Tis the Season to be Jolly, Unless You’re a Heart!

Like many of you, the holidays are my favorite time of the year. Unfortunately, our hearts aren’t quite as keen on the occasion. So what with all the ballyhoo over Ebola — and not to worry, we’ll be back with scary infectious diseases with my next posting — let’s talk about something that might actually kill you or one of your loved ones this year. How’s that for the Christmas spirit!

The_Santa_Clause[1]SONY DSC
Popular culture — possibly part of the problem??? But oh so much fun!

The holiday season, especially the time between Christmas Day and New Year’s Day, carries with it an increase in cardiac death. The reasons for this are still somewhat debatable, but an interesting 2004 study published in Circulation attributed the effect at least in part to the duel threat of increased stress and a delay in people seeking medical care. This makes a lot of sense as we already know that the most common time of day for suffering a heart attack is in the morning due to levels of stress hormones, specifically corticosteroids, being highest at that time of the day. This increase in stress hormones increases strain on the heart and makes it more likely that a plaque in a coronary (heart-feeding) artery will rupture and cause the heart tissue that it feeds to die — a heart attack (myocardial infarction). Furthermore, hospital workers from coast-to-coast invariably will attest to the fact that the holidays are usually a slow period around the hospital. Since it’s safe to assume that this isn’t because Christmas and New Year’s Eve don’t magically make people less sick it logically follows that sick people must be putting off going to the hospital on these important family holidays. Unfortunately, ignoring a bad situation, especially a heart attack, is the one sure way to transform it into worse news, the take home message being that if grandpa is feeling sick at the Christmas party you should really put his butt into the car and drive him to the nearest ER for evaluation whether he likes it or not.

640px-The_Waltons_1974

I ain’t need no doctor. What I need is some a’ this bacon off a’ this ole hog!

Holiday Heart is another interesting holiday phenomena. Holiday Heart is an irregular heart rate that classically affects otherwise healthy young people after a drinking binge. The exact causation is unknown, but excessive alcohol (and it generally takes A LOT) consumption somehow screws with the conduction system of the heart and can push it into a pathologic rhythm called atrial fibrillation. Recall the normal conduction system of the heart, which is nicely reviewed in this diagram (don’t be lazy, it only takes 10 seconds to get it).
2018_Conduction_System_of_Heart[1]

The normal conduction system of the heart is illustrated by the yellow arrows. The electrical current flows from the SA node (the pacemaker of the heart) down the atria to the AV node and then to the ventricles. The electrical current causes the muscle cells of the heart to contract. This system allows the atria (top of the heart) to contract first, filling the ventricles, which then contract slightly later to pump blood to the rest of the body. Venous blood from the body flows into the right atrium (located on the upper left-side of the diagram — medical diagrams are drawn as if you were facing the patient) which then pumps blood to the right ventricle ,which then pumps blood to the lungs where it is oxygenated. Blood from the lungs flows back to the heart via the pulmonary veins, which empty into the left atrium (upper right hand corner of the diagram — again, imagine that you are facing the patient). The left atrium dumps its blood into the left ventricle which then contracts to pump blood to the entire rest of the body.

Heart_conduct_atrialfib[1]

In atrial fibrillation the electrical current in the atria goes totally screwy. Instead of moving in one direction, from the top of the atria to the AV node and then on to the ventricles, the electrical current in atrial fibrillation zips around the atria every which way. So instead of a nice regular current reaching the AV node (and then the ventricles) every second or so, the heartbeat in atrial fibrillation sometimes skips beats and sometimes goes really fast. The skipping beats is usually what scares people enough to go to the ER, but it’s actually the speeding up of the heart, which sometimes last just a few seconds but sometimes can last hours, that is really dangerous and that can even cause the heart to fail.

The good news about Holiday Heart is that it usually self-resolves (goes away on its own) within about 24 hours. The bad news is that if it doesn’t resolve within less than about 24-48 hours then the treatment is anticoagulation followed by electrical cardioversion. Electrical cardioversion is shocking the heart back into a normal rhythm with electrical pads, and you have to be anticoagulated first because the irregular rhythm of atrial fibrillation (if it persists) predisposes the body to forming blood clots in the heart. Shocking a heart with a big honking blood clot hanging out in the atria back into a regular rhythm is a bad idea because it can dislodge the clot and cause a massive stroke. This is the reason why most people (generally the elderly) who have chronic atrial fibrillation have to be on lifelong anticoagulation.

