I still remember with absolute clarity the sequence of events which occurred when I had a heart attack five years ago. I woke up around midnight with a crushing pain in the centre of my chest which made me ‘feel’ that I could not breathe, along with pain down my left arm and jaw. I managed to pat my sleeping wife on her back and when she woke up, I said quietly (I could not speak louder due the pain and increasing dizziness and confusion I was feeling) that I was having a heart attack, and that she should phone my old medical colleague and good friend Chris Douie, who was working in the same area as we lived and worked in New Zealand back then. Fortunately, he answered his phone and instantly told her to phone the emergency number and get an ambulance to our house, and set off driving to come and help at the same time. Events started becoming confused and I vaguely remember my wife giving me some ibuprofens and B-blocker tablets (which I used for migraines), then Chris and the emergency first responder folk being in my room as I was sweating profusely and telling them I couldn’t breathe and that it may be old asthma I experienced as a child coming back, then next bouncing around in an ambulance on the way to hospital, and finally I ‘came round’ and started improving when I was in the Emergency Room of Waikato Hospital, with an oxygen mask on my mouth, Electrocardiogram (ECG) and IV drips on my chest and in my arm, and a kind Emergency Room Doctor taking bloods and doing an ECG trace recording. Chris told me I had had a heart attack which was obviously evident from an abnormal trace found on the ECG, but was lucky as the bloods had come back showing I had no evident damage to my heart muscle, and that I would need a stent bypass, but should be okay. I was kept in a Cardiac intensive care ward overnight being observed (which meant that I was not in acute danger as if I was they would have operated immediately), and the next afternoon I had a stent inserted into my blocked heart vessel, and I went home the day after that with a bucket full of pills to take, but fine again, and have had no heart problems since then. This incident definitely ‘focussed my mind’ on heart attacks and what causes them, and I was astonished to find how commonly occur, and also how many folks in their late forties and early fifties have them (I was fifty years old when I had mine). In the years that followed, perhaps due to my mind being more alerted to them, I read about a number of prominent internationally successful folks who died of sudden heart attacks, including both of South Africa’s World Cup winning rugby team’s wings from 1995, Chester Williams and James Small, as well as more recently the world-famous cricket player Shane Warne, amongst a host of others. When friends and associates heard about my heart attack, several came forward to say one or several of their family and friends, or indeed themselves, had similarly experienced a heart attack, and I noted during my short two day stay in the Waikato Hospital Cardiac Critical Care Unit, that the place was a bit like Piccadilly Square tube station, with folks in the midst of having heart attacks, waiting pre-operatively for heart vessel repair, or having post-surgery monitoring of their hearts coming in and out seemingly constantly from an always full ward. All this got me thinking of heart attacks and its underlying pathophysiology, ischaemic heart disease, why so many folks suffer from it, and why I was one of those folks who had for a short while been ‘knocking on heaven’s door’ due to a blockage in one of my heart vessels which almost took me away to the after-world, in such an apparently unexpected way.
A heart attack is caused by ischaemic heart disease, in which one or several blood vessels which supply the heart muscle itself becomes progressively more blocked until eventually no blood can flow past the blockage at all, meaning that no oxygen can be transported to the working muscles of the heart (hence ‘ischaemia’ – which is defined as inadequate blood flow), which if occurring for a long enough time, causes the death of the muscle tissue supplied by the specific blocked vessel. It has long been thought that these blockages are the result of the build-up of plaques which are the result of high cholesterol causing damage to the arterial wall, but contemporary thinking is that the artery wall may be damaged by a variety of substances (including high blood sugar) in the blood which stimulate inflammation and then damage at one or several sites in the heart muscle arteries, and this leads to a build-up of plaques as the damaged tissues calcify and harden. Whatever the cause, the lumen (central ‘hole’ of the artery through which blood flows) becomes partially closed, and eventually either a piece of the plaque breaks off and lodges further down the artery closing it completely, or the plaque grows big enough to shut off the artery completely. There are a number of different arteries which supplied the different components of the heart, with the arteries bifurcating (dividing into two) into smaller vessels, or sending off smaller vessels, thus theoretically a blockage ‘further down’ the ‘piping’ of the heart arteries causes lesser damage than if one of the initial ‘big’ arteries near where they enter the heart muscles to supply them is damaged. I was both unlucky and lucky in my particular blockage. I was unlucky for the reason that the blockage was in one of the main big arteries right at the start of where it starts supplying the heart – the Left Anterior Descending Artery – a blockage of which is known as the ‘widow-maker’, as only twelve percent of folks who suffer a blockage there survive, and most folks die before they can get help in any shape or form. I was lucky in that the artery was only ninety five percent blocked, which meant a little trickle of blood kept going through the blockage site, which probably was just enough to save me and my heart muscle from being damaged. I was also lucky in that it was the only vessel that showed any sign of blockage. with the rest of my heart arteries being absolutely fine, hence a single stent insertion at the blockage site was enough to cure the blockage and leave me with a well-functioning heart, hopefully for the rest of my life, however long it is.
