What can we learn about our heart from a cardiac stress test?

Upper Kananaskis Lake, Alberta, Canada. (Dr. Noorali Bharwani)
Upper Kananaskis Lake, Alberta, Canada. (Dr. Noorali Bharwani)

Let us start by understanding the difference between cardiac stress test and cardiac Holter monitor.

What is cardiac stress test?

Robert Arthur Bruce (1916-2004) was an American cardiologist who invented the treadmill cardiac stress test used to diagnose heart disease. Patient’s heart signals are monitored on a treadmill set at successive stages of difficulty. Bruce also created the Bruce Protocol in the early 1960s, monitoring the heart signals of a patient on a treadmill.

Why is cardiac stress test important? Some heart problems only appear when your heart needs to work harder. Cardiac stress test helps to show how your heart copes under stress.

A cardiac stress test is done in a controlled clinical environment. It measures the heart’s ability to respond to external stress.  The stress response is induced by exercise or by intravenous injection of a medication.

What is cardiac Holter monitor?

Norman “Jeff” Holter (1914 – 1983) was an American biophysicist who invented the Holter monitor, a portable device for continuously monitoring the electrical activity (ECG) of the heart for 24 hours or more. Holter donated the rights to his invention to medicine.

The test is used to identify any heart rhythm problems. The device is the size of a small camera. It has wires with silver dollar-sized electrodes that attach to your skin.

Who needs cardiac stress test?

Any person who has a worrisome symptom like chest pain – especially in older men with risk factors for heart disease. An exercise stress test is not 100 per cent accurate. But it helps decide what the next step should be.

When to get a cardiac stress test?

The U.S. Preventive Services Task Force, an independent panel that makes recommendations to doctors, urges physicians not to routinely offer exercise stress testing to people without symptoms or strong risk factors for coronary artery disease.

Main indication for ordering stress test is when a person complaints of chest pain. Chest pain is not an uncommon complaint. Chest pain can have many possible causes besides heart disease.

For example, chest pain can be due to indigestion, anxiety, or muscle injury. If your doctor finds that you probably don’t have a heart problem, you may not need a stress test at all, says Choosing Wisely (2017 Consumer Reports. Developed in cooperation with the American Society of Nuclear Cardiology).

If you do have a heart problem, your first choice should often be a simple stress test without imaging. This test has little risk and is inexpensive. It is usually accurate for people with a low risk of heart problems.

Imaging stress tests are usually safe and can use little or no radiation. But for people at low risk, the tests may produce false alarms. This can lead to follow-up tests that you don’t really need. The extra tests can expose you to more radiation. Inappropriate testing can also lead to unnecessary treatment, says Choosing Wisely.

An imaging stress test can cost 10 times more than a regular stress test. You should only get an imaging stress test when it will help your doctor manage your disease or lead you to a better treatment. Discuss your symptoms with your family doctor. We can learn a lot from cardiac stress test if appropriately ordered.

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Control heartburn and acid reflux.

Calgary, Alberta. (Dr. Noorali Bharwani)
Calgary, Alberta. (Dr. Noorali Bharwani)

As you may know, heartburn has nothing to do with your heart. Heartburn is a symptom of acid reflux from your stomach to the esophagus.

Heartburn is a common gastric complaint. For example, in the U.S. it affects more than 60 million people each month. Yes, each month. When does it become a disease? When the reflux symptoms occur frequently. Then it is called gastroesophageal reflux disease (GERD). If not treated then it gets complicated.

Distinguishing between heartburn, acid reflux, and GERD may be hard, because they may all feel the same. However, understanding the differences can help a person find the right treatment. Difference lies in the severity and frequency of the symptoms and the damage inflicted by the acid to the esophagus and lungs. Yes, it can damage your lungs.

Reflux can also occur in infants. Infant reflux occurs when food refluxes from a baby’s stomach, causing the baby to spit up. This is rarely serious and becomes less common as a baby gets older. It’s unusual for infant reflux to continue after age 18 months.

