat or high fat ingredients to look for are: • vegetable oil, coconut oil, palm oil, palm kernel oil, cottonseed oil • copha, animal fat, beef fat, tallow, lard, shortening • chocolate, monoglycerides, diglycerides, full cream milk solids. If a type of fat appears in the first three ingredients the product is likely to be high in fat unless the label shows otherwise. ‘Creamed’, ‘toasted’ or ‘oven baked’ may also mean high in fat. If a claim such as ‘reduced fat’ has been made the label must also have a nutrition information panel. Generally, if there is more than 10 grams of fat in every 100 grams the food is considered high in fat. What do the claims mean? ‘Cholesterol free’ This doesn’t mean the food is particularly healthy, low in fat or calories or low in saturated fat. All it means is that the food is free of cholesterol. Although some ‘cholesterol free’ food may be included in your daily meals others are not recommended. Plant foods don’t contain cholesterol but some, such as coconut and palm oil are high in fat and saturated fat and aren’t good choices. Commercial biscuits and cakes often contain coconut oil and palm oil, which are usually listed on the ingredient list as vegetable fat/oil. ‘Toasted’ and ‘oven baked’ Often used to describe breakfast cereals and biscuits. Usually they mean the food has been fried in oil, probably high in saturated fat. Toasted mueslis have around double the fat of untoasted mueslis. Low fat Generally means the food has 3 percent or less fat (if solid) or 1.5 percent or less fat (if liquid). ‘Reduced fat’ May not mean low in fat. Reduced fat cheddar cheese, for example, has 25 percent fat but is still considered a high fat food. Cream cheeses claiming to be 82 percent fat free are really telling you they’re 18 percent fat, which still makes them a high fat food. 22

Check nutrition information panels for total fat content. Generally if the food is more than 10 percent fat it is considered to be high in fat. ‘Lite’ or ‘Light’ Can mean anything. They may simply mean less salt or fat but you will have to check the label to see if they’re truly lower in salt or fat. In most cases Lite or Light doesn’t mean low in calories or low in fat. ‘Lite’ olive oil is light on flavour not light in fat or calories. The new Code of Practice on nutrient claims attempts to prevent the misleading use of Lite or Light on food labels. It recommends labels must declare the characteristics to which Lite refers, e.g. colour. The label should tell you this. What the label tells you “Pick the Tick” Too busy to read food labels? Shopping is a chore. Most of us want to get into the supermarket and get out again as soon as possible. We simply don’t have the time to read every label before buying our foods. Pick the tick The Heart Foundation’s ‘tick’ of approval can help you to make healthy food choices quickly and easily. Foods with the tick have been tested and approved by the Heart Foundation as being relatively low in saturated fat. Tick foods are good choices among foods of their type. They can be included in healthy meals that will help you to control blood cholesterol levels. Food with the tick won’t cure heart disease. The tick simply indicates that a food is a good choice. What’s on the menu? Now that your cupboard and refrigerator are stacked with healthy choices from the supermarket let’s put some meals together. Even on a tight budget there’s still plenty to choose from. The advice below applies to all meals: • plenty of cereal foods such as bread, rice, pasta, spaghetti and breakfast cereals (preferably wholemeal) • plenty of fruit and vegetables • plenty of legumes, e.g. baked beans, lentils, kidney beans • moderate amounts of reduced fat milks and other low fat dairy foods • small amounts of polyunsaturated or mono-unsaturated fats and oils. Breakfast Here are some suggestions Plenty of wholegrain breakfast cereal or porridge, low fat milk, fruit juice, fresh or tinned fruit. Toast with polyunsaturated or mono-unsaturated margarine and your favourite spread. Tea or coffee. If you like a hot breakfast try: • baked beans • spaghetti • grilled tomato, sweet corn • braised mushrooms • omelette (using egg substitute).

23

Light meals Some examples are: Lunchtime Sandwiches or rolls with polyunsaturated or mono-unsaturated margarine and your choice of lean meat, chicken, peanut butter, tinned fish and salad vegetables Fresh fruit Low fat yoghurt. Summer choice Salmon or tuna salad Plenty of salad vegetables Bread Polyunsaturated or mono-unsaturated margarine Juice, fruit salad. Winter favourite Thick vegetable soup Crusty rolls Polyunsaturated or mono-unsaturated margarine Fresh fruit Tea or coffee. Main Meals Examples are: stir fry chicken and vegetables plenty of steamed rice hamburger - wholemeal bun, lean meat patties, sauce, plenty of salad vegetables small serve of lean lamb, mint sauce, jacket potato, peas and carrots grilled fish plenty of cooked or salad vegetables spaghetti bolognaise small serve of meat sauce plenty of spaghetti, green salad Dessert Examples are: jelly and tinned fruit fresh fruit, low fat custard low fat ice-cream, gelato or sorbet fresh fruit salad and low fat yoghurt. Snacks Examples are: fresh fruit sandwiches with salad filling nuts and dried fruit low fat fruit yoghurt low fat fruit smoothies Takeaways Examples are:

24

steamed rice, stir fry vegetables and lean beef skinless chicken and corn cob burritos, beans and chilli sauce (no cheese) pita bread with tabbouli salad roll with lean meat or chicken lean meat shish kebab. Modifying recipes Don’t throw out those old cookbooks. All that is needed are a few simple changes to reduce the fat, especially saturated fat in those favourite recipes. The two steps to changing a recipe are: • change to a low fat cooking method • change ingredients by reducing, removing or using something else. Part 3: Answers to questions about heart disease What is heart disease? Heart disease is a gradual process which causes blood vessels (arteries) feeding the heart to become narrow. This process can start at an early age. Fatty deposits build up in the artery walls making it more and more difficult for blood to flow through. High blood cholesterol, smoking and high blood pressure all tend to clog the arteries. What is a heart attack? If one of the arteries feeding the heart becomes blocked by a clot, blood is prevented from flowing to part of the heart, starving it of oxygen and nutrients. This is called a heart attack. The severity of the heart attack will depend on where the artery is blocked. Can you unclog an artery? Lowering blood cholesterol can halt and even reverse artery damage in some people. However it’s better to avoid the problem in the first place. Should I be on drugs? Your doctor will advise you on this. Normally a low fat diet is enough to lower cholesterol. If a change of diet doesn’t do the trick after six months medication may need to be considered as well. Is family history important? Yes. If a close relative has died from heart disease before 60 years, your risk of heart disease may be increased. Can I reduce my risk? Many Australians die early of heart disease because of their ‘unnatural’ lifestyle. Our bodies aren’t designed to smoke, eats lots of fat or sit in front of the television three hours a day. The big three risks for heart disease are high blood cholesterol, smoking and high blood pressure. The good news is you can do something about all of them. Blood cholesterol. Keep it down - the lower the better. Use this book to help. Smoking. Don’t. If you’re a smoker contact the Heart Foundation for information on quitting. Blood Pressure. Keep it at a healthy level. If you don’t know your blood pressure get it checked. Too much alcohol, salt and being overweight can raise it. Exercise. Being active each day will reduce your risk of heart disease in the future. Walking is a great way to start. Contact the Heart Foundation for more advice. Weight. Keeping to a healthy weight helps keep blood cholesterol, blood triglycerides, blood pressure and blood sugar levels (diabetes) down. Diabetes. If you have diabetes keep it under control. People with uncontrolled diabetes double their risk of heart disease. The advice in this book is suitable for 25

people with diabetes, with the added recommendation to avoid highly sugared foods. Contact your local Diabetes Association or dietician for more information. Stress: Stress is not a big cause of heart disease as is popularly believed. Working long hours under pressure probably doesn’t cause heart disease but may make it more difficult to change eating, smoking and exercise habits. What about my blood test? What is measured? The three most common blood tests are for your total blood cholesterol, HDL, cholesterol and triglyceride levels. Do I need to fast? You should fast 12 hours before a triglyceride or cholesterol test. What is a high reading? Above 5.5mmol/L is too high for a blood cholesterol reading and a change in food choices is recommended. About half of adult Australians have cholesterol levels above 5.5mmol/L. You should aim to get your level as low as possible. The lower the level the lower the risk of heart disease. A high blood triglyceride level is more than 2.0mmol/L. A high triglyceride is less common than high blood cholesterol. RECOMMENDED LEVEL Blood cholesterol less than 5.5mmol/L Blood triglyceride less than 2.0mmol/L HDL cholesterol less than 1.0mmol/L What are triglycerides? Triglycerides are a type of fat occurring naturally in blood. When fats in a meal are digested they form triglycerides which are then absorbed into the blood to be carried around the body. Blood triglyceride levels rise after a meal then drop as the triglycerides are used by the body. Drinking less alcohol, losing excess weight and eating less fat will help lower triglycerides. What are LDL and HDL? Cholesterol appears in the blood in different forms. LDL cholesterol is known as ‘bad’ cholesterol as it tends to clog blood vessels. When a blood cholesterol reading is high it is usually because LDL levels are high. HDL cholesterol is sometimes called ‘good’ cholesterol and can actually help unclog the arteries. High HDL levels can be a good sign as long as LDL levels aren’t high as well. There’s no single food which raises HDL levels. The best way to keep HDL levels up is to be active every day, keep to a healthy weight and be a non-smoker. Do cholesterol and triglyceride levels vary? Yes. Cholesterol levels tend to rise and fall from week to week. Two or three blood cholesterol readings are needed to give you an idea of your true level. Triglycerides go up and down after each meal. When should I have another test? Your doctor will advise you. If your cholesterol was high then you should have another test about three months after changing to a low fat diet. People with a blood cholesterol less than 5.5mmol/L should have a repeat test every five years. What about my children? Children of a parent with high blood cholesterol should have their cholesterol checked. Children’s blood cholesterol levels should be less than 4.5mmol/L. What if I’m pregnant? It is normal for blood cholesterol to rise during pregnancy and drop again once the baby is born. Testing is not recommended during pregnancy. Does menopause affect my cholesterol?

26

Yes. Blood cholesterol tends to rise after menopause. Women on hormone replacement therapy may find that their blood cholesterol drops. Does age have an affect on blood cholesterol? Age does not cause blood cholesterol levels to rise. It is definitely worth lowering high blood cholesterol even if you are over 65 years. Can blood cholesterol levels get too low? No. Don’t you have to have some fats in the diet? Yes but you can get this easily through lean meats, poultry, fish, lower fat dairy products, wholegrain breads and cereals. Which is the best oil to use? No single oil is better than the others. Choose the polyunsaturated or monounsaturated oil that suits your taste and budget. How many eggs a week should I eat? The fat and cholesterol is an egg is found in the yolk only. If your blood cholesterol level is over 5.5mmol/L then limit yourself to two egg yolks a week. An egg a day is acceptable if your cholesterol is less than 5mmol/L. Can I eat avocados? Yes. Avocados are high in mono-unsaturated fats and calories but will not raise blood cholesterol levels. But eating too much of any food is not healthy. Are nuts fatty? Nuts are high in natural fats and contain mainly mono-unsaturated fat. This will not raise blood cholesterol levels but because nuts have a high fat content they are also high in calories. I’ve been told to cut out meat and dairy products. How will I get my iron and calcium? Dairy foods are a good source of calcium and meat; fish and poultry are good sources of iron. There’s no need to cut out meat or dairy foods. Instead, choose moderate serves of lean meat (about 120 grams of cooked meat a day). Low fat dairy foods are quite suitable for low fat eating. Some low fat milks and yoghurts are higher in calcium than the full cream versions. Everyone in the family eats the same foods. How come only my cholesterol is high? For genetic reasons people respond differently to food. It’s likely you are eating too much fat for your body. You can’t change your genes but you can change the amount of fat you eat. Can children follow the dietary recommendations in this book? Yes. Any child over the age of five years can follow the food recommendations of this book. Children under five years should use full cream milk rather than reduced fat milks. Is cholesterol the same as fat? No. Although cholesterol is fatty, cholesterol and fat are completely different parts of food. A food can be high in fat yet have no cholesterol, e.g. vegetable oils. On the other hand a food can be high in cholesterol yet be low in fat, e.g. prawns. Keeping the fat content of your meals low is the best way to reduce your blood cholesterol level. What is the best margarine to use? Choose either a polyunsaturated or mono-unsaturated margarine. Use sparingly as they are both high in fat and calories. For spreading on bread you might choose the

27

polyunsaturated or mono-unsaturated fat reduced spreads. They look a lot like regular margarines but have around half the fat and calories of regular margarine. Can I eat prawns? Prawns are very low in fat although they are quite high in cholesterol. Eating prawns once a week is unlikely to affect your blood cholesterol levels. Can I use cod liver oil? Cod liver oil contains cholesterol but several capsules or one teaspoon a day is unlikely to cause problems. Cod liver oil doesn’t lower blood cholesterol levels. What can I eat at Christmas and birthdays? On special occasions many of the foods presented may not be ideal if you’re watching your cholesterol. Our advice is don’t worry about it. Tucking in one day of the year will not do you any harm. It’s foods you regularly eat on the other 364 days that will decide your cholesterol level. Enjoy those special occasions and, as always, enjoy your food. The ABC of foods Alcohol Alcohol doesn’t raise cholesterol but it can raise triglycerides, blood pressure and body weight. If you drink alcohol enjoy no more than two standard drinks a day for women or four for men. Follow your doctor’s advice. Antioxidants Antioxidants such as vitamins C and E, beta-carotene and selenium may have a role in preventing heart disease but this is by no means certain. Low fat foods such as fresh fruits, vegetables and wholegrain cereal products are naturally rich in antioxidants. Coffee Coffee (regular and decaffeinated) in moderate amounts is considered safe. Up to five cups of instant or percolated coffee a day is unlikely to cause any long-term problems. Boiling ground coffee beans for long periods - not usually done in Australia - may lead to a higher blood cholesterol level. Dairy foods You don’t have to avoid dairy foods to lower blood cholesterol. It’s dairy fat that needs to be avoided so you can choose low fat milks and low fat yoghurts. Low fat dairy products aren’t recommended for children under five years of age as they need the extra fat for rapid growth. Dietary fibre Dietary fibre is the part of food not digested by our stomach or intestines. Fibre is found only in plant foods. There are two types, insoluble and soluble. Foods high in soluble fibre include fruits, vegetables, legumes (e.g. kidney beans, baked beans), oats, oat bran, barley bran and rice bran. The soluble fibre in these foods can help lower blood cholesterol. However, reducing saturated fat in the diet is a better way of lowering blood cholesterol. Insoluble fibre helps to keep bowels regular but has little effect on cholesterol. It’s found mainly in wholemeal bread, breakfast cereals and unprocessed bran. Evening primrose oil There’s no evidence that the gammalinolenic acid in evening primrose oil helps to reduce blood cholesterol. Fish and fish oils Eating fish can help protect against heart disease. As little as 200 grams - or two meals - of fish a week seem to help. If you like fish include some on your menu. This can be fresh, frozen or tinned. The good effects of fish may be partly due to the fish oils they contain. Fish that are high in fish oils include herring, mackerel, tuna, salmon and

28

sardines. It’s too early to say that fish oil capsules reduce your risk of heart disease. They probably don’t lower blood cholesterol but may be prescribed by your doctor to reduce high triglyceride levels. Garlic Garlic contains a compound, allicin, that can help lower blood cholesterol levels. The small amount of garlic normally found in food will have no effect on blood cholesterol levels. Hydrogenated fat This type of fat may be found listed in food ingredients. Hydrogenating a fat makes it more saturated so avoid it where possible. Lecithin Lecithin contains mostly polyunsaturated fat so it won’t raise blood cholesterol. There’s no evidence that it independently lowers blood cholesterol. Lecithin’s expense doesn’t justify its purchase. Lecithin is sometimes added to commercial foods as an emulsifier to stop fat from separating from the rest of the food. Oat bran, rice bran and barley bran All these brands contain soluble fibre but you need to eat large amounts to lower your blood cholesterol. Red meat All red meat contains some fat. However, most Australian meat is not heavily marbled with fat. The fat that is present is easy to see and cut off. Moderate helpings of meat, trimmed of visible fat, may be enjoyed as part of your weekly meals. Skinless chicken and fish are low fat alternatives to red meat and can be eaten regularly. Salt Too much salt in the diet can raise blood pressure but has no effect on cholesterol. About three-quarters of our salt comes from commercial foods. If your blood pressure is high, you should eat less salt. Choose low salt and no added salt foods and avoid using salt in cooking and at the table. Sugar There’s no direct link between sugar and heart disease. Sugar doesn’t raise blood cholesterol levels nor cause diabetes. Vegetarianism Vegetarianism has long been linked with lower risk of heart disease, probably because vegetarians eat less saturated fat and more foods with soluble fibre. You don’t have to be a vegetarian to experiment with meatless dishes. Too thin? Losing weight is a useful side effect for most people when they eat low fat meals to lower blood cholesterol. But what if you’re already thin and can’t afford to lose any more weight? Here are some ideas on avoiding weight loss: • eat plenty of bread, pasta, rice and potatoes. • eat a wide range of foods. A wide choice of foods helps the appetite - just watch people at a smorgasbord! • try eating many times during the day. Enjoy three main meals and three snacks each day. This means you’ll be nibbling constantly throughout the day. Here are some hints: • snack on dried fruit and nuts • drink milkshakes or fruit smoothies made with reduced fat milk • snack on peanut butter sandwiches • add extra skim milk powder to skim milk. Use in drinks and on cereal • snack on avocado on bread or crispbread 29

• drink plenty of fruit juice. Still too thin? Try a small increase in the amount of polyunsaturated or mono-unsaturated margarines and oils or high energy drinks like Sustagen. Have a chat with your doctor or dietician if your weight continues to fall.

LIFE AFTER A HEART ATTACK The Master said: “To learn something and then put it into practice at the right time: is this not a joy?” The Analects of Confucius, 1.1

You’re not on your own! Doctors, nurses and other health workers will help you recover both physically and emotionally and put you on the road back to a full, productive life. Programs in hospital get you back on your feet as quickly as possible and help you prepare for your return home. Modern medical treatment can greatly

30

improve your health outlook after you’ve had a heart attack. But your recovery and the success of treatment also depend on how you help yourself. Some positive and important changes in lifestyle will help prevent another attack. You must also follow your doctor’s advice about taking medication and resuming various activities. What is a heart attack? A heart attack occurs when the blood supply to part of the heart is blocked. Although the attack itself is sudden it usually results from a very gradual process. To understand a heart attack it’s important to know a little about the heart and how it works. The heart is a muscular pump which keeps blood flowing to all parts of the body through blood vessels. The blood vessels which carry blood away from the heart are called arteries. Those which carry blood back to the heart are called veins. The blood supplies the muscles and tissues in every part of the body with the oxygen and nutrients they need to grow and maintain themselves. The heart also needs a blood supply and this comes through the coronary arteries. The main underlying problem in heart attack and other forms of coronary heart disease is a gradual clogging process (atherosclerosis). Fatty deposits building up on the inside walls of arteries narrow the channel inside so there is less room for the blood to flow through. If a coronary artery is badly blocked a blood clot can suddenly form at the narrowed point and block it completely. If the part of the heart muscle supplied by that artery doesn’t receive any blood and the clot can’t be dissolved quickly by emergency drug treatment, there will be some permanent damage. The medical term for this damage is myocardial infarction. You may hear the doctor call your heart attack a ‘coronary’, an ‘MI’ or an ‘acute MI’. The main cause of blocked arteries is a high blood cholesterol level. This is common in countries such as Australia because our diet is usually too high in saturated (solid-type) fats. Too much saturated fat can increase blood cholesterol and start the build-up of fatty materials in the arteries. High blood pressure and cigarette smoking also contribute to the blocking process and do other harm as well. High blood cholesterol, high blood pressure and cigarette smoking are the three major risk factors for heart disease. Being overweight and doing too little exercise are two other important risk factors. These five risk factors are all preventable and attention to them is very important to your future. The artery-blocking process starts when we’re young and builds up slowly over the years. It’s often well-advanced by middle-age, when heart attack and angina (bouts of chest pain or discomfort) are more common. Atherosclerosis doesn’t disappear from your coronary arteries after a heart attack but there are signs that in some people its progress can be slowed, halted and sometimes even reversed a little. There is still no cure, however, for coronary heart disease - only control of its symptoms. How is a heart attack diagnosed? A heart attack is diagnosed through the story of your pain or discomfort and by blood tests and an ECG (electrocardiogram). The blood tests show up enzymes which get into the bloodstream if the heart muscle is damaged. The ECG traces the electrical pattern of a heartbeat and can indicate areas of damage. Extra tests can be used to help the diagnosis. The symptoms and tests indicate whether the attack is ‘mild’ or more serious. But the most important sign is your overall condition during and after the attack. What happens in hospital after my heart attack?

