Heart Valve Disorders

The heart has four chambers two small upper chambers (atria) and two larger lower chambers (ventricles). Each chamber is closed by a one-way valve. For various reasons these valves can malfunction, causing leakage (regurgitation) or failure to open properly (stenosis). The mitral valve, which allows blood to flow

from the left atrium to the left ventricle (the main pumping chamber of the heart), and the aortic valve, which allows blood to flow from the left ventricle to the aorta (the main artery of the body), are the most common sites for valve disease. These valves are under great strain from the powerful contractions of the left ventricle, which pumps blood throughout most of the body.

Mitral Valve Prolapse

Mitral valve prolapse is the most common valve disorder. Usually it is an inherited structural defect. The two parts, or leaflets, of the mitral valve thicken, preventing them from coming together properly. The leaflets bulge back into the left atrium as the ventricle contracts, allowing small amounts of blood to leak back

into the atrium. Prolapse is a term that means slippage out of position; in this case the valve leaflets have difficulty being in their correct position because they are too thick.

Most people with mitral valve prolapse experience no symptoms. Others may have a wide range of symptoms such as chest pain, palpitations (an awareness of one’s heartbeat), migraine headaches, dizziness, and fatigue that cannot be explained by the valve problem alone. Physicians diagnose mitral valve prolapse by using a stethoscope to listen to the characteristic clicking sound produced by the valves as they hit against one another. The condition also produces a heart murmur, or slight rushing sound, that the physician hears through the stethoscope when the heart contracts. Echocardiography (an ultrasound examination of the heart) allows a doctor to view the prolapse and determine its severity.

Most people with mitral valve prolapse do not need treatment. When symptoms such as extra heartbeats, a rapid heartbeat, or chest pain become bothersome, medications are prescribed to control them. In rare cases, when leakage becomes severe, surgical repair or valve replacement may be required. People with mitral valve prolapse are usually given antibiotics before dental or surgical procedures to decrease the risk that bloodborne bacteria will infect the heart valve.

Mitral Valve Regurgitation

Mitral valve regurgitation, also called mitral incompetence or mitral insufficiency, is leakage of blood back through the mitral valve into the left atrium each time the left ventricle contracts. This increases the volume and pressure in the left atrium, which, in turn, increases blood pressure in the vessels leading from the lungs to the heart. This results in lung congestion (fluid buildup). In the past, rheumatic fever was the most common cause of this condition. But with the advent of antibiotics, rheumatic fever is now rare in the United States, and the few cases that are seen are primarily in older people who had rheumatic fever in childhood. A more common cause of mitral valve regurgitation today is a heart attack, which can damage the supporting structures of the mitral valve. Mild cases of mitral valve regurgitation may not cause any symptoms. The condition may be recognized during a routine chest examination with a stethoscope, when a doctor hears a distinctive heart murmur caused by the blood leaking back into the left atrium when the left ventricle contracts. Diagnosis usually is confirmed by electrocardiography (ECG; an examination of the electrical activity of the heart) and chest X rays that indicate the left ventricle is enlarged. Echocardiography (an ultrasound examination of the heart) can produce an image of the faulty valve and indicate the severity of the problem. Since the left ventricle has to pump more blood to make up for the blood leaking back into the atrium, it gradually enlarges to increase the force of each heartbeat. The enlarged ventricle may cause palpitations (awareness of one’s heartbeat), which is particularly noticeable when the person lies on his left side. The left atrium also tends to enlarge to accommodate the extra blood leaking back from the ventricle. A very enlarged atrium often beats rapidly in an irregular fashion (atrial fibrillation). This reduces the heart’s pumping efficiency, and the lack of proper blood flow through the atrium allows blood clots to form. If a clot becomes detached, it may be pumped out of the heart and block a smaller artery elsewhere in the body, possibly causing a stroke or other damage. Finally, severe regurgitation reduces the forward flow of blood, causing heart failure, which may lead to coughing, swollen legs, or shortness of breath on exertion. Treatment for this condition can take several forms. Repairing the valve can either eliminate or reduce the regurgitation enough to make the symptoms tolerable and prevent heart damage. Atrial fibrillation accompanying mitral valve regurgitation is usually treated with medications that slow the heart rate and help control the fibrillation. In severe cases, the valve may be replaced surgically.

Mitral Valve Stenosis

Mitral valve stenosis is a narrowing of the mitral valve opening that increases resistance to blood flow from the left atrium to the left ventricle. This resistance causes pressure to build up in the atrium; the pressure then backs up through the veins of the lungs, causing increased pressure and congestion in the lungs. The increased stress on the lungs can lead to shortness of breath and eventually to congestive heart failure. Typically, the valve leaflets fuse together. Surgery is needed to widen or replace the valve. Mitral valve stenosis is almost always the result of rheumatic fever, which is rare today in the United States, where most cases occur in older people who had rheumatic fever during childhood. However, rheumatic fever can sometimes occur after an untreated “strep” throat infection (infection with streptococcal bacteria). Mitral valve stenosis also can be congenital (present from birth). Infants born with this condition rarely live beyond age 2 unless they have surgery to correct the condition.

If stenosis is severe, blood pressure increases in the left atrium and in the veins in the lungs, resulting in heart failure and an accumulation of fluid in the lungs (pulmonary edema). A person with heart failure easily becomes fatigued and short of breath. At first, shortness of breath may occur only during physical activity. Later the symptoms may occur even during rest. Some people find that they can breathe comfortably only when they are propped up with pillows or sitting upright.

Some people with mitral valve stenosis have a plum-colored flush in their cheeks. High blood pressure in the veins of the lungs may cause a small vein or tiny capillaries to burst and bleed slightly or massively into the lungs. Enlargement of the left atrium can result in atrial fibrillation (an abnormally fast heartbeat). To diagnose mitral valve stenosis, a physician uses a stethoscope to listen for a characteristic heart murmur as blood rushes through the narrowed valve from the left atrium. Unlike a normal valve, which opens silently, a valve

affected by mitral valve stenosis often makes a snapping sound as it opens to allow blood into the left ventricle. The diagnosis of mitral valve stenosis is usually confirmed by electrocardiography (ECG; an examination of the electrical activity of the heart), a chest X ray showing an enlarged atrium, or echocardiography (an ultrasound examination of the heart). Sometimes cardiac catheterization (a diagnostic test in which a thin, flexible tube is inserted into the heart through a blood vessel, to examine the heart) is performed to determine the extent and characteristics of the valve blockage. Treatment for mitral valve stenosis may include a variety of drugs. Betablockers, digoxin, and verapamil are used to slow the heart rate and control atrial fibrillation. Digoxin also strengthens the heartbeat if heart failure occurs. Diuretics are often prescribed to reduce the blood pressure in the lungs by reducing the volume of circulating blood. If medication does not reduce the symptoms adequately, surgical valve repair or replacement may be needed. People with mitral valve stenosis are given antibiotics before dental and surgical procedures to reduce the risk of a heart valve infection.

