Miniature electronics that power smartphones and gaming consoles are sparking new innovations in cardiology. Wireless devices monitor the heart 24/7 to save lives in specialized hospital units. Now, the sophisticated gizmos are standing watch over heart patients after they go home.

Today’s tiny implants monitor blood flow or heart rhythm, among other key measures. Then, when something goes wrong, the device signals a medical professional and alerts the patient to seek help immediately. Research proves that implanted heart failure monitors reduce hospitalizations and improve outcomes. Pacemaker and defibrillator monitors with wireless communication features routinely perform checkups without a trip to the doctor’s office.

On the horizon: an early warning system to detect heart attacks before symptoms occur, ensuring the best, most timely treatment possible. Clinical trials of the AngelMed Guardian device (the ALERTS study) are recruiting patients at nearly 80 study locations nationwide.

Innovations in Heart Health The Saturday Evening Post

Snow shoveling quickens heartbeat, dilates blood vessels, and boosts stress hormones. All these factors can combine to cause a heart attack in people with heart disease, high blood pressure, high cholesterol, diabetes, or who smoke.

Before grabbing your snow shovel, Indiana University Health cardiologists recommend training your heart for safe shoveling with daily aerobic exercise. Simple steps include parking farther away from the front door or taking the stairs in lieu of the elevator. It’s akin to getting ready for a marathon: strengthening the heart before the snow flies equips it to handle the future stress of heavy shoveling.

Is Your Body Shovel-Ready? The Saturday Evening Post

AEDs are computerized devices that check a person’s heart rhythm and deliver a shock to restore a heartbeat, if needed. Odds of surviving SCA drop about 10 percent every minute that a shock is not received.

“I like the analogy of AEDs and fire extinguishers,” says Dr. Page. “It’s unthinkable to not have fire extinguishers or smoke detectors in public places. When I give lectures about AEDs, I can usually spot a fire extinguisher nearby. But in many cases, I have not seen an AED on my way to the podium.”

Post: When were portable defibrillators first used in the U.S.?

Dr. Page: They were introduced in the 1990s, and American Airlines began putting defibrillators on aircraft in 1997. I was at the University of Texas Southwestern Medical Center in Dallas at the time. We worked with American Airlines and I reported the experience in the New England Journal of Medicine. A study of AEDs in casinos was conducted at the same time and those results appeared back-to-back with the aircraft article. In 2000, the American Heart Association named the AED one of the top 10 cardiac research advances. It’s gratifying that AEDs are being placed in more and more venues. But it’s distressing that they aren’t everywhere yet.

It is important to note that AEDs are automated external defibrillators rather than automatic external defibrillators. People get this wrong all the time. There is a wearable vest defibrillator that automatically gives a shock for SCA.  But the AEDs in health clubs, hospitals, police cars, aircraft, and casinos are automated, not automatic. These devices will not deliver a shock until the human operator pushes a flashing red button.

Post: Who can use a portable defibrillator?

Dr. Page: I think anyone can. Some states require authorization to use these devices, and I support the American Heart Association’s efforts to train the public. But the simplicity of these devices was demonstrated by investigators in Seattle, who did a small study with mannequins, 6th graders, and paramedics. They instructed the 6th graders (who had no prior experience with an AED) to figure out the device and save the life of a mannequin. Results published in the journal, Circulation, one of the best heart journals, showed that 6th graders delivered a shock in 92 seconds. Well-trained Seattle paramedics accomplished it in 60 seconds. So it is better to be trained, but almost anyone can figure out how to use an AED.

Training is important, but if I had a cardiac arrest and no one knew how to use an AED, I’d much rather that a bystander try to figure it out than wait 10 minutes for an ambulance to get to me. In the casino experience, a setting in which every arrest was videotaped, three out of four victims survived if they were shocked within three minutes. In contrast, less than one in 20 survives SCA in most cities.

Post: What about “no-hands” CPR?

Dr. Page: I was one of the co-authors that issued the AHA scientific advisory statement in 2008 recommending compression-only CPR for adults who experience sudden cardiac arrest outside of the hospital. The advisory group and the American Heart Association have gotten behind the idea of hands-only CPR.

This makes sense for many reasons. For example, if I have sudden cardiac arrest right now, I have plenty of oxygen in my blood—what I need is circulation. We know from some very important research in animals and in humans that in CPR you need to pump hard, fast, and continuously to maintain blood pressure. After every pause in chest compression, you have to work to build up the blood pressure again. Mouth-to-mouth breathing probably isn’t necessary. Chest compressions actually move some air, too.

