Author: noorali

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Anger, loneliness and traumatic events can lead to broken heart syndrome.

When the root is deep, there is no reason to fear the wind. (African Proverb)
When the root is deep, there is no reason to fear the wind. (African Proverb)

A recent newspaper report said, “Two days after fourth-grade teacher Irma Garcia was killed in the Uvalde, Texas school shooting, her husband, Joe Garcia, suddenly died as well. Family members attributed his death to a broken heart.”

Broken heart syndrome mimics a heart attack. The exact cause of broken heart syndrome is unclear. It’s thought that a surge of stress hormones, such as adrenaline, might temporarily damage the hearts of some people. This happens after an extreme stressful event.

A person has no previous history of heart problems or coronary artery disease. That is coronaries are not plugged with atherosclerosis.

Broken heart syndrome may also be called: stress cardiomyopathy, Takotsubo cardiomyopathy, or apical ballooning syndrome.

Incidence of heart attacks caused by broken heart syndrome is around two per cent. Around one percent of people with broken heart syndrome ultimately die of it.

What are the risk factors for broken heart syndrome?

People who have anxiety or depression may have a higher risk of broken heart syndrome. Intense physical or emotional event is usually a precipitating factor. Anything that causes a strong emotional response, such as a death or other loss, or a strong argument may trigger this condition.

Chronic stress is another risk factor. Taking steps to manage emotional stress can improve heart health and may help prevent broken heart syndrome.

The condition is most common among women ages 50 and up. Women represented around 88 per cent of cases of broken heart syndrome (Journal of the American Heart Association Oct 13, 2021). An article in Cureus. (2020 Sep) also found that anxiety disorders were more prevalent in patients with broken heart syndrome than among healthy people.

How do you know you have broken heart syndrome?

Individuals with broken heart syndrome have signs and symptoms that mimic a heart attack and may include chest pain, shortness of breath and/or irregular pulse rate should seek immediate help and call 911. Take these symptoms seriously. Especially, if something like this happens after a stressful event like death in the family or a heated argument.

Anger, loneliness and depression

There is no doubt your emotions have significant effect on your heart. Managing your emotions will save your life.

Cardiac psychology is receiving attention from experts as a new emotion-based approach to heart health. It is important to treat the mind to improve the heart with a particular emphasis on achieving optimal quality of life outcomes.

There are many things you can do at home to take care of your heart and mind. When you feel angry, shut your eyes and meditate for a few minutes or go for a walk. Follow these five principals:

  1. Avoid loneliness.
  2. Enjoy life and find humour around you.
  3. Follow Mediterranean diet. Generally considered to be world’s healthiest diet.
  4. Keep moving – motion is lotion. Exercise regularly.
  5. Have a positive outlook. Positive outlook equals longer healthy life.

Finally, I will quote what Dr. Ankul Kalra, MD said, “Self-care is extremely important when times are stressful.”

Managing your emotions will save your life.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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What do we know about COVID-19 vaccine booster shots?

A mosque in Cairo, Egypt. (Dr. Noorali Bharwani)
A mosque in Cairo, Egypt. (Dr. Noorali Bharwani)

Like many of you, I am curious to know what kind of protection am I getting after third and fourth dose of COVID-19 vaccine.

Is it necessary to have third and fourth dose?

What is meant by “fully vaccinated” against COVID-19?

How many vaccine doses do we need to remain protected against COVID-19?

As you may know, some medical conditions, such as measles or polio, completing the primary vaccination series usually provides lifelong protection against disease. For others, such as tetanus, diphtheria, and pertussis, periodic booster doses of vaccine are required.

With COVID-19 we have learnt levels of protection begin to wane over time, resulting in breakthrough infections. Breakthrough infection is usually not serious.

Many experts believe people are “fully vaccinated” either two weeks after they receive their second dose in a two-dose series, or two weeks after their first dose for single-dose vaccines.

However, “fully vaccinated” is not the same as “optimally protected”, says CDC (US Center for Disease Control and Prevention). “To be optimally protected, a person needs to get a booster shot when and if eligible.”

We know one- or two-dose series remains extremely effective at preventing severe infection and death. How can we maintain this level of protection?

On 30 March, 2022 the CDC recommended a fourth dose of COVID-19 vaccine for everyone over 50 years of age.

