MARCH 13, 1980
Heart Disease: The Modern Plague
AN ADDRESS BY Dr. Terence Kavanagh, MEDICAL DIRECTOR, TORONTO REHABILITATION CENTRE
CHAIRMAN The President, John A. MacNaughton
Ladies and gentlemen of The Empire Club of Canada: I am sure there are many people in this room today who will recall seeing this issue of Financial Post Magazine which is dated February 9, 1980. Two articles in it anticipated events on the March program of the Empire Club and served as introductions of our guest speakers. One is entitled "Brian Peckford Is No Newfie Joke." We will have living confirmation of that two weeks from now when Premier Peckford will be our guest of honour. The second is entitled "How to Survive Your Heart Attack," written by a gentleman who wrote from personal experience--experience not only with the anguish of a heart attack but also from the experience of participation in the program of the Toronto Rehabilitation Centre where today's guest of honour, Dr. Terence Kavanagh, is Medical Director and guiding spirit.
Dr. Kavanagh began his work at the Toronto Rehabilitation Centre, which is a public hospital, thirteen years ago. His specialty is rehabilitation medicine for which he has become internationally recognized. Recognition has come from many quarters. Within his profession it has resulted from the pioneering work done by Dr. Kavanagh on the medical aspects of his cardiac rehabilitation theory and from his contribution to the advancement of understanding of the psychological aspects of recovery programs. In the community at large Dr. Kavanagh's reputation has grown as "graduates" of his clinic have returned to their families and careers healthy and happy, and as they have gained acclaim as entrants in long distance endurance races.
The prologue to Dr. Terence Kavanagh's book, Heart Attack? Counter Attack!, tells the moving story of seven Toronto men, all heart attack victims and all Kavanagh patients, who decided to demonstrate the effectiveness of a methodical rehabilitation program by competing in the 1973 Boston marathon. Not only did the seven compete, but they also successfully completed the twenty-six mile course and became part of medical history by doing so. It is believed they are the first heart attack victims anywhere in the world to fulfill such an ambitious goal. One of the men, fifty-six years of age at the time, had suffered two heart attacks before becoming a Kavanagh patient. I am referring to Ken Smith whom I introduced to you a few moments ago as one of our head table guests and I say to him now that it is a pleasure for us to have one of the famous Boston seven here with us today.
Ladies and gentlemen, over the life of this club we have heard from many Canadians who have gained international reputations for their contributions to the medical sciences--the names of Best, Selye and Penfield are among them and today we have the honour of adding Kavanagh to the list.
Terence Kavanagh is a medical practitioner who teaches his patients the potential of their own bodies and the value of resolve. He clearly believes in the adage of poet John Dryden:
Better to hunt in fields, for health unbought,
Than to fee the doctor for a nauseous draught.
The wise, for cure, on exercise depend;
God never made his work for man to mend.
Dr. Kavanagh, in his practice, combines that opinion of poet Dryden with the humorous (but oh so reassuring) advice of a medical doctor named Ernest L. Wynder who wrote these words: "It should be the function of medicine to have people die young as late in life as possible."
Ladies and gentlemen, please welcome Dr. Terence Kavanagh, Medical Director of the Toronto Rehabilitation Centre, who will address us now on the topic: "Heart Disease: The Modern Plague."
Mr. Chairman, ladies and gentlemen: I feel myself singularly honoured to be given the opportunity to speak to you today. On the other hand, I must admit to being somewhat at a disadvantage. The successful after-dinner, or after-luncheon speaker usually has a light-hearted approach to his topic or, if his subject is a serious one, he can at least resort to the time-honoured custom of the introductory joke or two to warm up the listeners. My problem is two-fold--I mean, how light-hearted can you get with a title like "Heart Disease: The Modern Plague"? As for the introductory joke bit, I have never in my life been able to remember a punch line, so that's out!
