I awoke with a feeling of slight breathlessness and a sense of tightness under my breastbone. We both thought it to be indigestion and i took a couple of antacid pills, but to no avail. Apart from my jaws being very tight, there were no other symptoms. After an hour of fruitlessly waiting for it to subside, we called our family doctor and he suggested that we come in for a checkup. This was about 3 a.m. (dedicated doc Ravi Thyagarajan!). We got there about 3:30 and he checked my BP and pulse and both were normal. I had no temperature, no sweatiness, no chills, no other discomfort except for this steady 'almost pain' under my breastbone. The feeling of breathlessness had also faded away.
After some deliberation and observation Ravi put a tablet under my tongue, 'just to be on the safe side' and ordered me to a nearby cardiologist for an ECG (EKG) and whatever other tests they may decide. The tab melted off not too unpleasantly but then I felt a bit lightheaded and went home to sleep. This tab-under-the-tongue was concidence #2 for without it things would have gone from bad to worse that much faster!
On awaking, the discomfort was minimal, just a vague feeling of tightness and I was ready to ignore that but Aruna insisted and so at about 9 a.m., after sending the kids to school/college, we finally went to a nearby cardiologist's office where the ECG looked suspicious enough that they decided to do an echo and that showed that a heart attack was under way. The medical term is acute myocardial infarction, in this case affecting the muscles of the anterior wall of my heart. Due to a sudden lack of oxygen these muscle cells were unable to beat properly and would soon die altogether unless rapid action was taken.
I was rushed to a nearby hospital where good cath lab facilities were available. There, as luck would have it, mini miracle #3, a cardiologist who was also a good friend and the best in the city for interventional cardiology was handling the cath lab that day (Dr. J.K. Periyasamy) who on seeing my report, ordered me in for an angiogram. I went straight into the ICCU where an IV line was inserted, medication injected, test doses of the anesthetic and radio-opaque dyes were spotted onto my forearm and I was prepped for the angio. 
Within a couple of hours they had me under the moveable head of the x-ray machine in the cath lab, with a catheter working its way up my right arm towards my heart. I was conscious and by now enjoying the whole show. The monitors were on my left and I could watch by craning my neck around slightly. The dyes started to be injected in double puffs of black, highlighting the arteries of my heart. The x-ray head swung in all directions as they got a fix on the two main arteries and studied them for blocks. It didn't take too long to find TWO 90+% blocks right next to each other on the artery known as the LAD. 
This was obvious even to my untrained eye as Dr. J.K.P. pointed it out and then asked if he could go ahead and put in a stent. After careful measurements they decided that they had a stent that was just big enough to cover both the lesions and that's coincidence #4 as without that 30 mm stent, it would have been a bypass surgery for sure and I would have lost some valuable heart muscle while I awaited that surgery. A very worried Aruna was consulted and shown the blocks and after she agreed, the doc inserted the stent and sent me back to the ICCU.
It turns out that ad hoc stenting like this is almost never done in India. There are too many risks involved and the cardiologist has to be supremely confident that they have seen and diagnosed correctly without needing to ponder the films for a couple of days at least! Yet, I was in that critical window period where if the blocks were removed, my muscle would be preserved and back to normal within a couple of weeks, otherwise the muscle would soon die (about 12 hours is all that's there) and an infarct would result - that's the scar tissue that results from an untreated MI.
That next 24 hours was really painful. I was feeling fine but flat on my back with bandages swathing my arms and under the watchful eyes of the ICCU staff, who flatly refused to even let me watch my own monitors!
The next day I begged to be let out, and the doctor reluctantly agreed. Then after 2 more days in a room at the hospital under observation, I was finally let go of but under strict orders to take rest. I've even been kept away from my computer till today and hence the delay in informing all of you.
