Civilization, Whither Art Thou

Rosie O'Donnell and Heart Attack Symptoms

Rosie came out recently about her heart attack and how she missed the symptoms.  Everyone knows it seems that when the heart feels pain it can be felt in your left arm, cheat, neck, and jaw; but what people don't seem to know is that there are a variety of symptoms that people experience.  The problem I have with Rosie's special concerning acute myocardial infarctions (AMIs for short and the technical term for a heart attack, I'll just use MI here) is that she makes it sound like women have their own set of symptoms and that she knows exactly what they are.  The truth is that there are multiple types of MIs and they each can have their own set of symptoms; further, not everyone experiences all of those symptoms associated with that specific MI or even any of them sometimes (a silent heart attack).

To aggravate the problem, even organizations like Go Red For Women seems to not have many of their facts straight.  In the first link of this post you can find an article where GoRed editors post that an "EKG revealed that she had 99 percent artery blockage, a situation called “the widow maker.”  The truth is, "the widow maker" is a term that comes from a specific coronary artery, the left anterior descending coronary artery (LAD for short).  The LAD supplies around 50% of the blood to the left ventricle and also most of the blood to the septum of the heart.  If it goes, then the left ventricle is in big trouble.  Clearly, it's very important, hence it's name as the "widow maker."  Also, you can't tell the percentage of occlusion from an EKG.  You can get a really good idea of where it is and even possibly how bad it is, but not a percentage.  Further, all these numbers are estimates.  You can read about estimating percent occlusion here -- if you'd like.

But I want to move onto talking about symptomatology of MIs.  Let's start with the scariest one there is...having no symptoms at all, called a silent MI.  Whose at risk?  The truth is, we could all experience this.  It is estimated that up to 25% of all MIs are silent.  However, those with diabetes and the elderly are at the most risk for silent MI.  So what in the world can you do to mitigate this?  Well, first of all, manage your lifestyle so you minimize the risk for diabetes; second, exercise and try and live a healthy lifestyle (including managing stress).  You can't do anything about getting old, it is simply a privilege that only some of us have.  Lastly, you can visit your doctor if you think you are at any risk, and they can visualize your coronary arteries or run tests to see the health of your heart (preventative medicine!).

Alright, so what about the classic symptoms.  These would include chest pain that radiates down the left arm and/or up into the neck and jaw and maybe just not feeling well.  The truth is, that when angina hits, it often really hurts.  Nitroglycerin is a drug that treats angina, but it often doesn't manage the pain during an MI.  In fact, very often stronger drugs are given to manage the pain.  It is usually the case that these people are diaphoretic as well (sweating a lot).  Sometimes they are also pale, from either a lack of peripheral circulation or intense vasoconstriction in response to the sympathetic nervous system.  What to do if this happens to you: don't wait, call 911.  The longer the heart goes without getting oxygen and nutrients, the more tissue will die.  Barring advancements in science and medicine, that heart tissue will never come back, it will only scar over.

Well those two are relatively easy, but what about these other symptoms?  Alright, so the other major symptoms I haven't already mentioned include nausea, vomiting, shortness of breath, JVD, rales in the lungs, pain in the upper back, and fatigue; and of course, there are also symptoms I'm sure people who had MIs experienced and are thinking why don't I see that on the list.  Well, these are just the most common non-chest pain associated symptoms.  It does seem to be true that women experience these non-typical MI symptoms more than men, but it needs to be pointed out that the typical symptoms are still the most common symptoms in women as well as men!  Rosie states in her show that "we [women] don't even know our own symptoms."  The truth is that men can have these non-typical symptoms as well, not just women.  It just turns out that women have them more often than men, statistically speaking.

Each one of these non-typical symptoms is usually associated with a certain type of MI.  For example, 😲vhcv8&index=5&list=PLDF989DA794DC983F" target="_blank">rales are a certain type of lung sound heard on auscultation; they are associated with congestive heart failure (CHF for short) and are usually caused by fluid buildup in the lungs (pulmonary edema).  The failure of the heart is on the left side, and since the left side of the heart receives blood from the lungs, if it can't receive then the fluid backs up in the lungs.  Many people, including women, end up with CHF after a left sided MI.  Following this logic, JVD (jugular venous distension) can occur due to backup in the jugular veins due to right sided MI.  The right side of the heart receives blood from the superior and inferior vena cava, and the superior vena cava receives blood directly from the jugular vein.  Thus, when the right side backs up we can see it as JVD due to the convenient anatomy of the jugular vein to the surface of the neck.

