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Cardiovascular System
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"Ask the Doc" About Heart Conditions
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| Q & A to Inspire and Empower Your Inner Healer | |||||
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As one person's learning experience can often be valuable to others, we've posted below sample questions and answers about cardiovascular conditions that Dr. Sinatra has received over time from patients and his Heart, Health & Nutrition newsletter subscribers. We hope they will provide insight for you, or someone you know, who may be experiencing similar issues. Links to more Q & A may be found on our "Ask the Doc" page.
Q: When and how do you suggest using nitroglycerin? Are there any known side effects?
Nitroglycerine (NTG) is usually prescribed for patients who have been diagnosed with angina in order to treat episodes of inadequate blood flow to the heart muscle. It makes good sense to always carry NTG with you if your doctor has prescribed it for angina.
NTG can be taken to reduce the symptoms of angina, such as chest discomfort (which may be in the form of pain, tightness, heaviness or a burning sensation), indigestion or shortness of breath. Other symptoms might include tightness in the throat, a painful or aching jaw, arm/hand ache or numbness and back pain. If sitting quietly for 60 seconds does not eliminate your anginal symptoms, then it is a good idea to reach for your NTG.
I tell my patients to consider the symptoms of angina a warning to immediately cease physical exertion or to try to eliminate the emotional stress that is placing a strain on their heart.
Nitroglycerin has been the preferred treatment for angina for 100 years because it quickly dilates coronary arteries and increases blood flow to blocked segments of the heart muscle. Its dilation effects impact your entire cardiovascular system, however, so blood pooling in the arms, legs and the head may occur, which can lower blood pressure to the degree of extreme lightheadedness or fainting. For this reason, always sit down when you take NTG to avoid injury from falling. NTG will work in 3 – 5 minutes if not faster. You can arise slowly about 10 minutes after your last dose.
I recommend to my patients that they take up to three NTG tablets every five minutes for relief of angina. I tell them to start off by placing one tablet under the tongue. If your symptoms fail to subside, or only partially abate after five minutes, take a second NTG and wait another five minutes. If your symptoms persist after resting and taking three NTG at five-minute intervals, then you need immediate medical attention and evaluation.
For my patients with “stable angina” (the same oxygen demand creates a predictable angina symptom at a predictable level of exertion), I often recommend they use nitroglycerin up to 15 minutes prior to activities that have consistently precipitated angina for them, despite maximum medical therapy. This may include exercise, sexual relations or an event that they anticipate to be stressful, like the first hole of golf. Remember, if your symptoms increase in frequency, intensity of duration, or you find yourself upping your usage of nitroglycerin for relief, your angina has become “unstable,” and you must consult your physician immediately.
NTG is a safe and nonhabit-forming medication. The major side effect is a headache. Also, check the expiration date on your bottle to ensure that your NTG is “fresh”.
Q: Why does angina come and go?
Think of heart function as an economic system where oxygen is the main currency. Angina is related to the supply and demand of oxygen to the heart. With adequate blood flow in the arteries, oxygen delivery is balanced (inadequate blood flow usually occurs when the artery is blocked due to a fixed obstruction like plaque or a spasm of the artery wall). Anginal symptoms occur when the oxygen supply no longer meets the heart’s demands during increased physical exertion or psychological stress, thereby starving the heart muscle of oxygen.
Angina can also be triggered by air pollution, high altitude, cold air, excessively low or high heart rates, extremely high blood pressure, perceived stress, anxiety, withheld anger, grief or heartbreak. So always avoid exercise when any of these additional triggers are present if you have been diagnosed with angina.
Intermittent spasms in the walls of arteries may also account for angina’s sporadic occurrences. Blood vessels may narrow or expand depending on the balance of minerals, hormones and various substances that cross the cell membranes and determine the constriction or relaxation of blood vessel walls. On a daily basis, however, blockage in the arteries does not change, unless a new clot is formed.
Q: My neighbor told me that sometimes the symptoms of a heart attack and those of an angina attack are very similar. I have angina, and I’m worried that I won’t know when it’s necessary to call 911 because I’m actually having a heart attack. What are your guidelines for getting help?
This is an excellent question. Angina and heart attacks result from ischemia, a lack of sufficient oxygen to the heart muscle. In the midst of either attack, you might experience identical symptoms, which may include: chest pain or discomfort, shortness of breath, tingling in the arms/jaw/hands, indigestion, upper back discomfort and sweating.
