Earlier in the book, I introduced three of my cardiology patients: Nathan, age thirty-six, the video game developer with a poor diet and sedentary lifestyle; Angela, age fifty-seven, the cerebral rocket scientist with type 2 diabetes; and Frank, forty-five, the apparel entrepreneur with a Type A personality and hypertension. Each of them had a different primary risk factor for silent heart disease (and coronary heart disease). However, they also shared another common risk factor: they all suffered from anxiety, stress, and sleep impairment.
There’s nothing coincidental in all three of these patients having these common risk factors, because I believe the vast majority of people who suffer from coronary heart disease also suffer to some degree from one or more of these conditions. I literally have seen tens of thousands of patients over the course of my sixty years in practice as a cardiologist, and there’s no doubt in my mind that anxiety-related conditions are among the most common risk factors in these patients.
Until recently, the medical community didn’t believe that these conditions contributed directly to the risk of heart disease. After all, stress to some degree is part of everyday life. Running late for the important client meeting, an unexpected car-repair bill, a family member with a substance abuse disorder—all are examples of common, everyday stressors. Likewise, the idea that an impaired sleep condition like insomnia might be a primary factor in coronary heart disease was viewed skeptically by physicians and the public alike. As long as you got yourself to work every day, you could always compensate for your restless nights during the workweek by catching up with extra sleep during the weekend—or so the thinking at the time went.
Today, there is substantial evidence that stress, anxiety, and sleep impairment are conditions that not only commonly occur in patients with coronary heart disease (CHD) but may actually have a causal effect as important as cigarette smoking, high blood pressure, and high cholesterol, the three “classic” risk factors for heart disease. What’s more, stress, anxiety, and sleep impairment can also trigger development of other risk factors, such as obesity and substance abuse.
Stress, anxiety, and sleep impairment often have similar causes, so it is important to understand all of them because the most effective treatment depends on an accurate diagnosis. In this final chapter of Part II, we’ll address the ones that are most relevant as risk factors for silent heart disease.
The terms “stress” and “anxiety” are often used interchangeably by the public. Phrasing such as “I’m really anxious to hear back about my job interview” or “the long commute is stressing me out” are common colloquialisms. However, it must be recognized that stress and anxiety are two separate conditions, although they overlap in significant ways.
The best way of thinking about the difference is that stress is caused by external factors (lack of money, overbearing boss, crowded freeway), while anxiety is usually caused by internal factors—your view of or fears about the world around you. Both conditions can be treated, often with the same or similar treatment protocols, including medications, exercise, meditation, and psychological counseling. But for treatment to be most effective, it’s necessary to understand the differences between these conditions as well.
Stress is basically the quite normal response our bodies have to any change in our environment. Such changes can be either positive or negative and lie along a continuum in terms of being within or outside our control. The less control we have over the situation that is creating the stress we are experiencing, the more intense our stress reaction is likely to be. Not only do we experience stress as a response to even positive changes in our lives, but the stress reaction itself is also a positive and beneficial response at times.
The human body is designed to react to stress effectively. You probably have heard of the “fight-or-flight response,” which generates physiological changes in order for the body to successfully react to stressful situations. When this natural, healthy stress response is activated over a prolonged period, however, it can cause physical and emotional wear and tear on our bodies. Such a negative state of stress, or distress, can lead to serious health problems if left untreated. Many times, it is the physical symptoms of stress that drive people to the doctor. Work, the demands of family, social relationships, and financial problems are some of the leading causes of stress.
The following is a list of common responses to untreated stress:
•High blood pressure
•Digestive issues
•Headaches
•Muscle aches and pains
•Tremors
•Sleep disturbances
•Depressed immune system (frequent colds, viruses)
•Skin problems (rashes, hives)
•Memory problems (forgetfulness)
•Lack of focus and concentration
•Bouts of depression
Similarly, do you do any of the following when you’re “stressed out”?
