A Heart Attack and the Senior Athelete: A personal account.

Once again I found myself in an emergency room; this time, in Grand Junction at St. Mary's hospital.  Unlike my previous ER visits, this was not because of cycling, but in spite of it.  I was looking at my new favorite cardiologist and he was telling me that I was having a heart attack.  I had been rushed from the ECG room to the "Cath Lab" and was surrounded by a team of 8-10 doctors, nurses, techs and PA's. The entire team was serious and seemed competent (turned out, they were). But they were in a hurry:  Someone was pulling my clothing off, another was putting in an IV, and everyone in the room gave me aspirin to eat while they were injecting high octane anti-coagulants.  If the team could find the problem and resolve it in less than 40 minutes I had a good chance of having an uncomplicated recovery. As they were working, the right side of my heart, near the pacemaker node, was oxygen starved and cells in that area were dying. Their goal was to minimize cell death. Someone handed me a form saying I needed to sign it before they could proceed.  The cardiologist told me that mortality was 1% from the procedure.  However the team, and/or the drugs they gave me, made me feel secure in their hands. They let me call my wife, Deb; I left a message saying I was having some heart problems, but I was in good hands; however, it would be good if she could get to St. Mary's soon.  At some point, someone made an incision in my femoral artery near my groin and inserted a catheter. They guided the catheter from my groin to my heart using X-ray imaging, once the catheter was in position they injected a dye which was used to find the blocked artery. After they located the block, they cut through it using a catheter with a cutting tip.  They then maneuvered a steel-mesh stent into place to keep the vessel open. This particular stent elutes a drug that suppresses plaque formation, and helps to keep the stent open.  I was awake during the process and was unbelievably relieved when Deb hurried in just as they had finished the procedure.  From the satisfied vibe in the room I could tell that everyone was pretty happy with how well things went.  I was pretty happy too, both because of their response, and the wonderful happy-drug they gave me to take away the chest pain. I was moved to the ICU, one of my least favorite places to be, for any reason.

I have been an active person for most of my life.  Since 1973 I have been a climber, cyclist, XC skier etc, etc.  Hey, I lived in Boulder; it was the price of admission.  As a way to stay in condition for alpine climbing I had taken up cycling, which as I got older and the number of climbing partners dwindled, took on a life of its own.

On Mt. Hunter, Alaska

 Unlike climbing, I did not need a partner to ride and I enjoyed the occasional mountain bike race or organized road ride.

On the podium stage 3, the BC Race.  A 7 day Mountain Bike Stage Race. My teammate, Guy, (far left podium) is a former Pro Rider and one of the strongest mountain bikers I've ridden with.

I have cycled, hiked and climbed on a regular basis, usually riding 3-4 days per week.  I have paid attention to my diet, though I admit to an addiction to ice cream and if truth be told, red wine. My cholesterol numbers never reached the point that my family physicians thought it should be treated.  There is, as far as I know, no history of heart disease in my family.  Hypertension certainly was a problem for my mother and I always had slightly higher than normal blood pressure readings, never quite high enough for my doctors to suggest treating, though.  After being hit by a car in 2005, however, my blood pressure went way out of the normal range and since then has been controlled by the usual array of anti-hypertensive medications.  My weight has hovered between 148 and 153 for the last 15 years, a little on the high side for a 5’6” individual, but not excessive.  So all in all, nothing in my medical history or in my lifestyle suggested to me, or anyone who knows me that I was a candidate for cardiovascular disease. I figured, given the blood pressure problems and family history, that a stroke or cancer would close my door (molecular biologists of my era were exposed to radiation and lots of really nasty chemicals in the course of our training and careers). There is one other potential predisposing element.  Stress.  I am prone to it and had many years of fairly high level stress through my graduate school years and two start-up biotech companies, the last of which I was V.P. for R&D.  The scientific evidence linking stress to plaque formation is a bit murky with some studies showing a correlation and others not, but it may be linked to platelet activation which is one of the early steps in plaque formation.

In the weeks leading up to the event, I had been experiencing a burning sensation in my chest at the start of bike rides.  This was accompanied by indigestion.  I attributed these sensations to the fact that it was winter and I usually did not go for my rides until after lunch, when it had usually warmed up at least to freezing.  The idea that indigestion of some sort was the problem was reinforced by the disappearance of symptoms as I warmed up or increased the intensity of the ride.  I was pretty certain that if the symptoms were cardiac, that they should get worse as I increased my exercise intensity. The symptoms were also not the kind that I had read about. There wasn't a crushing sensation, feeling of tightness or pain that radiated into my shoulder and neck.  Nonetheless, I thought it would be a good idea to make an appointment with my primary care doctor.

