“I had just completed a workout class when I experienced a bizarre sensation of intense, full-body muscle fatigue. I broke into a bone-chilling sweat. My upper left arm throbbed, a deep ache next to the bone. I was heaving for air at a rapid clip. I grew nauseated. A fist was pressing through my chest to my spine. I was 56 years old, an exercise enthusiast, a non-smoker and a retired cardiac care nurse. And yet I had no idea that I was having a heart attack.
“It felt nothing like I’d imagined. It turns out that it’s hard to recognize a heart attack as it happens.”
Robin explained that what she didn’t understand until much later was this: a deposit of plaque had ruptured in her right coronary artery and caused a clot to form, depriving her heart – and brain – of oxygen. She knew that something was very wrong, but not what.
It was difficult for her to think clearly, or even determine if her symptoms were actually serious. Robin should have sought help, but instead she headed to the parking garage, where her symptoms seemed to ease up as quickly as they had arrived.
But after she got into her car and began driving home, they returned in force, as she described:
“Now I had to merge onto a major highway, then a second, and navigate through rush-hour traffic. I draped myself over the steering wheel, fighting for air. My eyesight narrowed. Instead of pulling to the side, I drove on, gripped by a primal urge to reach home.
“Clarity of judgment had evaporated, a dangerous symptom of lack of oxygen.”
Why had Robin’s heart attack symptoms eased up – and then come back again?
She explained that, most likely, blood flow had temporarily found its way around the clot in her coronary artery, restoring the flow through the damaged tissue, and flooding her heart muscle with oxygen.
But then Robin’s clot formed again. This frequently happens in heart attacks, she said, adding to the confusion that many patients feel as symptoms subside and then reappear. She arrived home just in time to alert a neighbour, who did call 911 for her.
But when her symptoms went away, even the paramedics who had just arrived on the scene seemed to relax:
“When my symptoms suddenly eased in front of the medics – the clot, breaking again, had allowed more oxygen through – they walked me to their van to get what they called a perfunctory EKG. But walking is a dangerous thing for someone having a heart attack. In another moment, my symptoms erupted again. The medic gaped as he read the EKG. He started oxygen, placed two IV tubes and infused morphine.
“As the ambulance raced back down the same highway I had just negotiated, my heart broke into an irregular rhythm. ‘Atrial fibrillation,’ the medic muttered. The right coronary artery, I told myself. A heart attack, definitely.”
Robin describes the Emergency Department as a blur – a team of seven or eight people, a chest X-ray, another EKG, more morphine, oxygen.
“My husband arrived in his own car. I love you, I told him as they wheeled me away. ‘Tell the children I love them.’ I thought it might be the last time I ever saw him.”
Robin Oliveira was lucky. She was diagnosed and treated immediately, with a stent implanted in her culprit artery , and recovered without complications in the Cardiac Care Unit.
Researcher Dr. Sharon O’Donnell of Trinity College Dublin calls this phenomenon of intermittent cardiac symptoms slow-onset myocardial infarction (MI, or heart attack).
In her study published in the Journal of Emergency Medicine, she explained that slow-onset MI is the gradual onset over time of intermittent heart attack symptoms, while fast-onset MI describes the immediate onset of sudden, continuous, and severe heart attack symptoms, particularly chest pain.(1)
When she and her colleagues studied 900 heart attack survivors across five hospitals following their hospital admission for heart attack, this is what they found:
“The most surprising finding for us was that for the majority of people in our study, their heart attack started off with mild or intermittent symptoms such as chest and left arm discomfort, shortness of breath and fatigue.
“For many years, we have tried to reduce pre-hospital treatment delays in patients experiencing heart attacks. But most people expect a heart attack to be associated with sudden, severe and continuous chest pain”
Dr. Anthony Tomassoni is a physician and professor of Emergency Medicine and Medical Toxicology at Yale School of Medicine. He warns against assuming that if your cardiac symptoms temporarily disappear, there is no problem:
“The onset can be very sudden and dramatic, or it can be gradual and subtle, or the symptoms can stutter. They can come and go intermittently, sometimes for months.”
As a result of this pattern, he’s concerned that many people may downplay their cardiac symptoms and fail to get medical treatment until it’s too late. Women are more likely to overlook symptoms of impending heart attacks or cardiac arrest than men are – especially if their symptoms are more subtle.
Dr. Sharon O’Donnell, in her study published in the Journal of Cardiovascular Nursing, interviewed heart attack survivors between 2-4 days following their hospital admission. She explained: (1)
“Whether a patient suffered slow-onset or fast-onset symptoms directly influenced the length of time it took patients to get to an emergency department or treatment by paramedics. And only a third of those with slow-onset symptoms traveled to hospital by ambulance.”
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.
Meanwhile, for three months after her frightening heart attack experience, Robin Oliveira had a series of conversations with her county’s Medic One emergency services.
“I tried to spur them to commit to retraining the firefighters and medics who had mishandled my treatment. The long-standing gender gap in cardiac care, from the time of first contact with physicians or first responders to arrival at the hospital, has improved in recent years – but it persists.
“Despite strides in awareness, women still arrive at the hospital more slowly than men. Time is everything in a heart attack. Women must recognize the danger signs, even amid doubt, and get the immediate help we need.”
1. Sharon O’Donnell et al. “Slow-onset and Fast-onset Symptom Presentations In Acute Coronary Syndrome (ACS): New Perspectives on Pre-hospital Delay in Patients with ACS.” Journal of Emergency Medicine, 14 October 2013
Q: Have you or someone you care about experienced the “evaporated clarity of judgement” during a cardiac crisis that Robin describes ?
NOTE FROM CAROLYN: I wrote much more about women’s heart attack symptoms (disappearing and otherwise) in Chapter 1 of 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 the JHUP code HTWN to save 20% off the list price).