Aortic Stenosis

Aortic stenosis is an abnormal narrowing or stiffening of the aortic valve, which controls the flow of blood from the left ventricle to the aorta (the main artery of the body). As the valve narrows, the left ventricle has to beat harder to push the blood through the aorta and out into the body. The most common cause of aortic

stenosis is the gradual buildup of calcium deposits on the valve, a natural consequence of aging. Although this condition may appear at about age 60, it usually does not produce symptoms until age 70 or 80. Aortic stenosis also may result from childhood rheumatic fever. When rheumatic fever is the cause, aortic stenosis

usually is accompanied by mitral valve stenosis, mitral valve regurgitation, or both. In aortic stenosis, as the ventricle attempts to pump enough blood through the narrowed aortic valve, the left ventricle wall thickens, and the enlarged heart muscle requires an increasing blood supply from the coronary arteries. Eventually the blood supply to the heart becomes insufficient, causing angina (chest pain) on exertion. An insufficient blood supply can damage the heart muscle, reducing its ability to pump blood through the body. This reduced functioning can lead to congestive heart failure. A person with severe aortic stenosis may faint on exertion because the narrow valve prevents the ventricle from pumping enough blood out of the heart to the rest of the body. In diagnosing aortic stenosis, a physician will listen for the characteristic heart murmur through a stethoscope, note abnormalities in the pulse and electrical activity of the heart, and look for an enlarged heart as revealed by a chest X ray. Electrocardiography (ECG; an examination of the electrical activity of the heart), echocardiography (an ultrasound examination of the heart), and cardiac catheterization (a diagnostic test in which a thin, flexible tube is inserted into the heart through a blood vessel, to examine the heart) may be used to determine the severity of the stenosis. In adults with fainting, angina, and shortness of breath on exertion caused by aortic stenosis, the aortic valve is surgically replaced, preferably before the left ventricle is damaged beyond repair.

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Preventing High Blood Pressure

Anyone, regardless of age, sex, race, or heredity, can lower his or her risk of developing high blood pressure

or lower existing high blood pressure by taking the steps described here. Maintain a healthy weight. As your body weight increases, your blood pressure rises. In fact, being overweight can make you two to six times more likely to develop high blood pressure than if you maintain a desirable weight. It’s not just how much you weigh that is important; it also matters where your body stores excess fat. Your body shape is inherited from your parents, just like the color of your eyes and hair. Some people tend to store fat around their waists, while others store fat around the hips and thighs. “Apple-shaped” people who store extra fat at the waist appear to have higher health risks than “pear-shaped” people who store fat around the hips and thighs.

No matter where your extra weight is located, you can reduce your risk of developing high blood pressure by losing weight. Even a small weight loss can make a big difference. And if you are overweight and already have high blood pressure, losing weight can help you lower your blood pressure. To lose weight, you need to consume fewer calories than you burn. But don’t try to lose weight too quickly. The healthiest way to lose weight and keep it off is to do it gradually, by losing about a pound a week. By taking in 500 calories less per day and being more physically active, you should be able to lose about a pound (which equals 3,500 calories) a week. Losing weight and keeping it off involves making permanent lifestyle changes. Here’s how to eat healthfully and lose weight:

• Choose foods that are low in calories, sugar, and fat. Naturally, choosing lowcalorie foods cuts calories. But choosing foods low in fat also can cut calories. Fat is a concentrated source of calories, so eating fewer fatty foods will help reduce your calorie intake. Cutting back on butter, margarine, fatty salad dressings, fatty meats, skin on poultry, full-fat dairy products such as milk and cheese, fried foods, and sweets will also improve your cholesterol profile.

• Choose foods that are high in fiber. These include fruits; vegetables; wholegrain foods such as cereal, pasta, and bread; and dried peas and beans. Foods high in fiber are excellent substitutes for foods high in fat. The former are lower in calories and are a good source of essential vitamins and minerals.

• Limit serving sizes. When trying to lose weight, it’s not just the types of foods you eat, but how much you eat. To take in fewer calories, you need to limit your portion sizes. Try especially to take smaller helpings of high-calorie foods such as fatty meats and cheeses. And try not to go back for seconds. Today many restaurants take pride in serving large portions of food. This does not mean that you have to clean your plate. Choose the doggy-bag option; eat only half of what you are served and take the rest home for an excellent “free meal” the next day.

• Keep track of what you eat, when you eat, and why you eat. Write it down. Note whether you snack on high-calorie foods while watching television or if you skip breakfast and then eat a large lunch. Once you clearly see your eating habits, you can set goals for yourself—for example, cutting back on TV snacks or, when you do snack, having fresh fruit, low-fat or air-popped popcorn, or vegetables such as carrots and celery. If there’s no time to eat breakfast at home, take fruit, a bagel (skip the cream cheese), or whole-grain cereal with you to eat at work. Changing your eating habits will help you change your weight. Exercise regularly. Another way to lose weight and control blood pressure is through regular physical activity. Cutting down on fat and calories combined with regular exercise can help you lose more weight and keep it off longer than with either diet or exercise alone. Aerobic exercise provides added benefits. It helps improve the fitness of your heart, blood vessels, and lungs, which, in turn, protects you against heart disease. Activities such as stair climbing, bicycling, swimming, brisk walking, running, and jumping rope are called “aerobic,” which means that the body uses oxygen to make the energy it needs during the activity. Aerobic activities provide health benefits if done at the right intensity for at least 20 to 30 minutes, three to four times per week. If you think you don’t have time to exercise, try to exercise for two 15-minute periods or even three 10-minute periods during your day. You will still gain health benefits.

