Heart Attack!

[doc henderson]

So there is a lot of confusion on this topic.  Many people report having many heart attacks assuming any pain in the chest is there heart let alone a myocardial infarction.  a MI is really like a stroke but to your heart.  It is a miracle that our hearts last long enough to let some live into their 90s.  how many other pumps do you have that run 24/7 for that long.  

Our arteries get cholesterol in the lining of the wall.  this is seen in children.  this over time gets hard with calcium being incorporated.  imagine fixing a tire or innertube with concrete.  You feel a pulse over and artery because it expands and contract with the pressure change or wave with each time the heart has a contraction and half empties the ventricles.  

If a hardened plaque gets a crack in it, it exposes collagen, and your blood thinks you are bleeding so it try's to clot it off.  the heart muscle has its own blood supple from the outside of the heart via the coronary arteries.  when these have a calcium laden plaque that cracks, and you get a clot, you have an acute MI.  the clots blocks the blood flow. This will give you pain in the chest (with exceptions) and the location will be represented on your EKG.  There are dozens of measurements and segments we look at on the EKG.  The ST segment is elevated, and we should get you to the cath. lab ASAP.  We call this an ST elevated MI or STEMI.

You may get a heart cath. in general, scheduled at a later date if you are having problems with angina, or loss of strength in the muscle.  not all heart caths are an emergency.  

I will post an EKG, but i have to remove any identifying data first.

here is the first image of a coronary vessel at heart cath.  note the area of narrowing.  that is the plaque with clot on it.  you are seeing the contrast dye going through the vessel or in other words, the out line of the inside, and flow through the coronary arteries.




 





 

you can see in the cropped area, the wire and the narrow segment.  In the center of the cropped pic.
next is after a catheter with a balloon is put in and blown up to expand the area, and then a stent is placed over a balloon.  think of a small tube made like expandable meatal that expands as the balloon is inflated, and it hold or "stents" the area open.



 


the next is the actual clot that was retrieved.  




 

we are lucky to have a cardiologist that is able to do interventions beyond the normal and help folks in a smaller facility like ours.  I hope this helps to alleviate confusion about a heart cath., how and why it is done, and why it is not always done emergently.  

[LeeB]

Glad it was not as I thought when I saw your title.

[doc henderson]

Thanks.  I like a catchy title.  I was working and collaborated with the cardio doc.

[Magicman]

From the pictures I thought that we were gonna bait our hooks and go fishing.

[metalspinner]

Are any diagnostics ever done prior to an event? Then treatment to prevent? 

[beenthere]

Doc 
Great info you present. For certain answered questions about "suspect" flashing pain that causes one to panic a bit. 
Last Wed. morning I got dizzy and couldn't function very well. Called 911 for a visit to the ER and right away hooked me up with sensors all over the body. Said I was dehydrated so the started me on a drip bag. 
This morning, I looked up EKG to see if maybe they did an EKG test and suspect they did. No mention of any heart problem so "assume" that part of me is okay. (Have a nurse daughter, a pediatric PA son, and a 3rd year med-student grand-daughter to look at those reports)

The ER docs wanted me to make an appt. with my Dr. soon, but found out my Dr. is on a month vacation. So accepted a visit yesterday with a PA. Nice young gal who interpreted the ER report that she had from the ER visit. 
While there, I inquired about a test to check out my carotid arteries. Reason was my father had dizzy/throw-up spells for several years, until a country Doc in Arkansas asked him if he ever had his carotid arteries checked out. He said no, but subsequently learned one side was almost completely blocked and the other 60% blocked (iirc). Not sure what the next step was, but after some surgery work he suffered no more dizziness. 
So next week scheduled for an echo cardio imaging which apparently uses ultrasound to check out the carotid arteries. Am sure not the same, but cut my professional eye teeth developing ultrasonics tests to locate defects in wood. 

Doc: Much appreciate the knowledge you share with us here on the FF. We are quite fortunate.

[barbender]

That is something I think about a lot. My Dad had 2 heart attacks and a quadruple bypass surgery by the time he was 50. All due to blockages. The family has a disposition towards that, we have a lot of heart problems that come with Native ancestry. Going from a hunter/gatherer culture to a modern diet in less than a generation was kind of tough on us and we haven't adapted yet😊 

 Anyways, I did get a bunch of testing done, including a stress test, about 8 years ago. All was well at that time, but since then I have put on weight and had to start taking medication for blood pressure and cholesterol. Triglycerides are always off the chart, even when my other numbers are good. 

