I suspect I am having a heart attack when I leave the ice after a hard shift. We are defending the blue line in a one-goal game. My breath is shallow, and I pull breaths through a clamping pain below my sternum. It doesn’t feel like indigestion; the pain doesn’t move.

I reach the bench and sit, head resting in my hands, shifting positions, trying to move the pain. “Are you okay?” Lots of pain,” I say, “in my chest.” “Breathe. Take it easy.” A few of the guys hover over me. “Someone needs to drive me to the hospital,” I gasp. There is a flurry of activity; someone brings a blanket, and I lay on the concrete under the bench. Todd, the arena manager, arrives out of nowhere, and a teammate gives me an aspirin. “I’ve called 911,” Todd says, “they’re on the way.”

I am conscious, but my awareness is confined to the unrelenting tightness in my chest. I have time to think, almost too casually, that I might be dying and never again have a chance to see my grandchildren. I am not anxious at the thought nor sad; the thought arises like a statement of cold logic and fact. I’m having a heart attack.

The fire safety crew and paramedics arrive and clear a space in the narrow confines of the bench. An attractive, athletic female paramedic straddles me and announces, “Let’s cut this jersey off.” “Not in your life!” I say through the pain and begin lifting my arms to remove it. The jersey connects me to the team and the game’s spirit. Someone helps get the jersey and shoulder pads over my head, and leads are connected to my chest, attaching me to a machine that reads my heart’s function. After helping me onto the waiting gurney, the paramedic tells me, “You are having a heart attack.” And I am relieved. The pain is accurate, and my interruption of the game’s flow is justified. “We’ll take you to the cardiac care unit at St. Mary’s Hospital.”
  
Heart disease is the second leading cause of death among Canadians, and cancer is the leading cause. Twelve people over twenty die each hour from heart disease in Canada. Most will die of ischemic heart disease when the heart is deprived of blood by a blockage caused by plaque buildup in the coronary arteries. This is what is meant by coronary heart disease.

Coronary heart disease is gendered. Men are twice as likely to die from a heart attack than women. They are also expected to be diagnosed with heart disease ten years earlier than women, perhaps because heart attack symptoms differ for women, presenting as flue-like symptoms rather than full-on pain or tightness in the chest. Men are more likely to die from coronary heart disease than women are, and at an earlier age.

Besides being male, other factors increase the risk of death by heart attack. These include medical risks such as high blood pressure, diabetes and high cholesterol. There are also lifestyle risks like unhealthy weight, alcohol and recreational drug use, lack of exercise, smoking, unhealthy diet, and stress. Other risks like age, sex, family history and ethnicity are uncontrollable. These risks are outlined in a detailed pamphlet called “Living Well with Heart Disease” that they give you when you are recovering in the hospital. Good reading to help assess where you went wrong and things you might have done differently.
 
I am an active sixty-eight-year-old man. I play hockey twice weekly. I ride my bike in commutable weather, hike for two hours each week with other seniors older than me and try to keep up, take regular walks with my partner and go on long canoe trips each summer. I eat well. I have a sweet tooth, but my diet is reasonable. I limit the red meat I consume, try to find plant-based protein sources, and include lots of vegetables and fruit on my plate. My Body Mass Index is 23; I actively work to keep my weight regular because extra weight shows on my petite frame. My cholesterol is within the high-normal range.
In sum, before my heart attack, I was doing pretty much what I should have done if I had followed the book to a tee. Like many, I have been listening to the repeated warning signs ad nauseam on living a healthier and more productive life. So, where did I go wrong? Really wrong!

My doctor told me when I met with him a week after my impromptu visit to the cardiac care unit that my chances of surviving after the hockey game were fifty-fifty. Several fortuitous events improved my survival odds. I was in the arena; people knew what to do (Todd’s quick call to 911 and the aspirin were lifesavers). Within a short time, the cardiac surgeon removed a large blood clot from my right coronary artery via a catheter in my right arm. That night I was in the right place, surrounded by people who were able to help.
 
