Category Archives: stone shaped heart

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Soldier on

Older
bolder
golder
told yer
moulder
soldier on

What is older? Anything and anyone older than me? At one point I have 5 women who are over 100 years old as patients. Two are 104. One is local indigenous tribe and tells me about white women moving to another pew if she sat down near them in church, back when she is in her twenties. I am apologetic at that visit because it is hospital week. Our pacific northwest hospital has chosen cowboys as the theme so being a bit oppositional defiant, I have braids with one feather hanging down. I swear that EVERY ONE of my indigenous patients comes in, including the 104 year old. I apologize, but they mostly seem amused by my rebellion.

They also influence me. Now when a 72 year old complains about being OLD, I say, “You are not old in my practice.” They look confused. I say, “I’ve had five people over 100 all at once, so you don’t get to complain about being old until you are 90.” People laugh, but they also usually look pleased. Over 100 is a LOT older than 72. When someone is over 100, I don’t really doctor them much. I might say, “This is what the book says we should do.” “I’m not doing that,” says my 101 year old. “Ok, cool.” I say. It’s hard to argue with.

And the joke about the centurian? What do you like best about turning 100? “No peer pressure.” Um, yes. I want them to tell ME what they’ve done to reach 100. The one thing that they all have in common is that they are all stubborn. I don’t know if stubbornness is what gets them there or if we just get more stubborn as we get older. Both, perhaps.

By stubborn, I don’t mean that they don’t learn and do new things. I had a woman in her upper 70s who I diagnosed with diabetes. At the next visit she said cheerfully, “I found these five apps for my phone. This one tells me the carbohydrates, this keeps track of the distance I walk, this one tracks my blood sugar.” I don’t remember what the other two did. This was a decade ago. She was retired from Microsoft. I wanted her to teach a class for me and all of my other diabetic patients.

My grandmother took classes in her 80s in lip-reading. She was going quite deaf and her hearing aides were not terribly helpful. She had videotapes and a rather shy teacher who would come to the house. She would glare at him and the videotapes. She attacked learning it like a piranha and was furious that she couldn’t learn it faster. I am like that too and my son learned some patience from the violin. He couldn’t play well immediately and found that practice works.

At what age is someone old? I think that’s moving target and the older we get, the older we think it is. I do think 104 is a lot older than 72. When does your culture think that people are old? My fierce grandmother said that she would look out her window. “I see little old ladies across the street and think, oh, poor things, they are so old. But then I think, OH, I am older then they are!” She died at age 93, fierce until the end and curious about death too. Her last words to my father were, “Look, Mac, I’m dying.” He said, “I’m looking,” and she stopped breathing. She was always curious and funny and could tease quite terribly and she and my mother butted heads and loved each other. She loved my father too, and me.

The photograph is my maternal grandmother, Katherine White Burling and it’s one I took.

For the Ragtag Daily Prompt: older.

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Turtlehead

I don’t know if this monolith is named turtlehead, but it certainly looks like one to me.

I lost the trail early on and had to backtrack. There was a turn and then rock steps down that I missed. I was more careful after that. I like the way they mark the trails here: rocks and more rocks.

Here is the sign at the start.

Here is a future monolith near the top of the Corkscrew Trail.

For the Ragtag Daily Prompt: monolith.

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Safe/Not Safe

I think safety is an illusion. BUT it is also nice to feel safe and embrace the illusion.

I sleep best in tents, because as a child, I felt safest at our families “shacks on a lake” in Ontario. Cabins, but pretty much one room cabins. No electricity, outhouses, and my family lived in tents. I loved it. I was more afraid of people than bears.

The pandemic, or this pandemic, has made people feel less safe. But that safety was an illusion too. I had influenza in 2003 and was out sick for two months. I had a racing heart and it hurt to breathe. No asthma. Only rest seemed to help. My doctor and I had no idea when it would resolve. It resolved after two months. My partners accused me of malingering and lying.

A fast heart rate can come from a panic attack, but it works the other way too. If your heart rate is very fast, you may feel panicky. When I nebulize people with albuterol for the first time, I warn them that it may feel like adrenaline, it may speed their heart and they might feel panicky. A friend with Long Covid kept saying that maybe they were just anxious. I got them to have an Urgent Care test them: a resting and a walking heart rate. At rest 72 beats per minute. Normal. Walking, their heart rate jumped to 165, very abnormal! Normal is 70-100 beats per minute, though if one is out of shape, 110 or 120 can result from unaccustomed exercise. But there is no way an athlete in their 20s should jump to 165. The Long Covid heart rate was driving the anxiety, not the other way around.

