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Please help me understand how one can have a fatal heart attack missed ...
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Please help me understand how one can have a fatal heart attack missed by doctors?

My husband, 45 years old, thin, active (smoker though) recently passed away from a fatal heart attack.  He had no previous history except in the early 90's was told that he had a heart murmur during a pre-employment physical.  (His late mother had heart attacks) He NEVER went to the doctor......until the last couple of months before his demise.  He had been complaing of back & left shoulder pain (but his shoulder had bothered him for years so I thought it was the same) as for the back pain I told him he should go to the doctor.  He did not have medical insurance due to layoffs, was unemployed, so for him to feel the pain was bad enough to go to the Urgent Care/Emergency Room Hospital & pay out of pocket speaks for itself.  They told him he had strained his back and gave him a perscription for Ultram.  He went back several times because it was not improving.  They just kept taking his money, wrote the prescriptions, and sent him on his way.  The Sunday after Thanksgiving he had mentioned that he felt "funny" but couldn't elaborate, and that his left arm ached and thought he had slept on it wrong, but I don't know if he told them when he went to the Urgent Care that afternoon (I wish I had went with him-but I didn't).  They just wrote him a refill.  He left the facility on foot and headed to the drug store (which is just across the parking lot about 50 yards) and just after entering the store he stumbled, sat on floor short of breath and collapsed.  By the time the paramedics got there he was already gone.  They were unable to revive him.  The autopsy revealed that the heart attack ("Cardiac Insufficiency") was due to Aortic Stenosis and Cardiomegaly, and that they have been present for years.  I have been doing some research trying to make sense of it all and have found that the stenosis can be detected by hearing a murmur.  I obtained the Urgen Care's records and they marked the box that indicated no murmer present.  I would really like to know how the stenosis can be so bad that it causes a fatal heart attack yet be missed by the doctor who saw him literally just minutes before the fatal event?  It just doesn't seem right.   Am I wrong in believing they should have caught it?
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I am so sorry for the loss of your husband.  It is always hard to lose someone you love, and it is very shocking when it is so unexpected.  

Unfortunately, there are a lot of things that could have happened to your husband's heart that weren't necessarilly predictable by Urgent Care.  It is common for any type of heart problem to be misdiagnosed as back strain initially, even when the real problem is a more common type of heart problem than what your husband had.  I notice that the autopsy report did not say "myocardial infarction," which is the typical type of heart attack.  If your husband had had that, the Urgent Care clinic would have had a much better, although not 100%, chance of catching it.  Even with a myocardial infarction, the terminal event can happen the moment the person walks out of the clinic and not before.

Aortic stenosis and cardiomegaly don't happen overnight, but their diagnosis requires careful work-up -- usually by means of a number of different tests, some of which are usually administered by a cardiologist rather than a primary care or emergency doc. In most cases, the whole process takes a period of weeks or months, wit the patient going from one appointment to another.  Aortic valve problems are notoriously hard for doctors to recognize.  

It took probably about a year for my own aortic valve disease to be diagnosed.  My primary care doc completely missed it and did not even think I needed to be referred to a cardologist.  I went to an emergency room one night, and the doctor there ruled out myocardial infarction and basically had nothing else to say about what was wrong.  I finally referred myself to a cardiologist, and even then she could not tell me on the first visit exactly what the problem was.  She referred me for an echocardiogram, which took another appointment, and only when I came back to see her for the follow-up visit to get the echo results, did I find out, at age 49, that I had a cogenitally defective aortic valve.  When I was told that I even had a valve problem, I was also told that the valve was badly deteriorated and that I needed open-heart surgery.  So the problem was very advanced, by the time I even found out about it.

I don't mean to take the focus off of your husband and onto me, but I think that what happened to me, in terms of the very delayed diagnosis, is common with aortic valve patients.  Your husband did not even have a primary care doctor, and he never got to see a cardiologist.   Tragically, he was not diagnosed until he got to the autopsy table, and he is far from the first aortic valve patient that that has happened to.  You can look up the stories of John Ritter, the actor, and Jonathan Larson, the playwright who wrote Rent.  John Ritter died on the cath table, and Jonathan Larson had been to two emergency rooms on the weekend before he died.  There are many other, more anonymous aortic valve patients who have succumbed to sudden cardiac death because no one knew what they had.    

