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The most important questions are often the ones you didn't know to ask. Even the best doctors in the world can't give you the right answers unless you ask them the right questions first.
But how do you know what the right questions are? "Ask your doctor." You've heard it a million times, but do you really know what to ask? What if you don't know very much about heart disease, feel intimidated by your doctor's expertise, or simply feel overwhelmed by your diagnosis or the diagnosis of a loved one?
More than ten years ago when my mother suffered a major heart attack, I felt overwhelmed. As I nervously watched her vital sign monitors bounce around, it occurred to me that I didn't know what to ask the doctors about her condition. In that moment of total helplessness, the only thing I had was questions. But I just didn't know what to ask.
I vowed to learn how to ask better questions. When I started taking my mom to her follow-up doctor appointments, I spent time researching her medical options and planning questions for her doctor. I wanted to be a well-informed consumer for her sake so that I could make sure she was getting the very best care possible.
This experience sparked my interest in questioning skills. As I read about questions, I was surprised to learn how little attention most people pay to them. It seems that our society is so focused on solutions and answers that we rarely stop to consider the quality of our questions.
I started teaching questioning skills as part of my graduate-level business classes in Washington, D.C., and Perth, Australia. My students liked it so much that I developed the concept of "The 10 Best Questions" as a way for them to learn questioning skills, team dynamics, and research skills all at once. Since 2003, I've taught hundreds of students who have interviewed thousands of experts. For example, my students have researched what to ask when you buy a house, get married, adopt a dog, hire a financial planner, change careers, invest in stocks, retire, plan a wedding, talk to your teenagers, choose a university, and for great sex.
To learn their secrets, I conducted a series of interviews with top question askers. Helen Thomas, the legendary White House reporter, is famous for her press conference questions to every president since John F. Kennedy. She told me, "Before a news conference I would think, What's the best question to ask? I have the courage of ignorance in my questions. I always get nervous, figuring out what to ask a president. But I believe you have to be curious and keep asking why."
Dorothy Leeds, who has authored nine books on questioning skills, told me, "Everything in my life has come about from asking questions, every major change. It's amazing how questions can enrich your life, both from a career and personal standpoint."
Peter Block, an international management consultant and the author of the book The Answer to How Is Yes, said, "There's a deeper meaning to asking questions. It's a stance you take in the world, a desire to make contact and get connected."
I talked with many professional interviewers like Susan Sikora, a TV talk show host in San Francisco; Debbie Nigro, a New York radio host; and Richard Koonce, a journalist and consultant in Brookline, Massachusetts. Each responded with a version of, "You are only as good as the questions you ask." Since then, I've focused my consulting work on helping CEOs and organizations develop their own Best Questions.
For the information specific to this book, I interviewed two former U.S. surgeons general and the president of the American Heart Association. I also interviewed prominent experts in cardiology, heart surgery, cardiac rehabilitation, nutrition, exercise, women's cardiac issues, preventive heart health, stress, fitness, special populations, smoking and alcohol cessation, and personal and family relationships.
So, what are the traits of the best question askers? They are smart, curious, and fearless, yet humble enough to learn from someone else. They value listening and inquiry. Great question askers see every person they meet as a walking encyclopedia of valuable information just waiting to be unlocked by the right questions. And finally, as Albert Einstein once said, "The difference between me and everyone else is my ability to ask the right questions."
The 10 Best Questions in this book won't make you an instant Einstein. And as the Question Doctor, I certainly don't claim any Einstein-like brilliance. I believe that a good mind knows the right answers, but a great mind knows the right questions. Now that great mind is yours. This book is for "smarties," not dummies.
Each list of The 10 Best Questions is derived from as many as nine hundred questions from hundreds of sources, including books, journals, worldwide print media, Web sites, and expert interviews. A Best Question has to really earn its title of "Best." I've also included the "best answers" that my experts and research provided so that you'll know when you are hearing the full story. The information in this book should not replace medical guidance or professional counseling.
There is one more question per chapter that I call "The Magic Question™." A Magic Question is that one great question that even smart people rarely think to ask — a gut-level question you usually think of when it's too late.
In writing this book, I've taken a practical and holistic approach to heart disease to make you an empowered patient. I want to help with your key decisions, choices, and relationships by suggesting what you can ask your doctors, medical experts, partner, family, friends, and ultimately yourself after a heart attack or the diagnosis of heart disease.
Your lifetime prescription for good health is to stay informed. As former surgeon general Dr. C. Everett Koop told me in an interview, "There's nothing that will lead to better medical care than a knowledgeable patient."
