Ischaemic Affairs of the Heart

The heart attack

One would imagine a heart attack involves stabbing chest pain, confusion and dizziness, followed by collapsing onto the ground and gasping for air.

In my case… not at all.

I was walking to my local railway station along a 800m route I had done hundreds of times. The chest-pressure started about half-way. It was a hot day and — frankly — I'm almost 60 and getting out of shape, so didn't think much of it.

But the chest pressure kept getting intense the more I walked. I remember reading a few years ago that a heart attack was like an elephant sitting on your chest, but it didn't feel like that at all. It was more like a hand pressing down onto my breastplate — hard. Otherwise the rest of my torso or legs were fine. Could even keep walking as there was no pain, just some really serious pushing onto the central part of my chest.

My arms did feel heavy though. Not sore or numb, but like I was carrying 10 kg weights. The left arm felt a little heavier, but not by much. My shoulders and neck were also stiff, but I've had a rickety neck since playing rugby as a teenager, so nothing unusual there.

The chest pressure was continuous, not stabbing or even throbbing. On a scale of 1—11, maybe 7. Kept telling myself that it couldn't be a heart attack as I wouldn't be able to keep walking if it was.

And that's it. No cataclysmic collapse or bright lights at the end of a tunnel. Frankly, have had worse toothaches or indigestion.

So I continued to the top of the hill, caught my breath and then crossed the road to the station to catch the Penrith bus.

Early warnings

It wasn't the first time this had happened.

The first occasion was ten days earlier while doing my twice-a-week 1000m freestyle swim. The chest-pressure while swimming was so mild that I assumed it was from having swallowed too much air. Sure enough, upon completing the twenty laps I stood up and did a large burp, and by the time I got out I was fine. Likewise the next swim four days later. Laps, pressure, burp, fine.

During the following swim on Saturday, three days before the station-walk, things were more intense. This time the chest-pressure started during the second lap, with it becoming extraordinary by the 300m mark. I also noticed that my arms and shoulders were weirdly “heavy”. So I stopped and got out. It took almost ten minutes before I felt normal again.

The next morning I took my dog for a walk before breakfast, along a hilly 2km route we had done for years. Again there was chest-pressure and heavy arms, although not as intense as during the swim. Assumed I was just out of shape, so maybe all I needed to do was take things easy for a couple of days. So Monday did some light gardening and cleaning — no problem. Likewise Tuesday morning, again no problem. But during the walk to the station that afternoon… kapow.

Later that evening when in hospital, I recounted all this to a cardiologist. She said the Saturday swim would have been my first significant heart-attack, the Sunday morning dog-walk a milder second, with the station-walk being the most significant third. In her opinion I was lucky I didn't drown during the Saturday swim (!)

Ambulance

When I got home I phoned “000” for an ambulance, which arrived five minutes later (!)

This would have been extraordinary in more connected parts of Sydney, but out in the Blue Mountains it was unbelievable. By contrast an ambulance I called for my mother on 2020-11-10 took 40 minutes to arrive, while another on 2020-12-18 took just under 4 hours.

So it was reasonable to assume there was at least 30 minutes to prepare. Plenty of time to pack an overnight bag plus leave notes for the neighbours on how to feed the pets. Yet the knock on the door came so early that everything had to be slapped together in a rush. Managed to pack and lock up okay, but forgot to include two of the most important things: a toothbrush & toothpaste.

The paramedics at my door were a couple of small women in their late twenties. Very professional and friendly. They told me I was lucky they were driving down the highway a couple of kilometres away when they got the call. Their ambulance appeared brand new, although it was narrow and cramped inside — how would you fit a really huge person in here, and how would these slight women ever manoeuvrer them? Because COVID-19 was still a thing, we all had to wear surgical masks, although they told me I could remove mine once I was allocated a hospital bed.

They asked which hospital I wanted to go to. As they had just driven from Katoomba, they warned that things were seriously backed up, and since their facilities were also very limited (would they even have a cardiologist?), we chose Nepean.

During the unhurried drive — no sirens or swerving or running red lights — one of the paras took down my details & emergency contacts & inserted a cannula in my right arm & stuck silicone electrode-tabs onto my torso & recorded an ECG & measured my blood pressure. She also asked me to describe what had happened, what medication I was taking, how old, tall and heavy I was, whether I smoked or drank alcohol and was there any history of cardiac illness in my family…

Indeed there was. Almost every adult on my father's side has Type II Diabetes. My mother had hypertension from her 30s onwards. Most importantly, my father died of pericarditis when he was 52, his brother due to thrombosis at 47 and the brother's son of a heart attack when he was 41. All of them suddenly without warning.

That raised an eyebrow.