31

If you go to hospital quickly enough you may have been given a drug which can dissolve the clot in your coronary artery and restore its blood flow. This treatment is called thrombolysis. The sooner it’s given the better its changes of reducing the damage to the heart muscle. However, thrombolysis isn’t suitable for everyone. In the coronary care unit As a heart attack patient you would probably have gone to the hospital’s coronary care or intensive care unit for routine close attention by specially trained staff. Patients there are connected to an ECG machine because a heart attack can disturb the heartbeat and the machine can indicate when special treatment is needed. A ‘drip’ tube is put into a vein in the arm so that medication and fluids can be given. While in the coronary care unit patients are encouraged to make the first moves towards getting up and about again. In the general ward Usually, within a few days, you’re transferred to the general ward. There your activity will be gradually increased. At first you’ll spend most of the day in your room but soon you’ll be walking around the ward. Each hospital has its own program to get you back on your feet. Being a little more active every day is vital to help you recover faster and prepare you for going home. If you have chest pain, shortness of breath or feel unwell in any way tell the nurse or the doctor. Pain or discomfort can be eased and the cause treated. You may need some extra tests. If you have a problem which is best treated in the coronary care unit you’ll go back there to be on the safe side. Feeling worried and depressed It’s normal to feel worried after a heart attack and find it hard to accept. One moment you may feel happy and grateful to be alive, the next you’re depressed and concerned about your future. Your depression usually isn’t so bad if you understand what has happened to you and know that others feel the same. It’s normal to worry about: • dying • another heart attack • losing your job • your financial future • not having a normal sex life • getting your confidence back. Fortunately these serious worries don’t usually last long. Talk about your concerns to the people around you - your doctor, the nursing staff, the unit social worker, your family and friends. You’ll find out how normal your reactions are and how readily your fears can be put to rest. Before leaving hospital Before going home you’ll probably have some tests to help assess the damage to your heart and your risk of another attack. An exercise test on a bicycle or treadmill helps the doctor measure your exercise capacity. This test will also give you confidence to resume physical tasks at home. It involves pedalling a stationary bike or walking on a treadmill while you’re attached to an ECG monitor. This records your heart’s response to exercise. Your blood pressure will be taken regularly and you’ll be asked if you’re feeling any chest discomfort.

32

You may also have an x-ray of your heart, called a coronary angiogram, to look for any more blockages in your coronary arteries and to see how well your heart is pumping. You’ll probably be given prescribed medication to take long term. Aspirin and drugs called betablockers are often used. In some hospitals there is a team of health workers who will help you plan your recovery. Back at home …. You’ll go home when you’re feeling better, have no chest pain and your condition is settled. This is usually within a week or two. After leaving hospital it takes a few days to adjust to being away from the care of the staff. At first you may feel you’re not improving as fast as before, but be patient. Nearly everyone who recovers from a heart attack can return to a normal life. Recovery depends on a number of things, including how much your heart was damaged. But a lot depends on you. When will I see a doctor again. You’ll probably see your cardiologist a few weeks after you leave hospital. You should see your family doctor within a few weeks too, because he or she will be looking after you long term. When you see your doctor take your prescription book from the hospital so he/she knows exactly which tablets you’re taking. How active can I be? In the first week or so don’t do too much too soon. Recognise when you’re tired and rest. You don’t need to avoid doing anything if it’s part of everyday life. You should get up and get dressed every day. In a number of weeks you should be able to do whatever you did before. From the beginning keep increasing your activity very gradually. Talk to your doctor about when you can restart various activities and how to build up an exercise program. Some hospitals run out-patient group ‘rehabilitation’ programs. Usually the physiotherapist, occupational therapist or nurse will have told you about these programs, while you are still in hospital, including when you should first attend. These programs continue the gradual increase in activity you began in hospital and also advise about how to live with heart disease and change your life for better health. There are also cardiac support groups run by people with heart disease to help others who have had a heart attack or a heart operation. If these are available you should make the most of them. Ask your hospital or local Heart Foundation office if there’s a support group in your area. How much exercise should I do? Regular moderate exercise is a vital part of your return to normal life. Within six weeks most people can exercise as much as they want to. Just after leaving hospital it’s important to progress gradually since your heart is healing and shouldn’t be strained. Do a bit of easy walking around the house and garden or out in the street. Try to walk each day on flat ground. Build up gradually to walking further and going up-hill. Walking is the best exercise but you can also try some cycling or light daily exercises as well. If it’s difficult for you to go walking,

33

swimming or riding an exercise bike are usually good alternatives. Usually you can go back to golf and bowls after four to six weeks and tennis within six to eight weeks. If you become light-headed, short of breath, get irregular heart beats or chest pain slow down or stop, then contact your doctor. You may need advice about levels of activity and possibly some treatment. You may find that you can do less on cold days, as the cold increases the work of the heart. What about walking up stairs? Stair climbing should be increased gradually but if there are stairs where you live there’s no reason why you shouldn’t climb them slowly as soon as you come home. As a general rule, if you can walk normally at your usual pace you can climb two flights of stairs at your usual pace. When can I start working around the house again? Again, start slowly and don’t do more than you’re comfortable with. Let others help you for a while, especially with the more strenuous jobs such as chopping wood or vacuuming. But don’t let yourself be waited on hand and foot too much or for too long. It’s best to get back to normal as quickly as possible. Resuming sex Most people can resume sex within a few weeks after the heart attack. Because making love is a form of exercise it has an effect on the heart. The physical activity in sexual intercourse can be compared with walking about one and a half kilometres or up a few flight of stairs. Early on, you may have to try new positions, to minimise your physical movement. Remember to stop any activity, including intercourse, if you have any pain or discomfort in the chest. Some short-term lack of interest in sex is common after a heart attack. Also, some heart drugs can affect your sexual interest and capacity. Your doctor can advise you about this. It’s also important to discuss things with your partner because you could both be feeling unsure. Is it safe to travel? Jet aircraft are pressurised so air travel is quite safe. Some light aircraft are not pressured and should be avoided for a couple of months. It’s fine to travel by train straight away but make sure you have a seat so you don’t get too tired. Travelling as a passenger in a vehicle for long trips can be tiring and you may also get car sick more easily than usual. When can I drive? This depends on how quickly you recover, physically and emotionally. Physically, you should be able to drive within a few weeks. But you may still feel insecure about driving at this time. Your family may also be worried about you driving. To start with don’t drive alone. Stick to routes you know and avoid peak traffic periods until your confidence returns. Is it normal to feel emotional and irritable? The fears you first felt in hospital can last for some time until you get your strength and confidence back. You may also have trouble sleeping. These feelings are common and will pass. See your doctor, social worker or cardiac support group is you’re worried that you’re not coping - there’s always someone who understands and can help. What should the family do? It’s important that your family understands exactly what has happened to you and why. Suggest they read this book for a start. You need their support and encouragement for the lifestyle changes which are so important to your future. Friends may offer you all sorts of well-meaning advice which is not always correct. The best thing is to follow the advice in this book or ask your doctor.

34

Returning to work Just about everyone can go back to work after a heart attack, usually within a few weeks. It’s a very important part of your overall recovery. You should decide with your doctor when you go back to work. This will depend on how quickly you recover and how much physical work your job involves. If your work is physically active you may first have to build up your strength over two to three months. Most people should be able to return to full duties within a reasonable time and only a few will need to stay on lighter duties. Even if your job involves lifting, you should be able to return to whatever weights you were lifting before the attack, as long as you start with reasonably light weights and build up slowly. The kind of activity you do at work should also be part of your home recovery program before returning to work. If you attend a group rehabilitation program at your hospital or other centre you’ll be given advice to prepare you for getting back to work. Whatever your job, make sure you’re ready before you return to work. And give yourself time to settle back. Ask your doctor for a certificate spelling out what you can and can’t do - this will help both you and your employer. On the other hand, if you’re near retiring age and had been thinking about doing so before you had your attack this might influence your timing. The important thing is to keep mentally and physically active. Chest pain or discomfort If you get bouts of chest pain after you return home, see your doctor straight away. Some people continue to have angina. A small pill called Anginine, dissolved in the mouth, will relieve the discomfort when it strikes. If you get angina your doctor may advise you to have an exercise ‘stress test’ or a coronary angiogram, Coronary angiogram A coronary angiogram is done in hospital and involves taking an x-ray of the coronary arteries to show up any blockages and their extent. A thin flexible tube is put into an artery in the arm or leg with the help of a local anaesthetic and then threaded towards the heart until it reaches the point where the coronary arteries branch off to the heart. A special dye injected through the tube enters the coronary arteries and outlines them under x-ray. Patients are awake so they can move as the doctor takes different x-ray pictures but they can’t feel the tube moving through the arteries. If the coronary arteries are badly blocked the doctor may advise having an angioplasty or coronary artery bypass graft surgery (CABG). Angioplasty Angioplasty is a method of opening up a clogged artery from inside. Under a local anaesthetic, a small flexible tube is threaded up through an artery towards the heart until it reaches the blockage in the coronary artery. A small balloon at the end of this tube is inflated to open out the narrowing and restore the blood flow. Again, patients are awake but sedated during the procedure. It’s normal for them to feel some chest pain as the balloon is inflated. Angioplasty patients usually go home within a couple of days and can often return to normal activities, including work, within a week or two. They will see their specialist within two weeks and probably have an exercise test to see how much they can exert themselves without chest pain. Angioplasty is often so successful that people can be medication-free.

35

Bypass surgery Thousands of Australians have successful bypass surgery every year. The operation involves taking a healthy section of blood vessel from another part of the body, usually the leg or chest and sewing it onto the coronary artery above and below the blockage to bypass it. This restores blood flow, resulting in less angina or none at all. A typical hospital stay is about one to two weeks. It can take up to two months or longer before bypass surgery patients can resume normal activities such as work. If the hospital has an outpatient group rehabilitation program patients will be given appropriate exercises and support to help their recovery. The speed of recovery depends on how quickly they’re able to build up their fitness. Bypass surgery and Angioplasty patients usually return to a full and active life. But in some people the grafted or cleared coronary arteries can become blocked again, sometimes within months. Everything should be done to reduce the factors that can contribute to this blocking - by eating a lower fat diet, exercising regularly and not smoking. What if I have another attack If an episode of angina doesn’t pass within five to ten minutes after a tablet or rest, you should take another tablet. If the pain is still there after another five minutes treat it as a heart attack. This means you should get straight to the nearest hospital - by ambulance if immediately available. How to cut the risk of further blockages and attacks The first step: be positive For many people a heart attack is the trigger to make the positive changes they’ve been thinking about for years. Some changes will be necessary - but they needn’t be huge sacrifices. The steps recommended here can add to a full and enjoyable life. Be a non-smoker Giving up smoking is the most important step you can take to prevent another attack. You’ll be urged and helped to do this during your first few days in hospital after your heart attack. Smokers who stop have half the risk of another heart attack compared with those who keep smoking. Watch your cholesterol level: eat a lower fat diet Raised blood cholesterol is a big risk for heart disease. Generally speaking, the lower the cholesterol level, the better. In most cases raised blood cholesterol is caused by diet. The main culprit is saturated fat, which is found mainly in animal foods such as meat and dairy products. Heredity certainly affects blood cholesterol and a few people will have a very high level, no matter how good their diet. But most people can keep to desirable levels if they follow a healthy varied diet which is lower in saturated fat. For a lower fat diet, eat a wide a range of foods including plenty of fresh vegetables, more bread, fruit and fish, along with low fat dairy products, lean meat and poultry. Because you have heart disease you should have your cholesterol checked by your doctor at least every year. Control your blood pressure High blood pressure is a common problem in Australia. Because it rarely gives warning signs it should be measured regularly and treated by a doctor. In most cases the cause of high blood pressure is unknown. Factors such as overweight, alcohol, diet and lack of exercise, however, play an important role and blood pressure can be reduced when they are changed. If it’s not controlled, high blood pressure can

36

overload the heart, accelerate artery blocking and lead to another heart attack or other problems. High blood pressure can often be controlled safely and simply with a few lifestyle changes, such as losing extra weight, cutting down on alcohol and salt and getting regular exercise. In many cases tablets are needed as well. Keep to a healthy weight Being overweight contributes to high blood pressure, high blood cholesterol and diabetes. Most people can keep to a desirable weight with healthy eating and regular exercise. Enjoy regular moderate exercise As well as being an important part of your recovery from your heart attack, regular moderate exercise has benefits for heart health in general. It helps control your weight, improve your blood cholesterol and blood pressure levels and reduce the changes of another attack. Following the steps above can make your life more active and enjoyable and reduce the chance of further ill health from heart disease. And that’s an opportunity worth seizing.

TRUE FRIENDS To act the part of a true friend requires more conscientious feeling than to fill with credit and complacency any other station or capacity in social life. Sarah Ellis (1812-72), English missionary, writer. Pictures of Private Life, ch. 4 (1834).

Through my own experience, I have discovered that people view tragedy and life threatening illnesses from many different perspectives. The people I most expected to be empathetic and caring in many instances had no idea how to deal with what was happening, so they disappeared. Those I least expected to offer support, in fact showed themselves to be most caring. As Australia is a highly diversified multi-cultural nation, I was able to draw some comparisons. Those who showed the least amount of concern were from the Spanish community. Those who demonstrated the greatest empathy were from Asian countries, in particular the Chinese. I was also quite surprised that many of the most flippant comments came from people who had undergone heart by pass surgery themselves. It is quite possible that heart surgery is similar to having a baby. After the event the joy of survival and success blocks out all memory of pain and anxiety, and produces a sort of euphoria which successfully masks negative memories. In contrast to these comments, however, the following has been written by my good friends Kris and Peter Shead:“Twelve years ago, when my father was unexpectedly diagnosed with heart disease, there were very few hospitals to choose from for a by-pass operation to be carried out. Living in Newcastle, a couple of hours north of Sydney, he was directed to the major

37

hospitals in Sydney, and fortunately into the capable hands of the Victor Chang team. At the time, I remembered that very little support was offered to the immediate family as to what they should expect. - a couple of photocopied pages of do’s and don’ts after the operation and that was the total extent of our knowledge. My mother and I met up together at St Vincent’s Hospital on the day of the operation and we were to stay a week in a fairly Spartan, but comfortable, tenement house provided by the hospital for close relatives of patients. My father was an extremely placid man. In fact, remarkable as it sounds, I can’t recall him ever raising his voice in anger, or even arguing with my mother. The morning of the operation, then, was just another of life’s events which he faced with his usual resignation. I remember him calmly squeezing our hands for reassurance before he was wheeled off to the theatre, and that was the extent of his visible concern to us! The next six hours were then before us. Whereas my father was calm, my mother was visibly worried. She was a former nurse and only too aware of the problems that could ensue. She envisaged spending the next six hours within earshot of the phone in the nurses station. After twenty minutes of such intense concentration, and no dreaded phone call forthcoming, I was able to convince my mother that my father must have weathered the worst, and now it would be all plain sailing. Because everything was obviously going as planned, we could go for a long refreshing walk around the interesting back streets of Darlinghurst. After her initial horror of deserting my father in his hour of need, we compromised and went for half-hour strolls, returning at regular intervals to that phone “just in case”. As the hours ticked by, and the phone remained silent, my mother increasingly let go of her worries, and was very well controlled by the time we were ushered in to see my still anaesthetised father in the recovery area. He looked very strange, trussed up like a Christmas turkey with tubes, and feeling to me very cold. It was then that the assistant surgeon explained the reason for the coolness, and the procedures of the operation. (This particular surgeon was one of a pioneering team for heart-lung transplants, so we were treated to quite a dissertation on the marvels of late 20 th century medicine). I might add that when I first saw my father after his operation, I went up to him, stroked him and told him in a raised voice (he always conveniently professed deafness, so I wasn’t going to take any chances!) that he had “made it !” I felt that it was important to let him know that everything was OK, and that there were no complications. I owed him that - the first hurdle had now been safely overcome. The next day when I visited him, and he was fully conscious, he remarked “I heard you. Thanks for letting me know that I had ‘made it’. I heard you loud and clear”. The next few days were plain sailing for my father. He gradually learned to move about the ward and it seemed like no time at all before he was packed off home. My parents then worked together on his physical fitness, but before long he was strenuously walking on his own about the local district. That habit remained until his death from an accident eight years ago, but my mother still walks daily. When Jeremy faced an imminent heart by-pass operation, Peter and I were introduced for the first time to the physical symptoms of heart disease, the medical complications of the operation, the psychological difficulties and the differences of medical practitioners and practices. In effect, by the time Jeremy was to have his major surgery, we too were ready. Our minds were convinced of the need and mode of the entire

38

operation, and we were convinced that Jeremy was making the correct choices. We, too, had to work our way through his sufferings, both physical and psychological, overcoming hurdles in our minds, so that we, also, were able to finally front up to the theatre door. In a very real sense, his dilemma was our dilemma. We had to work our own way through the denial of his condition in our minds - ‘How could someone of our vintage have heart disease?’, through the anger we felt at the unfairness of Jeremy being ‘struck down’, to the sadness that he had to undergo such a major ordeal. Amidst a collection of photos on Jeremy and Rhonda’s hallway wall is a picture of Jeremy as a toddler, peacefully asleep. I used to feel incredibly sad when I saw, or thought of, that dear little boy growing up unaware that he would have to face life threatening disease and major surgery when only half way through his life. My reaction on the day of the operation was as much a surprise to me, as to Jeremy and Rhonda. I arrived at the hospital just after he had received his pre-medication. Outwardly, he was calm, resigned to the imminent operation, but as I held his hand I could feel the fear and sadness, so overwhelming that I could not cope. By the time he was wheeled into the theatre I was out of control, and I am embarrassed to say, had to head for the nearest bathroom. For the rest of that day, I vomited. I staggered about the hospital between bouts, and was of no practical use or support to Rhonda whatsoever. Only when the anaesthetist came and told us that the surgical team were sewing Jeremy up, did the intense nausea ease, and after the surgeon told us that all had gone well, all feelings of sickness stopped. There was a tremendous feeling of relief that it was all over. We rang intensive care to check on Jeremy’s progress, but didn’t visit as we felt he was entitled to his privacy at that time, and knowing what he must look like, felt it best to keep his younger daughter, who was staying with us, away. (Kathleen had had an unpleasant experience in hospital, and seeing her father in intensive care at that time would have disturbed her). When Jeremy was placed back in his room Peter and I did visit him with Kathleen. He looked wonderful, and was obviously recuperating rapidly. Each day we were amazed at the progress that he was making. By the second day, he was even working on his laptop computer! Once released from the hospital there was no holding him back, and after his recent admission that he was running now as well as walking and swimming, we are quite convinced that he must be making a bid for the Sydney 2000 Olympics! So, how would I summarise the perspective of being the friend of someone undergoing major heart surgery? Basically, Peter and I can only feel the emotional tension, but wonder if we can offer much more. We can but listen, see and feel. I’m reminded of an incident when I was very young. It was Christmas, and Santa in his misjudgement had left two wheeled bikes for all my friends but had omitted me. Not to be outdone, I resurrected an antiquated, rusted, flat-tyred adult’s bike from beneath our house, and joined my friends on a Kamikaze race down a steep dirt road at the end of our street. Joy soon gave way to abject terror when it became apparent that I was leading the pack pedalling a brakeless monster. The judder of the crash that followed left me torn, bruised, and inconsolable. Hurt pride is a bitter pill to swallow. I limped home on my friend’s shoulder where I was consoled, bandaged, bathed, and fussed over. All the love and attention I was getting miraculously eased my sorrows, making me feel happy and loved in a hostile world. I would like to think that this is the sort of feeling that our true friends can always receive from us”.