After I had the 2003 influenza, I read a book of essays about the 1918-1921 influenza pandemic. And I realized that we would probably have a pandemic in my lifetime. I thought it would be influenza, not coronavirus! Hopefully the world will learn a little from this one and change a little over time and be a little more sane if (ok, when) there is another pandemic.

I saw this video today. Wow, what costumes (all 1970s) and dancing! Wonderful! And such a sad song about a broken friendship that used to feel safe.

I hope that you have places or people that you feel safe with. Elwha sometimes likes to sit in the cat tent, even if it is partly open. It feels safe.

For the Ragtag Daily Prompt: safe.

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Shattered

Is the wave, the water being shattered?

Or is it really the rock that is shattered, bit by bit, over time?

Stone shaped heart

your heart is an agate
clear stone

you have won
sort of
you think

but I am water
I am waves
I will smash you against the other rocks
and wear you down

I am water
I carve you like a laser
you wear my name
carved in your stone shaped heart

it is already written there
on your stone shaped heart
faint, because water wears slowly

water wearing stone
over time

________________________

written in April 2022

For the Ragtag Daily Prompt: shattered.

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Soft my heart

Soft my heart forgives and lets go,
lets go of reconciling. We won’t. I won’t.
I have waited long enough. I forgive all
and I am done waiting. I let it all go and
walk forward into a different life.
The Sufis lead me: the teacher must judge when
the student is ready. I am not a teacher.
I am always a student. I want to learn
always and change. I let go. Farewell, my dears,
you still have my love but you do not have me.
I no longer care, I don’t long for your love,
I let you live your stuffed and twisted lives
in peace, without me importuning you,
to listen to think to grow with me
and you don’t want to so I am free.

____________________________

Written February 17, 2024. As with most of my poems, I don’t know how it will end until I write it. Poem as prayer. The ending surprised me, too.

For the Ragtag Daily Prompt: reconcile.

I don’t know who took the photograph. From left to right, my sister, cousin, me, cousin, taken at Lake Matinenda in Ontario, Canada.

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Stitch

I like to play with word cliches
Geraniums red and chrysanthemums white
As I wander busy through my day
Delphiniums blue, all are dark at night
Least said, soonest mended
Except for murder, rape and pillage
Loose lips sink ships, war ended
Sinner gossip round the village
Time will mend a broken heart
A stitch in time will save nine
You’ll never finish if you don’t start
Mend that heart and change the rhyme
Absence makes the heart grow fonder
Your love grows daily, what a wonder

For the Ragtag Daily Prompt: absence.

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Covid 19 and the heart

This is from the University of New Mexico Roam Echo PASC (Post Acute Sequelae of Covid-19) talk on 11/9/2023 over Zoom.

Cardiovascular Outcomes in Post-COVID Conditions
Jeffrey Hsu, MD, PhD, FACC, Assistant Professor, Division of Cardiology – University of California, Los Angeles Health and Founder, COVID Cardiology Program – University of California, Los Angeles 

I am going to include the references in the order that Dr. Hsu talked about them. This is a sobering and upsetting lecture with the research showing a post Covid-19 increase in cardiovascular risk factors (cholesterol, hypertension, diabetes), and an increase in cardiovascular events in people with no previous cardiovascular diagnosis including heart attack, stroke, pulmonary embolus, blood clots and sudden death.

I don’t expect the general population to read the studies, but look at a few of them. It is very very impressive, the amount of work being done. Now let’s explore the talk and boil it down to three sentences for primary care to explain in clinic. Right. (You can always skip to the last two paragraphs if you get overwhelmed, and come back later.)

Part 1: The Research.

The first paper is about veterans without cardiovascular disease, followed for one year after Covid-19, matched with a cohort who did not have Covid-19. This is before immunization was available. They were studying the heart and cardiovascular risk. The veterans who had had Covid-19 infection were twice as likely to be diagnosed with cardiovascular risk then the veterans who had not had Covid-19. The risk was higher in the veterans with more severe Covid-19, the risk was present in all subgroups: old, young, male, female, with or without other risk factors. At two years out, the people who had been hospitalized for Covid-19 still had a persistent increased risk of death and cardiovascular incidents (heart attack, stroke, sudden death, blood clots).