As far as what exactly happened to your husband's heart on the day of his death or at the moment of his death, it could have been any one of a number of things, from a sudden break-off of plaque to an arythhmic event, to the final shutting down of his aortic valve.  Sometimes there is an aortic aneurysm that dissects or ruptures, but if the autopsy report does not mention that, then I don't think that is what happened.  I don't think anyone here can tell you, at that level of detail, "what killed him," as far as that goes.  In a perfect world, maybe an urgent care doctor could have forseen whatever was about to happen.  But in an imperfect world, your husband needed ongoing primary care and cardiology care that he did not get.  And he needed expensive tests, like an echocardiogram and probably a
CT scan.  

As far as the murmer, some murmers are hard to hear.  One doctor may hear it and another may not.  It can depend on the placement of the stethoscope and other variables.

Again, I am so sorry.
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367994_tn?1304957193
Sorry for the untimely death of your husband.  

For some insight, one may develop an enlarged heart (cardiomegaly) could be of long term (chronic) or temporarily because of a stress on your body with a medical condition, such as the weakening of the heart muscle, coronary artery disease, heart valve problems or abnormal heart rhythms. Six years ago I had an enlarged heart due to stress of breathing without a mask in a very dusty environment.  The condition caused the heart to pump weakly enough to cause congested heart failure putting me the ICU for several days to stablize my oxygen level.  Fortunately, the condition didn't cause a heart rhythm disorder.

Cardiomegaly can set the heart into arrhythmia (abnormal heartbeats) and cause fatal cardiac arrest. It is not uncommon for cardiomegaly to cause sudden death, and younger people are not immune.

Again my condolences, and don't feel your husband or family member is responsible for not doing something in a timely manner.  I had a silent heart attack and no symptoms until heart failure!.
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Avatar_f_tn
kenkeith, if a person has a fatal arrythmia that was induced by cardiomegaly, is it possible that the individual could be in normal rhythm one minute and that the heart could then start beating abnormally just moments later, without any specific warning that the arrythmia was about to happen?
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I don't mean to answer for Ken, but yes a heart can go into a sudden arrhythmia without warning. All it takes is a trigger, most likely in this case is was the heart getting too large and causing conduction issues.

It can happen that quickly. So sorry for the OP's loss.

Jon
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Avatar_f_tn
kenkeith stated above, "Again my condolences, and don't feel your husband or family member is responsible for not doing something in a timely manner.  I had a silent heart attack and no symptoms until heart failure!"

kenkeith is right.  Also, terileefun, I want to tell you that smoking does not cause aortic valve disease such as your husband had.  More than likely, he was born with a bicuspid aortic valve or BAV (such as I had myself, before I underwent valve replacement surgery).   BAV is the most common cause of aortic stenosis in a non-elderly person.  It is a congenital heart defect that is very, very often not discovered until the affected person is in his 30's, 40's or 50's.  The autopsy report probably did not say anything about BAV in your husband, because by the time a valve like that gets as stenosed as your his, it is encrusted with a calcium deposit that covers it up, and no one can tell anymore what the valve originally looked like.  In a very elderly person, sometimes aortic stenosis is due simply to age, but in a 45 year-old, I'd bet my last $100 that he had an undiagnosed bicuspid aortic valve.

As I alluded to above, my own BAV was not diagnosed until I was 49, and I was just lucky that I was still alive at the time, and in my case it as diagnosed by an echocardiogram and not by an autopsy.  The doctors could  tell that my valve was bicuspid because it wasn't covered up with the calcium deposits like your husband's was.  But my own valve was still very dysfunctional, by the time it was discovered.  There is more than one way that bicupsid valves can fail.  

But I've never heard of anything else that causes aortic stenosis in people in their 40's, other than a congenitally defective aortic valve.  And congential defects are not lifestyle-determined.  BAV is something that you are born with, and it just catches up with you later.  A few  people with BAVs are diagnosed as children, and some people with BAVs manage to get through a normal lifespan without it's ever causing any particular trouble.  But a slender, active, apparently healthy, male person in his 40's is the typical BAV-er.

