The Heart Healers Read Online Free Page B

started by resting both hands gently on her arm as I palpated her radial pulse. “Laying on of hands” speaks without words. It says I understand your unspoken anxiety. It recalls a parent’s touch that says, “I’m here to take care of you.” Greta’s pulses were all normal. By finding the tap of her heart on her chest wall, I determined that her heart size was normal. Listening with my stethoscope, I heard her heart valves closing normally, with no heart murmur and normal breathing sounds. With a normal heart size, no murmurs, and no evidence of heart failure, I was confident that congenital and valvular was not the cause of her pain and heart muscle disease was unlikely. That left the coronary arteries. Most people with undiagnosed CAD, like Greta, have a normal physical exam. Greta’s history and physical exam brought us face-to-face with the ultimate uncertainty, a 50/50 coin flip about CAD. So we would need a test.
    Now I had choices. I could recommend either an exercise stress test, or even the definitive test, a coronary angiogram. Because an angiogram is expensive and invasive, I chose a stress test. There is no “right” choice, but this one cost a lot less, and it was immediately available.
    The stress test was distinctly abnormal. In her brief visit, Greta’s probability of having CAD had skyrocketed from less than 1% to perhaps 90%. For Greta, a nagging unease over a morning cup of coffee was about to ramp up into a pounding anxiety, like a powerful migraine that obliterated every other thought. The diagnosis of CAD with its sinister implications would be a stunning, life-changing, shattering event.
    CAD is due to deposits of fat in blood vessels (called plaques or atheromas). Large ones impede the blood flow particularly when the heart needs more oxygen during exercise or emotional stress. Like all muscles deprived of oxygen, the heart sends a pain signal to the brain. When the need for oxygen diminishes, the pain disappears. So, like Greta’s chest pain, typical angina is directly behind the chest, precipitated by stress, and disappears within a minute of termination of the stress. Atheromas create two life-threatening risks. They can cause abnormal heart rhythms, including ventricular fibrillation and sudden death. Rapid complete obstruction of a coronary artery by an atheroma causes heart muscle to die (a heart attack or myocardial infarction).
    I was taught in medical school that people under thirty-five seldom contemplate their own mortality. Yet this would be Greta’s fate this afternoon. How do I tell a thirty-five-year-old mother that she has life-threatening disease that needs immediate attention, when she has never before been sick? I plodded back to talk with Greta, wondering how my sympathy could possibly match her struggle to absorb this personal tragedy. I stopped by the waiting room to ask Tyler to join me. He jumped to his feet with an expectant smile. We locked eyes; his smile vanished as I said simply, “Please join us.” As I ushered Tyler in ahead of me, I took a deep breath, and closed the door. I drew my chair from behind my desk to sit beside Greta and Tyler. “Greta,” I began, “let me show you what we found.” I showed them the ECG. I knew that neither was trained to interpret what they were looking at, but I felt Greta and Tyler needed assurance that specific, objective information provided a foundation for her diagnosis. Allowing Greta to focus on a piece of paper rather than blurting out the dreadful news directly could give her just a little more emotional space and time; a cushion, however small, for her psychic turmoil.
    “What’s the next step?” she asked after they had seen the test results. My reply was shaped by uncertainty, cardiology’s loyal twenty-first-century companion. We had solved the uncertainty of Greta’s diagnosis, only to arrive at a new one. In Edgar Allan Poe’s famous 1843 Gothic short story “The Tell-Tale Heart,” a murderer is