Slow-onset heart attack: the trickster that fools us

19 Apr

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by Carolyn Thomas    @HeartSisters

As I’ve noted here previously, there were a number of very good reasons that I believed that Emergency Department physician who sent me home with an acid reflux misdiagnosis. Despite my textbook heart attack symptoms of central chest pain, nausea, sweating and pain down my left arm, these reasons included:

1.  He had the letters M.D. after his name;

2.  He misdiagnosed me in a decisively authoritative manner;

3.  I wanted to believe him because I’d much rather have indigestion than heart disease, thank you very much;

4.  The Emergency nurse scolded me privately about my questions to this doctor, warning me: “He is a very good doctor, and he does not like to be questioned!”  (The questions I’d been asking included, not surprisingly: “But Doctor, what about this pain down my left arm?”);

5.  Most of all, what I had always imagined a heart attack looking like (clutching one’s chest in agony, falling down unconscious, 911, ambulance, sirens, CPR) was not at all what I was experiencing. Instead, despite my alarming symptoms, I was still able to walk, talk, think and generally behave like a normally functioning person, i.e. one who is definitely NOT having a heart attack!*

So it all made sense to me as I was being sent home from Emergency that day, feeling very embarrassed because I had clearly been making a big fuss over nothing.

My experience, however, might have been what researchers in Ireland refer to as “slow-onset myocardial infarction”.  

Dr. Sharon O’Donnell, lead author of a study published in the Journal of Cardiovascular Nursing, interviewed heart attack survivors in Dublin between 2-4 days following their hospital admission. She explained in her paper that slow-onset MI is the gradual onset of relatively mild heart attack symptoms, while fast-onset MI describes the immediate onset of sudden, continuous, and severe heart attack symptoms, particularly chest pain. (1)

“Over 60 per cent of our study’s participants experienced slow-onset MI, but had expected the severe symptoms associated with fast-onset MI. The mismatch of expected and experienced symptoms for participants with slow-onset MI led to both their mislabeling of symptoms to a non-cardiac cause, as well as protracted help-seeking delays.”

Study participants who had experienced the more severe symptoms of fast-onset MI, however, quickly chalked up their symptoms to a cardiac cause, which meant significantly faster decisions to seek medical help.

This makes perfect sense.  No wonder we wait far longer than we should in mid-heart attack when we’re experiencing non-severe or atypical cardiac symptoms. As Dr. O’Donnell explained:

“Educational information provided to the public needs to be reviewed. Slow-onset MI and fast-onset MI provide plausible definition alternatives, and possibly a more authentic version of real MI events than what is currently used. They also provide a unique ‘delay’ perspective which may inform future educational initiatives targeted at decision delay reduction.”

She also pointed out that both slow-onset and fast-onset presentations are associated with uniquely distinct behavioral patterns that significantly influence how long that important pre-hospital delay turns out to be. With slow-onset symptoms, patients can wait dangerously longer than they should (believing symptoms to be “nothing serious”) while in fast-onset, patients seek emergency help faster because severe symptoms convince them that “this IS serious!”

In a later follow-up study published in the Journal of Emergency Medicine, Dr. O’Donnell  looked at the phenomenon of slow-onset symptoms among patients presenting to hospital with Acute Coronary Syndrome (ACS) – a term used for any condition brought on by sudden, reduced blood flow to the heart muscle – including heart attack or unstable angina. (2)

Out of almost 900 ACS patients studied, she and her team found that 65% of them experienced slow-onset symptom presentation.  And just like her earlier study, this group of patients had been significantly more likely to wait longer at home before going to hospital to seek emergency help (3.5 hours, vs. 2 hours for those with fast-onset symptoms).
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I’m particularly interested in treatment-seeking delay, because I personally became the all-time unofficial poster child for this phenomenon.  After being misdiagnosed and sent home from hospital – embarrassed and humiliated – on that fateful day, it took me two full weeks before I finally returned to Emergency – and only because my increasingly debilitating bouts of continuing cardiac symptoms had by then become truly unbearable.  Well, that plus the fact that I could no longer walk five steps without having to stop because of pain.
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Most of us are socialized from childhood to not make a fuss over every little twinge or ache.  We regularly dismiss all kinds of suspicious symptoms because they frequently do get better on their own, or after a good night’s sleep.  Or we simply become used to putting up with symptoms as merely the annoyance of getting older. Or because a Real Life Doctor tells us we’re fine. (And really, if we rushed to Emergency over every single bubble and squeak, our health care systems would be even more impossibly overwhelmed).
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Careful consideration of new or puzzling symptoms is important – but so is knowing when to get help.
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Most heart attacks do start slowly. Most involve discomfort in the center of the chest that lasts more than a few minutes, or symptoms that go away and come back later over hours or even days as mine did. Cardiac symptoms can feel like uncomfortable pressure, squeezing, tightness, fullness as well as pain. Around 8-10% of women (some studies suggest that could even be as high as 40%) experience no chest symptoms at all in mid-heart attack – instead reporting signs like crushing fatigue, shortness of breath, pain in either or both arms, jaw, throat, shoulders, or nausea/vomiting.(3)
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Ironically, even the most painful cardiac symptoms don’t necessarily mean more serious heart muscle damage than less severe pain does.
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Not surprisingly, it’s very common for those people affected to feel unsure about what’s wrong with them, and then to wait too long before getting help.  See also: How women can tell if they’re headed for a heart attack
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So we silently monitor any new aches or pains, tallying them on an invisible abacus, ranking their severity on a secret leaderboard. It’s often only when we can no longer stand to quietly tolerate the intolerable that we force ourselves to pro-actively seek help. But this delay can be a dangerous and often deadly decision if those symptoms are due to a cardiac event.
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And those slow-onset symptoms are the easiest to ignore. When that Emergency physician told me to see my family physician for an antacid prescription, well, that was all I needed to hear.  Nobody had to tell me twice.  When I returned home that morning, I dutifully called my family doc’s office as directed, made an appointment for two weeks down the road when she’d be back from vacation, and then got right on with the rest of my life.
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And when the cardiac symptoms returned two days later (of course they did!), this time while sitting quietly at my desk at work, I knew instantly there was no way I was going back to Emergency. Hadn’t a highly trained, experienced physician told me in a decisively authoritative manner:
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“You’re in the right demographic for acid reflux!”
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And when those same cardiac symptoms kept on returning (of course they did!), I began to normalize them even as they grew increasingly debilitating: This must just be what acid reflux is like.  How can other people with acid reflux stand this?  Acid reflux is BRUTAL.  Where’s my Gaviscon . . . ?
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Most other studies that investigate treatment-seeking delay behaviours in heart patients have tended to overlook slow-onset symptoms.  See also: Downplaying symptoms: just pretend it’s NOT a heart attack
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 The bottom line:

If you are experiencing symptoms that might be signs of a heart attack (whether they’re slow- or fast-onset!), call 9-1-1 or your emergency response number. As with men, women’s most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, unusual and extreme fatigue, nausea/vomiting, and back/throat/jaw pain. Learn more about heart attack symptoms in women. . Learn these signs, but remember this: even if you’re not sure it’s a heart attack, get checked out by a physician.
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(1) O’Donnell, S. et al.  Slow-Onset Myocardial Infarction and Its Influence on Help-Seeking Behaviors. Journal of Cardiovascular Nursing, August 2012. Volume 27  Number 4. Pages 334 – 344.
(2) O’Donnell, S. et al. Slow-onset and fast-onset symptom presentations in acute coronary syndrome (ACS): new perspectives on prehospital delay in patients with ACS. J Emerg Med. 2014 Apr 11; 46(4):507-15.
(3) S. Dey et al, “GRACE: Acute coronary syndromes: Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events”, Heart  2009;95:1 2026.

NOTE FROM CAROLYN: I wrote more about women’s slow, fast, typical and atypical heart attacks in my new book, “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University, November 2017). 

❤️

Q:  Did you or somebody you care about wait too long before seeking help because of ‘slow-onset’ symptoms?

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* My own misconception about what a heart attack really looks like was actually more like sudden cardiac arrest (an electrical problem) than a heart attack (a plumbing problem!)
See also:

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70 Responses to “Slow-onset heart attack: the trickster that fools us”

  1. Andrew Harvard December 3, 2017 at 8:18 pm #

    Thank you again for this blog… you are shining a light to help others. I had 4 stents inserted 5 months ago and it’s been a challenge since then (but improving). I’ve highlighted your blog in these posts, here and here.

    Please keep up this good work.

    Liked by 1 person

    • Carolyn Thomas December 3, 2017 at 9:15 pm #

      Thank you Andrew – at five months, you are still in what’s considered ‘early days’ yet. I hope you continue to improve! Best of luck to you…

      Like

  2. Janet Arroyo October 18, 2017 at 12:35 am #

    Hi my name is Janet and I’m 17 years old. Yesterday morning my chest was feeling a little sore but it went away so I didn’t think much of it. In the afternoon though as I was sitting in class and suddenly got this extreme pain in the middle of my chest. It was the worst pain I’ve ever felt and started to feel dizzy and lightheaded but it suddenly stopped. A couple hours later I felt my heart beating really fast and had the same experience but it wasn’t as painful and once again went away in a flash. My heart still feels like it’s beating fast occasionally but I haven’t gotten any pain yet. Should I go to the ER ? Thank you !!!

    Like

    • Carolyn Thomas October 18, 2017 at 5:48 am #

      Hi Janet – I’m not a physician so cannot comment on your specific case except to say that it would be very unusual for a person your age to be having a heart attack. But something is causing these puzzling symptoms – call your family doctor today for an appointment. You might be relieved to know that 85% of chest pain admissions to hospital end up being NOT heart-related. Here are some other potential reasons. Good luck to you…

      Like

  3. Edith September 28, 2017 at 4:10 pm #

    I have been to the ER twice in the last two years with a chest pain on my right side. Both times two different Drs, same hospital. Have sent me home with Gastritis… I am definitely going to follow through with my Dr.

    Ps It took what seemed like forever to get pain medication.

    Liked by 1 person

    • Carolyn Thomas September 28, 2017 at 8:00 pm #

      Hello Edith – Something is causing your symptoms, but right now you do not know if they’re heart-related or not. If they are in fact due to gastritis, what treatments did the physicians recommend (e.g. antibiotics, histamine blockers, antacids, etc?) Chest pain can also be caused by non-cardiac conditions – more info on that here. Best of luck to you in solving the mystery…

      Like

  4. Cathy Mahardy September 18, 2017 at 11:34 am #

    Hello. It’s nice to see this particular website. My sister suffered a heart attack 2 days ago and she is 60 years of age. The doctor at first said it would take two to six months to recover and that she should stay very calm. Now a day later he says you can go back to work in 2 to 3 weeks. She is too weak to find a new doctor right now and we are trying to help but I’m not quite sure how..

    Liked by 1 person

    • Carolyn Thomas September 24, 2017 at 7:41 am #

      Hello Cathy – sorry for the delay in responding (somehow your comment got buried on a busy day!) It may be premature to decide that your sister needs to find a new doctor. In a way, everything that her doctor said is correct, even though his advice may seem to make no sense. For example, when your sister can return to work depends on many factors (how severe her heart attack was, how much heart muscle was damaged, what kind of cardiac procedures she had, how much support she has at home and at work, the kind of job she’s returning to, etc). More on returning to work after a heart attack here.

      Many heart attack survivors who are perfectly able to return to work with no problems also say that it does take time to finally feel like they’ve completely recovered after a cardiac event; even when they return to work (or hobbies, sports, social activities, etc), it takes a while to get back to ‘normal’. There are often significant emotional and psychological issues following such a life-altering diagnosis.

      Your sister’s doctor was also correct in advising your sister to try to remain calm (that’s good advice for all of us, heart attack or not!) It does not mean she needs to lie on the couch scared to move a muscle all day. Just the opposite, in fact! She needs to get up and moving as much as possible! If she has not been referred to a supervised cardiac rehabilitation program, she needs to ask her doctor for a referral. Cardiac rehab has been proven to improve a heart patient’s quality of life, improve longterm outcomes, and reduce the risk of having a second heart attack.

      I’m guessing that your sister has a follow-up appointment booked with her doctor very soon; before she goes, she should make some written notes about any questions she has. She should never leave a doctor’s office from now on without understanding every word that the doctor says. Sometimes, patients prefer to sit quietly and nod as if we understand even when we don’t, so that we won’t take up too much time, or come across as not paying attention. But it’s the doctor’s job to explain what’s happening in clear, understandable language before the patient leaves the room. A freshly-diagnosed heart patient is often overwhelmed and afraid. That’s a very common way to feel.