If you want to read more about BAV, including some information about other cases of sudden cardiac death in people who had undiagnosed aortic disease, there is a website that has a lot of good, accurate information.  You may not be up to reading it now, and if you aren't that's fine, but here is the irl.  www.bicuspidfoundation.com.
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I meant, "stenosed as his."
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Thank you for your comments and condoloences.  It's been so frustrating trying to make sense of it all.  I've researched the conditions online but it helps to hear about your experiences and knowledge.  I hope you don't mind if I ask, but...what were the symptoms that made you think there was something wrong with your heart?  I'm curious if my husband had any of the same symptoms over the years that we just didn't connect it to his heart.  Also, I would like to be able to tell his siblings what to be aware of.  I know his Mom had heart attacks but I don't know specefics, and one sister had to have a stint put in a few years ago.  I have already suggested that they ask their doctors to check them for heart problems.  And I am also very concerned for our childrens heart health.  Do you know if these conditions are hereditary?  Again, thank you for your insight and condolonces.
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I am so sorry for your loss.  At some point you might want to do a search on my posts as i lost my dad suddenly to a heart attack.  The specifics are slightly different and also he was older, 64 years, but he was known for being a healthy active and if anything very fit and busy 64 years old.  He didn't eat hardly any fatty foods, and didn't smoke (though i recognise that smoking wouldn't have cuased your husband's condition necessarily).  I think we are fed a lot of useless information by the media.  I think we are given such basic facts....as if we are not clever enough to cope with any more.

If i had been a little more informed, my dad would have been at the ER two days before his fatal heart attack.  I won't let this go.  I have other issues i am dealing with at the moment, but i am still on the case on this one.

I am so sorry for your loss.  There will come a time when the good memories will comfort you, though right now you won't believe that probably.  If you need anyone to talk to any time message me.

Rosemary349
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Just lost my post because of a glitch, but I'll try again later.  In the meantime, check this out.

http://www.rjmatthewsmd.com/Definitions/aortic_stenosis.htm
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Also in the meantime, do you live near a major heart center, and do you mind saying which one?  Because to have your children checked, it would be preferable to go somewhere that the doctors will understand aortic valve disease, and if you don't mind saying the general area where you live, I might be able to suggest someplace where you will be taken seriously.  Also, do you children have insurance coverage?  If they are apparently healthy right now, I don't think there is any great urgency that they get checked immediately, but yes, aortic valve disease does run in families.  So it would be excellent for the children and all of your husband's relatives to get checked for aortic valve disease and aortic aneurysms, whenever they can.  But you don't want them to, in essence, get the brush-off like your husband did, so they need to go to the right place.

I'll post more later.  I've got to get ready for work.  
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I too, send my sypmathy to you and your family. There is a high chance that your husband died as a result of a type of cardiomyopathy known as Hypertrophic Cadiomyopathy. The wall of the heart becomes too thick and loses it's blood flow (or the bloodflow is reduced) which will cause chest pain/aching sometimes even while at rest. Because of the lack of bloodflow, the heart becomes 'irritated' which, in turn, causes the cells of the heart to start firing and an arrhythmia ends up being the end result. Without immediate treatment, it is fatal. The murmur can be heard on some occasions and not on others, that can be typical. The murmur is a type of murmur not heard often by doctors and therefore that can easily be dismissed. HCM is not that common, it runs in families and may be what your mother-in-law also has. Everyone should have an echo done to rule this out and if you have children they should also be checked for both this form of cardiomyopathy as well as having an EP Study done of the electrical system so that another sudden death event doesn't happen. My best to you.  
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My main problem that caused me to go to a cardiologist was severe, intractable hypertension that did not respond to any antihypertensive medication.  When I was in my 20's, I had low blood pressure, like 90/70, and I felt fine.  Then when I got to be about 30, it was "normal" for a while. like about 120/70.  Then, in my mid- to late-30's, I got mild hypertension, and then it got worse and worse from there.  That is kind of a typical progression with BAV, although nothing is really typical with BAV.  Eventually, my blood pressure hovered around 200/100, and no medication worked to bring it down.  Also, toward the end, I started having PVC's that felt like I had a fish flopping around inside my chest.  As far as chest pain, I only had that after I was already scheduled for surgery, and I think that was not from my heart but from the ascending aortic aneurysm that I had by that time.  