As the heart arteries are increasingly narrowed, ‘warning’ symptoms occur, in particular chest pain, also called angina, which increases when exercising or stressed, and which disappears when resting. This pattern of angina is called stable angina, and folks feeling such chest pains when exercising (or at rest), should immediately seek help and visit their GP, who will likely refer them on to a cardiologist (a heart specialist), who will do a number of tests to determine whether there is indeed a blockage and how severe it is. Some cardiologists and countries recommend ‘watch and wait’ for stable angina, but others are less conservative, and would operate immediately dependent on obstruction metrics. When angina switches from being ‘patterned’ to occurring randomly, or while sleeping as happened to me, it is called unstable angina and is a more extreme warning sign. Some folks have no ‘warning’ symptoms at all, and the first time they are aware they have a heart problem is when they have a major heart attack. Classic symptoms of a full-on heart attack include crushing chest pains that can spread down the arm, to the chin or down the back, with difficulty breathing, dizziness and sweating, but one can also have ‘atypical’ symptoms, such as a pain in one’s stomach region, tightness in the chest, indigestion, anxiety and extreme fatigue, nausea and vomiting, or light-headedness. Most of these ‘diffuse’ symptoms are caused due to sympathetic nervous system (fight or flight response) activation, but one should be aware if one has several of these symptoms with no chest pain, they could be caused by heart artery narrowing or actual heart attack. One may think that anyone experiencing such worrying symptoms would rush to see their doctor, but this is not always the case. It’s difficult to determine how many folks have early symptoms of heart artery blockage – notably angina – and don’t respond to them, either due to denial, fear, or lack of knowledge of what it may be a warning sign for and of, because of the fact that so many folks die and therefore cannot give a prior history, or live and are embarrassed by their lack of earlier action in response to their symptoms. Men are particularly more prone than women to not seek help when having symptoms of serious illness, perhaps due to ego or other issues. My own history is a good case in point. A year or two before my heart attack, I started getting chest pains when cycling up big hills on my bike. At first, I thought they were due to chest muscle issues, and then when it was pretty clear (due to their repetitive and striking in the left side of the chest presence) that it was angina, I got scared and refused to go to the doctor, even though I was paradoxically a doctor myself. I remember riding up a hill from the sea promenade in Durban to my good friend James Adrain’s house higher up on the Berea hillside, and my chest pain became particularly sharp and radiated down my left arm, and while I was always much slower than him, I went at an even slower rate than usual to try and control the pain, and was relieved when I got home okay. Like most men I had not gone for a health check for about twenty years prior to suffering a heart attack, even though I used to get massive migraines at least once a week, but when I took up a job in New Zealand after a year of having angina symptoms, I was forced to have a full medical examination as part of getting a work visa, and it was found that I had very high blood pressure, though 24 hour blood pressure monitoring found this was stress related and high in peaks during the day (which probably caused my migraines) and returned to normal at night. Because of this normal night level blood pressure, we got into New Zealand okay, and we enjoyed settling down in that beautiful country. However, the angina pains continued each time I did sport, and then a few weeks before my heart attack, they worsened, suddenly occurring ‘out the blue’ at rest, and becoming much more severe during any exercise. The day before my heart attack, I was driving home and drinking a cup of coffee in the car, and I had what must have been a first heart attack, with severe chest pain which would not go away, sweating, dizziness and all the other symptoms of early heart attack. I just made it home, and like a real fool did not tell my wife and went to lie on my bed and was fortunate that the symptoms slowly went away. Curiously, my dog picked up that something was very wrong, as he normally disliked it when folk came too close to him, but when I was lying breathing rapidly on the bed, he came and sat right up near my head, and put his face next to my ear, in an obvious gesture of concern. Why did I, as a doctor in particular, not respond to all these obvious warning signs. Fear of dying, fear of operations, fear of being out of control, fear of any one of hundreds of things I guess, but I am still astonished at my own reaction, or lack of it, even though I know countless folk do similar, particularly men, and I guess I got very lucky I eventually did respond the next day, and woke up my wife, resulting in the actions described above, which have lead me to spend a normal and happy life for the five years past since the heart attack and stent operation.