      What can you do to help? Look for a book called “Thriving With Heart Disease” by Dr. Wayne Sotile to give to your sister. That book was a lifesaver for me in the early weeks/months after my own heart attack. My own book (“A Woman’s Guide to Living With Heart Disease” won’t be in the bookshops until November, but you can pre-order it now).

      (By the way, you may not have been told yet that your sister’s heart attack under the age of 65 means that you and your siblings – and any children your sister may have – are now considered to have a family history of heart disease). Best of luck to your sister and your whole family! She is lucky to have you as such a good sister…

      Like

  5. Kasey August 5, 2017 at 10:57 am #

    I’m 42 and relatively healthy at least according to my last CBC and to my knowledge never had heart issues. However, I have been under an autoimmune umbrella for 15 yrs. I was adopted so I have no family history. 2 days ago I had significant pain in the middle of my chest and shortness of breath that lasted about 20 min. It dropped me to my knees and scared me as well as my 8 yr old who I muttered to call 911 if something happened but because I’ve never had heart issues, wouldn’t allow him to call to avoid an embarrassing ambulance ride to be told it was indigestion etc… I hadn’t recently eaten anything. After about 20 min the pain disappeared as quickly as it came and was able to restore my breathing although with the help of my inhaler. I didn’t have arm pain or tingling during the episode but woke up with a tight heaviness in the left side of my neck and arm. Post incident, I have searched the internet to research what I experienced.

    Although heart issue still seemed far fetched I also don’t think it was indigestion or reflux, I hadn’t recently eaten anything but yogurt about 2 hrs before. I decided to make an appointment with my doctor but can’t get in for another few weeks. I guess I’m just not sure what to think or what to do. Other than feeling very tired and having some wheezing and coughing I seem to be functioning fine. Pain in my chest nor heaviness or tightness in my arm have continued.

    In all the experience, research, and stories you’ve heard…does this sound familiar?

    Liked by 1 person

    • Carolyn Thomas August 5, 2017 at 3:23 pm #

      Hello Kasey – I’m not a physician so cannot comment on the specifics of your case, but I can tell you generally that something is causing these symptoms and you need to find out what. Good call to make an appointment with your own physician to get some help solving the mystery! Meanwhile, try keeping a symptom journal (details of symptom, date, time of day, what you were doing in the hours leading up to symptoms, how long did it last, what relieved it, etc) which might start to indicate a pattern that could be useful for your doc. Right now, you have no idea if any of your recent symptoms are heart-related or not (and the odds are in fact that they are NON-cardiac, but you don’t know that for sure). If your symptoms “drop you to your knees” again, call 911. Again, I’m not a physician; your doctor can help narrow this down to what the problem is NOT (so many medical issues are about the process of elimination). Best of luck to you…

      Like

    • Bryon Haslam August 6, 2017 at 8:19 am #

      Hello Kasey, It may be wise to have someone drive you to the ER if you can’t get in soon enough to see your Doctor. It may be nothing or it may be something. This is how it “SNEAKS” up on you.

      I remember the stabbing pain in the center of my chest, shortness of breath, forearm pain in both arms and being on my knees waiting for it to pass. I even used my wife’s inhaler to help me breathe. The symptoms came and went lasting 20 minute to half an hour. This went on for 2 weeks. I thought it was gastritis.

      Go to the ER, tell them you are having chest pains (lie if you have to!!!) Let them run some tests. Let the ER Doc admit you so they can do a work up. It may not be your heart but it may be one of your arteries clogging up. My LAD was clogging up in a big way. Go get checked out, DON’T WAIT. I did (2 weeks) and almost died of a major heart attack.

      God Bless,
      Bryon Haslam

      Like

      • Carolyn Thomas August 6, 2017 at 10:11 am #

        Hi Bryon,
        Thanks for your comment. It would be a big mistake, however, to advise Kasey or anybody else to “LIE if you have to” about having chest pain. I’ve heard of people who say this just to be seen quicker in the ER. Those who do this, however, clog up limited ER resources (even at the expense of those who are actually having a heart attack behind them in line.

        It’s important to remember that 85% of all admissions to hospital for chest pain turn out not to be non-cardiac. If we start advising people to lie about chest pain in the ER, those numbers will explode.

        The ER is not a walk-in clinic, and any genuine symptoms that feel like heart attack should warrant an immediate call to 911.

        Like

  6. Rob June 28, 2017 at 11:54 am #

    Hi Carolyn,

    Can I just ask how is it you don’t have heart failure after having heart attack lasting two weeks? They say time is muscle, surely the amount of damaged muscle after all that time had to have been quite substantial?

    Liked by 1 person

    • Carolyn Thomas June 28, 2017 at 4:19 pm #

      Hello Rob – that’s what I asked myself as well. I used to think heart attacks were essentially like sudden cardiac arrest – BOOM! You get it and you are down on the ground, a single event. Dr. O’Donnell described slow-onset MI in her research, however, as: “a more authentic version of real MI events than what is currently used” – and especially for women. There’s no way to know for sure, of course, but my cardiologist now believes that my prior 19 years as a distance runner likely enhanced my collateral arteries, which may have helped them continue supplying some blood flow despite debilitating symptoms.

      Like

      • Bryon Haslam July 23, 2017 at 7:01 am #

        Hello Carolyn, I agree. Great article. I waited. Bad move. Thought it was Gastritis. Two weeks between onset of symptoms that came and went, ER visit, Cardio Doc visit, phone calls.

        The morning of the real heart attack, the pain and shortness of breath returned. I could deal with it. It hurt and I couldn’t breath properly but thought it would pass as always. I waited 4 hours before letting my son call an ambulance.

        Your article is spot on. It’s what happened to me.They got me to the hospital and saved my life. I am a Widow-maker survivor. (100% LAD blockage) The symptoms (not always the classic ones) leading up to the event is your body telling you it needs help. It’s your heart saying “Hey I’m starving for blood!” It’s not gas or heartburn!! It’s your arteries clogging up.

        Don’t wait. Don’t be embarrassed to call for help. Time is heart muscle that dies. Listen to your body. Stay well.