•Eat to calm down
•Speak and eat very fast
•Drink alcohol or smoke
•Rush around but not get much done
•Work too much
•Procrastinate
•Sleep too little, too much, or both
•Slow down
•Try to do too many things at once
Ultimately, people feel and react to stress in different ways. Your stress reaction depends on specific environmental factors in your life, although certainly society as a whole can be under stress. For example, much has been written about how the benignly termed Information Age—gee, who doesn’t like information?—has created a modern-day milieu where we’re never really disconnected from the Internet of Things. Just the other day I marveled at how a young man, who appeared to be a professional dog walker because of the half dozen canines he was walking, could not bring himself to stop texting on his smartphone—never mind that in doing so he posed a danger to his charges, himself, other pedestrians, and the vehicular traffic all around him. This inability to unplug from the Internet can easily cross the line into obsessive-compulsive behavior.
How much stress you experience and how you react to it can lead to a wide variety of health problems—and that’s why it’s critical to know what you can do about it. Excessive stress can contribute to everything from high blood pressure to asthma, ulcers, irritable bowel syndrome, and coronary heart disease.
If you feel anxious now and then, that’s perfectly normal. Like stress, a little anxiety can spur you to take positive action that may benefit your health, such as getting screening tests, doing regular exercise, or embracing a healthy diet. But excessive worrying can have the opposite effect.
Anxiety is more than just feeling stressed or worried. Anxious feelings are a normal reaction to feeling under pressure, and usually these symptoms disappear once the stressful situation has passed, or the “stressor” is removed. However, for some people these anxious feelings happen for no apparent reason or continue even after the stressful event has passed. For a person experiencing clinical anxiety, anxious feelings often cannot be brought under control easily.
Anxiety can be a serious condition that makes it hard for a person to cope with daily life. There are many types of anxiety, and many people with anxiety experience symptoms of more than one type. In fact, living with coronary heart disease is one of many stressors that may trigger anxiety. Anxiety is common, and the sooner people get help, the sooner they can recover.
The symptoms of anxiety can often develop gradually over time. Given that we all experience some anxious feelings, it can be hard to know how much is too much. In order to be diagnosed with an anxiety condition, a person’s anxiety must have a disabling impact on his or her life.
Anxiety can be expressed in different ways, such as uncontrollable worry, intense fear (phobias or panic attacks), upsetting dreams, or flashbacks to a traumatic event. Some common symptoms of anxiety include the following:
•Hot and cold flashes
•Racing heart
•Tightening of the chest
•Snowballing worries
•Shortness of breath or difficulty breathing
•Obsessive thinking and compulsive behavior
•Feeling restless, wound up, or on edge
•Being easily fatigued
•Difficulty concentrating; mind going blank
•Irritability
•Difficulty controlling feelings of worry
•Sleep problems, such as insomnia or interrupted sleep
So, how can you tell if you’re just going through an especially stressful episode in your life or you have a clinical form of anxiety? One common form, generalized anxiety disorder, is characterized by at least six months of excessive worrying or feeling anxious about several unrelated events or activities almost every day. About 5 percent of adults in the general population meet the criteria for generalized anxiety disorder, but the incidence is higher among people diagnosed with coronary artery disease (11 percent) or heart failure (13 percent).
In a panic attack, an intense rush of fear or anxiety can make one feel just like he or she is having a heart attack, with chest pain, shortness of breath, sweating, nausea, lightheadedness, and a racing or pounding heart. These frightening episodes propel many people to seek emergency care, where oftentimes careful testing uncovers no evidence of a heart problem. Instead, these people receive a diagnosis of what’s known as noncardiac chest pain (NCCP), which is surprisingly common.
As many as one in three people experience NCCP at some point in their lives, according to a 2017 review article in the journal Psychosomatics. While some cases end up being traced to a gastrointestinal or muscle-related problem, people with NCCP often have very high levels of anxiety, says Harvard psychiatrist Dr. Christopher Celano.“If you’re having chest pain, you should definitely go to the emergency room to make sure you’re not having a heart attack,” he says.
But if it’s not a heart attack, what’s next? It’s not uncommon for people with an anxiety disorder—especially those who have panic attacks—to continue having symptoms and to end up back in the emergency room. Cardiologists see this problem all the time. The best way to tell the difference between a heart attack and a panic attack is through diagnostic testing.
Ironically, those who think they are suffering from a heart attack, even though it is in fact a panic attack, may actually be contributing unknowingly to silent heart disease. That is, researchers have reported that heart patients who have generalized anxiety disorder—constant, pervasive worrying, even about mundane matters—are more likely to have heart attacks and serious heart problems than patients who don’t have these symptoms. In a recent study, Canadian researchers analyzed studies of people treated in emergency departments for chest pain. Their conclusion: about one in five of those who underwent cardiovascular testing had experienced a panic attack, not a heart attack.