Warfarin_bottles_NIGMS
The most commonly prescribed anticoagulant for patients with chronic atrial fibrillation, Coumadin is both an extremely nasty drug and a drug that has prevented untold thousands of strokes. As with any medical intervention, it’s all about risks vs. benefits. Interestingly enough, Coumadin is also used in very high doses as rat poison. Rats are very intelligent creatures and it is difficult to design a poison that they don’t recognize and start avoiding after a few rats have died from eating it. Coumadin and its related compounds avoid this by slowly poisoning rats over time. The rats eventually bleed to death, but it takes way too long for the them to be able to identify the source of the poison. Coumadin works by inhibiting vitamin K, which is used by the liver to produce the clotting factors that exist in blood and that are activated when the body suffers damage that causes bleeding. One of the most common treatments for inadvertent Coumadin overdoses in humans is vitamin K, which is generally orally administered in present clinical usage.

Finally, I would be remiss not to briefly address heart failure exacerbations, which are extremely common around the holidays. Recall that blood from the body returns to the heart after delivering its oxygen through the veins. Heart failure occurs when the heart is unable to effectively pump the blood that is returning to it back to the body. Heart failure is failure of “the pump” and this causes fluid (blood and blood plasma) to back up into the lungs (left-sided heart failure), the body (right-sided heart failure), or both (combined heart failure). Patient’s with known heart failure are treated with medications that help the heart to fill with blood better, to pump blood more efficiently, and with diuretic drugs to decrease the amount of excess fluid and salt in the body (fluid follows salt in the body via the principle of osmosis; more salt retention = more fluid retention). The holiday cheer, with all of its salty foods and free-flowing goblets often results in a heart failure exacerbation for sufferers of this disorder who carelessly imbibe excessively.

Combinpedal

Pitting edema. A classic sign of a right-sided or combined heart failure exacerbation that is caused by the accumulation of excessive fluid and salt in the peripheral tissues. The most common cause of heart failure exacerbations is failure to adhere to salt and fluid dietary restrictions (medication noncompliance is a close runner-up).

Doc’s fiction and nonfiction books are on sale for the holidays. 99 cents on Kindle and sharply discounted in paperback as well. Click on the book covers and check them out! Thanks for reading!

The Life of a Colonial FugitiveIntrusive Memory E-Covershutterstock_97052615The Cannabinoid Hypothesis

 

Dr. Leonardo Noto

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 16-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

REFERENCES

1. The Santa Clause: http://en.wikipedia.org/wiki/The_Santa_Clause#mediaviewer/File:The_Santa_Clause.jpg.

2. Milk and Cookies: English: This photo was taken by Evan-Amos as a part of Vanamo Media, which creates public domain works for educational purposes. Please visit my other galleries and projects for other free media. http://commons.wikimedia.org/wiki/File:Oreos-%26-Milk.jpg

3. The Waltons: http://en.wikipedia.org/wiki/Will_Geer

4. Philips, David et al. Cardiac Mortality Is Higher Around Christmas and New Year’s Than at Any Other Time. Circulation. 2004;110:25 3743.

5. Electrical Conduction System of the Heart: http://commons.wikimedia.org/wiki/File:2018_Conduction_System_of_Heart.jpg. Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.

6. Atrial Fibrillation Image: http://commons.wikimedia.org/wiki/File:Heart_conduct_atrialfib.gif. Content: Skizze Erregungsleitung im Herzen bei Vorhofflimmern
author: J. Heuser –~~~~ {{GFDL-self}} Category:Physiology Category:Heart

7. Coumadin: http://commons.wikimedia.org/wiki/File:Warfarin_bottles_NIGMS.jpg

8. Pitting Edema: James Heilman, MD. http://en.wikipedia.org/wiki/Acute_decompensated_heart_failure#mediaviewer/File:Combinpedal.jpg

 

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