        Liked by 1 person

        • Carolyn Thomas July 23, 2017 at 8:02 am #

          Oh my! Byron, that’s a cautionary tale for all of us who try to deny or dismiss distressing symptoms – despite the evidence! Thank goodness your son persisted in finally convincing you that you needed emergency help. Keep telling your story – every person you tell will remember it and your experience just might save other lives, too!

          Like

          • B July 24, 2017 at 11:45 am #

            Can slow onset continue time and again, monthly 1 or 2 times for years and never be bad enough to go to the ER, especially when you’re about 70 years old? May go for hours and then take a nitrostat and finally gets rest and seems ok until the next time. Never goes to doctor to confirm heart issues..

            Like

            • Carolyn Thomas July 24, 2017 at 12:30 pm #

              Hello B – only a physician could accurately assess whether symptoms that go on for years are heart-related or not.

              Like

  7. Briana Hill March 27, 2017 at 6:46 pm #

    Hi. I am 25 years old. I’m 5’6 , I am 275. I had slight chest pains. I have been to the ER 4 times already. I had an ekg, mri, and xray. they said all tests were fine. they said i had bronchitis because my bronchial tubes were swollen. i dont believe them. the medicine just isnt working. what should i do? should i go back again

    Like

    • Carolyn Thomas March 27, 2017 at 8:18 pm #

      Hello Briana – I’m not a physician so cannot tell you what to do, but I can tell you generally that there are a number of other conditions that may cause chest pain, including bronchitis. It sounds like you’ve had many appropriate tests so far to solve this mystery, and some test results – which is all good. If the meds are not working, please see your family physician.

      Like

  8. Alicia Butcher Ehrhardt March 15, 2017 at 6:44 pm #

    I think you could boost this post – I read about 50 of your posts before hearing about slow onset. Sounds like what I was getting, which I was dismissing as just more slowing down due to my CFS.

    I’ve never heard about this before as a specific thing.

    Like

    • Carolyn Thomas March 15, 2017 at 8:16 pm #

      50 down, 652 to go! Lots more new stuff to learn as you go through all those posts…

      Like

  9. Bo Lee November 21, 2016 at 6:57 am #

    Who cares if the doctor likes to be questioned or not? They are human and make mistakes like the rest of us. At the end of their shift they can be tired like the rest of us. If you have questions, you should always ask them. That is why they say to get a second opinion on things. My wife had issues with acid reflux. With her they did an EKG because the symptons can mimic each other to some degree.

    But the pain down your left arm should have been the red flag to the ER doctor. He should have been questioned because he was ignoring a red flag sympton.

    Liked by 1 person

    • Carolyn Thomas November 21, 2016 at 1:18 pm #

      Thanks for your comment, Bo. Of course, in hindsight, I agree 100% with you. I’m not a doctor, but even I know that pain down your left arm is NOT a sign of indigestion… But given that my symptoms had already eased up that morning (not the end of his shift, but within an hour of starting his shift, actually!) – and I was already feeling embarrassed for wasting his very valuable time – and as I wrote, I’d much rather believe it was just acid reflux, not heart attack. I now tell the women in my heart health presentation audiences: “You know your body! You KNOW when something does not feel right!”

      Like

  10. Beth October 14, 2016 at 4:39 pm #

    Thank you so much for this post. I’m currently quite terrified because I feel like I could have the symptoms of this, but keep thinking it’s impossible since I’m only 19. For the last two weeks I’ve had extreme fatigue with spells of dizziness and one episode of vomiting, which I at first wrote off as coming down with flu. Then a pain in my upper back started so my doctor gave me antibiotics for a possible kidney or bladder infection. That was five days ago and now I’ve on-and-off been getting sharp chest pains right under my left breast, pains in my left arm and pains in my leg. I keep thinking it’s not possible because I’m only 19, even though I know it technically is possible, but I’m so uncertain.

    Like

    • Carolyn Thomas October 14, 2016 at 5:10 pm #

      Hello Beth – I’m not a physician so of course cannot comment on your situation. I can tell you generally that you’ll feel reassured to know that 85% of all hospital admissions for chest pain turn out to be NON-heart related after all (especially true in 19 year olds) and that pains in the legs would rarely if ever be a sign of a heart attack. Right now, if I were you I’d be far more concerned about whether your doctor ordered a lab test to confirm exactly what kind of bacteria are causing this urinary tract infection he diagnosed before prescribing that antibiotic prescription. If he didn’t, call the office and request a lab test to make sure antibiotics are what you actually do need now. (Antibiotics are widely over-prescribed for inappropriate reasons and you do NOT want to be taking them unless lab tests clearly indicate a need). Unfortunately you just don’t know what is causing your symptoms, but it might make you feel better to take a big deep breath and remind yourself that feeling dizzy and fatigued with one episode of vomiting over a couple weeks sounds much more like any number of flu-like bugs, don’t they? Feeling “terrified” can simply be making your symptoms feel worse by making each new little twinge feel even scarier, which then causes more symptoms, which can then make you feel more terrified, and it becomes a vicious circle. See your doctor if these continue but meanwhile, try to stay calm and relaxed. Best of luck to you…

      Like

  11. Cynthia October 10, 2016 at 9:14 am #

    This is an amazing information portal – I stumbled upon this site doing a search of symptoms after emailing (yes email not call) my doctor letting her know that since Thursday 10/06/16 I have been feeling unwell – fatigue – “indigestion” – nausea – general overall not good – pain in my neck / upper back-abdomen & right flank area… I have contributed the neck and back pain to injury from an auto accident 2+ yrs ago and surgery to fix part of it – the flank pain to the fact I have bilateral extra renal pelvis – but this not the normal pains I feel.

    Thursday I took 2 nitro pills before passing out asleep and not waking until my husband got home after 5pm, Friday I took 1 nitro while at work, have taken at least 1 over the weekend – and again this morning on my way to work.

    Let me give a bit of my history. In 2011 I had my first angiogram due to a hypertensive crisis and abnormal EKG during an ER visit – at that time I was diagnosed with a 10% blockage on my right side, a year later in 2012 I had just had surgery on a Thursday – on Friday I felt ill – nauseous – and indigestion – this went on all weekend, that following Monday while my daughter was in surgery a nurse approached me and requested I let her take me to the ER to be checked – I once again had an abnormal EKG and was admitted to the heart hospital where I underwent another angiogram and found out that in a year I had progressed to a 30% blockage. During a recent ER visit for a BP reading of 246/122 the tech looked confused at my EKG as she said it looked like I was trembling even though I was perfectly still (note: ER doc never addressed the abnormal EKG)… Earlier this year I was diagnosed with Unstable Angina…

    So could this “trembling” EKG a few weeks back and now the unstable BP I am having today (fresh out of bed 188/109 – arrived at work 172/101 – an hour later 134/84 – just about 10mins ago back up to 169/100), pulse ranges from 60-68 resting, mixed with all the other symptoms – could I be having a slow-onset HA?

