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Iqra Mazhar

Myocardial infarction or cardiac attack requires immediate first aid for heart attack. Realizing the causes of myocardial infarction help prevent an angina attack.

Life after MI

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Life After MI

Madeeha Syed

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Mid-Life Crisis In Men: What Does It Look Like Now?

Overview

Middle-aged individuals tend to go through a period where their identity and self-confidence suffer greatly. This is usually between the ages of 30 to 65 years, when these individuals start having to face their growing age as new physical ailments start popping up.&nbsp;

Some feel they have wasted their life so far and it&rsquo;s &lsquo;too late&rsquo; now. There can be a lot of <a href="https://merisehat.pk/disease/anxiety">anxiety</a>, remorse and sadness associated with it which tends to manifest in drastic decisions that don&rsquo;t really make sense for the kind of person they are.&nbsp;

This phenomenon is termed as midlife crisis. It was first coined in 1965 by Elliot Jacques. It tends to last between three to 10 years in men and two to five years in women. But it can even last only a few months in some individuals.&nbsp; 
&nbsp;

Even though it&rsquo;s mainly associated with ageing, there can be many precipitating factors along with ageing, such as a divorce, work troubles, children maturing and leaving the house, a death of a loved one etc.&nbsp;

This, however, is not a clinical diagnosis and is even thought to be a cultural phenomenon limited to western society. Studies have shown that it might not be as common as it was previously thought to be while there is also little evidence of it in other cultures, such as in Indian and Japanese cultures.&nbsp;

Men tend to go through their midlife crisis at the age of 40 and it is usually preceded by a feeling of inadequacy, being unaccomplished or having to face a crisis such as a parent&rsquo;s or a peer&rsquo;s death. It is also very abundantly portrayed in pop-culture where men are seen to pursue younger women, buying expensive things and being in denial about their receding hairline.&nbsp;

In real life, these clues might not always (mostly never) present.&nbsp; 
&nbsp;

Mid-life Crisis

<ul><li>They tend to turn into mopey individuals with more frequent bouts of sadness requiring alone time to process feelings of loss of control, disappointment and self-pity. Other markers of chronic sadness may also be there such as disturbed sleep, over eating or lack of motivation.&nbsp; </li><li>Other than sadness they might have turbulent moods where one minute they are down and next they are ready to party. These rapidly changing moods are usually the first time you will observe these men on an emotional roller-coaster.&nbsp; </li><li>They tend to become complainers who find fault with everything and have a largely pessimistic view of the world. They will nag everyone around them about the tiniest of things and nothing can ever make them happy. At the root of all this is a lack of satisfaction they tend to feel with their own life and self.&nbsp; </li><li>These men also tend to display poor judgement and might make impulsive decisions or purchases. This can be affected by their turbulent moods as well.&nbsp; </li><li>Some men will inevitably end up using substances to cope and deal with the crisis. This can lead to other poor choices such as gambling.&nbsp; </li><li>These men are also highly irritable in all areas of life. You can find them throwing a tantrum at the office and at home and it’s increasingly obvious that everything tends to frustrate them now.&nbsp; </li><li>Some men might also become withdrawn and give up on their relationships and goals. They stop doing the activities they usually keep themselves busy with and go into hermit mode. There is a sense of boredom with the life they have created for themselves so far and want to run away from it. &nbsp; </li><li>An acute and heightened sense of awareness and self-consciousness about their marital, work, health or economic and social status.&nbsp; </li></ul>These midlife crises usually have a peak after which they end and most people come out on the other side better and changed individuals. They tend to become more comfortable with the new normal and make their peace with it. There will be a re prioritising and refocusing of their perspective but they are ready for the challenge and the next phase of life.&nbsp; So how do these lucky ones navigate something so precarious?&nbsp;

