The Understanding Heart.

By George:

While the events chronicled here are absolutely factual, the names of the doctors have been redacted for obvious reasons

Monday, May 7^th - I looked up from my work, glanced at my watch and realized that I had ten minutes to catch my usual train home from the hospital where I work.  I quickly grabbed my stuff, put my computer to sleep, and bid my coworkers goodnight.  Since the downhill walk to the train is about 8 minutes, I was not too concerned; still I didn't saunter along, but proceeded with alacrity.

Arriving at the train station I noticed that my heart was racing, and I was puzzled because I didn't think that I was walking that fast.  The train arrived and I got on, figuring I just needed a little rest to get my heart back to normal.  I sat by the window staring at the passing scenery, feeling the unusual staccato pounding unabated in my chest. I took my pulse and it was racing at 155 beats a minute.  Having been a paramedic in my younger days, I had an idea of what was happening, but I was not ready to admit it to myself.  When I got off the train some 50 minutes later, the manic drummer was still pounding its incessant beat.

My wife was waiting at the station as usual, and during the short trip home I was mulling my options.  When she announced that she was going out to do some shopping with her friends and my pulse was still racing, I asked her to do me favor and drive me back to the hospital first.  I explained what was happening, but instead of driving me, she called the local ambulance corps who showed up with a paramedic on board.  

The paramedic slapped the EKG leads on me and verified my suspicion that I was indeed in atrial fibrillation (a-fib).  Protocol called for an IV and 20mg of Cardizem slow push.  I said OK, and by the time we arrived at the Emergency Room, my heart was back in normal (sinus) rhythm.  In the emergency room about a half dozen doctors checked out my neurological responses, took some blood tests, and eventually determined that everything seemed to be perfectly normal.

Although the ER doctors wanted to keep me for observation and additional tests for another 3 hours, I opted to go home.

A few days later we made an appointment with my cardiologist to try to figure out what happened to me, and above all, why?  My doctor’s associate saw me, and after examination he found nothing wrong.  He gave me scripts to have an Echo Cardiogram and a Nuclear Stress Test done, and to wear a Holter Monitor for a day.  Great, now we'll find out what is wrong.  He said that he is giving me Heparin to thin my blood because I am at risk for a stroke, but I countered that my blood is thin enough because I am taking aspirin, Vitamin E, Fish Oil and Ginkgo daily, all of which thin the blood.  Still my analytical mind wanted to know why it happened, and I asked the question.  He told me that we may never know why, but we'll treat it with medication.   I asked him "Could it be that it was caused by...", but never got to finish my sentence before the doctor held up a hand and said, "Stop.  Whatever you will tell me will be wrong."  Not exactly the right attitude to hit me with, and it resulted in me giving him a lecture on how throughout my whole life I always had to diagnose my own illnesses, because the doctors either didn't believe I was sick, or made the wrong diagnoses.

Thursday, May 17th – All the cardiac test were completed, and since I was at this time coughing up my lungs, I also went to my Primary Care doctor for a checkup.  He diagnosed a case of bronchitis so he gave me the stronger antibiotic Levoquin instead of Zithromax.  Went home, took the Levoquin and hit the sack.

At 1:36am I awoke and decided to make a pit stop.  I quickly sat up in bed, put my feet on the floor, but before I had a chance to stand up, the pictures on the wall turned psychedelic and there was no up or down.  Fighting nausea, I tried to find the bed so I can lie down, and having finally found it, I cocooned myself and tried to stop the swirling.  I told my frantically concerned wife that I had a major case of Vertigo and it wasn’t getting any better.  So for the second time in less than a week, she summoned the local Ambulance Corps.  They put me on a "stair chair" and carried me to the ambulance, but not before I did something I haven't done for at least 40 years.  I barfed.  And just to be consistent, I repeated it shortly after arrival to the Emergency Room.