 All of that said, anytime Doc is giving some real world info on heart issues I pay special attention.

[Claybraker]

Are any diagnostics ever done prior to an event? Then treatment to prevent?

I have a stent because I didn't study for my stress test. I failed. The doc called me back for a follow up in a couple days, then scheduled the heart cath 2 weeks later. Pretty uneventful procedure except for the delay because someone else showed up at the emergency room in heart failure so they had to wheel me back out of the operating room to deal with that patient first. Then he couldn't clear the blockage in the left anterior descending artery and placed a stent. that was 2017, I passed my stress test in 2018, next week during a routine visit I figure the doc is gonna tell me it's time for me to be a gerbil on a treadmill again.

[doc henderson]

BT the echo will look mostly at your heart.  if they  tell you your ejection fraction is 60%, that is perfect.  many come and tell me they only have 50% heart function, but the is a 2 d view how much blood is ejected from the ventricle with each beat.  cannot eject 100% with each beat.  so it is easy to misunderstand the wording.  you may need a dedicated carotid doppler if they do not spend time on your neck.  

There is a cat scan that looks at the calcium in your coronaries, but many think it is too much radiation (risk vs benefit) so if at high risk, or having mild symptoms, you get a stress test.  if older they may let you lay on a bed and give a med to stress your heart.  they may do an echo at the same time to make the test more sensitive.  they may give you a radionucleotide to see what part of the heart are working.  The ultimate is a heart cath.  it has radiation and iodinated contrast that can be hard on the kidneys.  

In the ED we do a lab test called a troponin that goes up with heart damage, and EKG to look for elevation or the ST segment.  or other subtle things to raise our suspicions.  high risk with family history or cholesterol, diabetes or hypertension also gets our attention.  most people decline to call it chest pain, and say it was a pressure like a weight, and then we are more suspicious.  women and diabetic may have subtle symptoms, but really that is a campaign to increase our suspicion, since we used to think of MI as a older mans disease.

[GAB]

I guess they are more generous with stents in this area cuz I didn't study either and got 4 of 'em.
GAB

[doc henderson]

sounds like you passed.  some will wait on a 70% blockage and save the stent for later.  not if they think that lesion is causing the reported problem like fatigue.  some time the blockage is in a bad location or too many for stents and they do a bypass.  sometimes if a cath. or surgery is too risky then they medically manage.  nitro and or bp meds.  also platelets start the clot so we use aspirin and or Plavix.

coronary clots usually start in the coronary over a ruptured plaque.  stroke clots can form in the artery in the brain, or in the neck and break loose and go the next smaller size artery in the brain.  they branch and get smaller like a tree.  for pulmonary embolism they usually start in the legs or right atrium, and get caught up in the flow and go to the lungs.  that is what embolism means, flows from somewhere else until it gets to a smaller artery and gets lodged.  

[Texas Ranger]

My wife, serious health nut, had a takotsubo cardiomyopathy,  Stress or broken heart syndrome.  Felt a tightness in her chest, blood test showed elevated enzyme levels.  Trip to the ER, tested, shipped to Houston.  Two days later no blockage, no serious damage that cardiologist said would be/ and is  being treated to return to full heart health,  New meds, cardiac rehab` and it is working.

Don't play with your heart, get to the ER if you don't know what is going on.  

[Peter Drouin]

Don't take much to take you out.

[doc henderson]

 

 

skinny spot inside the coronary.  sent to cath. for stent.



 

open post cath.  vessel to the bottom of the heart.
the one that goes to the "place you love everyone from".  

[doctorb]

Good visual example.

[barbender]

Haha Doc if that means what I think you meant, definitely want that one opened up.

[doc henderson]

I just meant if you "Love someone from the bottom of your heart". that vessel goes there.  

I do not always get pics, but this one is easier for non cardiologists to see.  pt. did very well.

[Peter Drouin]

What symptoms did the person have to go looking for that?

[doc henderson]

chest pressure.  more a weight than a sharp pain.

but the ST segment is elevated. on the EKG. A STEMI.

funny you should ask, I was just handed this.