Even cardiologists like myself cannot tell the difference between angina (a temporary lack of oxygen to the heart) or a heart attack (a prolonged lack of oxygen resulting in damage to the heart) without the benefit of an electrocardiogram or blood tests.
What’s most important to pay attention to, should either ischemic attack happen to you, is an awareness of a PATTERN of the symptoms. I tell my patients with angina (who have been prescribed nitroglycerin to alleviate their symptoms) to do the following:
Q: I have a valvular condition called aortic stenosis. My doctors had recommended that I undergo valve replacement surgery. Please tell me what I can do to prevent this. I also suffer from congestive heart failure. At the moment, I puff heavily if I exert myself or rush to do something. Am I in danger?
As you may already know, aortic stenosis restricts movement of one or all of the flaps of the aortic valve. The aortic valve controls blood flow from the left ventricle out to the aorta. If the valve opening is constricted, there may be an intermittent back flow of blood to the lungs, resulting in chronic congestion due to the heart’s failure to keep blood consistently moving forward. Exertion often causes the symptom you describe, even in less severe cases. If you have aortic stenosis, there is probably as strong relationship between the stenotic valve and your congestive heart failure.
Yes, you are in danger of flash pulmonary edema, which can be fatal. In the mean time you need a metabolic cardiology approach as does anyone with any degree of AS, which depletes coenzyme Q10 because of the strain on the heart muscle cells to generate extra ATP.
I recommend my patients with AS take:
Unfortunately, there is nothing short of valvular reconstruction or replacement surgery that will help when your condition becomes advanced enough to cause recurrent bouts of congestive heart failure. If your quality of life is unacceptable the way it is, and if you have an enlarged left ventricle with a tight aortic valve that restricts blood flow, you must have surgery to improve your condition. I recommend that 3 to 4 weeks before your surgery, you maintain a daily regimen of a multivitamin formula with coenzyme Q10 (the equivalent of 240-300 mg daily in divided dosages with food). This can help your heart maintain the strength it will need to come off heart-lung bypass and to reduce the risk of postoperative complications.
Q: I’ve just discovered that I have atrial fibrillation. My doctor doesn’t seem worried, but I am. Can you please explain the symptoms and the impact of this condition on my heart?
Atrial fibrillation (AF) is the most typical arrhythmia I see in my practice. Some of my patients complain of either a fast or slow, irregular pulse. Some patients say they feel no symptoms at all. Others feel like they have the flu or report feeling “strange,” “weak” or “out of sorts.” The most common symptoms are shortness of breath, fatigue, chest discomfort, sweating, lightheadedness or dizziness.
AF can be dangerous if an episode lasts longer than 24 hours, if your heart rate is either extremely high or extremely low or if you are very lightheaded from low blood pressure. Such conditions place a strain on your heart. In rare cases, they can lead to congestive heart failure or heart attack. Also, the risk increases for blood clots to form in the quivering upper chambers of the heart (fibrillating atria), which might lead to a stroke.
Most patients with chronic AF must take Coumadin (or other anticoagulants such as aspirin) to prevent clots from forming. If your heart rate is rapid, you may need anti-arrhythmic drugs to bring your heart rate back to normal. If you are hospitalized for uncontrolled AF, your doctor may try to reestablish your normal rhythm by administering an electrical charge to override the AF.
Please refer to the next question to see if your situation meets my criteria for starting a treatment program. If you would like to try my plan, I recommend that you work closely with your physician to get your heart rhythm normalized.
Q: I’ve had arrhythmia-like atrial fibrillation for some time, but lately I’ve noticed that my heart seems to speed up when I’m a little anxious or if I have coffee or even a cocktail or two. Is there something really wrong with my heart, or might this be due to just nerves or some other condition?
I’m often asked this question. The majority of patients who I treat for rapid heartbeat have atrial fibrillation (AF), a common type of arrhythmia. And often with this condition there is an interplay between emotions and physical symptoms that supports the concept that our minds and bodies are immeasurably interconnected. So, when you feel “a little anxious” about something, an increase in stress hormones (like adrenalin) may be causing the faster heart rate that you described. The reverse is also true of cardiac arrhythmias – when your heart is out of rhythm, you may feel increased anxiety.