39

GETTING TO YES, or BELIEVING THE INEVITABLE Mr Salter’s side of the conversation was limited to expressions of assent. When Lord Copper was right he said, “Definitely, Lord Copper”; when he was wrong, “Up to a point!” “Let me see, what’s the name of the place I mean? Capital of Japan? Yokohama, isn’t it?” “Up to a point , Lord Copper.” “And Hong Kong belongs to us, doesn’t it?” “Definitely, Lord Copper.” Evelyn Waugh, Scoop.

Many people placed in a life threatening situation will automatically place their faith entirely in the hands of the medical professionals and let them get on with vital surgery as soon as they are able. When people are suddenly confronted with the news that their life is at serious risk, and that immediate and major surgery is vital to survival, I believe that most people become numbed by the magnitude of what is ahead of them, and go into some form of mental shock. I had waited nearly thirty years for the inevitable to happen, yet when I experienced my first series of heart attacks my rational perspective seemed to completely shut down. If I had been offered an angiogram immediately following my admittance to Liverpool Hospital, I would probably have agreed to having it done. What I was unable to accept was having to wait for a week for a test which would probably confirm the need for major surgery. The longer I was forced to wait the harder it became to take the next step. Because of this, I believe that there is a psychological barrier which goes up in those critical first few days. Once the first window of opportunity was lost, I was unable to proceed. This may well have been a mistake, however it did allow me to go through the psychological difficulties associated with delaying surgery.

40

Not everyone is prepared to accept that they should have surgery. Ultimately, this is a personal choice. Advances in medical techniques are proceeding at such a rapid rate that it is hard to keep up. At one stage I rationalised (reasonably, I thought), that if I could hold off my surgery for four or five years, then I might not have to have open heart surgery. It is very possible that in five years from now very few heart operations will require open heart surgery. This will have a huge impact on survival and recovery. The two major killers are heart disease and cancer. I have experienced one but not the other. I had enough trouble coming to terms with my illness, which had a 98 % chance of being successfully reversed. Statistics can always be manipulated to suit; it is just as easy to say that my operation had a 2% chance of failure, which I saw as unreasonably high. I do not have any idea how people facing terminal illnesses such as malignant tumours are able to cope, yet in most instances they do. When my mother was diagnosed with having a malignant tumour in the brain, she learned that the chances of success were very slim. She made the conscious choice to not have an operation, and effectively chose to die. I now accept that this took an amazing courage which I certainly do not have. It is difficult to determine whether people agreeing to have major surgery are demonstrating courage or weakness. It may also not be too important where the truth lies. The will to live in most people is a very powerful factor in determining the course of peoples lives. The love and concern we have for our relatives and friends must also play a major part in the choices we make.

41

TIME FOR THE ANGIOGRAM When I had my angiogram I was most concerned about the pain I believed I would experience in my groin, as well as potential adverse trauma from the invasive surgery itself. I had a brilliant cardiologist who understood and empathised my concerns and needs. After all a 2% morbidity rate seemed unnecessarily high as far as I was concerned. My angiogram was done in a private hospital, and I was back home within six hours. I insisted on being heavily sedated, and I am delighted I took this choice. Rhonda stayed with me and watched the entire procedure. This achieved two things. Firstly, it boosted my confidence, and secondly, it allowed her the opportunity to understand at first hand what was going on, and indeed what would then come out of the exploratory procedure. What is a coronary angiogram? A coronary angiogram is a special x-ray of your heart’s (coronary) arteries to see if they are narrowed or blocked. It’s an important test used when your doctor suspects or knows you have heart disease. The test involves putting, under a local anaesthetic, a long thin tube (catheter) into an artery in the groin or the inside of the elbow. This tube is called a catheter, so the procedure is often called cardiac (heart) catheterisation. The tube is moved up the inside of the artery until it reaches the heart where a special dye is injected into the coronary arteries and x-ray pictures are taken. This gives detailed information about the state of the heart and coronary arteries. What is coronary heart disease? Coronary heart disease is a disease of the coronary arteries. These are the blood vessels which supply the heart itself with the blood it needs to keep pumping. When fatty deposits build up on the inside of these arteries they become narrower and less blood can flow through them. This can cause either chest pain (angina) or a heart attack. Angina usually occurs when the heart has to work harder than normal such as during exercise or emotion. The part of the heart supplied by the narrowed artery cannot get enough oxygen and the result is chest pain. With a heart attack, a narrowed artery suddenly becomes blocked completely because a clot forms at the point of narrowing. The part of the heart muscle supplied by that artery does not receive any oxygen and may be permanently damaged if the blood flow cannot be restored quickly. To treat angina and to try to prevent a heart attack, it’s useful to know where your coronary

42

arteries are narrowed are narrowed and how badly. Your doctor can then decide on the best treatment. Why is coronary angiography performed? There are several reasons why you may be having a coronary angiogram: • you may have chest pain which your doctor suspects is caused by narrowed coronary arteries but wants to be sure. • you may have definite angina and the degree of narrowing in your coronary arteries must be assessed to see if you could benefit from a procedure, such as Angioplasty or bypass surgery, to relive your symptoms • you may have had a heart attack. If you had treatment to dissolve the clot blocking your coronary artery or you have continuing chest pain or the results of an exercise test indicate the need for further investigation your doctor will need detailed information about your heart and arteries. Are there any risks involved? As with many medical tests there are some risks but serious problems are rare. Most people have no trouble and the benefits far outweigh the risks. You and your doctor should discuss any possible problems. Preparing for coronary angiography Most hospitals have a routine like this. • Before you come to hospital your doctor may arrange other tests to help assess your case. They may include blood tests, an electrocardiogram (ECG), an exercise test and a chest x-ray. • You will probably be admitted to hospital the night before or the morning of the coronary angiogram and stay for one day afterwards. In some hospitals some people are admitted and released from hospital on the day of the test. You will be asked to have nothing to eat or drink for four to six hours before the test. • When you are admitted to hospital a doctor will visit you to explain the procedure, give you a brief physical examination and answer any questions you or your family may have. You will be asked to sign a form consenting to the procedure. • You will be shaved in the area where the catheter will be inserted, asked to remove all jewellery and change into a hospital gown. Most people are given a sedative about an hour before the test to help them relax. You will, however, be awake throughout the procedure. The coronary angiogram Coronary angiograms are done in special laboratories (“cath-labs”) which look like operating theatres. You are taken there on a trolley or in a wheelchair and lie on a narrow table, which is moved from side to side during the test. You are also connected to a machine which monitors your heartbeat continuously. Many people have a small needle put into a vein in the back of one hand to allow medications to be given during the test. The doctor injects a local anaesthetic into your groin or arm and if the arm is used makes a small cut. The catheter is inserted into the main artery there. Local anaesthetic is used because you need to be awake during the test to follow the doctor’s instructions. The catheter is moved through the main blood vessel of the body (the aorta) to the beginning of the coronary arteries on the heart. Its progress is watched via x-ray pictures shown on a television screen. Most people don’t feel any pain or sensation during the test. There are no nerves inside the arteries so you can’t feel the movement of catheters through the body.

43

When the catheter is in place a small amount of x-ray-sensitive dye is injected into it. X-ray pictures are taken as the dye travels through the coronary arteries. These pictures are shown on a television screen and recorded on film. Different catheters are needed to study the various arteries. One is removed and the next introduced through the same place in the groin or arm. Some people have nausea or chest discomfort when the dye is injected but this doesn’t last long. A larger injection of dye is given if the heart muscle is being examined. This may give a warm feeling in the upper chest first, then over the rest of the body. The feeling lasts for about 10 to 15 seconds. The whole test takes about 30 to 40 minutes. The catheter is removed and pressure applied to the area where it was inserted. A few stitches are needed if the arm was used. You will be moved to the ward or recovery area to rest in bed for at least four hours. In some circumstances you may be allowed home after four to six hours. Most people stay overnight to make sure no bleeding occurs where the catheter was inserted. Some people need to stay in hospital longer for further monitoring of their symptoms. What happens afterwards? Your doctor will explain the results of the test. The information about the heart and coronary arteries will be used to decide your future treatment. Treatment for coronary heart disease Depending on the amount of disease in the artery, treatment for coronary heart disease usually includes at least one of the following: medication - this can either slow the heart rate, widen the blood vessels, lower the blood pressure or relieve the pain of angina. This lessens the heart’s workload and in some cases is the only treatment required. coronary angioplasty - this improves blood flow to the heart by using a special balloon to open out the narrowed artery in a procedure very like the coronary angiogram. Bypass graft surgery - a healthy section of blood vessel from the chest or leg, or from the inside of the chest wall, is grafted to the coronary artery beyond its most diseased part. The blood can then detour past the narrowing. What you can do to help It’s important to realise there are treatments, not cures, for coronary heart disease. The best way to cut the risk of further disease is to tackle the ‘risk factors’ which contribute to it. Changing to a healthy lifestyle is good for everyone, not just those who know they have coronary heart disease. Stop smoking. Smoking reduces the amount of oxygen in your blood and damages and weakens the artery walls. To stop smoking is the single most important thing you can do to reduce your risk of further coronary heart disease. East less fat, especially saturated fat. A diet high in saturated fat can raise blood cholesterol. High blood cholesterol is the main cause of deposits which build up on the artery walls and produce disease. You can lower your cholesterol level by eating healthily - lots of fruit, vegetables and cereals, more fish, poultry and lean meat and less fatty foods. Exercise regularly and keep to a healthy weight. Lack of exercise and overweight are both risk factors for coronary heart disease. Regular exercise can help lower cholesterol and blood pressure levels and helps control your weight. Your doctor can advise on the best exercise program for you. Control blood pressure. High blood pressure can strain your heart and also speed up the process of coronary heart disease. Have regular blood pressure checks. If your

44

blood pressure is high follow your doctor’s advice about diet and exercise and take your medication, if prescribed.

LIVING WITH ANGINA Thousands of Australians have angina and have learnt to live full and productive lives. Advances in treatment also mean much can now be done for the condition. What is angina? Angina is temporary chest pain or discomfort caused by a reduced blood supply to the heart muscle. The pain usually feels tight, gripping or squeezing and can vary from mild to very severe. Many people, however, don’t feel any pain - just an unpleasant sensation or discomfort in the chest. Angina usually comes on during exercise or emotion. It doesn’t occur all the time because the blood supply, although reduced, can usually keep up with the normal demand. Angina is usually felt in the centre of the chest, but may spread to either or both shoulders, the neck or jaws, or down the arm. It can even be felt in the hands and can sometimes occur in those other areas without being felt in the chest at all. If brought on by exercise the pain or discomfort usually goes away after a few minutes rest. Angina can affect different people in different ways or you can have different symptoms at different times. You may get the pain early in the morning only. Or you may get it at rest, even while sleeping. Many people tend to get it in cold weather or after a heavy meal. What causes angina? Your heart is a muscle which keeps blood flowing to all parts of the body through the blood vessels. To do its work properly the heart itself must have a good blood supply. It gets this supply from its own two special arteries, the coronary arteries. If the coronary arteries become clogged, blood flow is reduced and the heart can’t meet the demands on it to pump harder during times of exercise or stress. This can lead to angina or even a heart attack. This artery clogging process is called atherosclerosis and causes fatty deposits to build up on the inner walls of the arteries. The artery-clogging process probably starts in childhood and builds up gradually over the years. It’s usually not until middle age or later that the coronary arteries can become so narrowed as to cause angina or a heart attack. The primary cause of the artery clogging is: • a high blood cholesterol level. 45

• • • •

This is common in countries like Australia, which have a diet high in saturated fats. High blood cholesterol is one of the three main risk factors for heart disease. The other two are: cigarette smoking high blood pressure. Both can contribute to atherosclerosis and make its effects worse. A further two risk factors are: being overweight not enough physical activity.

Being male and having a family history of early death from heart disease are other major coronary risk factors which are beyond our control. In these cases you need to be more careful about reducing other risk factors which you can do something about. In many instances, women have arteries which are considerably narrower than those of men. Women also usually have the benefit of considerably lower levels of blood cholesterol during their child-bearing years. This often changes dramatically soon after menopause, and the build up of cholesterol can then be extremely rapid. Twice as many women suffer complications following heart surgery than men. Younger women should certainly not be complacent about their own health, particularly if they smoke, are overweight, eat fatty foods, or “snack” from the refrigerator. Stress may bring on angina if you already have clogged arteries but there is little hard evidence that it contributes to atherosclerosis itself. Men are not the only ones who suffer from this condition. Does angina damage the heart? Angina doesn’t mean that your heart muscle is damaged. It’s not a heart attack, which is caused by a blood clot blocking a narrowed artery and cutting off part of the blood flow to the heart muscle. Many people with angina live to a healthy old age without having a heart attack. Angina can interfere with an active life if it’s not treated effectively and because of the clogging of your arteries you have a bigger risk of a heart attack. How is angina diagnosed? Your doctor will usually suspect angina just from the symptoms you describe. You will be asked about smoking, your diet and family history. Your doctor will measure your blood pressure, listen to your heart and chest and assess your general condition. You may have some special tests, including an ECG (electrocardiogram), a chest x-ray and perhaps an exercise stress test. Can angina be cured? Although the symptoms can be treated this doesn’t mean the underlying clogging has been improved. But there are now hopeful signs that cholesterol lowering with medication or healthy lifestyle changes can slow and even reverse the clogging process in some cases. Living with angina Medical treatment and a healthy lifestyle mean much can now be done for your angina. You and your doctor should consult regularly about your angina and treatment and agree on a management plan. Medication Tablets can rapidly stop angina once it has come on. The most commonly used drug is Nitro-glycerine - mostly known as Anginine. A Nitro-glycerine spray is available as an alternative to the tablets. You may prefer this. Two sprays into the mouth will relieve angina quickly in most people. In some cases isosorbide dinirate (Isordil) may be 46

preferred. Anginine is absorbed in the blood stream from the lining of the mouth. The tablet should be chewed and the pieces slowly dissolved in the mouth. It doesn’t work if just swallowed. Isordil tablets are also dissolved in the mouth (Isordil can also be used in longer term prevention of angina). Both drugs improve the blood flow through the coronary arteries and also lower the heart’s demand for oxygen. They usually bring relief within a few minutes and should be carried at all times. As soon as you get an episode of angina stop and rest immediately and take a tablet. It’s best to find the smallest dose that usually works for you, whether it’s a full tablet, a half or even a quarter. Side effects* Anginine may cause a tingling or burning feeling in your mouth. You may also get a headache or a full feeling in the head or a slight hot flush feeling. These are normal reactions and will pass. If your headache is severe try using a smaller dose next time. *New drugs have been developed which are designed to overcome side effects and be more specific in their treatment. Anginine (and Isordil used in the same way) temporarily lowers the blood pressure. You may feel a bit faint if you’re using it for the first time or using too large a dose. If you feel dizzy lie down immediately and remove whatever is left of the tablet in your mouth. You should do this even if your chest discomfort remains. You may need to use a smaller dose next time to avoid faintness. Despite the drug’s side effects, it’s safe to take several tablets a day if needed. Storing your tablets Anginine tablets lose their effect if they’re too old or left exposed to warmth, light or air. • Keep them stored in the refrigerator. • Carry them in a dark glass bottle or a metal pill box. • Don’t throw out the specially treated cotton wool packing in the bottle. • Don’t carry them in plastic bottles or all-plastic pill boxes. Anticipating an episode If you know when an episode of angina is likely to come on, use your tablets to prevent it. Take a tablet just before the situation likely to bring on the pain - such as a walk in cold weather or some stress which you can’t avoid. If you take Anginine only as needed, you will not build up any resistance to it. Making angina less frequent and severe A range of drugs can help reduce how often you get angina and its severity. The drugs work in different ways and you may need to use them in combination. The use of more than one drug can be complex and all medication should be discussed with your doctor. Long-acting nitrates These drugs, which include Isordil, are related to Nitro-glycerine. They can be absorbed from the stomach instead of the mouth and so have a longer effect. For longterm action, Isordil must be swallowed three or four times daily. Up to eight or twelve tablets a day may be needed for the best effect. A new tablet called Imdur (isosorbide mononitrate) can be used once a day. Special Nitro-glycerine patches to let the medication be absorbed through the skin can also be used. The patches can be placed anywhere on the skin. Some people can have 47

skin reactions if the patches are left in the same place for too long, so it’s best to move them around. The patch should be removed for at least eight hours out of every twenty-four, so that your body can’t build up resistance to its effects. Overnight is a good time to remove it unless you get angina at night. In that case the patch should be removed during the day. Sometimes the patch is prescribed not only for angina but in some cases to help the heart work better. You should discuss this with your doctor. Beta-blockers Beta-blockers reduce angina by acting on the heart and blood vessels to reduce the heart’s work. Common examples are Inderal, Betaloc, Lopressor, Tenormin and Trasicor. These drugs can have side effects which must be balanced against the benefits in each case. Beta-blockers can make asthma much worse and should be avoided if you’re an asthmatic. Calcium channel blockers Calcium channel blockers help in several ways. They open out the narrowed artery as much as possible and they affect the chemical activity of the heart muscle cells. Isoptin, Cordilox, Adalat and Cardizem are common examples. Beta-blockers and calcium channel blockers are also used to lower blood pressure and are useful for people who have both angina and high blood pressure. Your doctor will work out the best drug or drug combination for you. What about aspirin? Small doses of aspirin are usually prescribed for people with heart disease. This is because aspirin can reduce the risk of heart attack by helping prevent clots forming in a narrowed artery. Aspirin can worsen stomach or duodenal ulcers and should be avoided if you have active ulcers. Looking after yourself Dealing with angina is not just a matter of dealing with the pain. Lifestyle changes such as stopping smoking and losing weight can sometimes be enough on their own to keep you free of angina. Be a non-smoker Smoking is a major risk factor for heart disease and many other diseases including cancer. It doubles the risk of heart attack. There is no safe level of smoking. If you smoke your doctor will strongly advise you to stop if you want to give yourself a fair chance of recovery and future health. Once you stop smoking the extra risk is reduced quickly and the heart benefits may appear as early as three to six months after quitting. Keep a check on your blood pressure High blood pressure can be a time bomb. It rarely causes symptoms until it has lasted long enough to cause a heart attack, stroke or heart failure. That’s why blood pressure must be measured regularly by your doctor and treated if it’s high. An important part of blood pressure control is keeping to a good weight, being physically active and following a healthy diet - which includes going easy on alcohol, salt and salty foods such as soy sauce, canned soups and vegetables and savoury sauces. Watch your cholesterol level High blood cholesterol is the most important underlying risk factor for atherosclerosis. Have your doctor check your cholesterol level at least every six months if you have heart trouble. A diet that is high in saturated fat can be a major cause of high blood