    Like

    • Carolyn Thomas October 10, 2016 at 8:19 pm #

      Hi Cynthia – I’m not a physician so of course cannot comment on your specific case, nor predict if a slow-onset heart attack is in your future. I can tell you generally that it would be highly unusual for a 30% blockage to cause any cardiac symptoms. Most blockages would not be considered even treatable until at least 70%. It’s important to clarify a couple of confusing terms with your physician: stable angina is typically defined as symptoms between neck and navel that are generally brought on by increased exertion and go away with rest (not an emergency situation). I’m not sure who diagnosed you with unstable angina (or acute coronary syndrome – ACS) but that is an emergency medical situation in which symptoms are brought on with little or no exertion and do not improve with nitro. You mentioned you had two abnormal EKG tests: you need to sit down with your doctor to clearly intepret exactly what “abnormal” means. Your blood pressure swings need attention (could also be associated with factors like fever, dehydration, fatigue, stress, food sensitivities, too much caffeine, etc.) Make an appointment with your physician to review your erratic blood pressure and a solid treatment plan to address that. Good luck to you…

      Like

      • Cynthia October 11, 2016 at 6:13 am #

        Thank you Carolyn, I am currently on three different BP meds – it just seems my body gets used to the dosage and starts going crazy again – I have been hospitalized multiple times due to hypertensive crisis – and yes I was diagnosed with unstable angina due to the chest discomfort happening with little or no activity – it was due to cardiac symptoms which lead to the angiograms that I was found to have the blockages – much of the same symptoms I am having now (have had for days), they come on and last anywhere from 45 mins to a couple hours then subside then return…. very scary….I was told nothing will be done about the blockage til I hit 80-90% but I could expect a mild HA in 5 yrs (so approx. 2017) and a massive one in 10 yrs (approx. 2022)….the abnormal readings on my EKGs was my rhythms were off both times – I have had a couple since that show flutters – so that combined with the unstable angina I was put on the nitro – just scares me that I will end up having these BP swings and the ER will not take it seriously and I will end up having a full blown cardiac emergency.

        Like

        • Carolyn Thomas October 11, 2016 at 6:37 am #

          Hi again – this sounds dreadful! Again, I’m not a physician, but I can tell you with absolute certainty that whoever told you that you will have a mild heart attack in 2017 and a massive one in 2022 is an idiot. I’ve never even heard of a physician predicting specific prognoses in that fashion. Here’s the reality instead: patients pass a “normal” treadmill stress test and have a heart attack the following month, or patients with multi-vessel disease live quite happily despite several arteries 70% blocked because of their well-managed nitro therapy. In neither case are medical predictions like the one you mention possible.

          If it were actually possible to predict with any accuracy whatsoever, all hospitals worldwide would be using such predictive tools. But it is NOT possible, that’s what so scary about heart disease, and it simply makes patients feel terrified. Whatever your diagnosis is or isn’t, it is clear that your symptoms are being poorly controlled. You need to seek a second opinion until you find a medical team that has experience working specifically with female heart patients, to come up with a comprehensive diagnostic and treatment plan so you don’t have to count on E.R. visits as part of your “normal” care. Best of luck…

          Like

          • Cynthia October 18, 2016 at 6:22 am #

            They were not giving an exact prediction – what they were stating is that I would see the first (mild) heart attack within 5 yrs (putting it on or around 2017) and a massive in 10 years (putting it on or around 2022) – they based this time line on the fact that in less than a year my blockage went from 10% to 30% and if I continued at this rate – this is what I could expect – of course the time line is dependent on making changes (which I have with exception of the hereditary factor of massive family history of heart disease and heart attacks).

            I failed my treadmill test back in 2012 – and as far as an update to the symptoms I described above – I was hospitalized just this past week due to irregular rhythms and a significant drop in blood pressure (79/55) – it was the discomfort (no chest pain – I have never had the chest pain) – the numb/heavy feeling in my arms and the getting out of breath just taking a few steps.

            As you stated, heart problems are hard to detect – diagnose and treat – we just have to have a doctor who will listen and pay attention – and I must say – I have an excellent team
            working with me in this regard.

            Guess my point i was trying to make – women are harder than men to detect what is going on. Stay on top of your symptoms and insist you are checked thoroughly and not dismissed as you and only you know how your body feels/works on the good, the bad and the ugly days.

            Like

            • Carolyn Thomas October 18, 2016 at 7:21 am #

              Again, no matter how those hospital staff may have explained their prognostication re specifying 2017 and 2022, there’s no evidence out there to support such crystal ball gazing. I worked in hospice/palliative care for many years and not even in end-of-life care do you see specialists predicting the year of each catastrophic health crisis. I would place as much value in such predictions as I would if they’d told the date you’re likely to be hit by a bus. Family history is just one of many cardiac risk factors, it’s not a death warrant. Although you describe your care provider team as excellent, if my symptoms were being as poorly managed as yours, I’d be seriously considering getting a second opinion, e.g. re those irregular heart rhythms. And you’re so right in your last paragraph! Best of luck…

              Like

  12. Susan Lynn April 24, 2016 at 6:50 am #

    I had a slow-onset heart attack in November 2015, caused by a Spontaneous Coronary Artery Dissection.

    I had a little bit of heartburn, which I thought was just a reaction to something I ate. The main symptom was shortness of breath. I’d had asthma as a teenager, so I thought that the asthma was coming back. Heart attack? I never smoked, I exercise, am at normal weight, no high cholesterol, perfect blood pressure. I had no personal history of heart problems. My parents are in their 80’s and have never had a stroke or heart attack.

    I had the shortness of breath for a week before I saw my doctor. And in that time, I was working, driving, doing housework, taking walks. Heart attack? Not I, said the Little Red Hen. Couldn’t happen to me. How could I possibly be doing all this if I were having a heart attack, or on the verge of one?

