A Patient’s Perspective: 41 Years after Coronary Bypass Surgery

by Joe Piscatella

I am a believer in the efficacy of healthy lifestyle choices for the primary and secondary prevention of coronary heart disease. As a result, I make a serious effort to engage in powerful health-promoting actions such as eating a healthy diet, exercising regularly, managing stress effectively, having a positive mind-set, and avoiding cigarette smoke. These actions help me to manage my weight, control glucose, c-reactive protein, cholesterol and other lipids, reduce inflammation, and keep in good physical shape.

Looking back on my life, I would love to tell you that my commitment to heart-healthy living was the result of native intelligence, but it was not. Instead, it was born purely out of need. For the first 32 years of my life, healthy living took a backseat to other, seemingly more important things that took my time and interest: my family, work, and community. Besides, I had always been healthy. Serious diseases such as heart disease and cancer happened to other people.

Sure, there were things that could have been improved. My cholesterol was too high, I could stand to lose a few pounds, and my exercise regimen was sporadic. There would be time, I thought, to improve my numbers and my health while I was rocking in retirement.

But I was wrong.

In 1977, I underwent coronary bypass surgery. I was 32 years old. My wife and I had not yet celebrated our 10th wedding anniversary. My daughter was six years old; my son was just four. And my new business had been in operation for three years.
That experience became the motivating force for me to understand the health impact of lifestyle habits and to take action to improve those choices. In retrospect, it was a hard way to learn important lessons. What I had to be taught for rehabilitation I should have learned for prevention.

A TEACHABLE MOMENT
It was a hot afternoon in July 1977, and for the second time in a week, I was seated in the office of a prominent cardiologist in Tacoma, Washington. I was bewildered as to why I was there.

Five days earlier, I had been to see my family doctor about what I thought was a bronchial problem. For about a month, I had experienced shortness of breath and a low- grade but nagging chest pain as I warmed up to play tennis.

The pain was dull, more like a feeling of fullness or pressure. By the end of the warm-up, it would usually disappear. I ignored the pain, hoping it would just go away. But one day, it remained with me through two hours of play. It was then that I decided to call him. “I’ve got a problem in my lungs, probably a touch of bronchitis,” I told him. He asked me to come in right away. I had seen him just four months earlier for an annual physical and the results then were excellent, so I was not expecting anything more than a short visit and perhaps a prescription.

The examination indicated that my lungs were fine. The results of an electrocardiogram, however, were not. The previous test from my annual physical showed normal results. The results now, however, were drastically different.

“Joe, the test indicates possible obstructions of the coronary arteries,” my doctor said. “I want you to see a cardiologist immediately, today. In fact, I’m closing my practice for the rest of the day and driving you to his office. I don’t want you behind the wheel of a car.” So, three hours after my “routine” examination, I found myself undergoing a thorough cardiac examination and exercise stress test. I did not take seeing a cardiologist lightly. But I did not believe there was anything seriously wrong, either; I was certain it was a mistake.

Like the electrocardiogram, the results of the stress test indicated a problem. I subsequently had coronary angiography that indicated three arterial blockages ranging from 50% to 95%. “You have coronary heart disease,” the doctor said. “I recommend coronary artery bypass surgery be done immediately… I mean within the next few days. At this moment, you are a heart attack statistic just waiting to happen.”

The shock of his words hit me like a slap in the face. This couldn’t happen to me. I was not prepared to hear what he had to say; I had difficulty understanding. He was speaking about a heart problem—my heart problem!- that, psychologically, I could not accept. Thoughts of escape filled my mind. “Just get up and leave,” I told myself. “It’s all a mistake. You’re not supposed to be here.” Once safely back in my world, I reasoned, I would surely awaken from this horrible nightmare.

As I continued to listen numbly to the doctor, I was confused. Like most people, I knew something about the workings of the heart and the coronary arteries, but the information was chiefly of the Biology 101 variety. It was not that information was not available. The American Heart Association, among others, had produced and disseminated a tremendous amount of it. But, quite frankly, it had been of remote interest to me. Such information, indeed the subject itself, was simply not relevant to my life. What did arterial blockages or heart attacks have to do with me, a young guy in the prime of life?

Unknowingly, I had succumbed to the “what I don’t know won’t hurt me” syndrome. In reality, what I didn’t know could not only hurt me, it could kill me.