No vaccine is 100 per cent effective. Breakthrough infections can happen with every vaccine, and do not mean that the vaccine does not work.

According to data from the US CDC, unvaccinated people are at 11 times the risk of death from COVID-19 than vaccinated people.

WHO (World Health Organisation) says, “Even once you are fully vaccinated, continue to practice the same prevention measures to protect yourself. Stay at least one metre away from other people, wear a well fitted mask over your nose and mouth when you can’t keep this distance, avoid poorly ventilated places and settings, clean your hands frequently, stay home if unwell and get tested.”

Why do we need booster dose?

The protection you get from COVID-19 vaccines can wane over time (4-6 months); so, booster doses are necessary. Boosters can help improve protection against severe outcomes by up to 90 per cent. They may also reduce the risk of post COVID-19 condition.

Many Canadians are reluctant to go for booster shots (third and fourth shot). According to an article in the Canadian Medical Association Journal (CMAJ April 11, 2022) only 56 per cent of adults, and far fewer children, have received three doses of a SARS-COV-2 vaccine. Meanwhile, vaccine manufacturers are warning that fourth doses may be necessary to maintain immunity.

Third dose is 95 per cent effective against hospitalization and death. It also brings vaccine efficacy to 97 per cent for Delta and 61 per cent for Omicron. However, it’s unclear how long good protection from a third shot will last.

Is fourth vaccine dose necessary?

Canada’s National Advisory Committee on Immunization currently recommends four doses for people who are immunocompromised, but most provinces are also offering fourth shots to seniors. Both groups may face increased risks of severe illness and greater declines in vaccine efficacy than the general population. Otherwise, experts remain divided on the value of repeat boosters.

Some argue the goal of vaccination should be to prevent severe disease and deaths, not infections, so three shots may be sufficient for most people so long as efficacy against hospitalizations holds, says CMAJ article.

Others argue it makes more sense to focus on distributing vaccines globally and developing new variant-specific vaccines rather than repeatedly using the same shots in a few wealthy countries, with diminishing returns. The evidence to support four doses is limited.

So, what do you think? Is fourth dose necessary?

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Facing the End of Life Cannot Be Easy

An Owl in the Dubai Desert. (Dr. Noorali Bharwani)
An Owl in the Dubai Desert. (Dr. Noorali Bharwani)

Right now, I know three individuals who are terminally ill. Two are my close friends and one is a close relative. I have known them for many years. It is hard to write how I feel about this.

Sometimes, I wonder, why some people die suddenly (like my dad, brother and sister died) or die from a terminal illness that can go on for weeks and months (like my mom, and other sister died).

I am pretty sure everybody has thought about how they would like to die. There are pros and cons to sudden death versus prolonged death. Now Canadians with incurable illness have a third option called medical assistance in dying (MAID).

Dying is part of life. Dying with dignity is everybody’s desire. Some are afraid to die because we don’t know what it feels like or what will happen once our heart stops beating and we stop breathing.

Is it possible to die with dignity? There are many end-of-life care options. For example: palliative care in an institution, do not resuscitate orders, refusal or withdrawal of treatment, palliative sedation to ensure comfort and finally MAID.

Before we discuss medical assistance in dying (MAID), I would like to mention one name – Dr. Jack Kevorkian (1928 – 2011). He was an American pathologist and euthanasia proponent, who gained international attention through his assistance in the death of more than 100 patients, who were terminally ill.

He publicly championed a terminal patient’s right to die with physician’s assistance, embodied in his quote, “Dying is not a crime”. He was convicted of murder in 1999 and was often portrayed in the media with the name of “Dr. Death”. There was support for his cause, and he helped set the platform for reform. He spent eight years in jail for assisting a patient with Lou Gehrig’s disease to die.

It has taken almost 30 years for Dr. Kevorkian’s dream come true.

According to Health Canada website, on March 17, 2021, the Government of Canada announced changes to Canada’s MAID law. The new law includes changes to eligibility, procedural safeguards, and the framework for the federal government’s data collection and reporting regime.

The law clearly defines who may be eligible to obtain MAID and the process of assessment. The law ensures eligible Canadians will be able to request MAID according to the new law, and that the appropriate protections are in place.

