Emotions and Heart Health: Need for holistic approach


Emotions and Heart Health: 
Need for holistic approach
Lt. Gen (Retd). Prof. Mahmud Ahmad Akhtar

Since very long and across many cultures, the heart was thought to be where our emotions resided. Many cultures have referred heart as the emotional seat of the soul- a symbol of romance, sincerity, fear and even courage (stout hearted) which comes from Latin word Cor. The word emotion derives in past from the French verb “emouvoir” meaning to “stir”, perhaps it is only natural that emotions would be linked to an organ characterized by the agitated movement.

Lt. Gen. (R) Mahmud Ahmad Akhtar

The poetry is full of verses depicting the heart fountain of emotions. In our poetry in Urdu and regional languages all sort of things can happen to his heart. There are popular film and folk songs. It can burst into thousands of pieces (Mohammad Rafi’s hit song). It can burn, it can melt, it can beat fast, it can stop beating, and it can be happy or unhappy. Have a heart is a common saying (metaphor) - Lion hearted, chicken hearted. Large hearted in poetry is generous, scientific medical terminology is heart failure, a serious heart disorder. It can be given or even lost. Ghalib’s verses suggest that constant sadness creates a ‘black spot’ on his heart. The black spot could well be compared to what we see in a damaged heart. Aristotle said “Treatment of heart and mind is essential for full treatment”. Brain is a Centre of emotions- the heart is most vulnerable organ both to positive and negative emotions- gut and other systems are also affected but not to that extent. A century ago the scientist Karl Pearson was studying cemetery headstones when he noticed something peculiar; husbands and wives often died within a year of one another.

The scientists have mapped seats of emotions in the brain, today we know that heart is not the source of emotions. The heart is a simple biological machine and vital organ simple a pump that circulates blood but it is also an astonishing work horse. It is the only organ that can move itself eating billion times in the average person’s lifetime with a capacity to empty a swimming pool in a week.

More and more the field of medicine has shown the connection between heart and the emotions intimate one. The heart may not be the organ of our feelings, but it is highly affected by them. Fear and grief can cause serious cardiac injury. During emotional distress, the nerves that controls the heart can set off a maladaptive “fight or flight” response with flooding of catecholamine’s that causes blood vessels to constrict the heart to gallop and the blood pressure to rise, resulting in damage in the body.

In other words, it is increasingly clear that our heart are sensitive to our emotional system- to the metaphorical heart if you will. According to Dr Sundeep Johar remarks, doctors are trained to think of the heart as a machine that manipulates with the tools of modern medicine. Those manipulations however, must be accomplished by greater attention to the emotional life that the heart, for so many years was believed to contain. One of the striking example of influence of emotions on heart is condition first described in detail by Japanese doctors called “Tokotsubo cardiomyopathy” or broken heart syndrome, in which heart actually weakens in response to extreme stress and grief sad as romantic breakup or death of spouse, financial worries, even to stressful emotions of life, public speaking, gambling losses, domestic disputes even as – surprise birthday party. “Out-breaks” of it have also been associated with wide-spread social upheaval. In 2004 for example, an earthquake-devastated part of Japan Honshu island. More than 60 people were killed and thousands were injured. On the heels of catastrophe, the researchers found that there was a 24 fold increase in the incidence of tokotsubo cases in the area one month after the earthquake, compared with before the location of the homes of the patients were closely correlated with the intensity of the tremor, in almost every case, the patient lived near the epicenter.

Patients (almost always woman - for no clear reason) develop symptoms that mimic of the heart attack. They may develop chest pain and shortness of breath even congestive heart failure. On an echogram, the heart muscle –frequently balloons into a distinctive shape, one that resembles Japanese octopus-trapping pot with a wide base and a narrow neck called tokotsubo. It is not known exactly why this happens, the syndrome often resolves within a few weeks. However, in the acute period it can cause heart failure, life threatening arrhythmias even death. The first studies of the condition were done on the victims of emotional or physical trauma who seemed to die not from the injuries but from cardiac causes. Autopsies showed tell-tale signs of heart injury and cell death. The coronaries are not obstructed. There is a characteristics akinesia of the mid-apical segments of the left ventricle on ventriculography or echocardiography and preserved basal function.

In 2005, a severe earthquake shook Azad Kashmir, devastating large areas, also causing enormous casualties. There were many casualties in the military cantonments - many military hospitals were raised to the ground. I enquired from the hospitals and Armed Forces Institute of Cardiac Diseases Rawalpindi about the cardiac emergencies occurring aftermath of the earthquake. The record showed that a lot of patients kept on reporting with chest pain cardiac emergencies. As we have not developed the research culture, therefore, no detailed studies were carried out - the only information was that there was much increase of patients suffering from chest pains, hypertension etc. This shows the difference between the progressive countries like Japan and Pakistan.