How to Cope

<ul><li>Acknowledge that you have these feelings and they tend to be overwhelming enough to lead you into a crisis.&nbsp; </li><li>Let your partner, colleagues and friends know and reach out for help. Chances are they are also feeling the same way and might have some groundbreaking insight. If nothing, you will at least realise you're not alone in this.&nbsp; </li><li>Accept that it’s completely normal to feel this way and it’s the natural progression of life. It’s just another stage in your growth and it too shall pass.&nbsp; </li><li>Try not to make any big decisions by making sure you consult either your partner or a trusted friend/mentor beforehand. This reduces your chances of making any impulsive decisions you might come to regret later.&nbsp; </li><li>Invest in your physical and mental wellbeing. Join a gym or pick up one physical activity that you enjoy doing and stick with it. Being active also makes you feel better emotionally. Meditation and yoga can also help calm down those recurrent feelings of anxiety.&nbsp; </li><li>Embrace the oncoming changes and appreciate the effect of time on circumstance. Recognise that ageing might not be the worst thing in the world and you can still continue to enjoy life in your older age.&nbsp; </li></ul>

Conclusion

The process of ageing can be daunting and life can seem quite overwhelming at any point in time. Some people tend to suffer through these crises earlier in life, which is happening more and more lately thanks to social media and the impending threat of climate change, food and water shortages and the general upheaval in society.&nbsp;People feel they are not only stuck behind while their peers have progressed and achieved so much more in life, but they also think any effort is futile since the world is ending anyway. This is what we call a ‘quarter life crisis’ which looks almost the same as having a mid-life crisis but in your 20s and 30s.&nbsp;In either scenario, taking a step back and looking at the whole forest instead of the trees might help and calm you down. It’s never too late to make any changes or achieve anything.&nbsp; However, if none of these things work it is likely that you're depressed and can benefit from seeking professional help. Although a midlife crisis is not the same as depression, it can still precipitate it.Recognising that with each stage of life there needs to be a readjustment and you’re more than capable of it can be a huge task. You don’t have to accomplish it alone.&nbsp;Another interesting concept to acknowledge here is that some renowned psychologists have deemed a midlife crisis as the process that leads to self-actualisation, the last need on Maslow’s hierarchy. Integrating all your knowledge, intuition, thoughts and feelings into a newer version of you can be daunting and can rightfully lead to a state of crisis. However, there is hope on the other side of it where your identity achieves a much more solid footing.&nbsp;

Dr. Safia Mehmood

This article or video has been vetted and verified by Meri Sehat’s specialists. It contains citations and research from validated sources.

Unveiling The Impact: How Growing Up With 'Shame' Affects Your Sex Life

The emotional landscape of our early years has a profound impact on our adult lives, particularly when it comes to our sexuality. Growing up with a sense of shame can cast a long shadow over one&#39;s sexual experiences and relationships. In this article, we delve into the intricate ways in which childhood shame affects your sex life. 
&nbsp;

Shame Affects On Sex Life

<ul>
	<li>Understanding Childhood Shame: Childhood <a href="https://merisehat.pk/article/shame-the-most-toxic-emotion">shame</a> often arises from various sources, such as strict upbringing, cultural norms, or traumatic experiences. It can manifest as feelings of unworthiness, guilt, or embarrassment. 
	&nbsp;</li>
	<li>Impact Of Caregiver Attitudes: The attitudes and behaviors of caregivers can significantly influence a child&#39;s sense of shame. Parents who exhibit judgment, criticism, or withholding of affection may inadvertently contribute to the development of shame. 
	&nbsp;</li>
</ul>

Lack Of Education: In many cultures, open and comprehensive sexual education is still lacking. The absence of age-appropriate information can lead to confusion, misinformation, and a sense of shame about one&#39;s body and desires. 
&nbsp;

Religious And Cultural Beliefs: Religious or cultural teachings that label certain sexual behaviors as sinful or immoral can foster feelings of shame around one&#39;s natural desires. 
&nbsp;

Negative Body Image: Childhood shame can lead to negative body image issues, making individuals feel self-conscious about their appearance, particularly in intimate settings. 
&nbsp;

Sexual Dysfunctions: Shame-related body image issues can contribute to sexual dysfunctions, such as erectile dysfunction or difficulty achieving orgasm, due to heightened anxiety and self-criticism. 
&nbsp;

<ul>
	<li>Fear Of Vulnerability: Shame can instill a fear of vulnerability in intimate relationships, making individuals hesitant to open up emotionally or express their desires and needs. 
	&nbsp;</li>
	<li>Inhibition And Avoidance: Those burdened by shame may avoid sexual encounters altogether or engage in sexual activities with a sense of detachment or emotional distance. 
	&nbsp;</li>
</ul>

