Staying Fit and Heart Healthy with Chronic Pain

Transcript Highlights
Dr. Katie Twomley
February 25, 2016

Welcome! Thank you for joining us today for “Staying Fit and Heart Healthy When Fighting Chronic Pain.” This Facebook chat will be hosted by Dr. Katie Twomley and will cover topics such as:

  • the importance of exercise and proper diet for people with pain
  • the signs of heart attack and stroke
  • the link between heart disease and stress
  • the types of medications that are safe for pain and high blood pressure
  • the link between overuse of NSAIDS for acute and chronic pain and the increased risks of cardiovascular troubles
  • And much more.

heart1Dr. Katie Twomley, MD, is a board-certified cardiologist in Lexington, North Carolina. She received her education from Duke University School of Medicine and completed her residency at Duke University Hospital. Dr. Twomley did her fellowship at Wake Forest Baptist Medical Center. She is board certified for internal medicine and cardiovascular disease.

Now, please join us in welcoming Dr. Twomley!

Dr. Twomley: Hello! As a general cardiologist in a community setting, I am accustomed to addressing all aspects of my patients’ quality of life in regard to their heart health including pain control. I am happy to answer your questions about heart health while dealing with chronic pain.

Taylor: I try and take over the counter pain meds when I can, is there really a link between NSAIDS like Advil and heart problems?

Dr. Twomley: Concerns over increase in cardiovascular events with NSAIDS via effects on vasoconstriction (increasing pressure in blood vessels leading to worsening hypertension) as well as platelet activation (encouraging platelet clumping to form blood clots)

Dose dependent effect
 Chan et al: frequent use defined as 22 days per month and increases risk cardiovascular events 1.44 times over those who do not use NSAIDS
. If >15 tablets per week then risk increases further to 1.86 times
 Tylenol/acetaminophen not completely safe as risk also increased but not as much.

Naproxen (Aleve) had least risk associated and without dose dependence
. The more selective COX-2 inhibitors were hopeful to have less of this risk but, Vioxx was taken off the market for very high increased risk (3.7 times); Celebrex is still available and risk is similar to ibuprofen and other NSAIDS.

What do I recommend? I advise patients to use NSAIDS sparingly but if an Aleve is enough to allow them to get out and walk for half an hour then perhaps the risk is worth the benefit of the exercise effect on cardiovascular risk. I also prescribe tramadol which is thought to be safest option in terms of cardiovascular risk.

Dr. Twomley: For Taylor and others: links regarding research on over the counter pain meds and heart disease:

COX-2 NSAIDS and CV events

NSAIDS and acetaminophen (Tylenol) and CV events

Terri: My mom has been diagnosed with afib but doesn’t have chronic pain and was wondering how many times a cardiologist would make her have cardioversion?

Dr. Twomley: Usually cardioversion is used when necessary to control a heart rhythm if it is causing a lot of symptoms. Often I try to get a person back into a normal rhythm with cardioversion at least twice before proceeding to a more advanced procedure like an ablation (which is when a physician cauterized an area of the heart to prevent the AFib from coming back) there is not necessarily a limit to how many times a person can be cardioverted.

Terri: My mother has afib—she is 83­­—and the doctors are trying to manage her on medications instead of putting in a pacemaker. How do you choose which is better. Being a daughter to parents who will not ask questions and get upset if you ask questions how can you find out about their conditions and know for sure they are getting the best care possible.

Dr. Twomley: Pacemakers are only used in atrial fibrillation when the heart rate goes too low while treating the AFib with medicines. There are lots of medicines out there that treat AFib well and those meds need to be customized to each patient for best side effect profiles and efficacy. When the meds used cause too low of heart rate, then a pacemaker can be used to help treat AFib.

heart2Anonymous: What are the benefits of exercise in heart disease? What are the best exercises for patients with chronic pain?

Dr. Twomley: The Nurses Health Study was a longitudinal observational study that followed the habits of nurses over decades and then documented their illnesses including cardiovascular events. Nurses who exercised for 30 minutes at least 5 times a week (mostly brisk walking) reduced their risk of CV events by 30% (this is as good a risk reduction as taking a statin drug – the widely prescribed cholesterol lowering agents like Lipitor)

Fit versus Fat study was a prospective observational study that followed individuals of various BMI and fitness levels. The bottom line is that those who exercised routinely, whether obese or not, faired the best in terms of cardiovascular risk. Those who did not exercise faired worse even if their BMI was in the underweight or normal weight category.

Take away: Exercise is good for you whether or not you lose weight from it! Multiple studies have shown that the benefits of exercise are dose dependent: The more you do, the more you benefit. Exercise in chronic pain is limited by fear of pain during exercise. However, studies show that exercise helps overall pain control and sense of well being in chronic pain patients.

Nancy: Is it okay to take aspirin with Eliquis?

