Sticking with Cholesterol....

The subject of cholesterol and the whole fats question is something of a vexed issue of late. If you were to search online you would find a huge amount of information, much of it completely contradictory. Some will tell you it is wise to keep your cholesterol levels as low as possible whilst others will insist that having a high level of cholesterol in your bloodstream will have no bearing on your future health. To be as honest and straightforward with my readers as possible, I will admit to being a member of the first group and believe firmly, especially if a person has had any heart problems, that they would be well advised to control their cholesterol levels.

Firstly, we need to establish exactly what cholesterol is. If you were to hold some cholesterol in your hand you would find yourself looking at a waxy substance that might remind you of the scrapings from a whitish-yellow candle. Cholesterol is a lipid fat that is made in the cells of your body. There are many different types of cells that create cholesterol but the most productive are those in your liver that make approximately 25% of the total. You do need some cholesterol to keep healthy but your body creates all the cholesterol you need. You do not need to add cholesterol from outside sources (ie your diet!).

Cholesterol itself is performs three main functions in the body: it is used as part of the coating of cells; it makes up the bile acids that help in the digestion process; it allows the body to create Vitamin D and certain key hormones such as testosterone for men and oestrogen for women. Cholesterol is not bad, indeed it is vital to healthy bodily functions, but an excess of the wrong type is.

Cholesterol comes in two main types:

HDL (High Density Lipids) often referred to a good cholesterol.

LDL (Low Density Lipids) sometimes referred to a bad cholesterol but, the really bad ones are VLDL (Very Low Density Lipids) these are the ones that clog up your bloodstream and result in the problem of atheroma and the resulting cardiac issues.

Atheroma is the process of the degeneration of the walls of the arteries. This is generally caused by the build up of fatty deposits and scar tissue. Over time this will result in the restriction of blood flow and lead to cardiac events of all sorts. This formation is what we hope to prevent and reverse using these dietary and lifestyle methods.

A general reduction in cholesterol levels will offer a patient increasing levels of protection from the risk of heart attack but it needs to be stressed that it is not just the levels that are important but the ratio of LDLs to HDLs. Many in the field recommend going for a ration of 3:1 but some go even further and say that ideally one would achieve a ratio of 1:1. Commonly, in countries suffering high levels of heart problems such as the UK or the US, levels of 7:1 or 8:1 are commonly seen although the average is roughly 4.5:1.

Dr. Esselstyn sets a very clear goal in relation to the desired levels and ratios of cholesterol. He aims for a total blood cholesterol figure lower than 150mg/dl (milligrams per decilitre) and levels of LDL lower than 80mg/dl. By following the plant-based diet he recommends (as given in the previous blog) these levels are readily achievable. According to the doctor, at this kind of level you not only protect yourself from the possibility of a future cardiac event but even make possible the reversal of damage to the coronary arteries.

One of the good pieces of news about a plant-based diet is that plants themselves are very, very low in cholesterol. Many websites will tell you there is none at all, but this is not entirely accurate. The levels are so low though that they hardly register. Also, it should be noted, that the sort of cholesterol they do have is of a type that your body can use in a protective manner. To give some idea of the scale, the yoke of an egg (not recommended on the Esselstyn diet!) has 15000 mg/kg of cholesterol; the most concentrated form in the plant world is the European False Flax that contains as much as 200 mg of cholesterol per kg of plant oil. That is a ratio of 75:1. Note that this is in the oil form, again something that Esselstyn warns against, so even these very low levels would be avoided following his diet.

For interest, and to complete the picture, meat contains up to 5000 mg/kg and butter 2500 mg/kg. Without going into the issue of saturated versus unsaturated fats (a subject for a future blog), suffice it to say that the saturated fats are the ones to avoid. Dairy products and meat are high in saturated fats. One can readily see how the avoidance of meat and dairy products logically forms the foundation of Esselstyn's heart-friendly diet.

Finally, after quite enough technical information for one week, a little inspiration. Doctor Ellsworth Wareham was a cardio-thoracic surgeon for most of his long career. A few years ago, at the age of 95, he decided it was time to retire although there was no deterioration in his competence levels and the hospital he worked at tried everything they could to persuade him to continue. He is now 98 years of age and, as you can readily see from the video, remains remarkably healthy physically and sharp mentally. Doctor Ellsworth has been on a plant-based diet since his mid forties...

The Aftermath. What to do?

The events referred to in my previous blogs transpired some two and a half years ago now. Happily, for me at least, I have survived this initial stage and even find myself in reasonably good health at the time of writing. Unfortunately, a fair percentage of heart attack victims never make it this far, particularly those who choose to continue the lifestyle that was, to a certain extent at least, responsible for them suffering a heart attack in the first place. Factors such as smoking, drinking to excess, lack of exercise and stressful lifestyles are obvious enough but perhaps the biggest single change that people such as I need to consider is their diet.

