Tag Archives: marriage

Burpees and the Dizziness of Aging

Last week a patient that I treat for an arrhythmia who is 60 years old and in outstanding shape told me that he was experiencing dizziness after doing burpees. His personal trainer told him he should talk to his cardiologist about it.

Dizziness is a common complaint of my older patients. Indeed, 30% of individuals older than 65 report dizziness and 50% of the “very old” (older than 85 years) experience dizziness.

If the dizziness is described to me as a sensation that the patient is about to “pass out” or lose consciousness or a feeling of everything turning black I figure it has a cardiovascular cause with the blood pressure in the brain arteries globally reduced transiently. I always take this very seriously as this type of dizziness may be the precursor of total loss of consciousness (syncope) or sudden death.

One study showed that 57% of patients with dizziness age 65-95 were ultimately felt to have a cardiovascular cause.

I find a common cause of dizziness in my patients, especially as they age and if they are on mediations which lower the blood pressure is orthostatic hypotension (.OH)

Orthostatic Hypotension.

Bear with me as I attempt to succinctly describe this very important physiologic phenomenon which everybody has experienced at one time or another.

Orthostatic (meaning related to standing) hypotension (low blood pressure) is defined as a sustained reduction of systolic BP >20 mmHg or diastolic BP >10 mmHg within 3 minutes of standing or following head-up tilt to ≥60o.[

Dizziness due to OH occurs when you stand up quickly or rise from  a kneeling position.

During the process of going from lying or sitting to standing your body has to make some major adjustments to ensure that blood flow to the brain is maintained. As you stand up from lying down your brain suddenly goes from being at the same height as your heart to being (depending on how tall you are) a foot or more higher. Thus, a higher pressure is suddenly needed to keep blood flowing to the brain. The major sensors of blood pressure (baroreceptors) within the vascular system are located in the carotid arteries (large neck arteries providing blood to the brain) and these are constantly sending feedback to the brain.

The carotid sinus baroceptors are stretch sensitive mechanoreceptors that modulate what is called the autonomic nervous system to keep arterial blood pressure constant.

A second process that occurs with standing is pooling of blood due to gravity in veins in the legs and abdomen. This pooling takes blood, in essence, out of the circulatory system, thus lowering the pressure in the heart which in turn can lead to less blood being pumped into the arteries. Part of the autonomic reflex response to standing then involves constricting veins to reduce pooling.

Things that make it more likely you will experience dizziness from OH include

-anything that lowers the volume of blood in your circulatory system. Thus being dehydrated (from vomiting or diarrhea, diuretics, excess alcohol, sweating) or losing blood. A common scenario for passing out from OH is the prep for colonoscopy which induces diarrhea and possible dehydration. Another common scenario is after surgery which causes a combination of blood loss and dehydration (plus other factors) .

-Medications which lower blood pressure

Burpees

burpee 1If you’ve been paying attention and know what a burpee is then you have probably deduced that my patient was suffering from orthostatic hypotension.

I was unaware of the term burpee although I had seen members of my gym (under the watchful eye of their personal trainers who seem to specialize in having their clients undergo bizarre and embarrassing exercises (most likely to justify their fees, After all, you don’t need a personal trainer to show you how to run on a treadmill and properly use resistance machines which, arguably, provides all the aerobic and isometric exercise you need for maintaining optimal cardiovascular and muscular fitness)).

It was named for an American, Royal H. Burpee, who wrote his PhD thesis on this exercise as a measure of fitness. Subsequently, the burpee or squat thrust was adopted by  the US military to assess the fitness of recruits in WWII.

burpee 2According to this Popular Science article from 1944 the army did not consider a soldier ready for the rigors of war until he could do 40 to 50 at an easy pace without resting.

Many personal trainers and boot camps are enamored of this exercise and Men’s fitness magazine  calls them “the most badass exercise”

One personal trainer, Jamie Atlas, believes you should not  do burpees because they put too much stress on the knees and lower back, the two most frequently injured areas of the body. He also points out that the burpee is a good test for a soldier:

the burpee is probably the very best exercise for the military. Or should I say more specifically, for people being shot at by other people with guns. It stands to reason that if a soldier can’t quickly get down to the ground and then quickly get back up again, they’re simply fodder for target practice. A primary need is to be able to drop into a firing position and then bounce back up lightning-fast to move to a safe position — and without a certain standard of ability to complete that particular movement, they are at a significantly higher risk of getting shot than their other, more agile companions.