48

cholesterol. Being overweight also tends to raise blood cholesterol levels and blood pressure. Keep to a healthy weight Losing weight helps to reduce the severity of angina symptoms and improve your long term health. This may be difficult if angina stops you from exercising. In this case you will have to consider your diet very closely and cut down on high calorie foods. A dietician can give you valuable support with this. Exercise regularly Exercise can be specially helpful for angina because trains the heart and muscles to work more efficiently. The heart then needs less oxygen to handle exercise. This means you can become more active without bringing on angina. Exercise doesn’t have to be hard or time-consuming to be of benefit. Naturally the sort of exercise you do must be guided by any pain you get and your general condition. You should build up your exercise level gradually under your doctor’s supervision. A regular brisk walk is one of the safest and best ways to exercise. Golfing, gardening, swimming, cycling and tennis can all be good forms of exercise. What if your condition gets worse? If your episodes of angina occur more often, last longer or don’t respond as well to tablets, contact your doctor promptly. You should also discuss any other symptoms with your doctor, such as swollen feet or cold limbs. If a tablet and rest don’t relieve an episode within five to ten minutes take another tablet. If the pain is still there after another five minutes treat it as a heart attack. Get straight to the nearest hospital - by ambulance if immediately available, or by car (someone else driving) if not. If it turns out you haven’t had a heart attack, it was better to have been safe than sorry. Any unusually prolonged pain, even if goes away, may signal a mild heart attack. Common questions about angina Q. How can I tell the difference between angina and a heart attack? A. Angina pain typically comes on with exercise and goes away after a few minutes rest. It’s also relieved by Anginine or Isordil. A heart attack can occur at rest or any time, the pain lasts much longer and is often more severe and if it’s not relieved by Anginine or Isordil. Nausea is much more common with heart attack than it is with angina. It can be difficult to tell the two conditions apart, however, particularly when the pain has only been going for a minute or so and when you may be frightened that this time it’s the ‘real thing’ - a heart attack. You’ll probably learn to recognise your angina if you’re unfortunate enough to get the pain often. Q. Can I be sexually active when I have angina? Yes, most people with angina can be sexually active without danger. This is particularly true for someone whose angina is well controlled with treatment. Sexual activity places a greater strain on the heart so if angina tends to occur during lovemaking you and your partner may need to find methods that are less strenuous. Q. Can I continue with my employment? A. Yes, most people who’ve had angina can continue with their usual form of work after treatment. There is no medical barrier to working in most cases and it often depends on how much you want to continue working. For some people the job may have to be adjusted to avoid too much physical or emotional strain.

49

Q. What about alcohol? A. There’s usually no reason why you shouldn’t drink alcohol but keep it to no more than two drinks daily. Excessive alcohol use is harmful, especially if you have high blood pressure or have not achieved a healthy weight.

HIGH BLOOD PRESSURE

50

High blood pressure rarely gives you warning signs and can be a silent killer unless it is measured regularly and treated by a doctor. The Heart Foundation recommends that all adults should know their own blood pressure level and what it means for their health. If it is not controlled, high blood pressure can overload the heart and blood vessels and speed up the artery-clogging process known as atherosclerosis. This can lead to a heart attack, stroke, heart failure and kidney failure. High blood pressure is one of the three main risk factors for heart attack and is the major risk factor for stroke. The other two are high blood cholesterol and cigarette smoking. Doctors can detect high blood pressure early and treat it better. This is probably one reason why there has been such a big fall in early deaths from heart attack and stroke over the past 25 years. What is “blood pressure”? “Blood pressure” is the pressure of the blood in your arteries as it is being pumped around the body by the heart. Your body needs oxygen and nutrients. These are carried in the blood-stream to all cells through a system of “pipes” – the blood vessels. As well as pumping blood, the heart continuously collects “used” blood from the body, sends it to the lungs for more oxygen, then pumps the oxygen-rich blood back out again. There are two kinds of blood vessels – arteries and veins. Arteries deliver blood from the heart to the body’s cells, and the veins carry the blood back to the heart, the entire system of the heart, blood vessels and blood is known as the circulation, or circulatory system. Arteries are strong and elastic so they can handle the pressure of the blood pumped through them. They branch out into smaller arteries which have special muscles in their walls and play an important part in controlling blood pressure. How blood pressure is measured As the heart pumps, the flow of blood in the arteries rises and falls in a regular “wave” pattern. Blood pressure peaks when the heart pumps (called systole) and falls when the heart relaxes (diastole). Blood pressure is measured by wrapping an inflatable pressure bag around the upper arm. The bag is connected to a pressure measuring device containing mercury. The entire instrument is called a sphygmomanometer. As the doctor pumps up the bag, the mercury rises. The bag squeezes the artery so no blood flows through it. When air is released from the bag the pressure slowly falls. The doctor watches the mercury fall and listens over the artery with a stethoscope. When the falling pressure in the bag just equals the peak pressure in the artery (systolic blood pressure), the heartbeat forces some blood through the artery. This causes a regular thumping sound. As soon as the thumps begin, the doctor checks the mercury level reading. This is recorded as systolic pressure. The thumps continue until the pressure falls to equal the lowest pressure in the artery, when the sounds fade away. The doctor then takes another reading. This is recorded as diastolic pressure. If your systolic blood pressure was 120 millimetres of mercury and your diastolic was 70 your doctor will record it as 120/70. Other machines which can be used at home can make it easier to measure blood pressure, but these machines are still checked for accuracy from time to time against the sphygmomanometer. How blood pressure varies Blood pressure varies from moment to moment. It will be affected by all sorts of things - body position, breathing or emotional state, exercise and sleep. It is usually lowest when we are asleep and higher if we are excited, stressed or exercising. Temporary rises are quite natural and blood pressure will return to normal when we rest. These constant changes can make it difficult to get a “true” blood pressure picture and your doctor may measure your pressure several times. Try to relax when it is being measured. Anxiety can make blood pressure rise temporarily and give a falsely high reading.

51

What is high blood pressure? There is no “ideal” blood pressure reading. But the following figures can be a guide: Normal less than 140/90 Borderline between 140/90 and 160/95 High more that 160/95 Very high more than 180/110 The medical term for high blood pressure is hypertension – not to be confused with nervous tension, which is quite different. In societies like ours, older people tend to have higher blood pressure. A rise with age is not inevitable, and high blood pressure in an older person should be considered carefully and treated appropriately. How does high blood pressure develop? Blood pressure depends on two main things – the amount of blood pumped by the heart and how easily the blood can flow through the thousands of small branch arteries. Muscles in the walls of these small arteries are important in controlling blood pressure. When an artery tenses, the channel inside narrows. When it relaxes, the channel opens out. The narrower the channels, the harder it is for blood to flow through them, and the higher the blood pressure. It is like the pressure that builds up in a garden hose if you shut the nozzle. Nerves, special chemicals in the body, or hormones in the blood also affect the strength and rate of the heartbeat. Why does blood pressure stay too high? We don’t know for sure. Normally, the blood senses temporary changes in blood pressure and sends messages to the brain to keep the pressure within healthy limits. If the blood pressure stays high for long enough the system adjusts to a higher level. What made the blood pressure high to begin with? Again, we are not sure. It may begin when the heart pumps more blood, increasing the volume in the arteries. In about one case in 20 a medical condition such as kidney disease is the cause. Birth control pills, steroids, and anti-inflammatory drugs can also raise blood pressure. Family history and lifestyle seem to influence high blood pressure in most people with the condition. If one, or both, of your parents has high blood pressure, you are more likely to develop it too. Diet, alcohol, weight and physical activity also seem to have a strong influence. What harm does high blood pressure do? The heart, brain and kidneys can resist higher pressure for long periods. That is why people with high blood pressure usually feel perfectly well for years. But that does not mean it is not damaging them. The higher the blood pressure, the harder your heart must work. If high blood pressure is not treated, the heart becomes too weak for this extra demand and cannot do its job properly. This may cause congestive heart failure, with tiredness, shortness of breath and maybe swelling of the feet and ankles. High blood pressure may also cause the arteries to clog up faster. This can lead to a heart attack or stroke if the arteries which supply blood to the heart or brain become clogged. Stroke can also occur when high blood pressure exposes weaknesses in the blood vessel walls of the brain. As well as being a major risk factor in heart and blood vessel disease, high blood pressure may also affect arteries to other parts of the body such as the eyes, kidneys and legs, and in the long-term seriously damage the kidneys. How do you know you have high blood pressure? Because high blood pressure usually has no warning symptoms, the Heart Foundation recommends you have a blood pressure check every two to five years, and during each routine visit to your doctor. If your blood pressure has been high in the past, or is still high, you should have it checked more often. How can you prevent high blood pressure?

52

One of the most important ways is to have regular checks. As a general rule, the milder the problem the easier it is to bring your blood pressure back to normal before it causes any damage. Controlling high blood pressure Many people need drugs to control high blood pressure, but others can reduce it – or lower the doses of drugs needed – with lifestyle changes alone. Your doctor will probably advise you to adopt the following lifestyle changes, even if you are put on tablets. A healthy diet A healthy diet is particularly important in controlling high blood pressure and reducing your risk of heart disease. There are no strict rules or magical potions. Healthy eating starts and finishes with “balance” and “variety”. This includes eating foods low in salt and drinking alcohol in moderation. Control your weight Controlling your weight is an important step to reducing your risk of developing high blood pressure. Being overweight puts a strain on the heart. If you have high blood pressure, losing excess weight will help control it – sometimes even drug treatment becomes unnecessary. Salt Most Australians eat more salt than they need. This salt comes mainly from processed foods. A high salt diet is linked to blood pressure. If you have high blood pressure, salty foods can also interfere with your control of it. Eating more fresh foods and choosing “no added salt”, “low”, or “reduced salt” processed food is best. The Heart Foundation’s “tick of approval” is a guide to foods that are relatively low in salt. Alcohol Excess alcohol can increase high blood pressure. If you drink three or more glasses of alcohol a day you are more likely to develop high blood pressure. If you are taking tablets for high blood pressure, alcohol can reduce their effectiveness. Less than two drinks of alcohol a day is advised. Physical activity Having high blood pressure does not mean you are an invalid in any way. On the contrary, exercise should definitely be part of your daily program. Try walking, swimming, cycling or games such as tennis and golf. Avoid more strenuous exercises such as body presses and lifting heavier weights, which can actually raise blood pressure too much while you are doing them. Ask your doctor about the best kind of exercise program for you. Drug treatment There is a variety of drugs to control blood pressure. If you need them, your doctor will start you on a small dose of drug and note its effect. If necessary, the dosage will be gradually increased, or other drugs used, until your blood pressure is well controlled. Two different drugs are often used to keep any side effects to a minimum. Once you start drug treatment you will probably have to continue for the rest of your life. The drugs control high blood pressure, not cure it. They will not “build up” inside your body, and the longer you are on them the better they will work. You should always carry a list of your drugs and their doses with you. Side effects Blood pressure tablets may cause side effects, but these can be kept to a minimum by adjusting the type of drug and dose. You must tell your doctor about any side effects and their severity. Drugs for blood pressure are effective and their benefits far outweigh the problems that can occur. Most people don’t have any side effects and can live a normal life style by working in partnership with their doctor.

53

Be a non-smoker Your doctor will strongly advise you to give up smoking. Smoking does not cause high blood pressure but it can make it more harmful, leading to heart attack, stroke and gangrene of the legs, and other damage. Once you stop smoking the extra risk is reduced quickly. Help yourself Keep doctors appointments. Your doctor will probably advise you to have your blood pressure checked regularly, maybe weeks or a few months apart. It’s important to keep appointments as your blood pressure and drug dosage need constant monitoring. Your doctor may advise you to monitor your own blood pressure at home with a device you can buy from a chemist. Take your blood pressure tablets as directed. If you think a drug is not agreeing with you, tell your doctor exactly how you feel. Your treatment will be adjusted and side effects minimized. Follow medical advice about diet, exercise and smoking. Make a strong effort to lose excess weight, switch to a healthy eating pattern, and exercise regularly. Even though it’s a team effort, you can do more than anyone else to bring your blood pressure under control – and keep it there. Common questions about blood pressure Q: Where should I have my blood pressure checked? A. It is best to have your blood pressure checked initially during a routine visit to your doctor, community healthy centre, hospital centre or hospital clinic. Your results will be assessed in relation to your age, family history and other factors such as cigarette smoking and high blood cholesterol. You may be referred to a specialist physician or clinic. Q: Why is my blood pressure measured several times in one visit? A. Several measurements are needed because blood pressure varies from moment to moment, depending on the position of your body, your breathing, your emotional state or level of exercise. The doctor may measure your pressure several times to get a “true” reading. Try to relax when your blood pressure is being measured. If you are anxious or nervous your blood pressure can rise temporarily and give a falsely high reading. Q: How often should my blood pressure be measured? A. If your blood pressure is “normal” and you have no history of the condition, we recommend a check every two to five years, or during routine visits to your doctor. If it is “borderline”, or you have a history of high blood pressure, it is best to have it checked more often – about every three to 12 months. If your blood pressure is high on several occasions it is important to have it checked often, especially if your doctor has prescribed medication. Your doctor may want to see you every two weeks until your blood pressure is controlled, and then every one to three months until it is stable. Q: Can I tell if my blood pressure is too high? A. You cannot tell unless you have it measured regularly. The serious effects of blood pressure usually develop only after it has been high for some years – in the meantime there are often no symptoms to warn you. Generally, the milder the blood pressure problem the easier it is to bring back to normal. Regular checks allow early detection of any consistent rise in blood pressure before it reaches severe levels or causes any damage. Q: Can I lower my blood pressure without taking tablets?

54

A. Two out of five people with mildly raised blood pressure can lower their blood pressure to normal levels by losing excess weight, cutting down on salt and alcohol, and exercising. These are called “non-pharmacological” methods. If you try these, you will still need your doctor’s continuing help and supervision. In most people, however, medication is needed to reduce blood pressure to safe, controlled levels. Your doctor will make every effort to find the most suitable drug or combination of drugs for you. Even if you do need tablets, changing your lifestyle as we have described will probably mean you can take a lower dose. Q: How long do I have to take the tablets? A. Unfortunately, the drugs available do not cure high blood pressure, only control its level. Most people with the condition have to keep taking tablets over a lifetime. The medication won’t build up in your body, and the tablets actually work better the longer you take them. Q: What can I do about side effects? A. Side effects of medication vary from person to person, and sometimes cannot be avoided. If a drug has unpleasant effects your doctor can change the dose or give you another drug. You must tell your doctor about any side effects, especially in the first stages of treatment until it is determined what is the best medication for you. If your suspect your medication has caused a serious side effect, stop taking it and see your doctor immediately.

BYPASS SURGERY To the patient with coronary artery disease Coronary artery bypass graft surgery (CABG) is a very common and successful way of restoring health and vigour to people with coronary artery disease. What is coronary artery disease? This is a disease of the arteries that surround the heart and supply blood to the heart muscle. When those arteries become partly blocked by fatty deposits (atherosclerosis), this is called coronary artery disease. The blockage of the coronary arteries can reduce the amount of blood reaching the heart muscle. This may lead to bouts of chest pain called angina, or to a heart attack.

55

Why do I need CABG? Your cardiologist will have recommended CABG after assessing your symptoms and your coronary angiogram – a special x-ray of your heart’s arteries to see if they are blocked or narrow. The operation will either be to improve or remove angina and/or to help you live longer. Angina is a pain or discomfort usually felt in the chest, which is a symptom that the heart is not getting enough oxygen to meet its demands. How does CABG help? The bypass grafts improve the blood supply to the heart muscle, allowing it to function better and preventing angina. What is CABG? This operation bypasses the narrowed areas in the coronary arteries to allow blood to get to the heart muscle. The bypass is constructed from either an artery from inside your chest (the internal mammary artery) or veins from your leg. Sometimes bypasses are obtained from other areas too. The vein grafts need to be connected to both the aorta (the main artery leading from the heart) and the coronary artery, whereas the internal mammary artery is usually left attached to its inflow arterial supply and the end sewn onto the coronary artery. The bypass is sewn to the coronary artery beyond the narrowed part. How does CABG help? The improved blood flow resulting from the operation should mean a better quality of life: • Less or no angina • Less need for tablets • You can be more active. It may also help you live longer as well as better. How do I prepare for CABG? You and your family should find out as much as you can about the operation itself, your time in hospital and how to recover and return to normal living. It will help you make the most of the operation and reduce any worries (which are quite understandable). Feel free to discuss the details and any worries with your doctor and the medical team involved in the operation. The more you know about and understand the operation the less anxious you may feel about it. The hospital may run a “briefing” clinic for patients about to have surgery. This may be held a week or so before the operation and last a few hours. The clinic helps you learn about the operation and plan for it, and reduces the time you have to spend in hospital beforehand. What other arrangements are there before going into hospital? All efforts are made to reduce the need for a blood transfusion arising from the surgery, but some patients will still need one. You may be asked to donate some of your own blood in case it is needed during the operation. Arrangements must be made to do this some weeks beforehand. You may also be given a diet that builds up your iron levels. A week or so before the surgery you may also be taken off any medications that raise the chance of bleeding. When will I go into hospital? Usually you will go into hospital the day before to get ready for surgery and to meet the medical team of surgeons, cardiologists, anaesthetist, nurses and therapists that will care for you during and after the operation.