Nepean Emergency Department (ED)

Upon arrival we noticed there were already eight ambulances parked around the ED entrance. As by now I felt fully recovered, I offered to spare the ladies the hassle of using a gurney and instead just walk inside. One of them told me to stay where I was, as I might end up sitting on the floor for hours if I wasn't wheeled in.

As we went in through the entrance, I noticed a crudely hand-drawn Code Amber poster stuck to the window. Once inside, the waiting room was packed with dozens of people and trolleys, with only a few patients on the triage beds or chairs. The rest, like me, were on gurneys. As these were parked everywhere, my paras had to wheel me deep inside the building to a relatively uncluttered corridor. I asked one of the paras if it was always like this, she laughed and said she had seen it far worse.

Because I had a suspected heart-attack, I was triaged for priority attention. Blood samples were taken within minutes, likewise another ECG and blood pressure reading. I felt fully recovered by now, so had relaxed conversations with one of my paras about her job (the other had gone to do paperwork). Meanwhile, random patients attempted to use the toilet opposite us and kept banging on the door because someone had locked themselves inside. I asked my para whether she and her colleague should leave to attend other cases, but she replied they had to stay with me until I had been allocated a bed. If it took hours then fine, the downtime was welcome.

While still on the gurney in the corridor, an on-call cardiologist came to tell me that irregularities in my ECG and elevated troponin levels confirmed that I had a heart attack this morning (!) I told her that I felt completely fine by now, she smiled behind her mask and said I was lucky.

Within an hour of arriving I was given an ED bed, which apparently was very unusual. The paras wheeled me into the ward and bid me farewell. They also remarked how lucky I was to get a bed so soon, as one of their colleagues had been stuck in the waiting room with a patient all afternoon and still hadn't been allocated a bed.

There were six beds in my ward. The room and fittings had a 1990s vibe, clean but surprisingly antiquated. What was once white plastic had yellowed years ago. Fluorescent lights, no sunshine or view outside. No fresh air, although the air conditioning worked well and it was pleasantly cool. Was given a RAT nasal swab to check for COVID-19 — negative. Was asked again if I smoked — no. Then more blood samples, another ECG and blood pressure measurement. My shirt and undershirt were changed for a white full-length cotton smock, which was closed at the front but completely open at the back. This turned out to be a nuisance as there were sensor tabs were stuck all over the front of my torso, so it required major shuffling and squirming to get the smock above my shoulders to provide access.

My nurse was another slight woman in her late twenties, this time covered in tattoos. She told me she was nearing the end of a double-eight-hour-shift and was feeling light-headed, so was being ultra-cautious to avoid making mistakes. I noticed two of the six beds in our section were occupied by mental health patients, one by a bloke who insisted on getting up and wandering around to start pointless arguments. The other by an elderly lady who ranted loudly from her bed about how her family were out to get her. The bloke was eventually escorted away to the mental health unit, while the lady was calmed by an injection of haloperidol. I asked the nurse about this and she replied that people like them came to hospital all the time because they have nowhere else to go.

The cardiologist came back and stayed a while so I could tell her my “chest pressure” story. This is where she remarked about my luck of not drowning on Saturday. I didn't say anything, but it didn't make sense — I stopped swimming after six laps and got out, what's the big deal? She told me I had to stay in the ED until a cardiology bed became available upstairs, hopefully soon. Tomorrow I would get an angiogram, probably at midday or in the afternoon.

A little later a couple of administration people came by with clipboards and pages of admission paperwork for me to sign. I told them I had private health insurance, so they told me to tick a box on the form. Was later given dinner — a small roast beef sandwich — accompanied by a couple of tiny “blood medication” tablets. The ward supervisor came by and asked my nurse if she could do an extra shift (making it three in a row). The nurse laughed and politely declined.

It took 4½ hours before a Cardiology Unit bed was found, but I didn't mind as I felt fine. Even SMS'ed one my friends that I was a fraud lying among genuinely sick people. Eventually an orderly came. As I got out of bed he told get back in as they would wheel the entire apparatus to the cardio ward. It turned out later that, again, I was very lucky to get a transfer so quickly. Another heart-attack patient I spoke with the next morning told me she had spent 16 hours in the ED before they found her a bed.

Cardiology Ward

It was already night outside. While being wheeled through a long corridor, I asked the orderly if I was being transferred to the new 14-storey clinical services building which opened 9 months earlier in April 2022. He said no, I was stuck in the old building. The current plan was to move the ED and Cardiology units together to the new building in February 2023. They had intended to move a few months earlier, then postponed to December, and it had been put off yet again [i].

We caught the lift to the 5th floor and I was wheeled into a 4-bed ward (W5B), with each patient screened by movable blue curtains. My bed was placed at “Bed 26” near the door, and it quickly became apparent that the room was warm and unusually stuffy. There was no airflow at the head of my bed, so I started to sweat a lot.