It’s not totally clear yet why heart disease and anxiety are connected, but acute anxiety may actually be associated with acute heart attacks. Generalized anxiety disorder is associated with surges of the stress hormone cortisol and an outpouring of other chemicals involved in the fight-or-flight response. That in turn appears to make heart attacks and other cardiac events more likely. But why?
Let’s dig a little deeper into the relationship between cardiac health and cortisol. A review published in June 2017 in the journal Frontiers in Human Neuroscience concluded that inflammation is a common pathway of stress-related diseases. In a fight-or-flight emergency situation, the stress hormone cortisol affects nonessential functions, like your immune response and digestion. The hormone also fuels the production of glucose, or blood sugar, boosting energy to the large muscles, while inhibiting insulin production and narrowing arteries, which forces the heart to pump harder to start the stressor response.
Another hormone, adrenaline, is also released in these situations, which tells the body to increase heart and respiratory rates and to expand airways to push more oxygen into muscles. Your body also makes glycogen, or stored glucose (sugar), available to power muscles. In addition, stress decreases lymphocytes, white blood cells that are part of the inflammatory immune systems.
Pro-inflammatory cytokines usually do their job and then disappear, but when stress is chronic, they are “upregulated” in your system—meaning the cycle of stress and inflammatory response gets habituated in the body. Over time, these cytokines may perpetuate themselves. That’s when inflammation starts to have deleterious effects on the body. And while no one is completely sure why that happens (there are many mechanisms responsible for diseases), many conditions have chronic, low-level inflammation in common.
A hyped-up sympathetic nervous system—the response that primes your body to fight or flee—also works to constrict blood vessels, which forces your heart to work harder and raises blood pressure.
Inflammation is at the core of the development of atherosclerosis, a precursor to heart disease. Ironically, in its initial response to danger, cortisol is a potent anti-inflammatory that functions to mobilize glucose reserves for energy and modulate inflammation. On a psychological level, cortisol also may facilitate the consolidation of fear-based memories for future survival and avoidance of danger. Ultimately, however, a prolonged or exaggerated stress response may perpetuate cortisol dysfunction, widespread inflammation, and pain.
Another theory as to the correlation and possible causal effect between anxiety and coronary heart disease is that people with generalized anxiety disorder tend to have low levels of omega-3 fatty acids, which have some properties that may fend off heart disease. Another theory is that the real culprit is depression, despite the best efforts by researchers to tease apart depression and anxiety and investigate them separately. The boundary between major depression and generalized anxiety disorder is inherently fuzzy, at both the biological and psychological levels.
Still another possibility is that anxious patients with coronary heart disease may be less likely to seek preventive medical care, possibly due to an avoidant coping strategy. It is also possible that there exists a common background origin to stress and anxiety symptoms and the risk of cardiovascular disease—some still to-be-discovered interplay of genetic factors.
So, while scientists have not been able to pinpoint the exact reason for the correlation, there’s little doubt that high stress and anxiety can set the stage for heart disease. To frame it another way, those of us who perceive a lot of stress in our lives are at higher risk for heart attack and other cardiovascular problems over the long term.
Several studies have shown that about a quarter of people with cardiovascular disease have some kind of anxiety problem, and in some cases the anxiety seems to make the heart condition worse. The latest evidence comes from a new study of siblings in Sweden, published in 2019 in the British Medical Journal. Researchers identified about 137,000 people who had been diagnosed with stress-related disorders. Then the researchers identified about 171,000 of their brothers and sisters with similar upbringings and genes but no anxiety disorder. Next they compared the siblings’ rates of cardiovascular disease, including heart attacks, cardiac arrest, and blood clots, over a number of years. The Swedes who had a stress disorder, it turns out, had significantly higher rates of heart problems compared to their siblings. “We saw [about] a 60 percent increased risk of having any cardiovascular events” within the first year after being diagnosed, says Unnur A. Valdimarsdóttir, a researcher with the Karolinska Institute and professor of epidemiology at the University of Iceland. Over the longer term, the increased risk was about 30 percent.