<ul>
	<li>Substance Abuse And Risky Sexual Behavior: Some individuals may resort to substance abuse or engage in risky sexual behaviors as a way to cope with their shame and numb their emotions. 
	&nbsp;</li>
	<li>Promiscuity Or Avoidance: Shame can lead to polarized behaviors, with some individuals becoming promiscuous to seek validation and others avoiding sexual encounters altogether. 
	&nbsp;</li>
</ul>

<ul>
	<li>Therapy And Counseling: Seeking therapy or counseling can be a powerful step towards healing from childhood shame. Professional guidance can help individuals identify and address the root causes of their shame. 
	&nbsp;</li>
	<li>Self-Acceptance And Self-Compassion: Cultivating self-acceptance and self-compassion is essential. Learning to embrace one&#39;s sexuality without judgment or shame is a transformative journey. 
	&nbsp;</li>
</ul>

<ul>
	<li>Open Communication: Healthy relationships are built on open and honest communication. Learning to express desires, boundaries, and concerns with a partner can create a safe and supportive environment. 
	&nbsp;</li>
	<li>Mindful Intimacy: Practicing mindful intimacy, where partners focus on the present moment and emotional connection, can help individuals overcome the barriers created by childhood shame. 
	&nbsp;</li>
</ul>

Bottom Line

Childhood shame can cast a long shadow over one&#39;s sex life, but it&#39;s important to remember that healing and transformation are possible. By addressing the root causes of shame, seeking professional help when needed, and cultivating self-acceptance, individuals can unshackle themselves from the chains of shame and build healthier, more fulfilling sexual lives and relationships.

Rukhsana Rizwan

How To Find Meaning And Purpose In Life

In his book Love&rsquo;s Executioner, Irvin D. Yalom suggests that life is inherently meaningless, and the search for meaning must be conducted obliquely. This means that meaning arises from meaningful activity rather than actively searching for it. Here&#39;s how to cultivate a sense of purpose in your life. 
&nbsp;

purpose of your life

<h5>Connect With Yourself</h5>

To find a sense of purpose, it&#39;s important to connect with yourself. Start by connecting with your values and defining what brings you joy. These can be your <a href="https://merisehat.pk/article/the-role-of-hobbies-and-interests-in-maintaining-a-fulfilling-retirement">hobbies</a>, passions, or ways of connecting with the world. Become aware of your own talents and skills, and identify what areas of life you excel in.

Journaling and meditation can be powerful tools for elevating this practice. Writing can be a way of having a conversation with yourself and keeping a record. Exercises like this can bring your awareness to aspects of yourself you may not have been consciously aware of. 
&nbsp;

<h5>Ask For Feedback</h5>

Ask the people around you for feedback to get an honest picture of where your talents lie and what areas you could work on better. You can also use this feedback to cultivate a growth mindset and aim to do a little better today than you did yesterday. 
&nbsp;

<h5>Foster Community</h5>

Foster a relationship with your community by surrounding yourself with people who inspire you, people you can learn from, and those who are driven by purpose. Being around these individuals may help you discover new avenues to explore your own purpose. 
&nbsp;

<h5>Cultivate Altruism</h5>

Cultivate a sense of altruism by exploring different ways to make the world easier to live in for those around you and people who are less privileged than you. Volunteer at an animal shelter, raise funds for charity organizations, or offer your professional services pro bono. Diversify the ways in which you practice altruism to find at least one cause you&#39;re passionate about and can contribute to. 
&nbsp;

Remember that your purpose is not a destination or an end-goal to work towards. Having a sense of purpose is about living your life with intention, an intention that will shift and grow as you do and help you choose how you want to live your life.

By actively engaging in meaningful actions and interactions, we can give our lives a sense of purpose and create a meaningful life for ourselves. Cultivating a sense of purpose can contribute to our mental and physical well-being, and even help us live longer. However, it&#39;s important to remember that our purpose is not necessarily a divinely ordained destiny but rather a shifting and evolving intention that is rooted in our unique personalities, experiences, and inherited characteristics.

&nbsp;

To discover our purpose, we can start by connecting with ourselves, exploring our values, passions, and talents. Journaling, meditating, and seeking feedback from friends and family can all be effective ways to gain insight into ourselves. Additionally, fostering relationships with those who inspire us, diversifying our altruistic efforts, and surrounding ourselves with a supportive community can help us discover new avenues to explore our own purpose.