There is no one type of presentation -- no reliable sign or symptom -- that you can count on seeing with BAV.  Everyone with a BAV is different.  The standard diagnostic test for BAV is an echocardiogram, and even that is often false-negative until the valve is very badly deteriorated.  Early in life, the valve tends to work pretty well (also not always true, but usually so, and apparently it was true in your husband's case), and as long as it is still in good enough shape to be functional, it may not look abnormal on an echo.  If your husband had had an echo at the end, though, I can't imagine that it would have been negative, because his valve was so bad by that point that I'm thinking it would have HAD to have looked abnormal on the echo.  

So, the things that made it hard to diagnose what your husband had are:  
(1)  Aortic stenosis in a non-elderly person is not common.  It's not so rare that it's unheard of, but it's unusual.  It's not the first thing a doctor thinks of in response to chest pain, and it might not be the second, third, fourth or fifth thing.  (2)  It's hard to diagnose, because everyone who has has different signs and symptoms.  Something that is unusual to start with and then, to boot, presents differently in different people, doesn't give your average doctor much of a chance to learn how to recognize it.  It's just hard to start seeing patterns under those circumstances.  (3)  The test that can diagnose it is relatively expensive and is often unreliable.  It's hard to justify the cost of a $600 to $1000 test to either an insurance company or to a patient who is paying out of pocket, when the condition that the test MIGHT be able to identify is (a) probably not there, because it is an unusual condition, and (b) if it is there, it is not always visible to the test.  (4) To make things worse, your husband was unlucky enough to have a history of an old shoulder injury that had been bothering him for years, and it was his shoulder that was hurting, so that was like a red herring.

An EKG and the blood test for heart attack enzymes would not be diagnostic of what your husband had, but those are usually what are given to rule out a cardiac cause of chest pain.  They are relatively cheap, and they are familiar to any urgent care doctor, but they wouldn't have been helpful.  The EKG would have shown that his heart was enlarged, but if he had a history of high blood pressure, well then, longterm essential hypertension can cause the heart to enlarge.  So, the urgent care docs still would not have had any specific reason to suspect aortic stenosis.  

So how do you make sure that no one else in the family has what your husband has?  The best way is to go to a physician who specializes in aortic medicine, because that is the type of physician who will understand both the ambiguity and the danger.

BTW, with all due respect to grendslori, I think your husband's aortic stenosis accounts for his cardiomegaly.  The heart was straining for years against that occluded valve, and that typically does cause enlargement and, ultimately, heart failure.  But the test for both HCM and aortic valve disease is an echocardiogram, so the same test will rule out both.  You can't go wrong by having an echo.  Even if it is negative for both, you weren't wrong to have it.  
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I meant, "everyone who has it has different ..."
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367994_tn?1304957193
The heart-weakening effects of aortic valve stenosis will lead to heart failure. Heart failure symptoms include fatigue, shortness of breath, etc. Husband never had symptoms of low cardiac output.

My symptoms from reduced cardiac output was shortness of breath, fast heart rate (115bpm) sustained, fatique, etc. It is difficult to believe aorta valve stenosis that is moderate to severe will not have chest pain and shortness of breath due to reduced cardiac output...tire easily or may have chest pain with vigorous physical activity.

Because there is a family history of heart disease, grendslori's etiopathology of the condition is plausible.  Or there could be temporary overcompensation from a coronary spasm, etc.  that dilated the left ventricle causing arrhythmia and cardiac arrest.
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Aortic stenosis can be part of the picure of HCM. If the septal walls thicken they can block part of the aorta. This is known as Hypertrophic Obstructive Cardiomyopathy (HOCM).
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Okay, thank you.
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And terileefun, when I said what I did about the cost of an echocardiogram, I did not mean that it would not have been worth any amount of money to save your husband's life.  It's just that at the time, with no one knowing what was about to happen, everyone's perspective was different than it is now.  I think that came out wrong, and I'm sorry.  

