Matters of the Heart

“I got exhausted just washing my hair,” said DC-area yoga teacher F.J., who had a weakened heart valve that required surgery.

“Symptoms like shortness of breath are so common that they are often missed by doctors,” notes a New York Times article on the uses of AI in cardiology. Addressing a crucial problem—especially important for women, because their early signs of heart attack are often unrecognized—one AI model can “recommend certain patients for further care before they leave the hospital clinic.”

The “silent killers,” the most dangerous forms of cardiovascular disease, strike without warning. About 50% of stroke victims have no prior symptoms. As with high percentages of stroke and heart disease, familiar symptoms can also be absent with uncontrolled hypertension—itself a “silent killer”—which plays a significant role in both. Atrial fibrillation, which causes about one-third of strokes, can feel like butterflies or fish flapping inside the chest. But in many cases, there are no symptoms—with up to 30% of AFib cases remaining undiagnosed.

Shortness of breath and fatigue, often dismissed as natural occurrences that come with age, feature among often-ignored symptoms of cardiovascular disease — including anemia. “Tired, short of breath, a sort of malaise” were symptoms of dangerous anemia in one patient, according to the New York Times. And while blood ferritin measurements are the best indicators of low-iron anemia, reduced hemoglobin directly affects the oxygen-carrying capacity of the blood.

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Of 2,000 patients over the age of 65 at a Virginia outpatient clinic, about one in five had low hemoglobin levels—but only one-third had received a correct diagnosis of anemia. With decreased oxygen in the blood, the heart must work harder to compensate, causing weakness, fatigue, and in some cases heart failure. And while iron supplements help most anemia patients, some do better with occasional infusions of hemoglobin.

For women, the error rate for traditional heart health testing—running on a treadmill while hooked up to an EKG that measures heart rate, breathing, and blood pressure—may be as high as 30% compared to that for men, according to Prevention magazine. And even when blood cholesterol levels are in the healthy range, calcium buildup in the coronary arteries can be a better indicator of risk and the need for treatment, such as with statin drugs.

Unfamiliar and often undiagnosed causes of heart disease include infections from viruses, bacteria, and fungi. A few weeks after having the flu, Massachusetts-based internist B.L. had another bout of flu-like symptoms followed by AFib linked to myocarditis in the heart muscle. GI and respiratory illnesses can affect the sac surrounding the heart, called pericarditis. And bleeding gums due to poor dental hygiene or following dental procedures can lead to endocarditis, which is an infection in the heart lining.

AFib “is pretty much an epidemic,” according to electrophysiologist Andrew Rubin at Eisenhower Health in Rancho Mirage, California. Advancing age increases risk for AFib as well as for high blood pressure, which itself accounts for about one in five cases of AFib. Recently developed devices that monitor heartbeats—and one that both monitors and treats AFib—have brought renewed attention to the condition.

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When rapid heartbeats woke Lake Tahoe medical writer D.P. in the middle of the night, her doctor blamed them on nightmares she didn’t remember. D.P.’s ECG and exercise stress test were both normal, as was a second stress test from a heart rhythm specialist who “cranked up the treadmill incline as high as I could manage.”

But when D.P. mentioned a feeling of fullness in her chest and pressure in her neck that usually happened about 30 minutes after she snowshoed up to a high mountain ridge, her doctor repeated the ECG both 15 and 30 minutes after the treadmill test. “Lo and behold,” D.P. wrote, “there it was: the occasional too-close-together peaks on the graph.”

“Everyone over age 50 should wear a smart watch” is the belief of health reporter, K.G., who started using one to monitor her AFib after two of her brothers had strokes. Newer smart watches can also assess another indicator of overall cardiac health: average daily heart rate per step. In one study, compared to people with lower DHRPS scores, those in the top 25^th percentile were twice as likely to have heart failure and coronary atherosclerosis, as well as high blood pressure and Type 2 diabetes.

Asking more questions at the annual physical exam -- such as about blood test levels of hemoglobin and iron -- can help people “steer conversations with their doctors away from fatigue or other symptoms as inevitable results of aging,” according to the New York Times. “Perhaps they’re signs of anemia, and perhaps it’s treatable.”

For most people, though, fatigue is a relative issue. My question is: compared to what? Don’t I always wish I had more energy?

I’ve started reading the blood work results from my annual physical more thoroughly in search of clues to anything amiss. A few years ago, I took iron pills to raise low ferritin levels into a normal range. After recent bloodwork, my doctor recommended keeping an eye on both my hemoglobin levels, which look OK, and my thyroid: TSH (thyroid-stimulating hormone) was marked “high” on the results, which could indicate over-active thyroid glands.

For now, though, I enjoy afternoon “breaks” that often become short naps.