The bed to my right was completely screened off, but since the curtains were not soundproof, you could hear repeated loud moaning from an elderly man, presumably every time he took a breath: Oooh God … Argh … Ooooooh …. In the bed opposite was a young man in his 30s with his wife lying beside him on top of the cover, both quietly arguing with the head nurse that the she wanted to stay overnight with her husband because going home was “unsafe”. The nurse said no. The wife said she wouldn't move. The husband emphasised it wasn't safe. The nurse said she would call security. And on and on until the stand-off concluded with the wife agreeing to sleep on a couch outside.

Meanwhile I had more ECGs and the dozen silicon tabs on my torso were reconnected to a bluetooth box hanging from a cloth pouch around my neck. Eventually managed to bed down for the night at 22PM, but was so encumbered with wires and it was so stuffy that falling asleep was difficult. Was then woken by a nurse every 30 minutes to reattach tabs which kept slipping loose due to my sweat and moving around. At 1AM we went out into the corridor and I asked her to tape the things down hard, as the half-hour interruptions were pissing me off unwelcome. She got a roll of hospital tape and then each of the dozen tabs was firmly affixed with a 10cm taped cross. We both laughed at the resulting overkill. Went back to bed and finally managed to get some sleep by moving the pillows to the foot of the bed, where there was at least a tiny amount of air.

Morning Prep

The next morning I went into the corridor to phone my Private Health Insurance fund to Ask A Few Pertinent Questions. They quickly cleared things up — my policy was valid and, among other things, it enabled access to treatment in a Private Hospital. If I wanted to transfer then I had to discuss it with my cardiologist. Most importantly, insurance also lets you avoid the 12–24 month waiting-list for so-called “elective” surgery.

Went back to the ward and was told, after an incredibly slight breakfast, that I was now Nil By Mouth until the angiography this afternoon. Was subsequently hooked up to an infusion tube to keep hydrated and help flush the Metformin from my system (apparently it didn't play well with the angiogram dye).

At 9AM a different on-call cardiologist came by on his rounds. Despite some confusion earlier in the morning, I was definitely booked for an angiogram after midday. In his opinion there was no point in transferring to a Private Hospital as I should be discharged by tomorrow afternoon. Also, he told me, there wouldn't be any specialists available in the private sector anyway, as they were all still on summer holidays. (I confirmed this a week later when I phoned Nepean Private Hospital.)

A little later I received a visit from a young doctor who said he was once my Y11 Chemistry student. He recognised my surname on the admissions whiteboard and guessed it must be me. A little later a nurse recognised me as her Y10 science teacher. Then another nurse appeared with a toothbrush (easy) and toothpaste (hard — he had rummage through a storage cupboard in a ward downstairs). Even he remarked how hot and stuffy it was in my ward.

Another nurse then came by with a weighing chair to measure me: 110kg! I had gained 12kg in the last two years =/

Spent the rest of the morning in an armchair beside my bed, reading a book on my phone while trying to ignore the moaning from my elderly neighbour. At one stage I got up and went for a short walk in the corridor to cool off, and then came back to have a conversation with a patient in a bed near the window. She told me about her heart attack a couple of days earlier when she was watching television; the long delay she experienced while stuck downstairs in ED; and how the angiogram she had this morning was over before she even thought it began.

The young man in the bed opposite wasn't so lucky. An angiogram typically requires a thin tube inserted into the artery in your right wrist and is then pushed up your arm towards the blood vessels near your heart. If that doesn't work, then they try your left wrist. If that also doesn't work, then they go in through the femur artery in your groin. Which is what happened to him, and even though he wasn't in any pain, he now had to lie absolutely still for a number of hours to prevent the incision from reopening. Hence the preference for wrists, as they can move quite freely after the procedure.

Mid-morning I was prep'ed by shaving my wrists and also with some confusion, my groin. They handed me an electric shaver and the wrists were easy enough, but there was considerable ambiguity in the instructions for the groin: how much do I shave and were? The sides. The sides of what? Your groin. Where do I shave again? The sides.

Midday. An orderly arrived to wheel me and my bed to where the angiogram was done. Finally got to be in a ward with air-conditioning… bliss. Was given a local anaesthetic and lay there for 20 minutes before being wheeled into the diagnosis theatre, just before 13PM.

Angiogram, Stents & Sonogram

The theatre mostly continued the antiquated 1990s vibe, although there was a brand new and huge (85"?) flat-screen monitor mounted onto a swinging arm on the wall beside me. There were metal rails criss-crossing the ceiling and I was surprised by how dim the lighting was. There were about four medical personnel in the room, all wearing light blue surgical gowns and masks. The cardiovascular surgeon, however, was in lime green.