This was obvious even to my untrained eye as Dr. J.K.P. pointed it out and then asked if he could go ahead and put in a stent. After careful measurements they decided that they had a stent that was just big enough to cover both the lesions and that's coincidence #4 as without that 30 mm stent, it would have been a bypass surgery for sure and I would have lost some valuable heart muscle while I awaited that surgery. A very worried Aruna was consulted and shown the blocks and after she agreed, the doc inserted the stent and sent me back to the ICCU.It turns out that ad hoc stenting like this is almost never done in India. There are too many risks involved and the cardiologist has to be supremely confident that they have seen and diagnosed correctly without needing to ponder the films for a couple of days at least! Yet, I was in that critical window period where if the blocks were removed, my muscle would be preserved and back to normal within a couple of weeks, otherwise the muscle would soon die (about 12 hours is all that's there) and an infarct would result - that's the scar tissue that results from an untreated MI.
That next 24 hours was really painful. I was feeling fine but flat on my back with bandages swathing my arms and under the watchful eyes of the ICCU staff, who flatly refused to even let me watch my own monitors!
The next day I begged to be let out, and the doctor reluctantly agreed. Then after 2 more days in a room at the hospital under observation, I was finally let go of but under strict orders to take rest. I've even been kept away from my computer till today and hence the delay in informing all of you.
I would like to thank in particular Senthilkumar (our adopted brother) and the staff of his company Ventura Omnitech Pvt. Ltd. for the constant and selfless support during a time of crisis!
If I can figure out how to podcast bits of my angio, that may also show up on this blog one of these days...
If I can figure out how to podcast bits of my angio, that may also show up on this blog one of these days...
35 comments:
We're all glad to see you back on line so quickly!
It appears that God wants you blogging!
Thanks Jon. I guess so, or it may just be that he has it in for all of you and left me here to continue to be a thorn in the flesh.
it's good to be back, blogging and otherwise!
sam just saw the post, and thank goodness (Aruna). But, how could you let it to get to this level. You must stop smoking, ie, if you havent already. Or else, we are coming over.
hello hello,
im glad ur still ticking because god knows, theres not enough people in the world who wud derive such enjoyment from watching their own angiograms.
glad ur ok and back at it. i have been following ur blog for some time (albeit sporadically, because im working most hours of most days now).
BIG hi to everyone. how are you all doing/. its been way too long!
Thanks for the good thoughts and beieve me i am glad to still be around with all you wonderful folks!
i quit just about everything and am even being a good vegetarian, no oil at all, etc. and this continues for at least a couple more weeks.
My checkup yesterday confirmed that things are indeed ok so far and thankfully they removed a lot of my medications.
Non of this should prevent you guys from coing over - it would be great to see all of you again!
I'm so happy that your wife was so attentive! Good that you're back with us. How did your children react? Did you give them the same thoughtfull explanation as you give us on your blog?
See you!
Odile, thanks for dropping by.
Our kids were taken completely by surprise. My daughter called from college about lunchtime and so found out that i was in hospital though at that time the angio was not yet done so she got permission and came to the ICCU around 4 p.m. and i managed after persuading a soft hearted nurse to let her in for a few minutes and was able to calm her down as i really was feeling o.k. by then.
My son came in late at night and was allowed to peek in through the doorway but they woulln't let him in as he is still technically a child.
By the next day they were both fully into their new roles of keeping a naughty dad under control so the tables were turned and I was severely outnumbered!
These are the days that you remember as a child more than others. They must be relieved about how you stay calm and continue to explain everything that happens. Are they pampering you? That must be fun.
If you want to see a picture of my current house: e-mail me at schmiodile@denkt.nl
I'll send you an Url.
Yes, it's a whole new experience for me as I rarely get sick. I think we are all enjoying the role reversals a bit!
I'll be sending you a mail. Still, as you are so keen on selling the house, it would be perhaps helpful if you did a blog just on that and gave the URL to your friends so that anyone at anytime could promote the idea...
That's a good idea! I'm going to do that. Thanks.
