By Russell Bikoff / Fairfax, Virginia
I am an athletic 69-year-old man and two weeks ago, I dodged a heart attack. My weight (168 pounds) and BMI (25.5) are normal and doctor’s notes characteristically refer to me as well- or solidly built. Before the pandemic, when I commuted to my downtown Washington, D.C. office, I ate an apple every day for decades on the drive home, hoping and believing (as my mother and grandmother used to say) that would “keep the doctor away.”
When the pandemic began in March 2020, I stopped my weekly one-mile swims at my local indoor pool because of my concerns about pandemic safety. Though I felt safe swimming regularly during the outdoor pool season last summer. I reduced my bicycle rides, normally between 30 and 50 miles every weekend, because I did not want to be near other cyclists on the roads and the trails of suburban Washington D.C. Still, I was sure I was living a healthy lifestyle, because I was eating a balanced diet pretty low in animal fat (except for weekly hotdogs, bacon, or an occasional sausage product) and while working from home, walking nearly every afternoon. These walks would be from two to four miles on most weekdays; on weekends, I joined my wife and sometimes one or more of our visiting sons in hiking or walking briskly, a minimum of four miles and usually more, at nearby parks.
I was in fine cardiac shape, and had the heart of Superman, or so I thought. I was controlling my risk factors, which were few, as my statins were keeping my cholesterol numbers low and impressive at under 160 total cholesterol, with high HDL (good) and a fine ratio of LDL to HDL below 3. I was on my third statin over the past 15 years or so, now taking Crestor (rosuvastatin) at the low dose of 10 milligrams a day. But something worrisome started to happen. On my local walks, alone or with my wife, there were gentle uphill sections, some of which extended about half a mile. Why was I now feeling a slight burning in my esophagus, a little nausea, and excessive salivation on these uphill segments? Was it a change in my diet? Maybe switching to Passover foods and eating matzoh? Was it a reaction to the Moderna vaccine? Maybe it was just excess gastric acid I could control by taking an acid blocker after lunch. Thinking that this was unusual, but not a critical threat to my life and health, I decided to put up with the annoyance and hoped that it would go away.
I told my wife and my sisters about this, and finally, after three or four weeks when I’d had enough, I contacted Doctor G, my primary care physician. He told me to come in the next day, which I did. With the second Moderna vaccine more than two weeks behind me, I did not hesitate to go into his office though double masked. As the son of a doctor, I thought I could contribute to the diagnostic process, so I told the doctor that the symptoms were probably gastrointestinal. Doctor G told me that I needed to see my cardiologist so both doctors could exclude a heart issue before addressing other possible causes. I had not seen my cardiologist, Dr. K, in three years, so I tried to make an appointment online. I got to the central scheduling number of his multi-office practice, and told the scheduler that I had an order from my internist and was experiencing symptoms, which I specified. She gave me an appointment for mid-September! (I learned later that she placed me in the wrong “basket.”)
That was unacceptable to Doctor G, who immediately got me an appointment with another cardiology group. This was on a Friday, April 9. The young cardiology fellow, Doctor E, who met with me scheduled an echocardiogram the following Monday and a “nuclear” stress test (i.e., with isotopes, so a type of scan that collects data from the heart before and after a patient goes on the treadmill) two days later, on Wednesday, April 14.
Now I was focused on my heart. I began to think about other people’s hearts from the distant past, as well as more recently. I had just written a condolence card to a good friend of my youngest sister. The friend had lost her husband to a heart attack recently at age 55. And several months ago, a good friend and former neighbor of ours, Michael, had died in his sleep at age 71 from what sounded like a heart attack. My dear friend Tom survived a heart attack several years ago in his early 60’s and ended up with catheterization and a stent.. My late father, whose cardiac issues (another risk factor for me) started with a heart attack at age 82 that he survived, had lost two close friends to heart attacks in the 1970s and ‘80s when he was younger. His friends were in midlife. Dad, a Harvard Medical School-educated and Boston Beth Israel-trained surgeon who practiced general medicine on Eastern Long Island for 40 years, had a triple bypass in 2007 and lived to 2017, to 91 years.
I also began some web research about coronary artery disease (CAD). I looked at a report from the National Institute of Health and a series of informational guides from the Cleveland Clinic. Over 16 million Americans suffer from coronary artery disease, with about half a million cardiac events taking place every year. Coronary diseases are still the number one cause of death for Americans. American men have nearly a two out of three chance, and American women a one out of two chance, of developing coronary artery disease after age 40. I also read that most heart attacks end in death, because people are unable to get care from emergency medical services or hospital emergency rooms in time, when every minute is critical.
While waiting quietly at home over the weekend to have the echo test on Monday, April 12 and the stress test two days later, I began to feel annoying pressure in my chest. I attributed this to the reading and to the phenomenon of psychosomatic symptoms. It was not. The Monday echocardiogram seemed to go well, but on Wednesday I flunked the nuclear stress test. I experienced chest pressure despite an extra-long 10-minute rest and recovery from the treadmill. While waiting after the tests, I had chest pressure again, this time more intensely, and told the technician about it. That led to a second, unplanned electrocardiogram. When the supervising cardiologist came into the treadmill room, she told me that I would not be going home but would go across the street by EMS ambulance to the emergency department of Fairfax Hospital.