 

the flat area right after the spike, is the ST segment, and it should be in line with the rest of the baseline.  go to cath lab, do not pass go do not get 200 bucks.

[dougtrr2]

Went to the ER this weekend.  History of heart issues in family.  Father had bypass surgery.  Five years ago brother (two years older than me) had heart problem and required  stents.  He died two years ago after being given a clean bill of health a month prior.

Saturday I had chest pain like a band tightening around my chest.  I've had minor episodes of this but shake them off.  But this time I also had jaw pain.  So off to the ER I go.  The jaw pain is what spooked me.  I have never experienced that before.  Chest pain, could just be exertion.  I normally don't worry about an ache or pain if I have some idea of what caused it.  

They found nothing, EKG okay, heart enzyme stable, not further pain.  Blood pressure was high, to be expected I guess. I normally run low. Sent home and making a followup with primary care this week.

Doug in SW IA

[doc henderson]

I do not see your age, Doug, but they may want you to run a stress test.

[Iwawoodwork]

Doc, Thanks for the very understandable info and the visual pictures. 

[dougtrr2]

I do not see your age, Doug, but they may want you to run a stress test.

I'll be 69 this year.  At my last physical I related some of the minor/annoying issues I have.  Mainly, a random shortness of breath unrelated to activity.  He suggested if it was bothering me we could consider a stress test.  I have had them in the past, in fact I had one right after my brother's heart issue.  At that point I looked and him and said " Doc, last week I did a 108 mile ride on my bicycle with no issues,  do you think a stress test is going to find anything?"  He kind of chuckled and said" probably not".  We will see what comes out of today's appointment. With my family history, I do have a cardiologist.  I am not overly concerned, just being very mindful of the family history. 
Doug in SW IA

[doc henderson]

Everyone thinks heart.  get  follow up with the cardiologist.  there mare several systems that make the heart go.  may need an echo to check muscle strength, and poss. a monitor to r/o intermittent arrhythmia.  next may be a pulmonary doc and a pulmonary function test.  the bike rides are a good sign you are in overall good health.  some marathon guys drop over from having too conditioned a heart.  It could be reactive airways like asthma or even vocal cord dysfunction.  If you are a gaget guy, you can get a pulse-ox and check your own sats and heart rate during an episode.

[beenthere]

Last week had an echocardiogram, 48 hour Holter monitor, and carotid ultrasounds. The words that explain it get to be long and hard to understand, but so far the test reports are sounding good. Heart mostly normal, carotid arteries show minor plaque, and am waiting to hear the results from the Holter monitor, which I believe is an electrocardiogram.

Had a CT head scan and the Dr. said they found nothing..    But smiled and said found nothing in the brain to be concerned about.
Was some additional words in the CT report "patchy areas of white matter in a pattern.... comparable with chronic microangiopathic white matter disease". Being in Wisconsin, sounds like cheese in the brain and probably because I am a cheese head. No other explanation.

[doc henderson]

the Holter is an electrical recording for an extended period.  not twelve leads like a formal ekg.  It is for finding arrhythmia and the computers now count every beat, and give max and min. intervals ect.  almost too much information.  if you are getting runs of v-tach (potentially fatal) or atrial fibrillation it will record all of that.  It will usually let you push a button that says, "i am feeling off and this is why I am getting this study".  It may correlate with say V-tach and you need a pacemaker/defibrillator, or it may be blue sky nothing to do with you heart rhythm.
your white matter disease is from years of high blood pressure, diabetes, smoking ect and means none of us are going to live forever, and you may not be able to recall the unusual name given to you 20th grandchild.  The damage is to the tiny arterioles at the capillary level on a wholesale basis, and not a plaque or clot in a vessel you could stick a pencil in.  think of a vessels that supply the cells, and the red blood cells almost have to line up to get through.  It is why we do not live forever.  

[RetiredTech]

@doc henderson 
  I had a chemical stress test and echo-cardiogram yesterday. Is there any significance to not having a reaction to the medication? I felt a little funny a few seconds after they put it in the iv, but it passed almost immediately. I only ask because my followup isn't until the end of April. They did say they'd call if anything that needed immediate attention was found. The tests were ordered after discovering a right bundle branch block in preparation for foot surgery. The diagnosis was more stressful than the tests. I had always heard horror stories about the chemical stress  test.

