2009-09-08

A Fateful Anniversary

Two years ago this afternoon the heart attack hit. What a shock! After all, I was only sixty-one years old! As I write, I have the Cardiovascular Risk Profile my doctor did for me at my general check-up the previous April. It shows my risk of developing any cardiovascular disease at all at ten percent over the next ten years (as compared to a population average for men my age at twenty-one percent). That was so very reassuring at the time and exacerbates my shock at actually having a heart attack so soon afterwards.

As so often is the case with a first heart attack, this came totally unexpected. The only inkling I had that something might be wrong occurred on the Friday before, during my swimming workout. For some time before, I had maintained a working-out pattern of swimming 2500 metres on Monday, Wednesday, and Friday mornings (five 500 metre intervals with the last 100 metres of each as a sprint on Mondays and Fridays and a continuous distance 2500 metres on Wednesdays, sprinting only for the last 100 metres) and a short, 6.7 kilometre bicycle ride on Tuesday and Thursday mornings. The family and I had been away for a couple of weeks in August and that had interrupted my work-out routine, so I eased off a bit in resuming my workouts that week by making all my swims just continuous distance 2500 metre swims without the intervals and sprints and no change in my cycle rides. My Wednesday swim that week felt absolutely glorious; I swam so smoothly and felt such real power in my strokes that I could easily have just kept right on going if I had wanted to take the time (normally, roughly 55 minutes for the 2500 metres, I didn't time my swims closely -- in the pool without my glasses, I can't read clocks readily). I came out feeling great and had just about decided to go back to intervals and sprints for my Friday swim. In contrast, on Friday I felt sluggish and heavy, too much so for sprints. I swam my steady pace swim and. even at that, I had to stop each thousand metres. I swam two one thousands and a five hundred and really felt I had had enough when I got out of the water. I puzzled at not having my usual oomph during my work-out but put it down to day-to-day variability in my response to physical activity and got on with my day.

The attack hit on 2007, September 8, Saturday afternoon. We were to catch a plane to Calgary to help my brother, John, celebrate his sixtieth birthday. During the taxi ride to Vancouver International Airport, I started to feel a bit of burning under my sternum notch, a very familiar sensation from acid re-flux at my hiatus hernia or whenever I have had helicobacter pylori infections give me stomach ulcers. I had gone a few years then, since my last h pylori infection and had been free of heart burn from stomach acids, but this felt totally identical to that well remembered burning. Through check-in and as we browsed airport shops before heading for the waiting area, the burning increased. When we settled into the waiting area, ready for our flight, I asked Tina to get some antacids (we had long ago run out of the proton inhibitor acid reducing medication I had been prescribed in conjunction with h pylori treatment -- they were always wonderfully swift at getting rid of the burning). While Tina was gone, the burning increased significantly, a strange weariness sort of discomfort started in the pit of my left elbow, and I started to sweat inexplicably. When she came back to me I suggested, "I think I'm having a heart attack," and asked her to call paramedics. Tina was wonderful as her nursing background kicked in and she calmly comforted me and went to the attendant at the loading desk to request paramedics. David and Angela responded well also, keeping calm and out of the way as I curled myself up into a foetal position to await the paramedics (I forgot to bring my feet up onto the seat for a true heart attack rest position).