Things began to move quickly. I received emergency department care through Wednesday evening, then went up to a room in the cardiac section— private, possibly because of the pandemic. On Thursday, with the chest pressure noticeable and seeming to get worse, I along with my wife Sue and my brother-in-law Steve, a retired pediatric cardiologist, waited in the hospital room until late afternoon. Then a nurse and transport person wheeled me to the hospital’s basement and into the Cath lab for a cardiac catheterization from Doctor H, an expert interventionist with a leading group in Northern Virginia.
To my surprise, I was awake for the procedure, with only mild sedation. This procedure is considered nonsurgical and noninvasive, because the doctor and team thread a catheter from the wrist through the blood vessels to the aorta, then explore the cardiac arteries. The doctor found a blockage in my left anterior descending artery (LAD) and was able to clear it with a balloon in a procedure called angioplasty. The blockage was the result of plaque, a combination of calcium, lipids— fatty deposits from the blood— and platelets, with a hard-shell covering. He then placed a stent there. A smaller blockage further along in the LAD was not critical enough to repair this time, because it was not interfering with blood flow. The hospital released me the following day, on Friday morning.
A week ago, on April 20, I returned to the cardiology practice and met with my regular cardiologist, Doctor K, an experienced and highly regarded doctor, like his partner who had performed the catheter procedure on me. I learned that my blockage was 95% and it could have been the result of a rapid buildup of a clot stemming from a breakup in the plaque that had been growing in my arterial walls for decades. A 100% blockage would have caused a myocardial infarction, a heart attack. In the LAD, which branches off from the left main artery and brings blood to the left ventricle, a portion of which is known as “the widow maker,” this is not good.
So where do I go from here? I am still recovering from the procedure and feeling occasional pressure in my chest, the phenomenon called angina pectoris. I can relieve this with nitroglycerin, but if it gets worse or crushing, I will need to get to the emergency room— fast. I am cleared to resume cycling, swimming, and hiking, the sports I typically do, in two to four weeks, building back slowly and stopping if I have symptoms, including angina. In the meantime, gentle walks of one to two miles are encouraged, as well as joining a cardiac fitness program at a local hospital. I am on new medications, Toprol, a beta blocker to relax the heart, and Effient, a blood thinner to prevent clotting around the new stent, which the body treats as a foreign object for a while. Plus, a new dose of statins (40 milligrams), four times the amount of my previous dose. And back to baby aspirin, 81 milligrams, for the rest of my life to act as a blood thinner.
For now, I’m only allowed one alcoholic beverage at a time, infrequently. In six months when I am off two of the meds, I can resume moderate drinking, i.e., two glasses of wine at dinner on occasion. The doctors advised me to reduce red meat consumption, because of its inflammatory effects on the circulatory system. Travel this summer should be fine, since my wife and I are planning a trip to the Southwest that will give opportunities for moderate hiking, but certainly not from the top to the base of the Grand Canyon and back.
What did I learn from the doctors, my reading, and this experience? First, good cholesterol numbers are not enough. Low dose statins, which I had been on, were completely misleading and gave me a false sense of confidence. Low doses, recent studies show, do not have the same beneficial effects on the coronary arteries as medium and high doses. I am hoping now that the high doses, as my cardiologist explained, will do the cleanup work of reabsorbing some of the plaque from inside the arteries.
Second, I absolutely should not have waited three or four weeks while speculating about the causes of my set of symptoms. I should have gone to my primary doctor immediately. He explained to me that in the 1980s, before cost-saving measures went into effect, my symptoms would have led me straight to the cath lab without pausing for a stress test (presumably for diagnosis and ballooning, since I understand that stents did not appear until the early 1990s). The cost-savings studies changed American medical practice in this regard, and for the worse in Dr. G’s view. He asserted that he knew the issue was cardiac from the start, because my symptoms were all “exertional.”
Third, I was the fortunate beneficiary of Doctor G's compulsive approach to medical practice. He made multiple calls to ensure that I saw a cardiologist quickly after he had seen me, that I scheduled the tests, and that I had the catheter procedure without much delay. Fourth, the cardiology fellow helped me by quickly scheduling the two screening tests, putting me on baby aspirin over the intervening weekend, and telling me to take it easy. Fifth, I am indebted to the cardiology practice that quickly got me into the cath lab and was able to successfully clear the blockage with angioplasty and place the stent. Had that procedure failed, the next option would have been coronary bypass surgery with grafts for one or more new arteries. This is major invasive surgery, performed by a thoracic surgeon, not an interventional cardiologist.
As I told our three adult sons, I am now living with a new reality of CAD, which I had had without knowing it and now know I will have for the rest of my life. I see in retrospect how lucky I was to have symptoms that led to nothing more than catheterization and a stent. If you have any symptoms, any one or more things that are out of the ordinary, especially if related to exertion or exercise, I urge you to reach out to your primary physician ASAP, and make sure the whole process and the people involved move quickly. As I learned at great risk, the key word is “quickly.”
Russell Bikoff has been a prosecutor in the Manhattan District Attorney’s office and a federal official in the foreign affairs community and the U.S. Department of Justice. For the past 15 years, he has practiced law in Washington, D.C., focusing on criminal defense, civil litigation, and other civil matters.