Nice diagrams, very educational. Will there be a bypass down the road, or are you good to go?
I see one of your fears in your last post had to do with losing your health. It seems that you reacted with aplomb to the feared event, which should provide you with some additional assurance that you can handle what comes at you. Do you find yourself worrying about relapse? I'm wondering about the PTSD potential of your experience.
If I am a really good boy, stick to my diet, get enough rest, do good aerobic exercise and take my medicines, then the chances are that I will be spared a bypass, but then the body is a strange thing and they haven't really figured out why some people restenose (about 15% get blocked up again) and why others don't.
In some sense I was too fascinated by the experience to really be scared, at least on a conscious level. This is stuff that I read about very regularly and I knew that I was on the cutting edge of what medicine can do today and wanted to get every bit of it, a bit too Socratic for my own good?
I do worry about the fear factor for Aruna, who was not at all amused to say the least. She was the one waiting in the waiting area for news and only aware that it was very serious and that 'anything could happen'.
She is a strong and capable person but I can still see the worry and fear in the way she keeps me under tabs and is never away from home for any significant period of time. I had to go to the bank today and she kept calling to ask me to remember to get this or that on the way back, but i think it was to make sure that I was 'getting on' ok more than anything else.
The kids are more resilient and less prone to worry and seem to have accepted that i am recovering ok but one never knows what traces have been left and when they will choose to 'engage the membrane'.
I've had that calling episode and was happy to talk about it with my husband. That's one of the things that are so good in our relationship.
So what now Sam? How long are you to rest up for? Did you ever have a cardiac check before this Sam?
Ivan
Ivan, Hi.
I had a checkup that included an ECG in February and that didn't send up any warnings. It looks like it was a completely silent build-up that finally was set off by some small bit of clot (they think). It was also in February where I did some really serious hiking for three days, with lots of hills and keeping a pretty good pace and there was nothing then either!
I will be checke up once a month from now on for some time and modern medication is pretty good at keeping cholesterol uner control so i should be here for some time to come, God willing!
Did you ever have a noticable Cholesterol problem Sam?
Ivan
Ivan, I haven't ever had a really 'bad' lipid profile. My cholesterol levels hover around 200 and that is marginally over the normal. In February when we checked, my triglyceride levels were a bit high (around 250) but we had been to a party the night before and I went to town on some very oily dishes. You need to have fasted for 12 hours for a proper lipid profile and that day it was only 8 hours so we did not pay much attention to that at the time.
You certainly were a very lucky boy Sam.
Ivan
Sam how are you doing? Hope everything is alright and you are being a "good boy." what are the medicines you are on? I just want to know something. Apart from cholesterol (not much elavated) and sugar (normal), what were your cardiac enzymes like, since you were just short of an attack (maybe quite normal because the muscle escaped damage just in time). Was there a hsCRP done? Was it elevated? Should anyone with a chest discomfort and even remotely suspects the source to be heart, ask the doc to do a hsCRP, I mean if he/she is not on statins already?
Ivan, there's a number of ways to look at that. I could have been on the way to bigger and better things, or at the least would have found all the answers to our debate! On the whole, though, i tend to agree with you!
Paru, I had an elevated CKMB and an elevated troponin I. They didn't check anything else.
Actually even this was superfluous as the echo was quite diagnostic. The analysis was that the muscle was 'stunned' and starting to get badly damaged but somewhat just within the recovery period.
and yes, so far, I have been a 'good boy'. My checkup a couple days back was good.
The major medications now are aspirin, clopidogrel, pantoprazole and fenofibrate. All the BP medications, ismo, ramipril and carvedilol have been removed as my BP got too low.
I am to start fish oil supplements from tomorrow.