Paramedics arrived quickly (they must have a depot in the airport terminal building), with ambulance attendants following shortly after, just as our flight got called for boarding. Needless to say we did not board. By this time, the pain under my sternum had got intense, accompanied by companion pain down my left arm and profuse sweating that soon drenched my clothing. The paramedics gave me sprays of nitro-glycerine under my tongue to no effect. I remained able to give them good history and describe my pain as they loaded me onto a stretcher and injected clot busting medication. I could not feel any benefit of that but I did settle into tolerating the pain; it seemed to remain at the same intensity but, under care, I felt confident rather than distressed. The short ambulance ride to Richmond Hospital brought immediate admission into the emergency ward and a quick decision to send me on to the catheter operating room in Vancouver General Hospital. I can still remember Oak Street out the ambulance back window rapidly passing under the wail of the siren and blare of the ambulance horns. VGH seemed remarkably quite as the ambulance attendants unloaded me and rolled me through empty halls into the operating room. I found it momentarily empty but a team of nurses and a surgeon abruptly appeared and immediately prepared me for surgery. It seemed such a brief time, must have taken only five to ten minutes, from the moment when the surgeon announced that she was making the small cut at my groin to insert the angiogram catheter until she announced it was out and told an assistant to “plug him up.” The pain was gone, in fact, at that moment, I felt I could just hop off the operating table and go about my own business. The operating room nurses asked if I would like to see a replay of the view of my heart and turned a monitor my way. It showed an image of the arteries supplying my heart with one large area black and blank. They had set a stent and, when the replay reached the point when they expanded the stent to open the affected artery, I saw the previously blank area light up as vessels recovered their blood profusion. I felt awed! Nurses asked me if I felt any nausua. I did not, right then and there, but a sharp wave of nausea hit me promptly after and I vomited vigourously onto the operating room floor. The pain had gone; only at this point did I begin to feel otherwise ill as a deep weariness began to set in. Of the ambulance ride back to Richmond Hospital from Vancouver General Hospital I remember only leaving the emergency parking lot. I simply fell asleep after having remained fully conscious through the entire heart attack and medical response. Fortunately, the attack had never stopped my heart beating.

I awoke Sunday morning in an intensive care ward at Richmond Hospital to a whole grain English muffin for breakfast, my family around me, and a young cardiologist, Dr. Wong, seriously concerned. Something remained not right as I showed signs of congestive heart failure. I simply felt ill. After a quick telephone consult, Dr. Wong sent me back to VGH, to the Coronary Care Unit, this time anaesthetized and intubated lest I “crash and burn” during the ambulance ride. I have no memory of that ride, in fact my next memory takes me to the Monday morning, the voice of a nurse calling to me with an order to “breathe deeply.” I found myself in the VGH CCU, weak in the extreme and feeling deeply ill. Simply breathing proved to be hard work at first. Tina was there and, when the nurses were sure I was fully awake, they brought her to me. What a comfort! I was under the care of another Dr. Wong, a very senior cardiologist at VGH. In due course, as I recovered, he explained what had happened. I had suffered a total obstruction high on the left anterior descending coronary artery (one I would later learn has the nickname “the widow maker” among medical professionals) and it had been opened with a bare metal stent. Damage was extensive and only time would determine how much my heart would recover. I remained in CCU until mid September, initially on complete bed rest but within a couple of days allowed out to walk around my bed and a few more days on to walk around the whole ward. Before I got sent home, I was taking brief walks outside. While in CCU and later, at home, I read heavily, my favourite way to occupy and divert myself while ill. I remain deeply thankful for the wonderful care I received in CCU.

Coming home did not quite end the drama but it certainly marked a milestone in my recovery. I rested a lot, continued to read a lot, and took gradually increasing daily walks around and about the neighbourhood. At first, a walk just around the immediate block taxed me but with Tina at my side and her loving encouragement, the distance steadily increased. When I attended David’s scholarship presentation at Delta Secondary (DSS gives scholarships in September, bringing receiving graduates back for a special presentation rather than with the graduation ceremony before summer), few people there even knew I was ill and that felt satisfying. The drama lay in the mystery of blood periodically appearing in my urine. Except that the heavy blood thinners I had to take permitted me to bleed easily, this had nothing to do with the heart attack. Thinned blood pointed the way to early detection of a cancerous tumour in my bladder that was very superficial and easily removed the following March, once I had finally been off the blood thinners for a while. Two atrial fibrillation attacks in October sent me back to the VGH emergency ward but proved self correcting. The first got me another angiogram that showed no new damage and the second corrected before I even got to the hospital. Through the rest of the fall and into December I steadily increased my walking endurance and distance until I actually felt relatively fit for Christmas. That was a specially joyous Christmas for the whole family.