I should also explain that the bulk of my speaking experience to date has been in the areas of science and medicine. The format used there, as many of you know, is not at all suitable for these surroundings. A typical scientific presentation commences with a short mumbled introduction by the chairman who often mispronounces your name (which, incidentally, has already been misspelled in the program), after which you bob up on the podium and, before the audience has had a chance to catch even a glimpse of your face, you immediately ask for "lights out." This plunges the hall into darkness, and your disembodied voice describes a series of slides which are projected on the screen at the speed of a subliminal advertisement. The slides themselves usually contain a mass of minutely printed statistical data, totally impossible to read. As a matter of fact, the seasoned, sophisticated medical lecturer will even draw attention to this fact, laconically remarking, "I realize that you can't possibly read all the material on this slide, but you really don't have to; I will summarize it for you briefly." He then goes on to pick out those figures which support his argument while ignoring those which don't!
Question time is really no problem, since the majority of questions are what we call "self-aggrandizing queries." These usually come from individuals who are fully equipped with their own set of slides and usually commence by saying, "Dr. Kavanagh, I found your comments most interesting, but I think it only fair to say that my own work has some direct bearing on yours and, with the audience's and the chairman's permission, I would like to refer briefly to my own findings; I happen to have some of the essential data with me, so if the projectionist wouldn't mind, etc., etc., etc."
As a matter of fact, I should be honest and tell you that I have developed in recent years a reputation for being a reasonably good performer when addressing the lay public on this matter of "Heart Disease: The Modern Plague"! To be perfectly fair, however, I have to admit to adopting rather despicable tactics in order to achieve even a modicum of success. The essence of the thing, of course, is to commence with a statement which sends a bolt of fear through your typical post-luncheon listener--the obese, middle-aged, heavily-stressed, cigarette-smoking businessman--something like, "Every male over the age of forty-five in this room has a one in three chance of dying from a heart attack!"
or, "Did you know that coronary artery disease is the major killer, responsible for about three-quarters of a million deaths a year in North America alone, and about half of these are so-called 'sudden deaths'?"; or, "About a quarter of all the cases of individuals suffering from disease of their coronary arteries have sudden death as their first, last and only symptom of the disease"; or, "Of the people who do suffer a heart attack, only half survive"; or, "The disease costs Canada some two billion dollars a year and is responsible for occupying one-fifth of all the acute general hospital beds." All of this I could tell you but, since you are not only friends and, indeed, fellow club members, I prefer not to use such rather shameful tactics to jolt you into a state of arousal.
Neither would I shake your confidence in the medical profession by telling you that we do not really know the exact cause of "atherosclerosis," the medical term for the disease. Precisely why those small fatty patches form throughout the blood vessels of the body and, with such devastating effects in the small coronary arteries which supply blood to the heart muscle, we cannot be sure. All that we can say at this stage is that there are a number of risk factors which are associated with the development of the condition. These are: a diet high in animal fat, cigarette-smoking, untreated high blood pressure, lack of exercise, and possibly the effects of environmental stress. In short, we are obviously dealing with a modern life-style disease.
Interestingly, in the United States there has been a slow decline in the incidence of coronary artery disease in the past ten years or so. The drop is, as yet, insufficient (about 1.5 per cent a year) to make much impression on the disease's position as the leading killer. To be honest, we cannot satisfactorily explain this decline, and, so the Americans are in danger of spending more money trying to find out what they did right than they have spent in trying to find out what they should have done right.
So, we have a disease process which is, to this day, still responsible for more than forty-six per cent of all deaths. Its history is intriguing. It has been described as an entity as early as 1768 by the famous English physician Heberden, but the average medical text book of the 1920s would probably not have devoted to it more than a paragraph or so. It usually occurred in individuals over the age of sixty, and was invariably fatal. After the First World War, it began to appear in younger and younger age groups, and, in complete defiance of our modern attitudes towards sexual equality, became very much a male-oriented disease, killing men as opposed to women in the ratio of five to one and up. Characteristically, it accompanies affluence.
Treatment, of course, has changed considerably over the years. When I was a student, hospitalization was prolonged. If you were lucky enough to survive your heart attack, then you could expect to be six weeks in hospital, after which you "took it easy" for about three months, and often it was six months before you were back at work. Now we know how detrimental this prolonged period of bed rest was for the patient, both physically and psychologically. Not only that, but this concept that the diseased heart needed rest and that too early mobilization might cause rupture of the scarred wall, successfully prevented any attempt at early and active rehabilitation.