Ultimately, finding a sense of purpose is about living our lives with intention, a purpose that will evolve and shift as we grow and change. By focusing on the journey rather than a specific destination, we can create a life of meaning and purpose that is uniquely our own. 
&nbsp;

Ayesha Binte Rashid

Introduction

A heart attack is a scary thought. But did you know a lot of people are able to recover from their first heart attack and resume their regular lives, enjoying many more years of productive activity? It goes without saying that a heart attack necessitates adjusting some aspects of your life. Depending on the extent of the damage to your heart, your doctor will advise drugs and lifestyle adjustments. 
&nbsp;

Following a heart attack, you&#39;ll be required to stay at the hospital for 2-7 days. This period will be prolonged if you experience difficulties in recovery or if you&#39;ve undergone other complicated surgeries, including bypass surgery. 
&nbsp;

Depending on your health, doctors initially recommend bed rest but at times, they might also allow few activities. For example, you could be well on your way to recovery within a few weeks, or you may need 2-3 months before you can resume all of your regular activities, including employment. 
&nbsp;

In the United States, about 865,000 people experience a<a href="https://merisehat.pk/disease/myocardial-infarction"> myocardial infarction</a> or heart attack annually. The projected total cost of heart disease, including direct as well as indirect costs, in 2007 was $277.1 billion. Cardiac rehabilitation, a crucial part of post-heart attack recovery therapy, promotes healthy lifestyles, lowers the risk of mortality and disability, and encourages heart attack sufferers to lead active lives<a href="#accordion">[1]</a>. 
&nbsp;

If you or a loved one has suffered a heart attack, heart failure, or any heart condition that warranted surgery or medical attention, cardiac rehabilitation is crucial.&nbsp; This is a monitored program which consists of the following: 
&nbsp;

<ul>
	<li>Physical exercise, such as cycling that improves your cardiovascular and muscular fitness</li>
	<li>Education with respect to living a healthy lifestyle, eating well, taking medications as directed, and not smoking</li>
	<li>Support in terms of counseling the patient and familiarizing them with methods of stress reduction and mental health enhancement 
	&nbsp;</li>
</ul>

You might receive assistance from a group of people during cardiac rehabilitation, including your medical team, fitness experts, nutritionists, physiotherapists, and counselors. 
&nbsp;

Understanding the Life after Myocardial Infarction(MI)

There are numerous short and long-term health advantages of cardiac rehabilitation, including: 
&nbsp;

<ul>
	<li>Recovering from a heart attack by fortifying your body and heart</li>
	<li>Alleviating heart disease symptoms, such as chest pain</li>
	<li>Forming better habits, such as increasing your level of exercise, giving up smoking, and adopting a heart-healthy diet&nbsp;</li>
	<li>Having a nutritionist or dietician monitor your intake of foods &ndash; fewer items with bad fats and more items that are rich in fiber, vitamins, and minerals</li>
	<li>Lowering stress and anxiety&nbsp;</li>
	<li>Coping with depression&nbsp;</li>
	<li>Increasing your strength and energy making everyday tasks easier, such as carrying groceries and climbing stairs</li>
	<li>Motivating you to take your prescribed medications in order to reduce your risk of developing future heart issues</li>
	<li>Reducing the risk of heart disease-related sickness and mortality&nbsp;</li>
	<li>Studies have shown that cardiac rehabilitation reduces your risk of dying by roughly 35% in 5 years following a heart attack or bypass surgery 
	&nbsp;</li>
</ul>

<h5> 
1.&nbsp;Make Prevention Your First Concern</h5>

While recovery from a first heart attack is possible so much so that you can go on to lead long, fulfilling lives, it&rsquo;s also a fact that 20% of people aged 45 and older have another heart attack within 5 years of their first. So, at the moment, your priority should be to avoid another heart attack. 
&nbsp;

<ul>
	<li>Follow the directions on your prescriptions and do not skip your medications. Some drugs significantly reduce the risk of having another cardiac episode.&nbsp;</li>
	<li>Attend your follow-up appointments. Doing so will enable your medical professionals to monitor your condition and recovery. Also, if you take it seriously and actually prepare for your appointment, then you will definitely be able to take full advantage of it.</li>
	<li>Engage in cardiac rehabilitation. Cardiac rehabilitation is a program under the direction of a doctor that helps in your recovery following a heart attack. When you were discharged from the hospital, you should have received a referral to cardiac rehab; if not, talk to your doctor.&nbsp; 
	&nbsp;</li>
</ul>