To be clear, this is NOT Long Covid patients. This is just a cohort of veterans who had Covid-19. This would indicate that everyone who had Covid-19 has an increased cardiovascular risk.

Here is the first paper: 1. https://www.nature.com/articles/s41591-022-01689-3

Two more papers looked at more general populations who got Covid-19 before the vaccine was available and found the same thing. The veterans tended to be older and more male patients, but the general population studies found the same pattern in women and younger patients. Papers:

2. https://www.scientificamerican.com/article/the-risk-of-heart-disease-after-covid/, “Health modeller Sarah Wulf Hanson at the University of Washington’s Institute for Health Metrics and Evaluation in Seattle used Al-Aly’s data to estimate how many heart attacks and strokes COVID-19 has been associated with. Her unpublished work suggests that, in 2020, complications after COVID-19 caused 12,000 extra strokes and 44,000 extra heart attacks in the United States, numbers that jumped up to 18,000 strokes and 66,000 heart attacks in 2021. This means that COVID-19 could have increased the rates of heart attack by about 8% and of stroke by about 2%. “It is sobering,” Wulf Hanson says.

3.https://www.nature.com/articles/s41591-023-02521-2

Non hospitalized patients had decreased risk for some cardiovascular problems but not all and still had significantly higher risk than people who had not had Covid-19. I am busily thinking UH-OH, this is really bad, in this lecture.

He stated that the data is not in yet about vaccination, whether it lowers the cardiovascular damage compared to unvaccinated.

The initial study was on veterans, mostly male and mostly white, but then was replicated in other similar studies that were not on veterans, but on a general population.

From the second and third study, 700,000 patients with a mean age 40 and more than half female, were studied for new cardiovascular disease in the year following Covid-19 and found an increased risk of death within one year, 0.34% vs 0.28% HR 1.6. That was in 2020, a nonvaccinated population. Another study showed similar results, 13,000 patients with Covid-19 and 26,000 without, average age 51. There was a similar risk increase in cardiovascular disease and an increased risk of death within one year.

4. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00349-2/fulltext

5. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2802095

So do other infections do the same thing? Studies of acute risk of myocardial infarction risk after influenza, done before the pandemic, indicate an increased risk of myocardial infarction within one week after infection, but not beyond that week. So Covid-19 is really really nasty to our cardiovascular system.

6. https://www.nejm.org/doi/10.1056/NEJMoa1702090

7. https://www.nejm.org/doi/10.1056/NEJMra1808137

Pneumonia and sepsis can increase risk of cardiovascular disease, but there have not been the extensive studies as in Covid-19. More and better studies.

One to two years after diagnosis, there is increased cardiovascular and cerebrovascular risk, both:

  1. Cardiovascular risk factors, worsening after covid
  2. Thrombosis risk

8. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00044-4/fulltext

The risk of is up diabetes 40% in the post Covid-19 patients. That does not mean that 40% are diagnosed with diabetes, but that the risk is higher after Covid-19. For example, if in the non-Covid cohort 100 of 1000 40 year olds develop type 2 diabetes, then it’s 140 of 1000 in the post Covid-19 group.

The risk of dyslipidemia in 50,000 patients went up 24%. Dyslipidemia means increased LDL cholesterol or increased triglycerides and lower HDL or all of them.

9. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00355-2/fulltext

10. https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.123.21174

Hypertension is up too and weight gain.

11. https://www.nature.com/articles/s41577-022-00762-9

New onset hypertension is up 22% in hospitalized patients post Covid-19 and 11% in unhospitalized post Covid patients.

Myocardial infarction (heart attack) and ischemic stroke both go up. Ischemic stroke is the more common kind of stroke and is the clotting version. Bleeding strokes are less common.

Why does Covid-19 do this? What is the mechanism? The studies are pointing towards thromboembolism as the mechanism in both increased cardiovascular risk factors (dyslipidemia, hypertension, stroke, heart attack, clots). Thrombosis means clots. Remember the talk about micro-clots? (My write up here: https://drkottaway.com/2023/04/14/xeno-or-infection-phobic/). Micro-clots can lead to bigger clots. A clot in a heart artery causes a heart attack; in the brain an ischemic stroke; a clot in the leg can break into pieces and block the lung arteries. Irritation in the heart and the arteries can increase blood pressure. I’m not sure how it can increase diabetes, but it does.

Next he shows a slide about thrombosis and how complex it is. Sars covid-19 seems to promote perfect storm of events that leads to environment for thrombosis in multiple ways.