The treatment of heart attacks (and angina) is relatively straight-forward. There is drug-therapy – techniques that can dilate the heart vessels and potentially clear out blocked vessels, but more importantly, there have in the last 50 years have been fantastic developments in surgical management of heart attacks which have made some of the greatest ‘jumps’ in treatment of what was previously an incurable event. Up until the 1960’s, if you had a heart attack, nothing could be done for you except to give you medications that would either dilate the heart vessels, or make the heart pump more strongly, but if one had a blocked artery, that artery stayed blocked, which almost always led to the heart muscle supplied by the blocked muscle being damaged and eventually dead, replaced by non-functional fibrotic tissue. This would cause the heart to pump abnormally, either due to damage to heart nerves which led to rhythm defects, or due to mechanical damage to the heart muscle which led to abnormal pump activity and eventually an enlarged heart as the uninvolved heart muscle tried to compensate for the dead muscle tissue, and heart failure ensued where due to a reduced capacity to pump blood ‘forwards’ around the body, it built up in the lungs and lower limbs – causing respiratory breathing difficulties (with coughing up of frothy blood as part of them) and swollen ankles and abdomen. These folk were called cardiac ‘cripples’, and it was only when the first heart transplant occurred in the 1960’s (in Cape Town in the hospital where I trained, of all places rather than the USA or Europe) was there a ‘cure’ for cardiac failure as a result of heart attack, or other heart pathology. But heart transplants were problematic and needed a huge amount of medical skill, intervention and ‘luck’ for folks having it to survive for any prolonged period of time, and an even better curative surgical development was that of Coronary Artery Bypass Grafting, where healthy vessels were ‘harvested’ from other parts of the patient’s body and ‘grafted’ (stitched into) the damaged heart artery on either side of the blockage, which allowed the blood to flow freely to the peripheral heart muscle beyond the blockage. This is still used today when scanning shows that several arteries are blocked at the same time, though for single heart blockages, coronary angioplasty (where the blockage is ‘scraped away’) and stent insertion (where a piece of manufactured graft is put across the previously blocked areas so as to keep the vessel lumen clear and functional) is surgically performed. Astonishingly, this latter surgical intervention is performed with the patient awake, and the surgery is performed in the heart via a cut made in the artery in the lower arm / wrist region, and long ‘bendy’ wires are pushed through up into the heart vessels, with a tip that either clears away the blockage or has the stent on it when it is inserted. I can’t deny this procedure to me was as terrifying as the heart attack itself, and when they cleared out the blockage, obviously for a short period the same heart artery was ‘blocked’ by the surgical wires, and it felt like I was having a heart attack again, with chest pains reminiscent of the heart attack itself. However, I felt fine immediately after the operation, was allowed home the next day, a week later was slowly going for walks, and two weeks later for slow bike rides. In many ways thus angioplasty and stent insertion are thus a miracle cure, and to me it is so sad to think of all those folk over the last few centuries who died as cardiac cripples, as I would have done, due to not having these amazing surgical procedures available at the time of their heart attacks.