Physicians and nurse practitioners can legally provide MAID.

Pharmacists, health care providers and family members can legally help. These people can assist in the process without being charged under criminal law. The federal legislation does not force any person to provide or help to provide MAID if it is against their religious or other beliefs.

There are two types of MAID available to Canadians. They each include a physician or nurse practitioner who directly administers a substance that causes death. Second option is known as self-administered MAID. A doctor can provide or prescribe a drug that the eligible person takes, in order to bring about their own death.

Several conditions have to be met to be eligible for MAID. A person should be at least 18-years-old and mentally competent. Should have a grievous and irremediable medical condition, make a voluntary request for MAID that is not the result of outside pressure or influence, and give informed consent to receive MAID.

We know one day we are going to die. To die with dignity is the best way to go. How do we prepare for that? There are no simple answers. As Woody Allen said, “I am not afraid of death. I just don’t want to be there when it happens.”

I wish you all good health, happy times with long life.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Unexplained shortness of breath should be investigated urgently.

Sunset in Drumheller. (Dr. Noorali Bharwani)
Sunset in Drumheller. (Dr. Noorali Bharwani)

Recently, a relative of mine died. She had shortness of breath. She went to ER and was admitted to a hospital. She was investigated. After a week of investigations, she underwent coronary angioplasty for a narrow coronary artery. Two days later she was discharged. She went home and within an hour she fainted and died. That was sudden and tragic.

Statistics show one in 20 patients with unexplained shortness of breath in the primary care setting will have heart failure as its cause.

Statistics also show 38 per cent of patients with unexplained shortness of breath do not receive a definitive diagnosis within six months post-referral.

When a person presents with shortness of breath, the clinician has to determine whether it is due to cardiac (heart failure) or pulmonary cause.

Heart failure – also known as congestive heart failure – occurs when the heart muscle doesn’t pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.

What causes heart failure?

Common causes of heart failure are coronary artery disease, heart valve disease, high blood pressure and cardiomyopathy. If you’ve been diagnosed with one of these conditions, it’s critical that you manage it carefully to help prevent the onset of heart failure.

How would you know you are in heart failure?

Swelling of the feet and ankles, shortness of breath, fatigue, abdominal fullness due to swelling and distention of the liver are early manifestation of heart failure.

If you have these symptoms, you should see your doctor immediately. The doctor will order investigations which will include: blood tests, chest x-ray, echocardiogram, stress test, CT scan, MRI, coronary angiogram etc.

Some doctors rely mostly on NT-proBNP testing to monitor patients with heart failure. You do not need to fast or do anything to prepare for the test. Levels go up when heart failure develops or gets worse, and levels go down when heart failure is stable. In most cases, BNP and NT-proBNP levels are higher in patients with heart failure than people who have normal heart function.

The result helps your doctor determine if you have heart failure, if worsening fatigue or shortness of breath are due to heart failure or another problem or if heart failure has progressed toward end-of-life. It is important to note that this test is only one method your doctor uses to monitor your condition. Based on your results, your doctor can choose the best treatment plan for you.

Sixty-seven per cent of patients with unexplained shortness of breath did not need further diagnostic work-up after taking NT-proBNP test. A very useful test for patients with chronic unexplained shortness of breath.

The Canadian Cardiovascular Society recommends NT-proBNP screening to help confirm or rule out heart failure in patients with shortness of breath when clinical diagnosis remains uncertain. This can aid in decision-making and accelerate the pathway to appropriate referral.

In Alberta, Laboratory Services has offered B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) testing in hospital laboratories across the province since 2012. Emergency Department physicians and cardiologists are able to order these tests to assist with diagnosing and treating heart failure. This test has improved quality of referrals to cardiologists and has reduced diagnostic delays.

Treatment for heart failure:

For most people, heart failure is a long-term condition that can’t be cured. But treatment can help keep the symptoms under control, possibly for many years.

The main treatments are: healthy lifestyle changes, medications, devices implanted in your chest to control your heart rhythm, and surgery. Treatment will usually need to continue for the rest of your life.

The life expectancy for congestive heart failure depends on the cause of heart failure, its severity, and other underlying medical conditions. In general, about half of all people diagnosed with congestive heart failure will survive five years. About 30 per cent will survive for 10 years.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!