After examination and tests by the ER doctor, the parade of "specialists" started.  Cardiologist, Neurologist, Electro Physiologist, the guy who empties the trash and God only knows who else.  Consensus ran toward the Vertigo having been caused by my taking the Levoquin, so they changed my antibiotic to Zithromax. They gave me a few doses of anti-vertigo medication, and when that didn't relieve the vertigo, I was admitted to the hospital for observation.  Spent a restful Saturday under the wonderful care of the nursing staff and my empathic wife, but still the only way I could make the ten step trip to the bathroom was by desperately hugging the IV pole.  By Saturday night I was able to walk the hallways unassisted, albeit reeling like a happy drunkard after a night of reveling.  That was good enough for me to get discharged, and we returned home.

 A few days later we revisited my cardiologist to receive the verdict on my tests of the previous week.  All were fine, showing no damage to my heart.   He stopped me from taking the last dose of the Zithromax because it was not good for my heart.  In addition, he told me to keep away from antihistamines to for the same reason, which eliminated all medication usually prescribed for Vertigo.  Since I was still doing a great "drunken" imitation walking, I asked him what I could do about my vertigo (which my research told me was BPV).  He gave me the name of a good ENT (Ear, Nose, Throat) doctor, who upon examination agreed with my diagnosis, and told me that it will take 4 to 6 weeks for my body to acclimate to the vertigo, which it later did.  

Since my cardiologist had suggested that a neurologist examine me to make sure that I didn’t suffer a stroke, I consulted a neurologist who sent me for a brain MRI. The MRI results showed my brain to be perfect (in spite of what my Liberal friends keep telling me).

By the end of June my body has adapted to the vertigo, and life has returned to normal.  I had resumed my uphill walks from the railroad station to my office, weather permitting.  On a sunny Tuesday morning, I hopped off the train, glanced towards my waiting shuttle bus, and decided to walk to work. About a block and a half later, I suddenly felt my heart switch gears into the trotting cadence of atrial-fibrillation.  I tried to judge the most prudent choice between returning to the shuttle bus or plodding slowly uphill to the hospital, and I decided on a slow trek onward. When I reached the next street and waited to cross, one of my coworkers pulled up and offered me a ride.  (Hmmm.. Very interesting since in all my years of walking to work, no one ever stopped to offer me a ride, and my coworker told me that this is the first time he ever picked anyone up.)  Gratefully I accepted, and he dropped me off at my office. I sat at my desk for a while, but eventually I called a doctor friend at the Emergency Room, and told him that I’ll meet him there in ten minutes.  I walked to the ER, was admitted, and told my friend that I had a-fib and needed 20mg of Cardizem slow push.  He verified my claim with an EKG, and gave me the Cardizem.  When I told him that I’d be fine in 20 minutes, he smiled knowingly and said he didn’t think so and most likely I’ll be admitted to the hospital.  He returned 25 minutes later, glanced at my monitor showing a normal sinus rhythm, and asked incredulously “Did you will yourself back into normal rhythm?”  I gave him an “I told you so” grin, and asked him if he had any idea why my pulse rate was straddling 50, instead of my usual 60?  He said that it was normal as long as it didn’t cause me any negative symptoms.  I thanked him, decided to take the day off and went home with my wife.

This time the return to normalcy was lagging, because periodically any movement that was jarring to my body, caused my heart to flutter and skip a few beats.  In addition, there was also the feeling of tightness in my chest from time to time. As these feelings persisted for an additional day, I reluctantly called my cardiologist, only to find that the office was closed for the day with just one doctor “on call” in the hospital.  I had him paged twice to no avail.  Growing more desperate, I called my neurologist, who sent me to see his own cardiologist.  After this surrogate cardiologist examined me and listened to my complaints, he suggested that I check myself into the hospital immediately for an angiogram.  As we left his office, my mind was awhirl.  This whole thing was escalating out of control.  I tried to reach my cardiologist one more time, and this time his associate called me back.  I related to him what has been happening and what the doctor has just set up for me to do, and he said that he himself would do the angiogram for me tomorrow morning.  I agreed, and my wife drove me directly back to the hospital to be admitted and prepared for the procedure.

