Heart Attack

On Monday, July 9, while I was exercising at the YMCA, I felt some discomfort in my chest. I curtailed my exercise regiment and went home and ate breakfast. The discomfort hadn’t changed and thinking it was indigestion, I lied down. The discomfort remained the same, however, 10 minutes later, I decided to drive myself to the hospital. I told the emergency physician of the discomfort and they did an EKG, took my blood, started an IV, checked my blood pressure, etc. The EKG was normal and while I was waiting for the results of the blood tests, I started sweating, had trouble breathing and the pain increased. They did another EKG and told me that I just had a heart attack. They treated me with clot busting medication and after 30 minutes, the pain subsided. I was then rushed to another hospital, where they did an emergency catheterization and put 2 stents next to each other in the clogged artery. My doctor told me that the artery was 85% and a second artery was 40% blocked.  My Tropinin level was 53.  I was discharged from the hospital on Friday, July 13 and I have a post discharge appointment with my doctor on July 26. I am a 58 years old male.

Due to a family history of heart problems, I’ve had yearly nuclear stress tests and echocardiograms. For the last 2 years, I’ve been exercising at the YMCA 5-6 mornings per week. My regiment includes 45 minutes on an elliptical machine and 15 minutes swimming. At maximum speed and resistance, my pulse gets to 140 beats per minute. I’ve also lost 45 pounds over the last 1.5 years and I know weigh 185 pounds. I have a Type A personality, strive for perfection in everything I do and take life too seriously.  Over the years, I’ve talked to my doctor about doing the catheterization as a diagnostic tool, however, he advised that the results of my tests are fine and, since the catheterization has risks, the cauterization is not needed.

My understanding of the mechanism of a heart attack is the plaque cracks exposing the underlying fat deposits, which provides a surface for red blood cells to attach and form a clot. The clot closes the artery causing the MI. I have the following questions:

1) If the artery was 85% blocked before the blood clot, on the average, how long does it take for the clot to form and block the artery causing the MI?
2) If the artery was 85% blocked, shouldn’t the nuclear test have shown some reduced flow in the artery?
3) On the average, how long does it take to go from 75% blocked to 85% blocked?
4) Can an individual have an MI with an artery 85% blocked and no blood clot?
5) I have a second artery that is 40% blocked and it will be treated with medication. I asked my doctor why he didn’t put a stent in and he told me there isn’t any reduction in blood flow. I don’t understand why there isn’t any blood flow reduction since the artery has a 40% blockage.
6) I was taking caduet and quinniparil and I’m now taking plavix, coreg, lisiniprial, vytorin, omacor, ecotrim and nexium. My blood pressure has been averaging about 95/56. Is it too low?
7) I will begin a cardiac rehabilitation program and I’m concerned about exercising and causing additional problems with my heart. Should I be concerned?
8) Since 30 minutes elapsed from the time I had the MI until I felt relief from the clot busting medication, is there any permanent damage to the heart? It’s my understanding that the damage is a function of the time from the MI until the blood flow is resumed. It took additional 90 minutes to get to the other hospital and complete the catheterization.

I will certainly ask my doctor these questions, however, I'd like the input of a second prefessional. Thank you.

[MysteryChemist]

Mitchden,

You have a list of very interesting questions.  I am not a MD. I am a 54 year old male who had a heart attack 15 months ago.  I can only give my opinion based on what I have read the past few months.  It would  be interesting to get your doctors answers.  Your doctors answers trump my answers!