Dr. Twomley: Nancy, yes, most of my patients on Eliquis take a baby aspirin a day along with the medicine. Eliquis is a blood thinner to prevent stroke in AFib and with all blood thinners, you should be careful to watch for signs of bleeding. if any signs of bleeding, alert your doctor immediately. Low dose or baby aspirin is safe in combination in most people.

Becky: Heart murmurs? Tell me more about them.

Dr. Twomley: Becky, a heart murmur is a sound made by blood flow across a valve in the heart. The heart has 4 valves that control the flow of blood. Valves can build up calcium over time and become restricted causing the noise or valves can leak causing a noise. Most often, these problems are followed every 6-12 months with an echocardiogram (ultrasound of the heart).

L. Bowma: I have intractable nerve pain. I want to exercise but I’m not sure what is the best exercise activity for me to do that will not cause an increase in my pain level? Do you have any suggestions on low-impact exercises? Also, is it common for people with nerve pain to have an increase in pain from exercise—will it calm down over time? Thanks!

Dr. Twomley: Exercise has been shown to benefit patients with chronic pain no matter what type in research studies; however, individuals have specific scenarios obviously. Most often, I refer patients to pool exercise to help with joint pain but neuropathic pain can be trickier. I think yoga, Pilates, and other low impact options may be beneficial. while these exercise classes can be expensive, I have seen several DVD options advertised to allow you to do them at your own pace at home.

heart3PainPathways Magazine: Pool exercise information

Barby: I have severe vascular flow issues in my arms, hands, feet and intestines due to reflex sympathetic dystrophy. I also have cardiac ischemia and backflow issues in my heart. Are my chances higher for a stroke (my father had a couple before passing a few weeks ago)? Is there anything I can do to prevent a stroke?

Dr. Twomley: Yes, prevention of stroke is similar to prevention of heart attack—the goal is to prevent plaque build up in the arteries. A healthy diet (look for a post soon regarding this), exercise, and management of risk factors such as high blood pressure, cholesterol, and diabetes can help prevent stroke. Also, if your risk is considered high, aspirin is still shown to be beneficial in stroke prevention in women.

PainPathways Magazine: This site has an assessment tool where you can answer questions and determine your heart health and cardiovascular risk factors.

PainPathways Magazine: Read more on the link between chronic pain and heart disease in this great article.

PainPathways Magazine: Another good article for chronic pain sufferers of various conditions.

heart4Dr. Twomley: Diets? Here are my thoughts: this is tricky as there are lots of reasons for a “diet.” There are diets for heart failure and kidney failure and diabetes. There are diets targeting weight-loss, which are generally calorie restricting diets (I recommend weight watchers for ease of use and accountability in meetings)

There are diets for heart health, which are generally based on the Mediterranean diet (lean proteins, especially fish and seafood; lots of fresh fruits and vegetables; good fats like olive oil, nuts, avocado; avoidance of simple carbohydrates and saturated fats).

Belinda: I have fibromyalgia, many times with activity my legs feel like they are turning to stone, any thoughts? I’d like to walk because of hypertension and diabetes

Dr. Twomley: I would suggest that you find the best time of day for you in terms of you pain and energy level, plan to take your prescribed meds for pain control, and then set out to walk 15-30 minutes. Just that amount of walking will benefit your blood sugars and lower your risk of heart disease events in the future. I wish you the best!

PainPathways Magazine: This article may be helpful, Belinda.

Anonymous: What about stress and heart disease?

Dr. Twomley: STRESS and cardiovascular disease —Acute stress can cause heart attack without any blockage in the heart arteries. This is called “Takutsubo,” or more simply stress cardiomyopathy. Patients present with classic symptoms and findings of heart attack but have no blockage to explain it. Most patients recover the function of their hearts over the following 3-6 months. Often there is a tragic event or social stressor preceding this heart attack.

Everyday life stressors can also lead to blockage in arteries forming earlier in life and progressing faster than expected. Theory is that the chronic stress leads to inflammation in the body and inflammation is a factor in driving atherosclerosis. How likely stressors will advance atherosclerosis in a patient depends on the individual’s personality: how resistant or vulnerable they are to stress. Studies have noted increased atherosclerotic in areas of war or civil unrest or times of economic depression.

PainPathways Magazine: Read more on the link between stress and heart disease.

Becky: How to know if your heart is healthy enough for an exercise regimen.

Dr. Twomley: Most often, if a patient has been sedentary for a period of time due to illness or disability and considers a new exercise regimen, I recommend a stress test, especially if they have risk factors for heart disease. A stress test observed by a cardiologist is a good indicator of your risk with exercise.

PainPathways Magazine: Hi everyone! This is Amy North, editor of PainPathways Magazine. On behalf of the magazine, we’d like to thank Dr. Twomley and all those who participated in tonight’s chat! We are excited to be offering this great forum for information and inspiration. Have a good night everyone!


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All information provided is for educational purposes only. Neither PainPathways Magazine nor their Facebook Chat hosts are responsible for a medical diagnosis. Individuals should seek a physician for evaluation and personalized treatment plan.