No such thing as a “small” heart attack

by Carolyn Thomas  @HeartSisters

As I have written here earlier: 

“There are few life events more stressful, in my considered opinion, than surviving a heart attack.

“Not only is the actual cardiac event a traumatic and overwhelming experience in itself, but what very few cardiologists tell us before they boot us out the hospital door is how debilitating the day-to-day angst about every subsequent bubble and twinge can actually be. 

“I can recall, for example, feeling virtually paralyzed with fear over unexpected chest pains following my heart attack (symptoms, I later learned from my cardiac nurse, that are often called stretch pain – common in coronary arteries with recently implanted coronary stents).  These frightening symptoms can last for weeks.”

Yet even among those survivors who don’t experience distressing symptoms like these, the severe emotional blow that lingers after a cardiac event can be shockingly debilitating to many.

That’s why there is actually no such thing in reality as a “small” heart attack.

Now, for a straightforward clinical example of rating a cardiac event, California cardiologist Dr. Daniel Lee Kulick illustrates how doctors might assess the severity of a heart attack – usually to help predict how much time is required for the dead heart muscle that’s been deprived of oxygenated blood flow during the attack to complete its scarring process – or simply how much time this patient should be off work:

  “After a small heart attack (little damage to heart muscle), patients usually can resume normal activities after two weeks. A moderate heart attack (moderate damage to heart muscle) requires limited, gradually increasing activity for up to four weeks, while a large heart attack (much damage to heart muscle) may result in a recovery period of six weeks or longer.”

This fairly straightforward and dispassionate prognostication is basically a patient’s back-to-work timeline, but it misses the boat entirely.

While focusing on long-held algorithms of diagnostic scans and test score numbers, Dr. Kulick’s summary fails to acknowledge the profound psychosocial impact of surviving a heart attack that is independent of the severity of the cardiac event.

A heart attack is simply so unlike any other health issue.

Briefly, physicians assess the seriousness of any heart attack based on the amount of heart muscle that is damaged by a sudden lack of blood flow to that muscle – either due to a blockage or spasm in the coronary artery feeding that muscle. If you’re a physician, there are two main types of heart attacks you have been taught to look for:  STEMI and NSTEMI (or Non-STEMI). 

By the way, a growing number of cardiologists support both revised names and definitions for heart attacks; read more about why U.S. cardiologists like Dr. Stephen Smith, Dr. Pendrell Meyers, Dr. Ken Grauer and many others are now supporting this movement here

But until those revisions happen (things move glacially slowly in cardiology!) here’s how these two cardiac events are currently described:

STEMI means an ST-segment elevation myocardial infarction in which a coronary artery is completely blocked and part of the heart muscle is left without an oxygenated blood supply. “ST segment elevation” refers to a heart rate pattern that shows up on an electrocardiogram (EKG).

NSTEMI (Non-ST segment elevation myocardial infarction) shows a depressed ST segment on an EKG. It is generally thought to be a less serious heart attack.

IMPORTANT NOTE:  According to Emory University researchers Dr. Tina Varghese (internal medicine) and Dr. Nanette Wenger (cardiology), women diagnosed with NSTEMI are less likely than their male counterparts to receive guideline-recommended treatments and interventions:

“One evident contributor to this gender disparity is the predominance of middle-aged men in cardiac studies on cardiovascular disease; women are significantly under-represented in cardiac research. The 5-year risk of death from NSTEMI for women is 42% (versus 29% in men).”

The specific location of a coronary artery blockage, the length of time that blood flow is blocked, and the amount of heart muscle damage that occurs because of that reduced blood flow all help to determine the type of heart attack that physicians will describe.

But both this specific focus on accurately interpreting an ECG reading and the lack of medical attention to the profound psychological impact of any cardiac event can mean significant factors are often overlooked.  Speaking of ECGs: not every physician can accurately interpret these diagnostic tools, nor are all ECG electrodes correctly placed on the body. See also: Were Your 12-lead ECG Electrodes Placed Where They Should Be?

In fact, even among correctly placed ECG leads, only about half of all ECG results are accurately interpreted. As Yale cardiologist Dr. Harlan Krumholz wrote in the New England Journal of Medicine’s Journal Watch

“This sobering study reports low accuracy in the interpretation of electrocardiograms across a wide range of groups. Cardiologists did best, but still had a high prevalence of errors. And training had only a modest effect in the studies.”

