Jim

Angina

Heart attack

High blood pressure

Stalked by a silent killer

Jim thought heart attacks always came with the kind of crushing pain seen on TV. So he was surprised to discover he’d had a heart attack without knowing it. In 2004 he wrote this story about his experience of heart disease.

It seems that people’s experience of heart disease can be as varied as the lifestyle of your “typical kiwi bloke”. My own heart attack was quite different to many I had read about previously.

I was in my late forties when I was first diagnosed with heart disease. At the time I was working as a freelance writer. I had been a competitive runner from my teens to my mid thirties, when family pressures lead to my retirement from competition but I continued to have an active outdoors lifestyle.

I have never smoked, am not overweight, but have a family history of heart disease. My father had high blood pressure as far back as I can remember. He smoked, played golf, and had a stressful job. He suffered a number of heart attacks and strokes from his mid forties onward, and lived to 73. I have been watching my salt intake since the 1970s, and have never liked butter, or any fatty foods.

Silent heart attack

A check-up in 1996 identified high blood pressure. I was given a thorough examination, and this uncovered heart damage from a ‘silent heart attack’. To this day I still have no recollection of this event, but it had left its mark on my heart, and ECG (electrocardiograph).

Interestingly, when I mentioned this to my mother she told me that the same thing had happened to my father when he was in his forties.

I was immediately prescribed tablets for the hypertension, and given a stress test. A stress test is carried out on a treadmill. I was connected to an ECG, and the treadmill was set off at an easy pace. The pace increased every three minutes until I couldn’t go on. I lasted 15 minutes with no additional signs of angina or any other heart abnormalities.

I was prescribed medication to decrease my blood pressure, decrease the risk of blood clots, and lower my cholesterol, and I was to have quarterly check-ups. Although my cholesterol was below average, it was above the recommended level for someone accumulating risk factors like I was. I was told the damage to my heart should not stop me doing anything at all.

Following this, I set out to increase my fitness. Although I had been a bit of a fitness nut in my younger years, I have never really enjoyed exercise for the sake of getting fitter. It had always been for the enjoyment of the experience, or to compete.

Now I didn’t feel I had anything to prove in competition any more, so my exercise programme needed an element of fun – supplied by rock ‘n’ roll dancing, and achievable targets – supplied by a range of long distance cycling and walking events and regular mountain bike rides.

Second heart attack

Early in November 2003, a week after my quarterly check-up, I was feeling a bit unwell. I had a half days work on the Friday, but really couldn’t be bothered finishing it off – not my usual self at all.

The next morning I woke up feeling a little stiff across my left shoulder – must have slept in a funny position – there was a band of gentle pressure under my left pectoral (chest) muscle, and over the bottom rib. Not pain, just a gentle pressure like the weight of a blanket... 

I got up, sure that with a little movement it would wear off, and I got on with my day – a coat of varnish on the door I was renovating, and finishing off Friday’s job.

By lunchtime the feeling was still there. I wasn’t concerned – it still didn’t hurt – but I knew that one day my heart trouble was going to reappear. In fact I had visited emergency doctors with false alarms three times over the six years since the discovery of the “silent” attack.

So it was off to the after-hours medical clinic. I didn’t get past the receptionist – her instructions were, “Go to the hospital now.”

Unstable angina

In Accident and Emergency, I was given blood tests and had an ECG. Once my file was found, and the irregularity of my ECG sorted out, it was confirmed that this feeling was angina.

I was treated for angina, put in the Intensive Care Unit (ICU) for observation, and instructed on the use of an angina spray.

Next day, I was moved to the medical ward with the recommendation that I have another stress test on Monday. I lasted 10 minutes on that stress test, with no sign of any angina. I heard the doctor mumble, “He has angina at rest, and goes like this under stress!”, and to me, at the end of the ninth minute, “Can you do another minute?”

The report from the doctor was, “There is something going on. It was OK, but there were minor ECG changes right at the end when you were under the most stress. I would like to have you checked out with an angiogram on Wednesday. Can you stay here until then?”

Tuesday, while lying on a hospital bed doing no more than reading, another angina attack. No more painful than before – probably less, as I was becoming sensitive to them by now. The spray didn’t work. I was put on slow release nitrates, which cleared the angina but introduced me to a new form of headache.

I was told I had “unstable angina” – angina which is unpredictable and often occurs when resting.