Any cardiac arrhythmia can be frightening because it is a change in the timing or rhythm of the heartbeat. Let me explain what happens. During episodes of AF, the upper cardiac chambers (atria) are bombarded with electrical conduction discharges and actually quiver or “fibrillate,” instead of fully contracting. AF may occur in a healthy heart and is usually not a problem. But when it’s associated with heart disease, it can be problematic and precipitate bouts of congestive heart failure if the rate is not adequately controlled. I have treated this condition in both young and old alike, but older patients are more often affected. 2% to 4% of individuals over age 60 experience symptomatic AF.
AF may also be the result of any of the following:
AF may also occur if the heart’s electrical system has been overstimulated by drugs, nicotine, caffeine or stress. So, if you are vulnerable to episodes of AF, you should abstain from alcohol, excessive sugar, chocolate and other foods that contain caffeine; avoid exposure to the toxins in cigarettes, exhaust fumes and heavy air pollution; and don’t use over-the-counter cold remedies that contain stimulating chemicals like ephedrine.
Q: I had bypass surgery seven months ago, but I still don’t feel like my “old self.” I’m so tired most of the time. Some of my friends, even people older than me, bounced right back after their bypasses. I don’t have any medical complications, and I’m not taking medications, so what’s wrong?
Your concern is not uncommon. In fact, a fellow cardiologist surprised me by reporting he didn’t feel like “his old self” for almost a year after his own open heart surgery. His year-long recovery, however, has changed the way he treats his patients and the way he lives his life for the better. My friend often muses that “life begins anew after heart surgery.”
For the first six months after heart surgery, fatigue is quite normal. Prolonged fatigue, however, may be a symptom of depression, which is also not uncommon after major surgery. Depression is associated with disrupted sleep patterns – middle of the night awakenings anytime between 2 a.m. and 4 a.m. is common – eating disturbances (overeating or lack of appetite), memory difficulty and an overall lack of interest or pleasure in activities. If you have some of these symptoms, ask your physician for guidance. A few visits to a counselor may be very helpful to you to explore the emotional impact and the symbolic meaning your heart surgery may have for you.
Your tiredness also could be the result of spending extra energy in evaluating your life and priorities following major, traumatic surgery. A comment made by a daughter of one of my patients made me ponder the emotional complications of life after open heart surgery. She remarked that her father’s heart had “been touched” by the surgeon and her dad claimed that his life has not been the same since. For him, the recovery process became a period of realizing his vulnerabilities, reevaluating his priorities and reassessing where he was in life. Remember, you too have had your heart “touched” by another human being in order to be healed. Are you aware of feeling more vulnerable and/or are you examining the quality or purpose of your life?
Don’t forget you may need more nutritional support and exercise to boost your energy level during this time. I also recommend that if you did not join a cardiac rehab program after surgery, now is a good time to do so, even for a short period.
Q: During my annual physical, my GP informed me (almost like an afterthought) that I have mitral valve prolapse. He said there’s nothing to worry about. Is my doctor correct?
Your question is not unique. Although it sounds ominous, mitral valve prolapsed (MVP) is relatively common, yet benign, condition that affects about 4% of the population. Physicians most often pick it up as a click, a murmur or regurgitation when listening to the heart. 99% of those diagnosed with MVP are asymptomatic or have only mild symptoms and require no medical treatment.
More severe symptoms of MVP like chest pain or shortness of breath can be brought on by excessive fear, anxiety, stress or overuse of caffeine or alcohol. And it can last a lifetime, or it can be gone tomorrow.
I was fortunate to train with Dr. Robert Jerasaty, an authority on the subject of MVP. His book, Mitral Valve Prolapse, covers hundreds of cases and is considered a major contribution in cardiac circles. Because of Dr. Jerasaty’s mentoring, I’m confident that the majority of people I’ve diagnosed with MVP (who are asymptomatic) over the last 20 years, needed only reassurance, not medical intervention.
If you’re feeling anxious about your diagnosis, get an echocardiogram to confirm your doctor’s finding. This procedure displays a moving picture of your heart’s valve structures and will show whether the mitral valve in fact prolapses into the left atrium when your heart contracts, and if so, the degree to which it prolapses.
Q: I had a heart attack last summer, and my recovery has gone very well. I still take Lopressor and Cardizem, am back to work and feeling fine. But my wife thinks I’m different – that I’m moody and sometimes forgetful. Could the drugs be causing such changes?