Your husband's death was tragic, but the tragedy wasn't necessarily as simple as an incompetent doctor's overlooking something obvious, and it wasn't as simple as the fact that the test he needed was expensive.  If anyone had known that he was living the last day of his life, of course someone would have found the money for whatever tests he needed.  He would have, you would have, the hospital would have, or someone would have.  That makes everything different, but no one knew.  

You can't say the doctor didn't make a mistake, because obviously he did.  He made as bad a mistake as an ER doctor can make:  he let someone walk out of the ER who was about to die within minutes.  That's bad, as bad as it gets.   But was there anything that should have told the doctor that your husband was about to die?   That's the question that you started the thread with, and I still don't know that there was.  Maybe.  But not necessarily.  Your husband had a bad, complicated, unusual, hard-to-diagnose disease that is known to sometimes kill people without warning.

In a way, it would help if there was an enemy to blame.  That stupid doctor.  If that stupid doctor had just done his job right, my husband would still be alive today.  But it may not have been that way.  It may be that your husband's death was more of a "perfect storm," with everything that could go wrong, going wrong at once.

I keep saying this, but I'm so sorry.  This kind of death is just as bad as it gets.
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The autopsy states calification of aorta valve causing stenosis (narrowing).  As a consequence of stenosis, pressure within the left ventrical chamber will increase to overcome the gradient pressure of the valve stenosis to pass blood through the narrow valve into circulation. There will be a reduction of the cardiac output!.  Regardless of the underlying cause, a severe reduction of cardiac output will produce shortness of breath, possibly chest pain, fatigue, etc. Husband never stated any low cardiac output symptoms.

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367994_tn?1304957193
"Aortic stenosis can be part of the picure of HCM. If the septal walls thicken they can block part of the aorta. This is known as Hypertrophic Obstructive Cardiomyopathy (HOCM)"

>>>Obviously, HOCM didn't cause aorta stenosis...there was some calcification of the aorta valve according to the autopsy. There wasn't an enlargement of the heart's septum that skewed and obstructed blood flow through aorta orifice.  

Unfortunately, people of all ages have a fatal cardiac arrest.  There isn't any signs and symptoms that forewarn many cardiac arrests, and husband's back ache doesn't suggest a heart problem!  Having a family history of a heart disorder and smoking should place husband on a short list to have periodic physical exams, but from what I have read, I don't see any fault that can be directly attributed to anyone. My experience with doctors has not been totally positive, but I don't see it here...maybe if you can be more specific.
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I'm agreeing with you.  There does not seem to be any obvious fault that can be attributed to anyone.  Sorry if I wasn't clear on that.  That is what I think, also.

We really don't know all the facts of what terileefun's husband told the doctor or what the doctor told her husband.  But from what terileefun has shared, it seems that yes, her husband could  have died of a sudden cardiac event that was unforseeable even minutes before.  Even so, you still have to call it a mistake that the doctor let him walk out.  It was a mistake, given the outcome.  To say that it was not a mistake would be to say that the doctor meant to let him walk over to the pharmacy and die.  It was a mistake, by definition.  It was a wrong decision.  But not all mistakes constitute negligence, which is what terileefun basically started out asking.  

What if terileefun's husband had died while he was still in the exam room with a monitor on him?  It could have happened that way.  What if he had sat around and thought about it at home for an hour or so longer, before he decided to go to the urgent care center that day.  So that when he got there, he was an hour closer to the fatal event, and when it happened, he was still lying on a gurney in the hospital or urgent care center or whatever it was.  Same outcome, ultimately, but the doctor would have called up terileefun and said, "he had massive heart attack while he was in here, and we worked hard on him, but we just couldn't pull him back.  It was too massive, and there was just too much damage.  Some people we can't save, even if they have a heart attack while they are in the ER.  He had every medical advantage, and we did everything we could, but there was nothing anyone could have do to save him, given the catastropic nature of what happened inside his chest."  Somehow that has a whole different feeling to it.  But that's not the way it happened.  And as to why it happened the way it did, I don't think there's an answer.  It's one of those things you can ponder over, like why did someone not go to work at the World Trade Center on 9-11-01, or why did someone take someone else's place at work at the World Trade Center that day.  But why things happen the way they do, I don't know.  