My own personal history in this matter seemed, at the surface level at least, to be relatively good. I had been a vegetarian for 27 years, had only smoked during my distant youth and I barely drank alcohol, only indulging in the odd glass of wine or beer once or twice a month. Unfortunately, all was not as it seemed though. My diet, although lacking meat and many of the problems related to the ingestion of it, was still not good. I had an ongoing weakness for cakes, biscuits and many other mass-produced, high in sugar, confections. Added to this, I had also spent many years in a high stress occupation that necessitated working long hours on shifts, often having to work with some degree of intensity late at night. During that period of my life I faced several health challenges and although that was long in my past now the ongoing effects were not so easily eradicated.

So it was that I found myself in middle age having to deal with the reality of suffering a heart attack and the somewhat disconcerting feeling that it could all so easily happen again. I had thought that the current, relatively low stress lifestyle that I adopted at the time would protect me. My exercise options were somewhat more limited than most due to the impact of a long-term back injury but I still managed to swim three times a week. The heart attack had proved me wrong though. Whatever it was that I was doing it was clearly not working. At this stage I have to admit to a certain feeling of helplessness, of being a passive victim of circumstances. This was not a good feeling...

The after-care advice that I received from my health provider basically told me to do all the things I had previously been doing anyway: exercise, avoid fast food, de-stress, don't smoke. There seemed also to be an unwritten and unspoken assumption in all this too, a sense that all a patient could do was forestall the inevitable, to put the dreaded event back in time but not to heal, not to actually get permanently better.

So it was that I found myself feeling like a ship without a rudder, sailing to who knows where but with the certainty that eventually it would not be a good place. I recalled from my earlier studies in psychology a group of experiments conducted by Martin Seligman into learned helplessness. Basically the results of these were that when you put an animal into a no-win situation it acquired a habit of not looking for other options even when these were in fact open to it. The animal 'learned' to be helpless. This now felt much like the situation I found myself in.

This continued for some months after the initial heart attack. There was a certain wariness to everything I was doing, as if I was at some level expecting another 'event' at some stage. When and how it would happen I had no idea, but there was a persistent feeling of inevitability that tended to take much of the fun out of life. The feeling of no longer being in control, of no longer having choice, is not a good one in this situation.

During this time of drift, through sheer serendipity, and through a mutual interest in psyhology, I had met a certain Russell Monsurate on Facebook. His posts interested me and he seemed to have a very positive attitude to life in general, which I greatly appreciated at this stage. In particular, he often seemed to post articles relating to cardiac health. It was one of these that was to change both my psychological and, if my current well-being is anything to go by, my physiological state. 

The article itself referred to the changes in former president of the US Bill Clinton. This piece originally caught my attention as I had long been an admirer, although not an entirely uncritical one. Despite his shortcomings, one always had a feeling that his heart was in the right place, even when that heart appeared to be ailing as he reached his fifties.

At the age of fifty eight Bill Clinton had undergone a bypass procedure. Such drastic occurrences in one's life do tend to focus one's attention. In Bill Clinton's case, despite making some changes, he did not fundamentally address the problem of his famously indulgent diet. The former president had always been known for his appetite and, despite the warning, his excesses in this area still remained relatively uncurbed. Three years later he suffered another 'event', this time calling for the insertion of a couple of stents.

At this stage his former medical adviser, Dean Ornish, wrote a letter to Clinton pointing out the inevitable result of continuing down the path he was taking and a way that he could, with patience and persistence, avoid this apparent inevitability. What Ornish suggested was a drastic change of diet. He advised the avoidance of meat, fish, dairy products and any processed so-called 'fast foods'. He also advised a minimal reliance on oils.

Ornish's view was further supported by Dr. Caldwell Esselstyn. Clinton reviewed the evidence and his own parlous state of being and decided that he needed to take the plunge. What followed was an immediate improvement in the state of his health. He began to lose weight, going down some 20 lbs in the first year alone. Blood tests started to show, and continued to show, a great improvement in all the classic markers related to coronary health. The former president, on seeing the obvious success of the diet in his own case, became not only a follower but a keen advocate of this vegan, plant-based diet.

From my personal point of view, if Dr. Esselstyn's book was to be believed, the really good news in all this was that cardiac problems of this sort could not only be slowed down but the process can actually be reversed. It seems that the body's remarkable ability to heal itself applies to this area too. Not that surprising really, but having subconsciously assimilated the assumptions of many in this area, I had believed that all that was left to me was delaying the inevitable. Now, for the first time, I realised that one has a lot more choice, a lot more control than that. One can not only slow down the progress of heart disease but, if one remains disciplined, one can actually reverse the process.

 This was good news indeed.

It's Deju Vu All Over Again...

I have to admit now, looking back from a distance of a couple of years, that part of me was tempted not to have the second procedure. By this time I had read about and was well aware of the relatively slight dangers of an angiogram and the much greater risk of having another angioplasty. I wanted to find some good, or even not so good, reason to say that a second operation was unnecessary, thus avoiding the seeming inevitability of having to go through the same thing all over again.