You need to see your doctor before starting an exercise program if you:

• have a health problem such as high blood pressure

• have angina (chest pain)

• tend to feel dizzy or faint

• have difficulty breathing after a mild workout

• are middle-aged or older and have not been active

• are planning a vigorous exercise program Otherwise, get up off the couch, get out, get active, and get fit.

Choose foods that are lower in salt. Most Americans take in more salt (sodium) than they need, which may help explain why the United States has higher rates of high blood pressure than countries where people eat less salt. Salt attracts water. Normally, if you have eaten too much salt, your kidneys eliminate the excess salt from your body along with a certain amount of water. But if your kidneys cannot get rid of the extra salt, your body retains the water that clings to the salt, which raises blood volume and, in some people, blood pressure. Certain people appear to be salt-sensitive, which means that their blood pressure goes up when they eat salt. Researchers think that about half of all people with high blood pressure are salt-sensitive and that as many as 70 to 80 percent of blacks are salt-sensitive. Other groups that seem to have a high incidence of salt sensitivity are older people, people who have diabetes, and people who are overweight. There is a good chance that if you are a member of one or more of these groups, decreasing your salt intake would be beneficial to your health. Research suggests that the average person needs only about 200 milligrams of sodium per day. Doctors recommend that people with high blood pressure take in no more than about 6 grams of salt per day, which equals about 2,400 milligrams of sodium, or about 1 teaspoon of table salt. A teaspoon of salt may seem like a lot to you, but remember that this refers to total salt intake for a day. This includes salt in processed and prepared foods, salt added during cooking, and salt sprinkled on food at the table. Americans eat an average of 4,000 to 6,000 milligrams of sodium each day, so many people could probably benefit from cutting back on their salt intake. The key to cutting back on salt is in teaching your taste buds to enjoy less salty foods. Here are a few tips for cutting back on salt:

• Check food labels for the amount of salt in the foods you buy. Choose foods that are low in sodium. Look for labels that say “sodium-free,” “very low in sodium,” “low sodium,” “light in sodium,” “reduced sodium,” “less sodium,” or “unsalted.” Then check the label for the amount of sodium per serving.

• Choose fresh or frozen vegetables, or canned vegetables labeled “no salt added.” Choose fresh poultry, fish, and lean meat rather than canned, cured, smoked, or processed varieties.

• Use herbs, spices, salt-free seasoning blends, and lemon juice instead of salt to add flavor to your food.

• Cook rice, pasta, and hot cereals without salt. Avoid using instant or flavored rice, pasta, and cereal mixes because they usually have added salt.

• Choose “convenience” foods that are low in sodium. Cut back on frozen dinners, packaged dinners such as macaroni and cheese, packaged mixes, canned soups or broths, and salad dressings, which often contain large amounts of sodium.

• Buy low-sodium, reduced-sodium, or no-salt-added versions of canned soups, dried soup mixes, or bouillon; canned vegetables and vegetable juices; low-fat cheeses; margarine; condiments such as ketchup or soy sauce; crackers and baked goods; processed lean meats; and snack foods such as chips, pretzels, and nuts.

• Rinse canned foods, such as tuna, to remove excess sodium. Drink alcoholic beverages only in moderation. Drinking too much alcohol can lead to the development of high blood pressure. To prevent high blood pressure, or if you already have high blood pressure, limit yourself to no more than two drinks per day. A drink is defined as 11⁄2 ounces of 80-proof distilled spirits, 5 ounces of wine, or 12 ounces of beer (regular or “lite”). Do not use tobacco. Although it is not a direct cause of high blood pressure, smoking puts you at risk of developing the disease. The chemicals in tobacco smoke can damage the artery walls, making them more susceptible to plaque formation. Plaques narrow the arteries and interfere with blood flow to the heart,

brain, and other organs and tissues. Blood clots can form on the rough surface of a plaque. A blood clot or plaque can block an artery, causing a heart attack or a stroke. The nicotine in tobacco is a powerful stimulant that causes the heart rate to increase, the arteries to constrict, and blood pressure to rise. Smoking also affects cholesterol levels in the blood: it can increase LDL (“bad” cholesterol) levels and decrease HDL (“good” cholesterol) levels. All of these tobacco induced effects can contribute to the development of high blood pressure. Although it is sometimes promoted as a smoke-free alternative to cigarettes and cigars, smokeless tobacco also puts you at risk of developing high blood pressure. The nicotine, sodium, and licorice contained in smokeless tobacco products all can raise blood pressure. Considering these health risks, it makes sense to give up your tobacco habit now. Here are some other factors that may help prevent high blood pressure:

• Potassium. A certain amount of potassium is essential for proper body function. Eating foods rich in potassium may help protect some people from developing high blood pressure. Many people get enough potassium from eating fruits, vegetables, dairy products, and fish, so potassium supplements are rarely needed. Too much potassium can disturb your heart rhythm.

• Calcium. People with low calcium intake have higher rates of high blood pressure. It is best to get the calcium you need 1,000 to 1,500 milligrams per day for adult men from the foods you eat. Low-fat and nonfat dairy products such as milk, yogurt, and cheese are excellent sources of calcium. It has not been proven that taking calcium supplements helps prevent high blood pressure.

• Magnesium. A diet low in magnesium may make your blood pressure rise. However, doctors do not recommend taking magnesium supplements to help prevent high blood pressure. The amount of magnesium you get in a healthy diet is enough. Magnesium is found in whole grains; green, leafy vegetables; nuts; seeds; and dried peas and beans.

• Fish oils. A type of fat called omega-3 fatty acids is found in fatty fish such as mackerel and salmon. Evidence suggests that eating fish at least twice a week can help reduce high blood pressure. Talk to your doctor if you are considering taking fish oil supplements. Most fish, if not fried or prepared with added

fat, are low in saturated fat and calories and are a good source of essential nutrients.

• Fats, carbohydrates, and protein. Varying the amount and type of fats, carbohydrates, and protein in the diet has little if any effect on blood pressure. But for overall heart health, it is crucial to limit the amount of fat in your diet, especially the saturated fat found in foods such as fatty meats and full-fat dairy products. Saturated fats raise your blood cholesterol level, and a high cholesterol level is another risk factor for heart disease. Foods high in fat are usually also high in calories. Foods high in complex carbohydrates (starch and fiber) are often low in fat and calories so eat these foods in moderate amounts instead of eating high-fat foods. Always check food labels.

