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There are two sources that fool us into thinking we are ill with angina and, perhaps, an impending heart attack. The first source is our stomachs—the gut tricks us into believing our heart is malfunctioning physiologically. The second source is our minds—we trick ourselves into believing we’re sick psychologically. Both are symptomatic of something wrong, but not, necessarily, a heart ailment. Often the two states go hand-in-hand; other times, they don’t. In either case, we may be on the cusp of a myocardial infarction and call an ambulance. But it’s probably truer that we are not ill: feelings and sensations mislead us.
Heart patients learn quickly what angina is. Web MD reminds us that angina comes on as any combination of lightheadedness, dizziness, fatigue, shortness of breath, indigestion, and chest pain. In men especially, the feeling is constrictive and heavy, the three-hundred-pound sumo wrestler sitting on your chest, an ache that pulses and radiates—the rollercoaster wobble and dive is the worst—in your neck, shoulders, arms, throat, or jaw.
Pain worried away, or that passes on its own, is labeled stable angina (angina pectoris). If there’s no response to rest, it’s unstable—a true emergency. The stable kind of angina, like a child’s nightmare, can be soothed and forgotten. The unstable kind shrieks for help. A real heart attack doesn’t just pop on, ache like hell for a while, then pop off. It can build over time, a day or a weekend, the grimacing feeling an unmistakable sign. (When a heart attack is truly sudden, it’s cardiac arrest: the fate of James Gandolfini where, mercifully, he went fast; there was probably no way, alone and in a hotel room, for help to have arrived soon enough to save him.)
Thus, there’s a DMZ where angina roams, taking its time to declare its motives. This is where psychological and physical symptoms cohabit. Who wants to believe you’re having a heart attack if you’ve never had one? You’re disinclined to think it’s the Big One if you’ve endured chest tightness and stomach indigestion other times in the past—and, after rest, such symptoms have left.
The physiological problem can be as simple as heartburn. Even that word is misleading: the heart is not burning, the esophagus is—that foul, burped, rag-and-bone smell of an acidic stomach. (The Maximum Strength Pepcid AC package states: “Heartburn with lightheadedness, sweating, or dizziness may not be heartburn. It may be a sign of a more serious condition.” Nicely vague, isn’t it.) The burning reason is that the esophagus curls around the trachea and touches the aorta. Nature bundles our core indeed.
Either angina is agitating the aorta and infecting the esophagus/trachea, or reflux is annoying the aorta and portending cardiac distress. Differentiate them if you can. Misdiagnosing angina as heartburn can be fatal. The one key turn that heart patients learn to identify: with reflux, there’s no sweating; with angina, there’s sweating.
The psychological element is inscrutable. The numbers are astounding: five million people each year go to the emergency room with chest pains; ten percent are actually having a myocardial infarction. What complicates this further is that of those who do have a heart attack, twenty-five percent are asymptomatic—and so never make it to the ER. Thus, there’s a strange simultaneity: most people with symptoms think they’re heart-ailing when they’re not and a sizeable number of those most vulnerable won’t even get to have that false alarm.
So be careful, those who have symptoms: Chest pain can be a sign of pneumonia or pleurisy. The jitters, indigestion, and a pounding heart rate (palpitations) may be a panic attack, not heart trouble. Perhaps you’ve raised your blood pressure and heart rate to a worrisomely high level—because, what? You’re in love, you’re hiking at 8,000 feet, you’ve been in a traffic accident, or your kid did not graduate from high school? You fear some switch in your operational center has shut down—but it’s probably not a clogged artery, despite your feeling of oncoming doom.
Is this a false adaptation, believing the end is nigh and we need an ambulance? One thing’s for sure: many websites and heart-savvy pamphlets declare that “if you think you’re having chest pains, call 911.” The greater availability of emergency wards and fully-equipped first-responders means that we will, we do, use them just like new lanes added to city freeways. And who can blame us. No one wants to wrongly self-diagnosis; few want to be Mr. Heroic and gut it out, which, sadly, is the case for some men who reason that with willpower they can outlast the pain as though it’s a hangover or a hangnail.
The major downside of this availability-upside is malingering, the opposite of the male wish-it-away response. I love this definition in the Gale Encyclopedia of Mental Disorders: malingering, “the act of intentionally feigning or exaggerating physical or psychological symptoms for personal gain.” Sounds rather tawdry—like an adolescent faking sick (cough, cough) to an anxious mother to get out of an algebra test.
As an adult, to whom are you feigning or exaggerating? Your family because you want them to pay attention to you? Your doctor or clinic because such querulousness gets them to take your complaints seriously? “Personal gain” is troubling because when you malinger (and millions upon millions do), you bind the wrists of the emergency staff with your histrionic handcuffs much like the boy who cried wolf.
Yet, again, I wonder whether we will—as we evolve in the West with trigger-point technologies that may soon, based on enzyme levels in the blood, alert our cardiologists remotely and we’ll be rushed in and saved (all at great expense)—give up our ability to self-diagnosis reliably. It may be, evolutionarily, a good thing to err on the side of overreaction; it does save one in ten. Even for the ninety percent who fake an illness or present false symptoms (and both of these can feel as real as the real thing), these are signs that something’s wrong with the person—perhaps more psychological than physical.
Finally, all this is re-informed by a late September essay in the Sunday Review of The New York Times, “The Woman’s Heart Attack.” The writer’s conclusion, based on her case and study, is that women have a broader range of symptoms, in kind, severity, and bodily location, than men do. What’s more, men typically have sharp chest pain while women experience nausea, a strange new fatigue, insomnia, and a much slower onset of the attack. The other shock is gender bias: Women and heart disease have been ignored and understudied, and often viewed by the medical establishment as having mental, not bodily, symptoms of a disease—it’s all in their minds or it’s pure malingering.
The difficulty is that some women have taken this on as their role, making it that much harder for them to know and to tell their doctors when they are truly sick.
