Jim, a seemingly healthy man, suffered an unexpected heart attack at age 56. Here's what happened.
Shortly after breakfast on a January morning, while on a business trip, Jim developed a feeling of "fullness" in his esophagus. He had experienced this in the past and attributed it to heartburn. The difference this time was that the feelings recurred. Over the next 90 minutes he experienced four or five episodes of discomfort with nausea, sweating, and generalized upper body weakness in a crescendo pattern. His co-workers noted that he was very pale and called 911.
Jim was admitted to a hospital in Massachusetts. The EMT folks in the ambulance told him he wasn’t having a heart attack - that most likely he was having acid reflux and that the symptoms were often the same. He was given nitroglycerin spray to help relieve the pressure in his chest.
On arrival at the hospital Jim was seen by a cardiologist who noted that, although his EKG was normal, his blood enzyme levels had risen slightly in the first few hours since the heart episode earlier that morning.
Jim's enzyme levels continued to rise during the six hours after the heart episode. This was crucial to his diagnosis and treatment. Remember - his EKG was “normal.” Twenty years ago Jim probably would have been released from hospital without the treatment he desperately needed because only in the last few years have enzyme levels been measured during the hours after a likely heart attack.
At the hospital Jim was put on an IV and given blood thinner, aspirin, and blood pressure lowing medications. He was transferred to the Cardiac Care Unit at Boston Medical Center where he was scheduled to have a cardiac catheterization (angiogram and likely angioplasty) the next morning.
Jim's wife and father flew from Florida to Boston to be with Jim. They arrived at Caritas Christi Norwood Hospital by car about two hours before the transfer to Boston Medical Center. Jim's Dad drove in the ambulance with Jim, and his wife followed in the rental car.
The next day, during the catheterization, the surgeon found that one of Jim's three major coronary arteries (the left anterior descending artery or LAD) was 90% blocked. The other two coronary arteries were clear. The plaque in Jim's coronary artery had cracked for some unknown reason.
Most adults in North America are walking around with as much plaque as Jim, but the problem was that Jim’s plaque cracked. When that happened, the platelets got caught on the tear and formed a clot. That clot is what blocked Jim's coronary artery and caused the unexpected heart attack.
To correct the blockage the cardiologist inserted a metal stent in Jim's blocked coronary artery after he removed the clot. The surgeon noted that Jim's artery had a large diameter, and consequently the stent in his artery was relatively large, which was in Jim's favor as large stents do not block again as easily.
After the heart procedure, Jim was not allowed to move his right leg for at least eight hours due to the catheters that were inserted into the femoral artery in his right leg. When the catheter was removed, a collagen plug was inserted into his artery so that he didn't bleed. Immobilizing the leg is essential to prevent bleeding. Jim's insertion site became very bruised and purple, which often happens.
Jim was given an echocardiogram on the day after the catheterization. The standard (ultrasound) echocardiogram showed that the heart attack did very little damage to Jim's heart - thank God.
The heart attack occurred on Tuesday morning. The cardiologists at Boston Medical Center did the catheterization, angioplasty, and inserted a stent on Wednesday. Jim was released from the hospital on Friday.
He was instructed to contact his primary care physician upon return to Florida and arrange for follow-up and referral to a cardiologist
Jim was advised that because he’d had a heart attack he will always have
He was also told if he had taken a stress test the day before the unexpected heart attack, it would have most likely been normal.
He saw his doctor the day after arriving home in Florida. She told Jim and his wife that she was very surprised to hear of his heart attack. In fact, Jim's cardiology case had been much discussed and researched in the local medical community because Jim did not fit the profile of a 56 year old individual likely to suffer a heart attack. She referred Jim to a local cardiologist who saw him two days later.
Jim was told that he needed to begin a cardiac rehabilitation walking program after a couple weeks of recovering from his angioplasty. He went to a cardiac rehab program three times a week, early in the morning for a total of 36 sessions.
Overall, he felt he was able to greatly improve his fitness level by going through the program. There were periods when he had to travel on business, but when he was out of town, Jim made sure to continue exercising on his own.
An important part of Jim's recovery was a serious effort to lose weight. At the time of his heart attack in January, 2008, he weighed 225 pounds. Initially the doctor suggested that Jim should reduce his weight to 200 pounds (Jim is 6' 2"). Later he suggested aiming for an even lower body weight... 170-190 pounds is the healthy body weight range for a person of Jim's height, according to the BMI (Body Mass Index) calculation.
Here's how Jim's weight loss progressed:
Week 1: 220 pounds
Week 2: 216.5 pounds
Week 3: 215.75 pounds
Week 4: 213.8 pounds
Week 5: 214 pounds
Week 6: 210.5 pounds
Week 7: 210.5 pounds
Week 8: 207.8 pounds
Week 9: 207.8 pounds
Week 10: 206.2 pounds
Week 11: 205.8 pounds
Week 12: 206.4 pounds
Week 13: 206.6 pounds
Week 14: 205.5 pounds
When Jim met with his primary care physician to review his blood test results, the best news was that Jim's LDL (bad cholesterol) level had plunged from the 109 level that he had on the day of the heart attack to just 44. The more concerning news was that Jim's HDL cholesterol (the good cholesterol) level was 27. The HDL level needs to be above 40. The doctor said that exercise and eating the good Omega/fish oil fats and flax seeds will usually raise the HDL cholesterol level.