That’s sobering indeed, especially if you’re a heart patient like me whose heart attack was misdiagnosed as acid reflux after my ECG was interpreted by an Emergency Department physician as “normal”.  That was right before he sent me home, feeling horribly embarrassed because I’d just made a fuss over“nothing”.  

Dr. Gilles Dupuis of the Université du Québec and the Montreal Heart Institute reported in the Canadian Journal of Cardiology that post-traumatic stress disorder following heart attack is an under-diagnosed and often unrecognized phenomenon that can actually put survivors at risk of another attack.

There are, of course, individual differences in recovery depending on a broad range of factors.

And recuperation from a heart attack or any other traumatic cardiac condition cannot be compared to that experienced in the world of acute medicine where recovery from surgery or other treatments can often be realistically plotted, barring unforeseen complications.

When I went through three months of cardiac rehabilitation, a man in our group bragged to the rest of us one day that he was now golfing three times a week.  I felt both impressed and dismayed. He had undergone triple bypass surgery about the same time as my own heart attack happened. I had not had bypass surgery, yet was barely able to function from day to day.

How could he possibly be happily playing golf already?

One of the differences was that he had NOT actually experienced a myocardial infarction (heart attack) that damaged his heart muscle;  his surgery had been done as a scheduled, non-emergency, elective procedure related to the stable angina symptoms he’d reported to his doctor, and the subsequent cardiac tests that showed three blockages in his coronary arteries –  not enough to cause a heart attack or serious heart muscle damage, but enough to convince his cardiologist that open heart surgery was necessary to “save his life”.  By the way, many patients will describe their cardiologists as being “life savers” – even when death was hardly imminent.

Meanwhile, I had survived a misdiagnosed heart attack that then resulted in ongoing cardiac issues including heart muscle damage and what doctors call “refractory angina” (this is chest pain and other symptoms that do not respond to usual meds or treatments) due to my subsequent second diagnosis of  Inoperable Coronary Microvascular Disease.

Some heart patients, on the other hand, experience massive heart attacks, cardiac arrest or other life-threatening events and yet seem to proceed calmly through an uneventful recovery.

Overall, doctors have dismissed the unique mental health issues of heart patients for far too long. See also: When Are Cardiologists Going to Start Talking About Depression?

An Israeli study(1) out of Tel Aviv University, for example, examined the association between new-onset depressive symptoms in heart attack patients and subsequent hospital admissions more than a decade after the initial attack. The study’s results were troubling:

“Heart attack patients who suffer mental health issues as a result of the attack are more likely to be re-admitted for cardiac events and chest pains in the future, and have 14 percent more days of hospitalization than their counterparts.”

Unlike longterm clinical depression, post-heart attack depression is often called “situational depression”, or “stress response syndrome”, and what mental health professionals call an adjustment disorder that can strike following a traumatic life event as we struggle to make sense of something that makes no sense.

Patients who are struggling emotionally after the trauma of a heart attack can also be far less likely to successfully make post-discharge lifestyle changes like regular exercise, smoking cessation, stress management or heart-healthy eating.  In fact, the Israeli researchers found that patients who suffer new-onset depression following a heart attack were:

  • 20% less likely to be physically active
  • 26% less likely to participate in a cardiac rehabilitation program
  • 25% less likely to quit smoking

So it can become an endless vicious circle loop of:

“Feel bad→ Don’t exercise→ Keep smoking→ Poor eating choices→ Feel bad!”

How much social support you have while you’re recuperating can also affect quality-of-life outcomes. For example, the commonly-used social support assessment tool called ESSI (ENRICHD Social Support Instrument) can assess those people at risk for poor social supports by asking patients to answer seven questions before they’re discharged from hospital.(2)  The first six use a 5-point LiKert scale numbered 1 (strongly disagree) to 5 (strongly agree).  The seventh item is a yes/no question, scored 4 for yes and 2 for no. Total scores range from 8 to 34.  Cardiologist should be aware of how much social support you’ll realistically have after you get home – but my guess is that most are not aware at all.

If your hospital has a cardiac social worker on staff, request an appointment before you’re discharged home to discuss your own ESSI scores.

The seven ESSI items are:

  1. Is there someone available to you whom you can count on to listen to you when you need to talk?
  2. Is there someone available to you to give you good advice about a problem?
  3. Is there someone available to you who shows you love and affection?
  4. Is there someone available to help you with daily chores?
  5. Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?
  6. Do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide?
  7. Are you currently married or living with a partner?