• Caffeine. The caffeine found in coffee, tea, and colas may cause blood pressure to rise, but only temporarily. In a short time your blood pressure will return to its previous level. Unless you are sensitive to caffeine, you do not have to limit caffeine intake to prevent high blood pressure.

• Garlic and onions. Increased amounts of garlic and onions have not been found to affect blood pressure. Of course, they are rich in antioxidants and are tasty substitutes for salty seasonings.

• Stress management. Stress can make blood pressure go up for a while and over time may contribute to high blood pressure. Stress management techniques such as biofeedback, meditation, and relaxation can help you to deal positively with the stress-producing events in your life, and may help you control your blood pressure.

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High Blood Pressure

High blood pressure, or hypertension, increases your chances of developing heart disease or kidney disease and of having a stroke. About one in every four American adults has high blood pressure but may not be aware of it. It is often called “the silent killer” because it usually causes no symptoms. However, high blood pressure is easy to diagnose, and there are practical steps you can take to bring your blood pressure under control. Blood pressure is the force of blood pushing against the walls of the arteries that carry blood throughout your body. It is measured in millimeters of mercury, or mm Hg, using an instrument called a sphygmomanometer (pronounced sfig'mo-mah-nom'e-ter). Blood pressure is highest when the heart contracts (beats) and pumps blood into the arteries. This is called the systolic pressure. Between beats, when the heart is resting, the pressure falls. This is called the diastolic pressure. A blood pressure reading is always given as a combination of these two pressures; the high (systolic) pressure is written above or before the low (diastolic) pressure. For example, if your blood pressure reading is 120 over 70, it is written as 120/70 mm Hg; 120 is the systolic pressure, and 70 is the diastolic pressure. 

Different activities make your blood pressure rise or fall. For example, normally, blood pressure rises when you are exercising and falls when you are resting. A blood pressure reading of 140/90 mm Hg or lower is generally considered normal. High blood pressure is classified according to guidelines that reflect the levels at which blood pressure begins to pose significant health risks. The guidelines for classifying blood pressure are shown in the following table:

A diagnosis of high blood pressure is based on two or more blood pressure readings taken at separate visits to the doctor’s office. If your systolic pressure falls into one category and your diastolic pressure into another, the higher reading will be used to classify your blood pressure. For example, a blood pressure of 160/90 mm Hg would be classified as stage II. A reading of 170/120 mm Hg would be classified as stage III. Because diastolic pressure represents the lower and more constant level of pressure in the arteries, physicians may emphasize it more, especially in younger people. However, the systolic blood pressure is more important for determining the risk of heart attack or stroke. People with high blood pressure have elevated blood pressure most of the time. Their blood is pushing against the walls of their arteries with higher than normal force. If left untreated, high blood pressure can lead to:

• Atherosclerosis. Uncontrolled high blood pressure causes the artery walls to thicken and lose elasticity. This encourages formation of fatty deposits on the artery wall, which narrow the channel and interfere with blood flow throughout

the body. In time, atherosclerosis can lead to a heart attack or a stroke.

• Enlarged heart. High blood pressure causes the heart to work harder. Over time this causes the heart muscle to thicken and stretch. The heart becomes less efficient and has to work harder and harder to pump blood throughout the body. Eventually this can result in heart failure.

• Kidney damage. The kidneys act as filters to rid the body of wastes. Over a number of years, high blood pressure can narrow and thicken the blood vessels of the kidneys. The kidneys then filter less blood, and waste builds up in the bloodstream. This could lead to kidney failure. When kidney failure occurs, dialysis (a technique to remove waste products from the blood and excess fluids from the body) or a kidney transplant may be necessary.

• Stroke. High blood pressure can weaken the walls of the arteries or cause them to thicken. A weakened artery wall in the brain could break, causing a hemorrhage. If a blood clot blocks one of the narrowed arteries, a stroke may occur. In most cases, the cause or causes of high blood pressure are unknown. This type is known as primary or essential hypertension. Primary hypertension cannot be cured, but it can be controlled. Secondary hypertension is caused by, or is “secondary” to, another disease. For example, some cases of high blood pressure can be traced to tumors of the adrenal gland, chronic kidney disease, or hormone abnormalities. Secondary hypertension can be cured by treating its underlying cause.

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Stress Management

Doctors don’t know all of the ways that stress and illness are connected, but they do know that the central nervous system (the brain and the spinal cord) and the immune system can influence one another during stress. Short-term positive stress can be invigorating, stimulating us to respond positively to meaningful challenges and opportunities. Short-term negative stress can be life-saving, causing us to flee dangerous situations. The brain releases hormones into the bloodstream, causing the heart to beat faster, the face to flush, and the arm and leg muscles to tighten, allowing the person to run away or escape. Once the danger is over, the body repairs damaged areas and returns to its prestressed state. In long-term stress, the hormones continue to be released but the body does not have time to make repairs or to rest and recuperate. This is the type of stress that creates health problems. Under constant stress, a person becomes so conditioned to expect potential problems that his or her body tightens and remains in that state until the stress stops. Under this long-term stress state, the body can develop stress-related problems. Many connections between stress and chronic conditions are known. Stress increases blood levels of adrenaline and cortisol, two so-called stress hormones. Cortisol can suppress the immune system, making people more susceptible to infectious diseases such as colds and flu. The effects of stress on the circulatory system (a quicker pulse, narrowed blood vessels, and thickened blood) can make people more susceptible to heart rhythm irregularities, angina (chest pain), high blood pressure, and stroke. Muscles tighten as stress starts, often causing intense headaches, backaches, and gastrointestinal problems. Stress also can cause testosterone levels to decrease and blood vessels in the penis to constrict, often resulting in erection problems. The rush of hormones caused by a stressful situation can bring on an asthma attack in a person with a history of asthma. Stress also draws the blood supply away from the abdominal area and encourages overproduction of acids in the digestive system, often leading to indigestion and other gastrointestinal problems. Other problems related to stress include insomnia and irritability. The number of hours worked does not seem to cause as much stress as do two other occupational factors: lack of control and inadequate social support. Men who have little control over the demands of their jobs feel more stress than those who have more control. Men who also experience a low level of social support from coworkers have even more problems. What is stressful to one person may be relaxing to another. Some people, for example, like to keep busy all the time, while others need to take frequent breaks. Some people can keep track of multiple tasks, while others prefer to do tasks in sequence. If you are under stress, it is important to recognize it and deal with it in a positive way. Here are some tips to help you relieve stress:

• Exercise regularly. You can decrease stress and release tension through regular exercise or other physical activity. Running, walking, swimming, dancing, playing tennis, or working in your garden are some activities you may want to try.

