by Carolyn Thomas ♥ @HeartSisters
One of the most surprising things about having a heart attack was experiencing cardiac symptoms that appeared, and then went away, and then returned, over and over again for two weeks until I was finally appropriately diagnosed. What was happening to me? In my (mistaken) stereotype of what a heart attack looks like, I had pictured sudden chest-clutching agony that became swiftly worse until you keeled over, unconscious and/or dead.
Every time those come-and-go symptoms eased up, it helped me to believe the Emergency physician who had misdiagnosed my symptoms as acid reflux before sending me home.
(It turns out that those worsening chest-clutching symptoms DO happen, but they’re far more likely to be caused by a sudden cardiac arrest (an electrical problem) than a heart attack like mine (more like a plumbing problem). Read more about the differences here.)
During a heart attack, it is in fact possible to have alarming symptoms that fade away, and then come back later. A compelling example of this phenomenon was described in the Washington Post by author, former cardiac nurse and heart attack survivor Robin Oliveira.
“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.
She survived.
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
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Q: Have you or someone you care about experienced the “evaporated clarity of judgement” during a cardiac crisis that Robin describes ?
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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 30% off the list price).
.See also:
This is NOT what a woman’s heart attack looks like
Heart attack: is it a clogged pipe or a popped pimple?
Skin in the game: taking women’s cardiac misdiagnosis seriously
Can early warning symptoms predict a heart attack?
Women’s early warning signs of a heart attack
Hysterical female? Just anxious? Or heart attack?
Researchers openly mock the ‘myth’ of women’s unique heart attack symptoms
Time equals muscle during women’s heart attack
Women fatally unaware of heart attack symptoms
Is it heartburn or heart attack?
What is causing my chest pain?
Heart Sisters 
Great article and reassuring. I had a similar experience, symptoms and ER visits without cardiac diagnosis only weeks before I ultimately had massive Widowmaker MI with total blockage main artery.
My MI symptoms were abnormal but persistent for over a week before I got to the ER for diagnosis and 2 stents.
Thanks to you, I now know this to be slow onset MI. The extended delay caused lots of complications in ICU and even now, 5 months later, but I survived!
I am glad to have found this site and and will follow you.
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Hello Cheryl – and welcome to the very exclusive club that none of us ever wanted to join!
I’m glad you found this site, and I’m especially glad that you were finally correctly diagnosed.
Take care, stay safe… ♥
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I have a very unique problem with my heart condition. I have had eleven stents and a Double Bypass. I get my Angina/Heart attacks(2) when I am resting and not when I am exerting myself.
When I go to my Cardiologist for a checkup I run on the treadmill and ECG is perfect, yet I tell him I get severe pains when I am watching TV or in Bed, and sometimes the pain even wakes me. He doesn’t understand and does an Angiogram,and finds blockages.
So anyone out there who has same symptoms when resting, please be aware,you may need a Angiogram and stent.
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I’m glad you mentioned this, Craig. The textbook cardiac signs of stable angina are known to be “symptoms that come on with exertion but get better with rest”, but yours is a good example of UNstable angina (pain at rest) – that shows why paying attention to your body when you know something is just not right is SO important!
Unstable angina like you have experienced is a serious warning sign of an impending cardiac crisis.
Stable angina, on the other hand, is less of an emergency (in fact, many people can live happily with stable angina for years, well-controlled by medications). More about angina here.
Thanks for that reminder!
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That scenario sounds much like my experience of a heart attack. It was a Sunday evening and I was in a yoga class; hadn’t practiced for a while and it was a strong class, and various bits of me were aching particularly around the lower rib cage and arms – which I put down to the exertion. I ended the class on my back on the floor, feeling distinctly unwell with pain around my ribs and down my arms. A heart attack never occurred to me as the cause!
After about 10 minutes it eased off and I got up, showered, changed and drove myself home. Then did another class on Tuesday evening with no issues, and felt great afterwards…
It wasn’t until late on Wednesday, after dinner, that the pain in the lower rib cage and arms returned and refused to go away. Called an ambulance at around 11pm and just after midnight we rolled into the emergency department. But it still took several hours to confirm that I was having a heart attack – NSTEMI but troponin level sky high – and even longer to organise the nitro infusion needed to properly ease the pain.
