Is your heart suffering from circular stress?

Cardiologist Dr Boon Lim tells Luke Mintz how the constant pressure of lowlevel lockdown stressors could have aggravated our blood pressure

On 20th March 2020, doctors at Favaloro Foundation University Hospital in Argentina were bracing themselves for the onslaught of Covid-19, the biggest challenge of their careers. One day earlier, President Alberto Fernández had announced one of the world’s toughest lockdowns. Schools and restaurants were shut; exercise was banned, as was dog-walking.

Concerned about the impact on public health, doctors at the research hospital designed an experiment. Almost every patient admitted to A&E usually had their blood pressure taken; researchers wanted to see whether the stress of lockdown was showing up in those readings. The results were disturbing, if not particularly surprising: 24 per cent of patients in the spring 2020 lockdown recorded a high blood pressure, compared with 15 per cent in the three months before lockdown, and 17 per cent a year earlier. The increased blood pressure was seen in patients who entered hospital for reasons unconnected to their heart, such as a broken leg.

Dr Boon Lim, a leading cardiologist at Imperial College London, uses this study in his new book, Keeping Your Health Healthy (Penguin Life, £9.99), to illustrate what he considers a disturbing and potentially deadly impact of lockdowns: the impact on our hearts. It’s hardly exclusive news that lockdowns wreaked havoc on our health. Research shows we ate more junk food, exercised less and drank more alcohol. But Dr Lim worries that another factor has largely flown under the radar: the gnawing impact of constant, lowlevel stress, circling us like a shiver of sharks in the ocean; the sort of anxiety that hums in the background, too quiet to complain about, but still profoundly damaging.

Indeed, the thesis of his new book is that doctors have for too long ignored the effect of lifestyle factors, and specifically stress, on our cardiovascular systems. Overburdened and under-resourced, too many cardiologists rely on “knee-jerk, textbook” responses to heart issues, usually involving quick-fix medication, he thinks.

Take hypertension (high blood pressure), Dr Lim tells me over the phone. “The patient comes in … and if their blood pressure is high, the doctor prescribes medications and says, ‘Come back in four weeks, six weeks, six months, whatever the interval is, to come and have your blood pressure checked again’. And off the patient goes. But very seldom do doctors say, ‘What is going on in your life?’”

We already know stress aggravates our blood pressure, which over time can damage our major organs.

Traditionally, we have talked about this threat in the context of personal crises, like job losses or relationship breakdowns. But Dr Lim worries that the trauma of the pandemic has affected all of us, to varying extents, creating a new generation of everpresent circular stressors.

The trouble, he says, is that our cardiovascular systems were simply not built to cope with the pressures of modern life. In the prehistoric era, humans evolved a robust bodily response to danger, in which our heart played a major role. If a sabre-toothed tiger leapt out in front of us, he says, our brain released adrenaline into our blood, causing our heart to beat furiously. That surge of energy helped us to escape. Afterwards, we could retire to our cave and relax. But in the industrialised 21st century, the nature of the threat has changed. Work, financial and family woes now loom on the horizon instead, threats that never seem to go away.

“Imagine now the sabre-toothed tiger is circling around you in the long grass,” says Dr Lim, “and hasn’t pounced yet. You have to live with that 365 days a year. What would that do to your state? You can never relax, you can never eat properly, you can never have your bowel movements regulated. You can never be fully calm. And that state of deep-seated anxiety is akin to how we live in society today, [particularly during] Covid.”

In the UK, pandemic life forged some new social bonds. Hundreds of new charities arose from the crisis; good Samaritans delivered food to their elderly neighbours; many of us stood on our front steps and clapped for our carers, for a few weeks at least. But, as far as our heart health is concerned, Dr Lim worries these flickers of hope were outweighed by the sense of claustrophobia felt by many. “I suspect feeling trapped and being unable to have your social routine were two major factors.”

Dr Lim is particularly interested in the widely-discussed Compassionate Frome Project, a study launched in the Somerset market town in 2013. GP practices created a network of groups to bring isolated people together: choirs, creative writing workshops, exercise groups and “men’s sheds” (where men make and mend things together). They were designed to forge social connections and, in doing so, reduce stress. Between 2013 and 2017, emergency hospital admissions fell by 30 per cent in the town of 26,000 people. In the rest of Somerset, emergency admissions over the same period rose by 17 per cent.

And he’s not the only one banging this drum: the dire impact of stress and loneliness on heart health features heavily in Together: Why Social Connection Holds the Key to Better Health, last year’s book by Dr Vivek Murthy, President Obama’s Surgeon General.

Particularly interesting for Dr Lim is research around atrial fibrillation, the UK’S most common heart condition, which usually causes an abnormally fast heart rate, increasing the likelihood of stroke. Cardiologists usually prescribe drugs, but a study from Melbourne University looked at “non-aggressive, non-surgical” treatments, such as weight loss and sleep therapy. It suggested stress might be the key component. Those treatments led to, “and this is quite remarkable,” says Dr Lim, “an improvement equivalent to state-ofthe-art surgery”. It all points, he thinks, to the need for a more “holistic” approach to cardiovascular health that takes into account the emotional impact of the pandemic with its health worries, school closures and economic turbulence.

“There are times in a consultation when instead of typing, or writing furiously in the clinical notes, doctors should put down their pens, look into the patient’s eyes. Often, if you allow the patient to be vulnerable and open up [it] will become very clear. They will say something like, ‘My kids are having trouble at school, I’m very stressed that they’re not performing; and by the way, I’m having trouble with my spouse’. Or, ‘I’m suffering from long Covid and haven’t been to work for three months’. Those are the fundamental issues that drive high blood pressure: chronic stress.”

It all sounds lovely, I tell Dr Lim, but in a famously overstretched NHS, will GPS and cardiologists realistically have time to ponder a patient’s life so thoroughly? “All it takes is 10 minutes,” he replies, and “not every patient needs this approach.” The doctor can run a bit late in their clinic, he points out, “maybe 90 minutes later in the day. My clinics are notorious for over-running.”

And what of the dreaded remote appointments? Can a patient with a heart ailment really expect a “putdown-the-pen moment” from a video or phone meeting? “Physicians are more able to read emotional clues and body language in a face-to-face consultation,” Dr Lim admits. “But when I use video, I can often have profound consultations as well. I think face-to-face and video are not very different. But face-to-face and telephone consultations are extremely different.” In phone appointments, he thinks, “I would lose I guess 40 per cent of the communication”.

People can, of course, take heart health into their own hands, he thinks, focusing on breathing, sleep and lifestyle. The pandemic probably inflamed our blood pressure but, as we move on from Covid, we can certainly do what we can to bring it back down again.

‘Imagine the sabretoothed tiger is circling you – and hasn’t pounced yet’