I got up out of bed and was asked to lie on a specific point on what was essentially a waist high rectangular table. No one explained what the procedure required, but I mostly knew anyway. A tube would be inserted up an artery (arm or groin) and then pushed close to the blood vessels around my heart. Then a dye, which is opaque to x-rays, would be injected. The dye would then make the vessels around my heart visible and thus make any issues obvious.

I was asked to shuffle around a bit on the table to properly align myself with the continuous x-ray source (which I assumed was beneath). A large detector box was then positioned over my chest and my right arm was clamped to the table. Use of the word “clamp” here was no exaggeration, as I could not move my arm at all and still had a bruise from it a fortnight later. The surgeon then did his thing.

I was conscious throughout the entire procedure, although couldn't see much because of the large white box hovering above my chest. I didn't feel the tube going up my arm, and was considerably relieved that they could use my right wrist and didn't have to resort to jabbing my inexpertly shaved groin. As my fellow cardiac patient remarked this morning, there was no pain or discomfort.

A few seconds after the dye went in, the surgeon exclaimed: Jesus! Look at that! He made a few verbal notes into a Dictaphone and then swung the huge monitor-screen around so I could see a faint grey 5× larger-than-life outline of my pumping heart, with the coronary arteries visible as thick black wiggly lines. He pointed to a part of a thick artery that looked obviously pinched, similar to the neck of an hour-glass. He told me You have a 95% blockage here, did you ever feel fatigued for no reason? Told him that I didn't, and even after the heart attack I was fine while resting. He then pointed out another blockage a little bit downstream, which he said was “≈80%”, along with a couple of others in minor arteries which were “< 70%”.

A decision was made to insert two metal-mesh stents immediately (Balloon angioplasty), to clear the “95” and “80” blockages. The other ones they made a note of, but would leave for now.

Here unfortunately things did get painful. As the surgeon went about his work, pushing the stents up my arm and toward the blockages around my heart, a strong dull pressure built up inside my chest to a level where it became quite uncomfortable. He reassured me: Just a bit more, almost done… Yeah well, I replied — so was I. He paused for a moment… and then resumed. Another couple of minutes and he was finished.

While working he told me he had a stent himself, while his brother had actually died because he neglected to seek treatment for the chest soreness he'd experienced on and off for a year. So my attendance here today was timely…

I was told the process of inserting stents would push plaque from the main artery into some of the smaller tributaries, but I would be given medication to help break it down. The surgeon used an analogy of a snow-plough pushing snow off a street, but blocking a few driveways in the process.

A bed was wheeled in, the industrial-strength-arm-clamp was released and I climbed off the table and onto the bed. Was then wheeled into the recovery ward outside, a few metres opposite the theatre entrance. Within minutes a lady sonographer appeared at my left side, introduced herself and told me why she was there.

Her role was to use ultrasound equipment to measure the blood flow through my heart, and also check for any heart muscle scaring. This sounded reasonable, but she then spent 20 minutes painfully pushing a TV-remote-sized probe onto my chest and ribs. While she went about forcefully prodding my sides, a couple of cardiologists and the lime-green surgeon also appeared around my bed. They all had crinkly eyes from broad smiles behind their surgical masks. You have no idea how lucky you are! Another couple of months and you'd be gone.

I shook the surgeon's hand and thanked him. He took off his mask and we spoke for a couple of minutes. He looked exhausted and must have been near the end of a very long shift, similar to my ED nurse yesterday.

The sonographer finally completed her extreme prodding and told me the blood flow through and around my heart was normal and, most importantly, there didn't appear to be any scar tissue. She contrasted this with a man in his 30s she scanned yesterday, who had 30% scaring because he kept putting off getting his chest “soreness” examined.

Critical Care Unit (CCU)

Was then wheeled to the Cardiology Ward CCU room “No. 5”, which had a single bed with dedicated vital-monitors and an en suite. It also had a west-facing balcony with floor to ceiling glass windows and door. The balcony exterior was covered in thin steel wire mesh and unfortunately its door was locked, but at least the windows let in natural light. Most importantly, I noticed the air-conditioning worked, although not as well as the recovery ward I had just come from.

I was then plugged in to a 1200ml Tirofiban infusion to help prevent platelet formation and flush the angiography dye from my system. The flow rate was adjusted to last 12 hours.

Was comfortable enough lying in bed, although my right arm was hooked up to the infusion tube, while my left bicep had a blood-pressure cuff on it which was programmed to automatically do measurements every 30 minutes. Most of the time it reported 130/85, which under the circumstances was normal.

With the monitor wires on my torso connected to the vitals-monitor above my left head, plus the left-arm BP cuff and right-arm infusion tube — I was effectively immobilised. Had to ask permission from the nurse to unhook myself so I could use the en suite, although I had to carry the infusion apparatus with me (its wheels didn't roll).

