Would you recognise a gradual-onset heart attack?

This article was taken from: https://www.theguardian.com/society/2019/sep/22/would-you-recognise-a-gradual-onset-heart-attack

By Amy Fleming

We think of an attack as a ‘big bang’, but the symptoms can build over hours or days – and even doctors can misinterpret them

In spring 2018, Tim Walker was working on a PhD in microbiology. Over the course of a week, he started feeling a little breathless during his morning commutes to University College London and had what felt like muscle aches around his upper back and shoulders. He put the symptoms down to a nasty virus. “I was 31,” he says. “Why on earth would I suspect that I was having a heart attack?”

As the days passed, his symptoms grew more pronounced. Eventually, he woke on a Saturday morning to “the most intense pain I’ve ever experienced – an otherworldly, constant stabbing pressure in the collarbone area, neck and jaw, on both sides”. He started coughing and vomiting, but there were no chest pains. “I’m not a religious man, but I remember praying at one point.” After no more than 10 minutes, the symptoms went away, just as suddenly as they had appeared. He assumed it was a really nasty bug. Later, he became feverish and decided “to take a few days off uni to get my strength back”.

It wasn’t until he was sitting at his desk the following Thursday, more than a week after symptoms had begun, that he sought medical attention. “My left arm suddenly went cold and numb.” He walked to the nearest A&E, where he was examined by a flurry of bemused doctors. Before the day was out, he had been diagnosed with a heart attack and undergone emergency surgery. An artery had been blocked and needed two stents to re-open it.

While Walker’s age was an additional red herring (the British Heart Foundation estimates that the chance of a 31-year-old having a heart attack is 0.02%), the slow onset of these easily misinterpreted symptoms is surprisingly common – yet little known. A recent US study published in the European Journal of Cardiovascular Nursing found that, while 57% of patients reported an “abrupt symptom onset”, the other 43% experienced “gradual symptom onset”.

“Both are a medical emergency and require urgent help,” said the study’s author, Sahereh Mirzaei, from the University of Illinois. However, those with a gradual onset of symptoms experienced, on average, eight-hour delays in getting life-saving treatment.

The study highlights the need for greater public education, says Prof Sir Nilesh Samani, the medical director of the British Heart Foundation. But even people in the medical profession can be misled. “I know doctors who have put their own heart attacks down to indigestion and gone to bed for a while. Sometimes if you’re having a heart attack you feel you want to be sick – they think it’s all to do with what they might have eaten. These are features that sometimes delay diagnosis.”

Walker’s case is unusual not only because of his age, says Samani, who is also a consultant cardiologist at Glenfield hospital in Leicester, but because of the duration of his symptoms, even for a slow-onset attack. “Usually, it doesn’t go on for a few days, but several hours, as opposed to a ‘big bang’ heart attack when within a few moments you know something has changed.”

Sudden heart attacks occur because an artery is completely blocked. However, Samani says this is one end of a spectrum of possibilities. “The reason you get a heart attack is that the inner lining of the artery breaks down, which exposes the underlying cholesterol plaque to the flowing blood, allowing a clot to form which blocks the artery.” In gradual heart attacks, he says, the artery is only partially blocked, “but then the clot might go downstream and block a smaller artery, so many can feel chest pain and then it settles as the clot breaks down and breaks away”. An ECG machine may not detect anything wrong, further delaying treatment.

Apart from acute chest pains and sharp arm pain (usually in the left arm), symptoms include “chest tightness, tingling fingers, jaw pain, stomach or back pain, breathlessness and indigestion”, according to Philippa Hobson, a senior cardiac nurse at the British Heart Foundation. It may seem bizarre to feel pain in seemingly unrelated places, says Samani, but “the nerves that send heart pain to the brain also supply the jaw and the left arm and so on” – the brain can’t distinguish where it is coming from. The advice is to call 999 or an ambulance. “Particularly as you get older, err on the side of caution,” Samani says.

However, even if you are armed with the symptom list, if you are not expecting a heart attack, you, or a doctor, will be likely to attribute experiencing any of them to another illness, or even a panic attack. The thing to look out for, Samani says, is something you have never felt before. Walker says that, when his arm went numb, “it was distinctive and felt alien. We’ve all had our arm go to sleep now and then. It wasn’t like that. It felt as if I didn’t have an arm any more.”

However, even as he was being transferred to another hospital for surgery, having had an aspirin and some rest, he was surprised at how well he felt. “I was starting to feel embarrassed, expecting they were going to take me there with all this fanfare and it would just be indigestion,” he says. But if he hadn’t visited A&E when he did, “I probably would have gone into cardiac arrest”.

Doctors still don’t know what caused Walker’s heart attack. He doesn’t smoke or take drugs, although his BMI at the time was just within the obese range. Since his recovery, he has lost 25kg (4st) and taken up cycling. He considers surviving his heart attack “the best thing that ever happened to me”.