An angiogram on Friday showed 99% blockage in LAD and 80% blockage in another artery. The hospital kept me in CCU over the weekend (with everyone tiptoeing round me like an unexploded bomb) and I had 5 stents implanted on Monday morning when all the cardiologists were back from their fun weekend. It was only afterward that I realised I could have died on the floor of the yoga studio…
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Remarkable how “normal” your daily routine seemed in between those dangerous symptoms, wasn’t it? Also remarkable that a 99% blocked artery (the left anterior descending, the so-called “widowmaker”) wouldn’t be considered serious enough to summon on-call cardiologists to help you during the weekend!
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It was a bizarre episode altogether. Even on the Wednesday evening, I didn’t think “heart attack”, I thought the pain was something like really bad indigestion – until the ambulance crew broke the news…
The yoga class on Tuesday was one of the strongest classes I’ve done! Not to mention walking dogs and going to work as normal.
The angiogram was done around 5pm on Friday; I had the bizarre experience of seeing first one, then two, then ultimately FOUR cardiologists looking at my images onscreen (while I was awake and still catheterised on the table) and sucking their teeth in what I now realise was amazement – at how blocked my arteries were and how relatively stable I seemed to be.
Obviously there could have been complications over the weekend if they had stented there and then, especially as I finished up with stents in LAD, CIRC and OM; they collectively decided that there was too much complexity and risk of being called in off the golf course, and to keep me stable over the weekend until the hospital was fully staffed again on the Monday. And in fact that was the right decision, the blockage had apparently reduced somewhat over the intervening period.
Even better, I escaped with very minimal damage to the heart muscle – but it was a close run thing and could have gone sideways in many different ways!
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That’s an interesting phenomenon, Paul – the fact that blockages can sometimes be seen to reduce in size over time. But there’s another mantra in cardiology: “Time is Muscle” (supporting the need for us to seek help sooner instead of later). I’m not a physician but I’m guessing you were on a number of cardiac drugs over that weekend (clot-busters, vasodilators) to help ward off a serious heart attack. Collateral arteries may have helped, too.
In any case, you made it!
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Definitely yes on the medication front: clopidogrel (plavix), aspirin, heparin, statins, ACE inhibitors, beta blockers… and confined to bed, no exertion at all. I wasn’t even allowed to walk 20 yards to the bathroom, and was hooked up to monitoring equipment every second of that weekend.
Modern cardiology is a marvellous thing.
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It is indeed.
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My sister and I are coming to the Mayo Clinic March 20-22. Teresa has a widow maker heart attack 2012 leaving her with just a third of her heart working. We are coming there for a second opinion as the doc here wants to put a defibrillator in. Would it be possible to speak with a woman who has had the procedure? Teresa is 59. I think it would really help her in making the decision if the doctors there feel she should have one put in.
Thank you
Sharon
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Sharon, that’s excellent news that you’re accompanying your sister to her Mayo consult. You might want to post your question in this article (What heart patients want ICD makers to know) where more readers living with an ICD will be. You might also check into the WomenHeart online support group where your sister can ask questions or just read stories from many women living with ICDs. There are dozens of specific topics to browse. It’s free to join, and thousands of heart patients available to chat 24/7. Best of luck in Mayo…
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My GP ordered CT scan of my brain with contrast. They couldn’t get an IV in me. Then,
after several abusive attempts, I asked to speak to a radiologist. I was told I did not need contrast! Ladies advocate for yourselves always.
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Don’t depend on doctors to keep you well!
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It’s not always that black and white, Roslyn. I can depend on my own abilities in general, but when I’m really ill (as Robin demonstrates so well in this article), diminished blood flow to the brain means many decisions/choices I might make during a crisis are not sound (e.g. “Clarity of judgment had evaporated, a dangerous symptom of lack of oxygen.”) I do depend on my doctors for both important skills and support, especially when I’m not well.
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It’s always a smart idea to advocate for ourselves if we are able.
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