[doc henderson]

some people have a bad reaction and we reverse it.  that is not related to having a blockage.  too much for some.  The longer you do not hear from them the better.  If they see and area not perfusing, they will move to a heart cath.  there is also sometimes a radio-isotope component as well.  the are looking for areas of the heart not taking it up (decreased blood flow)  before and after exercise.

[RetiredTech]

@doc henderson 
  Thanks, That makes me feel better about it.

[Nebraska]

I sent this picture this morning to Doc H. I thought he might get a kick out if it.





 

I had that gallery viewing my work as I did a cesarean very early this morning. I felt like one of those surgeons operating in an operating theater, with the crowd above  watching  me work.  Of course you never see the scene where the farmers wife is  keeping the viewers from roosting over the top of the surgery with a piece of 1/2 in pvc pipe. She kept the  birds from inappropriate perching and took care of the calf once we got her out. While her husband helped me lift the calf out and kept hold of the uterus while I closed the doorway and finished the surgery.    Doc suggested I post the picture in his heart attack thread so this is a thread hijack with permission. At last check mom and the baby were doing fine, the surgeon is a bit sleep deprived but not on call for a few days.. Now back to a little cardiology......

[doc henderson]

[NE Woodburner]

I lost a friend to a heart attack a few days ago. Service today. He was younger than me at only 55. I had to cancel my last checkup and forgot to reschedule. I just scheduled the appointment for the next available time slot.

[Raider Bill]

Doc.
I've had several pass from the "widow maker" What is that?

[doc henderson]

In my opinion it is the fist take off of the Left coronary system before it divides to the left anterior descending artery and the Left circumflex.  these do circulation to most of the left side of the heart.  Just off the aorta, if you get a clot there, it makes the whole left ventricle stop working from lack of blood supply.  It can be a sudden death from an arrhythmia from any heart ischemia in lay terms.  Ill see if I can find a video or diagram.  the vast majority of heart attacks (blood clot in a tiny artery) make it to the hospital and to heart cath. to live another day.

[doctorb]

The Cleveland Clinic agrees with doc h.

“ A widowmaker heart attack happens when you have a blockage in the biggest artery in your heart. That means blood can’t move through your left anterior descending (LAD) artery, which provides 50% of your heart muscle’s blood supply. Immediate treatment is crucial for a chance at survival.”

[doc henderson]

that first opening is too short to put a stent and often requires a bypass surgery.

Left anterior descending artery - Wikipedia



I call it at #4, but number 1 is bad as well in terms of the effect on the heart and propensity to have a fatal sudden arrhythmia.  this is where the AED comes in.  

Automated external defibrillator - Wikipedia

[realzed]

Interesting.. I had a session in late January last year, where I just didn't feel right / pressure in my chest and sweats, along with some general inability to straighten up when standing..
Asked my wife at 11 PM - to drop me off at the ER as I didn't feel good in general..
When she did I was in there for 12 hours or so with little good info resulting from my visit.
Returned a couple of weeks later for the 'medically induced' test and I knew I failed badly from my own general reaction along with the looks on the staffer's faces during and after.
Still wasn't told much at the time except that I would be contacted and after quite a while that it took me to get feeling stable enough and get my act together, I drove home.
One concerned nurse had me park for a while in the hallway and had me sit in a chair she found, so I could get settled down!
I got a call a few days later announcing an angioplasty app't in '3' months (great health care system we have here in Canada - despite what the government says is 'World Class'- you may think you aren't paying much, but you are in taxes and you do have to wait A LOT..)
Finally - in mid May I hear a Doc say "I have found your problem Mr. D. and I will fix you all up".. but didn't answer any questions at that time while 'on the table' as to what 'my problem' was still..
Finally after a visit later in June, I found out that my Lower Anterior Descending Artery was apparently 95% blocked and that I had a coated stent inserted which apparently patched everything all up!
I also have another blockage about 45% somewhere else that they won't touch until/if it worsens.. lots of pills now (I hate pills!)..
Pretty difficult to get good feedback as you can see - but your info, diagrams, and pictures, have filled me in a lot - so Thanks so much DR. H for your efforts here in the past day or two!!
I have passed a real treadmill test 'sort of' lately = (BP was 220 over 100 something I could tell much even after striving to peek around while walking - which I doubt is good and a couple of past induced med tests since - so I guess I'm good to go for a while yet, but the lack of good (not for lack of asking or trying) info is hard to put up with - as is all of the waiting when you know and your body tells you, that something just isn't right..
Lots of MD's here now present a substantial language barrier and smugness, and there is little to no choice or alternatives - is all I'll say here..
My family GP who got tired of all of the BS and quit his (and my) practice just recently, used the term "widow maker" during my subsequent visit to him, and I sense I was pretty lucky - and that was his assessment and facial expression, as well!
Thanks again..