1.  Vicki Myers et al.  “Post-myocardial infarction depression: Increased hospital admissions and reduced adoption of secondary prevention measures — A longitudinal study.”  Journal of Psychosomatic Research, Volume 72, Issue 1, January 2012, Pages 5-10.
2. Mitchell, Pamela H., et al. 2003. “A Short Social Support Measure for Patients Recovering from Myocardial Infarction.” Journal of Cardiopulmonary Rehabilitation 23 (6). Ovid Technologies (Wolters Kluwer Health):398–403.


Q :    Have you been surprised by psychological fallout after a serious diagnosis?

NOTE FROM CAROLYN:  I wrote about surviving a misdiagnosed widow maker heart attack – and much more! – in my book, A Woman’s Guide to Living with Heart Disease. You can ask for it at your local bookshop or library, or order it online (paperback, hardcover or e-book) at Amazon – or order directly from my publisher, Johns Hopkins University Press (use the JHUP code HTWN to save 30% off the list price).

See also:

The New Country Called Heart Disease

Post-stent chest pain

Chest Pain of Angina Comes in Four Flavours

Squishing, Burning and Implanting Your Heart Troubles Away

10 Non-Drug Ways to Treat Depression in Heart Patients

How We Adapt After a Heart Attack May Depend on What We Believe This Diagnosis Means

“What Was That?” A Poem for Heart Attack Survivors

Women’s Heart Pain is Both Physical and Emotional

Why Hearing the Diagnosis Can Hurt Worse Than the Heart Attack

Depressed? Who, Me? Myths and Facts about Depression Following a Heart Attack

“I’m Not Depressed!” – and Other Ways We Deny the Stigma of Mental Illness After a Heart Attack


18 thoughts on “No such thing as a “small” heart attack

  1. Hello my name is Sonia, 48, went to Drs and they did a EKG on me and said I had a small heart attack, I don’t know when. Not sure how to take it… 😑 I thought a heart attack of any sort isn’t good..

    Liked by 1 person

    1. Hello Sonia – no wonder you’re having trouble making sense of this: any cardiac diagnosis is a big emotional shock. I’m not a physician so I can’t comment on your specific situation, but I can tell you generally that physicians often describe the size of a heart attack based on how much heart muscle has been damaged; to determine this, they use an EKG just as you had, or a cardiac ultrasound (echocardiogram). Damaged heart muscle is a problem, because unlike hurting a shoulder or arm muscle, heart muscle doesn’t heal and will become scar tissue, which can then affect the heart’s ability to pump effectively. The more heart muscle has been damaged, the more serious the effect.

      What any heart attack diagnosis tells you, whether big or small, is that something has happened inside your coronary arteries to interrupt the normal flow of blood to feed your heart muscle. You’re right, it is not “good” to ever have a heart attack. The only positive to come out of this is that it’s a clear ‘heads up’ for you to pay much closer attention to your heart health from now on. We know that up to 80% of heart attacks are preventable. Here’s more on this. Next time you see your doctor, ask about what you can do to minimize your chances of having another heart attack. Best of luck to you…


  2. Thank you so much for this article. It will be 2 years on the 29th of July since my heart attack back in 2016. I needed to know that my continued struggles have a name and my feeling are valid. I had a STEMI – 99% occlusion in my left circumflex artery.

    Liked by 1 person

    1. July 29th will be your Heart-iversary, Jackie! I celebrate my own every year (May 6th) because we never forget this life-altering event.

      Your continued struggles do indeed have a name and your feelings ARE valid. You are not alone. I’m not a physician, but I can tell you generally that the unique location of your blockage (in the left circumflex) is estimated to happen in only about 20% of heart attacks, and can often mean a tricky diagnostic dilemma (sometimes delayed or even missed diagnoses) compared to patients with the more common and readily recognizable left anterior descending (LAD) or right coronary artery blockages.

      On July 29th, I hope you plan something suitably enjoyable to celebrate your brave little heart’s will to survive!


  3. In 2009 I had “just a little heart attack” at the age of 34. I don’t feel as if I was treated by healthcare staff as if this was a little thing. I believed my cardiologist was shocked and afraid of my unexplained heart attack. Every time I saw him over the first year following my heart attack, he would say things like “We don’t know why this happened to you.” or “Wow. You are our youngest patient.”