Today, the average period of hospitalization is ten days to two weeks. We have new, more aggressive concepts of acute coronary care. We aim to get the patient to the hospital as quickly as possible where we can monitor and control disturbances in his heart rhythm. If the heart stops, we can start it again. We can arrest the degree of damage being done to heart muscle, and we can treat the heart which begins to fail. The complexity and sophistication of our equipment is beyond the wildest dreams of the physician who retired from practice even as recently as the 1950s, with electronic monitors which can observe the heart beat, pacemakers which can control it, drugs which can speed it or slow it; the list is endless. Despite all this, however, many patients die before they reach hospital, others within minutes or hours of arriving. The overall picture, while varying from centre to centre, nevertheless still continues to show a fifty per cent death rate within the first four weeks.
Obviously, in so far as the primary attack is concerned, our aim should be one of prevention rather than cure. This involves educating physicians and the public about the risk factors I have mentioned--the dangers of smoking, the necessity to be treated for high blood pressure, the adoption of prudent dietary habits with a reduction in the intake of animal fat, the necessity for regular physical exercise. In addition to all of this, prevention requires research in order for us to discover the true mechanism by which the primary cause of the disease, atherosclerosis, is developing at an earlier and earlier age.
It always surprises visitors to our exercise classes to see that we really have a number of patients under the age of thirty; the youngest so far is twenty-four! Thirty years ago, there were many who considered that atherosclerosis was inevitable. Such a nihilistic approach is now totally obsolete. Scientists have been able to show regression of the fatty patches in the walls of the arteries by animal studies, and, more recently, in a limited number of studies on humans.
But if, indeed, this condition is due to interaction of a number of risk factors, a so-called multi-factorial disease, as opposed to the simple "germ" disease of a previous era, then the ultimate responsibility for its elimination will rest with you. I believe that all Canadians have to assume responsibility for their health maintenance behaviour, and to attempt to reduce coronary risk factors is not incompatible with a satisfying, enjoyable life style. The active, lean, non-smoking businessman feels as good as he looks. Success is no longer measured by the size of your waistline!
I now want to move to my own particular area of interest and work--the rehabilitation of the heart attack survivor. One might wonder why rehabilitation is necessary. After all, hasn't the patient recovered? It's not as if he has lost an arm or a leg and required training in the use of an artificial limb. True, but then I can assure you that the after-effects of the heart attack, although not so obvious, can be just as disabling. After discharge from the hospital, the patient's morale is often very low. He is depressed and frequently lacking in self-confidence. He may be frightened to return to work, or to exert himself, or to have sex. The period of enforced rest in the hospital, followed by the "take it easy" approach engendered by fear, has not only sapped his confidence, but also weakened his muscles and reduced even further his already deplorable level of physical fitness. Finally, there is evidence that his life expectancy may be reduced because he is more prone to another heart attack.
For all of the above reasons, I felt that the Toronto Rehabilitation Centre should offer a program for these individuals. In essence, this consists of a supervised exercise regime which involves attendance at the Centre one evening a week, with the patient working out four times a week on his own. Initial and continuing levels of exertion are prescribed individually from the results of an exercise stress test. After an initial series of lectures at which the patient is introduced to the rudiments of his disease and the principles of training, he is carefully instructed in such basics as pulse-taking and symptom-interpretation, the jogging technique, choice of correct exercise clothing and shoes, how to adapt to varying climatic conditions, and so on. He completes a training diary every week and, from this, his subjective and objective responses to effort are charted by the staff. Telemetry, or the use of a portable transmitter which is strapped to the patient's back and broadcasts his ECG to the laboratory in the Centre, is often used during actual exercise sessions. Repeat stress tests are carried out at regular intervals. Attendance is for a period of one to two years, depending on progress. The aim is to achieve endurance fitness, relieve symptoms, improve mental outlook, and alter life style so as to eradicate the heart disease risk factors I have referred to earlier.