Was given a small hot dinner at 18PM, the first food I had eaten since the light breakfast at 6:30AM. Unfortunately the pressure in my chest increased remarkably while I was eating. Buzzed for the nurse and she responded immediately. She then paged a doctor, who arrived within 10 minutes. Blood samples were taken for enzyme and sugar analysis, he checked my vitals, did another ECG and after a while came back to let me know that all the data indicated that everything was okay. By then the chest pressure had abated, so there was nothing to worry about.

I had been advised that after the stent insertion there would be a bit of temporary chest discomfort as my heart and organs got used to the new meshes. Nothing overwhelming, but definitely noticeable. Eventually tissue would grow over the mesh and they would become fully encased within the artery walls.

Overnight Observation

After dinner I tried to watch TV, but found the channels were all locked and could only listen to various smooth-music radio stations — was told you have to pay extra if you wanted to watch TV. Fair enough, but discovered later that full TV access was included in my private health insurance policy, all I had to do was ask.

With all the day's excitement, found it very difficult to fall asleep. Finally managed to do so, but was awoken almost immediately by aggressive beeping from the vitals-monitor above my head. Apparently my resting pulse-rate, already low, triggered an alarm whenever it dropped to less than 50 BPM, which was when I started drifting off. After a few more false alarms, followed by protracted negotiations with the nurse, we agreed to reset the warning limit to 46 BPM. This finally silenced the thing.

Eventually, and with great difficulty, went to sleep. Was having a complicated dream about walking through a crowd in a park and then sitting on a knee-high brick wall, talking to someone beside me. Someone else came along and tapped my left arm, indicating they wanted to interrupt. I told them to wait a minute, but they forcefully grabbed my left elbow and started squeezing hard. What the hell!? I suddenly awoke to find the BP cuff had fully inflated and was doing an automated BP measurement. Buzz the nurse, who laughed when I told her about the dream. We started negotiating again, this time about the frequency of measurements — finally agreeing to lower the frequency to every 2 hours, as my BP values had been consistent since arriving at the CCU.

Discharge

CCU final morning

First thing next morning I asked the nurse if it was okay to unhook myself so I could walk around. As the infusion expired at 3AM, she told me it was — provided I came back within 15 minutes. Used the time to visit the lady patient in my previous ward, with whom I had the angiogram conversation yesterday. She looked surprised to see me and was relieved that I was still alive. She told me that orderlies had quietly come in the afternoon to gather my effects and then vanished without explanation, so everyone had assumed the worse.

Went back to my CCU room and was re-hooked. While lying in bed, another nurse came in to ask if I wanted stay another day — I said no thank you.

After 9AM received a quickie visit from the on-call cardiologist. He did a review and said it should be okay to go home at midday. During discharge I would be given more information about medication and what to expect next.

Half an hour later a nurse arrived to confirm I was being discharged before midday. She then removed the monitor tabs stuck to my torso — yanking out a lot of chest hair with each strip of tape. I then had time to have a quick shower, and walked out of the CCU at 10:45AM.

While waiting at reception, the Head Nurse told me to find a different cardiologist through my GP as the one who inserted the stents yesterday didn't work in private practice.

A small woman orderly then arrived with a wheelchair to take me to the “Transit Lounge” (sic) on the ground floor. The detailed conversation we had on the way down was fascinating: in her home country she was a fully qualified specialist nurse, but as her qualifications were not recognised in Australia, she had to completely re-do a Nursing degree, of which she still had a year to go. Meanwhile she worked as an orderly and had to fight the urge to speak up whenever she noticed something wrong.

Transit Lounge

The ground-floor “Transit Lounge” was actually the room where patients were processed before being discharged. While waiting in a lounge-chair, another senior Cardiology Nurse arrived to give me a detailed briefing:

• I needed to see my GP within 3 days
• No driving for 2 weeks
• Very gentle daily exercise at first, increasing to more as the weeks go by
• For the next week, no lifting more than 2kg with my right arm, to prevent the cannula and wrist incisions from opening
• Use the small bottle of Glyceryl Trinitrate spray provided to temporary relieve any angina (chest pain)
• Always take the blood thinner medication to prevent the stents from getting blocked

She then provided a detailed breakdown of what had happened. With the aid of a heart diagram from one of her brochures, she showed where my blockages were located: the 95% was almost the entrance to the Left Anterior Descending (LAD) Coronary Artery, with another 80% blockage a little further down. She told me I also had a few other less significant blockages, one at 70%, but they were in sub-arteries much further along, which at the moment didn't warrant intervention.