There were some signs that part of my problems may have been down to the medication, I had been prescribed beta blockers which had the effect of making my already slow heart rate even slower. Indeed, on the first night in hospital, it had regularly been recorded at around 42 beats per minute. Such a rate is fine for a high level marathon runner or someone intending to take part in the Tour de France, it is not so good however for a middle aged gent leading a somewhat more easy-going lifestyle.

Dr. Amersey, on seeing the charts, immediately changed my now long list of medications to exclude the beta blockers and also reduce the statins intake. My cholestrol reading had come back as 3.6; relatively low and not really in need of being controlled by medication. In view of these changes, I was tempted to ask for a reprieve, say two or three weeks, to see if the new regime changed the way I felt, and thus avoiding the need to undergo another procedure. Feeling I had dodged a bullet the first time, I felt no particular enthusiasm to put myself in the firing line once more.

The doctor, calm and logical as ever, explained the advisability of taking things a step further. Given the nature of my condition the risk of not undergoing the procedure was far greater than then risk involved if it was avoided. There was still some reluctance on my part but I understood that, in real terms, it was the most sensible course of action.

So it was that I found myself signing the consent form once more. There was a sense of surrender, a sense of ‘que sera sera,’ whatever will be will be. For me, oddly, there was also a sense of peace in that inner surrender and I found myself surprisingly calm as I settled down to await the procedure. I had been told I was second in line so to just make myself comfortable for a while until it was my turn.

I had just opened a copy of ‘Alex’s Adventures in Numberland’ when the doctor suddenly reappeared.

“Sorry George, the previous operation has been cancelled, you’re next!”

And so it was that within a bare few minutes I found myself once more being wheeled into theatre. A lot of the nurses were, by now, familiar from a fortnight before.

“Back so soon?” one of them asked, smiling.

“Yes, I enjoyed it so much the first time that I just couldn’t wait to come back for more… ” I explained.

Once more the nurses busied themselves with the usual attachments, once more I was positioned on the long, narrow bed, my hand tucked beneath my body, once more the brief explanation as to what was going to happen next.

Having punctured my oh so sensitive right groin the first time, it was now decided that they would go in through the left side. A young doctor, trying hard to affect a level of nonchalance, injected the lignocaine into the top of my thigh and proceeded to attempt to feed the needle into the femoral artery. The process did not go well however and, several times, I was told to ‘relax.’ Not the easiest or most natural thing to do when someone is trying to puncture a vital artery in a very sensitive part of your anatomy, followed by pushing a rather large needle into the hole thus created...

Dr. Amersey took over at this point. I felt it as something of a relief to be back in his capable hands. Within just a couple of minutes the dye was dispersed once more into the arteries of my heart and then… silence. For a minute or two all I heard were a few faint mumbles as the team went into something of a huddle.

Eventually, Dr. Amersey appeared from behind the perspex screen, a look of some concern on his face. I had seen this expression before. In fact this was the third time. Deja vu all over again…

“We have had a look and although the first two stents look fine there does seem to be something of a blockage in a branching artery.”

He waited for a response but what could one say?

“Go on.”

“Well, from the previous images we looked at, the blockage would appear to have developed in the last couple of weeks.”

He let the implications of this sink in for a second or two. The obvious question was why would it have developed now when the flow of blood around the heart should have been improved by the previous stenting?

“I think the best course of action would be to insert a further stent into the branch artery… with your permission?”

Again, what can one say in such a situation? As the patient you are caught between a rock and a very hard place. Potentially damned if you do, almost certainly damned if you don’t. Not a real choice, you have to go for it. I nodded my assent.

“OK, thank you. By now, you know what to expect,” he said, with a certain underplayed irony in his voice, “It’s possible you may feel some build up of pressure in your chest. Let me know if it becomes too uncomfortable.”

With this he disappeared once more behind the perspex screen and made his preparations. Lengths of catheter tubing were requested along with a smaller size drug eluting stent than the previous two. In but a few short minutes all was ready.

I listened to the soft voices of the doctor and the team, calm yet focussed, reassuringly concentrated on the task in hand: rescuing my ailing heart. Within a minute or two the catheter was being inserted. The next stage involves guiding the stent itself up through the arterial system. In theory, one cannot feel any of this directly but you do notice small changes in pressure in your chest. After all, the flow of blood in the arteries is outward, away from the heart. The sheath, catheter and stent are all opposing that flow to various degrees.

Somehow, this time, although more aware of the dangers than previously, it felt easier. I was well aware that there are risks involved but I felt a high degree of confidence in the team of people performing the task. There was something very reassuring in the professional manner in which they worked. Requests would be made, curtly yet politely, responses would be made, quickly and accurately. If there was a problem it was quickly and efficiently dealt with. The thought crossed my mind, this procedure may not end well but it would not be for lack of effort on the part of these people.