Prevention of heart attacks is a challenging issue, but clearly the most important method to enhance survival rates is early diagnosis and treatment. Reducing body weight, eating healthily, performing regular exercise, treating high blood pressure and other disorders of ‘excess’ such as diabetes mellitus, appear to improve one’s chances of not having a heart attack during one’s life. But some very healthy-looking folks, who eat all the right things and exercise regularly still die of heart attacks, and clearly there is a genetic component to it, as well as factors that are still to be discovered. My father was one year older than me when he had a similar heart attack, though while I had only one vessel affected, he had three, and needed a ‘triple heart bypass’ operation to make him healthy again. While neither of us ate as healthily as we would have liked to, and carried too much weight, clearly it is not extreme to say something genetic got passed down from him to me that predisposed me, like him, to having blocked heart arteries at about the same age (in his case, as it goes, he died in his early seventies not from heart disease, but of cancer, so his bypass procedures lasted for twenty years and longer). In a clear genetic causation cohort, folks with familial hypercholesterolemia have very high cholesterol levels, and a high degree of blockages to the heart arteries, and related heart attacks.
Diagnosing acute heart attack is relatively easy with things like the ECG, echocardiography, coronary angiograms (I still have my pre-op and post-op angiograms which my treating cardiologist kindly gave me copies of) and other advanced diagnostic devices. But when folk come to a GP with chest pains, it is quite common for these to be caused by a variety of pathologies, and even anxiety can lead to severe chest pain. I remember a friend from kayaking days who was under a lot of stress had crushing chest pains when getting money out of an ATM and collapsed to the ground sweating and gasping for breath, and went to hospital in an ambulance, only to find there was absolutely nothing wrong with his heart, and with a discharge diagnosis of anxiety-related panic attack. Having said that, prolonged anxiety is a cause of, or at least a predisposing factor for heart attacks, due to the effect it has on blood pressure and the sympathetic nervous system, and in a number of folks these days, the management of a heart attack includes long term anxiety treatment to go with the routine aspirins, statins and other drugs all patients are put on when leaving hospital. In particular in women, there is occasionally no chest pain at all, with the patient rather complaining of shortness of breath as their main symptom of heart attack. Why this is, is currently unclear, but it does make treating early warning signs of heart vessel damage challenging, particularly given the high cost of diagnostic interventions like angiograms, and the time requirements of stress-ECG and even resting ECG testing. It is perhaps better to be over-cautious and check things early is now my mantra, but heck, who am I to say such, when I myself ignored the symptoms I had for so long, and so recklessly, given I had a young family that depended on me for their safekeeping.
One thing that is not often described as part of a heart attack is the psychological effects of having one and surviving. Chris Barnard, who performed the first heart transplant in Groote Schuur Hospital as described above, famously declared that the heart is just a pump. The reason for him saying this is perhaps because in society folk think of the heart as being more than a pump, and he wanted to demystify the heart for ethical reasons so as to allow him to do the first transplants. For many folks, for a long time in the past, the heart was thought to be the centre of a person’s soul. The heart was also thought to be the centre of one’s emotion’s (think ‘heart vs head’ in so many debates on whether to go with one’s emotions or whether to be ‘rational’ when making a decision), and is currently still the symbol for love, peace and all things good. Bravery is also related to the heart – think Richard the Braveheart, or the film Braveheart, where the character William Wallace, played by Mel Gibson, does things which require astonishing feats of courage – as also is love lost, or when someone has lost something or someone dear to them, where folks describe themselves as being ‘broken-hearted’. So, the heart is a ‘big thing’ in even modern society (even if the brain would argue that it should occupy the most exalted human organ space!), and if it physically ‘breaks’, that is a big thing for those it happens to. There is a high incidence of depression and anxiety in those that survive heart attacks, and even cases of post-traumatic stress disorder, as well as survivor guilt. I can’t deny that for several months I was ‘knocked sideways’ by having had a heart attack, particularly as being an old ‘sport-person’ who saw myself as being physically strong and usually always successful in all I tried to do, having a heart attack exposed something that was a ‘weakness’ in me of which I was not previously aware of, or at least that is how it felt for me at the time. For a short period after my heart attack, I experienced a lack of confidence, and a concern for what the future held, and