I frequently hear similar comments from the spouses of my patients. To be frank, often someone who knows you well will notice subtle changes in your personality or behavior that you may not be aware of.
Beta-blockers, and particularly Lopressor, can cause moodiness and interfere with short-term memory. If patients are frustrated by their forgetfulness and mood swings, they may lose their tempers more than usual, adding to the stress on the family.
I recommend you ask your physician about trying other water-soluble beta-blockers such as Corgard or Atenolol. These do not cross the “blood-brain barrier,” so they do not affect your mental functioning. Some of my patients have had dramatic improvements in mood and memory because of this simple adjustment in medication.
Q: I know that family history is a risk factor for the heart, so what must I do to take myself out of the line for cardiovascular disease?
First of all, follow the best preventive plan you can. I believe that my core program of seven paths outlined in my report, Healing the Secret Causes of Heart Disease, covers the essential steps to keep you physically and emotionally well.
Secondly, I would encourage you to “reframe” your family history in a different way – think of it as an opportunity to reduce your controllable risk factors such as stress, obesity, smoking, unhealthy diet and lack of exercise. Prevention is something everyone should focus on, regardless of genetics, due to the fact that a heart attack is often the first symptom of heart disease.
I believe that some of the coping skills learned in our families pose a greater threat to our hearts than our gene pools, especially if you mirror self-destructive parental actions, behaviors or habits. The term “psychological genetics” is becoming more and more popular among cardiologists. For example, if you watched a parent constantly overeating or stuffing food to cover up uncomfortable feelings, and you avoid your painful feelings by using food in the same way, you will be vulnerable to chronic problems with weight, self-esteem and self-expression.
The psychological risk factors can be just as lethal as the physical risk factors. Heart health depends on paying attention to the profound physical effects that emotions have upon the body. As we mature, we unconsciously pattern expressions of love, anger and fear after our role models. If your family tends to deny or suppress these emotions, and you find that you are emotionally bottled up or cool and isolated from people, you should consider looking more deeply into your emotional self in order to protect your heart.
Also, I encourage you to feel thankful for your family “messengers” – reach out to them in their suffering, and risk opening your heart a little further. And keep taking risks with your feelings, as you have done by reaching out to me with your concerns.
Q: Since my husband’s heart attack, he hasn’t been interested in physical intimacy. I don’t want to complain, but is there anything I can do?
My patients and their spouses often tell me about their difficulties resuming sexual closeness after a heart attack or surgery. For starters, I recommend they consider the following factors that may contribute to lack of interest in intimacy:
I would encourage you to bring up this subject by reaching out in a loving manner to your husband. When you speak with him, please don’t see yourself as complaining, but as communicating, with the hope of exploring one another’s viewpoints. Look at this approach as an important opportunity in the healing and recovery process for both of you. Your husband, most likely, will appreciate the chance to relate his feelings so that you can understand him better.
Sometimes all that’s needed is a gradual return to intimacy, starting with cuddling, bathing together or the comforting touch of massage. Set aside time for intimacy when you are both rested, relaxed and free of distractions from work or family.
Also, if it’s been longer than three months since you and your husband have been sexually intimate, you may want to talk to his physician to explore the factors I discussed earlier. It may be a good idea to evaluate the possibility that he is depressed or emotionally unsettled. I know that talking about your sexual relationship can be a difficult subject to bring up with your doctor, but be assured, you’re not in a unique situation.
Q: I recently had bypass surgery. How long should I wait before I resume activities like sex?
That question is on most patients’ minds who have just had heart surgery. First, you can resume sexual relations anytime after surgery, but it’s important to lower your expectations. Remember that both you and your spouse have been through a stressful experience stemming from your coronary artery bypass surgery. It’s important for you and your partner to ease back into your sexual relationship (this also applies to patients who had recent heart attacks or angioplasty) and not expect too much from each other.
It’s also very critical for you to talk openly about your fears, expectations and, above all, any anxieties you may have about impotence or frigidity. Choose a time and place for a sexual encounter that is relaxed and familiar to you. Try positions that use minimal energy such as lying on your side. Avoid placing strain upon the chest muscles. If you’re a man, try lying on your back with your partner on top. If you’re a woman and your chest is sensitive, you may want to try a more upright position. I also caution my patients not to have sexual relations within one to two hours after eating since this may place any additional burden upon your heart. And by all means, avoid excessive consumption of alcohol.