My father was a kind of reverse role model for me on how to live with a heart condition. Like him, I was born with a congenital heart defect. I was born with a ventricular septal defect, a hole in the heart corrected through surgery when I was a young child. A defect unrelated to my current emergency, although I worry that the heart attack may have implications for a weakened heart in the future. My dad’s heart troubles differed, but I grew up knowing my heart was vulnerable. Despite this awareness, I copied my father in at least one of his bad habits. I started smoking at age eighteen and didn’t quit until I was thirty-one. It took my father a bit longer.

My dad was an angry alcoholic. He was in his forties when he suffered his first heart attack and subsequent warning from his doctor. When the second heart attack happened a year or two later, the doctor told him, “If you are going to keep smoking and drinking, you needn’t come back to see me. You will die.” My father was scared enough to quit both habits, cold turkey, to turn his life around and live another fifteen years.

His final and fatal heart attack occurred two days after the last time I saw him. In 1990 he came for a visit on my son’s second birthday. He had retired a few years earlier to North Wales and had bought a home on the coast, below the Snowdon range. The day after the visit, on March 14, my aunt Eileen and a neighbour called to let him know that the storms had breached the sea wall at Towyn and had flooded the lowlands between there and Kinmel Bay. His retirement home was underwater. He and his wife prepared to fly home on the 15th. While waiting to board the plane at Pearson Airport in Toronto, he suffered a major heart attack and died before reaching the hospital.

I don’t remember my father as a happy man. He lived with a depth of pain I never understood. He was gregarious and had plenty of “mates” with whom he was all too willing to spend time drinking. He’d spend his weekends, starting Friday night, at Duffy’s Tavern, and when the spirit overtook him came home to his family. He’d be hostile when questioned about his drinking and usually retreated when my mother badgered him about where he’d been and why he couldn’t be a better father to his kids. Specifically, I was the kid he’d failed, and he took to name-calling and sarcasm to indicate his disapproval of me. In my teens, his favourite nickname for me was Know-It-All-Do-Nothing, a name that would send me into a rage, much to his satisfaction.

I can recall only a few times when my father behaved affectionately toward me. When I was fourteen, I had a seizure on the upper floor of our house. When I regained consciousness, I saw my father kneeling over me and sobbing. He held me up and carried me downstairs, repeating, “Barry, don’t die, please don’t die.”

The other time I was coming home from school on the bus and saw my father slumped in a seat. He had been drinking. I could tell by the way his body drooped and the silly smile he wore as if the world was a joke. When he spotted me, he motioned for me to come and sit with him. The gesture was unusual; I was initially reluctant because my friends were looking on. When the seat became available, however, I went to sit next to him. I could smell the liquor on his breath as he leaned over and cried, “I’m so sorry, son. I’m so sorry. I’ll get better, you’ll see.” I wanted to believe him. I always wanted to believe him. It wouldn’t be long before the drinking and the fights would start again – my father’s cold hostility and my mother’s rage.
 
The hospital reading material doesn’t say anything about hostility and anger. It hints that stress can contribute to coronary heart disease but offers no helpful information about what kind of stress and is mute on the topic of irritation, frustration, and rage. It has a lot to say about cholesterol and medications. I suspect that the so-called “hard sciences” are considered more credible than the “soft sciences,” such as psychology or psychiatry.

In some ways, the silence on hostility and anger is not surprising. I heard from a colleague some years ago who was invited to sit on a National Institute of Health (US) panel that included physicians, nutritionists, drug representatives and other healthcare professionals who looked into the obesity epidemic among American children. My colleague, a psychologist, was excited about the opportunity to introduce behavioural strategies that promoted healthy eating and nutritional education in families as a prevention strategy. She left the panel a few months later, discouraged that the group’s primary focus was the search for a medication that could lower the body’s intake of carbohydrates and thus make obese children skinny. The panel panned the idea of behavioural strategies – like nutrition counselling or teaching kids to avoid sugary cereal as being outside of the medical model.

Timothy Smith and colleagues have collected several decades of research establishing a clear link between hostility and coronary heart disease. The evidence gets to the nitty-gritty about what type of stress is toxic; it isn’t anxiety or depression, which are not risk factors. The type of stress that kills is anger. Anger is learned and, by age thirty, well established in those who suffer from the affliction. Most healthcare professionals are likely to get angry if you tell them that the effects of these behavioural patterns rival what they believe about cholesterol and statin medication.