<h5>2. Get Assistance</h5>

After a heart attack, it&#39;s common to feel insecure, worried, afraid, or puzzled. You can deal with it by seeking assistance from family members or those who have also had a heart attack. You can get in touch with other heart attack survivors and caregivers through different support networks. 
&nbsp;

<h5>3. Control Your Risk Factors</h5>

It&#39;s critical to control risk factors after a heart attack by taking medication, eating a healthy diet, giving up smoking, and exercising. Risk factors, like high blood sugar, high blood pressure, and <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes </a>would make you prone to another heart attack. 
&nbsp;

<h5>4. Reduce Your Alcohol Intake</h5>

Alcohol consumption can increase the risk of heart disease, cancer, stroke, and other disorders, as well as raise blood pressure. It can cause irregular heartbeats and elevated triglyceride levels. <a href="http://merisehat.pk/disease/obesity">Obesity</a>, suicide, alcohol addiction, and accidents are all caused by excessive alcohol use. 
&nbsp;

<h5>5. Manage Diabetes&nbsp;</h5>

At least 68% of patients with diabetes mellitus who are over 65 years old pass away from hypertension, whereas 16% die from strokes. The risk of cardiovascular disease for someone with diabetes significantly increases when you consider additional risk factors, such as high blood pressure, smoking, high cholesterol, obesity, and a lack of daily exercise and activity.&nbsp; 
&nbsp;

<h5>6. Exercise Regularly</h5>

A heart-healthy lifestyle and recovering from a heart attack depends heavily on exercise. When participating in cardiac rehab, your progress will be tracked over time. Any symptoms and changes in heart rhythm while exercising will be observed and reported to your doctor.&nbsp; 
&nbsp;

It will also help determine your functional capacity following a heart attack. This refers to your ability to perform daily tasks that call for physical effort. The aim initially will be to raise this effort by 20%. You&#39;ll get on a treadmill, working out for at least 30 minutes a day, most days of the week during your cardiac rehab period, so medical professionals can see your functional capacity<a href="#accordion">[2]</a>.&nbsp;&nbsp; 
&nbsp;

<h5>7. Consume Heart-Healthy Foods</h5>

It is crucial to make dietary adjustments to lower cholesterol and saturated fat intake as well as salt intake. The Mediterranean Diet, which is regarded as the healthiest eating pattern, encourages: 
&nbsp;

<ul>
	<li>Eating primarily fruits, grains, vegetables, olive oil, and nuts&nbsp;</li>
	<li>Limiting red and processed meats while including some fish and chicken</li>
	<li>Limiting dairy and sugar intake 
	&nbsp;</li>
</ul>

<h5>8. Reduce Blood Pressure</h5>

Cardiovascular disease and persistent high blood pressure are strongly related. However, you can lower your blood pressure with weight loss, exercise, less salt intake, and prescription drugs. 
&nbsp;

The stress on the heart and the chance of having a heart attack or stroke in the future can both be decreased by lowering your blood pressure to less than 130/80 mmHg. 
&nbsp;

<h5>9. Acquire A Healthy Weight</h5>

You may be able to shed weight and improve your heart health by eating better and exercising more.

The risk of cardiovascular events may be decreased, and quality of life may be increased with weight loss to a BMI target of &lt; 25 kg/m2. 
&nbsp;

<h5>10. Don&rsquo;t Ignore Mental Health&nbsp;</h5>

Most people don&#39;t realize how much damage a heart attack can inflict on their mental health. Patients and their families face a lot of challenges.

It is especially important to look after your mental health after a heart attack because studies suggest that people with heart disease are more inclined to experience depression than people who don&#39;t have it. 
&nbsp;

Don&#39;t disregard changes in your mood, and keep an eye out for depressive symptoms, like

<ul>
	<li>Sadness</li>
	<li>Weariness and exhaustion</li>
	<li>A drop in enjoyment or enthusiasm for activities</li>
</ul>

Contact your healthcare practitioner to talk about these issues if you have them. 
&nbsp;

<h5>11. Maintain Optimal Blood Cholesterol Levels</h5>

Having fat clogged up in your arteries is a recipe for disaster. In the end, it might result in a heart attack or stroke. Exercise and reduce your consumption of saturated, trans fat, and cholesterol.&nbsp; 
&nbsp;