I then waited for an hour until midday for my exit materials. Was given three copies of discharge papers, containing a medical summary of what happened, treatment and medication I needed to take. Was also given a bag of prescription medicines which looked like they would be sufficient for a week.

Finally at midday a mate arrived to give me a lift home. The Transit Lounge admin then escorted me to the main hospital entrance. I made sure of letting him know how impressed and happy I was with the treatment I received.

The heart attack was just before midday on Tuesday, I had arrived at Nepean at 15:30 PM in the afternoon and left at midday on Thursday — less than 48 hours later.

Silent Ischaemic Heart Disease

The Cardiac Nurse told me my condition was known as Clinically Silent Ischaemic Heart Disease, which is usually only diagnosed during an autopsy. It is a common condition for men of my age, especially with my risk factors (see below). Plaque builds up inside the cardiac arteries (Atherosclerosis) until they become sufficiently blocked to starve the heart muscle of oxygen and nutrients. The heart then stops, you faint and die. Because I didn't experience any symptoms until the exertions a few days earlier, hence clinically silent.

It used to be known as a Widow Maker heart attack, but in the last twenty years the term has fallen out of favour because women get it too. Despite this, a Google Search for the term reveals it is still in common use in the USA.

The really big question is, how come I survived?

There were a number of reasons. When you have two major blockages near each other, like I had, a piece of plaque would typically break off one to completely block the other. Lucky for me that didn't happen (hence the exclamations by the cardiologist during the angiogram). I had also never smoked and spent years swimming and walking, so my heart muscle was unusually strong and could still function adequately with lower than normal blood-flow. Another plus was that I have an unusually low resting pulse-rate of 55 BPM, so there was less lifetime stress on my heart muscle. Most crucially, I have always had normal cholesterol levels. And I was lucky.

The remark by the ED cardiologist about drowning during the first attack finally made sense. My heart muscle stops because it is starved of blood-flow. As I'm already face down in water… game over.

According to the ABS (2022) Causes of Death, Australia (Retrieved: 2023-01-27), the leading cause of death in Australia is Ischaemic heart disease, with it being responsible for 20.1K deaths in 2021. Then add another 3.4K for Heart failure and complications and ill-defined heart disease. Furthermore, according to a SMH (2023) Fatal heart attacks surged in Australia. Here's Why article (Retrieved: 2023-01-27), monthly cardiac-related deaths in 2022 have increased by 17% due to the impact of COVID-19.

The Nepean experience

Nepean Hospital has a reputation which is far from ideal (Retrieved: 2023-01-27).

I had already seen how they “treated” my mother when she became sick towards the end of 2020, with things being so dysfunctional that I lodged a formal complaint with the Health Care Complaints Commission a few weeks after her death (Submission ID 20961, Outcome File No. 21/00195).

So I was expecting the worst. Yet this time, to be honest, my experience was overwhelmingly positive.

Despite the “Code Amber” alert and overcrowded waiting room, I secured an ED bed within an hour. An on-call cardiologist attended within 30 minutes and followed-up later in the ED. I was transferred to a bed in the Cardiology Unit within five hours. The angiogram and stents were done 18 hours later. Was given a solo CCU room with attentive nurses and doctors and was even offered an extra day if I wished. Staff were always helpful, polite and professional. The discharge admin even walked me to the front entrance and wished me well.

When I departed from Nepean Hospital I felt relieved, elated and even a little confused. Why had everything gone so well for me and yet so appallingly for my mother in 2020?

The following is purely conjecture, but it may help explain:

• I was 59 years old, otherwise healthy and worth saving (my mother was 86, frail, with terminal cancer)
• Heart attacks are treated as top-priority (as opposed to the ill-defined stomach cramps my mother had) and treatment has to be given immediately to prevent cardiac muscle damage
• The Cardiology Unit would be among the busiest in the hospital due to Western Sydney's demographic issues (Retrieved: 2023-01-27), meaning it is staffed 24/7 and they really know what they are doing
• I had private health insurance and “ticked the box” on the admission form. Which meant the hospital received payment from the insurance company in addition to their usual government operating budget (my mother was Medicare only)
• Maybe they recognised my name from the 2021 HCCC complaint?…

Dr EFF

Not his real name.

Upon release from hospital, you are given a few days medication with instructions to visit your GP to obtain prescriptions for longer term use.

I called my GP the day after release, a Friday. Was informed by the receptionist that he had resigned from the practice a couple of months earlier. In that case I told her any GP would do as all I needed was prescriptions and a referral to a cardiologist. She did a bit of typing and the first available GP booking was Monday 10:50AM — in three days. As there was no hurry I agreed.