    My doctor scolded me for waiting that week to come in. I thought, “Oh please, you can’t go to the doctor for every little ache or symptom.” I’d always been so healthy; nothing could be seriously wrong. Her nurse did an EKG in the office — and that came out normal. I thought, “See? Waste of my time and the doctor’s; I didn’t need to come in today.”

    She drew some blood for testing and sent me home. That was how my heart attack was diagnosed: my troponin levels were very high. Her associate called me when the test results came in and told me that I needed to hang up and call 911 immediately, as I had either just had, or was having a heart attack. Even then, I couldn’t believe it. I thought that the blood test had to be wrong, but I did call for the ambulance, and yes, it was a heart attack.

    Even at the hospital, the staff constantly asked me, “How is your pain today?” It seemed like a strange question. I never really had pain, other than a few moments of heartburn-like pain three days before I went into the doctor. My main symptom was always the shortness of breath, and a bit of tightness in the chest. It really didn’t feel bad enough to require a visit to the doctor. Yes. Carve that on my gravestone: “Oh, I’m sure it’s nothing serious.”

    Liked by 1 person

    • Carolyn Thomas April 24, 2016 at 7:38 am #

      Susan, I love that gravestone epitaph! Yours is a textbook example of how a number of symptoms that could easily be attributed to some other benign reason can be so easily dismissed. I too had that sensation of denial while I was still able to go to work, drive, think, walk, talk, fly to Ottawa for my mother’s 80th birthday: how could any of my symptoms possibly be heart-related when I’m able to live “normally” like this? It’s because we (mistakenly) harbour that stereotype of what heart attack looks like (i.e. NOT like us!)

      Like

  13. Sheila RN BSN April 22, 2016 at 12:17 pm #

    FEELS LIKE SLOW ONSET Cardiac Event:
    Greetings ladies,
    Had abnormal EKG yesterday with inverted T waves on two leads, in the presence of my heart feeling like it’s skipping, running and dropping off beats, and fatigue.

    End of February had shortness of breath and substernal chest pain with drop in bp 80/40 after I took bp meds on empty stomach. I was at pain clinic appt while this happened, had EKG, which nurse said was a little abnormal but I was too sick to ask details. Was trying to stay alive. ER doctor said EKG was normal, all cardiac enzymes normal, other labs normal except wbc mildly elevated. ER doctor said it was from a lack of tissue perfusion from bp being so low. I accepted that but still figured I should go see a cardiologist.

    Got sick washing dishes this past Sunday, dizziness, mild nausea, vague heavy feeling in chest– and felt like I did last time–strange feeling like I would lose control. Worked next day. Walked nearly 5 miles after work. Got sick feeling again at nearly midnight and heart started racing, skipping. Thought maybe low blood sugar so I ate and drank juice. That helped some.

    Stayed off work next two days with extreme fatigue and heart skipping. Worked some Thursday and went to doctor. This EKG was abnormal with inverted T waves. Cardio appt next Friday. Heart still skipping and I’m very tired.

    I wondered if this is an acute process and should I rest it out? Job is extremely stressful and I just can’t deal with the stress. It makes the symptoms worse and makes me feel sick. Also, have Sjogren’s, Lupus, diabetes and hypertension. I’ve been walking for a few years now but the lupus pain hinders it. Past few months I’ve walked 2-3 miles even when every step hurt.

    Thank you for your lovely website and allowing me to post. Waiting upon the Lord….

    Liked by 1 person

    • Carolyn Thomas April 22, 2016 at 12:40 pm #

      Hi Sheila – it strikes me that the one good thing from this distressing list of symptoms is that you now have an appointment with a cardiologist next Friday. I hope this meeting will help to explain both symptoms and the diagnostic test results. Right now, you just don’t know whether your symptoms are heart-related or not, especially living with other conditions like lupus and Sjogren’s (both have been associated with palpitations, for example). I’m so impressed by your persistence in keeping up with your walks, and I wish you good luck in solving this mystery!

      Like

  14. River Song March 24, 2016 at 1:12 pm #

    Was rushed to hospital with chest pain twice last year. Both times all tests were clear, they even said I was imagining the pain and I wanted to be ill. Now past 24 hours, I’ve had pain radiating from my shoulder across my chest and into my neck and jaw. Crushing pain taking my breath away and horrible palpitations. BP is 208/129. Pulse is 87. I’m terrified to go to hospital to be made to feel belittled again. I just can’t do it. Had two almost crippling attacks of pain last night and have just felt wiped out all day with niggling pains on and off. I don’t know what it is and I feel stupid seeking medical help.

    Like

    • Carolyn Thomas March 24, 2016 at 5:20 pm #

      River Song, I’m not a physician so cannot comment specifically on your case, but I can tell you that, according to Mayo Clinic cardiologists, blood pressure of 180 or higher (systolic) OR 120 or higher (diastolic) is known as hypertensive crisis, and emergency medical treatment is needed. Right now you have no idea if your symptoms are heart-related or not, but you need to find out what is causing this BP spike. Do not be embarrassed about going back to get this checked out and do not accept “wanting to be ill” as a diagnosis.

      Like

      • ZooMama April 19, 2016 at 2:26 pm #

        I have the same radiating pain symptoms (shoulder into neck and lower jaw) and was diagnosed with a bulging disc in my neck at C5-C6. It occasionally causes radiating pain that makes my shoulders and both arms to go numb and I lose my breath.

        It was diagnosed by CT and MRI of the cervical spine. None of the doctors at the ER saw the disc problem…it was only after having a spine specialist on the other side of the country review my scans that I finally had an explanatory diagnosis.

        Liked by 1 person

        • Carolyn Thomas April 20, 2016 at 6:47 am #

          Yoiks. A bulging disc?! Amazing that it was missed by ER docs and caught (long distance) from “the other side of the country”. Best of luck to you…

          Like

  15. Andrei October 22, 2015 at 6:39 am #

    What kind of people are you having heart attacks at under 40 ?
    What lifestyle do you have? The blog owner even says in her description that she is a marathon runner. Seriously, I cannot believe one single post from here!

    Like

    • Carolyn Thomas October 22, 2015 at 3:40 pm #

      Andrei, you are misinformed if you believe that younger women somehow do not get heart disease (indeed, in some heart attacks like Spontaneous Coronary Artery Dissection, the average age of patients with this type of heart attack is 42 years; approximately 80% of SCAD patients are female, fit, healthy, and with few or no cardiac risk factors.