We met, and he, too, said that the symptoms did not seem like they were cardiac in origin and thought they could be indigestion too.  I had made the appointment to talk about the chest pain and also for my annual physical, so I was surprised that he did not do an ECG.  In the past this had always been a part of my physicals. I think the root of his mistake was my appearance and his knowledge of my attention to diet and exercise. Although I weighed more than I like, at 148 I wasn't grossly overweight.   If my friend Guy had been his patient, I suspect that he would have ordered a followup, simply based on appearance when in fact Guy probably has equal or better cardiac fitness than I do.   My mistake was that everything my doctor said was what I wanted to hear. I did not want to believe that I might have cardiovascular disease, and was elated to hear that my doctor thought it unlikely. Given that I am married to a physician and have probably slightly better knowledge of medical issues than average, I really should have not just walked away from the appointment without asking a few more questions and given the potential seriousness of a misdiagnosis I should have gotten another opinion.

What I did instead, was to go for a ride. It was winter and a ride along the base of Colorado National Monument is spectacular in the winter.

Colorado National Monument

 I did not eat before I left, expecting to avoid the indigestion problems.   However, the usual symptoms soon appeared, but I continued the ride.  The burning sensation lasted for the full 25 miles this time, subsiding a bit as I rode the final 400 foot hill to our house.  I was a little concerned but, my doc had assured me that my heart was OK.  So, I showered had some lunch and went to run some errands.  As I was paying for a hard drive at Best Buy, the chest pain came back in the same form it had always had, a burning sensation.  The intensity ramped up quickly and by the time I was finished paying, I was pretty sure that something bad was going on.  Was it lung cancer, a heart attack or really bad indigestion again?  I figured if it was the middle bit, I best get myself to the ER, about a 10 minute drive away.  I know I shouldn't have driven, but I also knew that it would probably take at least twice as long to get help via 911.  My wife thinks I have a high tolerance to pain and if that's true, it did become useful on the drive to the hospital, particularly at one of Grand Junction's notoriously long red lights. By the time I reached the ER, the pain was sensational.  I described it as “chest discomfort” to the nurse at admissions.  A word of advice, don't downplay chest pain.  Even though I had, the nurse was a pro; she had me in a wheelchair in no time and taken in for an ECG.  A few minutes later, my favorite cardiologist was telling me that I was having a heart attack.

Why did my primary care doctor (who is no longer my primary care doctor) blow it? I was having a heart attack about 4 hours after leaving his office.  I've already discussed some of the reasons.  My symptom profile was decidedly atypical.  Why did the pain go away while exercising, after all physicians use an exercise stress test to detect cardiac problems?  One of the endpoints of a stress test is exercising to a level that causes angina (chest pain). It is supposed to get worse not better as your exercise intensity increases.  Well, my cardiologist explained that to me.  If the block grows slowly and you exercise regularly, your body can build a bypass of vessels around the block.  When you exercise, increasing cardiac load, these bypass vessels dilate (get wider), allowing blood to flow to an otherwise blocked area. So, until the block became 100%, my vessels would constrict, as the exercise intensity dropped but the low level of blood flow through the plaque-restricted vessel would be enough to deliver oxygen and prevent angina.  However, once100% blocked,  the constriction of the bypass vessels prevented adequate blood flow and the heart attack occurred. I have talked to several "elder-athletes" that had no trouble passing a stress test only to either continue to have angina while riding or running or to actually have a heart attack.

 This pattern fooled me and my regular doctor.  I wanted to be fooled so I have an excuse. In my opinion, my physician  should have done several things:  He should have told me to refrain from intense exercise; drawn blood to check for markers of heart damage; arranged for an ECG; referred me to a cardiologist; and, I think, given me a prescription for nitroglycerin to use when the chest pain presented itself.  Nitroglycerin causes a near immediate dilation of blood vessels and if the chest pain is relieved in response to a dose, it is a strong indicator of a cardiac problem.  This should have been done based on the risk factors I do have: age, sex and hypertension.  For my part, I really should have insisted on this course and if Deb had been with me I'm sure she would have insisted. Deb is a physician and a good one. If I had said more to her about the chest pain while riding I'm sure she would have insisted on a full cardiac workup. But, I was in denial and did not talk very much about it until a few days before my MI.

Why was my vessel blocked? After all I thought I was doing everything right.  We eat mostly a low fat Mediterranean style diet, that is low in cholesterol and  I exercised regularly.  Well, all of the recommendations that a person gets, for example keeping cholesterol below 200 and HDLs high, are based on the results of studies done with populations of people and averages.  For many people these guidelines work. It is useful to keep in mind that 60% of patients with coronary artery disease have no or only one risk factor. My father-in-law is 84 and eats a diet high in cholesterol and was a smoker for many years. He is perfectly healthy for an 84 year old, hell, for most 64 year-olds.  He comes from British ancestry so perhaps he has the Keith Richards Gene which protects against all known toxins. 

 In hindsight I had probably become symptomatic more than a year prior to my heart attack.  I had noticed that I was not tolerating altitude as well as I used to. I have always done well at altitudes above 9000 feet and have climbed a couple of 18,000 ft. peaks without significant acclimation problems. 
 

Selfie, on the summit of 18,000 ft Mt. Ishinca. Peru.