The results of this program to date have been excellent. About three thousand patients have been treated since 1968 to good effect. The restoration of self-confidence, the alleviation of depression and the improvement in self-image have been notable features of the psychological gains. Fitness has been improved in practically everyone.
Endurance fitness brings with it greater benefits for the post-coronary patient. The heart rate drops, while the stroke volume, or amount of blood ejected with each beat, increases. This makes for a more efficient smoother-working pump. The oxygen-carrying capacity of the blood increases, the muscles extract oxygen more efficiently from the blood stream, there is a reduction in the percentage of body fat, an increase in the HDL or "protective" cholesterol in the blood, a drop in circulating stress hormones, and a decrease in blood stickiness.
Our figures show that recurrence rates in the group have been extremely low, and despite the vigorous nature of the exercise, recurrent attacks during actual physical activity no higher than the expected level on the basis of chance alone.
Acceptance of the program by the medical fraternity has been extremely high. Whereas at the end of the first year only one per cent of all patients referred to the Centre were heart attack victims, currently these cases constitute well over thirty per cent of our annual referral rate. In fact, we now receive some ten to fifteen new post-coronary referrals a week.
This, of course, has put a considerable strain on our resources, but I am glad to say that, with the very generous help of a non-profit fellow rehabilitation organization, Marina Lodge, we have been able to complete a new wing which will be devoted entirely to this type of work and which will open later this spring. This is surely a first--a building devoted entirely to the rehabilitation of the patient with coronary artery disease. With a full-time staff of twenty, a part-time staff of twenty-five, and facilities which include a large gymnasium, six cardio-pulmonary testing laboratories, a lecture hall, and a 200-metre indoor/outdoor jogging track, we plan to treat not only the heart attack victim, but also the individual who is at high risk for coronary artery disease, as well as involving ourselves in community education, teaching of coronary rehabilitation techniques to professional staff, and, of course, increased clinical research.
We are flattered that our program, with minor modifications, has been set up in various cities in the United States, including Chicago, Houston and Los Angeles, and also abroad, in places as far afield as Singapore, Capetown and Oslo.
Of course, there is no doubt that the achievements of our post-coronary marathoners have helped considerably to show how effective our method is in restoring the cardiac patient's confidence in his physical ability. Obviously, only a small proportion of patients have the motivation and the time to train for such a gruelling event. To date, some thirty-two patients have taken part in over 120 official marathons.
Our first one was in 1973 when I accompanied eight patients to Boston. I still recall the momentous, if somewhat nerve-racking, weekend. We had decided some nine months earlier to tackle the Boston Marathon and had been training hard through an extremely miserable winter. I remember we drove to Boston in two cars, a station wagon and a large black limousine which, in point of fact, belonged to one of the runners who was a funeral director. In short, we went in a funeral hearse!
Little cameos still remain in my mind-some funny, some very touching--such as being interrupted while I was taking a blood sample from one of the patients at the finish line by a hippie shouting, "Hey Mac, I don't know what you are shooting him up with, but you better watch out for the cops; this place is thick with them." As Ken Smith passed through the seamier part of town, I heard an irreverent youth, after looking Ken up and down, turn to his friend and say, "What is that old fart doing here?" I witnessed Ken stagger to a halt, turn, face the pair and say plaintively, "I have been asking myself the same question for the last ten miles."
The marathon group has, of course, grown in numbers since those days. But it can take credit for initiating the Hawaii Heart Association's Cardiovascular Section in the annual Hawaiian Marathon, and most recently inaugurating the first cardiovascular marathon in Dublin, Ireland this past August. This will be an annual event organized by the Irish Heart Association. The group has really become a club, and like most clubs has developed its own particular traditions over the years. For example, on the tenth anniversary of each member's heart attack, we run the full marathon distance, twenty-six miles 385 yards, around a course close to the Centre, after which we shower, change and consume a breakfast which consists of two magnums of champagne, fried eggs and bacon, sausages, toast and coffee. We have had three of these wondrous occasions so far and they have proved extremely popular--so much so that at our next meeting there is a motion on the agenda to the effect that we celebrate fifth anniversaries!
