I. Chest Pain at the Fire Station
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Tony Spagnoletti was on overnight duty at Winston-Salem Fire Department Rescue 1, sleeping on the second floor of the oldest fire station in Winston-Salem, N.C., when at 4 a.m. he woke up with pain in his chest.
Spagnoletti, 47, was in good shape – his work as a firefighter required it, and he took those requirements seriously. Fighting fires is a physically demanding job in many ways – you don’t want be at a fire site dragging hose up a ladder and find yourself out of shape. Besides, Tony loved being a firefighter – it was his calling.
Tony’s chest pain was surprising. He and his wife, Allison, would walk and sometimes work out together. Except for a weakness for biscuits and gravy, Tony ate as well as a working family with two athletic teenage daughters allowed. He wasn’t overweight and he didn’t smoke. He had no family history of heart disease. For the most part, he did the right things to keep his heart healthy. He had recently found that his cholesterol was a little high, but that was about it.
Just the day before, Nov. 28, 2012, he had been climbing ropes and ladders all day as part of a training course.
Tony, Winston-Salem firefighter and EMT, suffered a massive heart attack one night when he was on duty at the firehouse. This is the story of how fellow firefighters, paramedics and a team of interventional cardiologists saved his life.
He simply couldn’t be having a heart attack.
As an emergency medical technician (EMT), Tony knew that a heart attack can hit when you least expect it. He also knew that there are many warning signs for heart attack from the common and well-known signs, like heavy chest pain, to less frequent ones, like a pain in the shoulder, nausea or cold sweats. For some women, the only warning sign may be sudden weakness, anxiety or trouble sleeping.
He always made sure he kept baby aspirin in his bag, his locker, and in his truck, just in case someone ever needed it. Aspirin helps to thin the blood, helping to keep the platelets from sticking together and forming a clot that could lead to a heart attack. He wasn’t sure he needed it, but he chewed four baby aspirin – just in case.
Tony tried to go back to sleep, but sleep didn’t come easy. He still didn’t feel right. The chest pain got worse.
Not wanting to disturb his fellow firefighters, Tony went to the ground floor to grab an EMT kit off of one of the fire trucks. Maybe a hit of oxygen or nitroglycerine would help.
Earlier that year, Tony had talked with a friend who had had a heart attack. He told Tony it was the “worst chest pain” he had ever felt. As Tony tried to drag the kit in from the garage, that’s exactly what he felt – the worst chest pain ever. There was nothing subtle about this warning sign.
He knew to alert the rest of his crew. What he didn’t know was that he was suffering from a type of heart attack caused by a clot in the left anterior descending artery – the artery that medical professionals dub the “widow-maker.”
Within minutes, his heart would stop beating.
II. The Widow-Maker
Every 34 seconds, an American has a heart attack. That day, it was Tony’s turn.1
A heart attack occurs when plaque totally blocks an artery carrying blood to the heart. Also called a myocardial infarction (MI), the reduction or complete blockage of blood supply can rapidly damage and destroy heart muscle.
Each year, about 620,000 Americans have a new heart attack, and about 295,000 have a recurrent attack, according to the American Heart Association (AHA). In addition, an estimated 150,000 silent first heart attacks occur each year.
Major risk factors for heart disease include smoking, lack of exercise, overweight or obesity, and family history and genetics, according to the AHA.
Critical to avoiding or battling heart disease are maintaining good health through not smoking, exercising and controlling weight; prevention measures, such as monitoring cholesterol levels and blood pressure; knowledge about the symptoms and signs of a heart attack; and quick action when a heart attack is suspected.
Except for the raised cholesterol, everything seemed in Tony’s favor as far as staving off heart disease. He had good health, knowledge and quick action. Unfortunately for Tony – and many like him – these are not always enough to avoid heart disease or worse, a major cardiac event like a heart attack.
Heart attacks cause 1 of every 6 deaths in the United States, killing nearly 380,000 Americans in 2010 alone, according to the AHA.
|Tony’s interventional cardiologist at Wake Forest Baptist Medical Center, Dr. Robert Applegate (center), knew there wasn’t much time to open Tony’s blocked artery. He and his team were ready when Tony arrived in the cath lab. In a procedure known as angioplasty, they inflated a tiny balloon inside Tony’s artery. The balloon flattened the two-inches of blood clot against the walls of his artery, clearing the way for blood to flow to the heart.
Every 83 seconds, an American dies of a heart attack.1
“Tony was not only having a heart attack, it was in an artery they call the widow-maker, the main artery that runs down the front of the heart and supplies most of the heart with blood. The survival rate of a complete blockage in this artery is very low,” Dr. Robert Applegate, Tony’s interventional cardiologist at Wake Forest Baptist Medical Center, noted.
It looked like Tony was about to become a statistic.
III. Emergency Response
It was 6:30 a.m., when Capt. Scottie Emerson got a call on the speaker phone from Tony, who was one of his crew as well as a long-time friend and colleague.
“Could you come downstairs?”
When Emerson got downstairs, he was surprised at what he saw.
“Tony was completely white, like a white wall,” he said. And he was holding onto his chest.
