For more than six months, Harriett Cooke had
been uncommonly tired, panting when she walked her sixth grade science class to
the cafeteria and struggling to keep her eyes open when she drove home at
night. One day, during a class trip outside the school, she just couldn’t go
on. “I sat there on the side, I put my head down on the table, and I knew I
shouldn’t be feeling like this,” said Ms. Cooke, 67, who lives in Durham, N.C.
Making excuses, she left and stopped at her
doctor’s office, where staff ordered an electrocardiogram (EKG). The test
showed that Ms. Cooke had suffered a so-called “silent heart attack” at some
indeterminate point, perhaps months earlier. Few people know about this type of
heart attack, characterized by a lack of recognizable symptoms. Yet silent
heart attacks are even more common in older adults than heart attacks that
immediately come to the attention of doctors and patients, according to a
recent study in The Journal of the American Medical Association. What’s more,
they’re equally deadly.
The research underscores the importance of
paying attention to lingering, hard-to-pin-down symptoms in older adults,
experts say. Many elderly men and women tend to dismiss these; caregivers
shouldn’t let that happen.
The JAMA report is based on data from 936 men and
women ages 67 to 93 from Iceland who agreed to undergo EKGs and magnetic
resonance imaging exams to detect whether heart attacks had occurred. EKGs assess
the heart’s electrical activity, while M.R.I.’s look at its mechanical pumping
activity.
So-called “recognized” heart attacks were
identified when signs of heart damage were evident, and the patient’s medical
record indicated that medical attention had been sought and a diagnosis
rendered. “Silent” heart attacks were also signified by heart damage, but in
those cases evidence from medical records was lacking.
When results were tallied, silent heart
attacks were twice as common (22 percent) among older patients as recognized
heart attacks (10 percent). Five years after tests were administered, death
rates for patients with both recognized and silent heart attacks were 23
percent, almost double the 12 percent death rate for older adults who’d never
experienced a myocardial infarction, the technical name for this medical event.
Recognized heart attacks may be more serious
in the short run, but silent heart attacks are equally dangerous in the long
run because they don’t receive medical attention, said Dr. Andrew E. Arai, the
lead author and chief of the cardiovascular and pulmonary branch of division of
intramural research at the U.S. National Heart, Lung and Blood Institute. Indeed,
seniors who had the silent version were less likely to get treatments for
coronary artery disease — aspirin, beta blockers, and cholesterol-lowering
statins. Yet tests documented they had higher-than-average risk factors:
elevated blood pressure, high cholesterol, hardening of the arteries, and
evidence of plaque buildup in blood vessels.
Results from Iceland may not be fully
generalizable to the United States since more people smoke in Iceland, and
there’s greater diversity in the population here. But a key takeaway message is
that heart attacks aren’t always easy to detect, especially in older people. “Not
everyone has classic symptoms — chest pain, maybe radiating to the arm, nausea,
sweating, shortness of breath,” Dr. Arai said. “In reality, many patients, have
much less clear cut symptoms,” he continued. “They may think it’s a bad case of
indigestion or the flu, or this may even occur during their sleep and they
won’t realize that anything happened.”
If you’re an older person and you’ve been
feeling seriously unwell for a while, “go see your doctor, don’t blow it off,”
Dr. Arai said. That’s not an invitation for people to run out and demand
M.R.I.’s of the heart if they’ve been feeling flulike for several weeks.
Although M.R.I.’s identified more silent heart attacks than EKGs in the JAMA
report, these tests are expensive, not widely available, and stress
echocardiograms, nuclear stress tests, and computerized tomography (CT)
coronary angiograms are good alternatives, said Dr. Michael Shen, section head
of cardiac imaging at the Cleveland Clinic in Florida.
Tests should be based on the patient’s family
history, personal history, symptoms like shortness of breath or tightness in
the chest, and risk factors like cholesterol levels, high blood pressure,
smoking and diabetes, Dr. Shen said. In the JAMA study, 26 percent of patients
with diabetes (266 altogether) had silent heart attacks, compared with 11
percent who had clinically recognized heart attacks. “We don’t really
understand what causes one person to have chest pain and another person not to
have chest pain,” said Dr. LeRoy E. Rabbani, director of cardiac intensive care
and the cardiac inpatient service at NewYork-Presbyterian Hospital/Columbia
University Medical Center in New York. But diabetics, who are prone to nerve
damage known as neuropathy, “may have impaired sensation that extends to chest
wall.”
To illustrate the point, Dr. Rabbani tells of
an elderly patient who had undergone coronary artery bypass surgery and had
stents implanted in his arteries to prop them open. Each time his heart gave
him trouble over a period of a dozen years, he had felt chest pain. But one
day, after developing diabetes in his 80s, this patient felt a little dizzy,
noticed a nose bleed and fainted after arriving at his ear nose and throat
doctor’s office. In the emergency room, tests showed that he had had a heart
attack, with no symptoms this time, six hours before. “Even in a given
individual, things can change,” Dr. Rabbani said.
There’s no opportunity to restore heart muscle
damaged in a silent heart attack, but there is opportunity to intervene to
prevent a second heart attack or heart failure. “One has to look at (a silent
heart attack) as a potential marker for coronary atherosclerosis and take a
more detailed look to see if risk factors are being treated adequately,” said
Dr. Christopher O’Connor, chief of cardiology at Duke University School of
Medicine. If damage is relatively mild, “there are a whole host of medications
we can use to prevent the occurrence of a second event,” he said. If damage is
more significant, bypass surgery, stents, and even devices like implantable
defibrillators may be warranted.
Afterward, doctors monitor patients more
frequently and “pay much more attention to ambiguous symptoms like prolonged
fatigue, confusion or shortness of breath,” Dr. O’Connor continued. “Before, we
thought these silent events were less important. Now, we realize they’re
equally important as symptomatic heart attacks and deserving of careful
follow-up.”
NY Times
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