Covid-19 infects epithelial cells, causes a hyperactive immune response, orchestrates subsequent response, causes platelet hyperactivation and then hyperactive innate immune response, causes damage to glycocalyx that protects and vascular endothelial injury, decreases antithrombogenic and increases prothrombogenic activity which promotes thrombosis in the vasculature, platelet activation and coagulopathy. Got that? No? Me either, my last immune system class was in 1988 when I was working at the National Institutes of Health. It’s bad, meaning it can kill us or cause damage that is disabling.

12. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30937-5/fulltext

My notes are a bit disjointed here: The endothelial cells (which line arteries) express H2 receptors that Covid-19 virus needs to enter the cells. The H2 receptors are also in glomerular capillary loops (kidneys), and immune cells and cause apoptosis of lung endothelial cells. Apoptosis is a form of programmed cell death that occurs in multicellular organisms and some eukaryotic microorganisms. So you don’t want your lung cells doing that. Lung, small bowel, and pulmonary microvasculature can all be affected.

13. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00355-2/fulltext

Plaque in human coronary vessels, in the immune cells, spike and Sars cov 2 identified in coronary artherosclerotic plaque.

Direct on coronary and cerebrovascular cells. (Ok, I don’t know what I meant by this note.)

Part II: Now what? What is our approach to healing this?

There is still limited data! (The clinical trials are roaring along but they take time.) Here are a bunch of studies, all using blood thinners. Blood thinners include aspirin, plavix, heparin, enoxaparin or apixaban. Do NOT start aspirin at home at this point, because when you add a blood thinner, there is a risk of bleeding, including bleeding stroke and intestinal bleeding. So far, the studies are discouraging.

Aspirin 150Mg Recovery trial: no difference in mortality: major bleeding 1.6% vs 1/0 % Lancet 2022. This is a double baby aspirin dose, 30 days in study, no benefit in acute setting.

14. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30937-5/fulltext

Non critically ill hosp patients ACTIV 4A trial P2Y12 inhibitor – heparin alone or clopidigril (plavix) plus heparin, no benefit, major bleeding 2.0% vs 0.7% so worse in the both group.

15. https://www.nejm.org/doi/10.1056/NEJMoa2103417

16. https://doi.org/10.1001/jama.2021.17272

Harmed patients with severe disease.

ACTIV-4B aspirin or apixiban in outpatient, stopped early, event rate low, higher rates of minor bleeding in the 5mg apixiban group.

Feedom covid 19 trial: Non ICU Hospitalized, compared prophylactic heparin to enoxaparin or apixaban. Signal to provide benefit, lower rates of death and intubation, similar bleeding rates

17. https://www.sciencedirect.com/science/article/pii/S0735109723045278?via%3Dihub

So what does our Post Covid Cardiologist recommend to physicians and patients:

First year post covid: look for cardiovascular symptoms.

Screen for risk factors, hypertension, diabetes, hyperlipidemia, obeisity.

Optimization of risk factors, smoking cessation (and I would add that alcohol also causes damage to the heart and arteries, though tobacco is worse.

Assess candidacy for statin therapy for primary prevention.

18. https://cardiab.biomedcentral.com/articles/10.1186/s12933-021-01359-7

There is a study of triple therapy (meaning THREE blood thinners) that showed improvement but that was in older patients who already have heart disease before Covid-19. So it doesn’t apply.

He says there aren’t any good studies of blood thinners in Long Covid-19 yet and it is not clear that the Long Covid people are worse as far as the cardiovascular risk than everyone else. And remember, these studies are on unvaccinated people, so for the year following the first year of Covid-19. We don’t have the results for vaccinated people. He says that if someone is high risk or has cardiac symptoms chest pain etc put on 81 mg aspirin and a statin (and work it up, of course. Do the testing.

For now use anticoagulation (blood thinners) only if there is clear evidence of thrombus: deep venous thrombosis or pulmonary embolus. Freedom covid-19 study showed major bleed risk 0.1-0.4%.

The cardiologist speaker has not started triple therapy on any patents given unknown benefit at this time, with known significant major bleeding risk. He recommends shared decision making, meaning the patient should be presented with the risks and choices. Um, ok, boil this talk down into three sentences. Good luck. EEEEEEE!

Part III: Summary.