What I didn’t know was that coronary heart disease usually develops silently, insidiously, over a long period of time, generally 20 to 40 years. Once it surfaces, however, the primary result, a heart attack, is often immediately devastating.
What I didn’t know was that more than 13 million Americans have coronary heart disease and that every year, some 1.5 million people suffer a heart attack, causing 600,000 to 800,000 fatalities— equal to the casualties from 10 Vietnam wars!
What I didn’t know was that heart disease causes about 45% of all deaths in the United States each year, more than cancer, AIDS, auto accidents and airplane disasters combined.
What I didn’t know was that for about one third of heart attack victims, the first heart attack was the only one, resulting in sudden cardiac death.
What I didn’t know was that while genetic history is important, most Americans with heart disease have it because of poor lifestyle habits involving diet, exercise, stress, and smoking. As Dr. William Roberts, Editor in-Chief of the American Journal of Cardiology, stated, “For every one person with heart disease primarily because of bad genes, 499 have it because of poor lifestyle habits.” But, conversely, improving those habits could contribute to better cardiac health.

Such information was simply outside the realm of my everyday life. But it all changed for me on that July afternoon. As the diagnosis sank in, the age of innocence and ignorance ended for me.

I was gripped by pure stomach-churning fear. At 32 years old, I had felt a kind of immortality that only the young experience. The concept of death had been a remote one. I pictured it at the end of a long life, after years of accomplishment, fulfillment, and joy. Old age was something that I looked forward to sharing with my wife. I had never contemplated the idea of death taking me in my prime.

On that July day, the alarm clock of reality rang. I realized that not only could death happen now, but also it probably would happen now, the result of a time bomb located inside my chest. A decision was made to undergo the surgery.

A week after surgery, I went home to recover, elated simply to be alive and with my family again. But I was very concerned about my future. Surgery had circumvented the immediate problem—having a heart attack—but had not stopped the disease. Bypass did not “cure” me. As my doctor counseled, “You had heart disease the day before surgery, you had heart disease the day after surgery, and you have it today as well. The surgery took away the pain but it did not remove the disease. Only a change in your lifestyle habits can reduce your future heart attack risk.”

This knowledge was complicated by the prediction of another doctor, a nationally-known lipid specialist. I saw him after the surgery for advice on how to manage my cholesterol. “Should I change my diet?” I asked. “Don’t bother,” was his reply. “You have an aggressive form of coronary heart disease at a very early age. Frankly, I’d be surprised if you live to be 40. The chances of seeing your children graduate from high school are slim.”

While his bedside manner was harsh, I had to acknowledge that he might be right. For a week or two, I was depressed, unable to see a clear path or take decisive action. Then my wife put it all into perspective: “His prediction is not pre-destination,” she said. “It’s true, you can’t change the cards you were dealt. You do have aggressive heart disease at age 32. But you can change the way that you play those cards. And we are going to do every- thing possible to eat healthier and exercise more effectively to even up the odds.” And that is what we have done.

How has it worked? I recently celebrated the 41st anniversary of my bypass surgery by hiking on Mount Rainier with my wife. My current biometric measurements—cholesterol, weight, and blood pressure—show that I’m in better health now than in 1977. As a result, I have experienced the joy of seeing my daughter and son graduate from high school, college, law school, and graduate school; of walking my daughter down the aisle and making a toast at my son’s wedding; of celebrating 51 years of marriage; of gathering with family at my 74th birthday; and of holding our four grandchildren. None of this would have happened without practicing healthier lifestyle habits.

IF I WERE A DOCTOR
Let’s face it: most patients come to the doctor’s office looking for a pill or a prescription that will make everything right. This is complicated by the fact that many physicians are enamored with emerging cardiac science.

But if I were a doctor, I would spend less time discussing the science and more time instructing the patient on healthy lifestyle habits. This is critical as no one has the ability to in influence patient behavior more than physicians do. How many anecdotes have we heard about the heart patient who continues to smoke because “my doctor never told me to stop?” So, while it is easy to become enthralled with the science of cardiac health, helping the patient create a healthier lifestyle is the core issue.

If I were a doctor, counseling patients on primary or secondary prevention of coronary heart disease, here is what I would advise based on my 41 years of managing my own heart disease successfully.

STOP SMOKING
Responsible for more than 500,000 deaths annually, smoking has historically been the single most preventable cause of death in the United States. According to the American Lung Association, if a person starts smoking before age 20, each cigarette costs about 20 seconds of life. For a two-packs-a-day smoker, this means throwing away more than eight years of life span.

Most people assume that the greatest health risk from smoking is cancer. And while it is true that smoking leads to more than 150,000 cancer deaths each year, the impact of smoking on the risk of heart disease is much greater. By increasing risk factors such as elevating blood pressure, decreasing exercise tolerance, and increasing the tendency for blood to clot, smoking contributes to about 40% of all cardiac deaths. Smokers are twice as likely as nonsmokers to have a heart attack and are five times more likely to die from sudden cardiac death.