Soon I heard the now familiar count once more: “Going up, 2,4,6,8, 10 and 12…stopped at 12.” The count was spoken once and then echoed in confirmation. I felt the pressure climb in my chest. For a brief moment it was actually quite uncomfortable. I waited for a few seconds, still felt the pressure, and so pointed it out to the doctor.

My comment was acknowledged but, fortunately, almost immediately the feeling of pressure subsided. For a few more minutes there was the sound of muffled conversation from behind the screen, as hard as I strained to hear I could only pick out the odd word here and there.

The doctor pushed back the screen. He smiled briefly, reassuringly, before telling me that he considered that it had gone well. The only downside was that a blood blister had appeared beneath the site of the opening in the femoral artery and they would therefore not be able to plug the wound in the normal way. Pressure would need to be applied to the site for some time in order to get the wound to set.

I was relieved to have made it through once more and the prospect of some pain as the left groin area was pressed firmly immediately over the wound seemed, relatively speaking, of little consequence. I have to admit though… it really did hurt!

The nurse apologised a couple of times for causing me such pain but there was no need. Pain inflicted when one is aware that the intention behind the process is your well-being is much easier to bear.

In no time at all I was back in the familiar environs of Elizabeth Ward. It felt like I had hardly left the place. Many of the same staff I had met the first time around were on duty once more and it actually felt good to be reacquainted with them. For the first few hours I was confined to the bed, most of the time spent completely horizontal to give the wound a chance to heal properly. After about three hours I was allowed to gradually increase the angle of my body until, finally, I could sit up in bed.

My younger brother, David, appeared at this point. It was good to see him once more. We chatted away for some time. David tends to be in one of two modes, the first is rather self contained and one struggles to eke even a few words out of him, the second is much more open, voluble and effusive. Fortunately, on this occasion, he was very much in the second mode and the conversation flowed easily and interestingly. The only downside for me was the ongoing effects of the diamorphine I had been given which rendered me a tad sleepy at times.

A couple of hours later it was time to knit the wound together. This involves more pressing on the groin. The pressure needs to be very firm for it to work so there is an amount of pain involved for the patient but it also tends to be hard work for the nurse. The sister who was to carry out the procedure was in charge of the ward that evening. She was of a somewhat slight build and the sheer physicality of having to try to hold the pressure on the groin for that length of time was clearly quite a strain. She stuck to the task however and, after the fifteen minutes and numerous apologies for causing me discomfort, the wound was sealed. I think we were both quite grateful!

The week following the second angioplasty was both better and worse than previously. Better in the sense that, although I was not exactly glowing with health, the improvement was clear. I no longer experienced the breathlessness I had before and the light sensitivity seemed less intense. The downside was the injury to the groin, collateral damage from the procedure, as our transatlantic cousins might term it. The bruising was a sight to behold as it came out over the first few days. Gorgeous long lines of purple, separated by about six inches, in between which the skin was a strangely exotic shade of muddy yellow.

Walking, even very short distances, was more than a tad difficult for a few days. My cat, Cooking Fat, often seems to display a certain empathy at one level, oft times sleeping beside me when I have been low. On another level she displayed an almost criminal disregard for the sensitivities of my much bruised groin by leaping unexpectedly onto my lap from all angles and at any time. Not so good…

There was a feeling of gratitude that persists to this day. I feel grateful to the people who have helped me on this occasion, grateful to those who helped me on previous occasions, grateful simply to have come through at all. Several times in my life it could have turned out very differently. In particular, I am grateful to the NHS and the staff therein. They come in for a lot of criticism at times but I for one have good reason to be thankful to both the institution itself and the staff within.

I had gotten through the worst of it, now it was time to figure out how I could avoid going through the same thing again, if at all possible...

The Phoney War

Back on the ward, there was a feeling of relief, a feeling of simply not wanting to be in this same situation again in this lifetime if I could help it. The wound was uncomfortable but I knew this was just a temporary setback. It seemed that, for now at least, I had come through relatively unscathed. A few words from Churchill came to mind; “There is nothing quite so exhilarating as being shot at without result!”. Exhilaration may have been too strong a word in this case but there was a definite sense of having ‘dodged a bullet.’

After an angiogram/angioplasty procedure one is confined to bed for several hours in order to allow the wound in the groin time to heal. In this particular case, they had inserted a plug into the hole in the femoral artery, a relatively modern technique which avoids the need for a lengthier and more painful procedure whereby the site of the wound is pressed upon very firmly for some 15 minutes or so. For those of us who are a tad sensitive in the groin area, the very thought of it brings tears to the eyes!

For the next day or so, until the moment I escaped the confines of Whipps Cross Hospital, I was feeling strangely elated, almost slightly euphoric. Whilst in the limited spaces of Elizabeth Ward my increasing mobility and sense of general well-being were very reassuring. On the Tuesday morning I found myself busily engaged on the phone arranging all manner of things that needed to be done for those around me and myself. It felt good to be in charge of one’s life again, instead of just a passive victim of circumstance. As much as I appreciated the care and attention of the staff in the hospital, there was still a strong desire to be released from their ministrations and, once more, to feel oneself a free and independent person.