It is important to note, however, that rales and JVD are signs of other disorders, and not just MI.  You can get fluid in your lungs, have fatigue, and probably some mild chest discomfort from a cold.  Clearly you can have nausea and vomiting from many things other than an MI.  So how do you know when to make that call to the emergency room?  It's a great question, and one that researchers are trying to figure out.  I can only tell you how we in a hospital or ambulance determine if it is very likely an MI (medical jargon: "have a very high degree of suspicion").  

First, we usually take a history.  This clearly involves why we are seeing you today.  Then, if you have any of the following it raises our suspicion that you might be having an MI: hypertension, diabetes, previous MIs or heart disease, smoker, or if you're over 50.  In fact, if someone comes in with abdominal pain and is over 50 the hospital will almost always do an EKG (truth be told, MIs are so variable that many people get hooked up to at least some rudimentary EKG).  If why we're seeing you today is for chest pain, and you have one of those risk factors, we're worried about MI and are going to run an EKG.  While the EKG is getting set up we can listen (auscultate) the heart and lung sounds as well (this is where we'd listen for rales).  We look for certain features on EKGs that are indicative of MIs, and if we see them we can (with a 12 lead) get a good idea of which artery is affected.  But even if the EKG is clean, the hospital will still probably run blood work and look for a certain protein that is highly specific for MIs.  If any of those tests turn up positive you get sent to the cath-lab and are treated for acute myocardial infarction by balloon angioplasty, maybe some drugs, and possibly a stent.  If you get into the cath-lab quickly enough, then the chances of survival are actually pretty good.

What of this can you do at your house?  Probably not much besides the history taking.  You can't interpret an EKG because you aren't trained to and also due to the fact you don't have the machine!  You don't have the equipment to check blood work.  You also probably don't have a great stethoscope or even if you do you probably don't have the experience to definitively say, oh yeah, those are rales or, oh yeah, my lungs sound fine (plus it's damn hard to listen to your own lung sounds, trust me).  And you definitely don't have a cath-lab in your house.  Thus, the best defense you have for MIs is, again, good diet, exercise, and regular check ups with your doctor.  If you know you're at risk for an MI, you have a huge advantage over someone who doesn't.     

To conclude, if you know you are at risk and you are unsure if you're experiencing an MI, then get to the ER and consider calling 911.  If you have no idea if you're at risk, get evaluated.  Hopefully, this little post helps to elucidate the variability of the symptomatology of acute myocardial infarctions, and we didn't even really get into comorbidities or confounding factors.  So yes, Rosie is right, and she is also a bit misleading.  Her songs, which are really fun, suggest that women feel hot, exhausted, are pale, puking, and pain (she calls it HEPPP).  It's a really good list.  The problem is that not everyone is going to have all those symptoms, and that men have those symptoms as well.  Her show and her interviews make it seem so clear cut.  Women are like this, men are like this; but that isn't the case.  In most cases women will experience a heart attack the same as a man; and in some cases men and women will experience non-typical symptoms with heart attacks, and women will experience those non-typical symptoms more than men on average. 

If you don't like men as the reference point, then just flip it all around!  In most cases men will experience heart attacks the same way as most women; and in some cases men and women will experience non-typical symptoms, with women more likely to experience those non-typical symptoms.  But again, here are the big risk factors that need to be managed!  Hypertension, high cholesterol, diabetes, and smoking.  If you don't smoke, then don't start, if you do, then quit.  If you don't have hypertension or diabetes, then make sure to try and keep it that way by eating right and exercising.  If you don't have high cholesterol then great, keep it up; if you do then get it under control.  Heart attacks almost always happen because a coronary artery becoming blocked with fatty stuff (atherosclerosis).  All of those risk factors increase the chance of the arteries from getting that type of blockage.  In the end, for most people, you have the most control over your heart's health.  

Note: I think it was good that Rosie came out with her story.  And I like her HEPPP song.  It is getting people out there looking into heart attacks and their own health.  That's a good thing.  The reason I wrote this was to point out that it is much more complicated than what Rosie is saying.  I don't want someone to watch Rosie in an interview or on her special and think: "Oh, well, I'm a woman and I'm not hot, exhausted, puking, or in pain.  I'm a little pale and there are these veins sticking out of my neck, but that's probably something else.  I guess I'm not having a heart attack."  If you watch the Dr. Oz interview with the Today Show, you'll see that his list of symptoms is different from Rosie's HEPPP list.  Again, I like that Rosie is out there, and I like that people are talking about this, but people need to go to their health care providers, get evaluated, and learn about their risks and talk to a professional.  We cannot be a society that gets its information from comedy specials.   

If you would like to continue reading more, the previous article is called To Eat, or Not to Eat; That is the Question, the next article is called Do We Only Use 10% of Our Brain?.