Reflux in adults is fairly common. In 2005, a systematic review of population-based studies found the prevalence of reflux to be 10 to 20 per cent in Europe and North America and less than five per cent in East Asia. If reflux is not controlled then the acid will damage the esophagus causing inflammation, narrowing, ulcers and bleeding.

Managing early stage of heartburn and reflux

In early stages if occasional reflux is the only symptom then you can take care of it by simple life style changes: eat small meals, avoid any food that gives you heartburn, avoid big spicy meal, do not lie down after eating, do not smoke or drink alcohol, lose weight and use antacid, like Rolaids or Tums.

Managing late stage of heartburn and reflux

If measures like life style changes and antacids do not help then there are medications called H-2-receptor blockers and proton pump inhibitors (PPI) that can be tried.

H-2 receptor blockers

These medications reduce the production of acid in the stomach. H-2-receptor blockers include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac). H-2-receptor blockers don’t act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours.

Proton pump inhibitors (PPI)

These pills block acid production and heal the esophagus. They are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Examples include lansoprazole (Prevacid 24 HR) and omeprazole.

According to Choosing Wisely (2017 Consumer Reports prepared in cooperation with the American Gastroenterological Association), in most cases, you don’t need a PPI for heartburn. More than half of the people who take PPIs probably do not need them.

You can get relief from a less powerful drug. And when you do need a PPI, you should take the lowest dose for as short a time as possible. Preferably for less than one year. Although generally well-tolerated, these medications might cause diarrhea, headache, nausea and vitamin B-12 deficiency. If you take it for more than a year then the risk of complications include: fractures, kidney problems, heart attack, dementia, pneumonia and colitis.

While you are being treated with different pills, you will probably undergo investigations like upper GI endoscopy, ambulatory acid (pH) probe test, esophageal manometry and x-ray of your upper digestive system. If indicated, your specialist will consider you for a surgical procedure.

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Marketing of Bottled Water Exploits People’s Worries

Sunset in Medicine Hat, Alberta. (Dr. Noorali Bharwani)
Sunset in Medicine Hat, Alberta. (Dr. Noorali Bharwani)

“Thousands Have Lived Without Love, Not One Without Water.”
W.H. Auden, American-English poet, author and playwright.

Bottled water is drinking water from various sources (well water, distilled water, mineral water, spring water) packaged in plastic or glass water bottles.

It is important to remember, bottled water labelled as “mineral” or “spring” water, is potable water (fit for human consumption) that comes from an underground source. It cannot come from a public water supply.

In Canada, bottled water is regulated as a food and therefore it must comply with the Food and Drugs Act. Under the Act and its regulations, all bottled water offered for sale in Canada must be safe for people to drink.

According to Health Canada website, illness caused by bottled water is very rare, because the water is treated, disinfected, and monitored to make sure it does not contain harmful microorganisms or chemicals.

To maintain the safety of bottled water, we must also handle and store it properly.

Other types of bottled water may be manufactured from public sources, including tap water and well water, says Health Canada website.

Consumers should remember, no matter what source water comes from, all bottled water sold in Canada is inspected and treated during the manufacturing process to ensure that it meets Canada’s requirements for safety and quality.

Bottled water is a handy and convenient way to store large amounts of water for emergency purposes. Most Canadian manufacturers of bottled water indicate that the product has a shelf-life of one to two years. Some people prefer to choose bottled water because they prefer the taste when compared with water from other sources (tap water, well water).

Some people think that bottled water is safer than tap water, but there is no evidence to support this, says Health Canada website. The quality standards for bottled and municipal waters in Canada are similar. All bottled and municipal waters that meet or exceed the required health and safety standards are considered to be safe.

Bottled water gets contaminated with germs if not handled or stored properly. Keep in mind that the plastic containers holding single-serve bottled water were designed to be used only once. Avoid refilling them. Where possible, recycle these bottles.

As concerns about the safety of the nation’s municipal tap water have increased, so have sales of bottled water. It’s now the top-selling bottled beverage.

