Living a Healthy Life with Chronic Pain (47 page)

High blood pressure (hypertension) increases the risk of coronary artery disease. Blood pressure is a measurement of the amount of pressure in an artery, expressed as two numbers. The higher first number is the pressure in the artery when the heart contracts and pushes out a wave of blood. The lower second number is the pressure when the heart relaxes between contractions. Both numbers are important because a high reading for either can compromise the ability for your heart to function normally, especially over time.

High blood pressure is often called the silent disease because most people who have it have no symptoms. Because they feel perfectly well, they find it hard to believe that anything is wrong and so they may not seek treatment. However, the silent disease may not stay silent. Over years, untreated high blood pressure can damage blood vessels throughout the body. In some people this damage can cause strokes, heart attacks, heart failure, or damage to the eyes or kidneys. To prevent these serious complications, it is extremely important to get your
blood pressure checked regularly even if you feel perfectly well.

What is normal blood pressure? A healthy blood pressure is below 120/80 (described as “120 over 80”). A condition called prehypertension is indicated by a reading that is above 120/80 but below 140/90. Hypertension is 140/90 or higher. For most people, lower blood pressure is accompanied by less risk of complications. It’s important to note that if you have diabetes, your acceptable blood pressure range may be even lower. Consider having a discussion with your primary care provider about the blood pressure range that would be the right target for you.

Hypertension is diagnosed when blood pressure measurements are high at two or more separate times. Except in severe cases, the diagnosis is never based on a single measurement because everyone’s blood pressure varies from minute to minute. That’s one reason it is important to have repeated measurements of your blood pressure.

Some people’s blood pressure tends to go up only in the health care provider’s office. This is a stress reaction called “white-coat hypertension.” That is another reason why it is helpful to have additional measurements for both diagnosing hypertension and monitoring blood pressure treatment.

There are many ways to get your blood pressure checked. Ask at the pharmacy, fire station, or senior center. You can even get a machine and take your blood pressure at home. Collect three or four blood pressure readings and see how they vary, depending on what you are doing. Take the results with you to your health care professional.

People can often lower their blood pressure by eating a low-sodium diet, exercising, maintaining a healthy weight, limiting alcohol, and using prescribed medications. Don’t be reluctant to take these medications due to fear of side effects. Many people with high blood pressure actually feel better (less fatigue, fewer headaches, and so on) when they are on the medications.

Peripheral vascular disease (PVD) occurs when the arteries in the legs harden, form plaque deposits, and narrow (atherosclerosis). Atherosclerosis in the legs is usually the result of the same disease process that happens with atherosclerosis in coronary artery disease (see
page 304
).

The main symptom of peripheral vascular disease is leg pain when walking. Some people may also experience leg sores that don’t heal or heal slowly. Treatments are similar to those for coronary artery disease (which we discuss in detail later in this chapter). They include stopping smoking, exercise, medications, and sometimes surgery to help restore blood flow to the legs.

Sometimes the symptoms of coronary artery disease are clear and “classic” such as angina pain in the chest during physical activity. But others have atypical angina and experience only vague symptoms. Fortunately, there are now many tests available to determine the presence and severity of coronary artery disease. The following are the most common tests for coronary artery disease:

• Blood tests
  . Blood tests to measure cholesterol and triglycerides estimate your risk of coronary artery disease. They are also used to monitor the effects of cholesterol-lowering medications. If you are having chest pains, your physician may order tests to confirm the diagnosis of a heart attack.
  

• Electrocardiogram
  . An electrocardiogram (EKG or ECG) measures patterns of electrical currents produced by your heartbeat. This test requires you lie still for only a few minutes. Ten thin wires are attached to your chest, arms, and legs. The electrical patterns of your heartbeat are recorded by the wires and plotted on a paper graph for your health care provider to read. The EKG is a “snapshot” of your heart’s activity. It can show a lack of oxygen to the heart, a heart attack, heart enlargement, and irregular heart rhythm. The test may need to be repeated to see if a heart attack is occurring. Sometimes a portable monitor is worn for several hours or days to detect abnormal heart rhythms that come and go. An EKG cannot predict the risk for a future heart attack.
  

