I suspect that I am having a heart attack the moment that 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 am pulling breaths through a clamping pain below my sternum. It doesn’t feel like indigestion; the pain doesn’t move.
I reach the bench and take my seat, head resting in my hands, shifting positions, trying to move the pain. “Are you okay?” Lots of pain,” I say, “in my chest.” “Just 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 down 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 field of awareness is confined to the unrelenting tightness in my chest. I have time to think, almost too casually, that I might be dying, that I may 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. This is likely 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, to the spirit of the game. Someone helps get the jersey and shoulder pads over my head and leads are connected to my chest that attach me to a machine that reads my heart’s function. By the time I am lifted onto the waiting gurney the paramedic tells me, “You are having a heart attack.” And I am relieved. The pain is real and my interruption of the flow of the game is justified. “We’re going to take you to the cardiac care unit at St. Mary’s Hospital.”
Heart disease is the second leading cause of death among Canadians. Cancer is the leading cause. Twelve people over the age of twenty die each hour from heart disease in Canada. Most will die of ischemic heart disease, which happens when the heart is deprived of blood by a blockage in the coronary arteries. Obstructions occur when there is a buildup of plaque deposits in the blood vessels leading to the heart. 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 likely to be diagnosed with heart disease ten years earlier than women; perhaps because heart attack symptoms are different for women, presenting as flu-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 and triglycerides. There are also lifestyle risks like unhealthy weight, alcohol and recreational drug use, lack of exercise, smoking, unhealthy diet, and stress. Some risks are not controllable like age, sex, family history, and ethnicity. These risks are outlined in a detailed tract called, “Living Well with Heart Disease” that they give you when you are recovering in hospital. Good reading to help assess where you went wrong, 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 amount of red meat I consume, try to find plant-based sources of protein, and include lots of vegetables and fruit in on my plate. My Body Mass Index is 23, I actively work to keep my weight regular because extra weight shows on my small frame. My cholesterol is within the high-normal range.
In sum, before my heart attack I was doing pretty much what I should have been doing if I followed the book to a tee. Like many, I have been listening to the warning signs repeated ad nauseam on how to live a healthy and more productive life. So where did I go wrong? Really wrong!
My doctor told me when I met with him a week or so after my impromptu visit to the cardiac care unit, that my chances of surviving post 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), and 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 totally unrelated to my current emergency, although I worry that the heart attack may have implications for the defect into the future. My dad’s heart troubles were different from mine, but I grew up knowing that my heart was a vulnerability. 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 years old. 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 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, 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 would harangue him about where he’d been, and why he couldn’t be a better father to his kids. Specifically, I was the kid whom he’d failed and he took to name-calling and sarcasm to indicate his disapproval of me. In my teens I became known to him as “Know-It-All-Do-Nothing”, a name that would send me into a rage, much to his satisfaction.
I can recall only a couple of times that 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 picked me up in his arms 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 and at first, I was 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 though before the drinking and the fights would start again – my father’s cold hostility and my mother’s hot 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.
The silence on the topic of hostility and anger is in some ways 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 health care professionals charged with looking into the obesity epidemic among American children. My colleague, a psychologist, was excited about the opportunity to introduce behavioral 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 primary focus of the group 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 that establishes a clear link between hostility and coronary heart disease. The evidence gets to the nitty gritty about what type of stress is toxic; and it isn’t anxiety or depression, both of which are not risk factors. The type of stress that kills is anger. These are the simple facts; people learn maladaptive coping strategies in early life, the adult personality is well established and relatively unchangeable by age thirty, hostility is a learned response that is immutable in the absence of therapeutic agency, and hostility has a direct impact on physical health. Most health care 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.
Prospective studies recruit people before there is any indication of health risk. They are the benchmark of proper research because they avoid the biases inherent in looking backwards over the data and predicting after the fact. In the prospective studies reviewed by Smith and his colleagues there was an increase in coronary heart disease and fatality among participants who were deemed high in measures of anger and hostility at the outset of the study. In one study that followed the same 1000 men over a thirty-year period 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 out of the equation. Findings such as these have been replicated numerous times and yet the medical community seems not to have taken notice. 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. The work cited by Smith and others, however, 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 heart attack than anyone else.
As long as I can remember I have lived with anger. In its more benign stages it is the underlying current of irritation that 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 at the time. It still does. The attributes of aversive personality include such things as antagonism toward most things, analytic thinking, irritability, and fault finding. I have tried to tame this inner beast for the simple fact 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 out into my life with other people.
On a road trip with a friend this summer we had a conversation about anger. He told me that the reason he left his wife was that he no longer wanted to live with anger and hostility. He said his days now 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 that I had acted out of anger toward my friends. On reflection, his observation of the change in me coincided with the work I had done over a ten-year period studying and teaching mindfulness-based stress reduction therapies. I had come to the understanding 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 body, the attitudes we express about the way the world works. Awareness offers me a way to limit the effects of anger in my daily life.
A month after my on-ice myocardial infarction I drop 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. In my sixties now, I don’t behave that way anymore (not all that 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 doing some thinking about the reasons 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 might others 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.