Before leaving I was treated to a visit from Caroline of rehab who offered enlistment into a program of exercise for those who had suffered a heart attack. I let her know of my limitations (the back injury) in such areas but gladly accepted her offer. Next came the rather exotically dressed lass from the pharmacy, a sight for slightly sore eyes resplendent in figure hugging dress and knee high boots, dispensing drugs and advice on how to take them. The list of medicaments was long, seven in all if one doesn’t count the ‘emergencies only’ GNT spray. There were statins, ACE inhibitors, anti-platelets and even beta blockers. I was a tad concerned at the last as my heart rate is pretty slow at the best of times but I was assured that in this situation it would take a load off of the embattled organ.

Phil Johnson, a good and trusted friend of many years standing. picked me up at around half three in the afternoon. He carried my bag along a section of the seemingly endless corridors of Whipps Cross. He was not walking particularly fast but even so I had to ask him to slow down. The light outside seemed somehow brighter than usual even though the day was overcast. I waited near the outpatients  department and enjoyed the sights and sounds of life going on around me once more.

Phil drove at a reasonable pace back to his maisonette just off Hermon Hill. Although his driving was by no means unreasonable, I still seemed to feel every bump along the way. On arrival, I got slowly and tentatively out of the car, feeling surprisingly vulnerable and frail. This was not at all what I had expected. I was well aware that I had had a heart attack but, at the same time, had felt like I was getting stronger and stronger, particularly during the previous 24 hours. That was in the hospital though. Now, exposed to the outside world, it was becoming obvious that all was not yet well.

I stayed with Phil and his wife, Simone,for several hours, most of which was spent strewn across their huge red sofa, being supplied with all I needed for the evening. They both seemed somewhat concerned, I think I may have looked even frailer than I felt. Eventually, around ten or so, Phil drove me home.

The next week was spent very gently reading, writing a little, waiting for the expected recovery. Indeed, for a time, I did seem to get a little better but would still find myself breathless climbing stairs and would still experience moments of faintness. The bruising in my groin and upper thigh was impressive, gorgeous shades of purple, blue and yellow. As ever, I rationalised my lack of a faster recovery, if my groin and thigh were like that then it would seem only natural that something similar had occurred internally. Recovery would be a matter of patiently waiting for the bruising internal and external, to subside.

I had been encouraged to take some exercise when I could so I went for a short stroll beside a lake in Wanstead Park. It was a sunny day and pretty soon I found that I was reacting badly to the light. After just a few minutes I had to sit down just  to allow myself the chance to recover. This wasn’t the recuperation that I had hoped for.

Over the next few days I struggled on and, after a couple of weeks or so, I was actually feeling a tad more comfortable, although the photo phobia seemed to grow more and more bothersome with every sunny day. Two friends, John and Erica, had invited me to share a trip to the British Museum to see an exhibition on early European Christianity’s addiction to the notion of relics. It sounded interesting so I decided to take a chance and embark on my first trip to London for a month.

I had only just started driving again which felt like something of a liberation.  I left the car in a side street close to Woodford Station and tried to walk the short distance to the ticket office. It was a sunny day and immediately the photophobic effect was obvious once more. Every white, or even light, coloured wall  or surface seemed to glare unbearably. It felt a little like the snow blindness I had experienced in Austria many years previously, this time though it was accompanied by feelings of light-headedness and even nausea. When I reached the barriers I was feeling quite ill and had to make a decision whether to go or stay; once through, I was more or less committed to the journey.

With some reluctance I decided to go. Taking the seat on the train I immediately felt better and was relatively fine until reaching my destination, Holborn. Once there though, I had to walk a short distance to a coffee shop where we had decided to rendezvous. Reaching the meeting point, even though it was but a short distance, became a struggle, so much so that I could feel the sweat running down my back at the effort involved. Every light coloured surface seemed to be breaking up into darker blotches. Finally, and much to my relief, I reached the basement of the coffee shop. John and Erica were already there and looked concerned at my discomfort. After taking a seat in a deep and cosy chair  and chatting with some expectation about the exhibition I soon became much more comfortable.

The exhibition itself turned out to be a beautiful presentation of a variety of relics from the early Christian era. Across Europe in the middle ages, all manner of relics recovered from the crusades were revered for having been involved in the story of Christ. There were splinters from the cross, a piece of bread from the last supper, even a towel said to have been wrapped around the head of Christ as he took the cross upon his back. All incredibly implausible of course, but bread (literally in the case of the relic!) and butter to the early Christian church. People would make pilgrimages in order to have a chance to even simply be in the proximity of such relics. Added to those connected to the Bible story there was also many artefacts connected with various saints. Many of these were body parts taken from the corpses (allegedly!) of martyred saints immediately following there martyrdom. Quite gruesome and, in many cases, equally implausible.