The 10 Best Questions in this book give you the actual script in hand for each major conversation and decision you are facing. Be sure to ask plenty of your own questions, too. Question guru Helen Thomas says, "There's no such thing as a bad question, only a lot of bad answers."
As the Question Doctor, I sincerely hope that this book will give you the strength, comfort, and knowledge you need to embrace a lifetime filled with good health — and lots of good questions.
Copyright © 2009 by 10 Best Questions, LLC
— Robert Benchley, American humorist
Heart disease can sneak up on you in the prime of life. Like a lion stalking its prey, it moves silently into your heart's arteries and waits to pounce as a heart attack or chest pains (angina). Most people don't realize they have heart disease until they develop symptoms, chest discomfort, have pain, shortness of breath, or have a heart attack.
You are not alone. In the United States, heart disease is the number one killer of both men and women. It takes another life every thirty-four seconds. Every year, more than 1.5 million people in the United States have a heart attack. About four hundred to five hundred thousand of them die. Half of the deaths occur before reaching the hospital.
A heart attack happens when the blood flow to a section of your heart muscle becomes completely blocked. If the flow of blood isn't restored quickly, the heart becomes starved for oxygen, is damaged, and begins to die. The medical terms for a heart attack are myocardial infarction, coronary thrombosis, and coronary occlusion.
The main culprit in heart attacks is coronary artery disease (also called CAD), which results when a fatty material called plaque builds up over many years on the inside walls of your coronary arteries (the arteries that supply blood and oxygen to your heart). An area of plaque can rupture suddenly, causing a blood clot to form on the surface of the plaque. If the clot becomes large enough, it can block the flow of oxygen-rich blood to the heart.
The diagnosis of a heart attack is made from your symptoms, the electrocardiogram, and blood tests taken during your initial evaluation. This chapter's Best Questions assume that you've already had a heart attack and are now well enough to have a conversation with your doctor. A loved one or a nurse can also ask these Best Questions on your behalf.
1. Did I have a heart attack? How do you know for sure?
The first step in diagnosing a heart attack is to be suspicious that one has occurred, especially if you didn't have the classic crushing chest pains or other typical symptoms. About one-third of all heart attacks lack dramatic symptoms, especially for women.
Your medical team is likely to be fairly certain. Tests can quickly confirm a heart attack, so emergency treatments can be started immediately to restore blood flow and minimize heart damage.
An electrocardiogram (ECG or EKG) records the electrical abnormalities typical of a heart attack and can identify the areas of the heart muscle that were deprived of oxygen and damaged. Blood tests measure the cardiac enzymes (creatine phosphokinase or CPK, special subfractions of CPK, and troponin) that are typically elevated in the blood several hours after a heart attack. A series of blood tests during the first twenty-four hours confirms the heart attack and the amount of heart muscle that has died.
A heart attack is very different from cardiac arrest or sudden cardiac death. A blockage stops blood flow during a heart attack, as compared to cardiac arrest, when the heart suddenly stops beating due to abnormal or irregular heart rhythms (called ventricular arrhythmias).
2. Why did I have this heart attack? What caused it?
The definition of a heart attack is the death of heart muscle due to the sudden blockage of a coronary artery by a ruptured blood vessel that causes a blood clot. Coronary arteries are the blood vessels that supply blood and oxygen to the heart.
A blockage causes injury to the heart muscle, chest pain, and the feeling of chest pressure or other symptoms. These other symptoms include sensations like indigestion, burning, a tightness or heaviness, feeling like a band or belt is tightening across your chest, jaw discomfort, back pain, numbness in your arms, a shortness of breath, or unusual fatigue.
Blockages are caused by plaque buildup in a process called atherosclerosis. Atherosclerosis has no symptoms, which is why heart attacks often surprise their victims and are called "silent killers." Symptoms from atherosclerosis generally occur only after the blockage is greater than 70 percent. But many heart attacks are caused by blockages of less than 50 percent that rupture. When this happens, the result is a blood clot in the artery that causes a complete blockage and results in a heart attack.
3. How much heart damage is there? Where is the damage located? Is my heart permanently damaged?
Time spent is heart muscle lost. The longer it took to get medical attention after the onset of your heart attack, the more heart damage there is. The heart muscle that has lost blood supply begins to die. The amount of damage depends on the size of the affected area and the time between onset and treatment.