    Although I believe his comments were made out of shock and bewilderment, they still made me feel afraid, isolated and alone. I don’t think my cardiologist knew how to interact with me. Because I feel like I didn’t have time to cry at home (I had children who were 4 and 8 at the time), most of my tears and grief were reserved for my cardiology appointments. My cardiologist didn’t know what to do with this.

    In the absence of support for my emotional recovery from my heart event, I went on with my daily life as usual. I had two young children to take care of and so I didn’t have time to process the emotional impact of my heart event when they were around. Because I was trying to keep it together for my kids, I didn’t let in any emotions that would overwhelm me and distract me from taking care of my kids.

    I believe I have experienced a certain degree of PTSD since my heart event. I understand that PTSD is especially common among heart attack survivors younger than 50. Sirens seem overwhelmingly loud and the sight of a moving ambulance with lights flashing is extremely distressing to me. Attending cardiac rehab at the hospital was very stressful and overwhelming — especially when I took the wrong elevator one day which forced me to walk past the cath lab to get to cardiac rehab. I had to step into a restroom to cry and recover from the experience before I went to cardiac rehab. Attending doctor’s appointments at the hospital can also be very anxiety-provoking. I have considered moving appointments to my cardiologist’s other office which is located in an office park that is near the hospital as opposed to inside the hospital. I have even considered changing doctors as I wonder if just the sight of my doctor provokes a certain degree of PTSD.

    I don’t think cardiac rehab programs focus enough on the psychological effects of heart disease or a heart event. I don’t think it’s the cardiologist’s job to be a counselor. Not only should cardiac rehab include weekly exercise, but I think weekly individual or group counseling sessions should be offered as a part of the recovery process. Physical and emotional recovery are equally important, and cardiac rehab programs need to address both equally. Our emotional well-being dramatically effects how well we comply with the need to take care of ourselves physically.

    Liked by 1 person

    1. I think you are 99% correct, Angela. Not all physicians seem to know quite how to respond to their patients’ emotional pain. As Mayo Clinic cardiologist Dr. Sharonne Hayes once explained: “Cardiologists may not be comfortable with ‘touchy-feely’ stuff. They want to treat lipids and chest pain. And most are not trained to cope with mental health issues.”

      It’s also entirely possible that the symptoms you describe are indeed those of PTSD. It’s never too late to seek help for these debilitating responses – please see a counsellor, pastor or mental health professional experienced in working with post-traumatic stress. Finally, all studies on cardiac rehab report just what you describe: the most successful results come from programs that offer BOTH supervised exercise classes AND psychosocial support.

      The 1% of your comment I’d disagree with is your observation: “I don’t think it’s the cardiologist’s job to be a counselor.” With about one-third of all heart patients reporting significant PTSD symptoms, no cardiologist can dismiss psychosocial support as being “not my job”. Even if he isn’t a trained counsellor, it was absolutely your cardiologist’s job to be proactive in recommending/referring you to a professional therapist or support program – ESPECIALLY at your young age. See also: “When are cardiologists going to start talking about depression?”

      Changing doctors and/or changing appointment venues to a non-hospital location can both be effective ways to avoid common PTSD triggers. My favourite part of your comment is a profoundly true statement that I wish more physicians would heed: “Our emotional well-being dramatically effects how well we comply with the need to take care of ourselves physically.” So true…

      Best of luck to you, Angela.


  4. Thank you!! This describes so much of how I’ve felt and, at times, still struggle with.

    In Aug, 2015 at age 52, I had a “mild” heart attack. This resulted in a stent procedure. Unfortunately, what is typically a 1 1/2 hour-2 hour procedure, turned into 6 hours due to complications that almost took my life. When I was finally in the quiet of my home, I realized how devastating this has been emotionally for me AND my family. Two weeks later, I had to go back in and was diagnosed with Inoperable Coronary Microvascular Disease. All those little pains (stretching) and every little nuance in my body was cause for fear and anxiety.

    This has meant BIG changes to my lifestyle, especially in my physical fitness options. I am happy to say that I have a very supportive family and have discovered Yoga! That said, my fears and anxieties are ongoing and I often find myself feeling quite depressed, have difficulty making decisions and long-term plans, and feeling a bit lost in my “after heart attack” life.

    It’s getting better and it helps to know I am not the only one feeling out of sorts!

