DrSamGirgis.com has the pleasure of hosting the following post by contributing blogger, Dr. Richard Andraws MD, who is a Board Certified Cardiologist
Keith is a 51-year-old man who has no significant medical problems. He’s married with a daughter who’s about start college. He’s built a secure career for himself, having become a “company man” in an era when that’s rare. Keith’s entered middle age with a sense of personal satisfaction and optimism for the future.
And then, one day at work, the pain began. It wasn’t pain actually; it was tightness, as though a giant hand had wrapped its fingers around his chest and started to squeeze. Samuel Levine had observed patients make the “clenched fist” gesture when describing it. It became harder to breathe. He had just had lunch, and he’d indulged a bit. It was probably just a bad case of heartburn. A colleague shared a few antacid tablets; maybe it was a little better.
But it never really went away. It waxed and waned in intensity, and now he felt beads of perspiration. It hadn’t been very warm that day. The shortness of breath was still there. He also had vague nausea. This was more than heartburn: it was probably food poisoning. No one minded when he asked to knock off early. He wasn’t looking so good, after all. He drove himself home.
Those were the first rumblings of Keith’s heart attack. He was hospitalized and received three stents to his right coronary artery. And unfortunately, because he had waited to get to the hospital, his heart had been irreparably damaged and weakened. Despite the stenting and an arsenal of proven medications, his heart remained weak enough that three months later, Keith received an implantable defibrillator to protect him against sudden death.
He was blessed with a caring family and amazing friends. He would be fine, they assured him. He was back on the softball field that summer. He’d undergone a cardiac rehabilitation program. His cardiologist had given him clearance to resume as much activity as he could tolerate. Blood pressure and cholesterol were ideal.
But that occasional twinge of pain he sometimes got: was that another heart attack? Sometimes it went away but others times it lingered. Keith ran back to the hospital when that happened, but the emergency room doctors told him he was fine and sent him off after basic testing. Keith knew he’d never get back on the softball field, and he didn’t want to. When it came time for the family vacation, he didn’t want to go: he didn’t want to be too far from home; just in case. Would he see his daughter graduate? Get married? What was this thing, this defibrillator, that they had shoved into him, what was it really doing? Was that a shock he had just felt?
In the last quarter century, cardiologists have learned how to diagnose and treat heart disease quite well. Billions of dollars and hundreds of thousands of patients in research have shown us which medicines to use, which stents and defibrillators to implant. But when is that not enough? Does heart disease simply take a physical toll that can be addressed with a higher dose of beta blocker, or does it leave lingering, more profound scars?
Researchers at Columbia University recently examined this question in a pooled analysis of research addressing post-traumatic stress disorder (PTSD) in survivors of heart attacks. PTSD is often associated with traumatic life events, most commonly the experience of armed combat. Yet any traumatic event may trigger the anxiety, intrusive thoughts, and behavioral changes that characterize it. The authors found that up to 12% of heart attack survivors may manifest the symptoms of PTSD. More troubling, these patients had double the risk of a recurrent heart attack and/or death.
The study reminds doctors that our patients are more than a collection of test findings. It is important for them to address our patients’ mental health as well (and to remove the stigma of doing so, a stigma often felt most acutely by the patient). It may be time to broaden the armamentarium; it’s time to help Keith find the satisfaction and optimism he lost the day he first felt that awful squeezing.