As part of my occasional Dear Carolyn series featuring my readers’ unique narratives about how they became heart patients, I offer today a medical mystery from an Oregon reader. After dueling physicians differed in their opinions of her diagnosis, Lynn Bay now wonders if she actually did have a “real” heart attack, as one of them had diagnosed. Her story may seem familiar to you if you’ve ever had your medical experience dismissed or minimized. Here’s Lynn’s story, with her permission:
“I am a 75-year old retired law enforcement officer, in good shape otherwise. I am also a researcher who has studied forensic science, and many medical journal articles. My first husband had a massive heart attack at age 45. I was his caretaker for 13 years until a heart transplant was needed. He did not survive the wait for a new heart. So when I say I know about heart disease, I’m not kidding. I lived with it.
“I have had a heart attack. I went to the ER in my small coastal town of Lincoln City, Oregon with chest and jaw pain. The Emergency physician there told me that the EKG showed an MI (myocardial infarction, or heart attack). The first cardiac enzyme blood test was ‘normal’, but he said we’d wait for further test results. I had more blood tests over the next two hours. When the enzymes began reacting, he shouted, ‘I knew it!’ and pumped his fist. He showed me the EKG strip where he had circled one part and explained, ‘That’s your MI.” The enzyme numbers kept rising and that’s when he decided to send me to the trauma center in Salem, where they found a 70% blockage and implanted a stent. I was placed on anti-platelet medications and prescribed nitro tablets.
“Five months later, it happened again. I woke from sleep one morning with an awful chest pain, radiating front to back. I took a nitro pill. Five minutes later, I took a second nitro. I then broke out in a wet, clammy sweat and started to pass out. My husband was with me the whole time and called an ambulance.
“But before the ambulance got to the house, the pain was completely gone. Poof. They took me to the ER anyway. It was during shift change at the hospital, so they took one blood test (‘normal’), then the doctor went home, and a second doctor who just arrived told me I had acid reflux and released me.
“My husband was stunned. He had had a heart attack years before and is also a retired police officer, and said: “(bad words) I know what a heart attack looks like and dammit, you had one!”
“So, I take it that you cannot have a heart attack unless you have heart damage. True or false?”
“Your heart sister,
My response to Lynn started with my usual disclaimer that I am not a physician so couldn’t comment specifically on her own experience, but I could share with her some credible resources to help understand just what is or isn’t a heart attack.
These resources include guidelines for diagnosing a heart attack, as described here by Harvard cardiologist, Dr. James Januzzi, Jr. (a member of the Joint Task Force for the Universal Definition of Myocardial Infarction – so I’d say he’s a guy who knows what he’s talking about). These guidelines suggested that a diagnosis of myocardial infarction (heart attack) is appropriate if a person shows a troponin (cardiac enzyme) level in the blood that’s substantially higher than normal, plus one or more of the following:
- – symptoms of heart attack
- – worrisome changes on an ECG (EKG) or imaging test
- – identification of a clot in a coronary artery (e.g. during an angiogram procedure in the cath lab)
When doctors talk about a myocardial infarction, they typically mean that plaque inside a coronary artery that brings oxygenated blood to the heart muscle has ruptured. Cholesterol and other substances lining the artery spill into the bloodstream, and a blood clot forms at the site of that rupture. If it’s big enough, it can block the flow of blood through the artery, starving the heart muscle of oxygen and other nutrients. That’s a heart attack.
But according to Mayo Clinic cardiologists: there are actually distinct forms of heart attack:
1. STEMI or ST-elevation myocardial infarction is caused by a sudden complete (100%) blockage of a coronary artery. It’s a heart rhythm abnormality that’s detected on a 12-lead EKG test, referring to the behaviour of S-waves and T-waves of the heart’s electrical recording.
2. NSTEMI or non–STEMI is a heart attack caused by a severely narrowed artery, but the artery is usually not completely blocked, thus still allowing some (limited) blood flow to the heart muscle.