      Whether or not you choose to believe what you read here, try doing your own homework to learn more before you blurt.

      Like

      • Jane April 6, 2016 at 8:28 pm #

        If my opinion really does matter, I’d remove Andrei’s post, especially given the fact that our symptoms are often blown off. You do a fine enough job illustrating that “lifestyle” ain’t the whole deal.

        Liked by 1 person

        • Carolyn Thomas April 6, 2016 at 9:33 pm #

          Hi Jane – Every once in a while, I get a perverse thrill in allowing a troll comment through, just to illustrate what we’re up against… 😉

          Like

  16. Gloria Sponselee May 2, 2015 at 8:00 pm #

    Hi Carolyn, Sternum here

    This is the best article I have ever read on heart attacks and women.

    As you know, my HA in 2007 was slow onset and I waited 24 hours before going to the ER, only to be told I was having a gall bladder attack.

    On April 21, I experienced my second HA ….. Nothing like the first one at all.

    This was a fast onset. All symptoms tumbling on top of each other. No hesitation in calling 911 this time. The ambulance arrived so quickly and were able to contact the hospital. The cardiac team was waiting for me and went immediately into action.

    That is why l find this description so great.

    I can vouch for its accuracy from personally experiencing both types and having doctors react so badly to the slow onset.

    Liked by 1 person

    • Carolyn Thomas May 3, 2015 at 4:41 am #

      Hello Sternum – so great to hear from you again (although I’m very sorry to hear about your second heart attack). You raise an important issue here: that a second (or third) heart attack does not necessarily present exactly the same way that the first one did. Symptoms could be far more urgent (like yours were) or far milder – yet we need to respond just as quickly in either case! I hope you are recovering well – best of luck to you…

      Like

  17. TL Miller April 23, 2015 at 5:38 pm #

    I’d been suffering from chest pain for 1.5 years along with fatigue, nausea and sweating. Every instinct I had told me there was something wrong with my heart. I had a cardiologist laugh at me when I told him the veins in my neck hurt. I went to the ER after nearly fainting and was ignored in the waiting room. When they finally brought me back and did an EKG, a nurse informed me I was having a heart attack. I then listened to three different Drs tell me I “didn’t look like I was having a heart attack.” I was diagnosed with Dilated Cardiomyopathy and Heart Failure.

    Frankly, I’m pissed that I wasn’t taken seriously from the very beginning.

    Liked by 1 person

    • Carolyn Thomas April 23, 2015 at 6:07 pm #

      Yikes. No wonder you’re pissed, TL. If only your doctors had Googled your specific symptoms during those 18 months (chest pain, fatigue, nausea and sweating), wonder what would have popped up? Hope you are doing okay these days…

      Like

  18. The Accidental Amazon April 22, 2015 at 8:14 am #

    Great post, Carolyn. It’s really helpful to see a review of slow-onset symptoms. They are just the sorts of things that so many people can and often do choose to ignore for days on end — never mind doctors who may ignore them — until they become too severe.

    It’s definitely better to get the right help earlier. Thanks!

    Kathi

    Liked by 1 person

    • Carolyn Thomas April 22, 2015 at 8:32 am #

      Thanks Kathi – you can understand how tempting it is to ignore those slow-onset symptoms especially at the beginning! So when a doctor suggests that they don’t mean what they mean, it simply reinforces our belief that we’re “making a fuss over nothing”.

      Liked by 1 person

  19. Linda Dowdy April 20, 2015 at 8:24 pm #

    I have CHF and a defibrillator, GERD, recessive MS, chronic bronchitis, Crohn’s-IBS and skin cancer. So needless to say, I have aches and pains everywhere. I’m also 40 pounds overweight! I have some horror stories with Dr and ER before my diagnosis, oh yeah manic-depressive because Bi-polar wasn’t a catch word yet.

    I’m doing well on my meds which I take, but worry about chest pains and such so I don’t become a statistic, I would rather walk on fire than go to a Dr or worse ER. Any advice? Worry to death comes to mind occasionally, however I am a strong positive woman.

    Liked by 1 person

    • Carolyn Thomas April 21, 2015 at 5:39 am #

      Linda, you’ve brought up an interesting and all-too-common problem here – when people have more than one serious chronic condition, it can be challenging to figure out which symptoms are due to which diagnosis. It’s hard to continue being a “strong positive woman” while living with such a long list of significant health issues. Use your strength and positivity to seek out a doctor you can trust (and who will help you avoid worrying to death – that’s a futile way for anybody to go). Meanwhile, you can only do what you can do, step by step, day by day, starting small with those issues you do have some control over. Best of luck to you…

      Like

  20. MaryKay April 20, 2015 at 6:14 am #

    I also went to the E.R. with arm pain upon exertion and also got the diagnosis of acid reflux. One week later – yes one week! – had to have a stent placed. 95% blockage!

    Liked by 1 person

    • Carolyn Thomas April 20, 2015 at 10:19 am #

      Whoah – I still hate hearing these stories, MaryKay. Hope you’re doing better now…

      Like

  21. Penny Wolf April 19, 2015 at 11:51 pm #

    Thanks so much for this terrific, informative and a bit alarming post! The doctor assuring that it was GERD, particularly disturbing. (Do they do that with men, I wonder?) This is as much an indictment of our present medical care as it is informative about recognizing cardiac event symptoms in a timely fashion. But it does amplify how important it is that we listen to our own bodies and try to follow our gut instincts as much as possible–even if we think we might be embarrassed by a false alarm.

    Liked by 1 person

    • Carolyn Thomas April 20, 2015 at 6:30 am #

      You’re so right, Penny: we MUST learn to follow our gut instincts! When it comes to men’s care vs women’s: in 2010, the American College of Cardiology found clear differences in treatment between male and female heart patients despite highly similar clinical characteristics:

      – men were 72% more likely to receive clot-busting drugs than women
      – men were 57% more likely to receive a diagnostic angiogram
      – men were 24% more likely to have balloon angioplasty to reopen a blocked artery once identified via angiography
      – the death rate among men was 48% lower than that for women during their hospital stay

      So I’d guess that the answer to “Do they do that with men?” would still be a resounding NO.

      Like

  22. Annette D. from Florida April 19, 2015 at 2:31 pm #

    I am so glad I found your website. It is educational and women’s stories are so right on!

