May 12, 2004

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Palo Alto Online

The beats go on

by Diana Reynolds Roome

Peter Pond celebrated his 90th birthday this year -- another 365 days where his heart ticked away "at the rate of 100,000 beats per day, the same rate as most others," he said with a chuckle.

His heart wasn't always so tranquil. Diagnosed with silent ischemia (painless partial blockage of coronary arteries) in 1971, he later suffered three dramatic cardiac episodes -- first while traveling in Ecuador, later in the Paris Metro and Morocco.

In the years since, Pond's heart has not only survived but has mostly thrived, despite several challenges including two bypass surgeries and a valve replacement. For just over one-third of his 90 years, he has attended the Cardiac Therapy Foundation of the Midpeninsula, one of the longest-running heart health projects in the country. Under its supervision, he has exercised two to three times per week for 32 years -- in a carefully monitored program that also offers dietary counseling and other support.

By Pond's calculations, this amounts to a total of 4,992 hours of dedicated, heart-strengthening exercise -- spurred on by the camaraderie of others in the program, and the tough love of the staff, co-directed for the past nine years by Robin Wedell, RN and Donna Louie, RN with medical supervision from Frank Koch, MD.

On most days between 7:30 a.m. and 6:30 p.m., the CTF gym at Cubberley Community Center in Palo Alto is abuzz with the purr of stationary bikes and the chatter and laughter of men and women taking care of themselves. Many are in their 70s to 90s, though the youngest is in his 40s. Although heart disease is the primary cause of death for women as well as men in the U.S., probably two-thirds of participants are men.

All do 10 minutes of careful warm-up with music, safely increasing their range of motion and cardiovascular rate. After 30 minutes on the bike, they practice weight resistance, stretching and relaxing. Those who wish can cool down in a chair, and some exercises can be while seated for those who need to take it easy.

Referral by physicians, initial evaluation by program directors and ongoing supervision ensure that everyone taking part is in stable condition. All participants regularly monitor their own pulse rate. Some people become so proficient they can accurately guess their own heart rates, and most increase their capacities -- in some cases, dramatically.

"One person came in with such severe congestive heart failure that he was short of breath just talking to us," said Wedell. "Encouraged by his physician, he started exercising in 30-second increments. He now goes for 30 minute walks and plays golf."

With the support of dedicated health professionals, patients gain the confidence to make such strides over time. Nurses are trained and certified in advanced life-support techniques and the facility has a defibrillator and crash cart, with oxygen and appropriate medicines, on hand. In fact, the incidence of heart attack or other emergencies is miniscule -- the CTF has had four or five emergency incidents in its 33 years. Structured cardiac rehabilitation programs like CTF are estimated to reduce mortality of heart patients by 25 percent compared to exercising on their own.

In many ways, the program prevents incidents by acting as an early-warning system. The nurses get to know their clients well and are quick to notice signs or changes, such as unusual fatigue or weight change. They check blood pressure regularly and talk to participants about what they might do to counteract problems. By helping to reduce repeat events and hospitalization, cardiac rehabilitation programs save money (one U.S. trial showed savings of $9,200 per year of life).

At CTF, the first three months cost $150 per month, and it's $120 per month thereafter. Insurance usually covers the first six to eight weeks, and those who have difficulty paying on their own can apply for scholarship money.

"A lot of people are healthier than they've ever been," said Wedell, pointing out that the same regimen that reduces the recurrence of heart disease can also help prevent diabetes and cancer. One participant who needed an angioplasty every six months to reduce plaque in his coronary arteries no longer needs the treatment.

"I'm a zealous follower [of the program]," said Judge Barton Phelps, a retired superior court judge for Santa Clara County who has been involved with CTF for 14 years and was president for two. Before his diagnosis of coronary artery disease, he played an occasional game of golf. Now he exercises daily, even while away from the program for extended periods.

"It's a part of my life, like drinking my coffee. I'm no Tarzan, but I have my walking routine, stretching and hand weights even at home."

Rather than causing dependence, CTF builds greater self-confidence as patients learn more about their own disease, the best ways to manage it, through diet, exercise, stress reduction and sometimes behavior modification. For example, the Type-A modification program requires a one-year commitment, in recognition that this is about profound change in attitude and behavior.

"It's helping calm me down a lot," said John Ferrandin, who nevertheless admits he's busier now than when he worked as an engineer at NASA/Ames. Slim and fit, he jogs around the gym in shorts and a sweatband, stopping long enough to talk about his first silent heart attack at the age of 36, around the time the CTF program first started. "The guy in the bed next to me died," he recalls. "Here we all have a common goal -- to stay alive and do it in a healthy way."

"Exercise is a magic bullet," said Wedell. "It does so many great things physically and is such a great psychological booster and energizer."

Those who drop out after the first six to eight weeks, which is typically covered by insurance, are often people who have an exercise system in place that still works, or are those who have never exercised much and find it hard to build the habit into their lives.

"It's sad to think of this as a short-term thing," said Louie. "If someone has not exercised for 60 years, six to eight weeks is not enough time to persuade them to start. It's not like a knee replacement. Heart disease is chronic and therefore needs a complete lifestyle change; it's what you think and how you eat and exercise."

Those who commit themselves to making that lifestyle change develop a warm camaraderie. They share health discoveries (from recipes to medications), support one another in times of ill health (whether heart-related or not) and sometimes go out to coffee after class.

"There's an element of joy, with repartee, jokes and friendship that forms while riding bikes or walking outside," said Pond, who was associate dean at the Stanford Graduate School of Business until 1981 and now lives with his wife in a Woodside retirement community. "This humanity is one of the things that draws you back."

Friendship and support also emerge as vital players in "Heart Attack: Advice for Patients by Patients," a book written by CTF participants and medical staff for people who have suffered heart disease and their families. Though it contains informative chapters by experts, it is not a medical text but a highly readable collection of stories -- of people who suffered the physical and emotional shock of their life and, with dedication and discipline, recovered to take up their lives again.

The directors' and nurses' involvement and encouragement is also a powerful force.

"It's their love that gets this going and keeps it going. When you don't show up, you get nagged the next time," said Ferrandin, with a broad smile.

Patient-owned and directed (though programs are run according to national and state cardiac rehabilitation guidelines), CTF has been remarkably stable, with few changes of staff since the original group of heart patients was assembled by cardiologist Gary Fry, M.D. (now retired) of the Palo Alto Clinic and coronary care nurse Kathy Berra in 1970.

Pond joined that original group and became part of a research project, which ultimately failed to prove that exercise could reduce heart problems. That conclusion is overwhelmingly contradicted by virtually every statistical study today, which consistently show the dramatic improvement a carefully designed program of exercise and diet can bring to patients with conditions ranging from angina to congestive heart failure, as well as those recovering from heart attack, bypass surgery and even heart transplants or valve replacements.

Cardiac programs are now common throughout the country though only 20 percent of eligible patients actually take advantage of them (in contrast to almost 100 percent in Europe). "There are way more patients who could benefit than are being referred," said Louie, citing a number of reasons why people might be missing the opportunity to claim back their heart health.

For those who do participate, there's little doubt of the program's effectiveness, said Pond. "When you take the exercise, the TLC and camaraderie and put it together, you've got someone like me -- 90 this month."

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