3. Another cause of a heart attack is a spasm of a coronary artery that stops blood flow to part of the heart muscle. See also: Misdiagnosed: women’s coronary microvascular and spasm pain
4. A less common but dangerous cause can also be Spontaneous Coronary Artery Dissection (SCAD). This heart attack is the result of spontaneous tearing in the coronary artery wall, and is most often seen in young, healthy women with few if any cardiac risk factors.
Here’s the issue: you can be just as dead whether blood is unable to reach your heart muscle caused by a blockage, a spasm or a torn flap in a coronary artery.
The blood test results that Lynn’s first Emergency physician was excited to see were likely blood tests for a cardiac enzyme called troponin T.
This enzyme is part of a family of proteins found in skeletal and heart muscle fibres; blood tests can measure the level of cardiac-specific troponin in the blood to help detect heart muscle injury.
Normally, troponin is present in essentially undetectable quantities in the blood. But when there is damage to heart muscle cells (for example, during a heart attack), troponin is released into the blood. The more damage there is, the greater the concentration of troponin. Troponin levels increase soon after heart damage occurs, and they can remain elevated for up to two weeks.
The tricky thing is that there are other conditions that can also raise troponin levels in the blood. These include heart conditions like heart failure or cardiomyopathy (which Lynn was diagnosed with a few years earlier). Some conditions are unrelated to the heart, such as severe infections or kidney disease. A number of studies have found that prolonged and intensive exercise (doing an Ironman triathlon, for example) can also cause elevated troponins in approximately 80% of athletes. (1)
But for all non-triathletes, troponin that’s detected in the blood is a cardiac danger sign.
Many of the various edits over the years to the definition of a heart attack have focused on the kinds of heart attacks experienced by (white, middle-aged) male heart patients, largely ignoring women’s heart attacks – especially in younger women.
That’s why Yale University cardiologist Dr. Erica Spatz worked on a unique range of heart attack categories (based on the international VIRGO study) that offer another list of possible heart attack descriptions specifically in women under age 55. I wrote about her work here.
Q: Did Lynn have a “real” heart attack? Was that physician correct when he said, “You have to have crushing chest pain that goes to your arms”? *
1) F. Sedaghat-Hamedani et al. “Cardiac Biomarker Changes After Endurance Sports: Expert Analysis”. April, 2016. American College of Cardiology.
(3) J. Canto et al, “Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality,” JAMA. 2012 Feb 22;307(8):813-22.
(4) C. Kreatsoulas et al. “The Symptomatic Tipping Point: Factors That Prompt Men and Women To Seek Medical Care.” Presented at the Canadian Cardiovascular Congress, October 2014. Canadian Journal of Cardiology Volume 30, Issue 10, Supplement, Page S132.
(5) M. Edwards et al. “Relationship Between Pain Severity and Outcomes in Patients Presenting With Potential Acute Coronary Syndromes.” Annals of Emergency Medicine, Volume 58, Issue 6, December 2011. 501 – 507
IMPORTANT: If you are having alarming symptoms that you believe might be heart-related, please seek immediate medical help. Do NOT leave a comment here asking me what you should do. I am not a physician and I cannot advise you.
NOTE FROM CAROLYN: I wrote much more about how heart attacks in women are diagnosed (or misdiagnosed) in my book, A Woman’s Guide to Living with Heart Disease. You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
For definitions of confusing cardiology terms, visit my patient-friendly, jargon-free glossary
* Trick question, dear heart sisters. . . As you may already know if you’ve been a regular Heart Sisters reader here, some women in fact do not experience any chest symptoms during a heart attack; studies have estimated a range of between 10%(2) to as many as 42%(3) of us. And even women who do report chest symptoms often do not use the word pain to describe these symptoms (instead, using words like pressure, heaviness, fullness, tightness, etc.(4) Researchers have also found that the severity of cardiac chest symptoms has no association with the severity of a heart attack or outcomes(5).