• Echocardiogram
  . This test uses sound waves (ultrasound) to generate a moving picture of the heart. A computer converts echoes and displays them on a monitor to show the shape, texture, and movement of heart valves as well as the size and function of the heart chambers. It provides a more detailed picture of the heart than can be seen in an X-ray. This test does not involve radiation exposure, does not require any special preparation, and does not cause any pain or discomfort. To prepare, a gel is spread on the chest to help transmit the sound waves, and a device called a transducer is moved over the chest wall. An echocardiogram is very helpful in determining if there is any type of dysfunction of the chambers or valves of the heart. It may also be done while you exercise (stress testing) to see how your heart responds to stress.
  

• Stress test
  . Sometimes problems appear only when the heart is under increased stress. (In this case stress refers to something that makes the heart work harder, not emotional stress.) A stress test is done while a person is exercising on a treadmill or stationary bicycle or after a doctor injects a chemical to stimulate the heart without exercising. If the test is performed while you are exercising, you begin to walk on the treadmill or pedal the bike, and the intensity of the exercise increases every 2 to 3 minutes. Your blood pressure, heart rate, EKG tracing, and any angina pain or discomfort
  are monitored throughout the test and for a few minutes afterward. The test is stopped if you experience angina or become short of breath. While a positive test result may suggest the presence of coronary artery disease, sometimes stress tests can give false results, especially in women. Sometimes, people with coronary artery disease will have a negative test, and people with no coronary artery disease have a positive test. It is a safe test, and is often done in conjunction with another test to confirm the results.
  

• Nuclear scan
  . During this test, a weak radioactive substance is injected into a vein. Then a scanner or special camera takes two sets of pictures—with and without stress (induced by exercise or medication). By comparing the pictures, your doctor evaluates blood distribution to the heart muscle and how well your heart is pumping.
  

• Cardiac catheterization and coronary angiography
  . For this procedure, a long plastic tube called a catheter is inserted through a major blood vessel (usually in the groin) and gently guided into the heart. A dye is then injected into the catheter. This allows your coronary arteries to show up on X-rays. This test helps your physician decide the best treatment if the arteries are clogged. It can also give information about the function of the heart muscle and the valves.
  

There are three general approaches to help prevent and treat coronary artery disease and angina: lifestyle changes, medications, and procedures and surgery. Most people will benefit from one or more of these. In this chapter we first address the lifestyle changes and nondrug treatments and then we discuss medications, and procedures and surgery.

Heart attacks and high blood pressure can often be prevented or controlled by adopting the following lifestyle changes and/or nondrug treatments:

• Not smoking.
  Smoking damages the inner lining of the blood vessels and raises blood pressure. Quitting is the best thing you can do for your health. Fortunately, there are now a variety of support programs (from telephone counseling to online and group programs) and medications (from nicotine gum and patches to calming medications) that can help you quit and stay quit.
  

• Exercising.
  Exercise strengthens your heart. It can also lower your cholesterol and blood pressure and help you control your weight. Inactive people double their risk for coronary artery disease. Even small amounts of daily physical activity can lower your risk of coronary artery disease and help you feel better and have more energy (see
  Chapters 7
  ,
  8
  , and
  9
  ).
  

• Eating well.
  The higher your cholesterol level, the greater your risk for coronary
  artery disease. Lowering the amount of cholesterol in your diet can reduce the risk of heart attacks and strokes (see
  Chapters 13
  ). Unfortunately, not all cholesterol can be controlled by what you eat or drink. The body also makes cholesterol, and medications may be necessary. (See
  pages 305
  –
  307
  for more on cholesterol.)
  

• Maintaining a healthy weight.
  Being overweight makes your heart work harder, raises your cholesterol and blood pressure, and increases your chances of developing diabetes. Carrying excess weight around the midsection is a particular risk factor for coronary artery disease. Regular exercise and healthy eating are the most important steps to lose weight and maintain a healthy weight. (See
  Chapters 14
  .)
  