On the other hand, coaching middle-aged and older post-coronaries brings with it problems totally unlike those experienced by the coaching staff which accompany our track teams to the Pan-American Games, the Empire Games, or the Olympics. For instance, I rarely have to worry about my athletes being out on the town the night before a run. They usually start nodding off about 10:30 or so, possibly, if they feel really daring, over a copy of Playboy. Other things assume greater importance--most typically, the character, quality and regularity of their early morning bowel movement. It is, indeed, a matter of considerable concern if this happy event does not take place at a preset time, each individual feeling that the slightest deviation in this time-hallowed routine is to be feared even more than another heart attack. Consequently, I have to ensure that they do not forget to bring their bran with them and, just to be on the safe side, I carry a liberal supply of laxative suppositories. Breakfast itself can be a problem. Inevitably, all of the "athletes" forget to bring their reading glasses with them, with the result that we sit around a large table while I, who am myopic and therefore can read print by taking my glasses off and holding the menu about two inches from my nose, read each line two or three times so that they can form a mental picture of what it is they want to eat.
Is it necessary to run a marathon to benefit from the program? Of course not, but the example of those who do is a powerful stimulus to the rest of us. Imagine the hope it gives a patient who is lying in hospital recovering from a heart attack to learn that such a feat is actually a possibility. Some of our most gratifying results have been far less dramatic--like the sixty-year-old business executive who was forced to retire from his highly successful business after his attack, and whose condition when he was referred to us seven years ago was so bad that he could barely walk two hundred yards without having to stop and take medication to relieve the pain in his chest. Today he is back at work, and walks four miles five days a week--a greater feat for him that running twenty-six miles might be for some.
Heart attack has been quite vividly described as an "ego attack." Quite suddenly, frequently without prior warning, a previously healthy person is faced with the immediate, and often terrifying, prospect of death. Even as this threat recedes, the coronary patient is left with doubts about his employability and future earning capacity. He may visualize himself as old and dependent. He begins to wonder which of life's pleasures he will have to give up.
In this light, it would be reasonable to believe that he is more in need of psychological help than an exercise prescription. This would be a superficial assessment; most cardiac patients view their disorder as a physical, rather than a non-physical impairment. The psychological trauma that is experienced relates mostly to the fear that the heart attack has left the patient physically incapacitated.
For this reason, some form of activity program is essential for virtually all cardiac patients, as it is probably the most effective for restoring the cardiac patient's confidence in his physical ability. This fact was recognized by the famous Dublin physician, William Stokes, who advocated walking therapy for cardiacs in his historical work Diseases of the Heart and Aorta, published in 1854.
The heart attack survivor knows that to live and work comfortably he must have a certain level of physical fitness. Once his exercise prescription takes him beyond that level, he then has positive proof that his illness need not interfere with his future enjoyment of life.
In prescribing exercise for the post-coronary patient, our approach is to give the patient the facts, even to the point of letting him know that his life expectancy is sub-normal. We then re-educate him towards a healthier, more active life. The emphasis is always on the patient's active participation in his own rehabilitation. He learns that he is expected to work conscientiously and assiduously on his own, altering his life style to accommodate his five exercise sessions each week. If he chooses to accept our approach, he knows
that we are always there to help and co-operate with him in this joint health venture.
We believe that exercise prescription after heart attack is the vital ingredient in the successful rehabilitation of the cardiac patient. It is a method by which the patient will become an active and aware participant in his healing process. It is the way to achieve the benefits described by one of the patients at the Toronto Rehabilitation Centre: "I'm not jogging to live longer, I'm jogging because it's made me fit, and I can now enjoy certain pleasures in life that have always been important to me. I no longer have angina when I stay up late at night, I can play longer and harder than ever before, and for me, that's what living is all about."
In the final analysis, that is also what cardiac rehabilitation is all about.
The thanks of the club were expressed to Dr. Kavanagh by Michael A. Stevenson, a Director of The Empire Club of Canada.