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Can constipation cause a heart attack?
Dr Bikash Rai Das, Senior Consultant Heart Surgeon, Health City Hospital, Guwahati, drbrdas@gmail.com

 
 I have been getting a lot of queries from patients on the co-relation between these two peculiar topics. The surge in questions began after the release of the Amitabh Bachchan and Deepika Padukone-starrer Bollywood flick Piku that highlighted this often ignored topic. I am not surprised by the queries as almost everyone gets constipated some time during his or her life. And constipation is a topic very few like to talk about.

Most of us know that the great Elvis Presley died at a young age of 42 from a heart attack. However, I recently read that his longtime physician George Nichopoulos believed Elvis died from chronic constipation. How does someone die from that?

According to the autopsy report, hypertensive cardiovascular disease and a “colon problem” were the likely contributing factors to his premature death from a heart attack. His now-retired personal physician said Elvis suffered for years from chronic constipation and that his colon was markedly distended at autopsy. Elvis was reportedly found on his bathroom floor, leading to speculation that a “straining effort” might have triggered the heart attack. The straining of bowel movement in the setting of underlying heart disease and high blood pressure certainly could cause a heart attack, stroke, or fainting episode.

Elvis was prescribed pain medications, including codeine and hydrocodone – two drugs known to be very constipating. If he had some sort of underlying tendency toward chronic constipation, as Nichopoulos has speculated, any pain medication would have made things worse.

When one strains to have bowel movement, the effort transiently reduces the flow of blood back to the heart. There is a transient reduction in blood pressure and cardiac output, and a marked rise in heart rate. When the straining effort ceases, there is a rush of blood to the heart followed by a gradual fall in the heart rate towards normal. This is called the Valsalva Manoeuvre. If there is underlying heart disease, such straining could result in a fatal heart arrhythmia or heart attack.

What is constipation?

Although constipation is common in older adults, it can affect individuals of any age. However, women and elderly people are more affected. This symptom can occur anytime during life and is often not a serious condition. But some people may experience constipation more often than others and it may be a cause for concern for those who have heart disease. The estimated prevalence of constipation varies from 22 to 28 per cent, and the number of persons reporting constipation increases with age. Constipation is generally defined as fewer than three bowel movements per week.

Causes of Constipation:

Constipation is not a physiologic consequence of normal ageing. Many age-related problems like decreased mobility, co-morbid medical conditions, increased use of medications with a side effect profile that includes constipation, and changes in diet may contribute to constipation in older adults.

Constipation can be divided into primary and secondary causes. An important secondary cause of constipation is the use of medications, especially those that affect the nervous system, nerve conduction, and smooth muscle function. In a study of patients who considered themselves constipated, 40 per cent were using medications known to cause constipation. Over-the-counter medications, such as calcium or aluminium containing antacids and iron supplements, may also cause constipation. Irritable bowel syndrome is a common cause of constipation.

Common causes of constipation

* Inadequate intake of water

* Inadequate fiber intake

* Disruption of diet or daily routine, such as traveling

* Immobility or inadequate exercise

* Stress or depression

* Eating too much dairy products

* Postponing bowel movements

* Overuse of stool softeners or laxatives

* Taking antacids containing aluminum or calcium

* Certain medicines

* Pregnancy

Health conditions that may lead to constipation

* Eating disorders

* Irritable bowel syndrome

* Colon cancer

* Hypothyroidism

* Neurological conditions like multiple sclerosis and Parkinson’s disease

Treatment for constipation

If a medication or a medical condition is the cause of constipation, eliminating the medication or treating the medical condition may relieve constipation. However, certain conditions require the use of a medication despite its side effects. Although opioid therapy almost always causes some constipation, individual opioids induce constipation to different degrees. In most cases, a prophylactic laxative can be taken when someone takes chronic opioid therapy because tolerance to the constipating effects of opioids does not develop over time. When no secondary cause of constipation is identified, management should begin with non-pharmacologic methods to improve bowel regularity and should proceed to the use of laxatives only if non-pharmacologic methods are not successful. If the constipation is refractory to medical treatment, the patient should be referred to a specialist for further diagnostic evaluation.

Treatment and prevention of constipation

* Eating a balanced diet that includes high fiber foods such as fruits, vegetables, and whole grains

* Drinking at least one-and-a-half to two quarts of water daily. (One quart is equal to approximately 1.14 litres)

* Avoiding milk or coffee, which can cause constipation

* Exercising regularly

* Moving the bowels when the urge is felt

What is bowel training?

Having a bowel movement may be partly a conditioned reflex. Most people with a regular bowel pattern empty their bowels at approximately the same time every day. The optimal times to have a bowel movement typically are soon after waking and after meals, when colonic activity is greatest. People should be encouraged to attempt defecation first thing in the morning, when the bowel is more active, and 30 minutes after meals, to take advantage of the gastro-colic reflex.

What should be the dietary fiber intake?

Inadequate fiber intake is a common reason for constipation. Increased dietary fiber intake leads to decreased colonic transit time and to bulkier stool. The daily recommended fiber intake is 20-35 gm daily. If fiber intake is less than this, one should be encouraged to increase intake of fiber-rich foods such as bran, fruits, vegetables and nuts. Prune juice is commonly used to relieve constipation. The recommendation is to increase fiber by 5 gm per day each week until reaching the daily-recommended intake. Adding fiber to the diet too quickly may cause excessive gas and bloating.

How much fluid should one take?

Adequate hydration is considerd important in maintaining bowel motility. However, despite the belief that lack of fluid increases the risk of constipation, few studies have provided evidence that lack of hydration is associated with the incidence of constipation. Decreased fluid intake may play a greater role in the development of faecal impaction.

What about regular exerise?

Low physical activity is associated with two-fold increased risk of constipation. People who are sedentary are more likely to complain of constipation. Prolonged bedrest and immobility are often associated with constipation. Although people should be encouraged to be as physically active as possible, there is no consistent evidence that regular exercise relieves constipation. In a study it was found that physical activity two to six times per week was associated with a 35 per cent lower risk of constipation.

What are the pharmacologic treatments?

Increased fiber intake and use of laxatives generally improve the frequency of bowel movements in adults. A laxative may be used to relieve temporary constipation. However, anyone should not use laxatives for long term to treat chronic constipation. Many laxatives are available, both over the counter and by prescription. Laxatives can interact with a number of medications, so it is better to talk to a doctor before taking one if someone also takes other medication.

Can constipation cause a heart attack?

People who have severe coronary heart disease or who have experienced a heart attack are often advised by doctors against straining while defecating. To relieve or prevent constipation in such people, stool softeners and other home remedies are prescribed to avoid drastic changes in circulatory function, which could lead to a possible fall or rise in blood pressure and/or heart rate.

Although constipation itself does not cause a heart attack, frequent or excessive straining could put a patient with serious heart disease at risk of a heart attack. A study showed that patients who died from heart disease or heart failure experienced a wide range of symptoms, including pain, difficulty in breathing, and constipation, which were poorly controlled.

Constipation is a risk factor for cardiovascular disease in postmenopausal women. Women who experienced moderate or severe constipation were more likely to suffer from cardiovascular events such as a heart attack compared to those with no constipation.

Bottomline

Although a causal relationship between constipation and heart disease has not been demonstrated, researchers speculate that severe constipation may trigger an inflammatory process that could accelerate the development of cardiovascular disease. And obviously straining while defecating in people who have severe coronary heart disease or who have experienced a heart attack can be dangerous and a stool softener can judiciously be used.

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