• Managing emotional stress.
  Stress increases your blood pressure and heart rate, which can damage the lining of the blood vessels. This can lead to coronary artery disease. (See
  Chapters 4
  and
  5
  for ways to manage stress.)
  

• Limiting alcohol.
  Drinking a little (one drink per day for women, two drinks per day for men) may
  reduce
  the risk of coronary artery disease, but drinking more or binge drinking (more than five drinks at one time) can
  increase
  the risk of both coronary artery disease and high blood pressure. If you do use alcohol, limit your consumption.
  

• Controlling diabetes.
  If you have diabetes, your risk for coronary artery disease more than doubles because high blood sugar damages blood vessels. By controlling your blood sugar and taking certain heart-protective medications, you can greatly lower the risk of heart attack and stroke.
  

Exercise can be both safe and beneficial for many people with coronary artery disease and angina. To make the most of your exercise, work closely with your health providers to find the best exercise program for your needs. Remember that regular, well-chosen exercise is an important part of treatment and rehabilitation. It can lower your risk for future problems, reduce the need for hospitalization, and improve your quality of life.

Coronary artery disease and angina can limit the kinds and amount of exercise you do. Follow your health care provider’s advice about exercise and exertion if you have poor circulation to the heart. If your condition is severe, your health care provider may want to change your treatment before giving you clearance to exercise. For example, if you have poor circulation to the heart muscle, your doctor may recommend medications, bypass surgery, or “balloon” angioplasty to improve blood flow to the heart before clearing you for exercise activities. (See the material later in the chapter on
page 317
for more on heart procedures and surgeries.)

If you do not have any restricting conditions or a health care provider’s advisory, it is safe for you to begin the exercises in this book (see
Chapters 7
,
8
, and
9
). The following are special considerations for people with coronary artery disease:

• Strengthening activities such as isometrics, weightlifting, or rowing can increase blood pressure and stress your heart needlessly. This can be dangerous if you have high blood pressure or your heart has poor circulation. If strengthening exercises are part of your fitness program, pay special attention and make sure you do not hold your breath while you exercise. Remember to breathe out as you exert. One way to be sure to breathe is to count out loud or breathe out through pursed lips.
  

• If you have not exercised since your coronary artery disease began, supervision by experienced professionals is a good way to start. Most communities have cardiac rehabilitation programs or professionally staffed gyms at a local hospital or community center.
  

• When exercising, keep the intensity well below the level that causes symptoms such as angina or severe shortness of breath. For example, if you get angina during an exercise treadmill test when your heart is beating at 130 beats per minute, you should not let your heart get above 115 beats per minute when you exercise. If you cannot easily judge your intensity to stay below your “symptom zone,” wear a pulse rate monitor (available at medical supply and sporting good stores) and check your heart rate at any time. Other ways to monitor the intensity of your exercise are the talk test or a perceived exertion scale (see
  Chapters 9
  ,
  page 151
  , and the Borg Scale of Perceived Exertion that follows.
  

• If your heart has poor circulation, avoid activities that cause you to strain. Try safer and more helpful conditioning activities such as light calisthenics, walking, swimming, and stationary bicycling.
  

• Always remember that if you develop new or different angina symptoms, while at rest or while exercising, you should stop what you are doing and contact your health care provider.
  

Some people with coronary artery disease and angina find it helpful to use a scale to monitor their physical exertion. The Borg Scale is one method of monitoring your level of effort on a scale from 6 to 20, with 6 being “no exertion at all” and 20 being “maximal exertion”—the most strenuous ever experienced (see
page 315
). More information on how to use the scale can be found online at the Center for Disease Control and Prevention website at:

www.cdc.gov/physicalactivity/everyone/measuring/exertion.html

People with peripheral vascular disease can experience pain in the legs during exercise. The good news is that conditioning exercises can help improve endurance and reduce leg pain for most people. Start with short walks or bicycling (see
Chapters 9
), and continue to the point when you start to have leg pain. Slow down or stop and rest until the discomfort eases and then start again. Repeat this cycle for 5 to 10 minutes. Many people find they can gradually increase the length of time they can walk comfortably or exercise with this method. A good goal is to be able to keep going for 30 to 60 minutes, which is long enough to get noticeable fitness benefits too. If leg pain continues to prevent you from being physically active, talk to your health care provider about your options. Remember, arm exercises won’t usually cause leg pain, so be sure to include them as an important part of your overall conditioning program.