56

A friendly but strong warning about continuing to smoke If you smoke you will be very strongly advised to give up before your surgery. This will put your lungs in much better shape for the operation. Some surgeons may refuse to operate is you cannot stop beforehand because of a much greater risk of problems. Even when you do stop, the surgeon may not be prepared to operate until you have been smoke-free for at least six weeks. You will also be strongly advised not to start smoking again after your surgery. If you do, there is much more risk you will need a second operation fairly soon. What happens during the operations? The surgeon cuts down the midline of your chest, through your breastbone, to reach your heart. During surgery your body will be kept cool to protect vital organs by slowing down their working rate so that they need less oxygen. A heart-lung machine takes over the function of your heart and lungs. If you need a blood transfusion, all blood products used for transfusion in Australia are strictly screened to protect patients against hepatitis and AIDS viruses. In some cases, arrangements can be made before the operation for you to donate some of your own blood in case it is needed during the operation – though this isn’t always possible if the aortic valve is damaged. If you object to having blood transfusions, please tell your doctor and surgeon before surgery. It’s important to discuss this with them. What happens straight after the operation? After the operation you will be taken to a recovery area or intensive care unit for close supervision by nurses until you wake up from the anaesthetic. You will probably stay in the intensive care unit for one or two days. When can I start eating again? After the operation a breathing tube is put into your windpipe, after you have been given an anaesthetic. The tube is usually removed within eight to 24 hours, and most of that time you will have been asleep. After that you will be able to swallow a small amount of liquid, building up to foods over the next couple of days. How active can I be? This will depend on your recovery. At first you will probably start just by sitting in a chair or walking around the room. Later, there will be short walks in the corridor and, eventually, stair climbing and brisk longer walks to prepare for home. Sponge baths are given right away, and within a few days you will be able to take a shower and wash your hair. Will I feel pain after the operation? You will probably feel quite sore, especially the first few days after the operation. Painkillers will be given regularly to ensure you don’t get severe pain. If the pain starts to build up, tell the nurse sooner rather that later. You and your nurse are a team that needs to communicate and manage your pain together. The soreness can be helped by sitting and moving your arms and shoulders frequently. Pain relief won’t get rid of all pain, but it can control it. The stronger pain-killing drugs are needed for only a few days, so there is very little risk of becoming addicted to them. What about healing? Soon after the operation the chest wound is exposed to the air, which lets it become dry. After a few days the wound can be cleaned. Sometimes wire or special strips of tape are used to hold the breastbone together. These do not need to be removed. It

57

takes about six to 12 weeks for the breastbone to heal completely. During that time you shouldn’t lift anything heavy. How long will I have to stay in hospital? This varies depending on your condition and response to surgery. On average it’s about six to nine days. Before you leave hospital follow-up appointments will be made for you to discuss your medications, wound care, and activities. Your cardiologist will continue to oversee your cardiology needs and your first outpatient appointment will usually be two to four weeks after you leave hospital. About four to six weeks after leaving hospital you will see your surgeon, or a member of the surgical team. You may have an x-ray at this time and a doctor attending you will check your wound and general progress. Getting back to normal Normal recovery from heart surgery takes four to six weeks. During this time you begin to strengthen your muscles and return to your usual activities. Some hospitals run outpatient rehabilitation programs. These continue the gradual increase in activity you began in hospital. After major surgery, such as heart surgery, the time for recovery may seem to pass slowly. Your body has been slowed down by the lowered activity, lack of good sleep, the medications and surgery itself. You may feel drained, physically and emotionally. When can I start exercising again? Once you are at home, start your activities at the same pace you started them in the hospital. Increase then gradually each day. Others in your family may want to over protect you and keep you from doing what you can do. You can help them by sharing this book and letting them be involved in your hospital rehabilitation program, which will show them how much activity you can stand. Use common sense. Set realistic goals for yourself. You don’t want to overdo it, but you don’t want to be totally inactive either. Rest when you are tired, and change an activity if it is making you very tired. Doing too much at this time won’t injure the heart. It will, however, make you very tired. If you have pain or a slight clicking or movement of the breastbone during your exercise, go easy on the heavy arm exercises for a while. The clicking is caused because the breastbone is still slightly unstable. This should stop in four to eight weeks, but if it continues let the surgeon know. When can I return to work? This decision is usually made after your four-to-six week check up. It will depend on your type of work and its demands, your strength, and other medical information. Office workers can usually return to work in six weeks. If you are involved in heavier work you should return on your surgeon’s advice. What should I be eating? A healthy diet is recommended for everyone, but especially if you have heart disease and are recovering from an illness. All fats and oils should be used in small amounts, but you should avoid saturated fats which are found in foods like butter, fatty meats, full-cream milk and cheese, cream, coconut products, pastries and biscuits. Grilling, microwaving and dry oven baking are ideal ways to cook. Choosing reduced fat dairy foods, lean meats and a wide variety of fresh vegetable and fruits and breads and cereals will ensure a healthy balanced diet.

58

What if I get pain at home? As you become more active you will get some pain associated with the wound or muscles in your chest, shoulder, neck and back. Continue to take your pain-relieving tablets such as Panadol and Panadeine when you need them. You will be able to reduce these gradually. Palpitations Many people have palpitations – thumping beats or fluttery feelings – after operations. Usually this is not serious. But if you notice it a lot or it lasts a long time, then contact your doctor. Don’t neglect any type of severe pain! Why am I so tired? Tiredness is very common after surgery, and it’s important to rest. Have a one to two hour rest in the afternoon. Even if you don’t sleep, lie down and read a book or listen to relaxing music. Try to get eight to ten hours of sleep a night. It’s important that you are free of pain when you go to bed to ensure a good night’s sleep. You might find if helpful to learn relaxation techniques or listen to tapes. You shouldn’t have too many visitors in the first weeks at home. Don’t let them stay any longer than an hour. And no more than two visits a day. Sometimes you may get breathless on exercise. This is to be expected but, if it continues after you have rested, or is associated with heart “flutters” or severe chest pain, contact your doctor. Why do I feel great one day, dreadful the next? “Up” and “down” days after surgery are normal. The best way to overcome this is to plan something interesting each day. But don’t plan too far in advance. Don’t alter your normal lifestyle too much either. Get out of bed at the usual time and dress in day clothes. You might also have trouble with your memory and concentration in the first few weeks after surgery. This will improve steadily and should not be a problem. What if I’m constipated? Unfortunately, many pain-relieving tablets can make you constipated. The best remedy is to eat foods such as bran, seeds, fruit and vegetables. Follow your exercise program. Exercise helps promote regularity. When can I have sex? If you can climb one flight of stairs without getting chest pain or shortness of breath you will probably be able to cope with the amount of energy required for sex. Avoid sex after eating a large meal, drinking alcohol or when very tired. You may find some positions more comfortable than others due to discomfort of your chest wound. Don’t try to make the first occasion after surgery a “command performance”. Questions for your doctor Heart surgery is a major event in your life and you should ensure you’re well informed about the need for surgery, its benefits, and any possible complications. Here are some questions you may want to ask your doctor: • What benefits will I get from the surgery? • Are there any risks or complications? • Will I need a blood transfusion and can I donate blood for myself? • How much will the operation cost and how much will be covered by insurance? • Is there a place nearby for my partner to stay while I’m in hospital?

59

• •

If you’re a country patient – How long do you want me to stay in town after my discharge? How often should I have follow-up visits?

WHAT YOU PROBABLY WON’T BE TOLD The traditional, and not necessarily ideal, method of coronary arterial graft is done by cutting a suitable large vein from one or both legs (or arms). What the cardiologist may not tell you is that not many surgeons (in 1998) have the skills necessary to avoid this type of surgery and take advantage of the newer and better techniques now readily available. My surgeon performed a quadruple by-pass using the mammary arteries which are located inside the chest wall itself. These arteries are large and should last a lifetime. In my case they were double the size of my blocked arteries. Leg vein grafts usually last ten to fifteen years and then wear out, requiring a second operation. Using the mammarian arteries takes an extra two hour or so on top of an already long operation (at least four hours), so some surgeons may prefer to avoid this technique. There is a second solid reason, from the patient’s perspective, to avoid leg grafts. The recovery period is considerably extended to allow the patient time to just be able to stand and walk again. Mammarian arterial grafts avoid this entirely.

60

SELECTING YOUR HOSPITAL I had staged managed my operation to the last degree like a military campaign. I found a cardiologist I liked and could believe in. He would tell me when my time was up. He found me one of the most skilled surgeons (it’s only plumbing after all !) in the country. We talked about early September 1998, and agreed that that was a likely scenario. I was also warned that if I did nothing then I would probably be dead by Christmas, which was quite a sobering thought in itself. My problem was now the selection of hospital. This is not a plug for private versus public hospital systems, but it might be worth some discussion as to how and why I made the choice I did. When I experienced my first series of heart attacks I spent 5 days in Intensive care at Liverpool hospital. I could not have received better attention or care from either the visiting surgeons or the hospital staff. The fact that I did have a level of private cover gave me the opportunity later on to choose when and where I would have both my angiogram and my bypass operation. The surgeons of my choice operated at both Liverpool Public Hospital and Prince of Wales Private Hospital. I would strongly believe that they would perform both operations with the same degree of skill and care, regardless of the location. The difference may be apparent after the surgery. I chose to have my angiogram at Strathfield Private Hospital. This allowed me to have Rhonda stay with me the whole time. This has a significant psychological benefit, and provided us both with an increased level of confidence. I was also able to choose the day and the time the angiogram would be carried out. Again, we both found this to be of benefit. Lastly, by having the angiogram done through the private system I was able

61

to insist that my cardiologist would perform the operation himself. If it had been carried out in a public teaching hospital, such as Liverpool, this work would have actually been done by a trainee under the supervision of my cardiologist. I saw no necessity for me to be a training ground for some aspiring junior physician, regardless of his actual ability on the day. When it came time to select my hospital and surgeon for my bypass operation, I was quite determined to make sure I would receive the best attention possible. Quite simply, when I asked my cardiologist who he would recommend to perform the surgery, he asked me if I wanted the best there was. Of course, I replied yes. In that case, he was prepared to recommend only two surgeons, both capable of performing mammary arterial grafts. One of these had recently operated on my cardiologist’s own father, and was well thought of in the medical field. He only operated at Liverpool Public Hospital and Prince of Wales Private Hospital. This left me with little choice but to go and have a look at the Prince of Wales. Rhonda and I did this the week following my angiogram, and we were looked after superbly by the staff there who spent a lot of time showing us around and re-assuring us in the areas where we showed concern. What of the costs associated with private care? Just how much was all this going to cost? In fact, when taking all costs into consideration, by having a “middle level” hospital cover, coupled with a top level medical cover “with extras”, I can definitely say that including my $500.00 once-only excess (not much different to my car accident excess policy) the cost of the angiogram and my bypass operation came to less than $2000.00. My entire operation cost somewhere in the order of $30,000, and while I am not a supporter of paying any “gap” when I have what is believed to be adequate private health cover, I readily accept that $2000.00 from my own pocket as a personal contribution towards saving a life (my own!), it is hardly a large amount, especially when compared other things I could have spent the money on. My only continuing cost now is for medication for cholesterol (I take a combination of Questran and the new wonder drug Lipitor), which currently costs about $20.00 a week in total, as well as the occasional visit to my cardiologist (a $20.00 Medicare gap, which is well worth the expense). My medication costs would be the same regardless of who performed the surgery. This may only vary if the patient is on a pension or disability allowance.

62

THE WEEKS BEFORE “♥” DAY The finality of death is a convincing motivator. The word apathy does not, and will not, ever belong to my vocabulary. While my family experiences convinced me that I was probably about to die, I was equally as determined that this would not happen. The first reason for this was that I was not ready to die: in my view my life was only half complete. The second, and the one that drove my ambition the hardest, was that I was not going to allow my family to be put through the emotional turmoil which I had experienced nearly three decades earlier. For both reasons I needed considerable amounts of help. My appeals to some fell on deaf ears, or ears which were simply not in tune with my cries for help; to others my appeals were met with empathy and kindness of a kind which draws people together in a way which has a lasting effect. Once I had returned from my disastrous trip to China and Hong Kong, and the decision to have major surgery had been made, I instinctively knew that Rhonda and I needed considerable help in getting through the next few weeks. A week before my angiogram my sister, Stephanie took time off from her busy schedule with her family and her parish in Oxford to fly to Sydney to spend five days with us. We were all delighted to witness her supporting us in this way, and while she was not really able to assist in a specifically practical way, this was a visible demonstration of the level of her feelings towards us as a family. I think we both sensed that we may never see each other again, and needed the comfort of close contact, even if for just a few days. The week after Stephanie returned to Oxford her son arrived on business and proved to be valuable in maintaining the close connection with my “English” family which I value so highly. I was fortunate in being able to gather around myself a small group of friends who kept an eye on both me and my family in the weeks running up to surgery. In today’s frenetic society it is not easy to devote quality time to helping others. This may seem a strange comment, however it seems to me that many people become so caught up in their own family interests and concerns that they often do not recognise others in need. 63

Most people have a wide circle of acquaintances, but true friends can be counted on the fingers of one hand. During the month prior to surgery I relied heavily on designer medication which went some way to reduce my levels of anxiety. I had difficulty sleeping, and when I did sleep the quality of that sleep was poor. Undoubtedly, this increased my agitated state and I am sorry to say that I became irritable, critical of others, and short tempered. I sought out friends who would let me take them to lunch so I could voice my concerns about my feelings on the world in general. My attitude towards others was not positive, and like a child picking at a sore my feelings festered. This was not a healthy situation and by the time I went into hospital my friends and family were probably as fed up with me as I was with myself.

TRUSTING IN THE LORD (WHY ME?) “Men are never really willing to die except for the sake of freedom: therefore they do not believe in dying completely”. Albert Camus (1913-60), French-Algerian philosopher, author. The Rebel, pt. 5, “Historic Murder” (1951; tr. 1953).

“I have wrestled with death. It is the most unexciting contest you can imagine. It takes place in an impalpable greyness, with nothing underfoot, with nothing around, without spectators, without clamour, without glory, without the great desire of victory, without the great fear of defeat”. Joseph Conrad (1857-1924), Polish-born English novelist. Marlow, in Heart of Darkness (1902).

“Trust in the LORD with all your heart, And lean not on your own understanding; In all your ways acknowledge Him, And He shall direct your paths”. Proverbs 3:5

I am a practising Christian. My particular denomination would probably be viewed by many as being particularly zealous. When I was christened nearly half a century ago in a tiny Anglican church in East Yorkshire, the parish priest took the unusual step of offering me up to God at the main altar. This village church is not large, yet it is beautifully decorated all around the walls, the font and the altar. The carved wooden pews and altar railings are also very fine. This christening took on a particular significance to my mother. She told me many times as I was growing up that she believed God had a special plan for me to achieve something significant. If this is really true, then I am still searching. I rather suspect, instead, that the vicar was offering extra prayers to protect me from a traumatic life ahead. This is far more believable to me. My sister keeps telling me that her observation of me is of a man who keeps getting up from one adversity after another, and just refusing to give up. My faith in God has certainly been tested, and has been shaken. It has not been broken. I think a positive Christian outlook on life must be helpful to anyone at any stage in their life, particularly so when facing major heart surgery. I believe that I would have

64

perceived other forms of major surgery (knee reconstructions and hip replacements for example) as being no more than an excruciatingly painful complication in my life, nothing more. There is something about interference with the heart which has a strange effect on an individual’s perception of how to handle the stress and other perceived problems as being more than just personal and invasive. While many devoutly religious people would say that they would be quite content to place their lives and their futures in the hands of God, I can honestly say that when you are the one affected, it just is a much more complicated issue than that. I also felt at the time that the members of my own church were not supporting either me, or Rhonda and the girls in the way I personally believed they should. I focused on this very heavily. This made me very bitter and resentful, and I didn’t act in a very charitable manner towards them. I felt they had betrayed my trust in them. I have since mellowed in my attitude and am trying to be somewhat more forgiving. I think it is more likely that they did not quite know what it was that I wanted them to say or do. After all I was totally confused and bewildered, and unbelievably frightened as to what would happen to me. I think now that I probably scared them away, and they may well have been offended themselves by my attitude and actions. I have made it no secret that I fully expected to die, and I was not ready. I struggled with my own fears and my mortality. Heart disease and open heart surgery is a very serious and sobering time. Many people have told me that they could not do what I did, rather they preferred to know as little as possible about facts and probabilities before their operation. While my personal faith in God is strong, I have found it impossible to express my feelings about my own mortality. Two weeks before my operation a man of great personal faith who was suffering from terminal cancer wrote an address to the members of my church in a different part of Sydney. The sentiments expressed by Arthur Russell demonstrate personal faith in times of extreme adversity. His complete acceptance of God’s plan in the weeks prior to his death demonstrate the strength of his own character at a time when his terminal illness was at its closing stages. The finality of my own illness was not quite so certain, and had some chance of being reversed. While God’s plan for me proved after my operation that my life was not yet complete, the uncertainty of my future (prior to my surgery) became a burden I struggled to overcome. This passage has been transcribed from a letter from Arthur Russell to those who attended his funeral. “Thank you for coming today to support my family at this time, but please do not be sad or depressed by this occasion. To help you understand why I say this, I would like to make a brief statement about what I believe in all sincerity, so that you can understand how I feel, and want you to feel. I believe in God, and know within the very depth of my heart and mind, that He is not slack concerning His promises! They will be completed at the right time as decided by Him long ago. I believe in the words of Paul when in Hebrews he says ‘But without faith it is impossible to please Him: for he that cometh to God must believe that He is, and that He is a rewarder of them that diligently seek Him’. I believe in the one true God of Israel, the creator and sustainer of the universe, who has so generously allowed us to call Him ‘Our Father, who art in heaven’.

65

I believe in the atoning work of Our Lord Jesus Christ, and have the confidence of Paul (in 2 Timothy) ‘For I am ready to be offered, and the time of my departure is at hand. I have fought a good fight, I have finished my course, I have kept the faith: henceforth there is laid up for me a crown of righteousness, which the Lord, the righteous judge, shall give me at that day: and not to me only, but unto all them that also love his appearing’, and in 1 John ‘Whosoever shall confess that Jesus is the Son of God, God dwelleth in Him, and He is God. And we have known and believed the love that God hath to us. God is love: and he that dwelleth in love dwelleth in God, and God in Him. Herein is our love made perfect, that we may have boldness in the day of judgement: because as He is so are we in this world. There is no fear in love: but perfect love casteth out fear: because fear hath torment. He that feareth is not made perfect in love. We love Him because He first loved us’. I believe in the literal fulfilment of the promises made to Adam and Eve, made to Abraham, made to David, and made to the apostles. I believe in the goodness and severity of God, yet hope in His mercy for He alone knows our heart and motivation. Although far from being perfect, I believe that at all times I have tried to enact the message of Micah in my life, ‘He hath shewed thee, O man, what is good: and what doth the Lord require of thee, but to do justly, and to love mercy, and to walk humbly with thy God?’ Why then should I, or you, feel sad when death is but an end of our mortal life, and an occasion of awaiting in painless sleep for the return of the Lord to establish that wonderful Kingdom and provide all those who truly love his appearing the opportunity to serve Him more fully for ever in His presence?”