Burpees and Orthostatic Hypotension

It would be hard to design an exercise that puts a greater stress than multiple burpees on the autonomic reflexes involved in keeping blood flow to the brain constant (I’m somewhat reticent to mention this because I may soon see members of my gym doing it but if you had an exercise that involved standing on your head and suddenly flopping to the ground then jumping up to a standing position that would be a greater stress. If this hasn’t been invented yet, I claim credit and would like it to be called a pearson ©).

My patient said that after doing his required 30 burpees he would stagger around in circles with a sensation that he couldn’t see properly and that he was in imminent danger of passing out and  falling down.

Added to the above-mentioned issues of moving from supine to standing we are now moving from a squat position. In this position the large muscles in the legs are tightened, thus squeezing blood back to the heart and initiating reflexes that are the opposite of those needed to compensate when standing is resumed.

To compound the confusion his body was feeling, my patient’s personal trainer had him jump or spring up from the squat position with his arms raised in the air and his feet leaving the ground. This further adds to the gravitational effects of blood pooling in the legs and abdomen.

Aging and orthostatic hypotension

Dizziness due to OH is more common as we age. We don’t know exactly why but it is likely related to multiple age-related changes in the cardiovascular system and the autonomic nervous system.

Some factors that may play a role include a decrease in baroreflex sensitivity, a decreased vasoconstrictor response to sympathetic stimulation, decreased parasympathetic activity and impaired relaxation of the heart muscle.

It may be possible for the young and fit to do multiple burpees without dizziness but I suspect that the vast majority of sixty somethings are going to notice significant dizziness with this kind of exercise.

Despite what my patient’s personal trainer him, I don’t think dizziness experienced with burpees is a reason to be evaluated by a cardiologist. I think dizziness experienced with burpees is a reason not to do burpees

Perhaps, personal trainers could change from the burpee to the Weak Horse, another exotic exercise and “toughening up” game that comes to us from the military.

Screen Shot 2015-11-07 at 9.10.11 AM

Dizziness experienced with aerobic exercise such as running  or rapid walking can be a sign of a serious cardiovascular disorder and merits being reported to your physician.

-nonburpeeingly yours

ACP

Mysterious AliveCor Mobile ECG artifact noted at Commander’s Palace

The skeptical cardiologist was in New Orleans last  weekend. There is no breaking low carb news to report but I did make it to Commander’s Palace for lunch.

Screen Shot 2015-10-29 at 3.18.45 PMThere the eternal fiancée of the skeptical cardiologist (EFOSC)  and I enjoyed delicious food, delightful company (Dave and Barb, who I wrote about last year when they dramatically improved their longevity by tying the knot in The Big Easy) and several oddly colored $0.25  martinis.

barbalivecor
Full disclosure. This was taken during brunch at Broussard’s and is a recreation of the aliveCor recording session at Commander’s Palace. Note the jazz trio in the background who later came by our table and played the St. Louis Blues.

During a lull in the activities I pulled out my iPhone and was asked by the lovely Barb what the funny looking thing stuck on the case was. This necessitated demonstrating my Alivecor mobile ECG device and recording her electrocardiogram.

CPalivecor annotated
The red arrows point to a regular artifact occurring at 200 beats per minute. Toward the end of the recording the artifact goes away and the normal QRS complexes (blue arrows) can be seen clearly.

Strangely enough, the recording was full of an odd artifact.

There was much discussion on the source of the artifact and we repeated the recording having her use her third and fourth fingers on the electrodes instead of the second and third fingers she used the first time.  Same result.

Barb speculated that it was due to the absence of husband Dave who had left the table to use the facilities.

When Dave returned we recorded his ECG and there was no artifact whatsoever.

Screen Shot 2015-10-29 at 3.15.04 PMI repeated the recording on Barb and lo and behold it was now free of artifact.