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Thank you for your dedication in trying to help me understand.  You both seem so knowledgable and passionate on th subject that you sound like cardiologists.  If so, then I'm grateful that you take the time to visit these forums and help people.  If not, then I applaud your efforts to gain the knowledge that you have.

Looking back over the years there were a few times that he would just be sitting on the couch or at the table and grab at his chest and say he had pain, but it was over in less than 30 seconds.  When I questioned him more he would say "it felt like my heart had a cramp for a few seconds" I told him "that's NOT supposed to happen!", and he just brushed it off as a muscle spasm or something.  I told him he should see a doctor about it but he just said he was ok.  These were very quick episodes without any other symptoms whatsoever, and again in the 22 years we were married it only happened a few times.  He was always getting weird cramps like in his big toe or a finger or hand or elbow, and he was always very, very dramatic about them in a waythat it always made me laugh....so when he said it was just a muscle spasm I really didn't worry too much, especially without other symptoms.  But as for being short of breath, I never witnessed it unless it was warranted, like lugging camping equipment, etc.  He was always doing something, fixing things, yard work, etc. and he never complained of being short of breath or heart pounding or anything.  He also did not have high blood pressure.  He was diagnosed in the early 90's with a heart murmur, but the recent records indicate none.  

In my original post it was not my intent to claim the doctor incompenent.  Please remember I have very little knowledge or experience with heart issues and had no clue that there were so many different causes of a "heart attack".   My mindset was if his stenosis was so bad that it caused my husbands death,  well it's still just hard for me to fathom that this would not have been heard when listening to his heart.  I don't necessarily "blame" the doctor as much as I think he might have rushed through the motions of an exam because they just thought he was back for a refill on meds,  period.   He told me that they never even checked him on one visit, just asked if he needed a refill, told him to take a seat in the back and the triage nurse brought him the script. He never even saw a doctor during that visit.  Yet, none of the records they gave me reflect this, they all show he was seen by a doctor and was checked.  As for the day that he passed away - I do know this - if my husband had the slightest thought that he was having a heart attack, he would have said something to the doctor.  But even if a person doesn't know or recognize symptoms of a heart issue the medical professionals do.  His age, family history of heart disease, and lack of physicals just add more reason a doctor should be more thorough, especially knowing that he didn't have a primary care doctor to tun to.  

And again, it would seem to me that if it were severe enough to kill him, that he have been short of breath walking in, or a murmur or some kind of sound would be heard through a stethoscope.  I just find it hard to believe that there could be no indication of some kind of problem when it's severe enough to cause death in minutes.

My husbands death has been incredibly, incredibly painful, I just don't ever want another family to suffer such a loss.  If I can build awareness to patients, doctors, nurses, ER's or Urgent Care's then just maybe we can prevent future loss and pain.  



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With the cardiomegaly, he could have had a sudden arrythmia, as kenkeith and erijon stated.  A healthy heart has its normal conduction pathways that carry the electrical impulses through the heart muscle, and those pathways activate with every beat.  Doctors have the conduction pathways mapped out, as there is normally a pattern that goes through the heart muscle in a similar way in all people.  It's part of the natural design of the heart.  

But when the heart gets enlarged, as your husband's evidently did from straining against the occluded valve for years and years, the conduction pathways get stretched out and distorted.  The electrical impulse that activates each heartbeat is no longer able to travel through the heart muscle in a predictable way.  One day the electrical impulse just "shorts out," so to speak.  With cardiomegaly, it's predictable that something like that will happen someday, but you don't know what day.  It's like the tipping of an iceberg.  The ice melts, and melts, and melts, and the iceberg is changing shape under the water, and one day it flips.  It seems like a sudden event, and on one level it is, but on another level, it isn't.  The flipping is the culmination of a long series of minute changes.  A catastrophic arrythmia in response to cardiomegaly is like that.  