66

ADMISSION TIME Admission time on the day before the operation can be extremely stressful, and is probably as emotionally draining as the discharge. Here is a letter from Andrea, the ward clerk at the Prince of Wales Private Hospital:“Dear Jeremy, As a ward clerk my job is not so important, but to those I meet in the cardiac unit my role is a very important one. On a patient’s admission, it is the ward clerk that they and their loved ones greet first, and it is when I first perceive the fear and anxiety of both parties. Upon arrival in the hospital room they have mixed emotions about their accommodation. Some do not notice their surroundings, but others just love their room and request that they return to that room on their return from the ICU. Sometimes this is possible, and I try to do my best to please everyone. After a run down on the room and its facilities, and providing some assistance for the relatives accommodation and their meals and other needs I wish them all the very best, and may the love of Our Lord be with them. On the day of the operation I make sure all the patients belongings are packed away properly and securely locked up. Often I have walked down the corridors alongside the partners, friends, and the children of the patient on their way to what would seem a mile long road to the theatres. I watch them farewell their loved ones, and this often nearly breaks my heart, and I am so glad that I am able to offer a shoulder to cry on. Two or three days have now passed from the transfer day to the recovery ward, with tears of joy and many times disbelief from overcoming such a huge ordeal, and a cuddly teddy bear awaits loving arms, delivery of mail and arrangements of beautifully coloured flowers start to flow in, and I have the honour and delight of seeing the warm and happy smiles of the patients receiving their mail and flowers. Watching the patients on their daily walks cuddling their bears is so sweet, and the occasional joke about this breaks out and relieves the tension. Ward clerks have not only the job of administration, but to me my job brings me such satisfaction and joy that I am able to comfort both parties involved. Many a time tears fall on discharge, and lots of well wishes go around, and in my heart another friend goes on his or her way to a healthy long life. With love, Andrea”

67

It is the people like Andrea who make all the difference between coping or not when the time comes to settle in at the hospital prior to the operation. Patients and their relatives are extremely sensitive to how people treat them at such a critical time in their lives. Communication skills and an ability to empathise with and help to relax people in a cardiac ward is an essential element to how well patients ultimately cope with having life saving surgery, and also how quickly they manage to overcome the psychological hurdles they have to go through while on the way to recovery.

PRE-SURGERY I arrived at the hospital just after lunch the day before my operation. I was a little intrigued as to what the nurses and doctors would be doing to me which would fill the rest of that day. The thing which took the longest was getting me shaved and smooth as a baby’s bottom from neck to toes. This feat managed to occupy two nurses, Rhonda and me for at least two hours, and had some amusing highlights. I am not a very hairy man, however I flattened the batteries on three electric razors. Doing such a good job with shaving gave me a good chance to understand what many women go through every week or so, but they don’t have their faces to shave, so we’re probably fairly even. It also meant that when plasters and adhesive tape were removed they did not grab any hairs, and therefore did not cause any discomfort.

68

IN THE HOSPITAL What happens the day before surgery? The surgical team will visit you about details of the operation and to answer your questions. The anaesthetist will ask you questions about your medical history and any known allergies. Much of your body hair will be shaved and the areas of the leg and chest where the surgeon will cut will be scrubbed with antiseptic surgical soap during the evening shower. Will the operation take place on schedule? In most cases, yes. But sometimes an operation has to be postponed because of emergency needs of other patients. What happens on the day of the operation? Personal items such as glasses and contact lenses, dentures, watches and jewellery should be given to family members or the nurse for safekeeping before you go into the operating room. About an hour before the operation you will be given medication to make you sleepy. Attendants will move you on a rolling bed to the operating room. There you will be given an anaesthetic that will keep you asleep during the operation. How long does the operation last? CABG usually takes from three to six hours, depending on what needs to be done. What happens during the operation? The surgeons will cut along the midline of the chest through the breastbone (sternum) to reach the heart. The bypasses are done with the heart not beating. The job of the heart and lungs is temporarily taken over by a heart/lung machine. There will usually be one or more cuts in the leg where the vein for the bypass graft is removed. Sometimes a cut is made in the groin also to get to the large blood vessels there. What happens immediately after the operation? After the operation you will be taken to a recovery area or intensive care unit where you will wake up after the anaesthetic wears off. At first you may not be able to move your arms or legs, but this will last for only a short time until your body and mind become co-ordinated. You will probably stay in the coronary care unit (CCU) or intensive care unit (ICU) for the first two days after your operation. What arrangements can be made for my family during and after the operation? Generally, it is not a good idea for your family to wait around the hospital. The hospital will call them at home after the operation to let them know how things went. However, most hospitals have a waiting area for families who decide no to wait at home. Be sure the surgeon knows where your family is so there will be no communication problem. Some hospitals may allow close relatives to visit briefly the recovery room or intensive care unit shortly after the operation, while you are still asleep. At other hospitals, the surgeon will ring relatives immediately after the operation and relatives will be encouraged to visit the day after. During the first couple of days visits to the CCU/ICU will be kept very brief because the most important thing is that you get plenty of rest. What about tubes and wires connected to my body? The tubes and wires attached to parts of your body after surgery are to help your recovery. Small tubes called cannulae will be in your arms. These are used to feed you drugs and fluids, withdraw blood samples and check your blood pressure. You will also

69

have some tubes in your chest to drain off fluid which collects normally during and after an operation. Wires attached to your chest will give an electrocardiogram (ECG) reading which lets nurses keep an eye on your heart rhythm and rate. There may also be small wires attached to your lower chest to help keep your heart beat regular, if necessary. A breathing tube in your mouth goes via the vocal chords and into your windpipe. It is not painful but it does prevent talking. The nurse will help you find other ways to communicate your needs. The tube is usually removed within 24 hours. How will I feel in intensive care? You may feel confused at first and find it hard to keep track of time. This is quite normal and caused by a number of things – the effects of drugs given for pain, the lights being on 24 hours a day, and all the activity going on around you. But any confusion should last only a day or two until you are moved to a quieter ward. What can be done to help me recover? Deep breathing exercises and coughing are important to help you recover quickly, even if they do cause some pain at first. You will be shown how to do this before the operation. Coughing reduces the chance of pneumonia and fever and will not do any damage. The nurse or therapist will clap her hands against the side of your chest to loosen substances in the lungs and make it easier to cough them up. You may find it easier to cough if your breastbone is supported by a pillow. You can also help your recovery by changing positions in bed often with the assistance of a nurse or physiotherapist. When can I start eating again? Once the breathing tube is removed you will be able to swallow a small amount of liquid, building up to foods over the next couple of days. How active can I be? This will vary, depending on your recovery. At first, it may be sitting in a chair or walking around the room. Later, there will be short walks in the corridor and, eventually, stair climbing and brisk longer walks in preparation for home. Sponge baths are given right away, and within a few days you will be able to take a shower and wash your hair. What’s the best position for sleeping? At first, it will be most comfortable to lie on your back propped up at about 45 degrees. It is important to change positions every few hours to relieve pressure on your skin. The nurses will help you with this. Will I feel pain after the operation? You will probably feel sore, especially the first few days after the operation, but if necessary pain-killers will be given regularly to ensure you don’t get severe pain. If the pain starts to build up, tell the nurse sooner rather that later. It is best to have a level of pain relief that still ensures you are not too drowsy to cough and clear your lungs. You and your nurse are a team that needs to communicate and manage your pain together. The soreness can be helped by sitting properly and moving your arms and shoulders frequently. Pain relief won’t get rid of all pain, but it can control it. The stronger pain-killing drugs are needed for only a few days, so there is very little risk of becoming addicted to them.

70

What about healing? Often, if the mammary artery has been used, there may be numbness down the side of the breast bone. This feeling usually changes to a super-sensitive feeling after a few weeks and then gradually returns to normal. The leg wound also often feels numb around the ankle and this can last for many weeks. The ankle sometimes swells and elastic support stockings and putting your legs up when resting can help this. Walking also helps and is good for the heart. How long will I have to stay in hospital? The usual time is six to seven days after your operation. Many patients feel “down” about four days after the operation. This will pass, but you should plan for it by having something to occupy your mind on the day.

INTENSIVE CARE

71

I woke up in Intensive Care (ICU) about 7.00pm on the day of my operation. I have no idea what happened in the Recovery Room. I presume I was there for about an hour. When I came to, the first question I asked was when were they going to start the operation. I rather think I thought I was still in the operating theatre waiting to be fully anaesthetised. I remember the bright lights in the ICU and not being able to focus on the wall clock on the other side of the room. This problem with my vision passed after about twelve hours. I also remember the chief Physiotherapist being with me. I vomited only a small amount of bile and felt immediately better, and then I became very emotional and wanted to know why this life of mine had to be so tough going. I really thought that none of this was at all fair. By having a good cry so early on, I believe that I coped better with my recovery as each day passed. I also attempted to redress the balance of control by having 25 long stemmed red roses sent to Rhonda with a note telling her how much I loved her and the girls. We had just passed a major milestone in our married lives -twenty five years of marriage. I knew that they all, and particularly Rhonda had had to cope with a significant amount of stress over the last few months. This was one of the most significant issues I attempted to deal with myself prior to my operation. I just could not find any justification at all as to why they should have to suffer the way I was doing. In fact, I focused a considerable amount of anger and frustration of a situation which, for once in my life, I was unable to control, or at the least, minimise. I think I was in the ICU for about thirty six hours. I remember Rhonda coming in to see me. I also remember a patient either side of me. He seemed to be recovering very rapidly too. I might be wrong, but my impression is that I did not sleep at all. I know that I had at least one nurse caring for me all the time I was in the ICU, that I was receiving morphine and other drugs intravenously, and that x-rays were being taken at regular intervals. At no stage did I feel any pain or discomfort. Ah! There was just one time. How easy it is to forget as time goes on. Twenty four hours after the operation it was time to remove the three tubes in my chest. These bits of rubber were about the thickness of a pencil and up to 15 centimetres long. They were located around the heart and exited my torso just above my belly button. These tubes externally were around two metres long and disappeared somewhere under my bed. On a regular basis the tubes were monitored for fluid discharge. The idea is that the drainage of fluid should slow down after a number of hours, at which point they are removed. It was only when the nurse told me these tubes were due to come out that I really seriously considered they were there, even though I could see the nurses checking the rate of fluid coming out of them on a very regular basis. I remember worrying that if they did not slow down at the “approved” rate then I might have to have my chest opened up again. I don’t know why this thought crossed my mind, but it did. When the nurse came to my bed to remove the tubes I immediately asked him to give me a local injection to prevent any pain. I had read somewhere that this was perfectly normal. He decided that a quick purge of morphine through the intravenous drip would be much more efficient, and within a flash the drains were out. I cannot actually say I felt any pain. I did feel a sort of pulling and sucking sensation. Either way, I know I was very relieved to be rid of those tubes. When I was in Intensive Care at Liverpool Hospital the year earlier I spent a couple of days hooked up to monitors with display screens in my room. These continually beeped or fell unusually silent. I found myself consciously monitoring the monitors! I

72

was checking up on the machinery which was checking up on me, and I was very sensitised to the potential results of a change in my heart beat. Prior to my operation I assumed that for the first few days following surgery I would experience the same levels of intense anxiety. For some reason this did not occur at all. In fact, I totally forgot about these concerns. I can only put this down to one or both of the following: Rhonda was constantly by my side and kept my confidence levels high, and the environment and care of the hospital staff provided me with strong levels of confidence. It is also possible that there were some residual effects of the euphoria experienced while being medicated with Morphine in Intensive Care carried over for some days and blocked some of my anxieties.

WHATEVER HAPPENED TO PAIN RELIEF? I went into surgery fairly well informed, however my actual knowledge of what to expect fell considerably short of reality. The best analogy I was able to come up with prior to surgery, when trying to keep things in reasonable perspective, was that the pain I would probably feel would be similar to that of having had a number of ribs broken. Focusing on this assumption helped me believe I was keeping things in perspective.

73

The first myth which needs exploring is the issue of having heart pain after the operation. After all, the surgeon is going to handle the heart itself for up to five hours and probably fully remove it from its usual comfortable position in the chest. The heart will have been stopped beating, and arteries will be removed and re-located on its surface. The heart will probably also have a significant layer of fatty tissue all over, and some of this will have to be removed to get access to the heart. All these actions must surely produce trauma and severe bruising. In actual fact the heart muscle itself carries no pain receptors. No matter how much bruising or damage is done during surgery, the heart itself will not transmit pain. In order to access the heart, the rib cage is cut open with an electric saw (rather like a fancy jig saw). The rib cage is then held open by a set of retractors, leaving an opening to the heart of about 20 centimetres. After the operation the rib cage is tied together with fine stainless steel wire which remains there forever. Some people assume that this wire will set off metal detectors at airports. In fact this is not the case. The wire is too fine to be detected electronically. The skin is then stitched back producing a neat scar the width of a pencil line. Some surgeons prefer to use metal staples which are removed after a week. Drainage tubes are left in for about a day, as well as a catheter into the bladder. As I have already said I was terrified these would hurt when removed. Prior to their removal I was given an extra large dose of morphine, and all I remember was a sucking squelch which lasted no more than one minute. I was also bothered that going to the toilet would be painful once the catheter was removed, but this was not the case. The catheter was inserted after I was put to sleep, and was held in position by a small balloon which was deflated prior to removal. I felt no sensation of the catheter at any stage, and after removal I also felt no indication of soreness. At no stage, either in hospital or at home during the following month, did I experience any direct pain which I could attribute to the operation. When I coughed or sneezed there was a short sharp tug inside which seemed to me to be pulling on the stitches around the grafts. I soon learned not to cough or sneeze too much. I felt no pain around where I had been cut open, however the scar area was a little itchy for a few weeks. My main complaint was back and neck aches. I found sitting for any length of time, and lying in bed quite uncomfortable, however by the fifth week this had improved considerably.

MAKING FRIENDS WITH YOUR PHYSIOTHERAPIST The light of the eyes rejoices the heart, And a good report makes the bones healthy. Proverbs 15:30

The Prince of Wales Hospital has a superb team of physiotherapists on hand to assist with the recovery from all types of operations. I am sure that most hospitals, whether public or private, can boast the same attention. Some people may wish to not accept the care offered by these professionals. I started to benefit from the encouragement of physiotherapists about one month prior to having my operation. I was concerned that

74

my lungs and cardio-vascular system might not be as strong as they could be, and so I found a local physiotherapist who checked me out, found me to be healthy and fit, and then suggested some breathing and stretching exercises which would keep me in good condition for the operation. This visit also gave me some comfort and confidence for the future. I had been very concerned right through the winter months that I might come down with the flu or bronchitis. This would have caused major problems for the anaesthetist, and could well have involved delaying the operation. I was finding it hard enough to cope as it was, without any other forms of potential stress. When I arrived at hospital on the day prior to my surgery, I was thoroughly examined by the physiotherapist, and pronounced to be quite healthy. I had to blow and suck on command into a number of machines, and all the results were duly recorded. Immediately after waking up from the surgery, I was examined by the physiotherapist who was extraordinarily helpful and encouraging to me. Waking up from major surgery can be quite an alarming time, and some people recover slower than others. While I felt no pain whatsoever during the time I was in the ICU, the attention and support I was given by the nursing staff and the physiotherapist definitely helped me well onto the way to a quick recovery.

RECOVERY AND YOUR PERSONAL TEDDY BEAR When I came home from hospital my youngest daughter was fascinated by the Teddy Bear provided by my hospital to all patients who have undergone a heart operation. She saw the teddy bear as a child’s toy, and couldn’t understand why her father would be interested in toys. I strongly believe that mental preparedness and attitude plays a major part in the recovery process after major surgery. Most of the people I have spoken to, admittedly all men, went into surgery within a fortnight of either having a heart attack or getting unfavourable results from a medical examination. The giving of the bear by the hospital was a demonstration of their empathy towards the patient, and also provided those patients with a light hearted reminder that even though things may appear desperate, there is room for kindness and a smile.

75

Heart surgery is literally life threatening, and in most instances today it is life saving, particularly when planned for. Nonetheless, the event is traumatic and frequently turns the lives of the sufferers as well as their families entirely upside down. If all sufferers are absolutely honest, I think they will admit that regardless of how confident they felt at the time, they had some reservations as their chances of survival. Statistics indicate that survival is now 98% assured, and by-pass heart surgery is performed thousands of times a day world-wide. Even so, it would be fair to say that the older one gets the higher the overall risk. Start including poor diet, lack of exercise, smoking, and general stress factors, and it is amazing the success rate is as high as it actually is. I believe most sufferers go through a substantial grieving process after their surgery. For the first couple of nights in hospital I had bad dreams which disturbed me emotionally. I was advised that this is quite normal, and is thought to relate to the anaesthetic used. I suspect this is heightened by the grieving process. There are many good books available which discuss the grieving process. What is important to understand is that it is quite normal for the trauma of a heart operation to produce feelings of grief in patients as well as their families in very much the same way as if they had actually died. This must affect their ability to recover, so any post operative rehabilitation needs to include the working through of grief and so allow recovery to develop unhindered. Because I delayed my surgery for sixteen months I was able to explore the full emotional experience of grief for a significant time, and learn to deal with it at my own pace and in my own way. While I found that this affected all of us in the family, and caused some of its own psychological damage, I did find that after the surgery I mostly only experienced psychological relief from the knowledge that the operation had been successful and now all the worrying we had been going through for so long was largely over. All I had to do was get better. I was then in a much stronger emotional position to focus all my physical and mental energies on recovery. I am convinced that this cut my recovery time down by at least two thirds.

PAIN AND DEPRESSION (LONG NIGHTS AND STRANGE DREAMS) By the time I was ready for my surgery I had decided that I should anticipate having a level of chest pain equivalent to being kicked in the ribs by a horse. When I suggested this to my surgeon he just grinned, and said that I was probably right. To my absolute amazement my wound and my ribs never hurt at all. Afterwards my surgeon told me that for some unknown reason about 30% of all patients do not experience any pain of consequence in the chest area. I did have a significant amount of trouble with neck and back pain, particularly in getting comfortable in bed, but apart from that it seems that I was fortunate indeed. For this reason I am unable to provide any first hand knowledge of severe localised pain. I do suggest, however, that if severe pain is anticipated then the discomfort might be more manageable. This is very much the case of anticipate the worst and hope for a pleasant surprise.

76

Medical science has also not come up with a logical reason to explain why people who are recovering from major surgery suffer from night-time depression. This often occurs between the third and fifth days. It is believed that there is a direct link between postoperative depression and short term psychological trauma. My attitude immediately following surgery was extremely positive and yet I still suffered from depression. On the third and fourth nights I woke up in the early hours of the morning feeling nauseous and very bewildered, as well as being somewhat teary-eyed. Small children often wake up in the middle of the night after a bad dream and become temporarily frightened. I suspect that after major surgery many people experience similar feelings. These feelings only lasted a short time on two nights, and I am convinced that my positive attitude firmly nipped any further development of depression in the bud. I had also worn myself psychologically out before surgery, and gone through a considerably drawn out pre-emptive grieving process. I believe this reduced my post operative depression to a manageable minimum.

GOING HOME SO SOON ? (HAVE A TRIAL RUN) My operation was on a Wednesday afternoon. On the following Monday morning the surgeon asked me if I felt ready to go home. What ! so soon. I had hardly arrived. We agreed that I would actually leave on the Tuesday morning, and so some friends of ours who lived only five minutes drive from the hospital, overlooking Coogee beach, invited us to dinner at their home. The dinner was wonderful, and as we had not seen each other for a great many years, the evening passed very quickly and delightfully. By 9.00pm I was starting to feel quite tired so we walked up through the front garden back to their car. The front garden was deceptively full of steps, and by the time I was half way up I ran out of puff. I was really exhausted now and got a little nervous. This was really tough going. After a few minutes rest I was able to get my breath back and get into the car. I was shaking quite badly by this stage and felt I needed to be back in the security of the hospital cocoon as quickly as possible. By the time I was back in bed in my room I was totally exhausted. I realised that going home the next day was not going to be as easy as I had hoped.