Q: My father died of a stroke, and I’ve just read that it is the third-largest cause of death in the United States. My husband and I are presently in excellent health but want to make sure that we do everything we can to avoid having a stroke. Can you give us some guidance?
First of all you get high marks for your proactive attitude. Your overriding concern should be to keep your blood pressure within normal levels (below 140/80, which is the upper range of “normal” blood pressure established by insurance companies) because elevated blood pressure is a leading cause of strokes, as well as a major risk factor for heart disease.
To keep your blood pressure within normal ranges, I recommend you do the following:
A word of caution. Even if you follow these lifestyle guidelines to the letter, “hidden risk factors’ such as repressed anger, hostility and fear are frequently responsible for soaring blood pressure. I recommend developing a strong emotional support system with people you care about and who care about you. Such loving connections will reduce any tendencies to hold on to anger and hostility.
Q: I was shocked to learn recently that six times as many women die from heart disease as from breast cancer (which I thought was my greatest health risk). What amazed me even more was the statistic that one-half of the women who die after the age of 50 are being lost to heart disease. Isn’t this anew phenomenon? Why is this happening?
Yes, it’s true. In the 21st century, the incidence of heart disease in women is rising at an alarming rate. In fact, in 1994, the American Heart Association reported the astounding statistic that women were surpassing men in deaths due to heart disease.
Often, when I inform some of my female patients that their symptoms are due to heart disease, they’re simply stunned because they always grew up with the common assumption that is men who have heart problems.
Although there are several factors responsible for this gender turnaround, one of the main reasons is that women are finding themselves locked into what I call “an unholy trinity” – they are expected to be feminine, yet act like a man at work and work like a dog at home. These multiple roles may be very stressful for some women. Of course, the impact of stress will vary, depending on the social and emotional support system available to the woman.
Luckily, a shift in medicine is occurring in recognition of the growing numbers of women at risk. We now recognize that the diagnosis criteria and treatment guidelines for heart disease in women are different than they are for men.
Much of the research on symptom recognition, disease course, treatment options and outcomes, has been based on large groups of men, and we’ve found that what is true for men is not necessarily the norm for women.
I’m so concerned about the recent developments regarding heart disease and women that I wrote a book on it entitled Heart Sense for Women where you can find an expanded discussion.
Q: I have just been diagnosed with heart disease. What should I do?
Unquestionably, it is a terrifying and unsettling moment when a patient learns that he or she has heart disease. Initially, you will be scared and anxious. But after a few weeks, you’ll come to accept your illness, and that’s when you’ll be ready to adopt a more hopeful and positive outlook. Believe me, you’ll recover faster if you strive to maintain a positive attitude. This is the most important aspect of healing.
The first thing you should do is accept your feelings and reach out to others, particularly loved ones, for support and guidance. It’s important to let your feelings come out by talking quietly and occasionally, using your voice to release your anger and even tears. Venting in this way will allow you to begin the important work of healing and freeing up the energy you need to modify your lifestyle.
Once you’ve had a chance to deal with the emotional impact of learning that you have heart disease, you should get on my safe, effective and inexpensive program.
Here’s a synopsis of my program:
A cardiac rehabilitation program, will also help to improve your mental and physical well-being. Supervised exercise, nutritional counseling and peer support can get you back on track and restore you to better health.
Q: Several times in the last few months I’ve had a “spell” where my breathing went funny and my heart felt like it was going to jump right out of my chest. I’ve been told this is a panic attack. Will this hurt my heart?
Panic disorder can mimic cardiac symptoms. I’ve noticed that it’s common for individuals in excellent physical health to see me for an evaluation, in response to sudden episodes of chest pain, shortness of breath, palpitations and a rapidly beating heart. It often turns out after a full history and complete cardiac evaluation that these patients are suffering from anxiety, not a cardiac disorder.
Nothing is wrong with their hearts. But they often find it hard to believe. This reaction often goes hand in hand with anxiety, for a very apprehensive person often finds it difficult to be reassured. It is common for people with high levels of anxiety to “doctor shop” in the hopes of finding a doctor who will eliminate or “fix” their uncomfortable symptoms.