According to Consumer Reports (May 9, 2019), in the U.S. there are more than 120 brands of bottled waters. Getting information about the quality of the bottled water you drink is hard. Unlike tap water, there is no public information for consumers to look up the quality of their favorite bottled water brand and see whether it is free of contaminants.

According to British Medical Journal (Getting well from water, BMJ December 16, 2004), bottled water exploits our worries about what affects health in the modern world. Bottled water is seen as natural, clean, fat-free, and with traces of health-giving minerals. In fact, tap water is as safe as bottled water and about 1000 times cheaper. The marketing of bottled water exploits people’s worries about what affects their health in the modern world. There is a message in that bottle.

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Do antibiotic-based ointments improve outcomes in wound healing?

Air boat tour outside New Orleans . (Dr. Noorali Bharwani)
Air boat tour outside New Orleans . (Dr. Noorali Bharwani)

After surgery, patients always ask, “Doctor, do I need to use antibiotics to prevent infection?”

Surgical incisions are usually closed by fixing the edges together with stitches, staples or steri-strips. This process helps the cut edges heal together and is called ‘healing by primary intention’. This has a very low potential for infection.

Minority of surgical wounds are not closed in this way. This happens when there is a high risk of infection. The wounds may be left open to heal by the growth of new tissue rather than by primary closure. This is known as ‘healing by secondary intention’.

There is a risk of infection in open wounds, which may impact on wound healing, and antiseptic or antibiotic treatments may be used to prevent infections.

We don’t have to use any topical antibiotics (like Polysporin or Neosporin) for surgical wounds which are clean. Yet we continue to promote its use for clean surgical incisions.

A clean surgical procedure requires a clean dressing that protects incisions from bacteria and keeps it clean and dry. Dressings should be changed daily or according to your doctor’s orders.

In a recent article (Five Things Clinicians and Patients Should Question) written under the leadership of the Canadian Dermatology Association in Choosing Wisely Canada (March 2019), the association advises Canadians not to routinely use topical antibiotics (like Polysporin) on a clean surgical wound.

This review article says that for wounds closed with stitches, the potential harms (like allergic contact dermatitis to topical ingredients and antibiotic resistance) outweigh the marginal reduced risk of postoperative infection achieved by use of antibiotics applied to the skin.

Only wounds that show symptoms of infection (pus, swelling, spreading redness, wound breakdown and systemic symptoms) should receive appropriate antibiotic treatment.

In another study published in 2015 (J Dermatolog Treat) the authors compared topical antibiotic prophylaxis for prevention of surgical wound infections and found no statistically significant difference in incidence of postsurgical wound infections between topical antibiotics (like Polysporin) and petroleum jelly.

The authors of the article recommend use of Petrolatum (petroleum jelly) instead of topical antibiotics as a prophylactic measure to prevent postsurgical wound infections in the outpatient dermatologic setting.

Other studies have shown with repeated usage, about 10 per cent of people will develop an allergy to local use of antibiotic ointment. These same studies have shown that white petrolatum jelly (Vaseline) is the preferred wound care agent after skin procedures. All you need is gentle daily soap/water cleansing, and applications of Vaseline.

What is petroleum jelly? Petroleum jelly (also called petrolatum) is a mixture of mineral oils and waxes, which form a semi-solid jelly-like substance. This product hasn’t changed much since Robert Augustus Chesebrough discovered it in 1859. Petroleum helps seal your skin with a water-protective barrier. This helps your skin heal and retain moisture.

What is Polysporin? Polysporin consists of two antibiotics, bacitracin and polymyxin B.

What is Neosporin? Neosporin consists of three different antibiotics, neomycin sulfate, polymyxin B sulfate and bacitracin.

There are many studies which encourage use of petroleum jelly for routine care of superficial wounds, because it is as effective for wound healing as over-the-counter antibiotic preparations and does not contribute to antibiotic resistance or allergic contact dermatitis.

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