Was He Really Having a Heart Attack?
The 67-year-old man dropped heavily into the plastic chair inside the Alta Mountain resort in Utah. It was his third day skiing the Rockies but his first at Alta. He had been excited to try these new slopes, but his run that morning was brutal. It was a clear, cold day, and the sharp mountain edges stood out crisply before the bright blue sky, so different from the slopes back East where he lived and usually skied. About halfway down an intermediate-grade slope on his first run that morning, the man started to feel bad, as if he were coming down with something. He rested for a few minutes and when that didn’t help, headed back to the lodge. The trip down was miserable. He felt a strange exhaustion and had to stop every few minutes, as if he were running up the mountain rather than skiing down. It was so bad that, at one point, he worried he would have to be taken in by the ski patrol. But he made it. Finally.
As he entered the warmth of the lodge, he was greeted by the usual scent of coffee and the cinnamon charm of freshly baked pastries, but he wasn’t hungry. Sitting by the fire, he tried to figure out what was wrong. He wasn’t out of breath anymore, and that was a relief. But now he had a strange ache in his chest, a few inches below his right clavicle, as if he pulled a muscle. And he was sweating like crazy. He could feel the cool of the saturated undershirt against his chest. He could see the dark dampness as it seeped through his turtleneck. A door opened, and the cold air chilled the sweat on his face. He just sat there, unable to do anything more. It was nearly an hour before he started to feel better; the ache in his chest was still there but the crazy sweating had stopped. And he felt well enough to return to those beautiful slopes.
But first he had to buy a new shirt; the one he was wearing was soaked, and he would be cold out on the mountain. Finally dry and relayered, he grabbed his skis and headed toward the lift. On his way, he saw the first-aid building. He felt OK now but was worried — was he well enough to ski? A young woman was working behind the counter. He described the strange and sudden fatigue he had on the slopes and the drenching sweats and chest pain he had in the lodge.
Out of nowhere a young man appeared. “I need you to come back with me,” he said, then introduced himself as the doctor on duty. The man needed an EKG, the doctor told him, and led him to an exam table. He placed the sticky tabs on the man’s chest, arms and legs. “You’re having a heart attack,” he explained gravely as the spikes of heartbeats moved across the screen. “No, I’m not,” the man replied promptly. He had never had a heart attack, but he knew what they were supposed to feel like. He had no chest pressure, just this ache. And it wasn’t even on the left side, where pain from heart attacks usually occurs. The doctor was insistent: The EKG clearly indicated a serious myocardial infarction. The man resisted. “Call my son,” he said. “He’s a doctor. He’ll tell you I’m not having a heart attack.”
“I Think You Should Go.”
The man’s son was in New York City, training to become an oncologist. He listened to the doctor describe his father’s symptoms and the resulting EKG. After a pause, the doctor held the phone out to the man now sitting on the exam table. “Dad, you’re having a heart attack,” his son said. The man answered a little testily, “I’m not.” The son was insistent. The doctor there wanted to send him to a hospital in Salt Lake City, and his son agreed. “I think you should go,” he said. Although the father couldn’t believe he’d had a heart attack, he was worried enough to cut short his day on the slopes to get checked out.
Dr. Kent Meredith, the cardiologist on call that day at the Intermountain Medical Center, was waiting as the ambulance pulled in. He introduced himself, then began to jog up the driveway to the hospital, indicating that the E.M.T.s should follow at the same pace. Based on the EKG done at Alta, the man was clearly having a heart attack, Meredith explained as they hurried down corridors. To protect his heart, he would need a cardiac catheterization.
In this procedure, Meredith would introduce a slender catheter into one of the vessels of the man’s wrist and thread it up the arm to the chest and then into the heart. Once it was in place, he would inject a dye into the arteries that provide blood to the cardiac muscle. A heart attack occurs when one of these vessels is suddenly blocked, cutting off oxygen-carrying blood to the hard-working cardiac muscles. Meredith would be able to see the effect of the blockage on a moving-picture X-ray: The vessel feeding a section of the heart — and lit up by the contrast — would suddenly appear to end on the scan. No blood meant no oxygen, and without oxygen, the muscle would die. The faster they could clear that obstruction, the less likely it was that the man’s heart would be permanently injured.
Moments later, Meredith was surprised by what he found — or didn’t find. There was no obstruction. The patient’s coronary arteries were wide open.
He hadn’t had a heart attack after all. There were two other possibilities. The same chest pain and EKG changes could have been caused by a spasm in one of the coronary arteries squeezing it shut just long enough to injure the heart. The fact that, during the catheterization, the artery looked normal would mean that the spasm had relaxed and the artery reopened. If that was the case, the EKG abnormality seen at Alta should be gone too. A second EKG was done. It was unchanged. This wasn’t a spasm.
That left a second possibility: a rare condition called Takotsubo syndrome, also known as broken-heart or stress-induced cardiomyopathy. In this disorder, the muscular walls of the left ventricle — the part of the heart that squeezes the blood into the body — are suddenly weakened, stretched out like an old piece of elastic. When seen on an ultrasound, the normally bullet-shaped space, defined by the strong muscular walls of the heart, appears enlarged, and the walls are thinned and distended. Its squeeze is weak and can pump only a fraction of its usual payload of blood into the body.
The syndrome was first described in 1990 by a Japanese cardiologist, who thought the injured ventricle looked like the thin-necked, elongated pot used by fishermen to trap octopuses — a takotsubo. The injury, often seen after a patient has had some kind of physical or psychological stress, is thought to be caused by a sudden surge of adrenaline or other fight-or-flight hormone. While the immediate effects can be life-threatening, the injury is reversible and function usually returns to normal within weeks or months. This man wouldn’t be a typical takotsubo patient: It’s most commonly seen in older women, and the classic story is of a brokenhearted widow, just after the death of her husband. It was clear from the earliest reports, however, that more ordinary stresses — such as singing karaoke or public speaking — could also be triggers. And some patients reported no stressors at all.
“You were right,” Meredith announced when the man woke after the procedure. He hadn’t had a heart attack. But his heart was far from normal. Meredith explained the diagnosis of stress-induced cardiomyopathy. Exactly how or why this happens is still not well understood, he told his patient, but he would recover soon. Until then he would need medications to support his weakened heart. He was discharged from the hospital the next day and told to follow up with a cardiologist at home.
He flew back to New Jersey and quickly found a cardiologist. A stress test done just a few weeks later was completely normal. That was eight years ago. The man still skis every winter and goes out to the Rockies when he can. He was offered a pass to Alta, to replace his day that was cut short. But he’s not interested; he gave it to one of his sons. He has never returned to those slopes. And, he says, he never will.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her at [email protected].