Coming out of the exhibition I still found myself weak and a little breathless but I did seem to be managing the demands of the situation quite well. Strange, looking back at it now, that same process of  rationalisation that I mentioned in a previous blog, that same willingness to believe the more mundane explanations for one’s symptoms, served to prevent me from the realisation that I will still in trouble. This process seems to be a defence mechanism that many of us share, a way of shielding us from the harsh realities that confront us at times in life.

All this was to change just two days later. I had been invited to undergo an exercise test at Whipps Cross to see if I was ready for the rehab program. It consisted of walking on a running machine whilst the operator, a sympathetic Irish fellow by the name of Brian in this case, gradually increased the inclination of the apparatus.

For the first half a minute or so I was OK. My body was festooned with connections so my heart could be monitored during the process and, at first, nothing unusual was apparent. Then the slope was increased. Within seconds the chest pain returned. I soldiered on. The inclination was increased and, almost immediately, so was the discomfort in my chest. I started to feel quite faint. Brian, monitoring the ECG and enquiring as to how I felt, decided quite suddenly to stop the test. He looked somewhat perturbed.

“George, I think you should come back into hospital” he said.

“Hmm, bit inconvenient right now Brian” I responded, “When do you think it could be arranged?”

“I think now would be the right moment!”

I had made all manner of arrangements for the coming days but I could see from the look on his face that he was quite concerned. I enquired if it was at least OK to return my car home and get a friend to bring me back but even this was, according to Brian, inadvisable.  When he said now he really had meant it and so it was that within a few minutes I found myself sitting in a wheelchair being wheeled along the interminable corridors of Whipps Cross back to Accident and Emergency to undergo further tests with a view to readmitting me.

Back to square one it seemed. There was some concern amongst the staff in A&E that I was having a second heart attack there and then. More electrodes were attached to my chest, ECGs were taken and samples of my blood were extracted from my much punctured arm.

My basic nature is, fortunately, inclined towards the optimistic, but, sitting there in A&E with little idea as to how serious this latest event might be, I have to admit to getting just a tad fed up with the vagaries of my heart.

Don't Stint On The Stents...

At the centre of the theatre was a long, narrow bench above which were an array of screens. At the head end of the bench was a heavy scanner on a semi-circular tracker. I was laid upon the bench which, for a change, was actually comfortably long enough to support my elongated frame. Four or five nurses buzzed around me, fixing a drip to the cannula in my left arm, attaching numerous electrodes for an ongoing ECG, placing my right hand beneath my buttock and then, all needed preparations completed, sliding a long, lime green, paper sheet over me.

I looked up at the ceiling where someone had thoughtfully provided an impressionistic scene of Epping Forest, canada geese wondering around a muddy pond. The nurses chatted reassuringly as they busied themselves with a multitude of tasks. Finally, Dr. Amersey came in and briefly went over once more the likely sequence of events. Normally, he explained, they would consider using an artery in my arm to gain access to the arteries around the heart but, in my case, the tubing that was normally utilized may prove too short for the task so they were proposing going in through the femoral artery in the groin.

All I could remember of the femoral artery was what I knew from reading Hemingway’s ‘Death in the Afternoon’ as a teenager. The femoral artery was the one place that the bullfighters in the book feared being gored as, once severed, the flow of blood tends to be both immediate and copious.

I was injected with a couple of shots of lignocaine to numb the site. To some extent it was successful but, even so, as the needle was slipped beneath the skin in the proximity of the inguinal lymph nodes, I began to experience some degree of discomfort. I tried to grin and bear it, focussing my attention on the meandering geese on the ceiling, but my efforts were doomed to failure as I winced from the pain.

“Would you like some sedative?” asked the concerned Dr. Amersey. An emphatic “Yes” was my reply. As a guy, the general expectation seems to be that one should put up with a degree of discomfort without moaning and, in general, I am pretty OK with that but... one also needs to know one’s limitations! A nurse was instructed to feed some anti-emetic into the cannula, mercifully followed by a dose of diamorphine. The familiar, slightly woozy, feeling flooded through my body quickly followed by the relaxing effect of the drug.

Every now and then I would receive the instruction to ‘relax.’ As you can readily imagine this was, in practice, much easier said than done! The procedure is not the most relaxing process in the first place but having someone slide a needle up through your groin and into your femoral artery would not be the first choice on my list as a way to relax. Still, I did as much as I could and tried to focus my mind on the pastoral scene above my head.

In time, and with a degree of difficulty, the needle was in place and a wire was passed up through the arterial system destined for the vicinity of my heart. I could scarcely make out anything that the doctor was doing as he worked behind a thick perspex screen designed to give him some level of protection from the radiation emitted by the fluoroscope. The surgeon also wears a leaded jacket designed to offer a further level of protection. As a patient you have no such defences but, hopefully at least, one is only exposed to the x-rays for the relatively short amount of time involved in the procedure.