But I would stress to my patients that there is hope for those who give it up. Research shows that within two to three years of quitting, former smokers reduce their risk of heart attack and stroke to levels similar to those of people who never smoked. And within five years of quitting, former smokers have a 50% to 70% lower risk of heart attack than current smokers. The bottom line is that if the patient is not a smoker, encourage him not to start. If the patient is a smoker, provide advice and information such as

Joining a stop smoking clinic or group
Using nicotine replacement products, and
Taking medication to help the patient to stop smoking

EXERCISE REGULARLY
“If exercise could be packaged into a pill,” says Dr. Robert Butler, former director of the National Institutes on Aging, “it would be the single most widely prescribed and beneficial medicine in the nation.” With physical activity ranking so high on the list of smart things to do for your heart and health, you would think most Americans would have gotten the message to exercise regularly. If you judged us by our appearance—jogging shoes, yoga pants, and warm-up suits—you would think the country was in the middle of a fitness boom.

Think again. Americans generally do not exercise. As one doctor told me, “We just buy exercise stuff!” According to government data, about half the adult population admits to being sedentary, and of those who claim to exercise, fewer than 15% do it often enough or hard enough to produce cardiovascular benefits.

Says Dr. Jeffrey Koplan, former director of the Centers for Disease Control and Prevention, “Physical inactivity, along with overweight, accounts for more than 300,000 premature deaths each year in the United States.”

This is a tragedy for heart health as regular physical activity confers so many benefits. It strengthens the heart, boosts high-density lipoprotein cholesterol, reduces blood clotting, lowers blood pressure, aids in weight loss, maintains muscle strength, and helps to manage stress.

A balanced exercise program should include daily physical activity (such as walking the dog), weight training for building strength, flexibility exercises (such as stretching or yoga) to prevent injury, and, most important, aerobic exercise to promote cardiovascular endurance and fat burning.

If I were a doctor, I would encourage patients to find a form of aerobic exercise that they like and will do. Brisk walking, jogging, aerobic dance, swimming, stair stepping—it does not matter what the exercise is as long as it conforms to the F.I.T. criterion:

F stands for frequency. The American College of Sports Medicine counsels an aerobic workout three times a week or, better still, every other day. Fewer than three days a week may not be as effective.

I stands for intensity. Aerobic walking, for example, is not a casual stroll. Instead, you have your arms pumping, your stride is long, and you have sweat on your upper lip. You should feel like you are late for a doctor’s appointment.

T stands for time. The historic recommendation is 20 minutes of nonstop activity as a minimum. But many people use the 20-minute mark as a maximum. It takes more time than that to produce cardiovascular bene t.

I would also counsel patients on getting an exercise partner. It is a key to making a commitment to exercise regularly.

EAT HEALTHY FOOD, BUT NOT TOO MUCH OF IT
Perhaps nothing is more important for cardiac health than eating a healthy, balanced diet. But the American diet is the antithesis of healthy eating. About 34% of calories consumed comes as fat, much of it saturated and trans fats; 24% comes as refined sugar (or about 150 pounds per year for adults); and 5% comes as alcohol.

There are also problems with what we do not eat: some 40% of adults eat no fruit, 80% eat no whole grains, and 40% eat no vegetables. (Actually, the vegetable number is worse as it seems that half of those claiming to eat vegetables list French fries as the only vegetable eaten!)

The Surgeon General’s Report on Nutrition and Health characterizes Americans as “gobbling their way to the grave.” The report identifies a causal link between the typical American diet and five of the ten leading causes of death: CHD, cancer, high blood pressure, stroke, cirrhosis of the liver, and the nation’s leading ailment, obesity.

There are many reasons behind such an unhealthy dietary pattern. Our fast-paced, out-of-time lifestyle has moved people away from shopping and cooking. Instead, they often eat on the run and settle for what is available, quickly, from restaurants, take-out places, and food stores. Many people have simply traded nutrition for convenience. “And when you add in what choices are available,” according to Dr. Kelly Brownell, an obesity expert at Yale University, “the problem is compounded. We live in a toxic environment for making healthy food choices.”

If I were a doctor, I would keep the nutrition message simple by recommending the Mediterranean diet: eat healthy fats such as olive oil; avoid refined carbohydrates such as commercially baked goods, sugary desserts and soft drinks; minimize saturated fat and avoid trans fats; center your diet on fruits, whole grains, and vegetables; eat cardio-protective foods such as oatmeal, fish, orange juice and nuts; when you eat meat, make it lean; stay away from high-sodium foods; drink water; have an occasional glass of wine; choose low-fat and fat-free dairy products; choose whole foods over processed foods; and, of great importance, cook more at home.