Come Monday I was at the surgery 10 minutes before the allotted time. Was told by the receptionist to sit in the corridor outside the doctor's consulting room. Forty minutes later I was beginning to get restless. The doctor appeared and noticed me sitting there. I looked at my watch and then at him. He fired back I'm running a little late. You're not dying are you? I quietly replied Well, I did have a heart attack last Tuesday.

Ten minutes later he ushered me into his room to start the consultation.

He was fiddling with his computer: This stupid @$%ing thing! Can never @$%ing find the page you're looking for! Then he read my discharge report from the hospital: @$% me! Jeez, you're @$%ing lucky!

What really got him riled though was hearing I had never been offered a Heart Stress Test. You're @$%ing kidding me! These @$%ing idiots! With your risk factors it should have been the first @$%ing thing any doctor does!

When I related how impressed I was by the care I received at Nepean, he was more sanguine: Well, we shouldn't have a hospital where you have to #@$%ing praise them just for doing their #@$%ing job.

We talked about how my heart attack was known in the 1980s as a “Widow Maker”. We also talked about former NSW Attorney General Paul Landa (1941-84), who died suddenly while playing social tennis in Vaucluse. This despite being perfectly fit and definitely not socio-economically disadvantaged.

Received the prescriptions I needed and then asked for a referral to a local cardiologist. Doc wrote one out, but cautioned it might take six months to see one. He suggested I should keep calling practices until I found someone who was available. They're all the @$%ing same mate.

The next day, with luck still on my side, I found a local cardiologist who had a cancelled booking, and was thus able to set up an appointment for mid February, in only five weeks time.

Cardiovascular Risk Factors

The following is from Hajar R. (2017) Risk Factors for Coronary Artery Disease: Historical Perspectives (Retrieved: 2023-01-27)

There are many risk factors for CAD and some can be controlled but not others.

The risk factors that can be controlled (modifiable) are: High BP; high blood cholesterol levels; smoking; diabetes; overweight or obesity; lack of physical activity; unhealthy diet and stress.

Those that cannot be controlled (conventional) are: Age (simply getting older increases risk); sex (men are generally at greater risk of coronary artery disease); family history; and race.

The following were pertinent for me:

• High blood pressure
• Diabetes
• Overweight
• Stress (12 years as a selective HSC science teacher)
• Age (59)
• Male
• Family History
• Race (Eastern European)
• Creased ear lobe…

Looking at that list, I was guaranteed to develop this disease. Had I taken a Heart Stress Test, say 8 years ago, then it's likely the blockages would have been detected far earlier before they became life threatening.

Meds

Am currently taking the following medication:

• Metformin 2×1000mg (diabetes II)
• Telmisartan “Micardis” 80mg (blood pressure)
• Candesartan 4mg (heart attack recovery & blood pressure)
• Aspirin 100mg (blood thinning)
• Ticagrelor 2×90mg (antiplatelet & prevent blood clots)
• Atorvastatin 80mg 40mg 20mg (cholesterol)

The Metformin and Telmisartan I was already taking before hospital [ii].

The Aspirin and Ticagrelor were only for 12 months. The Atorvastatin, despite my blood cholesterol levels being normal, was started at the maximum dose to help dissolve the loosened plaque. Over time it was then tapered down to ensure my cholesterol remains ≈ 3 mmol/L [iii].

Slow Recovery

Ambulance Bill Shock

The $568.34 bill for the ambulance arrived almost three weeks after hospital, although I am exempt due to my private health insurance.

It would of course be much cheaper to catch a taxi, but if you land in an ED waiting room as crowded as the one I did, then you won't have paramedics to attend nor a gurney to lie on while waiting for a bed.

Weight loss & Exercise

At the time of writing this article (2023-01-27) I lost 6kg since leaving hospital.

It was done by reducing portion sizes, eating mainly vegetables, reducing dairy, red-meat and carbohydrates (bread, pasta) and eliminating treats & snacks. The portion sizes I received in hospital were a wake-up call that I had been overdoing things for years.

Despite always being active, I was warned to go easy on the exercise. Start with gentle 5 minutes a day, then 10, then 15, then 20 etc. As at the date of writing I am walking 2km each morning before breakfast at a moderate pace (≈ 25 minutes). Intend to increase it to 3km in a month's time. The rest of the day I'm moving around as normal, although taking things slowly on up-hill stretches.

On 8th June 2023 I underwent a scheduled heart stress test and passed without issues. On 7th September I went on a Faulconbridge to Springwood bush-walk, a brutal trek which again caused no issues [iv].

Recurring Angina

Angina is chest pain from your heart. From what I have read it is very common after stent surgery, simply because you now have foreign objects forcing your cardiac arteries open.

Luckily for me the “pain” was intermittent and more like discomfort (barely 1/11). I was given Glyceryl Trinitrate pump spray to squirt onto my tongue if things got bad, but only ever felt the need to use it a couple of times since leaving hospital.