Post: Can someone be sued for using an AED if the victim dies or gets brain damage?

Dr. Page: Probably not, because every state has Good Samaritan laws in place. The operator has almost no liability risk, as long as he or she is operating in the best interest of the individual.

Post: You mentioned earlier that these devices are more accessible, but there aren’t enough of them. Why is that?

Dr. Page: One challenge is public awareness, getting the word out. Another is a mistaken concern about liability, as we’ve discussed. And finally, cost is an issue. If AEDs cost the same as fire extinguishers or smoke detectors, we would have more of them out there. I don’t generally support AEDs in homes because the overall likelihood of one being used is so small that our health dollars would probably be better served in other ways.

Post: Even though most sudden cardiac arrests happen at home?

Dr. Page: Yes. The problem is that many of these events occur when the person is asleep or alone, so having an AED would be of no benefit. Although a home AED would not hurt, and some people elect to purchase these, I am primarily interested in campaigns to place AEDs in more public places.

Post: If people are interested in doing something like that, where do they start?

Dr. Page: They can contact the Heart Rhythm Society or the American Heart Association for advice. The Heart Rhythm Society has advocated strongly on behalf of patients at risk for and who have experienced cardiac arrest, and we maintain an active Web site. Area physicians may also be a good resource for grassroots campaigns and local champions.

Post: What do you expect might be the next breakthroughs in preventing SCA and saving lives?

Dr. Page: I envision two avenues. One is better identification of those individuals who are at the highest risk for SCA and would benefit most from an ICD to modify that risk. The second (because we won’t identify everybody at risk) is to increase awareness of SCA, improve accessibility to AEDs, and increase the number of people who are trained in CPR and AED use.

I’ll tell you an interesting story that occurred while Charlie Jones, Heart Rhythm Society Vice President of Marketing, Communications and Membership, and I were visiting a number of media outlets on the east coast. After we landed in D.C. and were driving away from National Airport, Charlie noticed something unusual by the side of the road and said, “I think someone’s down there.”

We stopped, and there was a man in his 50s who had experienced sudden cardiac arrest while jogging along the road. Bystanders were already doing two-person CPR with beautiful respirations, so I didn’t interfere with that other than to take my turn at chest compressions. Occasionally the victim would make a gasping breath and people said, “Oh, he’s breathing, let’s stop.” But I said, “No, no, keep going” because I knew the gasping breath was a brain stem response, not a conscious one. When the ambulance arrived with the AED, a single shock was delivered. One shock, and he had been down probably 15 minutes or more! He awoke and actually gave us a thumbs-up when he got in the ambulance.

Isn’t that amazing? The experience reminded me that CPR, when well performed, pumps blood well to the heart and brain. CPR can keep someone alive until the person gets that lifesaving shock from the AED. Being familiar with CPR and AEDs really does save lives.

Click here for Part 1: Understanding SCA. 5 facts about sudden cardiac arrest and heart attack.
Click here for Part 2: Preventing SCA. Are you at risk?

Curing SCA with Defibrillators and No-Hands CPR The Saturday Evening Post

Millions of Americans are living with an overactive or underactive thyroid, according to the American Association of Clinical Endocrinologists (AACE). Unfortunately, many go undiagnosed until something goes terrible awry, at times wreaking havoc on one’s quality of life. In this Web exclusive interview, we offer information about diagnosing and treating thyroid disease from Dr. Jeffrey R. Garber, immediate past president of the AACE, chief of endocrinology at Harvard Vanguard Medical Associates, and associate professor of medicine at Harvard Medical School to accompany the Jul/Aug 2010 Post Investigates feature: “Thyroid: A Secret Culprit,” by Dr. Mehmet Oz.

Dr. Jeffrey GarberCourtesy AACE

Post: Who should be tested? Should it be part of a routine annual physical?
Dr. Garber: Thyroid testing was not part of President Bush Sr.’s annual physical. If you remember, his hyperthyroidism was diagnosed after he had problems breathing while jogging. Today, the American Thyroid Association recommends screening every five years, starting at age 35. Universal screening is not felt to be cost effective, but most experts would recommend testing women over 60, those with symptoms, and then targeted subgroups such as smokers or those with a personal or family history that includes autoimmune conditions.