Whether you had Covid-19 before being vaccinated or after, or aren’t sure if you ever had it, it is worth seeing your provider to check your blood pressure, do diabetes screening, stop smoking (anything, and I include vaping in that), reduce or eliminate alcohol, keep your weight reasonable, check your cholesterol and go to your provider if there is any weirdness post Covid-19. And if you have not been vaccinated, oh, my gosh. Unless you have an immunology problem where your immunologist says “NO!”, get vaccinated.

Lastly, I’ve heard many claims that death rates were “over reported” for Covid-19. No. In a death certificate, the acute injury or infection is reported FIRST and then other related causes. Such as: Covid-19, ischemic stroke, hypertension, tobacco overuse syndrome. There were MORE strokes and heart attacks and sudden death, with Covid-19 as the final straw in many people who already had cardiovascular disease. They died sooner than they would have if not infected. That is not over reporting.

____________________________________________________________________________

A friend, Brent Butler, took the photograph, used with permission. I think it shows how I felt after this talk. Yet I still have hope, because you can’t deal with something unless you know about it.

If you want a link for the talks, message me. Anyone can tune in.

Covid-19 continues to fandangle us. There. I verbed the Ragtag Daily Prompt: fandangle.

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Marijuana update

https://newsroom.heart.org/news/marijuana-use-linked-with-increased-risk-of-heart-attack-heart-failure

Marijuana is still illegal at the federal level, but some states have legalized it. I agree with legalization but I don’t think of it as benign or safe at all. It’s clear that it can be addictive. A study of teens (with parental consent and where they paid the teens to try to quit for a month) showed that the teens that smoked daily had real trouble stopping, even when quite motivated. The U of WA Pain and Addiction telemedecine said that about half of daily users have “overuse syndrome” and have trouble quitting.

I worked with two people who were trying to quit. The big issues for them in quitting were insomnia and anxiety. Marijuana can suppress both anxiety and help with sleep. However, our brains do not really like that sort of daily interference. The neurons can remove receptors from the cell walls if they are feeling overwhelmed. It is like trying to listen to music with ear plugs. You turn the music up. The drug is the ear plug: when the earplugs are gone, the music is way too loud. We can’t really “turn the music down”, so it is not much fun letting the neurons recover.

With the edibles and THC vs the other one, it’s even more confusing. I had many patients taking edibles or tinctures to sleep. Some said, “Oh, it’s CBD, so it doesn’t make me high. So it is not addictive.” We do not know it that is true. With opioids, people can have opioid overuse syndrome without ever getting high, just from being on pain medicine as directed. And marijuana does not have only CBD and THC. There are over 300 different cannabinoids in the plants, and CBD and THC are just two of them. I have no idea if the edibles and tinctures have the other 298 or more and what they do to the cannibinoid receptors in our brains alone or in combination.

I don’t want to have any overuse syndrome: alcohol, opioids, gambling, marijuana, whatever. I know I can get off caffeine in 24 hours, though it involves an awful headache. I am nearly off coffee now, because my body only likes coffee when I have pneumonia. I quit coffee from 2014 to 2021 and now am quitting again.

The two studies in the article look at people who do not smoke tobacco and who are using marijuana. They are seeing an significant increase in heart disease, heart attacks, sudden death and congestive heart failure. Congestive heart failure is pump failure, where the heart does not pump correctly. This is a major problem, as you might guess.

Be careful out there.

I took the photograph at Fort Worden last week on a day where both the wind and the tide were howling.

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Favorite

I used to have a favorite agate, chalcedony nodule
found on the beaches here, during Covid. Surprising me.
I did not expect anything and only long to find something
to sustain me, just a little. I find a stone shaped heart, agate hard
and not clear. Not chalcedony, murky with impurities.
Yet the stone sustains me and I keep walking.
Even when I see that the impurities are on the outside too.
Camouflage, refusing to be washed clean, refusing change.

That one is lost, back in its’ native mud and sand. Someday
it may be polished clear, but it shrinks as it is tossed
among the other stones. It is running out of time and surface area.
It may not be heart shaped any more. My favorite now is clear,
a rich red with tiny streamers of darker red inside. I carry it with me,
I carry it in my heart. It is more nearly shaped like a heart,
a real heart, then the conventional one that is lost.

Be warned, then, that that one may be on the beaches here.
Or it could be that it has already been picked up
and taken, the finder hoping to wash it clean and see
the clear beauty as the light shines through.
Transparency is rare. I walk a mile of beach to find even one
clear stone. Don’t be fooled by that one: the dirt is embedded.
I won’t say never, but the chances of transparency and love
shrinks as it is worn away by the restless tides
and crashing against all the other rocks.