    Liked by 1 person

    1. Thanks for sharing your perspective, Dana. No matter how “mild” your doctor described that initial heart attack, your subsequent procedures, complications and new diagnoses certainly don’t qualify this entire experience as “mild” at all! As Dr. Stephen Parker wrote once (he’s a cardiac psychologist and himself a heart attack survivor): “A heart attack is a deeply wounding event.” I wrote more about his work here:

      You are barely five months into your new life as a heart patient – no wonder you still feel “a bit lost”. But it WILL get better; they say the first year after a cardiac event is often a major milestone and a shift in one’s perspective (when you realize, as one of my readers just wrote recently, that you just might survive this!) It’s so great that you’ve discovered yoga (good for both mind AND body). You might also really benefit from talking to a professional counselor to help you adapt and adjust to the fears and anxieties you’re experiencing. Please get all the help you possibly can – you don’t have to struggle hrough this alone. Best of luck to you…


  5. People, do NOT take these risks.

    My dad, a very happy, athletic fit guy, went to a cardiologist one afternoon and was told his heart looked great. He was thrilled. He then did some very physical activity that evening, and died the next morning suddenly from a massive heart attack. Out of the blue. Did not even see it coming. Everyone was shocked. I still can’t believe it.

    DO NOT take any of these risks people, please, no matter how much people brag. It’s not worth it.


  6. Carolyn, agree 100% with you. There is NO such thing as a “small” heart attack; doctors who treat patients dismissively with this phrase do them a disservice while undervaluing the very real psychological impact of a cardiac event.


    1. The medical profession has not yet caught up with the literature that clearly confirms how psychologically traumatic cardiac events can be. Thx for your comment here, Calista.


  7. This article has such truth to it. Even though I have not survived a heart attack personally, several immediate family members have and I have tried my best to be their support system with information and encouragement because they were so emotionally fragile. Not to mention that I was a pharmaceutical rep and I sold a beta blocker.

    The emotional devastation was talked about with the physician as quality of life factors. To see the percentage of people that actually spiral down from those factors are not surprising. I would like to see specific care units and advisement that could be offered in the physicians office or at the hospital in a very aggressive and proactive way. I think this might give more people help.

    As usual this was a great article that gave insight not only to those who have been affected but also for those who are trying to understand and gain insight.


    1. Thanks so much for your perspective, Katrina – and also for reminding us that it’s not just the patient who struggles with the emotional burden of a chronic and progressive illness like heart disease.


      1. Hi Carolyn,
        I too think it’s great that you wrote this article. If you don’t mind me asking, how old are you? The reason I ask is … I am 48 and had a “mild” heart attack the end of May this year (2012). If one more Dr. including the ones in the hospital who saw me for 2 seconds during my 3 day stay say “You are too young for this to happen to you”… I am what? Going to give up, feel more terrible, scream, have another heart attack. Grrrrrr

        Symptoms were not severe at all, actually I was probably experiencing them for a few days before going to the ER. Including during my son’s birthday party the day before! Going for a followup appointment was more than frustrating when I was told the cardiologist who performed my “Procedure” could not see me until September and yet right after my “procedure” said: “I hope to see you in my office many time over next 50 yrs”.

        I was also told by office staff on way out of seeing NP “there is list of people more important for him to see, sorry.” I said to them with tears in my eyes and a lump in my throat, “Well, I had a heart attack, it’s kind of important to me” as I left the huge waiting room of grandmas and grandpas, feeling so alone and sad.

        I did end up seeing the NP for 3 weeks followup for a what seemed like one track typical, quick appt as though I did not have a heart attack. I left the office thinking, you aren’t going to give me an EKG or xray or anything to see if I am OK? You aren’t going to ask if I have any questions? And then the Dr office called me about a week later – maybe from my asking for Dr. and raising a fuss? idk.. asking if I’d like a followup appt with Dr in a week! I saw him and he said the infamous “You are too young for this to happen” and I just about lost it.

        I left him, sad again, with several scripts for medicines I hesitate to take. I have been taking plavix since my “mild” heart attack, in addition to my normal BP meds, and more. At end of appt I did manage to hesitantly ask if there was a support group for people like me. He gave me a card of someone to call about info. I said “are they too young like me?” ..

        Thank you for making me feel like I am not alone.


        1. Thanks for your comment, Beth. I hope you did contact that support group. (But your story does make you wonder why hospital staff wouldn’t be passing out those cards before patients are discharged from the cardiac unit instead of waiting until patients have to ask for info much later on their own!) BTW, in answer to your question: I was 58 when I had my heart attack.


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