Having symptoms of thyroid disease does not mean one has it. Making a diagnosis solely based on symptoms can be inordinately difficult. However, the diagnosis becomes straightforward by testing for it. People should target themselves based on symptoms. If you are aware of thyroid conditions and believe you are experiencing enough symptoms, it is easy for a doctor to justify testing.

In addition, doctors should target patients on the basis of other risk factors. For example, I would check someone who comes to my office saying “I feel perfectly well” if I felt a lump in their thyroid or there was a compelling history. Thyroid disease is very easy to overlook.

Post: Hypothyroidism seems to be frequently in the headlines. Any reason why?
Dr. Garber: I think we live in an era in which people are seeking holistic approaches—sometimes in a good sense, and sometimes in a way that they can get exploited, in my view. Thyroid disease lends itself to an approach by some practitioners that is generally symptom-based. The idea that a constellation of symptoms dictates a diagnosis, despite the lack of conventional proof, is where the tension comes in.

“What Your Doctor Won’t Tell You” is a great headline. What people don’t read about is the downside of taking thyroid hormone products. It is not a free ride. My major concern is the risk of over-treatment. The second concern is that by treating symptoms without a certain diagnosis, a doctor will overlook another important fact or condition. Hypothyroidism can masquerade as depression, but depression can masquerade as hypothyroidism, for example.

Then there is the cost of medicine and the cost of testing. I would never argue with someone who says they feel a certain way, but the data doesn’t support that treating marginal disease necessarily leads to benefit. If a person has borderline thyroid stimulating hormone (TSH) levels and no symptoms or compelling medical reason, such as planning a pregnancy, treatment may not be called for. If people are borderline and symptomatic, of course, try to treat it. But give it a limited time. Don’t just commit people to medicine and put them at risk for being over-medicated or being subject to costs and missing other possible reasons for what they are feeling. Fatigue is the 21st century complaint. We’ve got a lot of reasons to be tired besides our thyroid.

Thyroid drug analogs, or copies of thyroid hormone, are also being mentioned in the press. As recently as March 11, 2010, the New England Journal of Medicine featured a follow-up article on the subject. The concept is to design a thyroid hormone analog that has the benefits of, say, inducing weight loss or lowering cholesterol, but not the drawback of stimulating the heart.

Post: How far away is this concept from actual reality?
Dr. Garber: It was pretty far away until March 11. These researchers demonstrated that one particular analog did not affect the heart, and did lower cholesterol.

Another drug analog was studied in heart disease patients. Many lost weight, but 60 percent to 70 percent of the patients dropped out of the study because they felt lousy. Since the study was not designed to analyze weight loss, researchers couldn’t do a good job of finding out whether people ate less because they had a lousy appetite, which is a terrible way to lose weight, as opposed to eating less because their appetite isn’t as high.

Post: Is there a better test for thyroid hormone levels on the horizon?
Dr. Garber: Not at present. The current discussion is whether we need to take a new look at what is considered the normal range for TSH levels, depending on the situation. Data show that some TSH levels we now consider elevated—in the elderly—may not represent hypothyroidism. And, on the other hand, new guidelines are definitely going to set a lower TSH of approximately 2.5 as the upper normal in the first trimester of pregnancy.

Post: What is the link between thyroid hormone and heart attack and heart disease?
Dr. Garber: If you are profoundly hypothyroid, you often become hypertensive and hypercholesterolemic. As a result, your vessels become constricted as well. Hyperthyroidism affects the heart mostly through rhythm disturbances characterized by fast heart rates including atrial fibrillation and sinus tachycardia.

Post: Are there other new developments you would like to mention?
Dr. Garber: A recent discovery suggests there is a subgroup of people with a certain genotype that are more likely to feel better on a T3-T4 combination therapy. We are not at the point that we are going to start doing genetic testing on people, but the study found that certain people with a certain genotype were more likely to feel better on combination therapy. From a hot, new, and conceptual point of view, the discovery may provide yet another role for genetic testing.

Resources:

Click here for more information from the American Association of Clinical Endocrinologists and to find an endocrinologist near you.

Click here for an excerpt from “The Harvard Medical School Guide to Overcoming Thyroid Problems” by Dr. Jeffrey R. Garber, published by McGraw-Hill.

Thyroid Disease: A Post Web Exclusive The Saturday Evening Post