[Raider Bill]

It's my understanding that Men rarely survive a widow maker hence the name.
One of my ex's was feeling real bad one weekend. No chest pain she said. Thought it more of  stomach gas, sweats. She was in her lower 40's and in great shape.
Finally talked her into letting me take her to the ER.
They triaged her, got excited and whisked her away.
She got a couple stents early the next morning.
Doc told me a man would not have survived what she had and was called the widow maker for a reason. Something about how our systems are built different.
Of course that raised some thoughts on my end..

[doc henderson]

The term is an old one and more of a lay term.  Docs use it because it has been heard of.  If the definition is sudden death, then obviously not many survive.  you often have warning, and men tend to ignore them.  most chest pain is not pain at all, but described as a weight or pressure.  If you vomited and or got sweaty, then I really take it seriously.  a blockage takes years and is made up from cholesterol plaque in the wall after years of combinations of hypertension, high cholesterol and high insulin and blood sugar.  It will be very gradual symptoms and can be managed with medications.  An acute heart attack where you are rushed to the cath. lab, is when the plaque that has become hardened by calcium ruptures and the body thinks you are bleeding so it forms a blood clot in the lumen with sudden onset of no blood flow.  that is why there can be a difference in how fast they do the cath. and stents.  if you have diffuse disease (many blockages) or if there is one at a branch point, then you get a bypass surgery.  the left main artery covers over half of the heart, and the side that is required for blood pressure.  the right side of the heart just pumps the blood through the lungs.  As an analogy, think of a fuel injected engine, and loss of a fuel pump vs an injector to one cylinder.  

[Andries]

Doc H;
You’re doing an excellent job at describing immensely complex systems (and failures) with ‘plain language’, and even illustrations!
You’ve done this before, aintcha?
.
Thank you very much sir, from myself and prolly dozens of others who feel the same way.

[Raider Bill]

Doc H;
You’re doing an excellent job at describing immensely complex systems (and failures) with ‘plain language’, and even illustrations!
You’ve done this before, aintcha?
.
Thank you very much sir, from myself and prolly dozens of others who feel the same way.

Yes sir I agree!
Thanks Doc!

[doc henderson]

Coronary angioplasty and stents (msn.com)

[doc henderson]

not a heart attack, but did a little work in my shop.  



 

 

His wife moved a saw that he then stepped on taking steaks out to the grill barefoot.  he is my heating and air man and was in our troop with his son.  we get lots of off the books help with our stuff.

Get those projects done.  my barber and friend was dx. with a fast aggressive lymphoma.  Dx. hospice, and gone within a few weeks.  I will now finish the jewelry boxes we started for the girls in his life.  He was adopted, a good athlete, in the Army, and taught Hunters safety for over 50 years.  He also taught at the gun club.  He spoke many "languages" depending on who was in the room.  He was always sweet to my daughter Monique and she went with me to say goodbye.  His barber shop was part of their house and the family replaced his chair with a hospital bed. God Speed Frank.  I have promised him I will finish the 6 boxes made from a tree taken from his back yard.

 



 

 

[Old Greenhorn]

I am very sorry for the loss of your friend. That is a noble and worthy thing you are doing for his family. Good on ya!

 Nice work on the foot, looks like he lost a bit of a chunk there. Maybe you should call it a 'wood and meat shop'?

[doc henderson]

I know that magic gets you to say eww and ahh.  with permission I add a few recent issues.  

Edit:  sorry guys, I woke up at 3 am and decided that the pics of a patients leg before and after was too much.  the point of this thread is to help you understand common issues.  I posted the pic to shock a little and maybe even brag on the tough long repair that turned out well.  I think the medical folks see this all the time, but I decided my motivation was less than professional and served no real purpose to the thread.  an x-ray is a little less personal so I will leave this unless anyone objects.  Doc!