Jim was also prescribed to take Niaspan. It’s said to be very effective in raising HDL cholesterol levels but many people have had problems taking Niaspan because it often causes flushing (skin turning bright red). The doctor's nurse told Jim that he should take the Niaspan at night, and with applesauce. She said something about the pectin in the applesauce helps prevent the flushing. And it was very important that Jim take his daily aspirin 1/2 hour before he takes the Niaspan. (Editor’s note: follow your doctor’s instructions, which may vary depending on the patient)
Jim took the Niaspan as the nurse directed, and had no flushing at all-except for the one night he decided to take Niaspan without eating the applesauce. Sure enough, a couple hours later he flushed, and he described the flushing as fairly obnoxious.
The other surprising and concerning news was that Jim's glucose fasting blood level was 109 mg/dL. That is considered pre-hyperglycemic or pre-diabetic. The glucose blood level should be below 99. Jim needed to eat lean proteins and reduce his intake of grains and root plants (i.e. potatoes) – and any grains consumed should be whole grain.
He asked the doctor about salt intake. She said that Jim shouldn't eat more than 2000 milligrams (mg) of salt daily but she also said it really isn't possible to eat too little salt.
Jim asked if having had an unexpected heart attack at the age of 56 meant that his siblings or adult children should make changes in their own medical care. The doctor said family history is usually a medical wild card. His adult children would benefit by improving their diet and choosing a heart healthy lifestyle. She said that his siblings should consider discussing it with their doctors, and that their doctors would decide an appropriate course of action.
Jim had his second appointment with his cardiologist at the seven week mark. The appointment began, as most doctor appointments do, with the nurse checking his weight, blood pressure, pulse, and a review of his medications.
The cardiologist listened to Jim's heart, reviewed the blood test results, and concluded that Jim had a low relative risk for a future cardiovascular event.
Without warning one March night Jim, had a few dizzy spells beginning at about 10:15 PM. He had about four dizzy spells that lasted about 30 seconds each. The spells were about 10 minutes apart. One time he got dizzy when he stood up from a chair. During the other dizzy spells he was sitting in the living room using his laptop computer.
This was the first time that Jim had felt dizzy since his heart attack in January. He had no idea why it was happening. He called his cardiologist's office and the doctor who was on-call said the dizziness might be caused by one of the heart medications that he was taking. Jim's pulse was running between 55 and 85 that evening, which is normal for him. His blood pressure was the usual 100/60. The doctor said the dizziness could be caused by his medications. That was probably the case since his pulse was normal and steady. The doctor told Jim he could go to the Emergency Room and have his heart checked, but that it probably wasn't necessary, and that he should call his cardiologist the next day BUT if Jim felt anymore dizziness that night, he should go to the ER.
About an hour later, Jim felt dizzy again for about 30 seconds. At that point he and his wife decided he'd better go to the ER to get checked out.
Within 30 minutes after arriving, Jim was admitted and was in an examining room. The hospital had none of Jim's medical records since his heart attack occurred while he was traveling on business in Massachusetts, and he was treated at Boston Medical Center. So he told the ER doctor his heart attack history and how he had been treated. The doctor ordered blood work for Jim, a chest x-ray, and an EKG. All were normal. But the doctor also said that he would probably admit Jim so that they could measure the enzyme levels in his blood for the next 12 to 18 hours.
After about two hours in the ER, one of Jim’s physician's partners came by to examine him. He was checking to see if Jim had any signs of having had a mini-stroke. Thankfully, Jim did not. And he had not had any more dizzy spells in about four hours.
By about 1:00 PM the next afternoon, all Jim's blood tests had normal enzyme levels, so it was concluded he had not had another heart attack. Jim's cardiologist came by and said that all Jim's tests were fine. He said that the dizziness could have been caused by his blood pressure lowering medicine, Lisinopril. He told Jim to stop taking that medication, and to keep an eye on his blood pressure. If Jim's blood pressure was to rise above 120/80, then he was to call his cardiologist.
On the first day when he did not take the Lisinopril, Jim’s blood pressure was 115/65, so it was a little higher than it had been when he was taking Lisinopril but within the desired range. The other good news was Jim had no more dizziness either.
A month after the dizzy spell - Jim's blood pressure remained normal or below normal - without taking any blood pressure medication.
Why did this happen to Jim?
This is what is so puzzling about Jim having had an unexpected heart attack at age 56. He had NO risk factors. Jim never smoked one cigarette or anything else-not even in college. His cholesterol was in the normal range. All the cardiologists and his family doctor were absolutely stunned that this happened.
Jim's weight is 187 pounds and he’s doing well with his weight control. He NEVER deviates from his food plan. He plans to lose more weight, hoping to get down to 170 pounds. Jim's waist has shrunk from 42 inches to 35 inches, but he still wants to get rid of all of the abdominal fat he can. At his last visit with the cardiologist Jim's HDL level had increased to 40. Jim's blood pressure is stable at about 105/65, and he is not taking blood pressure lowering medications, though the beta blocker he takes does have a blood pressure lowering effect.
When asked how his life has changed, Jim said he does a whole lot more aerobic exercise now and a lot less eating!
Jim commented that he had led a sedentary lifestyle for about five years leading up to the heart attack. Now he exercises 50 minutes seven days a week! He walks on a treadmill 2-3 times a week at an 8.5% grade at 3.3 mph. He swims 1/2 mile two days a week. One day a week he walks for 60 minutes. The other days he bikes for 50 minutes. For all his exercise sessions (except for walking and swimming), he wears a heart rate monitor around his chest.
Since his heart attack, Jim has eaten a vegetarian diet except for nonfat dairy and salmon. He doesn't eat potatoes because of their high glycemic index. He has lost weight by following the Weight Watchers points plan that determines portion sizes and number of portions to eat perday.
And Jim takes his medications every day and at the same time each day (give or take an hour or so).
Jim's advice to others: Having normal numbers on things like your cholesterol doesn't mean that you're in good shape. It means that you have the normal amount of risk which is still considerable - considering that heart disease is the number one killer in North America.