A number of my readers contacted me recently to make sure I’d seen Gretchen Reynolds’ new Washington Post article (THANK YOU, dear heart sisters, for thinking of me!) For those who missed it, I want to revisit some key messages from a tragic story about Gretchen’s friend, Anne – her hiking/mountain biking/distance running (also non-drinking and non-smoking) buddy. Gretchen described 61-year old Anne as “kind and capable, modest and fit”. She died suddenly last month. Anne’s cause of death, as Gretchen wrote in her regular column in the Post, was “a bolt-of-lightning heart attack” : .
“One afternoon, Anne rode her bike, climbed off, and complained of nausea and fatigue. Her right arm ached. Blaming indigestion, she took Tums. They didn’t help. She vomited. Her husband suggested Urgent Care. She declined. The next morning, Anne collapsed in their bathroom and could not be revived.”
“Anne should have been safe. She did the right things. She did what I do. She did what I tell everyone to do!”
Cardiologist Dr. Martha Gulati at Cedars-Sinai Heart Institute was quoted throughout Gretchen’s article. She’s associate director of the Barbra Streisand Women’s Heart Center and president of the American Society for Preventive Cardiology (plus – full disclosure! – she also wrote the beautiful foreword to my book!) Here’s what she said in her interview with Gretchen Reynolds:
“There is no doubt that, on a population level, physical activity is extremely good for us and our hearts. People who exercise, people who are physically fit – those are the people who are most likely to stay alive. But on an individual level, fit, healthy people can and do develop heart disease, often silently. They can and do die of it, often suddenly. Any of us can be struck by lightning.”
When I was attending the WomenHeart Science & Leadership patient advocacy training at Mayo Clinic, our group of 45 women (aged 31 to 71, all of us living with heart disease) included vegans, triathletes, and even one very surprised physician. “How could this happen to ME, of all people?” was their shared gobsmacked protest.
This belief that if we do everything right, every day, we can somehow make sure bad things won’t happen is predictably pervasive. We tend to rail against the unfairness of life when this belief is challenged by tragedy. See also: There is No “Fair Fairy” in Life.
Yet I still asked that “Why me?” question after my own widow maker heart attack. I too had been a distance runner with no known cardiac risk factors. It took two years, post-heart attack, for me to accidentally learn in a New York Times interview with OB-GYN Dr. Graeme Smith that the preeclampsia I’d survived during my pregnancy years earlier meant a 2-3 times higher risk of heart attack down the road. See also: Pregnancy Complications Strongly Linked to Heart Disease.
It’s discouraging that we can do all the right things, as Gretchen’s friend Anne had done for decades, yet still succumb to heart disease. We do know that certain lifestyle decisions (to quit smoking, for example) – can in fact lower our risk of future heart disease – but we also know that the broad range of cardiac risk factors (diet, stress, family history, high blood pressure/cholesterol, etc.) can combine to create a perfect storm. (Read Improve Your Odds to learn more).
I’ve written several articles (listed here) about something important mentioned in Anne’s story. Cardiac researchers call it treatment-seeking delay behaviour. According to her friend Gretchen, Anne’s husband had tried to convince her to seek medical help at an Urgent Care Clinic the night before she died. But she declined to go. Nobody can know for sure if she would still be alive today if she’d taken his advice.
This Oregon study is one of many that have identified the six most common patterns of decision-making delays between the time that women first know that something is very wrong and the time when we make the life-saving decision to seek cardiac help.
These six patterns are:
- knowing and going (women acknowledged something was very wrong, made a decision to seek care, and acted on their decision within a relatively short time, typically 5-15 minutes)
- knowing and letting someone else take over (women told someone about their troubling symptoms and were willing to go along with recommendations to seek immediate medical care)
- knowing and going on the patient’s own terms (women wanted to remain in control, were not willing to let others make decisions for them, and openly acknowledged that they did not like to ask others for help – these are the women who drive themselves to Emergency!
- knowing and waiting (women decided that they needed help, but delayed seeking treatment because they did not want to disturb others.
- managing an alternative hypothesis (women decided symptoms were due to indigestion or other non-cardiac causes, and were reluctant to call 911 “in case there’s nothing wrong and I’d feel like a fool” – until their severe symptoms changed or became unbearable.
- minimizing (women tried to ignore their symptoms or hoped the symptoms would go away, and did not recognize that their symptoms were heart-related)
Remember that these patterns are common in both typically severe Hollywood Heart Attack signs as I experienced during my own heart attack (central chest pain, nausea, sweating and pain down my left arm) and when women’s symptoms are what doctors used to call “atypical”. Coincidentally, Dr. Gulati was chair of the writing committee of last year’s long-awaited Chest Pain Guideline – which encourages her colleagues to stop using the word “atypical” to describe women’s cardiac symptoms. These are “atypical” only if compared to men, but they’re perfectly typical in women.
Delaying treatment is especially dangerous when symptoms are described as new or very unusual. But you know your body. You know when something is just not right. What I didn’t know during my own heart attack was that women’s cardiac symptoms can come and go – and then come back again, sometimes for days. What I also didn’t know was that I’d be able to walk and talk and think and drive and go to work despite increasingly serious cardiac symptoms day after day. See also: Heart Attack Symptoms: What Women Expect vs. What We Get
Chest pain is the most common cardiac warning sign in both men and women. And as Dr. Gulati explained, chest pain as described in the new guideline does not always mean a heart attack, but it does merit immediate medical attention:
“ The majority of chest pain is not life-threatening. And in fact, the majority of chest pain is not cardiac – instead due to respiratory, musculoskeletal, gastrointestinal, psychological or other causes.
“But when it IS cardiac, it can be deadly. We have such good treatment, but time is heart muscle. The sooner we see you, the sooner we can treat you.”
And many women don’t use the word “pain” to describe their chest symptoms. Other warning signs that could be heart-related include these:
As Dr. Gulati explained to Gretchen Reynolds:
“If their husbands had those symptoms, women would take them to the ER. I always say, if you would take someone else to the hospital with those symptoms, make sure you get yourself there, too.”
Gretchen Reynolds’ article about the death of her friend Anne begs the question: should we just give up regular physical activity if it can’t even protect us from heart disease?
That question is an example of what behaviour scientists call an “avoidance goal” (e.g. I’m going for a long walk so I won’t become sick someday). Far better instead to undertake “approach goals” (I’m going for a long walk so I can sleep, look and feel better”). There is simply no downside in moving our bodies every day as we were meant to move them, improving every cell from top to toe.
And regular exercise is not a one-shot cardio-protective tonic, but a part of the many ongoing personal choices we make each day. For some women living with chronic illness including heart disease, exercise may look very different than the strenuous aerobic outings of Gretchen and her late friend Anne. For these women, it’s all about small steps, as the late tennis legend Arthur Ashe once advised:
“Start where you are, use what you have, do what you can.”
*Image: Anne, Monterey Bay Half Marathon, 2017. (Photo: Thomas Blog)
Q: Were you or your family shocked by your own cardiac event?
NOTE FROM CAROLYN: I wrote much more on women’s cardiac risk factors in my book, “A Woman’s Guide to Living with Heart Disease” (which includes Dr. Martha Gulati’s beautiful 4-page foreword). 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).