Angiogram reveals need for heart surgery

Wednesday was angiogram day. They put a catheter into my groin, and squirted dye into the blood vessels of my heart, while x-raying them to see where the blockages were.

The results from this brought home the gravity of my predicament. The damage was far too extensive for angioplasty and the placement of stents. I was to be put on the waiting list for Coronary Artery Bypass Graft (CABG, or ‘cabbage’) surgery in Wellington hospital.

I was sent home Wednesday night to await the call to Wellington, full of long-acting nitrates and anticoagulants, and strict instructions to ring an ambulance if the angina spray failed to work in 10 to 15 minutes.

I felt pretty incapacitated at this point. The headaches were reducing, being really severe for only three to four hours a day, but the medication left me feeling quite lethargic. We checked out our medical insurance, and started the process of having the operation done privately rather than wait for the inevitably slow process of being on a waiting list.

Saturday night after dinner, I settled onto the couch to watch one of the All Black World Cup games, and once again the angina appeared while I was totally relaxed.

Two squirts of my spray and a call to the ambulance later, I was stabilised, and whisked back to the ICU for the weekend.

Heart surgery in Wellington

On Monday I was transferred to the medical ward and informed that I had been accepted onto the waiting list at Wellington as an urgent case. The operation was scheduled for Thursday, so I would probably be transferred from Nelson by air ambulance on Wednesday. My wife, Adrienne, would be able to accompany me but they couldn’t confirm a flight time yet.

Confirmation came at 10.30am on Wednesday. We were to leave the ward at 11.00am, could Adrienne be here in half an hour?

This was our first introduction to ‘just-in-time management’ in the public health system. We found it a bit disconcerting, but the system is focussed on using scarce resources on the most urgent situation, and thus not allocating those resources until it is unlikely they will be needed for a more urgent case. Adrienne made it, and we were off on the most perfect of days.

The view of Nelson from the bed of an air ambulance on a perfect sunny day is one that makes you glad to be alive and in this part of the world.

The Wellington Hospital thoracic surgery ward was chaotic. Full with only the most urgent cases, with all resources and staff focussed on moving them on.

The rest of the day was spent on checks and briefings – any sign of varicose veins on my legs, where the donor vessels would come from? How were the arteries in my lower arms? If they used one of them would the hand on the affected side be OK with the remaining blood supply?

Four spots in my coronary blood supply had been identified as requiring additional blood, and the plan was made to use the internal mammary artery for one, and a piece of an arm artery for another, and two pieces of vein from my legs for the other two. (The final operation used the internal mammary artery for two grafts, and pieces of vein for the other two).

Accordingly, I had both arms and legs shaved, as well as my chest from navel to Adams apple. A visit from a physio and a detailed lesson on coughing properly finished the briefing.

Heart surgery delayed

Next morning I was ready to go, but surgery was cancelled. An emergency during the night, and there was no longer space in the ICU for me. My operation had been transferred to Monday. Resources are allocated to the most urgent at the time, remember.

The man in the bed opposite was up and about – walking slowly, and clutching a folded towel to his chest, but showering himself, dressing in real clothes and preparing to be picked up by his wife and taken home on the afternoon of the fifth day after surgery. That looked good for me! Could be home next Friday!

Friday saw the return of my angina. About 11am, the gentle feeling of tightness was back. A squirt of spray and it was gone, only to return after lunch. Two squirts and it was still there, so I called the staff. Instant consternation – here the rules are different – any sign of angina should be reported at once.

This attack was severe – still a very gentle feeling of no more than the gentle pressure of a pyjama top resting on my chest, but it would not retreat readily under the full onslaught of modern anti-angina drugs through an IV line.

The heart attack that had been stalking me for the last fortnight was still there, and ready to go. By late afternoon it was in retreat, and I was in the coronary care unit (CCU), under the care of another surgeon, with my surgery rescheduled for first thing in the morning.

The pattern in the CCU was one I was becoming used to: a cheery welcome, efficient settling down and connection to an ECG, followed by silence while they digested it, then a conference over my notes and the cheery smile would return with the comment that my ECG was normal “for you”.

On questioning I learned that my earlier heart attack had left me with a bundle branch block. My heart’s pacemaker system is a little slow on the right side because of the damage of years ago.