1) From what I understand, most heart attacks are caused by plaque rupture and not by the narrowed  arteries. In other words, it used to be thought that if your arteries became block or narrow, that the heart attack would occur in the narrowed areas.(the plumbing analogy).  It has only been since maybe the mid 90s that the MDs have determine it is the soft plaque rupture that causes the heart attack in most cases.   About 15-20% of the heart attacks occur in arteries that have been narrowed to 80% or 90%, etc.  The chief problems with having arteries that are > 75% blocked is that they can cause chest pain and /or shortness of breath.  Having a stent put in or CABG will definitely help  people with this type of  blockages.
2) I would say it depends on the individual. Some people have 90 or 95% blockages with no obvious symptons.  It depends on their activity level. As long as they stay in their customary groove of activity , they have no problems. If they exert themselves, they start to have problems.  This is why Drs push you on stress tests to get the heart rate elevated.  Another thing to keep in mind is that stress tests are not perfect. Sometimes they can’t detect problems.
3) It depends on individual in my opinion.  Some people will hit a plateau and stay there and some will keep going .
4) This is one for Drs. (I think the answer is yes as the blood clot occurs in the arteries are very small that cannot be visualize by catherization, but I could be wrong)
5) Drs don’t like to do stents until they are >75% block.  They like to treat it medically to reduce it. Your arteries, even though they are 40% block, are still pliable and can change to accommodate the workload.  All that exercising you did probably helped you out.
6) MY BP is typically 95/51 in mornings.  Some mornings it is 82/46. I don’t have any problems.  Others might have problems with BP this low. As long you are not dizzy or feel tire, it probably won’t be a problem. Ask your doctor.
7) Cardiac rehab is really cool.  I really benefited from it.  After my heart attack, I was concern about exercising.  I was worried about it.  Rehab showed me that I could exercise and  be fine. They want you to exercise 5 days a week for 30 min a day(not when you start Rehab but as you build your strength and endurance. )  I also like the classes on nutrition, exercise, etc.  Another neat thing is that you are with people who have had heart problems, like heart attacks, have survived, and  lead productive, happy lives.
8) It sounds like you got everything done in time. One way Drs can tell if there was damage is by the ejection fraction from the echocardiogram.  A normal heart will have a ejection fraction  50-65%.  A number below 50% indicates some damage.  If it turns out you did have some damage, it is not the end of the world.  The main thing, my cardiologist, was to concentrate on how I felt and not get hung up on a number.  My ejection fraction was 40% after my heart attack.  A year later it was 45%, a modest improvement.  Even if I didn’t know the number, I feel great.

Best of luck!

[surfgirl]

Very interesting indeed.  I disagree though with  the ejection fraction/damage part.  A reduced ejection fraction indicates heart failure, which may or may not be caused by a heart attack.  I heart attack, by definition, involves damage.........angina is decreased blood flow.  A heart attack is permanent, and will remain on an ekg as damage for the rest of your life...that is why the crucial first hour is so important.........I am an RN, and have  actually seen heart attacks happen on the monitor, while trying to set up NTG drips, and  open the arteries with meds.  The muscle goes from oxygen deprived to dead........the amount of damage varies according to each individual. .........how soon the blood flow can be restored and how hard the heart is working.

[MysteryChemist]

Mitchden,
I would like to clarify one point about rehab.  You should check with your cardiologist about how much and what  types of activities you can do before you begin rehab.  That information may be on your discharge papers. Once you start rehab, they start you off at a low pace and  you build up as you go. Your strength , endurance, and confidence improves with the increase in exercise time.

Surfgirl,
My understanding was the ejection fraction  lower than 40% could be a sign of heart failure.  One could have ejection fractions between 40-50%  indicating that the heart was damage without it being classified as heard failure.  A heart attack is one way to cause the damage. There are other ways to damage the heart..

[surfgirl]

well, yeah, there are degrees of heart failure.  And, ejection fractions can change over time.  What I meant was the heart could be damaged, and the EF could be normal too.   It depends on the area that was damaged, the degree of damage, and the patient's heart. The EKG is still the way to  see damage, and the echo is the way to see function.  I had an EF of 20% and it is now 55%, thanks to modern medicine.  While I did not have a specific area that was damaged, I had general damage to the entire muscle from a virus.  Fascinating.............and I agree totally with your comments about cardiac rehab......many patients report feeling better than they did in their 20s after rehab and lifestyle changes.............post MI too.