When cardiologists get together and talk about their profession, the conversation inevitably turns to how lucky we are. We get to think about physics, hemodynamics, and vascular biology, and we’re shielded from messier tasks like rectal exams or sputum inspection – chores that some of our hardier colleagues undertake every day. The thing is, though, the heart connects to everything, so cardiologists still need to be attuned to how other organs are working. Your heart’s most active connection is with your brain (see previous posts: “Octopus Pots and Your Heart,” “Depression and Your Heart,” and “Cheer Up People!”). I’ve also written about the heart as it relates to your microbiome (“Bacteria and Leaky Guts”). So, as a further nod to our gastroenterology colleagues, today we’ll explore another heart/gut connection – the relationship between your heart and, here it comes … your bowel movements.

One thing they don’t teach in Cardiology school is how much patients love to discuss their bowels. Here’s an example: My 65-year old patient returns from Johns Hopkins Hospital, where he just underwent aortic valve surgery and a 3-vessel bypass. The procedure involved sawing his breastbone in half, then re-wiring it together. He recounts an array of complications including bleeding, transfusions, a punctured lung, a racing heart, a bladder catheterization, and an infection. I marvel at his resilience. Then he leans in, locks his eyes on mine, and whispers, “None of that mattered, Doc. The most awful thing was 6 days without a ****. When my bowels finally opened, I knew I had survived.”

He’s not the only one. Last week, I asked a different patient how she was doing. I expected an update on her heart symptoms. Instead, she looked into the middle distance and said, “Doc, I’m blessed. I have a movement every day. I don’t strain. It’s soft, and requires little effort to get out.” That’s nice, I think. But, really, sometimes I wonder if people know I’m a cardiologist.

The human obsession with bowels is universal, and the older we get, the more all-consuming it becomes. Eventually, our attention focuses on a few simple things: We don’t want pain. We don’t want hunger. We don’t want to be hot or cold. And, good Lord, bless us with a daily bowel movement.

So, why should patients’ bowels matter to cardiologists? It turns out there are links between your heart and your bathroom habits. A 2011 American Journal of Medicine study showed that severe constipation was associated with a 23% higher risk of heart attack and stroke in post-menopausal women. A 2016 study in the journal Atherosclerosis identified low-frequency defecation (a bowel movement every 2-3 days as opposed to once or more per day) with a high risk of cardiovascular death, especially stroke.

How does constipation lead to heart attacks and strokes? One theory is that constipation changes the type of bacteria in our guts, and we know that this influences blood pressure, inflammation, and atherosclerosis. Another hypothesis is that it causes mental stress, which elevates blood pressure. Perhaps most relevant, straining results in an acute blood pressure rise (if you saw your face during a tough session, this makes perfect sense), one study documenting a 70-mmHg pressure increase during a bowel movement. It’s a little like bench pressing 500 pounds. Straining can also trigger a sudden slowing of the heart rate, which can cause lightheadedness or fainting.

Doctors and hospitals don’t make it easier. Hospitalization provides all the right ingredients for constipation – unfamiliar surroundings, dietary changes, forced bedrest, pain medications – the list goes on. Cardiologists are guilty, too – we restrict fluid intake and prescribe diuretics to heart failure patients, which leads to constipation. Also, some of our favorite medications (e.g., amlodipine, diltiazem) lower blood pressure by relaxing arterial smooth muscle. Because your intestines are also made of smooth muscle, they relax too, so things don’t move. Iron supplements and aluminum-containing antacids are other common offenders.

I asked our local gastroenterologist, Dr. Suraia Barclay, for her #1 tip to avoid constipation. Without hesitation, she said:

“You should eat a rainbow every day” – colorful fruits, vegetables, and whole grains are full of fiber, which draws water into the colon, making stools softer, bulkier, and easier to pass.

Need more tips? Try these:
Get regular exercise – not just aerobics like walking, but also abdominal wall exercises. Weak tummy muscles = weak pushing = constipation.
Drink plenty of fluids – at least 2 L/day, unless your doctor has told you otherwise.
Allow yourself adequate time and privacy – that’s why people like to relax and read on the toilet.
Keep your bathroom warm – icy toilet seats do not encourage relaxation.
A morning coffee has a stimulant effect on the colon. This, together with last night’s red bean soup, can be devastatingly effective. Too much information?
The “squatty potty” is a footstool that “changes your western toilet to an Indian version” by repositioning you into a squat. A slightly less racist claim is that “it aligns your colon for easier elimination.” Medical House advertises them for $39.95.
Stool softeners (Colace) and stimulant laxatives can be obtained over the counter or prescribed by your doctor.


A final thought on the heart and the bowels …
On a not-unrelated note: Why do people have so much trouble understanding the difference between Annals and Anals? My daughter in university loves to ask me how my free newsletter is going, but instead of calling it by its correct name – the Annals of Cardiology – she calls it the Anals of Cardiology. Several highly intelligent patients do the same. It’s especially disconcerting when someone says, “I enjoy reading your Anals.” I want to say, “No, I don’t think you would.” I remind them, the title is Annals, not Anals, but each time I’m left wondering whether they’re mocking me or they really don’t know the difference. So, for the avoidance of doubt, please note:
Annal (ANN’ el) = a record of events by year.

Anal (AY’ nel) = involving, related to, or situated near the anus.
Any questions? I feel so much better now that I’ve gotten that out.


For more news on the latest developments in cardiology, visit www.ShaneMarshallMD.com, subscribe to the free newsletter The Annals of Cardiology, and follow Dr. Marshall on Twitter @ShaneMarshallMD