• Talk about your stress. For example, talk to a friend, family member, teacher, or boss about what is bothering you. If that does not help to resolve the problem, consider seeking help from a professional therapist or counselor. Ask your doctor for a referral, or contact the employee assistance program at work.

• Know your limits. If a stressful situation gets beyond control, walk away. Return to deal with the situation when you have calmed down.

• Take care of yourself. Get plenty of rest and eat a healthy diet. If you feel irritable and tense from lack of sleep or if you are not eating properly, you will be less able to deal with stressful situations.

• Take time for yourself. Take a break from regular work and do something you enjoy. Just relax.

• Be a participant in life. Help yourself by helping others. Share your abilities with other members of your community by volunteering.

• Prioritize your tasks. To keep your schedule from overwhelming you, make a list of your tasks and check them off as you complete them.

• Be cooperative. If things do not go your way, try compromise rather than confrontation. A little give and take on both sides can help you meet your goals and make everyone feel better.

• Cry if you need to. Crying can be a healthy way to bring relief to your tension or anxiety.

• Create a quiet scene in your mind. You can’t always get away, but you can try closing your eyes and letting

your mind wander. A quiet country scene painted mentally can temporarily take you out of the turmoil of a stressful situation and help you to relax. Listening to beautiful music or reading a good book may help you achieve the same results.

• Avoid self-medication. When you need them, you can use prescription or over-the-counter medications to

relieve stress temporarily, but realize that they don’t remove the conditions that caused the stress in the first place. Becoming overly reliant on drugs or alcohol can only complicate matters in the long run. They may be habit forming, or they may interfere with your body’s ability to function normally.

• Learn to relax by using a specific relaxation strategy, such as meditation or deep-breathing exercises. Participate in activities you can enjoy without competing. Cycle, swim, or walk the dog. Forget about always

winning. Relaxation can stimulate the release of endorphin's brain chemicals that promote feelings of well-being. Relaxation strategies work by blocking conscious thoughts, resulting in decreased tension, lower heart and breathing rates, and slower metabolism. Several relaxation techniques, such as meditation, guided imagery, muscle relaxation, and deep breathing, can be used to relieve stress and bring on the relaxation response. If you feel that you are under severe or long-term stress, seek help immediately. Talk about your problems with your doctor. He or she can treat any stress related disorders you may have developed and will refer you to the appropriate mental health professional.

How to Get a Good Night’s Sleep

Sleep is a basic requirement for good health. The mind and the body need sleep to perform maintenance and repair. Even one night of disrupted or missed sleep can drastically alter a person’s chemical balance and cause daytime sleepiness and fatigue. The results of such sleep deprivation can reduce productivity as well as increase the chances of accidents at home or at work. Most adults need 7 to 8 hours of sleep each night, although sleep requirements may differ from one person to the next. For example, some people may feel rested after 5 or 6 hours of sleep, whereas others may still feel sleepy after 9 or more hours of sleep. In general, people tend to sleep less soundly as they age. They may wake up more frequently and have a harder time getting back to sleep. Many older men may find that they simply don’t need as much sleep as they did when they were younger. Overweight men may have problems getting a good night’s sleep. Snoring also may contribute to a loss of sleep. Sleep apnea (a condition characterized by brief episodes of interrupted breathing during sleep) is another common reason for losing sleep. Many people who have sleep apnea find it difficult to stay awake during the day. However, the most common reason for an occasional night of lost sleep is worry or anxiety. Here are some helpful tips for getting a good night’s sleep:

• Stick to a regular schedule for going to bed and getting up. Going to bed and getting up at the same time help set your biological clock.

• Do not sleep late on weekends, and avoid napping during the day.

• Make your bedroom exclusively a place for sleep and sex. This means no TV, work, or serious discussions while in bed. Keep your bedroom comfortable, dark, quiet, and not too warm (about 60 to 65 degrees Fahrenheit).

• Exercise during the day so your metabolism has slowed by bedtime and you are ready for sleep.

• Avoid stimulants such as caffeine, nicotine, and alcohol, and rich, heavy meals before bedtime.

• If you are not lactose intolerant, drink a warm glass of milk just before bedtime. But don’t drink so much that a full bladder disturbs your sleep.

• Have sex before bedtime; it may have a relaxing effect.

• Take a warm bath just before bedtime to help you relax.

• Set aside some quiet time about an hour or so before bedtime.

• If you still can’t fall asleep, get up and read or do a simple chore until you become tired.

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Developing a Good Relationship with Your Doctor

In the past, many people saw the same doctor for years sometimes for most of their lives. Today, people are much more mobile, making a long-standing patient-doctor relationship more difficult. People move to new locations, accept new jobs, and change healthcare coverage. Any of these situations may require a change of doctors. Some health plans restrict your choice of doctors to those who participate in their plans. Seeing a specialist may entail getting a referral from your primary care doctor. Choosing a new doctor takes more than just a word-of-mouth recommendation from a friend. You need to think carefully about what you are looking for when changing doctors. The area of medicine in which a doctor specializes is an important consideration. If you have a particular medical problem, such as heart disease, you will probably want to see a cardiologist (a doctor who specializes in diseases of the heart). If you are generally healthy, an internist (a doctor who specializes in the care of adults) or a family physician is probably the best choice. You may also

prefer a male doctor over a female doctor. Some people choose a doctor based on the hospital to which he or she admits patients. The location of the doctor’s office also is a factor. It should be easy to reach from your home or workplace, especially if you rely on public transportation. Once you have narrowed your choices, find out more about the doctors you are considering. Important information includes where they trained, how long they have been practicing, and their specialty area and whether they have been certified by the board in that specialty. To become board-certified, a doctor must have had at least 7 years of medical

training and must pass a comprehensive examination in his or her specialty (such as plastic surgery or otolaryngology). provides helpful information such as medical training, specialty, and board certification for more than 650,000 physicians in the United States. The least reliable source of information about doctors is probably paid advertising. After you have compiled a list of doctors, you will need to check their credentials.