After a night of thinning my blood with a heparin drip, I was ready for the procedure. My doctor pointed out to me that while he is checking for blockages in the arteries, he would immediately put in a stent if he does find one.  He wanted to make sure that I realized that if that were the case, I would have to be taking medications in spite of my stubborn reluctance to do so.  I acquiesced, so he jabbed a giant needle into my femoral artery (ouch).  The procedure took about 30 minutes, and when it was done, I was still “stent”less.  It seems that he didn’t find anything warranting intervention.  As I walked out of the hospital that Friday afternoon, I felt great both mentally and physically.  Not only was my mind relieved, but also all my previous symptoms were gone.

Two weeks later when my regular cardiologist returned from his extended vacation, I was there for checkup and chat.  He reviewed the charts, read the angiogram report and gave me his verdict.  He can’t put me on a Beta-Blocker because of my slow heartbeat, but since my cholesterol was borderline high and the angiogram did show a few small lesions, his solution was to put me on a statin drug, which he admitted that I would have to take for the rest of my life.  I asked why couldn't I simply reduce the cholesterol with just diet and exercise?  His brusque reply was "It won't work and my recommendation is the statin, but you do what you want."  I chose the "what you want".  Determined to get my body back into shape, I asked him for a note so I can rejoin the gym.  He did better than that, by giving me a note to start Cardiac Rehab, which is a gym paid for by my insurance.  Before leaving I asked my question.  Why is this suddenly happening now?  The answer once again was “Don’t know, but we can treat it.”

My wife started me on the Mediterranean Diet, and I started getting used to grazing in the salad pastures.  Fortunately, putting avocados into the salad, drowning it in olive oil and sprinkling it with salt and cayenne pepper, makes it actually taste good.  No alcohol, no coffee, no cake, minimum of meats, minimum of breads and pastas, lots of fish, vegetables and fruits, and suddenly I then understood why the word diet starts with the letters “die”.  What kind of life can you have without cake, coffee and alcohol?  But man learns to adjust.  Other than the diet, I returned to normal life and started looking forward to having our grandchildren (and our daughter) visiting us for two weeks.  Still had periods of irregular heartbeat, but it seemed like I always had it, so it didn’t bother me.

In the interim, my wife convinced me to visit her doctor who is “brilliant”, and we went.  I appreciated the fact that the doctor was actually taking time to try to figure out what was wrong with me and what could have caused it.  She sent me for quite a few blood tests to try to determine.  In the lab they drew 16 vials of blood, and I was wondering if I had enough blood left to make it back to my desk.  Later when the lab results came back, I was elated to note that everything was fine, and my cholesterol had dropped to the bottom half of the normal range with only one month of diet and exercise.

The Saturday preceding the arrival of the grandchildren, my wife and I were basking in the anticipation of the arrival of the 3 boys, whom we haven’t seen in person for over a year.  After the Sabbath meal, I retired for an afternoon nap with a smile on my face.  My wife woke me in time for Mincha (the afternoon prayer service), and as I was getting ready, my heart was pounding an irregular beat.  I proceeded to the Synagogue just a few houses down the street, but about halfway through the services I felt my heartbeat switch to the dreaded a-fib.  I went home and told my wife to make the call.  The paramedics arrived, verified the EKG, and administered the Cardizem as an IV drip.  By the time we arrived at the ER, my heartbeat was normal.  The ER staff went through the perfunctory motions by now, told me to go see an Electro Physiologist (EP) as per my cardiologist, then released me to await pickup.  Called Doctor S., the most recommended EP, but he was not available until after Labor Day.  Managed to get an appointment with his partner for a week earlier.

The grandchildren arrived, and the first week flew by as we bonded.  My plan was to take a vacation day while the kids were here, and I chose Tuesday of the second week to spend the day with them.  I awoke early on Tuesday morning to shower and catch the early Synagogue prayer service, so by the time the kids get up, I’ll be all ready for them.  My plans were slightly derailed, because my heart was once again irregular and pounding.  I quickly showered, said my prayers at home, then woke my wife and asked her to drive me to the ER.  This time we’ll nip it in the bud, and I’ll be back home before the kids are up and ready.  My wife was frantic, but she managed the drive to the hospital without getting us killed or arrested.  By the time I was registered and placed in a bed, I was in a-fib.