    I did not have a heart attack but was diagnosed with Stable Angina. One morning I woke up as normal and got out of bed, walked to the bathroom and immediately had a crushing pain in the middle of my chest that radiated to my back. It took my breath away and I broke out into a sweat. I could hardly yell out to my husband that I needed help. I just knew this was not right. I told him, “CALL 911”. 911 got me on phone and asked questions and said do you have aspirin, 325 mg Non-Coated. My husband got it and told me to chew it – No Water and said EMT will be here shortly. They came in, checked me out and took me to a nearby Heart Hospital. The ER Doctor asked me questions and without hesitation said, they will admit me and take lots of tests.

    All the nurses told me I did the right thing by calling 911. They say so many women don’t call and wait it out and think it is acid reflux or think the pain will go away. I passed all the tests in hospital and the stress test. The first thing they said to me, you had a Blip. Blood oxygen was not getting to the heart muscle. Not a major vessel but probably a small vessel. They released me the next day and gave me a prescription of Nitrostat to use in case I have another attack. My Doctor told me to make an appointment with the Cardiologist who took care of me. I will be seeing him at the end of April. Thru all of this, I have to carry this medicine with me at all times and mentally I am wondering when the other shoe will drop. This is not healthy so I am trying to put my mind at ease and go on with my life. Thanks for listening

    Liked by 1 person

    • Carolyn Thomas April 19, 2015 at 2:45 pm #

      Hello Annette – I love this part of your story: “All the nurses told me I did the right thing by calling 911.” That kind of response can be so reassuring for a worried patient to hear – particularly when it comes to heart issues. Your nitro is like a little insurance policy just in case you have further symptoms. Nitro is your friend – don’t be afraid to use it to help dilate your coronary arteries if you have symptoms. That’s what it’s there for. Best of luck at your cardiologist’s appointment!

      Like

  23. Pauline Lambert Reynolds April 19, 2015 at 2:04 pm #

    You are showing me that I’m too sure of myself regarding future symptoms, just because I have 12 stents, from 6 trips in 10 years. I have been thinking that “I know it all” because I’ve experienced left arm pain (1), breathlessness (4), chest/back pain (2) chest/back/stomach pressure pain (1), confusion after stubbing my toe !!! (1).

    While I’m not going to be frightened, I plan to be aware, generally, of what my body is telling me.
    Thanks.

    Liked by 1 person

    • Carolyn Thomas April 19, 2015 at 2:43 pm #

      Hi Pauline – it’s always good to be aware of what our bodies are telling us!

      Like

  24. Curious to the Max April 19, 2015 at 11:57 am #

    Slow onset – very interesting and informative (as always). Made me think about all kinds of conditions, biological or psychological (and geo-political!), that are slow onset and when we finally pay attention it’s because we’re in crisis and it’s too late for cure or amelioration.

    Liked by 1 person

    • Carolyn Thomas April 19, 2015 at 1:12 pm #

      Such an important point, Judy-Judith! When I worked in hospice palliative care, it was tragic seeing so many patients admitted for end-of-life care who had been ignoring/dismissing significant symptoms of treatable illness for years – until it was too late.

      Liked by 2 people

  25. Elizabeth Y., RN, BSN April 19, 2015 at 11:04 am #

    Hello Carolyn,

    Of course I waited, heck I even continued my shopping trip and driving on one of our busiest streets in town. The symptoms woke me up three times during the night and I was still having them while I was looking up my symptoms on the Internet the next morning.

    Once I made it to the ER, my symptoms abated and they were wheeling the 12-lead out of the room when I felt the symptoms coming back. I called to them to hook me up again so they could see what I was feeling. Next I knew there was a herd of medical people around me and I was being whisked off for my angiogram and a stent. Prior to that, everything had been slow, no MD in the room, questions about heartburn, possible injury to my arm, etc.

    What would have happened if I hadn’t had the actual “Big One” while I was in the ER? I may have been on the way home in the car when it happened.

    Wonderful article, thanks! I appreciate your efforts.

    Liked by 2 people

    • Carolyn Thomas April 19, 2015 at 1:08 pm #

      Elizabeth, I think about this all the time – that “what if?” scenario that could kill patients except for one lucky fluke of timing. What if you hadn’t called out and insisted they hook you back up? What if they had refused to do so? What if the symptoms had hit 20 minutes later while you were driving in the car, or at home by yourself? Not that you’re “lucky” to have a heart attack, but you were lucky to have it where and when you did – and that hospital staff also listened to you.

      Liked by 1 person

  26. Jane Claydon April 19, 2015 at 10:38 am #

    Thank you so much for this post. This is EXACTLY how I experienced my heart attack, over several weeks in early 2011.

    I was diagnosed with asthma, sent for a pulmonary function test, diagnosed with gastro-esophageal reflux, and even told that I probably had a rib out of place! At every doctor’s appointment, I said “I think there’s something wrong with my heart,” but that concern was brushed aside, even though my Dad and brother had both had heart attacks.

    Finally, one doctor agreed to send me for an ECG, and the next day I went to the ER with severe chest pains. The first diagonal artery off of my LAD was 98% blocked, and I was ambulanced to the Royal Jubilee, where I underwent an angioplasty and coronary stent. I was 36 when I had a heart attack. It has changed me in ways I didn’t know were possible. It has been the greatest burden and the greatest gift.

    Thank you Carolyn, for all your informative posts!

    Liked by 1 person

    • Carolyn Thomas April 19, 2015 at 1:02 pm #

      Asthma, GERD, dislocated rib – all misdiagnoses delivered despite your “I think there’s something wrong with my heart” insistence. At least you kept insisting!!! Jane, you were so young that your diagnoses were likely tainted by your age alone. Frustrating and potentially tragic! Best of luck to you…

      Like

  27. Mary April 19, 2015 at 10:07 am #

    This post is a GOLD NUGGET. Wait, make that a large DIAMOND of information…

    Liked by 1 person

Trackbacks/Pingbacks

  1. Differentian - August 5, 2016

    […] Slow-onset heart attack: the trickster that fools us … In a later follow-up study published in the Journal of Emergency Medicine….. ♥ Heart Sisters … […]

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  2. Curious to the MAX - October 10, 2015

    […] …cardiac symptoms often come and go – sometimes over a surprisingly long period of time.  They’re not always severe. We may believe that heart attack chest pain must be described… […]

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