There are several good sources of information about doctors. Three reference books—Directory of Medical Specialists, Compendium of Certified Medical Specialists, and The Official ABMS Directory of Board Certified Medical Specialists that list board-certified physicians by location are available at your local public library. You also can call your local hospital or the offices of the doctors you are considering to find out the following information:

• Training. Where did the doctor attend medical school? Has he or she completed a residency? If so, where?

• Board certification. Make sure that your physician has been certified by an appropriate certifying board, such as the American Board of Internal Medicine, the American Board of Surgery, or the American Board of Dermatology.

• Hospital privileges. To treat patients at a given hospital, a doctor must gain official approval of his or her peers at that hospital. At which hospital in your community does the physician have staff privileges? Contact the hospital to verify this information.

• Experience. For example, if the doctor is a surgeon, how many times has he or she performed the type of surgery you are planning to have? When was the most recent time? The surgeon you select should be up to date on the surgery you are considering.

• Professional society membership. Perhaps the most important organization to which a physician can belong is his or her specialty society the group that represents the medical specialty practiced by the doctor. Specialty societies certify their members and require that they participate in continuing medical education and adhere to a strict code of ethics. Once you have made your choice, your next step is to develop a good working relationship with your doctor. A good relationship depends on effective communication between you and your doctor. Before you see your doctor for a scheduled visit, think about what you are going to say. Write down important questions you have or symptoms you want to tell the doctor about so you won’t

forget them. When describing your symptoms, be specific; explain when they started and what you experience when the symptoms occur. Write down the names of all the medications you are taking, including over-the-counter drugs and vitamin or mineral supplements. Remember to bring your notes with you. Don’t hold back any information when the doctor asks you questions about your diet, alcohol or other drug use, smoking, or sexual activity. These factors can affect your health, and the doctor needs to know about them to get a full understanding of your condition and treat your problems appropriately. If you feel embarrassed about talking over sensitive subjects, it’s all right to tell your doctor about your discomfort. Rest assured that all of your conversations with your doctor will remain confidential. Your doctor needs to communicate well with you by fully answering all of your questions and explaining medical terms and procedures in language you can understand. He or she also needs to treat you with respect and keep waiting times to a minimum. If you feel that you are not getting all the information you need to follow your doctor’s instructions or that your appointment times are too rushed to address all of your medical concerns, try to talk to your doctor about

the problem before switching to another doctor. Keeping an established relationship is much easier and more valuable than starting all over again.

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Immunizations

Immunizations are not just for children. They continue to be important in adulthood to protect you from  several dangerous infectious diseases, although the number of immunizations you need drops dramatically after age 16. The three most important immunizations are those for tetanus, influenza (flu), and pneumococcal disease (a type of pneumonia). Tetanus is a bacterial infection that affects the central nervous system and can be life-threatening. The bacteria that cause tetanus are found in soil, dust, and animal feces and usually enter the body through an open cut. The bacteria produce a toxin, or poison, in the body that attacks the nervous system, stiffening the muscles. Tetanus is commonly called lockjaw because the muscles in the jaw and neck are affected first. You should get a booster shot of the tetanus vaccine every 10 years throughout adulthood. Influenza, commonly called the flu, is an infection caused by a virus that affects the respiratory system. Symptoms include fever, chills, headache, muscle aches, and a sore throat. Influenza is spread from person to person through direct contact, such as shaking hands, or by inhaling droplets containing the virus in the air after an infected person coughs or sneezes. New strains of influenza virus

appear every year, so you must get a shot of the influenza vaccine yearly, in the fall, just before the flu season starts. Doctors recommend the influenza vaccine for all men over age 65 and for younger men who have medical problems such as heart disease, lung disease, or diabetes or who have close contact with high-risk

people. Pneumococcal disease is caused by a bacterium. It can lead to pneumonia and a number of other serious complications. The most common symptoms are fever, chills, chest pain, a bluish cast to the lips and under the nails, and a cough. You should have a “pneumonia shot” if you are age 65 or over or if you have a

long-term health problem such as heart or lung disease, diabetes, or kidney disorders. The vaccine is taken once and provides long-term immunity; it can be taken at any time of the year. A person should be revaccinated if he received pneumococcal vaccine in childhood and has a chronic condition such as sicklecell

disease. Some men may need additional immunizations, depending on several factors. Hepatitis is a potentially serious inflammation of the liver caused by different viruses. The hepatitis A virus is transmitted through food touched by an infected person or in water that has become contaminated with raw sewage. The vaccine for hepatitis A is administered in two doses. Men traveling to countries in which the disease is common should get the first dose at least 4 weeks before departure, but preferably much earlier because the second dose is given 6 to 12 months after the first. The hepatitis B virus is spread through contact with an infected person’s blood or other body fluids. Healthcare workers who may be exposed to a patient’s body fluids, dialysis patients, people with HIV, and men who live with people infected with hepatitis B are at risk of getting the disease and should be immunized. The hepatitis B vaccine is given in three doses. The second dose is administered 1 month after the first, and the third dose is given 5 months after the second. A chickenpox (varicella) vaccine is now available for children and for adults who never contracted the disease in childhood. Chickenpox is a very contagious disease that causes only fever and an itchy rash in children. Although rare in adults, chickenpox can be much more serious when contracted in adulthood, causing sterility in men. Ask your doctor if he or she recommends that you get immunized for chickenpox. The vaccine is given in two doses, the second dose 1 to 2 months after the first.

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Common Screening Tests

Sometimes a physical examination of your body is not enough to tell your doctor the full condition of your health. In such cases the doctor may order a number of common screening tests. Blood tests and urinalysis help the doctor find out if all of the components of your blood or urine are at normal levels. Scanning techniques such as X rays, magnetic resonance imaging (MRI), ultrasound scanning, and computed tomography (CT) scanning produce pictures of the inside of your body without surgery to give your doctor important information about your overall health. If your doctor has ordered one of these tests for you and you don’t understand what exactly is going to happen, ask questions so you can feel more comfortable about having the procedure. Diagnostic techniques are changing rapidly, and newer techniques will undoubtedly be available in the near future.