As far as hsCRP, that's a screening test and won't be of much use in any acute situation (as far as I know). It may be a good test for seeing whether the post MI inflammation rate goes down and that's supposed to correlate with reversal of atherosclerosis, but I think they need some larger trials before that's confirmed.
yes, precisely, that's what I want to know. In your case, you were past screening. But hsCRP, being acute phase, should it be included as a screening test along with the lipid tests say after 50-55 years, especially when there is heart history in the family? Will it be increased proportionate to the degree of athrosclerosis, so that it makes necessary the other diagnostic tests? I just wanted to know if it was and how increased it was at your level of block (2 x 90%). And I thought CKMB and troponin I start elevating after an attack. So there was some damage to your heart muscle?
anyway hsCRP is useless if your are already on statins, which would be the case mostly, when you have a heart history in the family. Maybe it is only good as a monitoring test as you say.
I saw one study that suggested that post MI, on statins, hsCRP would help to monitor the rate of subsidence of atherosclerosis. Potentially it could be helpful in my case to ensure that restenosis is not taking place, but i think more studies will have to be done to confirm that.
It certainly should become a part of standard cardiac screening as it seems to both correlate well with cholesterol and provide more specific information on the probability and progress of ischemia itself.
Thanks a lot sam, this is exactly the answer I was looking for. So, why isnt hsCRP included as an important screening check for heart? It might be quite useful in deciding whether any further diagnostic test is required or not, at least for the moment. Especially for people who have diabetes or elevated cholesterol or both. Dont you think it should be made a routine screen?
Sam, dont statins reduce hsCRP? Or its elevation despite statin an indicator?
The medical community moves slowly. It tooks ages for BNP and troponins to get routinely done. hsCRP is still new and studies that evaluate its usefulness will take some time to do as the follow up periods are now typically 3-4 years. I do think it looks very promising and technically a less complicated test to do so I think it may well become popular.
Sam,
You and I should have a codeword to pass onto the other by the death of one of either of us. any suggestions?
Ivan
I agree, though I think it's been tried many a time before! No harm in giving it one more shot! We need to find a neutral person to 'hold the password' and to act as a cutout (perhaps John Doyle may agree?) Let's discuss the specifics at Ktismatics.
sam what about homocysteine? Should it be monitored even earlier to hsCRP?
Paru, there are so many tests. You can check homocyteine, myeloperoxiase, fibrinogen, Lpa and on and on but none of these are very good. A lot of people are now combining the results into a global risk score but this seems to me to be statistically a bit ridiculous.
If there are any signs i any of these tests that indicate higher than normal values, an echo an a stress would be wise but even with this the predictive value is only 50-70%! Short of doing an angiogram, none of the prognostic factors seem to me of any great use. As always, the avice that I never followed - prevention is better than cure.
Paru, have a look at these fascinating slies http://www.lipidsonline.org/slides/slide01.cfm?tk=37
erdman, thanks for your perspective. yes, of course, a global risk score is as useful as global warming score (you know it is there and YOU have made it). But studying the individual contributing factors dont make one feel that depressed that the total effect does. (It is like Sam watching his own angiogram like it is the most thrilling suspense thriller and Aruna worried dead waiting outside). I was just wondering about how homocysteine is contributing to the chemistry of atherosclerosis. It turns out that it is just another marker and not a causal agent.
Yes indeed, prevention is better than cure. I was just trying to learn at the cost of Sam! Sorry Sam.
I went through those highly interesing slides Sam, and sort of got the idea. Couldnt understand fully. I will go through them again, till it becomes more clear for me.
Sam...glad to hear you made it through and that it looks like you'll be OK...
I had an angiogram when I was like only weeks old. My Mom about had a heart attack herself! Turns out I had a heart murmur...a hole in my heart the size of a quarter. It healed on its own :)
Jason, I guess we both are lucky to still be here!
Paru, that actually was me tho named erdman, who happens to be a real friend and what started as a bit of a tease ended up confusing my online identity - fixed finally!
know what Sam, I sort of had a gut feeling about the identity. The language gives it away.
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