Source
: The Borg RPE Scale
^®
. Scales with instructions can be obtained from Borg Perception:
www.borgperception.se
.

Maintaining a healthy weight is a key way to managing coronary heart disease and angina. Healthy eating is an important step to lose weight and maintain a healthy weight.

People with coronary artery disease and angina need to eat healthy to prevent their arteries from hardening or getting clogged. Review the section on oils and fats in
Chapters 13
on
page 212
. Most of the fat you eat should come from the good (unsaturated) fats and very little from the bad (saturated) fats. You should eat little to no trans fat. If you have coronary artery disease and angina, increase the amount of fiber you eat. Fiber is plentiful in oats, barley, dried beans and peas, lentils, apples, citrus fruits, carrots, and psyllium seed. Fiber consumption can help you manage high blood cholesterol, a major risk factor for coronary artery disease.

To learn more about healthy eating, including how to make healthy choices, and increase fiber in your eating plan, see
Chapters 13
.

It is important to weigh yourself properly and frequently if you want to catch trends that may indicate health problems. Here’s how to do it:

• Weigh yourself daily at about the same time every day. We suggest weighing every morning, just after waking up (after urinating and before eating).
  

• Weigh yourself with the same amount of clothing on or without clothing.
  

• Use the same scale. Check to be sure it is set to zero and resting on a hard surface before weighing yourself.
  

• Write your weight in a daily log (a journal or calendar works well).
  

• Weigh yourself again if you have doubts about the scale or your weight.
  

• Bring your daily weight log to all your medical appointments.
  

• Call your health care professional if you gain two or more pounds in a day or five or more pounds in five days, or if you experience shortness of breath or increased swelling of feet or ankles.
  

To learn more about maintaining a healthy weight, see
Chapters 14
.

A variety of medications are available to treat coronary artery disease and angina, high blood pressure, and peripheral vascular disease. In the past, medications were prescribed only if lifestyle changes such as healthy eating and exercise failed. Newer research suggests that combining certain medications with lifestyle changes provides the greatest benefit.

Nitrates are medications that alleviate chest pain by expanding blood vessels to increase the flow of oxygen-rich blood to the heart and decrease cardiac workload. Examples include nitroglycerin (Nitrostat
^®
, Nitro-Bid
^®
, and Nitro-Dur
^®
) and isosorbide dinitrate (Isordil
^®
). Nitrates are categorized as immediate release (act quickly) or extended release (act over time) formulations. Immediate release formulations are used to prevent or manage an angina attack. These include spray or tablets, both of which are applied under the tongue. Extended release formulations are used as maintenance therapy to keep coronary vessels open. These include patches, which deliver nitrates through the skin, and pills, which are swallowed.

Nitroglycerine is often taken under the tongue (as a pill or a spray) at the first sign of angina. You must speak to your health care provider for specific guidance on using nitroglycerine, depending on your situation. You can also take nitroglycerine before activity to prevent an angina attack rather than just using it when you are having an attack. To learn more about this, speak to your health care provider. Always carry your nitroglycerine with you and be sure your supply is fresh. Arrange with your pharmacist to have your prescription refilled regularly. Nitroglycerine is sensitive to light, so be sure to keep it in the container the pharmacy provided.

Table 19.2
on
pages 318
–
319
lists other common medications for managing coronary artery disease and high blood pressure. If you have these conditions, consult your health care provider to find out if some or all of these heart-protective medications are right for you. If one medication is not working for you or is causing side effects, discuss this with your provider. Usually an alternative medication can be found that will work. These medications are not addictive and usually can be used safely over many years to reduce the risk of coronary artery disease and high blood pressure. Do not start or stop these medications without discussing it with your health care provider. Read
Chapters 15
for information on how to be better able to manage the medications you take.