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Dear Mr. Chrétien,

Congratulations on making it through your quadruple coronary artery bypass surgery. It must've been a strange week for you: one day you're golfing with your pals, and two days later it's open heart surgery. Lucky you had a cardiologist in your foursome. This supports my theory that it is always a good idea to invite a doctor when you visit resort locations.

I am writing because I have some advice for you right now. In medicine, we talk about teachable moments; moments where people are much more likely to realign their perspective and possibly even to change. This, Mr. Chrétien, is one of those moments for you.

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You've probably faced more challenges and crises than your peers, but this one is different. This crisis is personal, as it involves the prime minister of your own body, the heart. This organ has mythical significance for us. When the plumbing needs to be rearranged, it can shake your confidence.

For many patients, the time after a heart operation, especially the next four to six weeks, is a time of intense self-reflection. It can be a bit of an emotional roller coaster, actually.

I see a lot of weeping, homecoming grumpiness, and narrowing of partner communication. I also see patients who discover what is valuable to them and seize the desire to make life changes.

One of the funny things about health is that it can be a self-fulfilling prophecy. A big part of being healthy is thinking we are healthy. So when something major goes wrong, it can be unsettling. To get through this crisis and regain your self-confidence, you are going to have to learn to trust your heart again.

One thing to consider is your core perception of the bypass surgery itself. Having open-heart surgery seems a negative event (and I am sure this week it feels that way), but it helps to reframe this. Approximately 80 per cent of patients who have a bypass see their quality of life improve afterward. It's trickier to estimate gains in life expectancy, as it depends on how bad your arteries were, but probably this will have improved as well. You can dwell on the negative, or see that your problem was found before you had a heart attack and that you now have an improved heart.

Another way to work at getting back in the zone is to focus on your perception of how much you control your destiny. Studies show that people who perceive that the cause of their heart problems is out of their control (e.g. my stressful job caused my heart attack) tend to have a harder time returning to normal life.

Research on people who have had heart attacks or surgery shows the strong link between mind and body. Depression triples the risk of heart disease, and heart disease triples the risk of depression. It's helpful to know you are at heightened risk for despair, as this can normalize some of your emotions. It's also important to know the answers often don't come from doctors and hospitals, but rather from a social network of people going through the same thing.

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Mr. Chrétien, you are going to have good days and bad days in the coming weeks, but persistent, significant unhappiness or anxiety is not normal and should be flagged and treated.

I am guessing you have a hectic life and, although you might want to use your bypass surgery as an excuse to drop the stuff you don't truly enjoy, that might not be the way to go. The idea that competitive, Type A personalities have more heart problems has been debunked. If you enjoy being busy and vigorous, then keep going.

One thing you really should consider is a cardiac rehabilitation program. These can be run out of the hospital, the community or your home. The literature shows that formal exercising in a program should be offered at least twice a week for the next eight weeks.

There are statistics: Exercise training has been shown to reduce cardiac death by 31 per cent; stopping smoking has been shown to reduce repeat heart attacks by 50 per cent over the five years following an attack. My patients say they benefit from having a coach and meeting people facing the same problem.

A good program is tailored to anticipate your psychological challenges and reframe your diet and activity, and it also targets your unique risk factors.

What seems more important than formal short-term programming is making changes that can be sustained. Getting your family and your family doctor involved early can really help.

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People who are successful in improving their lifestyles start by making a specific plan (i.e., 'I will walk twice a week with Aline for one hour'). But what seems most crucial is to change the "why." Don't exercise because you should; exercise because it makes you feel better. Stop eating too much because it makes you feel bad; just make sure that you recognize this and hop back on your track when you can.

The English poet Samuel Taylor Coleridge said: "What comes from the heart, goes to the heart." I'll leave this for you to interpret, Mr. Chrétien, but it's time to chart a new course.

Bonne chance and be well.


Dr. Michael Evans is an associate professor and physician at the University of Toronto, where he is leading both the Health Media Lab at the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Patient Self-Management at the Centre for Effective Practice in Family & Community Medicine.

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