So, if stress and anxiety are normal parts of life, when do they become a risk factor for silent heart disease and coronary events? The problem is not that we occasionally experience the fight-or-flight stress response, an essential mechanism humans have evolved as the dominant animal species. When in danger, our ancestors counted on their bodies to smartly increase their heart rate and blood pressure to take immediate action—such as fleeing from a hungry predator with very large teeth. The problem comes if you start to experience these stress response “activations” even when there’s not an imminent threat—the lion is nowhere to be seen.
Of all the reasons to get a good night’s sleep, protecting your heart might not be top of mind. But maybe it should be. Sleep duration has decreased 1.5 to 2 hours per night per person in the last fifty years. But several recent studies show links between shortened sleep duration, defined as less than six hours of sleep, and increased risk of heart disease.
A 2011 European Heart Journal review of fifteen medical studies involving almost 475,000 people found that short sleepers had a 48 percent increased risk of developing or dying from coronary heart disease in a seven to twenty-five-year follow-up period (depending on the study) and a 15 percent greater risk of developing or dying from stroke during this same time. Interestingly, long sleepers—those who averaged nine or more hours a night—also showed a 38 percent increased risk of developing or dying from CHD and a 65 percent increased risk of stroke.
Researchers caution that the mechanisms behind shortened and prolonged sleep and heart disease aren’t completely understood. “Lack of sleep doesn’t necessarily cause heart disease,” says Phyllis Zee, MD, PhD, professor of neurology and director of the Sleep Disorders Program at Northwestern University’s Feinberg School of Medicine. “It really increases the risk factors for heart disease.”
Part of the reason for the lack of understanding is that sleep’s effects on the heart is a relatively new area of study. Another is that measuring sleep is complicated. Many sleep studies rely on self-report-ing, which may not always be accurate. Having your sleep measured involves wearing an activity monitor, which quite likely may change your usual sleep pattern.
Good quality sleep decreases the work of your heart, as blood pressure and heart rate go down at night. People who are sleep-deprived show less variability in their heart rate, meaning that instead of fluctuating normally, the heart rate usually stays elevated. “That is not a good sign,” Zee says. “That looks like heightened stress.”
Zee also identifies a host of other factors. Lack of sleep can increase insulin resistance, a risk factor for the development of type 2 diabetes and heart disease. Shortened sleep can increase C-reactive protein (CRP), which is released with stress and inflammation. “If your CRP is high, it’s a risk factor for cardiovascular and heart disease,” says Zee. Shortened sleep also interferes with appetite regulation. “So you may end up eating more or eating foods that are less healthy for your heart,” Zee says.
Individuals may have biological or psychological traits that increase their likelihood of developing acute sleep problems when faced with precipitating factors, such as stress or anxiety. In an attempt to compensate for poor sleep, individuals may unwittingly engage in behaviors that ultimately perpetuate their sleep problems.
Is there an ideal amount of sleep? The short answer is yes. While each of us is of course unique physiologically to some degree, by and large research has shown that the average person requires eight hours of restful sleep. Any less or any more is considered impaired sleep.
To be clear, spending more time in bed to compensate for poor sleep can have the unintended effect of disrupting sleep/wake cycles, decreasing sleep efficiency, and creating a conditioned association between being in bed and being awake. Others may compensate for poor sleep by taking daytime naps (which decreases the urge to sleep the following night) or increasing caffeine intake. Over time, individuals may come to regard nighttime as a frustrating struggle, which increases physiological activation and further decreases the likelihood of entering a comfortable sleep state.
Insomnia, a common type of impaired sleep that’s generally thought of as an inability to fall or stay asleep on at least three days in a week, is due to overarousal that persists into the evening and night. This means that the sympathetic nervous system has increased activity with increased release of stress hormones such as cortisol. Chronic activation of the stress system may have effects such as increasing insulin resistance and contributing to psychological problems such as depression and anxiety. Depression itself can increase the risk of cardiovascular disease. Insomnia appears to be associated with impaired glucose metabolism, and this may damage the cardiovascular system and contribute to the development of cardiovascular disease.
Dysregulation of the sympathetic nervous system has been linked to high blood pressure, cardiac arrhythmias, and heart failure. Increased levels of C-reactive protein have been linked to severe insomnia in men. Elevated CRP levels have been implicated in the development of plaques in arteries. Very chronic insomnia has been associated with increased risk of high blood pressure. This is especially the case when patients with insomnia also get less than six hours of sleep per night.