If the blood flow is not restored within a few minutes, the affected heart muscle cells can suffer permanent damage or die. Irreversible death of the heart muscle begins within twenty to forty minutes from onset. But the heart is very tough and can keep working even if a part of it has died. The heart heals itself by forming scar tissue.
Future complications depend in part on the location of the damage (either the right or left ventricles, which are the lower heart chambers). Your outcome is worse if the heart attack caused significant damage to the heart muscle and resulted in heart failure. Heart failure can be treated with medications (see chapter 9) and lifestyle changes (see part 3). Ask your doctor to explain more.
In addition, heart muscle damage can result in damage to the electrical signaling system that tells the heart to contract. Some people need a pacemaker to correct this function of the heart muscle.
4. What is my ejection fraction?
The ejection fraction is a comparison of the quantity of blood ejected from the heart's left ventricle during its contraction phase with the quantity of blood remaining at the end of the left ventricle's relaxation phase. A normal ejection fraction reading is between 60 and 70 percent.
If the heart muscle is damaged during a heart attack, it has an impaired ability to eject blood. This reduces the ejection fraction, which can result in heart failure.
The ejection fraction is one of the most important predictors of your prognosis (long-term health outlook). People with a significantly reduced ejection fraction typically have a poorer prognosis. However, with time to heal and the use of medications for heart failure, your heart can improve its ability to pump blood.
5. Which tests, treatments, and medications was I given?
If you had a heart attack, you probably were in the hospital's intensive care unit (ICU) or coronary care unit (CCU) and may have needed several days in the hospital to recover. You probably received several different tests and may have had a procedure called angioplasty or coronary artery stenting to open blocked coronary arteries. Some people need emergency coronary artery bypass surgery (CABG). See chapter 10.
You most likely received oxygen and were hooked up to an ECG machine to monitor your heartbeat. You may have received blood thinners, aspirin, and other medicines.
Find out the details, write them down, and request that copies of your medical records be sent to your family doctor.
6. Please explain my treatment options for interventions, surgeries, or medications. Which ones do you recommend and why?
Dr. Paul Kligfield, a medical director at New York's Cardiac Health Center, says, "Some patients tell their doctors, 'If I have a heart attack, you take care of it.' But the patient really needs to monitor his own treatment, risks, side effects, and problems. Patients are the ones with the disease, not the doctors, so they need to be actively involved."
Another important question is, "What happens if I choose to do nothing?" Choosing to do nothing must be a conscious decision reached by you with your doctor, not a denial of your heart attack or diagnosis. It's only natural to want to pretend it never happened. However, for most patients after a heart attack or with unstable, progressive heart disease, medical or interventional treatment and lifestyle changes will reduce the risk of additional cardiac events.
Also ask, "How long do I have to make decisions about treatments?" Depending on your heart's damage and disease and the amount of atherosclerosis in your arteries, you may have more time than you think for some clearheaded thinking and research.
Ask (especially if you've had major heart damage), "Do I need a pacemaker or an implantable internal defibrillator?" These are implanted devices that help to regulate your heart's rhythm or prevent cardiac arrest. See chapter 10.
Be careful to follow your doctor's recommendations. Many heart attack survivors are vulnerable to complications, especially soon after their cardiac event.
7. What can I do to help prevent another heart attack?
Your doctor will discuss risk factors and possible medications, surgery, or procedures. There are actions that your doctor will take (like performing surgery or prescribing medicine) as well as risk factors out of your control (age, gender, etc.).
But the point of this question is to learn what actions you can take personally and proactively to heal your broken heart. Think of this question as the beginning of a lifelong conversation about the lifestyle changes you are willing to make to help yourself and your heart. See part three of this book.
Medical experts unanimously agree that the most important things you can do to prevent another heart attack are the following:
Get more physical activity.
Eat heart-healthy foods.
Maintain a normal weight.
Go to a cardiac rehabilitation program.
8. Which lifestyle changes are the most important and will make me feel better?
Even if you were dealt a bad hand due to a family history of heart disease, you can fight back by controlling what you eat and your physical activity. Better lifestyle habits can dramatically reduce your risk for another heart attack and even reverse heart disease. Hearing this from your doctor is your most important first step to inspire you to make changes during your recovery.
Of course, for most people these changes are much easier said than done, especially if you belong to the couch potato club. This is why starting and sticking with a cardiac rehabilitation program is vital. Your goal is to improve your lifelong health habits.
9. Will you give me a referral for a cardiac rehabilitation program? How soon can I start?
If you are talking with your cardiologist, ask for a referral for a cardiac rehabilitation program. If you are talking with a doctor who you aren't likely to see again, hold on to this question until you are with your cardiologist or primary care physician.