Reality sets in

It was this night that my situation really got through to me. I was a ‘typical kiwi bloke’ active, with a body that did what I wanted it to. I had had my share of falls, dislocations, sprains and pulled muscles but had always left the minor ones to my regenerative system and sought medical attention only for ones that didn’t seem to be ‘coming right’ on their own or if it really hurt a lot.

This current event had had a surreal feeling up to now. It had all happened so fast, (just under a fortnight so far) and I was being carried along by the system, making no decisions for myself at all.

Initially my feeling had been that there really was nothing wrong – I was just getting things checked out. The angiogram had uncovered a plumbing problem, and it was going to be fixed – no worries, I can handle that, previous operations to fix stuff had always worked well.

This night was different. These guys, obviously very knowledgeable about people with cardiac problems, didn’t think I would last until Monday on my own. In fact, they were concerned that something serious was going to happen to me before morning.

But I was OK. The gentle pressure on my chest had never felt at all life threatening. Where was the “sudden, severe, crushing chest pain radiating into the arms” I had read about so often?

I had read somewhere that this was often accompanied with feelings of foreboding and doom. I didn’t feel that, but I was starting to feel frightened. There was something really dangerous out there and it was stalking me. I couldn’t see it, and it was unlikely to wake me if it attacked while I slept. I was completely dependant on the nursing staff watching for it on the monitors. I was suddenly way outside my comfort zone.

“I felt like a truck had hit me”

Saturday went well. I woke in the late afternoon in the ICU – Adrienne and Rosie, my younger daughter, were there. I felt like a truck had hit me, as I expected, but my every need was being met before it arose by an extremely competent nurse.

ICUs are very busy places, full of equipment capable of supporting or replacing every bodily function, and I was connected to most of them. The process now was, as my body woke up from the seven hours under anaesthetic, and took control of itself again, the piece of equipment supporting that function would be unplugged.

As soon as I had picked up the more critical functions, I would be transferred back to the ‘step-down unit’ of the thoracic surgery ward (Sunday), where I would be until I was no longer connected to anything, and I would be transferred to the ward itself (Monday).

Back in the ward I was under the scrutiny of those waiting for their operations, and their keen interest in my progress. I remained there until I reached the ward’s standard for self sufficiency – all toileting functions restored (with laxative and diuretic help), able to shower and dress myself walk to the stairs, and up two flights and back.

I met these standards lunchtime Wednesday, and flew back to Nelson that afternoon, barely able to walk, careful to cough only when it was really necessary and in the manner taught by the physiotherapist.

Recovery from heart surgery

Recovery from that level of surgery is slow, but progressive with the repair of bones, muscles and nerves taking their time. Although these events occurred almost a year ago now, the effects are still with me: a numb patch on my chest; an odd feeling in the chest muscles when I move my arms a certain way, or breathe heavily; and a real determination not to fall off my mountain bike.

Apart from that, life is very much returning to normal – working full time, and enjoying rock ‘n’ roll dancing, mountain biking and walking.

Has the experience changed my life? It’s really hard to say. I have always been aware that – due to family history – I was a prime candidate for a heart attack, so have never smoked, tried to eat a low-fat, low-salt diet, and have enjoyed an active life. Now I am a little more obsessive about salt and fat levels and have added sugar and other high Glycaemic Index foods to the list.

My fitness is slowly coming back. I spend an evening a week at the gym to strengthen my chest and back muscles as well as spending about 30 to 60 minutes in vigorous exercise each day.

The other effects are mental. Such an experience focuses the mind, and creates a determination not to wait for retirement to do the things I want to do. We have also joined the ‘Friends of St John’ and have thus paid for a year’s worth of ambulance trips in advance. I am not going to be macho and wait until things become serious before I get them checked out ever again.

Update 2017

I am retired now, we are still dancing, and doing lots of biking. Since retirement I have completed The Rimutaka Trail, Rainbow Road, and Dun Mountain trail.

Since I wrote this article not a lot has changed on the cardiac front. The numb feeling on parts of my chest have disappeared, but I still get funny feelings especially after a day of upper body work. I am aware that the ‘average’ life of vein grafts is 15 years, and mine are now 14 years old.

That combination of things has seen me in an ambulance a number of times wondering, “Is this the return of my angina?” or “If one of the vein grafts starts blocking up, what would it feel like? I would really like to catch it in time for a stent to fix it.”

I’ve stuck by the motto “better safe than sorry” – and it’s a motto that has served me well.

Shared December 2017