77

THE RETURN HOME How will I feel about leaving hospital? Many patients feel a little anxious and depressed about leaving the security of hospital to go home. Remember, you will only be allowed to leave if the doctor thinks you are well enough and will continue to recover well at home. When you first go home you will be able to do a few things for yourself like dress, shower, move around, put on your socks or stockings, and light household tasks. However, you will need lots of rest and help to do the shopping, cooking and heavy household tasks for several weeks after surgery. For the first two weeks or so, your family and friends will need to keep a close eye on you and give you the help needed. Can I drive, wear a seat belt? If you are being driven home, you must wear a seat belt as usual, as the law demands. It is safe to wear a seat belt across a jumper for extra protection. But third party insurance will often not cover CABG patients who drive within six to eight weeks of the operation while the breastbone is still healing. What if I have to go home on public transport? If you have to travel by train, bus or plane, arrangements can be made to board before other passengers. If you need a wheelchair, you can arrange this through the company’s passenger service office.

78

What can I eat at home? The doctor, dietician or nursing staff will advise you on this. A diet that is low in saturated fat and salt is important for reducing the risk of heart disease, mainly by helping to control your blood cholesterol and blood pressure levels. It is especially important if you already have the disease. What other things should I watch? Over the months and years ahead it is important also to watch your blood pressure, keep to a healthy weight and, of course, to avoid smoking. Your doctor will advise you on this and the Heart Foundation also has information to help. What medication will I need? Only take medications that are prescribed by your doctor. It is vital to check with your doctor about all the medication you were taking before your operation – they should not be continued unless definitely prescribed again – and over-the-counter (nonprescription) drugs as well. When should I contact a doctor? Call your doctor if: • You have any sign of infection, fever, chills, or swelling • You are short of breath • Are putting on a lot of weight • There is a change in the speed or rhythm of your heart beat, or • There is any other symptom that worries you. Are there special feelings after returning home? You may feel weak when you first go home. This is usually not serious, but due to under-use of the muscles, especially the big muscles, during your stay in hospital. Exercising is a good way to build up your muscle strength. Walking is an especially good exercise after CABG, but don’t overdo it. You may feel depressed as well. Again, this is quite normal after an operation. The best way to get over this is to talk about it with your close family members or friends. Sometimes family members may add to the depression without meaning to. This also should be discussed. You and your family may also feel angry and frustrated. These feelings usually lessen as life returns to normal. When can I return to work? Almost everyone will be fit for work after recovering from the surgery. If you have a desk job you can go back to work usually in four to six weeks. If you are doing heavier work the wait will be longer. A few people may not be able to return to exactly the same job if it is very physically demanding. You should get advice from your doctor or through a cardiac rehabilitation program before returning to work. What should the home routine be? When you return home, get back into normal routines as soon as possible: • Get up at a normal hour • Bathe or shower if possible • Get dressed. Don’t stay in sleeping clothes during the day • Take a rest mid-morning and mid-afternoon or after periods of activity. You should be able to: • Help with light work around the house • Go to places like a theatre, restaurant or church • Visit friends • Ride in a car

79

•

Climb stairs slowly.

If you are normally on your own, you will still need someone staying with you in the first two weeks or so. Shopping or doing the laundry will probably be too difficult to do your self. Meals on Wheels and other home care agencies can also help until you can manage on your own again. If you need extra community service, contact your local doctor. Exercise is an important part of your recovery. Build up your exercise level slowly to help regain your strength and fitness. Walking is ideal. Your doctor may recommend an exercise program. When should I see my doctor again? This will depend on your needs and your doctor’s wishes. Usually you will be told when to next see your doctor when you leave hospital. Make an appointment with your doctor when you return home. Will I have to change my lifestyle? CABG surgery is very successful and patients can normally return to an active and full lifestyle. However, surgery does not cure heart disease. You can reduce your risk of a heart attack or the need for further surgery by making a few changes to your lifestyle. The most important steps you can take to reducing your risk of further heart trouble are: • Be a non-smoker • Eat a low-fat, low-salt diet • Know your blood pressure • Keep to a healthy weight • Get plenty of regular exercise • For all the above, stay in touch with your doctor. Questions for your doctor 1 How soon after the operation will I be able to return to work? 2 Will I need a blood transfusion? Can I donate blood for myself? 3 How many bypasses will I have? 4 Will there be a lot of pain? 5 Will I live longer if I have the operation? 6 How much will the operation cost and how much will be covered by insurance? 7 How long can I expect to be in hospital? 8 Is there a place nearby for my wife/husband/partner to stay while I’m in hospital?

80

MUM, WHY IS DAD SLEEPING IN MY BED ? One of the biggest physical problems I experienced was getting comfortable in bed. Once I was back in the main Coronary Care Unit (CCU), I found that my back was starting to play up. I already had a history of back trouble, with my two lower discs being damaged in an accident twenty years ago, so I was not really surprised. I hadn’t really considered the physical effects of the operation. In the process of opening up the chest cavity, the ribs are forced open approximately 20 centimetres for a period of three to six hours. This must place an enormous strain on the tissues and the nerves around the spinal column. Next time you cut open a cooked chicken, just have a look at what is involved. It’s dramatic to say the least ! I experienced severe discomfort from my back all the time I was in hospital, and when I arrived home I had assumed that the most comfortable bed for me would be our king sized water bed. How wrong could I be. I managed to sit sideways on the bed and I literally became stuck ! I could neither get properly onto the bed or get back out again. Rhonda had to push both her hands, amid much painful laughter, right under my bottom and literally lift me from there. Next, we tried the brand new double bed in the guest room. Rhonda and I both lasted until 1.30 am and neither of us could sleep, the bed was so hard and uncomfortable. She took off back to the water bed and left me to it, not realising that she had left me in a position whereby I was virtually unable to move. By this time I had gravitated to the centre of the bed and it took me a painful hour (pulling my stitches) to reach the side of the bed to allow me to hook my legs over the side which gave me the leverage to sit up and then get out of bed.

81

By this time I was exhausted, and my old drain stitches really hurt, so I got myself into the warmest clothes I could find and spent the rest of the night sleeping (quite well as it happened) on the reclining arm chair downstairs in the lounge room, after Rhonda had provided me with some assistance in wrapping me up warmly in a large blanket. The next night I tried out my youngest daughter’s single bed. She was still staying with friends. This bed was much higher off the floor and consisted of two inner spring mattresses on top of each other. This gave me a much better night’s sleep. The following day we arranged to borrow a similar single bed from friends and placed it in our dressing room so that I would be within easy reach of Rhonda if I needed help in the middle of the night.

EXERCISE I am a young person, and reasonably fit. I also have a degree of determination which often tries to defy reality. I recovered quickly and was walking between two and five kilometres within three weeks of my operation. This cannot possibly be the same for all people who have undergone this type of surgery. Older people will certainly recover much slower, and no-one should attempt what I achieved without professional advise and good medical supervision. I also visited my local physiotherapist privately for a few weeks after coming home. This served two purposes. Firstly, if I was found to be overdoing my exercises or having difficulty coping with going back to work so soon, my physiotherapist would have been the first to see the effects, and would have cautioned me to pull back. Secondly, I was able to have my back and neck massaged on a weekly basis. I found this to be very useful, as I was finding that one of my biggest problems of recovery was back and neck ache. I have two slipped discs in my lower back, so these sort of pains were not new to me. I did find them a serious nuisance, in that they used to seize up when I got tired, and I developed a tendency to slouch when sitting which also produced back aches. The following notes were provided to me by my physiotherapist on leaving hospital, and are a useful guide as to how much exercise one should do after arriving home:“Exercise has numerous benefits for your health. These benefits are both physical and psychological. It also helps to improve the health of your heart, lungs and circulation, thereby improving several coronary risk factors. So, what do these benefits include? 1) Psychological benefits: increased confidence improved self esteem better ability to relax and sleep reduced anxiety 2) Physical benefits: increased fitness

82

increased endurance better ability to cope with everyday activities reduced fatigue with activity 3) Benefits for your cardiovascular system: more efficient heart and lungs lower cholesterol decreased blood pressure decreased stress healthier body make up - more lean muscle and less fat making it easier to achieve and maintain a healthy weight All this adds up to increased energy, the ability to do more every day for less effort, and a healthier body and heart. You need to exercise a minimum of three times per week for twenty minutes to gain these benefits. Make sure you start out slowly, and progress your exercise program gradually. This will help you to avoid injury, and prevent burnout from trying to do too much too quickly. Be aware of the signals your body is sending you - never force or strain your body. Stop and rest if you experience any chest pain, breathlessness, dizziness, nausea, undue fatigue or palpitations. Allow some time to warm up and cool down before and after your exercise. Wear comfortable clothing and appropriate, supportive footwear. Try to exercise when the temperature is comfortable, rather than in very hot or cold times of the day. Make sure you drink plenty of fluid, and don’t exercise within an hour of having a meal. Avoid exercise if you are sick, and don’t lift, push, or walk a pet on a lead for the first six weeks. The easiest and most convenient way to exercise is walking. This gives the heart, lungs and legs a good workout, and you can also exercise your arms by swinging them purposefully with each step. Walking can be done anywhere all year round, and the only equipment you need is a good pair of shoes, preferably a pair designed especially for walkers. Walk at a pace that you find comfortable - you should be able to carry on a normal conversation as you walk. Start and finish your walk at a slower pace as a warm up and a cool down. Make time every day for your walk, and make the most of an opportunity for some fresh air and sunshine. Start with an easy distance, and gradually increase the distance walked and your pace. You can also gradually add some hills or stairs into your walking routine. The following recommendations from the National Heart Foundation will help you to organise your walking program. WEEK MIN TIME (mns) PER DAY PACE 1 5-10 2 stroll 2 10-15 2 comfortable 3 15-20 2 comfortable 4 20-25 1-2 stride out 5 25-30 1-2 stride out 6 30 1-2 stride out Your household and leisure activities will also need some modifications in the first couple of months after coming home. Following are some guidelines to help you determine what you are able to do in terms of your sternum healing:-

83

First 2 weeks: From 3 weeks: From 4 weeks: From 6 weeks:

From 8 weeks: From 3 months:

Dressing, showering, cooking simple meals, watering the garden. Making the bed, hanging out light washing, gentle weeding, a small amount of ironing. Sexual activities. Light pushing activities - driving the car, vacuuming, sweeping, carrying light shopping (up to 4kg), washing/polishing the car, cleaning the bathroom, pushing a half full shopping trolley, pushing a stroller on flat ground, lawn bowls, freestyle swimming, cycling. golf - putting, swimming breaststroke. heavier pushing activities - lawn mowing, heavy gardening (e.g. shovelling), painting, fishing, horse riding, sailing, tennis, squash, golf.

Remember, if you have any queries or problems with your exercise program, do not hesitate to contact your doctor. Good luck, and enjoy your better health!”

THE FIRST WEEKS AFTER COMING HOME Rhonda and I were both convinced that when I came home from hospital I would be so seriously ill I would spend most of the first couple of weeks propped up in bed watching “soapies” on the TV and struggling to get up occasionally to go to the toilet. This has proved to be a total fallacy. Apart from my difficulties finding a bed which was comfortable, I was able to sit in my arm chair and walk around the garden as soon as I arrived home. Within a week I was conducting business calls on the telephone and walking 2 ½ kilometres a day. By the end of the second week I had attended four lengthy business meetings in the City (Rhonda drove me into the City) and was working from home for or five hours a day. By the start of the third week I was able to walk 5 kilometres at a go and our more intimate marital life was returning rapidly to normal (with just a little more care than normal, of course). By four weeks I had passed a physical and had medical approval to drive the car. The RTA and insurance companies have a policy that after heart and other major surgery you are legally banned from driving for the first six weeks unless you can pass a stress test. By seven weeks I was able to mow the lawns and weed the garden. Certainly, I would get tired quite quickly, but by being aware of the symptoms and having Rhonda act to some degree as my “minder” in this regard, I was able to do almost anything I wanted, as long as it was within reason. It must also be said that I was reasonably fit and healthy before my operation, as well as being half the age of many of my zipper club peers. I have always recovered well from physical illness. What I achieved may be possible for others also, but it should not be seen in any way as a benchmark for others to follow.

84

JEREMY’S HAVING A HEART ATTACK “Two such as you with such a master speed Cannot be parted nor be swept away From one another once you are agreed That life is only life forevermore Together wing to wing and oar to oar”. Robert Frost (1874–1963), U.S. poet. The Master Speed, inscribed on the gravestone of Frost and his wife, Elinor.

In the 80’s Jeremy was working for a South Australian wine company, and it was company policy for employees to have a health check which involved a blood test to check cholesterol levels. It was at this time we discovered that Jeremy’s cholesterol levels were higher than normal. He was in his early 30’s and we didn’t worry too much as he was only young. Like most people our age, we just thought that it takes a long time for cholesterol to build up in the arteries of the heart before it becomes a problem. Any way, surely heart blockages were an old persons disease. We did, however, check and make sure we were eating a healthy diet, and we were happy to find out that what we were eating was very close to the diet recommended by the Heart Foundation. This healthy diet was partly due to the fact that we have a daughter who has Attention Deficit Disorder, and I had already adjusted our diet to try and help her, by cutting out sugars and junk food. Jeremy’s cholesterol levels continued to rise until they were as high as eleven in 1993, when he was aged forty three. His triglycerides were also high, because he worked in the liquor industry, and business lunches and dinners were common.. Jeremy worked long hours and seemed always to be on call, which was quiet stressful too. Consequently, this influenced our decision to leave Melbourne in 1993 and move to Coffs Harbour to a more relaxed lifestyle, away from the liquor industry. Jeremy’s cholesterol levels did go down slightly when we were in Coffs Harbour, but they soon went up again when life became stressful once more when the business we were trying to set up didn’t work out as we had planned. Work in Coffs Harbour was hard to find. It soon became apparent that we needed to move back to the city. Our eldest daughter wanted to go to Sydney University to study for a science degree. Little did we realise at the time that Jeremy’s arteries must have been fairly solidly blocked by this stage.

85

We had been in Sydney renting for about a year when we decided to buy a house. It was around Easter time. Unfortunately the company Jeremy was working for had to move warehouses from the city because they only had the lease there until the building had to be knocked down. They found a suitable warehouse at Silverwater and they needed all the help they could muster when moving. The stress of moving house and warehouses put Jeremy under a lot of pressure. He ended up with pneumonia. This was aggravated when in the panic of moving warehouses the large fan system was not turned on. Poisonous carbon monoxide gases built up in the warehouse due to running the fork lift for three days without stopping. Jeremy’s lungs were already filled up with fluid from pneumonia and now he had carbon monoxide poisoning. This put even more stress on already clogged arteries in his heart and resulted in him being unable to breath, and feeling disoriented. He managed to find a medical centre in the city who put him on oxygen and told him he had pneumonia and gas poisoning. After that I insisted that he should stay at home in bed and rest for a few days. Jeremy doesn’t like resting in bed and after a couple of days in bed decided to go and sit in his chair downstairs. The next thing I knew he couldn’t breath again and I had to rush him to the nearest medical centre. When we there he looked so bad they hurried him into one of their rooms. The doctor looked at him straight away and put him on oxygen again. After a while he improved and they sent him home. A few days later, after I had been looking after him, he started to feel better. I had him sitting up in bed and had given him strict instruction to stay there while I went downstairs and made some lunch. Little did I know, while I was making lunch Jeremy had come downstairs and snuck out the front door and was in the front garden ‘mixing up concrete’, and was concreting the front drive and garage! The first thing I knew, he came in gasping for breath and holding his chest. I was totally bewildered and stunned and did not understand how he had managed to get himself into his current condition. After all, he had been upstairs resting in bed. Still, I knew straight away I had to get him to the doctor again quickly. I grabbed for my car keys. Jeremy signalled with his hand that I could not use my car for some reason. So I looked in the garage and quickly realised he had concreted my car in. So I asked him where the keys to his car were and he indicated that they were in his pocket. I grabbed them and called to Vanessa my eldest daughter who was upstairs. Luckily our youngest daughter Kathleen was at a friend’s house. Vanessa was as bewildered as I was to see her father in such a condition and went a bit white. Jeremy winced as I drove over still more wet concrete (which I didn’t realise was there, and was more of concern to him that his health) as I drove his car out of the driveway. The tyre marks are still there today. Vanessa and I helped him out of his car at the medical centre (which was only 2 minutes down the road) and doctors there once again came and looked at him immediately. This time the doctors laid him straight down and took blood tests and called an ambulance to have him taken to Casualty at Liverpool Hospital. After about 7 hours, when it was about 7 p.m., it was confirmed that Jeremy had enzymes in his blood which confirmed he had had a heart attack. As soon as this was discovered they moved very quickly and put him into the Cardiac Intensive Care Unit. When Vanessa and I got home that night quite exhausted we had a surprise waiting for us. We found we had to remove the concrete in the garage (which fortunately was still wet) straight away, or else the garage door was not going to be able to shut and this would leave the house unsecured. The concrete in the wheel barrow did harden,

86

however, and is now in the garden with flowers growing out of it, a monument to the incident. We have named it ‘Jeremy’s Folly’. He was at Liverpool Hospital about five days. Before Jeremy went into Liverpool Hospital he had booked to travel to England and Spain on business, which combined a visit with his sister and her family as well. As it happens, he was due to go overseas about 10 days after he came out of Hospital. On top of this, his heart attack episode was causing him to have panic attacks, and it is very difficult to tell the difference between angina, a panic attack (which probably makes the angina pain worse), and the beginnings of a heart attack when you are first becoming aware of all three conditions, (later Jeremy was able to differentiate between them but it was difficult at this time). He would have probably cancelled his trip except that he really wanted to see his sister and her family and he felt the break would do him good, plus, after all, his sister and her husband are both doctors, so surely he would be in good hands. Jeremy visited his sister in England first, where his health seemed OK, but in Spain he had a couple of panic attacks. This probably was brought on due to the hectic pace travelling all over Spain and the different cultural habits he encountered. They would have a late breakfast about 9 am and then a late lunch at 3 or 4 p.m. and then they would not have dinner until 11 p.m. It is amazing how you can sense sometimes when something is wrong with someone you love (maybe it is just feminine intuition), even if something is happening on the other side of the world. When Jeremy was in Spain I had a strange feeling that something was not right and rang him on his mobile phone. Somebody else answered and after quite considerable questioning by me Jeremy’s business friend managed to assure me everything was all right, although the feeling that something might be wrong did not go away. Later on I found out that in fact at the very moment I was on the phone Jeremy was being hauled off to hospital in an ambulance in Spain somewhere and had told his business friend not to tell me so I would not worry. In the end he had to cancel the last few days of his trip and fly back to England. His brother in law was able to recommend a psychologist who was able to help him with his panic attacks so he could travel back to Australia without any further episodes. I was glad to have him back home. Once he was home again in Sydney Jeremy and I put considerable effort into developing an exercise program. This was also spurred on because I was doing a psychology unit at university, and for one of my assignments I had to develop a personal change program. So I chose to develop a “get fit” program. This helped me look at how to design a fitness program that suited our personal needs and had necessary elements such as positive reinforcers (anything that increases the possibility of a particular response being made to a situation) such as rewards, arranging contingencies (identifying any excuses or adversities that might prevent me from exercising e.g. sickness), putting punishments in place (doing 30 minutes of ironing or putting $1 token towards an amount to be given to a local politician or worthy? cause I did not support) , shaping (deciding how, what, when, where and the amount of exercise I would need to do to get fit), executing and evaluating my program (personally designing and writing up a formal contract and signing the contract in front of my family and deciding who was to be in charge of my reward and punishment system), evaluation date (setting a date when my fitness can be evaluated and I can see how I am going on my program).