Blood Test 

A sample of your blood can provide many clues about the quantity and quality of the individual blood cells and whether your blood can clot normally. To obtain a sample of your blood, a medical technician will draw blood with a needle and syringe from your forearm and send it to a laboratory. At the laboratory, your blood will be analyzed in several ways. Tests will be done to check the number of your red blood cells and the concentration of hemoglobin inside them. Hemoglobin is the substance in red blood cells that carries oxygen throughout the body. A low red blood cell count or too little hemoglobin indicates anemia. Blood tests also will be conducted to detect the number of white blood cells, which have a major part in defending the body against infection. If an infection is present, the number of white blood cells in your blood will rise. The appearance of your blood cells is also important. Abnormally shaped red or white blood cells can signal the presence of diverse conditions such as sickle-cell disease, leukemia, or mononucleosis. Finally, your blood will be checked to see how well it clots by examining the number of blood cells called platelets, which help stop bleeding.


Cholesterol Levels Elevated levels of the fats known as cholesterol in your blood increase your risk for heart disease. When the excess fats build up inside the walls of your arteries, they narrow the arteries, obstructing blood flow to your heart. When the heart receives less blood, it gets less oxygen, which is transported by red blood cells. Your heart sends out warning signals in the form of pain and discomfort known as angina. When the blockage in the arteries supplying blood to your heart causes severe obstruction, resulting in a heart attack, the heart muscle can become permanently damaged.
Cholesterol comes in two forms: low-density lipoprotein (LDL), the “bad” cholesterol, and high-density lipoprotein (HDL), the “good” cholesterol. Somewhat like a delivery truck, LDL cholesterol carries most of the fat in your blood and deposits the excess inside your artery walls. Like a garbage truck, HDL cholesterol removes fat from your blood, preventing it from building up in your arteries. When testing your cholesterol levels, your doctor measures your total blood cholesterol as well as your LDL and HDL levels by taking a sample of your blood and having it analyzed in a laboratory. A desirable total blood cholesterol level falls under 200 milligrams per deciliter of blood. Doctors consider cholesterol levels above 200 to be high. One in five Americans has a total cholesterol level of 240 or greater, placing that person at risk of a heart attack. Your LDL cholesterol levels should be under 100,
and HDL levels should be 40 or higher. The higher your HDL level, the lower your risk for heart disease. All men over 20 years of age should have their total cholesterol levels checked at least once every 5 years. Your level of LDL cholesterol also should be tested if your HDL is less than 40 or if your total cholesterol is 240 or higher—200 if you have two or more risk factors for heart disease. Talk to your doctor about your personal risk factors for heart disease. Don’t hesitate to ask him or her anything you do not understand about cholesterol testing.


Urinalysis

Your urine provides crucial information about the presence of any disorders of the kidneys or bladder. If your doctor orders a urinalysis, you will be asked to pass some urine and collect a midstream sample (urinate for several seconds before collecting the sample of urine) in a small container, either at home or in the doctor’s office. If you are uncircumcised, you should pull back your foreskin and wash the tip of your penis with soap and water before urinating to ensure that your urine remains sterile. Your urine may be tested in a laboratory or in the doctor’s office, using special strips that the doctor can dip into the urine to test for any abnormalities. The presence of particular substances such as blood or
sugar in the urine can indicate certain diseases. For example, the presence of protein in the urine can signal some types of kidney disease.


X ray

The most common scanning test is the X ray, in which electromagnetic radiation passes through a body part to produce a picture of internal structures on film. X rays are a good way of showing dense areas of the body, such as bones or a tumor, that allow only a few rays to pass through. These dense areas show up as white areas on the film. Doctors use X rays to examine the chest, skull, and spine
and to view a bone that may have been fractured. Even organs filled with fluid, gas, or air—such as the arteries, colon, or bladder—can be viewed with X rays if the organs are first enhanced with a special liquid dye called a contrast medium. The contrast medium is injected, swallowed, or inserted through the anus; then the doctor or technician takes a series of X rays as the contrast medium moves
through the organ to facilitate viewing. Getting an X ray is safe because today’s X-ray equipment minimizes your exposure to radiation.


MRI
Magnetic resonance imaging (MRI) uses a magnetic field and radio waves to produce a picture of the inside of the body. When you undergo an MRI, you lie on a table that slides into a rounded scanner containing a doughnut-shaped magnet that creates a magnetic field. Radio waves are sent to the part of your body to be viewed. The atoms in your body respond by emitting energy, and a magnetic field detector measures this energy and sends it to a computer, which translates the signal and creates a picture that your doctor can read. The procedure can take from 30 to 90 minutes and is painless, but the magnetic field can interfere with a pacemaker, hearing aid, or metal implants, so your doctor needs to know if you have any of these devices in your body. MRI scanning poses no known health risks.


Ultrasound
Ultrasound scanning uses sound waves to produce pictures of internal body structures. Doctors often use an ultrasound scan to diagnose disorders of the heart, kidneys, bladder, gallbladder, and pancreas. If your doctor orders an ultrasound scan, you will be asked to lie on a table, and the ultrasound technician will spread a gel on your skin over the area to be scanned. The technician will then move a handheld instrument called a transducer over the area, sending sound waves into your body. The sound waves bounce off of your internal organs, and the transducer transforms the waves into an image on a screen or on paper. Ultrasound is risk-free and is not painful.


CT Scan

Computed tomography (CT) scans take hundreds of X-ray images of the body from different directions that a computer then converts into cross-sectional pictures on a screen. CT scans can pick up details of abnormalities that a conventional X ray cannot detect. Doctors often order a CT scan to check for tumors or other abnormalities in the brain, liver, spleen, lungs, kidneys, pelvis, or lymph nodes (a part of the body’s immune system). During a CT scan, you lie on a table that moves into a circular machine. A tube revolves around the machine, taking multiple, low-dose X-ray images from many angles. The procedure takes about 20 minutes. Although a CT scan takes a vast number of images, the amount of radiation generated in a CT scan can be the same as or even less than that from a traditional X ray.