The time came to inject the dye; I was warned that I might feel a little pressure at this point. I looked across to the screens above and to my left. Strange to see the motion of the blood and dye around one’s own arterial system. The images were very clear though, as was the problem that Dr. Amersey pointed out. One artery barely seemed able to allow blood to flow through it at all. He explained that now we were in this position, probably the best thing to do would be to immediately go ahead with an angioplasty. This involves place a stent, a small metal tube, inside the affected artery in order to hold back the atheroma (area where the artery has narrowed) and allow blood to pass through freely once more. He explained that although the procedure had a certain level of risk he believed that in this case it was the only sensible alternative.

I nodded my assent. I will admit I was not overly keen to undergo such a procedure but the alternative seemed even worse. It was explained to me that I would feel some pressure as the stent was put in place. The doctor asked for a length of what appeared to be plastic tubing and a stent of a certain size. Within a couple of minutes the process had started and he delicately, and very skilfully, pushed the stent into the affected artery.

Once again, I was told I may feel some pressure in the chest and, sure enough, within a few seconds, I did. It felt somewhat like having the heart attack all over again, maybe not quite so intense but really quite similar. The doctor and one of the nurses began to count in unison: “Going up, 2,4,6,8,10,” each confirming the other. This count is performed as air is pushed into the balloon that is inside the stent. Inflating the balloon causes the cage-like structure of the stent to expand. Whilst this is occurring though, there is a considerable build up of pressure in the chest. I could feel my temperature going up and was aware of a certain faintness. I was given the chance to rest for a second and then the count started once more: “Going up, 2,4,6,8,10,12…hold at 12.” The pressure was quite high at this point but, finally, it was done. The stent was in place.

There was some discussion taking place between the doctor and a couple of nurses but I could not quite make out what was troubling them. A minute or two later, Dr. Amersey appeared from behind the perspex screen, his expression an odd mixture of satisfaction at a job well done and yet clearly a little concerned at one and the same time. It was one of those “Do you want the good news or the bad news?” moments.

“Well” he announced, “that went very well. The stent is in place and it looks to have settled in well but, unfortunately… ”

I had some idea what was coming but let him continue.

“…as we carried out the procedure, one of the nurses noted a second arterial blockage. With your permission, I would like to go ahead and attempt to put a second stent in place.”

It was an odd moment for me. On the one hand I had thought that the procedure had finished and I had survived relatively intact, there was some sense of relief in this thought and to be told that this was not yet the case was not exactly what I wanted to hear. On the other hand, if there was a second blockage, I should be grateful to the nurse for being so attentive. There was no other sensible choice really, I gave my permission and even thanked the nurse who had noticed the problem.

The second one seemed more intricate than the first. Once more I was warned of the change of pressure, once more I felt this in my chest. The balloon holds back the arterial flow so it is scarcely surprising that pressure would result. For my part, I was just about exhausted at this point. The heart attack had generally left me somewhat weakened and this kind of continuous stress is quite difficult to bear uin that state.

As the pressure built up in my chest I found that I could not bare to look at the screens any more and instead focussed my attention on the red headed nurse standing at the back of the theatre, looking on attentively. In a normal sense, staring in such a way may have been perceived as quite rude but from my point of view consciously and quite deliberately distracting my own attention in those moments really helped.

I heard the now familiar counting in the background, felt the pressure building, was aware that my head was swimming a little and aware of the desire that this should all be over soon. For now, I had had enough.

A few brief minutes later, Dr. Amersey once more appeared from behind the perspex screen. He looked hot, a little flustered even, but elated. He confirmed that the stent was in place and, as far as he could tell, it had all gone as well as could be hoped. I looked across to the clock, nearly two hours had passed, and back to Dr. Amersey. He appeared tired and a little drawn now.

“Are you OK?” I asked.

“Back is aching a little,” he explained, ” these leather jackets weigh you down over time.”

I felt and expressed my gratitude to him. A wave of emotion, relief for the most part, rose up within me. I could scarcely speak. A nurse had to hold a plug in place in the femoral artery for some minutes. This was painful but the pain was of a type that was easier to bear.

I knew the worst was over, for now...

The Original Heart Attack (well, not that original...)

To start this blog I thought I would go back to the original problems using some notes that I wrote at the time. In the two and a half years since I have learnt a few things about surviving and even living well after a heart attack but I have also made a few mistakes along the way which, I hope, may be helpful to readers.

It started on a Saturday about two and a half years ago. I was laying in bed and trying hard to swallow but somehow finding it very difficult. Swallowing, hmm, not normally the greatest of achievements but in this case it was proving mare than a match for me. After an hour or so my somewhat fuzzy brain gave up the struggle and fell to sleep despite the difficulties.

The Sunday was a bright and clear day, or at least at the start. I busied myself with the normal comings and goings of existence until around about half twelve. I had arranged to chat to a close friend on the internet. Only problem was, when I finally did so, my voice had changed. Not substantially, not hugely, but definitely changed.

My initial reaction was that I was coming down with the symptoms of one of those annoyingly slowly developing colds that I seem to be a victim to every couple of years. Monday was fine though, even pleasant as I recall, no obvious symptoms but…..Tuesday….I got out of bed for an hour and promptly got back in again!