Reviewing a plethora of well-designed studies, Smith and his colleagues learned there was an increase in coronary heart disease and fatality among participants with high levels of anger and hostility. In one study that followed the same 1000 men over thirty years, the risk of coronary heart disease and myocardial infarction was three- to six-fold higher for angry versus non-angry men. These results held when other risk factors such as smoking, physical activity and alcohol consumption were taken into consideration. Findings such as these have been replicated numerous times, yet the medical community seems not to have noticed. Although I overheard one nurse in the cardiac care unit telling someone, “You’d be surprised at the number of type-A men we see here.” The common understanding of type-A personality is that the individual is driven and exacting in their pursuit of goals and outcomes. However, the work cited by Smith and others has been able to isolate the anger and hostility traits apart from type-A-ness. In other words, a non-angry, assertive, type-A person is no more likely to risk a heart attack than anyone else.
 
For as long as I can remember, I have lived with anger. In its more benign stages, the underlying current of irritation constitutes the better part of most days. A mindfulness teacher once assessed me as having an “aversive personality,” one of the Buddhist psychology character traits. This assessment made sense to me then, and it still does. An aversive personality’s attributes include antagonism toward most things, analytic thinking, irritability, and fault finding. I have tried to tame this inner beast because it makes me unhappy. The truth is, though, I always have to hold it down, and some days I am too tired, and it leaks into my life with other people.

On a summer road trip with a friend, we talked about anger. He said he left his wife because he no longer wanted to live with anger and hostility. He said his days were generally free from the unpleasantness he felt during married life. He then complimented me on the changes he had seen in me over the past few years. “You used to be pretty angry,” he said. At first, I was hurt; I wasn’t aware I had acted out of anger toward my friends. On reflection, his observation of my change coincided with my work over ten years studying and teaching mindfulness-based stress reduction therapies. I understood that anger isn’t always overt; it creeps into the spaces between people, the thoughts we entertain, the words we say, the way we hold our bodies, and the attitudes we express about how the world works. Awareness offers me a way to limit the effects of anger in my daily life.
 
A month after my on-ice heart attack, I dropped by the arena to coach the game and retire to the bar to buy the guys a beer and express my gratitude that they called 911 that day. I let the guys know that I’ll be back on the ice soon when I get the go-ahead from the cardiologist. They have a nickname for me earned when I was in my fifties when I took my share of retaliatory penalties and railed at the refs who sent me to the box for unsportsmanlike conduct. It’s a joke they think is funny because I taught psychology to college kids. At seventy, I don’t behave that way anymore (not often, anyway), but they don’t seem to notice. “Hey, Anger Management, it’s good to have you back.” “Me too,” I say. I tell them that I have been thinking about why people have heart attacks and that anger may play at least a small part. “But my anger on the ice has changed, don’t you think?” “Yes,” someone says, “ever since you had the heart attack!” I have this strong urge to hug these guys. And as it turns out, the desire to share a hug with others is the antidote Buddhist psychologists prescribe for the aversive personality: Metta or loving-kindness meditation.

 Let the mind follow the breath as it moves through the body. This breath. Take in this moment and notice how it is felt in the body. Notice areas of tensing up and let the body relax, not forcing, just letting go. When you are ready, take the time to consider yourself as though looking in a mirror, how others might see you, the times that you’ve been kind and reached out to a stranger or those you love. Notice the sensations as they arise. Concentrating on the intention rather than the words alone and looking into your own eyes, repeat; “May you be free from harm. May you be free from suffering. May you live in peace and know well-being. May all creatures live in peace and be safe from harm.” In this way, bring loving-kindness to others; a loved one, a friend, a neutral person in your life, and someone who wishes you harm.”

I tell the guys that I am hopeful that along with the blood thinners, the blood pressure medications, removing things from my diet (red meat, sugar and salt), the rehab program, and a dose of anger management training, I’ll return to the ice before the end of this season. They drink to that.