Over the last year I found that I was getting dropped by riding companions that I could usually keep up with and was even getting winded on pretty tame snowshoe outings. I was also sweating profusely during exercise.  I attributed all of these things to my age (64) and had resigned myself to this drop off in aerobic performance. Although it is unlikely that a physician would recommend these tests based on a drop in a 64 year old's athletic performance, two tests may have revealed a block forming:   Coronary angiography (http://www.nhlbi.nih.gov/health/health-topics/topics/ca/)  or an imaging technique called a coronary artery calcium scan (http://www.nhlbi.nih.gov/health/health-topics/topics/cscan/). The two links provided describe these techniques.  I as told, by some of the folks who worked with me at St. Mary's Cardiac Rehab Unit of several patients who had avoided heart attacks by having these scans done. The incipient blockages were detected and corrective action taken before they had heart attacks.  One of the two was asymptomatic.

Last week I had my 6 month check up with my cardiologist and was given the all-clear to resume normal activities, although I am to avoid all out efforts that would put me into an anaerobic training zone.  Rats, no intervals!  I went through the cardiac rehab program at St. Mary’s and strongly recommend it.  Unless you are a total stud or studette, your heart attack experience will uh, result in a somewhat subdued state of mind and body.  In other words, you may be unable to make yourself resume normal activities including your favorites (sex, running, cycling, climbing, whatever). The rehab program I experienced brought me up to speed by increasing my activity levels while monitoring my heart, pulse and blood pressure during exercise.  This is a comfortable and reassuring way to begin living your normal life again. I highly recommend it. During my rehab sessions, I was warned that many people who have had a heart attack will experience an intense depression at some point. Mine hit about 6-8 weeks after I got out of the hospital.  You want to be on guard for this and try to get help right away.  Most people cannot “walk it off” without help, I certainly couldn’t.  Depression is a risk factor for cardiac disease so it may well slow down your recovery and it is likely to keep you from resuming your normal activities as quickly as you otherwise might. Like me, a lot of people who have had heart attacks experience a pretty high level of anxiety afterward.  Any real or imagined chest pain would totally freak me out.  Luckily someone from Dr. Garmany's office was always available to discuss my problem and walk me through the reasons why it wasn't another freaking heart attack. It was helpful  to remember that my angiogram did not show any other signs of cardiac vessel blockage, and in reality, I was far safer now than I had been a year ago when remote mountain biking rides and hikes were things I did frequently.

Dr. Garmany and I at 6 months. Feeling happy about what he had to say.

The day of my heart attack, my cardiologist predicted that I would be back on my bike and riding the Monument Rim road in less than 6 months.  His confidence was a great morale boost and a terrific incentive for me to develop a recovery exercise plan. I am back on my bike, although my heart rate is limited by the drugs I am taking to help it heal the damage done by the heart attack. I have found that I have regained the endurance I thought I had lost forever. Most of my rides have been on the road.  Fortunately there are far fewer cars on the road in Grand Junction so it is not nearly as harrowing to ride here as in Boulder, where I had been hit by cars twice. Because of the anticoagulants I’m taking and my comical mountain biking skills, the road is the best choice for now.   The last time I rode my mountain bike, a minor crash left me looking  like I had been worked over by Bruce Lee. I find that all of my rides mean a lot more to me now and have a profoundly positive effect on me. I understand, given my propensity for solo adventures, that I am a very lucky man.

 Since my heart attack I have been able to meet up with my old pals, Tony and Darwin, for a climbing trip, which had its moments of drama for me. It was the first time I had been away and alone since I entered the hospital. My first night out, I was camped in an isolated part of the Navajo Reservation and had the mother of all panic attacks. I seriously considered packing up in the middle of the night and driving back home.

Ancient ruins near Navajo National Monument

 Fortunately my good psychiatrist had given me just the right prescription for moments like these. There was a moment of drama for Tony and Darwin as well when they lost sight of me when I took a wrong turn on the hike back to the car.  They were sure they were going to find me on the ground when they hiked back to look for me.  We combined the climbing trip with a birding trip; I am a complete newbie so it was good to be with two very experienced birders.  Tony and Darwin are two of the most calm folks I know, they just don't rattle easily and their low-key support was really helpful on my first outing.

Tony following a tricky pitch led by Darwin.  Tony has both an artificial ankle and hip. There is no accurate way to measure his pain threshold. If he actually has one.

 I also managed my two week volunteer gig with the National Park Service in Canyonlands without any problems. Deb came along for the first few days and that helped me ease into the isolation of the wonderful place I am assigned to. The 10 mile hike every day and the solitude were both calming and a boost to my confidence.
 

The Great Gallery in Horseshoe Canyon

 I really couldn’t have asked for a less complicated and more complete recovery than I am apparently having. I think this is a result of the fantastic cardiac unit at St. Mary’s.  For all of you senior athletes, remember that you are different than most other folks your age and your symptoms, if they should ever occur, may look very different from the textbook. The good news is, that if you are treated quickly,or even better, before you have a heart attack, you usually can recover and come back stronger than you were before, especially if your basal level of health is good. The recovery is much less complicated than coming back from shoulder surgery or spinal surgery. A friend of mine, whose wife is a powerful mountain biker, was happily surprised that after his stent was installed, he could keep up with her.

Thanks for reading.