By now my wife was an old pro at this.  She started giving orders to the ER doctor. Give him 20mg Cardizem slow push.  Why is his blood pressure so high?  Why is this taking so long?  The ER doctor was understanding, but a little rattled by the incessant questioning.  When 15 minutes later the a-fib hadn’t reverted and my wife’s concerns were apparent, he gave me an additional 25mg of Cardizem.  This did the trick, and more.  Back to normal rhythm, but the heartbeat down to about 40.  That took care of my early release, since they would not release me with such slow heartbeat.  I insisted on seeing an EP while I was waiting, and after a four-hour wait it was Dr. S. who arrived.  He scanned my chart and made his pronouncement. A pacemaker would not really help me avoid a-fib, so he recommended an anti-arrhythmic drug that might help me.  I would have to be admitted to the hospital for 3 days and be under observation while starting the medication(, since some people are actually harmed by this drug).  He didn’t actually tell me the last part, but I looked it up later on the Web.  Told him we’ll let him know what we decide.  I asked the ER doctor why they don’t just give me Cardizem to have at home, so I can take it myself if I feel something coming on.  He thought it was a great idea and wrote out a script.  My daughter brought the children to visit me in the ER, but by then I was ready to leave.  Of course my plans with the kids were shot, but we managed to get some quality time together nevertheless.

Next day at work I happened to bump into the CFO of the hospital in the hallway. Having been aware of my health issues since he is also a good friend, he asked me how I was feeling.  I brought him up to date in a few sentences, and he asked me if I have been to see Dr. T.?  I said that it didn’t occur to me to go see the hospital’s Chief of Cardiology.  He told me to go see him because he is a “savant”.  I thanked him, returned to my desk and called Dr. T.’s office.  He was in a meeting, but his nurse interrupted the meeting to relate my case to him and he instructed me to see a different EP before coming to see him.  (It was much later that I found out that my friendly CFO had already told him to expect my call.) I then called the recommended EP for an appointment, and managed to pull enough strings to be able to see him first thing in the morning.

I was at the EP’s office on time, but had to wait a while until the doctor showed up to open the door.  Filled out all the forms for the umpteenth time, got a couple of EKGs and was examined by the doctor.  His assessment was that the Anti-Arrhythmic medication is not good for me, what I need is a pacemaker.  Great!  Two EPs give me two diametrically opposed solutions.  I told him that I wanted to see Dr. T. before making a decision, and he picked up the phone, dialed Dr. T.’s number and got me an appointment for the following Wednesday.  I thanked him, got dressed and got ready to leave, when I got a call from Dr. T.’s secretary.  She said that Dr. T. just got a cancellation, and could I be there in a half hour.  I replied that I could be there in five minutes since I was right next door.

Dr. T.’s examination was short but thorough.  By the time he saw me, he was already fully familiar with my chart, judging by the questions he asked.  When he was done with the exam, we adjourned to his office to discuss my options.  I told him about the two different solutions I received from the two EPs, and he smiled. “What do you want me to do?  Play Solomon?”  He told us that the easiest way to treat my problem is to implant a Pacemaker to increase my heart rate, and then give me a Beta-Blocker to prevent the a-fib.  However, being aware of my extreme resistance to invasive procedures and taking medication for the long term, he was willing to start with something else.  First he challenged me to improve my cholesterol numbers even further.  I promised I would.  He then reviewed the medications and supplements I was taking, and I listed them all.  He evaluated them one by one.

“How much Aspirin?”  I replied with 325Mg.
“Good – how much Vitamin A?”    “10,000.”
“Good – how much Vitamin D?”  “3000.”
“Too much, cut it down to 1000 – how much Vitamin E?”  “400IU”
“Good, but you have to take Vitamin C with it to help it work properly.”

When we got to the Ginkgo, he looked up and said, “Are you aware that studies now show that Ginkgo Biloba can cause you to have a-fib?”  It took a few moments to absorb what he said, and then I asked him if he is telling us that my taking the Ginkgo could possibly cause all my problems?  He smiled and said that he wanted me to stop the Ginkgo, modify the other supplements per his recommendations, and he gave me a trace amount of Inderal to prevent the arrhythmias.  He suggested that I try Meditation as an additional mind/body control, and he also assented to become my regular cardiologist.  We thanked him profusely and I returned to work.