87

Jeremy on the other hand at this stage mainly walked at night and started out only going around the block but gradually increased it to anything from 30 minutes to an hour’s walk a night. About a month after I had submitted my assignment to my university, Oprah Winfrey and Bob Greene published out an excellent book on how to develop an exercise program for yourself called “Make the Connection”. This was tremendously helpful to us, and helped us to realise some of the issues about exercising that we had not realised before, such as it is better to exercise in the morning and that you should drink plenty of water before you exercise so you won’t get dehydrated etc. We found that we would get up about 6.30 or 7 am and have 1 or 2 glasses of water. It is important to have some water as, at that time in the morning, you have not had any liquid for at least 8 hours. We then do at least a 20 minute walk. We have developed various circuits so it is easy to make the walk shorter or longer depending how we feel and how much time we have available. It then takes about 10 to 15 minutes to cool down. During this time we have another glass of water. The water and exercise all help to speed up your body metabolism. We try to do this every day, This way we know that if we miss a day here and there we can still achieve exercising 3 days a week, which is recommended by the Heart Foundation. I think this is a program that most people could follow. You certainly feel better after exercising and it helps to relieve stress when you are working. On Thursday the 11th of June, 1998, I was busy working hard to finish my last assignment for university before the mid year break. I was happy and relieved to have finished and posted my last assignment by lunch time. Later after tea I drove to the airport so Jeremy could catch a plane to China for 4 days followed by 4 days in Hong Kong. By the time I arrived home from seeing him off at the airport it was about 10.30 p.m. I was only home for about half an hour when I had a phone call from Westmead Hospital to say that my father was sick and could I come immediately. I rang my sister in Melbourne and my brother in Port Macquarie, to tell them the bad news. When I reached the hospital it was just after midnight, and my father was already on the operating table. I was then told he had a burst aorta, and may not survive the operation. I stayed the night in the waiting room. When I saw my father after the operation he was heavily sedated, so he did not know I was there. It did not look like him at all. He was all bloated from the operation and the drugs. When Jeremy rang me the next night from Shanghai I told him what had happened to dad. The words just seemed to tumble out and I needed someone close to share my sadness with. I am glad now I told him because I hate not telling people things. This would have put a lot more strain on me which may have resulted in me getting sick sooner and not being able to cope and both of us being out of action. Any way, little did I know at the time that Jeremy’s arteries were so blocked that he was going to have trouble no matter what. I have also found out from Jeremy only recently that when he was overseas he was experiencing angina (heart pain) when he was lying down trying to sleep at night which demonstrates my point. Jeremy himself has thoroughly reassured me that the stress he experienced in China and Hong Kong was entirely due to trying to do business in a country with a culture and language very different from what he was familiar with. He should not have been travelling when he was aware he had some sort of heart problem, but then again many business men do every day.

88

When Jeremy had further problems in Hong Kong he rang my brother in law in Melbourne who had been to China and Hong Kong many times and knew the ropes. Unfortunately Jeremy did not ring me personally which some what confused matters and needless to say it was most upsetting for me to get the news about him fourth hand, especially as my father was already at death’s door. Jeremy managed to be admitted to a Hong Kong hospital after having to come up with AUD$2000 in cash (via a friend) which the hospital demanded before they would admit him. After spending the night there he discovered it cost AUD$2000 a night. He then had trouble convincing them to let him go especially since all the tests they ran on him pointed to the fact that he had serious heart problems. Finally they did release him from the hospital the next day. It was difficult because they had to have one of the doctor’s signatures before they would let him on the plane. Understandably, airlines do not like having this sort of responsibility on their aircraft. When Jeremy was on the plane on his way back to Australia he started experiencing chest pains again so they had to clear out first class so they could lay him down and put him on a heart monitor. They called a medical emergency and made the plane go flat out and got back an hour earlier than scheduled. When I picked Jeremy up from the airport in the morning he was very agreeable to go and see his cardiologist and have an angiogram. Within two weeks Jeremy had his angiogram, and found out he had four arteries blocked. My brother and sister arrived to see my father within a few days of me ringing them. I managed to see dad about every second day to begin with. It was a two hour round journey; an hour there and an hour back. Sometimes I was only able to see dad for ten or fifteen minutes because the hospital staff would be attending to him. I did not get to see him on his own as an elderly lady friend of dad’s was always there and I did not feel I should have to ask her to leave. This was made more difficult for me because my younger daughter has an intellectual disability. It was not suitable for her to come with me because she has a very annoying giggling behaviour which people do not understand and often take her mannerisms the wrong way. Also, my daughter would not have properly understood what was going on and it probably would have upset her. Unfortunately, she gets extremely depressed if she is left at home on her own day after day and begs me not to go. My dad remained sedated in hospital for about 3 weeks. For much of this time he had a tracheotomy tube in his throat, so he was unable to speak. It was arranged that Jeremy should have his angiogram on Wednesday 22nd July. Jeremy’s sister who lives in England was worried about him when she heard about his ill health and decided she should come and visit. She was especially worried since we had arranged over a year ago that we should have her son come and stay with us for a month in July. This time it looked as if Jeremy would have an angiogram and perhaps a heart by pass. We had all been looking forward to having Ralph for over a year and felt unhappy that these calamities should mar this happy event. I felt particularly pressured at this time with my father at death’s door, and knowing that if he eventually would come out of hospital he would need looking after. My sister could not stay long as her daughter was soon to be sitting for her VCE in Melbourne, an important time in all young peoples lives which effects what choices they will have in life. My brother had another trip to America planned for August and he unrealistically felt that getting dad well and back on his feet had to revolve around

89

this. He also gave me the impression that he felt dad’s illness was more serious than Jeremy’s and that I should be doing more for dad, particularly as I was the one who lived the closest. With all these pressures pushing down on me I felt myself under pressure with Stephanie coming to stay for a week. On top of this Jeremy decided this was the time to organise a dinner party to have friends over to meet his sister. I had been previously worn down with all the worry of dad, Jeremy, and how I was going to cope with Ralph’s stay as well, and so from this point on my health began to fail and ebb away little by little. To make matters worse my car broke down and needed major repairs which we could hardly afford at this time, especially since the company Jeremy had done consulting for was going into liquidation. If this wasn’t enough Jeremy decided the only way out of our financial troubles was to buy the company with two other friends of his. It isn’t any wonder that I developed a sort of distancing technique to help me through. It was similar to when your body has had the shock of being immersed in very freezing cold water and then your body gets so numb you don’t feel anything any more. You sort of drift into a dreamlike state because you cannot believe these things are actually happening to you. In fact it almost feels like they are happening to someone else, and you are just observing a video. You close down any hurtful emotional issues and distance yourself from these things and just get on with the physical job as best you can because you know if you get too run down and you ruin your health then you are no use to any one. Although we were all making sacrifices to help my father we all had various degrees of family issues that needed taking care of before we could be strong enough to help him. Jeremy finally had his angiogram at Strathfield Hospital on Wednesday 22nd July, even though it was urgent that he had the angiogram as soon as possible. He wanted to be well informed and make sure that he felt confident about the conditions in which the procedure took place were safe. After all an angiogram is still quite a tricky operation in which they insert a small tube right up into the heart. Around the same time as Jeremy had his procedure a friend of ours had to be rushed into hospital to have an angiogram because he had heart pains. A blood clot developed as a result which could have killed him if the clot had have travelled to his heart. We took the position that being forewarned is being forearmed, or it is better to make sure you have the best options you can. Jeremy’s cardiologist recommended Strathfield Hospital and 22nd July was the earliest he could get him in. All these delays helped Jeremy and I prepare better emotionally for what was to come and gave us time to discuss our worries and to resolve them. When Jeremy had his angiogram it was discovered that he had four blocked arteries. One 90%, two 65%, and another one 55% blocked. So it was obvious that he would have to have a heart by pass and the balloon treatment would not work in his case. The doctor allowed me to watch the angiogram on the computer outside the theatre as it was happening. I found this extremely interesting, but I would not recommend it for everyone. The whole operation is taped, so doctors can view it afterwards. It is amazing how quick and skilful the doctors are. The whole angiogram only took about 15 minutes. Jeremy was lucky he did not really develop much of a bruise around the groin which is the point of entry for the tubes.

90

On Thursday 23rd July, the day after Jeremy’s angiogram, Ralph arrived from England. It was fun having Ralph to stay. He was helpful, well mannered and polite. He did not stay with us all the time during his three weeks stay. He went on trips up to see the Gold Coast and one of the Barrier Reef islands, because he was doing a degree in hospitality and worked for a travel agent. Ralph also went and stayed with friends in Canberra. I enjoyed having Ralph stay. A week after he left, and two weeks before Jeremy had his heart by pass, my health totally went downhill and I ended up in hospital. I believe now it was mainly brought on by constant stress. I had a series of migraines, flu, bladder infections, bleeding haemorrhoids, and an ear infection that took some months to get better. I was constantly on antibiotics.

91

LETTERS & COMMENTS A letter from Sister Adrian Small (Brigidine Convent, Randwick) 20th September 1998 “……………….I feel that the by-pass surgery is rather wonderful, and gives the patient a much improved quality of life. I never cease to wonder at the skills of the surgeon and his helpers, in particular the anaesthetists whose task is so important in keeping the patient’s breathing and blood pressure etc. constantly under control. Both my parents died of heart attacks, my father at seventy two and my mother at sixty five. Such surgical skills were not known in the 1940’s. In 1986, when I was sixty eight, I felt my first angina pains and in December of that year suffered a heart attack which hospitalised me on and off until the end of January 1987. I was a patient in Hornsby District Hospital and was transferred to the Royal North Shore Hospital, where I had an angiogram which was followed by a triple by-pass. I made a good recovery. I don’t recall feeling over-anxious before the operation - just grateful that something was going to be done which would, hopefully, improve my quality of life. And so it did. I was very faithful to my exercises, especially walking, and I did an early morning walk of one hour during the next few years. Several people told me that the by-pass grafts would last ten years, but I didn’t keep a check on time, and felt so well. The RNS Hospital has an excellent program for patients who have had heart surgery there, and even though circumstances have mad it impossible for me to attend all the meetings I receive notices of their activities, and much useful information by post. However, the ten year prediction proved fairly accurate, as in mid 1996 I became aware of angina pains. My local GP gave me helpful medication and useful hints, but in August 1996 he sent me to a cardiologist in Perth (where I had been living for the previous six months) who sent me straight from his surgery to St John of God Hospital - Intensive Care. I had an angiogram a few days later which showed my previous three grafts had blocked plus now another artery, so surgery was regarded as urgent. I had a quadruple by-pass performed in the Mount Hospital in Perth on the 7th September. All went well, but the following day I had to return to surgery and have an operation for a collapsed lung. Thank God I came through that, and two days later was fairly aware of everything and everyone, only to find that I had a racing heart -about 160 to 180 beats per minute. I think they called this an arrhythmic fibrillation. It had a very weakening effect, and despite use of drugs of all kinds it was only brought to normal by the use of the electrical “zap” seven days later. Despite this I made a very good recovery and am grateful for the wonderful care given me by my surgeon and cardiologist, as well as all the hospital staff in all the hospitals, both in 1987 and 1996. It is just two years since that last operation, and I’m feeling very well and immensely grateful to God has given such skills to men and women who use them for the good of their patients. I have never regretted having both lots of surgery and know that without them I would almost certainly not be alive to write these lines. My sister was with me on both these occasions and so knew pretty well what she was facing just two weeks ago.

92

I did enjoy my chats with Rhonda and was pleased to meet with you just as you were returning home. I shall remember you in my prayers and hope that your by-pass grafts will give you many years of excellent health. Your “youth” should stand you in good stead. Best wishes to Rhonda and yourself Yours sincerely, (Sr.) M. Adrian Small” ~~~~~~~~~~ “You are with other people and this makes it a very supportive environment.” When doctors first told Norma Pitt she had suffered a heart attack the news failed to sink in. As far as the 50-year-old housewife was concerned, the last thing she thought she’d be was a candidate for heart disease. “I’m in the low risk category for everything except hereditary factors. My father had a heart attack thirty years ago,” said Norma. Following her heart attack, Norma had a coronary angioplasty procedure and started a cardiac rehabilitation program one week later. “I think the program is very good because you are with other people and this makes it a very supportive environment.” ~~~~~~~~~~ “It’s been really important to be there with Dad.” Doctors had to delay Tony Magrin’s triple bypass surgery to treat his emphysema. Prior to treatment, surgery and rehabilitation the 71-year-old retired machinist had difficulty walking ten metres. After the six week program Tony felt confident walking for an hour without stopping. According to his daughter, Marie Lombardo, “If Dad can do it (rehabilitation) anyone can do it.” Marie and her twin sister Louise accompanied their father to all the rehabilitation sessions. “It’s been really important to be there with Dad, to learn what he should be doing at home. The dietician’s sessions have been particularly helpful in teaching us how to read food labels,” she said. ~~~~~~~~~~ “You feel there’s a chance for you to recover.” Barry Riordan had his first heart attack at the age of 42. The only problem was he “ran right through it”. “I’ve been an athlete all my life and was training for a marathon when I first experienced tight chest pain. I ignored it and continued to train.” Eighteen months later I woke up with chest pain and was diagnosed with a heart attack” said the fitness consultant and instructor. “I was stunned.” Barry’s first experience of cardiac rehabilitation was not a good one. “I got as far as the door and then I turned around and bolted.” After five minutes sitting in my car, I realised I had nowhere else to turn and went back inside. From there I never looked back” he said. “The good thing is people work with you to explain how your heart works and how to fix it. You feel there’s a chance for you to recover.” Two years later Barry had quadruple bypass surgery and has never felt better. Six weeks after the operation and after a second cardiac rehabilitation program he was back running. He now runs between six and fourteen kilometres a day. “The real challenge is to take all the things you learn through the cardiac rehabilitation program and keep applying them to everyday life over a long period of time. It’s easy to drop good habits” said Barry.

93

GETTING HEART SMART AFTER HEART PROBLEMS “With adequate rehabilitation, most cardiac patients can return to their normal activities, lead enjoyable and productive lives and have a reduced risk of further cardiac events.” Dr Michael Jelinek, Cardiologist and Chair, Heart Foundation Cardiac Rehabilitation Committee

94

One of the most effective ways to reduce the risk of death from heart disease is to make lifestyle changes such as enjoying healthy eating, taking up regular physical activity and giving up smoking. Cardiac rehabilitation programs help people who have had a heart attack, heart surgery, coronary angioplasty, angina or other heart problems make sensible, potentially life-saving changes to the way they live. The programs also help patients and their families deal with physical, emotional, psychological, marital, sexual and work-related issues. WHO says? Both the World Health Organisation and the Heart Foundation recommend that structured cardiac rehabilitation programs be available to all patients with cardiovascular disease. Cardiac rehabilitation starts when the patient is admitted to hospital. Following discharge after cardiac surgery or myocardial infarction (heart attack), patients generally attend outpatient cardiac rehabilitation for up to 8 weeks. The duration of cardiac rehabilitation may vary for other conditions, such as coronary angioplasty or heart failure. Many centres throughout Australia also provide community-based maintenance cardiac rehabilitation programs. The programs are conducted by qualified health professionals, such as physiotherapists, dieticians, cardiac nurses, occupational therapists and social workers with input from the patient’s cardiologist and other medical practitioners who retain overall responsibility for patient management. Patients and their families are encouraged to attend group sessions where possible. In some communities such as rural areas, other forms of program delivery including home-based sessions, may be available. Group sessions are important because they: • they reduce anxiety and depression • reinforce lifestyle changes such as smoking cessation, increased physical activity, low-fat healthy eating patterns • dispel myths such as that old chestnut: sexual activity causes heart attack • foster camaraderie, with more advanced participants becoming positive role models for those starting the program • discourage over-protectiveness by other members of the family. What happens at each session? At the start of each cardiac rehabilitation session health professionals check pulse rates and blood pressure and monitor symptoms like shortness of breath, lethargy, loss of appetite or anything which may signify an underlying psychological or physical problem. A health professional addresses the group on a range of topics such as: • heart health assessment • what is heart disease? • risk factors for heart disease • understanding medications • investigations and procedures • healthy eating for the heart • physical activity • fears and emotions • dealing with stress • moving on - where to from here? 95

The group participates in gentle warm-up activities followed by individually prescribed physical activity programs. Why should I attend? Research into cardiac rehabilitation programs shows participants have an improved quality of life. They: • return to work earlier • demonstrate increased social independence • experience less depression and anxiety • have greater exercise capacity • are less likely to return to smoking. Thanks to the work of the Heart Foundation, cardiac rehabilitation programs are available at many metropolitan and regional centres in Australia. For details about your closest cardiac rehabilitation program call the Heart Foundation’s Heartline on 1300 362787.

GOOD ONE - LINERS ! • Nobody’s going to believe I had by-pass surgery, so I’m having photos taken to prove it. • You’ve lived a good life (sic 48 years !) and you’ve seen your children grow up, so why worry about whether you live or die. • Coping with a heart operation is much like being parachuted on to the top of Mt. Everest with nothing more than a pair of snow shoes and a world map to go by.

96

• Very late in December 1950 the 14th Dalai Lama was fleeing the Communist Chinese invasion of Tibet. Travelling with him was his brother Lobsang who had been in a swoon from a heart attack for a couple of hours. The Dalai Lama’s personal physician applied the same rough treatment as would have been given to a horse. His naked flesh was seared by a branding iron. And he survived !

GLOSSARY Anti-coagulants. Drugs used to treat and prevent abnormal blood clotting. Aorta. The main artery of the body. The aorta rises directly form the left ventricle (the main pumping chamber of the heart) and supplies oxygen-rich blood to all other arteries except the pulmonary artery. Aortic valve. The valve separating the left ventricle and the aorta. Atrium (pl. atria). One of the heart’s two upper (collecting) chambers. Bacterial endocarditis. An infection of the heart valves. Balloon valvotomy. A procedure using a balloon to open stuck valves. Biologic tissue valves. Valves made from human or animal tissue. 97

Homograft valve. A human aortic valve used for transplantation. Incompetent valve. A “leaking” valve which allows blood to flow back into a chamber of the heart (see regurgitant valve). Mechanical valves. Valves made from materials such as plastic or metal. Mitral valve. The valve between the left atrium and left ventricle. Murmur. A swishing sound caused by blood flowing forwards or backwards in the heart abnormally. Prosthetic rings. Special rings used to narrow an enlarged valve and make repairs stronger. Pulmonary valve. The valve separating the right ventricle and the pulmonary artery. Regurgitant valve. (See incompetent valve). Stenotic valve. A narrowed, stiff valve. Tricuspid valve. The valve between the right atrium and right ventricle. Ventricle. One of the two main pumping chambers of the heart. Warfarin. One of a group of anti-clotting drugs.

98