If it wasn't an arrythmia that killed your husband, it could have been one of a couple of other things I can think of that don't happen until they happen, and there's no obvious outward sign until they do happen.  Whatever it was, if it had happened while your husband was still in the ER and was on a monitor, the doctors would have tried to shock his heart back into a normal rhythm with the defibrillator paddles, and maybe that would have worked, and maybe it wouldn't have.  Unbeknownst to anyone, his heart was already severely damaged by then.  Even if the shock had worked, he still would have been very critically ill, and he would still have needed open-heart surgery to replace the valve, and he would not have been a good surgical candidate at that point.  He might not have survived the surgery, if he had lived long enough to have it.  

It is really weird and scary that someone can get that ill without even knowing it.  It is sad that he didn't get a thorough enough exam to show that there was something wrong with his heart.  Do you know if he even got a chest x-ray or EKG that day?  Either one of those things would have shown that his heart was enlarged, and what (if anything) the doctor chose to do about it would have been up to his or her medical judgment.  It would have been within the normal operations of an urgent care center to simply advise your husband to obtain primary care or cardiology care for that.  Regarding shortness of breath, if your husband was not short of breath when he left the house, then he probably wasn't short of breath when he got to the urgent care center.  It sounds like he didn't get short of breath until he walked into the pharmacy.  Or maybe he was a bit short of breath all the time, and he had gotten used to it.  He probably told himself that he needed to quit smoking.  

More about heart murmers.  When I saw a cardiologist for the first time, I had already been working with my PCP on my blood pressure for about a year, and I had already been to the ER one night.  No one had ever heard a murmer in my chest, never in my life.  That cardiologist put me up on an exam table, and she did the most thorough chest auscultation I have ever had, before or since.  She put the stethoscope on about five different positions on the front of my chest, same on the back, and she did that with me in three different body postures:  sitting upright, front and back; sitting forward at a 45 degree angle, front and back; and lying flat on my back, front of my chest.  She heard a faint murmer in one stethoscope position, with me lying flat on my back -- only.  She said it was faint enough that anyone who did not have very acute hearing (which includes a lot of middle-aged or older doctors) would not have been able to hear it at all.  Maybe if your husband had had that kind of physical exam at the urgent care center, a murmur would have been detected -- but again, it wouldn't necessarily have signified an emergency.  It would have been a reason for the urgent care doctor to tell him to seek primary care or cardiology care.  Maybe an urgent care or primary care doctor considers that kind of chest auscultation to be a specialty procedure that is normally only done by a cardiologist or pulmonologist; I don't know.

I appreciate that you are able to take my input in the spirit in which it is given.  I believe you are really seeking the truth, and I respect that.  In my opinion, you are responding to this terrible event in exactly the right way.  First of all, you are trying to understand it, and second of all, you are trying to make sure that the same thing doesn't happen to other people.  I think that's all you can do, at this point.  Your husband's death wasn't a good thing, but you can try to make something good come from it.  That is a positive response to a terrible loss.
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In case there is anyone reading this thread who thinks I am calling the urgent care doctor incompetent or stupid, no.  I'm not.  I'm saying that if the doctor had been incompetent or stupid, then that would be a simple answer to what happened to terileefun's husband, but I don't think it was that simple.  
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When my daughter's heart murmur was first diagnosed in her she was 6 years old and lying in a hospital bed. She was under the constant care of her doctor for having juvenile rhuematoid arthritis and steven johnson syndrome. No one ever heard a murmur in her. When she was discharged from that stay she should have been coming home in better shape than when she was admitted; instead I brought her home with a form of terminal heart disease! She was dying since birth and no one had a clue. She finally recieved a transplant. So heart disease does get missed. Pain and muscle pain in the back can certainly be a symptom of heart disease; it certainly is in women and is actually more common as a symptom of women than chest pain in the traditional sense. Because dilated cardiomyopathies are so common, people sometimes automatically assume that is always the case of what is happening. I don't know that was the case here. As the heart works hard to pump blood, like all muscles, it thickens to compensate. More muscle develops and in some eventually, the heart wall will thin out, but not in the beginning. The thickened walls can become very irritated and arrhythmias can kick in. As far as the shortness of breath, people think: hard time breathing or catching your breath. It can also be a very shallow, faster than normal, type of breathing. (the normal rate is 16 breaths per minute) Again, I am sorry for this loss in your life, I hope the things written here by so many experienced people will help you to understand and find peace once again.
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If I had stayed with my then-PCP and followed his advice, I would be dead now, because he didn't have a clue that I even had a heart problem.  I would be in the same place that terileefun's husband is in now.  But I can still say, my former doctor wasn't stupid or incompetent or a bad doctor.  He was just an average guy, doing a job.  In some ways, he is even a better-than-average doctor.  I have never had any thought of complaining about him to the medical board for missing the diagnosis, suing him for malpractice, or anything like that.  I didn't keep him as my PCP, because he obviously doesn't have a high threshold of awareness about something that we now know is my major problem.  But I wouldn't say he is a bad doctor.  