A word of caution, however. Women may be mistakenly told they “just have anxiety,” when there really is a problem with their heart. Symptoms of heart disease for women are vague and more generalized than symptoms experienced by men. Some common symptoms for women might be dull and continuous chest pain (lasting longer than an hour) with discomfort that radiates into the neck or jaw, or chest discomfort coupled with extreme fatigue. Also, studies have shown that fewer women than men are referred for appropriate diagnostic tests.
My advice is to have a full cardiological evaluation by a specialist. Then, if anxiety or panic are found to be causing your symptoms, you’ll need to address and treat your anxiety. Talking to a psychologist or psychotherapist is a good place to start, and anxiety support groups often meet at local hospitals.
Q: Are elevated iron levels a risk factor in heart disease?
It is true that an elevated iron level is a critical parameter in heart disease for some people. An elevated iron level combined with a high LDL cholesterol may be a prescription for plaque development. One of the problems with iron is that many of us unknowingly take excessive amounts when we don’t need to. Men over 18 and postmenopausal women do not need iron unless prescribed by their physician. Too much iron can oxidize LDL and cause inflammation lending to heart disease.
Sometimes, hematologists treat some deficient patients with injectable iron, particularly if they are severely anemic or if their bone marrow is severely depleted in iron. For this population, supplemental injectible iron is appropriate. Although the body regulates the absorption of iron, remember that oral iron is absorbed to some degree in everyone. If you are not losing iron and are constantly taking it in, this could be a problem.
The above Q&A has been reprinted or adapted from Candid Advice About Your Heart, a Heart, Health & Nutrition supplement, with permission from Healthy Directions, LLC.
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Natural Rhythms
Your four-chambered heart consists of two upper atria, and two lower ventricles. The atria receive blood from the rest of the body, send it to the lungs then forcibly propel the newly oxygenated blood into the ventricles. The ventricles forcibly contract to pump blood throughout the rest of the body. This series of contractions normally occur about 70 times per minute, and operate to a rhythm set by the heart’s pacemaker, or sinoatrial node.
The pacemaker will slow down or speed up your heart rate in response to electrical impulses sent by your autonomic nervous system. When you experience sudden anger or fear, for example, your heart rate increases as part of an adrenal, or “fight-or-flight,” response; it generally returns to normal as you relax and experience peace. Mind-body practices such as meditation, yoga, visualization, and deep breathing are useful relaxation techniques.
Identifying Subtle Symptoms of Cardiovascular Disease
While living a heart-healthy lifestyle is the best preventative measure against a heart attack or stroke, becoming better aware of the subtle signs of cardiovascular disease could save your life or the life of a loved one.
While these symptoms are not 100 percent gender-specific, women generally experience more vaguely defined symptoms than men.
MEN:
WOMEN:
Fats in a Nutshell:
Monounsaturated:
(+) Anti-inflammatory
(+) Do not oxidize easily
(-) Do not contain essential fatty acids
Sources: olive oil, avocado, some nuts and seeds
Polyunsaturated Omega-3s:
(+) Contain essential fatty acid (EFA): ALA
(+) Contain EPA and DHA
(+) Anti-inflammatory and cardioprotective
(-) Oxidize easily
Sources: fish / fish oil, walnuts, flaxseed, tofu, and green, leafy vegetables
Polyunsaturated omega-6 fats:
(+) Some contain LA, an essential fatty acid
(-) LA converts to AA, which is inflammatory in excess amounts; need to consume equal amounts of omega-3 and omega-6 fats to balance inflammatory potential
Sources: meat, vegetable oils (corn, safflower, sunflower)
Saturated fats:
(+) Convert to cholesterol in the body (animal sources)
(-) LDL cholesterol can oxidize in presence of high homocysteine, Lp(a), and ferritin levels
(+) Does not oxidize easily
Need to balance intake with other nutritious and anti-inflammatory foods
Sources: dairy and meat products, coconut and palm oils, chocolate
Hydrogenated / trans-fats
(-) Have artificially added hydrogen
(-) The worst!! Highly inflammatory
(-) Oxidize most easily
Sources: processed and fried foods
The health of the body begins to deteriorate when its physical, emotional, and mental processes fail to work in harmony. Establishing health and balance within a person requires a multidisciplinary approach which may include elements of proper breathing, exercise, release of painful emotions and past traumas, energy enhancement, nutritional healing, reopening of the heart to love, and the development of a spiritual connection.
-Heartbreak and Heart Disease
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