What was the source of this mysterious ECG artifact noted after an outstanding lunch and multiple 25 cent oddly colored martinis?

High blood alcohol level?

Strange electrical devices being utilized intermittently at Commander’s Palace?

Or perhaps I was recording the actual adverse electrical signals created by the absence of Barb’s devoted spouse, something heretofore not reported.

Further studies are clearly needed to fully define and characterize these waves which I have decided to call Commander’s electromagnetic marriage disruption waves or CEMDW’s.

martinily yours

-ACP

 

 

 

Death and Marriage in The Big Easy

IMG_3397
Built in 1857 for Richard Terrell, a wealthy cotton broker originally from Natchez, Mississippi, the Terrell House is a grand three story Italianate stucco-over-brick mansion. The main house features porches, galleries, and balconies framed in ornate cast iron and a brick New Orleans courtyard complete with several fountains and lush vegetation.

The Skeptical Cardiologist is not just researching low carb diets in The Big Easy. He has also been investigating the effects of marriage on cardiovascular risk.

I and the significant other of the skeptical cardiologist stayed at the wonderful Terrell House, a  bed and breakfast nestled among the magnolias on Magazine Street in the Garden District of New Orleans. There, we participated in the marriage of our close friends, Dave and Barb.

Was marrying a heart healthy choice for Dave? for Barb?

Science seems to tell us yes. Marriage has been associated with a lower risk of cardiovascular disease compared to being single or divorced in multiple studies and for both sexes.

A study of the rate at which individuals in Finland developed what are termed acute coronary syndromes or ACS (think of these as heart attacks or heart attacks about to happen) showed that ACS events were approximately 58–66% higher among unmarried men and 60–65% higher in unmarried women, than among married men and women in all age groups.

The chance of dying within 28 days of an ACS were even worse for the unmarried. These mortality rates were found to be 60–168% higher in unmarried men and 71–175% higher in unmarried women, than among married men and women.

This meant a rate of death of 26% in the 35-64-year-old married men, 42% in men who had previously been married, and 51% in never-been-married men. Among women, the corresponding figures were 20%, 32%, and 43%.

As with all such observational studies, association does not prove causation.

How on earth does being married confer a lower risk of developing cardiac problems and halving of the death rate once one has an ACS?

Some speculation from the authors:

1.  Perhaps a poor health status leads to not getting married or getting divorced more frequently.

2.  Perhaps married people have better health habits and enjoy higher levels of social support than the unmarried which promotes lower risk

3. Perhaps prospects in the pre-hospital phase are better because of earlier intervention (wife bugging husband to get that indigestion checked out)

Do I believe that Dave and Barb have suddenly halved their risk of dying from cardiovascular disease because they tied the knot last night?  Not at all!

Nothing has fundamentally changed in their lives that I can see that will have any significant impact on either one’s risk of a heart attack.

If Dave were a true bachelor and not in a committed monogamous relationship I can see certain factors that marriage would modify: perhaps unmarried Dave would be more inclined to engage in risky behaviors such as binge drinking, cigarette smoking, unhealthy food consumption or staying out late partying and  listening to wild music. Perhaps married Dave’s wife will be watching over him carefully for any signs or symptoms of heart disease and encouraging an early visit to the doctor to get checked out.

Perhaps the presence of kids limits the married parents engagement in risky or unhealthy behaviors either because the parents are spending more time parenting than partying or because they are trying to serve as role models.

Perhaps, and this is likely unmeasurable, it is the “love” in the relationship (and the associated change in neurohormonal milieu) that lowers stress and inflammation and is crucial in stopping atherosclerosis.

Two individuals living together in a committed and loving relationship would seem to have these same factors on their side and I can’t fathom how the legal or religious sanctioning of their union modifies those factors favorably.

Unfortunately, the myriad studies that have been published on this topic totally fail to capture the important distinction between single and unattached and single but living in a committed and loving relationship.

In any event, in the immortal words from my toast to them last night:

“May your fights be short and your apologies many
May your desire to be in each other’s company grow stronger every year
And may all your bartenders look like  Alan Alda”
Here’s to Barb and Dave and marriage and less death!