It is now four weeks later.  The grandchildren are back home, the house is once again quiet, I have gotten to enjoy the “diet” (though I miss my Friday night Kiddush wine), and with the Ginkgo removed from my vitamin regimen, the intensity and frequency of the flutters and the skipped heartbeats have slowly abated. 

I am cautiously optimistic, but at the same time seriously realistic.  Four weeks do not prove that we have solved the problem, but I am eating healthy, losing weight and working out. 

Yes, I still have a long road ahead of me, but I am sure of a positive resolution. Throughout this narrative you might have noticed many lucky coincidences, which in reality are nothing more than manifestations of God’s guiding hand.  And although it’s scary to think that I might have chosen an irreversible alternate treatment, in hindsight I can see the path that God charted to shepherd me to my inevitable destination.

PostScript

It is now nine months since I finished documenting this medical adventure, and an update is in order to disseminate some interesting developments brought on by my research and self-diagnosis.

At this point I am confident of the fact that Gingko was not the cause of my recurrent episodes of A-fib.  I base this statement on the fact, that since that diagnosis was made, I have had recurrences, two of which were Emergency Room visits, and a few that I treated at home with medication I had acquired from the E.R. physician. While there is still a possibility that some off-brand doses of Gingko may have acted as a catalyst at the inception, I now believe that I have correctly determined the actual cause of my problem.

During my latter E.R. visits and subsequent discussions with my physician and specialist, I kept insisting that the problem seems to be related to my stomach, because most of the episodes seem to be following a heavy meal.  Alternatively, perhaps there is something else impinging on the heart, the proximation of which could be effected by a distended stomach.  This theory was also bolstered by the fact that if something, such as a bag strap or even my arm, applied a light pressure to the left side of my chest just below the ribcage while I was walking, I would start to experience skipped heartbeats.  But in spite of my plaintive queries, my hypothesis and concerns were marginalized.

By now you probably realize that I am not one to sublimate my logical analysis in the face of professional disinterest, so I sought out the most recommended Gastro Intestinal (GI) physician and requested an examination of my stomach and its environs.  He performed  an abdominal sonogram, and an endoscopic exam.  Results were unremarkable, with the exception of a slight inflammation of the esophagus and stomach linings and a slight case of hiatal hernia.  The doctor prescribed some over-the-counter Pepcid to counteract the irritant effect of the daily aspirin I am taking, and dismissed the hiatal hernia as something not to be concerned about unless it gets worse. I was relieved, but intrigued.

After mulling it over for a few days, my logic told me that my a-fib problem had to be related to the hiatal hernia in some way.  Keying the term "hiatal hernia a-fib" into the Google search engine inundated me with references that showed the existence of a connection between the two. 

I further verified my findings by acting to forestall any more a-fib attacks. From experience I have found that bending forward, slouching or laying down while experiencing stomach distention, would trigger the arrhythmia, while repositioning myself to the straight vertical position would stop it. Those times when I have eaten more than I should have and started experiencing the arrhythmic precursor of Atrial Fibrillation, I would immediately straighten my posture to short circuit the trigger mechanism.  

The only question that still perturbed me was the reason for my first a-fib attack.  It was not caused by walking after a full meal, because the most I had before leaving work was a quick snack.  So what set it off?  It took a lot of thinking, and then it hit me.  Instead of carrying an attache case to work like others were doing, I used to carry my stuff in a knapsack on my back.  My wife surprised me by buying me a nice bag that also has a shoulder strap.  I switched from the knapsack to the bag, which I would sling over my shoulder with the strap across my chest.  The strap would sometimes be resting on the left side of my chest, on the area under my ribcage.  It was this pressure while walking that triggered the first, and probably some of the other attacks.  I have subsequently verified that the strap across the chest while walking, will start the arrhythmia.

By now I am relatively sure that I nailed down the cause, because I have not had any a-fib for about a year.  All that remains to be done is to convince my doctors, and formulate a course of action. I also believe that I found a way to "repair" my hiatal hernia, though that will require another trip to the GI guy for verification.  I will provide updates as events unfold.