With the 2008 New Year, I received clearance to enter the VGH Cardiac Rehabilitation Program, of structured and closely monitored exercise specific for heart patients. That was once a week, so I also maintained my schedule of daily walking. Another scare threatened to interrupt my progress when that familiar pain under my sternum sent me into Delta Hospital emergency. The pain increased to a certain level and reached a plateau, there to stay for some time. Doctors found no sign of any new heart issue but held me for observation and scheduled yet another angiogram at VGH. I had to wait five days for that one and for the first couple had to live with bed rest until I got cleared to resume some exercise by walking round and round the ward. Again the angiogram showed nothing new and I got sent home. Only after thorough checking of my heart did doctors check my stomach and find a small duodenal ulcer, likely caused by the aspirin I have to take as a blood thinner. A proton inhibitor added to my medication regimen settled that. The incident demonstrates just how indistinguishable chest pain associated with a stomach attack and chest pain associated with a heart attack can be. I had a repeat demonstration one afternoon just over two weeks ago when I developed chest pain, this time actually in my left side, and Tina dashed me into Delta Hospital emergency. Again, tests showed no indication of any new heart issue, the problem was my stomach and I got to go home in the wee small hours of the morning with further adjustment of my stomach medication.

After mid January, I resumed swimming, just a thousand metres in two and four hundred metre intervals. With the beginning of February, I resumed cycling right where I had left off at 6.7 kilometres, though likely much slower than before. Walking no longer gave me enough exercise and I quickly returned to my pattern of alternating days to swim or cycle, this time six days a week rather than five. I incrementally increased both my cycling and swimming distances over the following months until I recovered my 2500 metre swims at the end of May and reached just under fourteen kilometres on my bike by early November. I even started to better my previous (estimated then, I now wear a heart rate monitor watch to time and control all my workouts) swim times for that distance. I completed the VGH Cardiac rehabilitation in July, declared as fit as can be expected for the severity of my heart attack. I maintained my exercise routine working out six days a week, alternating between cycling and swimming (alternating sessions of intervals as before with sessions of single continuous distance) while really enjoying both until this June. When my back started complaining about having to hunch over the handlebars of my bike, I switched to swimming all workouts for the summer. My exercise routine is now a vital necessity. Before my heart attack, I exercised because I knew it was good for me but, whenever I missed, I never felt the lack. Now, if I miss a second day in a row, I actually begin to feel quite ill with hints of congestion. With my current exercise routine, I usually feel really refreshed after a workout.

The heart attack brought me other life changes in addition to my exercise pattern. At some places on the walls of my left ventricle the muscle has been destroyed and no longer contributes to the heart’s pumping action. I function with a forty-five per cent ejection fraction (normal is sixty per cent and less than thirty-five percent indicates need for pace maker support). I suppose I am literally half-hearted. I tire more quickly than ever I used to and need more rest when I do tire. My limit seems to be about an hour and a half at sustained activity (my exercise sessions are normally about fifty minutes, well within that limit). I hope that will increase as my physical fitness continues to improve. I dropped five kilograms of body mass through the heart attack incident itself, another two kilograms over the months immediately following, and a kilogram and a half more recently. I do not recommend this as a weight loss measure, but it certainly worked for me as those were all excess kilograms. My body conformation is now back at what it was when I was in my twenties. I have to take a lot of medication, much of which doctors tell me I will have to stay on for the rest of my life. This includes baby aspirin to keep my blood thinned, a pill to control cholesterol, blood pressure and heart rate control medication, a diuretic, and stomach medications to mitigate the impact of the other medications on my touchy stomach. Far more frequent doctor visits now make part of my life as doctors track the various issues consequential to the damage to my heart and the medication I have to take. I get to enjoy fresh fruit and raw vegetables with greater liberality than I used to allow myself. I had never used much salt but now have to avoid it as a poison. Hit just a bit of salt in my food and I immediately see the consequence in my blood pressure and feel listless and ill the next day. Before the heart attack my rest pulse lay in the low fifties, now with medication and a well established exercise routine it has fallen into the low forties and my doctors see this as keeping burden off my damaged heart. My doctors and I do everything we can to preclude a second heart attack.

I have to thank the many who shared thoughts, prayers, messages, and phone calls in response to my heart attack. My brother, Norman, shared all e-mail messages with me. Thank you, especially to those who turned their attention to Tina and to David and Angela with encouragement and support as they bore with the trying time. Today is the second anniversary of that event and I have so very much for which to give thanks, including modern medicine and many people’s deep concern.