See chapter 12 to understand why this is a Best Question, especially if you are older, a woman, or a person of color.
10. Considering my age and physical condition, how long will my recovery take? When can I resume my normal activities?
You'll want to know when you can start driving, working, and exercising. Ask again if you aren't sure or if the doctor gives you a vague answer.
Also ask these other important questions:
Are there any activities I should avoid altogether? If so, for how long?
Will my chest pains, weakness, and other symptoms go away?
When can I safely have sex again?
Are my feelings (depression, sadness, etc.) normal?
How normal a life can I expect now?
Do I need someone to care for me when I first get home from the hospital?
When should I call you if I think I'm having symptoms?
Do I need nitroglycerine tablets?
The Magic Question
What are the warning signs of another heart attack? What should I do?
Knowing these warning signs can save your life.
A heart attack is a medical emergency. If you have the symptoms of a heart attack, seek immediate medical help by calling 911, even if you aren't sure. Don't wait more than five minutes.
Some heart attacks are sudden and intense, but most heart attacks start slowly with only mild pain initially. This is why some people wait too long to get help. Here are the warning signs:
Chest, neck, jaw, back, or arm pain
Upper body discomfort
Heaviness in your chest
Squeezing or a tight band around your chest
Shortness of breath
Nausea or vomiting
Kathy Berra, MSN, the clinical director of Stanford University's Heart Network, simplifies the list of "triggers" for heart symptoms or chest pains. She says, "Remember the four E's: exercise, exertion, exposure to cold, and eating a large meal. If you have any warning signs plus one of the four E's, be sure to let your doctor know immediately. If the symptoms don't go away with rest, call 911 and go to the nearest emergency room."
Women are more likely than men to experience the less common symptoms, like nausea or shortness of breath. See the American Heart Association's Web site (www.americanheart.org/presenter.jhtml?identifier=3053#Heart_Attack) for more information.
You can probably relate to management consultant Dr. Caela Farren's memory of her 2004 heart attack: "The background tape that kept running in my head was, 'This can't be happening to me!'"
The good news is that many heart attack survivors have an excellent prognosis thanks to modern advances. This is especially true if treatment is started within one hour of the onset of symptoms.
The most important factor in treating a heart attack is time. Dr. Spencer B. King, III, an executive director and the interim president of the Saint Joseph's Heart and Vascular Institute in Atlanta, says, "Time is muscle. Time is the key ingredient."
Dr. Timothy J. Gardner, president of the American Heart Association, concludes, "I want to make one thing very clear. There is well-established evidence that the emergency treatment of heart attack patients with emergency or very rapid catheterization or clot-busting drugs with catheters is the best treatment for patients with acute heart attacks."
Copyright © 2009 by 10 Best Questions, LLC
Foreword by Vicki Rackner ix
Part I Talking with Your Doctor 1
The 10 Best Questions:
1 About Your Heart Attack 3
2 About Your Heart Disease 13
3 To Get Reliable Referrals for the Best Doctors and Surgeons 21
4 To Find a Top Cardiologist or Cardiac Surgeon 31
5 For Understanding Diagnostic Tests and Cardiac Procedures 41
6 To Ask When Getting a Second Opinion 51
7 About Managing Your Risk Factors for Heart Disease 61
8 For Women About Heart Health 73
Part II Choosing Treatments 83
The 10 Best Questions:
9 To Ask About Heart Medications 85
10 About Heart Surgery 95
11 For Choosing a Hospital 105
12 About Cardiac Rehabilitation 115
13 For Choosing Alternative Treatments for Heart Disease 125
Part III Mending Your Broken Heart with Healthy Lifestyle Changes 135
The 10 Best Questions:
14 To Tame Your Stress 137
15 To Loss Weight and Eat Healthy 145
16 To Find a Great Gym or Fitness Club 155
17 To Hire a Top Personal Trainer 163
18 To Break Nicotine's Grip 171
19 To Assess Your Drinking Habits 181
Part IV Building Your Future Life 187
The 10 Best Questions:
20 For Emotional Health for Heart Patients 189
21 When Talking with Your Partner After a Heart Attack 199
22 For Sexual Health and Intimacy After a Heart Attack 209
23 Before Joining a Support Group 215
24 For a Heart Patient's Financial Health 221
25 The 10 Worst Questions to Ask a Heart Patient 231
26 For Spiritual Health for Heart Patients 237
Conclusion: Living Well with Heart Disease 245
Meet the Experts 259