what my longevity would be before the next heart attack. It did not help that for the first time in my life things had not gone well in my job in New Zealand (this may have indeed contributed to having a heart attack), and in the months after my heart attack I had to cut my losses with the work role I had there, and our family made the decision to return to the UK. I was fast moving up the academic leadership ladder and was hoping for my next role to be one leading or in a leadership team at a university (a role for which I felt very equipped for, and still do), but my cardiologist advised me to ‘step down the work ladder’ for a few years until we got control of my blood pressure, and my post-heart attack anxiety had passed. It took me a few years to come ‘right’ completely, as I now feel I am, but I will for life be on aspirin and statins, and medications for my high blood pressure, which is perhaps a good thing, and if I had been for more check-ups with my GP before my heart attack, I would probably have been put on some of these medications far earlier than the time when I had my heart attack. I would like to say that I ate healthily and lived well after my heart attack, but that was another curious thing – for a few years after the heart attack I had something of a ‘who cares what I eat, drink or do’ attitude and did what I felt like doing at the time of me wanting to do it, and it has only been in the last year or two that I have started to ‘feel’ that I have a ‘long term future’ again, and am again counting calories, exercising as much as possible, and trying to cut back on my beloved Jameson’s Irish Whisky. Apparently, this is not an unusual response after having a heart attack or other near-death experience, but it did take me by surprise when I realised this is what I was doing. There is thus a whole lot more we need to know and do for ‘survivors’ of a heart attack, and while the heart may just be pump, as Chris Barnard suggested, it is still thought of as a ‘venerated’ organ in even modern societies, and real damage to it leads to interesting psychological effects, which needs perhaps more research to understand how and why these happen, and how best to treat them.
As I sit in my person cave / garden shed / home office and write this piece, on a very sunny and warm mid-summer day, I hear birds chirping around me, feel a faint breeze cooling me somewhat as I write, and see the beautiful trees and flowers in the garden through the window and open door, and it feels good to be alive. I think of my wonderful family – great wife, two super teenage kids, three faithful hounds and three squawking chickens – all my large number of friends I have made over the years all around the world, and all the great colleagues I have worked with or attended school and university with, all of which make up the rich mosaic of life with which I live daily. I thank the spirits, fate, destiny, or whatever which kept me alive through that harrowing few hours when I thought it all over, and allowed me more years on this great place called earth, living this great and mysterious thing called life. When everything started going dark when I was lying on my bed waiting for the ambulance, bathed in sweat, with a crushing chest pain and struggling to breathe, I did not think of those I hated, or those whom I perceived had done me wrong to date, or of the ongoing feuds with folk that are part and parcel of most folks’ life as in mine. Rather, I though as hard as I could of my family and friends, and all the good things that had happened in my life – kayaking down rivers in South Africa, my medical training years, visiting many places round the world as an academic, the joy of writing, reading and learning thing in my garden shed, and above all, the great simple times I have had with my family and friends. If I had not returned to the light and life after the short period of darkness which occurred in the acute phase of my heart attack, these would have been the last thoughts I would have had before moving on to the next life, or to the nothingness of no existence which may perhaps be our dying fate, as similar thoughts must have been for all the folks who died suddenly of a heart attack, or indeed the last moments of their life before its end in anyone and from any pathology, accident or disease. Recently I have thought, since some time gap has occurred since my heart attack, that it would not be the worst way to die, compared to some of the long, painful deaths such as cancer, or heart failure, or many other pathologies which kill one slowly but surely. A sharp chest pain, a short struggle to breathe, then everything quickly going dark, then the end of everything one has been, or will ever be. Perhaps so. But please, whatever spirit, goblin, deity, holy spirit, or brooding devil which decides these things, can I have a few more years smelling the roses, wondering at the beauty of life, enjoying my friends and family, and hearing my wonderful hounds barking joyously at the gate as I arrive home, before my heart breaks again, not just metaphorically, but physically enough to send me shuffling off this mortal coil into the next world or into the deep, dark abyss of nothingness. Pump, please keep that blood pumping long into the future, and if you do, I promise I will be better to you than I was in the past!