When I went to the cardiologist who found my murmur, I really still didn't think I was going to have a "heart problem," per se.  I thought that I had essential hypertension that for some reason wasn't responsive to first-line medications.  I thought that I would see the cardiologist once or twice, and she would tweak my treatment, and then I would go back to my PCP.  I was simply choosing to see a specialist who was particularly skilled in the type of medication that I needed.  Even when she told me that I had a heart murmer, I thought, "A heart murmur? Oh, wow.  So what?"  because a lot of heart murmurs are benign.  I still had no idea what I was about to get into.

What came next was two heart surgeries, the first of which was not done right.  I had to go to a world-renowned surgeon at a major heart center to get the surgery redone, and I nearly died in the process.  The first artificial valve that was implanted came unsewn 2/3 of the way around, and I was walking around with the stitches popping loose day by day, and who knows why I survived that.  That's another one of those things for which there is no answer.  Why did  those last few stitches hold until I could get into surgery again?  And why was I lucky enough to meet someone on the internet, a total stranger, who referred me to a second surgeon who was one of the few doctors on the planet who could have saved my life, at that point?  I don't know.  

But one of the things I have learned, through this whole saga, is that medical knowledge about aortic valve disease is not common knowledge.  It needs to become common knowledge, so that more people's lives can be saved.  That's the main reason I post on forums like this, to try to pass on the good that was done for me by someone on a forum.  That someone saved my life, as much as my second surgeon did, because I would never have gotten to the second surgeon if it hadn't been for her.

terileefun, you go, girl.
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It appears we are all common ground :)  I would like to add there could have been a coronary spasm that triggered the cardiac arrest.  This is supported by a history of an occasional unexplained heart pain... QUOTE: " Looking back over the years there were a few times that he would just be sitting on the couch or at the table and grab at his chest and say he had pain, but it was over in less than 30 seconds."  A coronary artery spasm is a brief involuntary constriction of a coronary artery. Very difficut to diagnose due to the infrequency of events, and an EKG is not able to capture any abnormal electrical impulse unless there is an event at the time.

QUOTE:"But one of the things I have learned, through this whole saga, is that medical knowledge about aortic valve disease is not common knowledge".  

>>>It may not be "common" knowledge, and you may be surprised regarding the distribution of relevant information about the subject on this forum.  Anyone that has read and participated on this forum such as Jon and flycaster, etc. for years have knowledge of the subject matter, and I have lived with valve insuffiency for years and read extensively on the subject. There are numerous threads on the subject. You are new to the forum,  may not be aware, but it should not be a surprise..

I hope there is an understanding of the relevancy regarding valve insufficiency and how it relates to an enlarged heart, and an enlarged heart can be triggered to cardiac arrest.  
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I wasn't being personal.  I was referring to having had a lifetime of experience with doctors who did not diagnose my condition and even then, after I was diagnosed, not getting appropriate treatment for a long time.  Certainly, there is a wealth of information on this site.  

Raising awareness among the medical profession would still be a good thing.  
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