I seemed tired beyond belief and yet I could not think why that should be the case. I slept until early afternoon, got up for a couple of hours and promptly slept again! I had planned to go out for some coffee based chatting and general all round socialising but my lack of energy made the prospect much less inviting than would normally be the case.

Angela, the lass who was staying with me at the time, was due to go to London on the Wednesday and so, despite feeling a tad fragile, I found myself at the centre of our great metropolis enjoying a mug of Starbuck’s coffee in Great Russell Street. I seemed to feel relatively good although still aware that I had some kind of bug. We took the hydrofoil down to Greenwich and enjoyed a rather copious but very tasty (and reasonably priced) Chinese curry at Tai Won Mein.

The next day, Thursday morning, I treated myself to a hearty bowl of oats only to find it disagreeing with me. It felt a little like indigestion but was more in the chest than the stomach. Angela had not risen from her pit at that time and so I was just checking e mails and such like when I became aware of just how uncomfortable I was feeling. I tried shifting position, laying down across the couch, turning around the other way but… nothing I did seemed to stop this discomfort.

I returned to bed to try to sleep it off but throughout the day I experienced an ever present discomfort. It seems strange now, looking back at it, that I did not understand what was happening to me. I think many of us share a common tendency in such a situation, namely to rationalise the obvious with more banal explanations.

That evening, at around seven, I was due to dine out with several friends at The Castle in Woodford Green but the feeling was now quite oppressive, so oppressive in fact that I thought it wise to forego the culinary pleasures of a Harvester and instead just take it easy at home.

At around eight that evening a friend of mine, Keith, rang and began what was planned to be a long and in depth conversation about life, the universe and everything. Keith is a modest guy but often has some very interesting and challenging views. They are usually couched in polite and non-combative language but can be quite surprising all the same. Normally, I enjoy the pleasures of ruminating on various issues with him but, on this occasion, the more he spoke the more uncomfortable I felt. My chest was getting tighter and tighter and it was becoming progressively harder to breathe.

After a couple of minutes the cold sweats started. The beads were running down my face and off the end of my nose. I felt terrible. So terrible in fact that it was becoming obvious, even to me, what was happening.

“Keith, excuse me, sorry for interrupting but I am not feeling so great. Could you call again in half an hour and, if I don’t pick up, call an ambulance?”

Keith was a little shocked but agreed to comply. As I put the phone down I was feeling worse by the second. ‘This is madness,’ I thought to myself, ‘if you are feeling that unwell then you should be phoning for an ambulance yourself!’

The operator at the other end of the line was efficient, advising me to leave the front door open (very wise) but then not to do anything at all. I unlatched the door but thinking I may be detained sometime, dragged my body upstairs to collect a kindle and a mobile phone. Fourteen steps…..felt like the side of a mountain! By the time I returned to sit on the next to bottom step I could hardly breathe at all and the world was beginning to disappear into yellow and black blobs.

The ambulance was prompt thankfully and within a minute or two I was ensconced in the back with an oxygen mask over my mouth and nose. The crew were chatty, bright and optimistic, almost annoyingly so, but they did a good job.

“We don’t think you’re having a heart attack’” I was informed reassuringly. Funny, I was pretty sure I was. The taste of the oxygen was just a little unpleasant, almost unnatural. One feels like taking the mask off and gulping great lungfuls of good, fresh air but….even in the somewhat confused state I found myself in I realised that this was not a good idea.

On reaching A & E I was rushed into the resus (resuscitation) unit. My skin was punctured in various ways, samples were taken and questions asked. Funny how, when one’s mortality is starkly revealed, everything becomes more precious. Looking around, I was aware of wanting to see every detail, to take it all in. If this was to be the last of my life I wanted, even in that situation, to live it well.

After a while, all such thoughts were put to one side as morphine was injected into my arm and I slipped softly into a kind of gentle oblivion, still conscious but, to a large extent, out of pain. Oddly, I remember finding the voluptuous curves of the young female doctor particularly attractive at this point. It seems that even at such moments in a man’s life some instincts remain fully intact.

I was assigned to the main cardiac ward , Elizabeth, at Whipps Cross Hospital. My bed was located close to the nurse’s station and, during the night, I would listen to snippets of their conversation, hanging onto normality, whilst also being aware of the rhythmic and high pitched beep of the apparatus that was constantly monitoring me. Every now and again it would emit a shriller tone and red lights would flash. My heart rate in particular seemed very inconsistent. At one moment, as I endeavoured to relax, it would be around 65 and the next, responding to the slightest of movements, it would shoot up to 130 or so. I remember feeling that this was of some concern at the time…

In the morning I was greeted with seemingly good news: “The test results came back and they were positive.” ‘Good,’ I thought, ‘Nice to know they were positive, I wonder what was happening to me then?’

“Yes,” the nurse went on to affirm, “they were positive. You have had a heart attack!”