The potential relationship between insomnia and cardiovascular disease may have to do with the insomnia along with the potential effect of short sleep duration. This state of hyperarousal involves increased systemic inflammation and a disruption of stress regulators in the pituitary-adrenal glands. These factors then impact various pathways to cardiovascular disease such as increasing heart rate and blood pressure, increasing the development of plaques in the arteries, and increasing resistance to insulin and raising levels of lipids such as cholesterol in the blood.
Most studies investigating the correlation between impaired sleep as a risk factor in coronary heart disease have used duration as the only measure of sleep. However, more recent evidence demonstrates that aspects of sleep other than sleep duration are also important to investigate.
A recent report found that the combination of sleep duration and sleep disturbance was a better predictor of coronary heart disease risk than sleep duration alone. The Whitehall II study was a major longitudinal study tracking the health of more than ten thousand workers, ages thirty-five to fifty-five, from twenty departments of the British Civil Service across fifteen years. Although both sleep duration and sleep disturbance were associated with increased coronary heart disease risk, only sleep disturbance remained significant after adjustment for environmental and genetic factors. Upon closer examination, it appeared that there was an interaction between sleep disturbance and sleep duration, such that those with short sleep duration were at increased risk of coronary heart disease only if they also reported subjective sleep disturbance. The Whitehall II data echo findings of earlier studies that reported that individuals with insomnia, one type of sleep disturbance, were at increased risk of hypertension if they also reported short sleep duration. Thus, in this study as well others, an indicator of cardiovascular disease is associated with increased sleep disturbance in the context of short sleep duration.
The most common reason for sleep interruption was urination during the night. Also, for female patients, self-perceived poor health, comorbidities, and depression were also contributing factors. Insomnia was reported by 32 percent of patients with heart failure in a recent study. The most mentioned problems with sleep were difficulty falling asleep, difficulty staying asleep, and waking up too early.
Factors that studies have found are correlated with insomnia are depression, anxiety, marital status (divorced, widowed), and something known in the medical profession as “dyspnea,” sometimes known colloquially as “air hunger.” Patients with dyspnea describe it as a shortness of breath or an inability to breathe in enough air.
Sleep apnea is a prevalent condition characterized by frequent pauses in breathing when a person sleeps. According to the National Sleep Foundation, more than 18 million people in the United States suffer from sleep apnea, many of whom have not been officially diagnosed. When sleep apnea goes unnoticed, people cannot receive the treatment they need. Initially, this can lead to daily issues such as headaches, fatigue, and poor memory. Over time, sleep apnea can lead to more serious health concerns, including diabetes, hypertension, and stroke.
The relationship between sleep apnea and cardiovascular disease most likely stems from repeated episodes of decreased blood oxygen levels, as breathing is cut off by the closing of the upper airway, and the repeated stimulation of the heart as the brain arouses the body to increase the tone of the airway muscles so that breathing can be restored. Over time this takes a toll on the heart and blood vessels. The ways in which insomnia may negatively affect the vascular system are not as well understood but most likely involve processes such as increased sympathetic nervous system activity associated with overarousal and increased inflammation.
Sleep apnea is estimated to affect 14 to 49 percent of the adult population; moderate to severe sleep apnea is present in around 10 percent of adults above thirty years of age, and its prevalence increases sharply with age. Sleep apnea is more common among men than in women.
There are a number of factors that increase risk, including having a small upper airway (or large tongue, tonsils, or uvula), being overweight, having a recessed chin, small jaw, or large overbite, having a large neck size (seventeen inches or greater in a man; sixteen inches or greater in a woman), smoking and alcohol use, being age forty or older, and being of certain ethnicities (African American, Pacific Islander, and Hispanic). Also, sleep apnea seems to run in some families, suggesting a possible genetic basis.
How can you tell if you have sleep apnea? Chronic snoring is a strong indicator of the condition and should be evaluated by a health professional. Since people with sleep apnea tend to be sleep deprived, they may suffer from sleepiness and a wide range of other symptoms such as difficulty concentrating, depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone, or driving. Left untreated, sleep apnea can lead to disturbed sleep, excessive sleepiness during the day, high blood pressure, heart attack, congestive heart failure, cardiac arrhythmia, stroke, or depression.