A quick web-search shows others are not so lucky, with some reporting occasional “stabbing pain”. This has not been the case for me (fingers crossed).

Pre-packed overnight bag

Having learned from my mother's example — where she was misdiagnosed and prematurely discharged from hospital only to return a few days later — in the three months after hospital I set aside an overnight bag just in case.

The following things were pre-packed:

• Toothbrush, toothpaste & small bar of soap
• Spare medication (see above)
• 2× underwear briefs
• 2× boxer-shorts to use as pyjama bottoms
• 2× spare socks
• Small towel
• 240V/ 5V USB phone charger with a 2m cable

There is no need to pack a top or t-shirt for bed-wear as the hospital will issue you with a smock/ gown.

If you need to call an ambulance, it's a good idea to wear a short sleeve top as it provides easy access to your arms for blood samples/ BP measurement etc. It's also a good idea to wear secure footwear that you can easily step into and out of, as you will be doing this a lot in hospital (in my case I used loosely tied trainers).

#1

The first time I almost killed myself was when I was 15 years old. I was making napalm on the apartment kitchen stove — as you do. The small batch I had made earlier worked fine, but going industrial with 2L of petrol was my undoing. This time the vapours exploded in a yellow-orange whoomf and then everything went black. I remember thinking Oh crap, I'm dead.

Clearly I wasn't. A few seconds (minutes?) later I awoke on the other side of the kitchen with a raging petrol fire on the stove. Triple-zero; fire-fighters; hospital; a stern lecture from the fire-station chief; then a friendly insurance assessor who laughed while writing up the claim as a cooking oil fire. Boys will be pyromaniacs.

#2

A couple of years later I was with my HSC high-school friends on a weekend away at Palm Jungle. We had gone off the main track and were setting up camp in the jungle, near the edge of ocean cliffs which run the length of the park. Having set up our hammocks, a couple of us decided it would be fun to chop down a tree and throw it over the cliff's edge — as you do.

We found a small tree that was about 8m tall, but with a trunk thin enough to be easy to hack through with our machetes. Did I mention my mate was wearing army-surplus fatigues, while I was in blue overalls and sporting a tweed pork-pie hat? “Deliverance” 2.0

So we cut down the tree and dragged it, with great difficulty, through the jungle to the top of a cliff. Except it wasn't a sheer edge, but rather a 20m rubble slope at 45° to the top of the actual edge, which then had a 50m drop to rocks and the roaring ocean below. We had to cautiously venture out onto the top of the slope, dragging the tree behind us, hoping its weight would cause it to slide down and over. Except it just sat there. So we dragged it a bit more, and then a bit more, until it suddenly started to move.

To our surprise we found ourselves entangled in its canopy as it slid past. The laughter stopped, and we were on our hands and knees scrambling desperately to get a hand/ foot hold on a slope filled with moving branches and leaves and loose rocks, while rapidly sliding with the tree toward the cliff's edge. I remember thinking Not yet! Not yet! I don't want to die!

Again, clearly we didn't. A few metres short of the edge we managed to dig in enough that the tree plunged over without us. After a suitable pause in the bright morning sunshine, we looked at each other and climbed back to safety.

#3

I was 35 when diagnosed with Cutaneous T-Cell Lymphoma — Mycosis Fungoides. When the biopsies came back my dermatologist told me I appeared to be early Stage I, and there were indications the disease may have two years to run (loved the vague cover-yer-arse language). He then helpfully showed me full-page colour photos of what the disease looked like in Stages III & IV… the stuff of nightmares. I was quietly told to get my affairs in order.

Was then referred to a leading oncologist at a major Sydney teaching hospital, who was very eager to see me because it allowed his research team to study the progression of the disease. Consequently I was measured and studied and photographed and prodded and probed and treated at irregular intervals for two years. An international mailing list was set up to update oncologists all over the world on the progress of my disease. Except there was one tiny problem: my illness wasn't progressing and indeed some of the red/purple skin lesions had actually cleared up on their own.

Around this time a leading non-Hodgkins lymphoma specialist was visiting from London. He was on the mailing list and wanted to see me. He had a look at the small patches on my arms and feet and said: That's not Mycosis Fungoides. Looks more like some kind of eczema. So more photographs and more biopsies, which this time all came back negative. Sorry about that.

#4

24 years later, cheating death for a fourth time was sobering. It's obvious that things can escalate with home-made napalm or easily-excitable specialists or doing perilous things at a cliff's edge. But just walking to the station on a warm summer morning?…

Once again the stars had aligned and a bullet was dodged. With all the good fortune many told me I should buy a lottery ticket. I never buy these things but what the hell… I bought two.

Well of course I didn't win. But then again, you can only stretch your luck so far.