The heart never sings in a minor key

Thursday, April 16, 2009

Danny Ainge is recovering at Massachusetts General Hospital after having a minor heart attack. He is recovering nicely. Mr. Ainge is expected to remain in the hospital for a few days.

A short press release from the Boston Celtics about the health of their 50 year general manager who earlier had undergone heart catheterization to open a blocked vessel and have a stent placed to keep it open.

There are many story lines that could be followed.

Ainge was an elite athlete playing both pro baseball and basketball. Who could imagine him having heart disease at such a young age.

His initial symptoms were of feeling poorly, not necessarily the classic crushing chest pain. Those symptoms arose later. Many patients suffer hear attacks without knowing it. Instead of chest pain the complaint may be indigestion or jaw, neck or arm ache, unexplained shortness of breath or just fatigue. Women, especially, may have atypical symptom presentation.

The rush to open the blocked blood vessel is a reminder that heart muscle that isn’t getting blood supply will die and be replaced with scar tissue. This leads to a heart that can’t squeeze or beat as efficiently. Heart catheterization is the gold standard. A cardiologist threads a thin tube into the heart arteries themselves, injects contrast dye and outlines the blood vessel anatomy. Blockages can be identified and opened wit ha balloon, in effect squashing the cholesterol buildup or plaque into the blood vessel wall. A metal cage called a stent can be placed across the formerly narrowed segment of artery to prevent the blockage from recurring. Since half the hospitals in the US don’t have cath labs, clotting busting drugs like TPA and TNK can be used to reopen the blood vessel as a temporizing measure.

But the real story is that people might believe that there is such a thing as a minor heart attack. There may be heart attacks that affect a small area of heart muscle but every heart attack is a major crisis and potentially a killer.

People die in the acute phase of a heart attack because heart muscle that is being starved for blood becomes very irritable. Irritable heart muscle may lead to ventricular fibrillation and V Fib equals sudden death. The heart is a two stage electrical pump that depends upon a coordinated electrical signal to have the heart muscle cells contract at the same time. This contraction allows the heart to beat and pump blood to the rest of the body. In V Fib, the electrical signal is chaotic and the heart sits there and jiggles like a bowl of jello. No heart beat, no blood supply to any organ of the body and sudden death occurs.

The treatment for V Fib and sudden death is electricity or defibrillation. Whether that electricity is delivered with an AED in a shopping mall or in an intensive care unit, the key to survival is early application of an electric shock.

Heart attacks come in all shapes and sizes. Classic chest pressure radiating down the arm may not always be the norm. Patients don’t read textbooks and may present with very atypical symptoms that end up being heart related. When death is the complication, it’s difficult to suggest that any heart attack can be classified as minor.

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