Medication may be the solution if diet and exercise by themselves are insufficient to lower those values. Take it precisely as your doctor has instructed. The breakdown of where those numbers should be is as follows: 
&nbsp;

Overall Cholesterol

Your total cholesterol score= HDL + LDL + 20% of your triglyceride level 
&nbsp;

<ul>
	<li>Low-Density Lipoprotein (LDL)</li>
</ul>

This type of cholesterol is known as the &quot;bad&quot; cholesterol. Your heart health benefits if you have low LDL cholesterol levels.&nbsp;

However, the American Heart Association&#39;s most recent recommendations state that your LDL cholesterol level should no longer be the primary determinant of treatment to avoid heart attack and stroke. 
&nbsp;

The recommendations state that people using statins are no longer required to lower their LDL cholesterol levels to a predetermined target level. LDL cholesterol might increase due to lifestyle factors, such as a diet heavy in trans and saturated fats. 
&nbsp;

<ul>
	<li>High-Density Lipoprotein (HDL)</li>
</ul>

HDL cholesterol is described as &quot;good&quot; cholesterol and, generally, higher levels are preferred for this type. The likelihood of developing heart disease is increased if you have low HDL cholesterol.&nbsp; 
&nbsp;

A reduced HDL cholesterol level is typically present in people with high blood triglycerides. Lower HDL cholesterol can be caused by genetic factors, type 2 diabetes, smoking, being overweight, and inactivity. 
&nbsp;

<ul>
	<li>Triglycerides</li>
</ul>

The most prevalent form of fat in the body is triglyceride. Age and sex affect normal triglyceride levels differently. Atherosclerosis, which increases the risk for heart attack and stroke due to the formation of fatty deposits in artery walls, is related to high triglyceride levels in combination with low HDL cholesterol or high LDL cholesterol. 
&nbsp;

<h5>12. Relieve Stress&nbsp;</h5>

You will learn stress-reduction tactics in cardiac rehab to boost your mental and emotional health as well as lower your risk of having another heart attack.&nbsp;

You&#39;ll discover methods for altering your behavior, such as how to breathe and how to control your stress and anger. Multiple studies demonstrate that those who participate in cardiac rehab recover from a heart attack more quickly than those who do not. 
&nbsp;

<h5>13. Quit Smoking</h5>

The truth is that it&#39;s imperative to stop smoking following a heart attack. If you need assistance quitting the habit, go to your doctor.

Smokers have a fourfold increased risk of dying from heart disease compared to non-smokers, and studies have shown that those who pick up the habit again after having a heart attack have a threefold increased risk of passing away. 
&nbsp;

<h5>14. Know When To Seek Medical Attention&nbsp;</h5>

Your first heart attack means you might get another one in future. Therefore, it&rsquo;s your responsibility to take care of your body and report any heart attack symptoms as soon as they manifest, no matter how insignificant they seem.&nbsp; 
&nbsp;

If you have any of the following symptoms, get emergency medical help right away:

<ul>
	<li>Any episode of sudden, severe tiredness</li>
	<li>Chest discomfort&nbsp;</li>
	<li>Pain in one arm or both arms</li>
	<li>Abnormally fast or erratic heartbeat</li>
	<li>Sweating without exertion&nbsp;</li>
	<li>Queasy feeling</li>
	<li>Swelling in one or both legs&nbsp;</li>
	<li>Breathing difficulties 
	&nbsp;</li>
</ul>

Your doctor probably gave you a lot of information and recommendations after your heart attack therapy. You might attempt to make sense of what transpired after some time has passed. At times, the path to recovery would seem challenging. There would be doubts, worries, and even panic routinely. Amidst all this, you should remember that a heart attack should not be taken as a warning to abandon life. Rather, the event signifies that you should prioritize your physical and mental health.

[1] Receipt of outpatient cardiac rehabilitation among heart attack survivors--United  States, 2005. MMWR Morb Mortal Wkly Rep. 2008 Feb;57(4):89–94.

[2] Arena R, Cahalin LP, Borghi-Silva A, Phillips SA. Improving functional capacity in heart failure: the need for a multifaceted  approach. Curr Opin Cardiol. 2014 Sep;29(5):467–74.