Other research findings also suggest that how important our emotions are for survival. Example, patients who are depressed after a heart attack are much more likely to die within a year than those who are not, irrespective of cardiac risk factor like high cholesterol hypertension, obesity and smoking. In another study middle age woman with no history of cardiovascular disease who expressed more feelings of hopelessness on a physiological questionnaire had more carotid artery thickening, suggesting another older vascular age, than otherwise similar woman who felt better about their life. Psycho-social factors also needs to be at front and centered-treating our heart optimally requires threating our minds too.

Likewise a happy heart has also been shown to help heal an injured one. In a seminal study, 48 patients with moderate to severe coronary diseases were randomly assigned to a control group in which they followed the advice of their personal physicians regarding their life styles, changes or an “intensive lifestyle” program, involving a low fat vegetarian diet, adequate aerobic exercise and regular “group psycho-social support and stress management advice. After a year, patients in the lifestyle group had on average a nearly 5% reduction in coronary plaque. The patients in the control group on the other hand, had an average 5% more coronary obstruction, after one year and 28 % after five years, they also had double the number of cardiac events include heart attacks, coronary bypass surgeries and cardiac related deaths. Researchers said that some patients in control group adopted diet and exercise plans that were almost as intense as those of the intervention group. However, their heart disease still progressed, diet and exercise alone were not evidently enough to roll it back. Stress management was more effective correlated with reversal of coronary diseases than exercise was. This shows the role of stress in the causation of heart disease.

The lesson is to give full importance to manage stress – provide full attention to pains, stresses and psychological problems. This needs providing sufficient time in listening to the patients, understanding their problems and dealing with them adequately. Sadly doctors including consultants do not listen to patients with full attention, empathy- do not treat their psychological problems, provide support and do not treat their ailments like anxieties and depression etc. to the peril of psycho-somatic medicine should be fully integrated with the organic medicine. This has been done in many countries with many successful outcomes. The WHO has also recommended it. Human body is fully integrated – organs and mind. Medical education is taught fully i.e. all subjects unlike engineering, law etc. which are separated in the initial stages like civil engineering, mechanical engineering etc. Higher specialization is meant for special procedures.

Dr. Sandeep Jauhar has written a book “Heart: A history”, describing all links between emotional health and heart health. Dr. Jauhar agrees that there have been remarkable technological advances like open heart surgery, artificial heart etc. but while these cardiac innovations have been transforming, Dr Jauhar argues that the field of cardiology needs to devote more attention to the emotional factors. It can influence heart disease like happy relationships, poverty, income inequality and work stress. I think the interactive technological advances would continue. He said “But the frontier is going to be in marshalling more resources to address the interaction of the emotional heart and the biological heart”. In fact this applies to all the systems of the body. It is aptly said “Human being is more emotions than tissues”. Medicines should be practiced holistically. One cannot separate psyche from organs and organs from each other. The social, psychic and spiritual aspects should be kept in mind and given importance that they deserve. In order to achieve this, doctors will have to spend time to unearth emotional factors playing havoc, affecting patient’s life and organs. This needs knowing patient very well, patient’s mind and organs. Medical education needs to be holistic. Cardiac departments / institutes should also have services of psychiatrist to advice on psychiatric aspects and for research studies. Treating heart optimally will require treating minds too.

Hippocrates, father of modern medicine said “Know the person before the disease”. There is no place for mono-organists in the rational practice of medicine. Sadly a large number of patients suffering from simple psychosomatic disorders are subjected to very expensive investigations even invasive ones and keep suffering due to mono-organistic type of education/specialization rather even inhuman approach. Even young girls suffering from panic attacks are not diagnosed- causing a lot of sufferings. This needs rectification. There is a tendency to label every sudden death due to coronary catastrophe. There are other causes to be kept in mind. Patients having prolong QT interval in the ECG may get cardiac arrest by using certain drugs. I have seen sudden deaths due to use of triglycerides, antipsychotics in patients with prolonged QT intervals which are preventable. Sudden death can happen due to toxic myocarditis with some drugs, typhoid fevers, viral myocarditis, bursting of aortic aneurysm etc.

Recently lead researchers, Prof. Dana Dowson at the University of Aberdeen in Scotland found that broken heart syndrome triggers a storm in the immune system which results in acute inflammation in the heart muscle. The heart muscle then spills inflammatory signals that circulate throughout the body. The new study, published in the journal ‘Circulation’, suggests that drugs that target inflammation could offer hope of fixing broken hearts. In this study 55 patients with acute Tokotsubo cardiomyopathy were recruited from five Scottish cardiac centers using sophisticated MRI techniques. The researchers found that the inflammatory immune response in the hearts of those with broken heart syndrome was heightened compared to healthy volunteers. The study also showed that signs of inflammation were still found five months later, albeit at much lesser level.

Professor Metin Avikran, Associate Director of British Heart Foundation which funded the study said “The discovery that is accompanied by inflammation within the heart and the rest of the body is an important step forward- we now need further steps to understand if inflammation causes Tokotsubo cardiomyopathy and determine if drugs that target inflammation could be the key to fixing broken heart.

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