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Routine Physical Examinations

Your doctor uses the routine physical examination to assess your current physical condition and to identify any undiagnosed disorders. A routine physical examination also helps your doctor become familiar with you and your health risks or medical problems. The frequency with which you see the doctor for a routine checkup varies, depending upon your age and whether you already have a medical condition. Before beginning the examination, the doctor will take a complete medical history by asking you a series of questions about your lifestyle habits, general health, and family health history. Taking a thorough medical history often takes as long as the physical examination itself but is just as important. When you go to the doctor’s office for a routine physical examination, a nurse or other healthcare worker will weigh you and take your temperature to find out if you have a fever, which could signal an infection. He or she also will take your blood pressure, using an inflatable cuff, pressure gauge, and stethoscope. A blood pressure reading measures how forcefully your circulating blood pushes against the walls of the blood vessels with each contraction of your heart. The reading records the pressure in the vessels both when the heart pumps blood (the systolic pressure) and when it rests (the diastolic pressure). The reading is expressed in two numbers in millimeters of mercury (mmHg)—for example, 120/80 mmHg, which is a reading within the normal range. The first number indicates the systolic pressure; the second number, the diastolic pressure. The higher the pressure in your blood vessels, the higher the reading. You will be asked to undress and put on a cloth or paper gown. The doctor will begin by examining your skin, checking for any paleness, flushing, yellowish or bluish cast, rashes, dryness, bruising, or broken capillaries (tiny blood vessels). He or she will examine your face, which can display a number of unusual signs, such as puffy eyes, and your neck, checking for swollen glands or an enlarged thyroid (a gland just below your larynx—your voice box—that has an important role in controlling the chemical processes in your body). Next, your doctor will look inside your mouth with a small flashlight and a tongue depressor to examine your tongue, teeth, and gums. The condition of your mouth can reveal a number of clues about your general health. For example, red, cracking areas on your lips can signal a vitamin B deficiency. The doctor also will check your throat as far back as possible. By using an illuminated instrument called an ophthalmoscope, he or she will look into your eyes to see the retina lining the back of your eyes. Another lighted instrument, known as an otoscope, helps your doctor peer into your ears, to check for any inflammation or a possible perforation of the eardrum. Listening to your chest with a stethoscope allows your doctor to assess not only the nature of your heartbeat but also the condition of your lungs. Any abnormal heart sounds will alert your doctor to the possibility of an enlarged heart, poor blood flow through the heart, or a disorder of the heart valves. When listening to your breathing with the stethoscope, the doctor listens for wheezing, crackling, or other sounds that could signal the presence of a lung disorder such as asthma. The doctor will probably also tap your chest and place his or her hands against your chest and ask you to cough so he or she can detect any fluid in the chest. This process is called percussion. Taking your pulse is an important part of the examination because your heart rate can reveal heart or circulation problems. The doctor will want to examine your abdomen, feeling and tapping it to detect any tenderness, abnormal masses, or fluid accumulation. He or she will continue to press on different parts of your abdomen and ask you to respond if you feel any tender areas. The doctor is also checking for the correct positioning of the spleen and the liver. As part of his or her examination of your digestive system, the doctor will probably perform a rectal examination. Your doctor will first cover his or her hands with disposable plastic gloves and lubricate the area to be examined with a cream or jelly. The doctor will gently and carefully place his or her fingers inside your rectum to feel for any tumors in the rectum or prostate. Many prostate tumors are first detected in this way. If the doctor notices any signs that indicate that you may have a disorder of the nervous system, he or she will assess your motor ability, or ability to move, by observing the way you walk. He or she may also ask you to move your arms and legs in various ways to see whether there is a difference in movement between the two sides of your body. Testing the reflexes at your wrists, knees, ankles, and soles of your feet will also tell your doctor important information about the proper functioning of your nervous system. To complete the physical examination, the doctor may order blood, urine, stool, or other tests (see next page) to help detect any abnormal conditions. Typical blood tests include the complete blood cell count, cholesterol testing, and a blood glucose test. The collected body fluids are sent to a laboratory for analysis. The doctor may also order X rays or other scans, depending on your condition. After your doctor examines you, he or she will write down his or her findings, along with the information obtained during the medical history, in your medical record. The doctor will also write down his or her orders to other healthcare workers in the office about your medications, diet, tests, and recommended treatments. Your medical record serves as a means of communication for all of the doctors, specialists, nurses, therapists, and other healthcare workers who care for you. It is a confidential and legal document maintained by professional records management workers. If you would like to have a copy of your medical record, contact the medical records department of your doctor’s office or hospital.

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Preventive Healthcare

In addition to eating a healthy diet and exercising, seeing your doctor regularly for recommended screening tests is a good way to stay healthy. Regular medical checkups are an important preventive health measure. During your periodic checkup, your doctor can detect any medical problems in the early stages so they can be treated promptly. Your doctor uses numerous medical tests and screenings to check for any health problems. Before deciding which tests to order, your doctor will perform a comprehensive physical examination and will take a medical history, which is a record of every factor that might affect your health. To complete the medical history, your doctor will ask you a series of questions about your personal habits, your family health history, any medical problems you had in the past, and any symptoms you might be experiencing at present. When answering your doctor’s questions, it is important to provide as much information as you can without holding back any relevant facts. Don’t be afraid to ask your doctor questions if you don’t understand something he or she has said.
The most common tests performed in men over 40 include the PSA (prostate specific antigen) test for prostate cancer, the fecal occult blood test for colon cancer, and a series of tests that screen for the presence of heart disease or your risk of having it. Such tests may include measuring your blood pressure and the levels of cholesterol in your blood; an electrocardiogram, which measures the electrical activity in your heart; and a stress test, which evaluates the heart’s response to physical exercise. If you have a family history of a certain disease that has a strong hereditary component, such as diabetes, you also may undergo a screening for that disorder. For example, in the case of diabetes, the doctor would perform a test known as a glucose tolerance test As you get older, you probably will need more tests during your regular checkups because common disorders such as heart disease and cancer occur more frequently in older people. Use this section of the book to learn about the various tests and screenings your doctor might order so you can become better informed.

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