There’s also a disturbing association between sleep apnea and diabetes, which is a leading risk factor in coronary heart disease. When a person is asleep, the parasympathetic nervous system—also called the “rest-and-digest” system—dominates, resulting in a slowdown of heart rate, blood pressure, respiration rate, gut movement, other bodily functions, body temperature, and basal metabolism. However, if sleep is disturbed too often, this rest-and-digest system is never triggered, resulting in a heightened load on the circulatory system, an elevated basal metabolism rate, and a higher level of stress hormones.
Research indicates the association between sleep and diabetes may be described as a vicious circle, where sleep disorders favor the development of type 2 diabetes. On the other hand, diabetes itself, when accompanied by poor metabolic control, is mostly followed by sleep disorders.
While the latest scientific research clearly indicates a link between cardiac health and stress, anxiety, and impaired sleep (including insomnia and sleep apnea), the medical profession is still playing catch-up. Because these conditions are so intertwined, their effects are more difficult to measure than the so-called classic coronary heart disease risk factors, such as high blood pressure, high levels of low-density lipoproteins, diabetes, and smoking. There’s no litmus test to determine if a patient’s stress, anxiety, or impaired sleep has crossed the line between inconvenient and potentially life threatening. And there is no single way to treat these conditions. It’s different for everybody.
My patient Nathan, the thirty-six-year-old video game developer, had sleep apnea in addition to poor diet and a sedentary lifestyle. For his sleep apnea, I recommended a physician colleague specializing in bioesthetic dentistry. Once Nathan’s mouth cavity was X-rayed, he was diagnosed with temporomandibular disorder, a condition characterized by a misalignment of the upper and lower jaw. Nathan’s abnormal jaw position caused a serous breathing problem when he slept. The solution? A customized ultralight orthodontic device that fit behind his teeth, making it nearly invisible, which over the course of a year properly realigned his jaw and cured his sleep apnea.
Angela, the fifty-seven-year-old NASA engineer with type 2 diabetes, had her first panic attack just one week before her team’s launch of a Mars landing rover. Needless to say, there was incredible pressure to get everything 110 percent correct, which was all the more intense because it was her first project as team leader. Her treatment was a personalized regimen of relaxation training that included a combination of tai chi, mindfulness meditation, and breathing exercises. We also discovered that her sleep was constantly being interrupted by her need to go to the bathroom. A tried-and-true medication for incontinency quickly solved that problem.
Frank, our gregarious, combative forty-five-year-old entrepreneur, still struggled with high blood pressure even with medications. After questioning at length about his sleeping habits, he admitted that he frequently struggled with insomnia. He solution was to “calm his nerves” with a couple of vodka martinis every night after work, but in fact his constant alcohol intake was only contributing to his insomnia. While the alcohol initially made him doze off in front of the TV, it also dehydrated him, compelling him to wake up frequently to quench his thirst. The solution was to limit his alcohol intake altogether and to drink no alcohol two to three hours before going to bed. With this new regimen, we broke his bad habit of falling asleep in front of the TV and actually got him to start scheduling his sleep time. Now, while the thought of scheduling bedtime might drive some people crazy, it was just what Type A personality Frank needed.
Still, Frank needed more. I had a hunch that he might have a clinical anxiety disorder, possibly borderline depression. Consultation with his wife revealed that he exhibited some classic signs of depression, including bouts of anger and reckless behavior, notably driving dangerously after a few cocktails. (Depression is often overlooked in men as a risk factor for not only coronary heart disease but suicide as well. Men suffering from depression are four times more likely to commit suicide than women.)
In short, Frank needed psychological counseling. I knew he wouldn’t have the patience for Freudian-based psychoanalysis, so instead I recommended a colleague who specialized in interpersonal therapy, which helps people find new ways of getting along with others and resolving loss, change, and conflict in relationships.
After a year of controlling his blood pressure, insomnia, and anxiety, Frank made measurable improvement across the board in all of his cardiac biomarkers (more about these biomarkers in Part III). Was he a new man? No, he was still the same Frank that those who knew him well couldn’t help but like.
“You know, Harold, I’m thinking of joining an improv comedy troupe on weekends as a relaxation technique. What do you think?” Frank asked during one of his regular six-month checkups. “And by the way, how’s the blood pressure?”
“I’m happy to report your blood pressure is normal. No kidding!” I said.