From a practical standpoint, this can be accomplished with three actions. First, don’t crash diet. It is a game for fools. Fad diets might help you lose a few pounds in the short run, but they are ineffective for a life-time. Consider this: we have had more than 60 years of quick weight-loss diet books. If a single one had worked—if the “cabbage soup” diet had worked! – we would be a nation of skinny folks.

Secondly, eat real foods. We struggled in our house to eat healthy foods after my surgery, as many of these foods were bland and tasteless. Then I came upon a piece of information that changed our thinking. Data show that most American families prepare 12 recipes 80% of the time. So, if you can identify your 12 favorites and modify them to make them healthier—but only to the point that taste remains—you get the best of both worlds: familiar recipes that are tasty and healthier.

And finally, talk to the patient about portion size. As compared with the 1970’s, the average person today consumes some 150 – 300 extra calories a day. Restaurant meals and processed foods have become “super-sized.” Dinner plates now look like hubcaps. Most people have little understanding of portion size and that has an impact on our obesity epidemic. Eating for heart health is not just about specific foods, it is also about how much is eaten.

A simple way to estimate healthy portions is to use your palm, fist, and thumb as a guide:

1 palm = 3 ounces. The size of your palm is about the size of a 3-oz serving of cooked meat, fish, or poultry.
1 fist = 1 cup. One cup of cereal, spaghetti, potatoes, vegetables, or cut fruit is about the size of a woman’s closed fist. A man’s closed fist is about 1.5 cups.
Thumb tip = 1 teaspoon. One teaspoon of butter, peanut butter, mayonnaise, or sugar is about the size of the top joint of your thumb. Three such portions make up about 1 tablespoon.
1 or 2 handfuls = 1 ounce of snack food. For nuts or small candies, 1 handful equals about 1 ounce. For chips or pretzels, two handfuls are about 1 ounce.

MANAGE STRESS
There is growing evidence that chronic stress can directly penalize cardiovascular health by raising cholesterol and/ or blood pressure, promoting coronary inflammation and triggering sudden cardiac death. While much more study needs to take place, there is great consensus about the indirect impact of daily stress: it can destroy healthy lifestyle habits. People under stress tend to smoke, eat a poor diet, and lead sedentary lives. More and more experts are now concluding that chronic stress may be the chief barrier to non-adherence to healthy habits, particularly diet and exercise.

Most people today are not overly stressed by “big- ticket” items such as a poor diagnosis from their doctor or a dip in their 401K. Instead, most chronic stress comes from the fact that we are out of time. We simply do not have the time to do all the things we need or want to do. One female executive recently told me, “I’m answering e-mails at 9:00 PM, doing my laundry at midnight, in a grocery store at 6:00 AM, then drive my kids to school and go to work. I do a lot of different things during the day, but because I’m always short of time, I don’t feel that I do any of them well.”

When people are stressed like this, it makes no difference how much they know about healthy living—and we know a lot!—a candy bar still becomes lunch, exercise is skipped, and cigarettes are smoked. If we have learned anything in the past 20 years of health messaging, it is this: cognitive understanding does not automatically lead to positive behavior change. If it did, we would be a nation of nonsmokers.

If I were a doctor, I would drive home the point that while stress cannot be reduced, it can be managed successfully with physical and mental techniques such as:

Deep breathing,
Regular exercise,
Meditation, and
Taking time out daily to relax your mind.

DEVELOP A POSITIVE MIND-SET
Many cardiac patients feel discouraged, some to the point of depression, about their health condition. I know that was my experience. Luckily, I had a doctor that not only explained what needed to be done to institute a heart-healthy lifestyle, but he encouraged me to develop a positive mind-set. His acting as a cheerleader gave me the support I needed to make sustained progress.

He encouraged me to establish a goal and set a specific time frame. Just to declare “more exercise” as a goal didn’t cut it with him. “Walking three miles in 45 minutes by month’s end” was more his style (and mine). He encouraged me to do one small thing today better than I did yesterday. If I had walked for 30 minutes yester- day, I’d do 35 minutes today.

He encouraged me to be resilient and persistent. “Failure is not falling down,” he would say. “That’s part of the human condition. Real failure is not getting back up.”

And finally, he would encourage me with motivational quotes. One of my favorites was “There are no gold medals for the 95-yard dash.”

A LAST WORD
Making healthy changes to benefit cardiovascular health is simple—not easy, but simple. Many patients can become discouraged, particularly if they have a lot to change or feel pressure to do it all at once. Advise them to make changes just for today. Don’t fret about yesterday; it’s over and you can’t call it back. Don’t be concerned with tomorrow as it is not yet here. Instead, live healthy today. Pretty soon, the days will add up to months and years, and changes will become habits. That’s what I’ve done for 41 years…one day at a time.