Motorcycle vs dump truck.  The rest of him was fine.



 

please do not try to beat that Magic Man!

[Magicman]

Am I allowed to say ouch?? 

[doc henderson]

of course!

[doc henderson]

both are doing well so you do not all worry.

[Old Greenhorn]

Am I allowed to say ouch??  

I'll bet the PT said a lot more than that. Geez Louise!
 I'd get guys like that in my ambo and if there pain was under control (they weren't screaming) and offer encouraging comments as we worked on them like "Well, it's gonna leave a mark, but you are gonna be OK", or "Man I bet that hurts!". One time time a guys that had a sense of humor I said "Man, I've had bad days but right now it really sucks to be you." he just replied "Ya ThinK?!" Ah good times. (No, I don't really miss it much.)

[doc henderson]

I have not been on as much, and no milling to speak of.  with the shortage of health care folks and companies pinching pennies, I have worked 215 plus hours in June and slated the same for July.  I post this here as colloquies are worried about that kind of work (hours) at my age.  Thank you to the FF friends that have reached out personally by PM noticing my decrease in posting.  Two more nights, then a few days off.  Lots of turmoil and pain in the industry right now.  Please be kind to the medical folks you meet along your day to day lives.  My wife is a pharmacist.  She is ready for us to retire.  A special thanks to @red  who seems to always be in tune with the needs of the friends on the forum.  

[beenthere]

Just said good bye to a grand daughter who is 4th year med student. Today was first day of a 6 week "tour" of duty in Michigan in an ER ortho surgery. Says her understanding is expect 90 hours a week at the hospital. 
When asked about the 90 hours, said it was down from more hours to now the limit of 90. Be there, and ready to go at moment's notice. 

Can understand how that doesn't sound like "retirement" duty for the Doc's, and how important they are to us when we suddenly find ourselves in the ER needing medical attention. So necessary for our comfortable lives. Thanks Doc Henderson. Pray that you get a break soon.  

[doctorb]

High energy fractures.  These are called segmental because they have portions of the bone separated into segments from the proximal and distal fragments.  Undoubtedly an open injury.  Needs the OR.  Debridement of the wounds and an IM nail.  Was my wheelhouse as a trauma orthopaedist.  Lots of other bad things can happen here.  Arterial injury, nerve injury, compartment syndrome, infection and possible amputation.  Kinda gets your attention.

[customsawyer]

I for one am very thankful for the info that our Docs share. I really like how they can explain it with a crayon, so I can understand it. Having met both of them, I can assure the rest, that they are mighty fine folks in person too.

[doc henderson]

Yes Doctorb, we shipped that to a level 1 trauma center.  He was a very responsible 60 something guy, that ran into the back of a stopped dump truck at 60 mph.  the leg was all that was seriously injured, but for scrapes and cuts.

[JD Guy]

Having had to use the services of the ER departments more than I like to admit I, for one am extremely grateful for y’all’s commitment and expertise. We are fortunate that we have a ER Doc that lives down the road from us and he has run interference for us more than once at our local Hospital. May God Bless each and every one of our Doctors and Nurses

[doc henderson]

Thanks JD and all.

[SwampDonkey]

Last week a coworker had a heart attack, not on the job. He had bad chest pains in the morning and went to the local hospital. He was waiting in the local hospital to be taken to Saint John regional 3 hrs south of here. 56 years old. He is a life long smoker.

[doc henderson]

Is he OK?  the majority of heart attack victims survive, but for the ones that have a fatal arrhythmia or major vessel blockage, "widow maker".  For some if the cath. or thrombolytics are soon enough, there is minimal or short lived damage.  It can be the best thing for some who then decide to loose weight, control blood pressure and diabetes, and stop smoking.

[SwampDonkey]

Not sure of his status, have not been in contact for about 2 weeks, when I saw him at work. He had just changed jobs. He's run a clearing saw for years. I'm sure he'll be fine, just not the same. He'll have to make adjustments I'm sure. He's not over weight, and has always worked hard.

[SwampDonkey]

Had an update today on my coworker. He had 3 stints put in and doing better, but hasn't his energy back yet.