Emerson told Tony to sit down and relax while he took his blood pressure – 150/100, which is high for Tony. Emerson gave Tony a couple of squirts of nitroglycerine under his tongue to relax and dilate his blood vessels.
“It usually reduces pain right away,” Emerson said. “It didn’t do that for Tony.”
He and Tony had worked together at the Winston-Salem Fire Department for many years. Firefighters see each other as brothers, and it was no different between Tony and his captain.
An ambulance was called. An oxygen mask was put on Tony. Emerson took his station out of service as it dealt with its own crisis.
|An electrocardiogram, or EKG, translates the heart's electrical activity into line tracings on paper. The spikes and dips in the line tracings are called waves. Tony’s EKG confirmed he was having a severe heart attack.
Fortunately, a Forsyth County Emergency Services ambulance was just coming back from the hospital and was five minutes away. When they arrived, the emergency technicians took Tony’s vitals. The pain was persistent. They ran an electrocardiogram (EKG), a test that checks for problems with the heart’s electrical activity of Tony’s heart. The EKG translates the heart's electrical activity into line tracings on paper; the spikes and dips in the line tracings are called waves. Emerson saw the classic shape of a German military spiked helmet – an indication that Tony was having a severe heart attack.
“Tony and I looked at each other,” Emerson said. “I said, ‘Tony – you’re having an MI.’ “
The two medics put Tony on a stretcher, hauled him into the ambulance and inserted some intravenous lines. Tony’s best friend and long-time colleague, Michael “Mac” Casstevens, rode with him. Drs. Robert Applegate and Sanjay Gandhi, interventional cardiologists, and the medical team, were ready for Tony in the ER. On the way in, one of the medics called the emergency department to tell them about Tony’s condition, including the troubling EKG reading. The ride from the station to the hospital took less than three minutes.
As Tony was being brought to the hospital, Emerson called Tony’s wife, Allison.
“I told her that Tony was in bad shape,” he said.
Allison was at their home getting ready for work as a physician’s assistant.
|Tony and wife Allison have always taken care of themselves. Tony’s heart attack seemed to come out of nowhere.
The younger of their two daughters was still at home when Emerson’s call came in. The Spagnoletti family lives in a small town called State Road, NC, about 50 miles away from Winston-Salem – where Tony was headed for the hospital at that very moment.
“At first, Captain Emerson called to tell me they were taking Tony to the hospital,” Allison said. “Then he called back to tell me Tony was having a heart attack.”
She grabbed her daughter and sped to the hospital. Given his condition and how far she had to go, there was little guarantee she would get there in time.
Back at the station, Emerson got a call from the hospital. Tony’s heart had stopped while he was in the emergency room, which medical professionals call “Code Blue.” They had been able to “get him back” by using a defibrillator to get his heart to start pumping again, but the cardiac arrest left Tony in rough shape.
Emerson’s cell phone had told him that a firefighter – one of his firefighters, one of his lifelong friends – had “coded.” Tony was, at least for a moment, clinically dead. There was a good chance he would not survive the morning.
Emerson hurled his cell phone across the room.
As soon as Tony arrived at the hospital, Drs. Applegate and Gandhi performed a second EKG, confirming he was having a heart attack.
“We knew we wouldn’t have much time to open his blocked artery,” Dr. Applegate said. “There’s a reason that artery is called the widow-maker.”
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Dr. David L. Brown, of Medical City Dallas Hospital and Baylor Regional Medical Center at Plano, discusses the type of heart attack often called "the widow-maker."
The reason is that this particular artery is critical to the functioning of the heart, and if it gets abruptly and completely blocked, it will cause a massive heart attack that can quickly lead to death.
Tony had arrived to the harsh lights, noises and flurry of activity of the ER. He was in intense pain – pain like he had never felt before. One a scale of 10, it was 10.
Shortly after he arrived, Tony’s eyes began to narrow. The harsh lights, the noise and pain all disappeared. He saw a graduated, beautiful light, like the sun cresting the horizon. He was at perfect peace, as though he were in a dream.
For the people who survive this state, it is called a “near-death experience.” In Tony’s case, his heart had stopped. Code Blue. He had had a cardiac arrest as the result of a fatal arrhythmia.
Then he opened his eyes. There were people staring down at him. He asked one of them – a nurse – what had happened. She told him he’d just been defibrillated – his heart had been shocked back to life.
He was alive. But just barely. The widow-maker was still blocked.
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|What Will You See in the Cath Lab? Angiogram tests and angioplasty procedures are performed in special hospital rooms called cardiac cath labs. In this video, Dr. John P. Reilly gives you a guided tour of the cath lab, pointing out the equipment you’ll see and explaining what it’s for. (Video provided courtesy of Dr. Reilly)
Tony was rushed to the cardiac catheterization laboratory – or “cath lab.” They wheeled him so fast they seemed in danger of tipping as they rounded the hallway corners. When they arrived at the cath lab, they immediately began work to open the blocked artery.
Tony looked extremely apprehensive when he arrived, Dr. Applegate said. “He was fearful he was having a fatal heart attack … and he was right,” he said.
In a procedure called angioplasty, Dr. Gandhi carefully guided a thin, flexible tube, called a catheter, from the radial artery in Tony’s wrist to the arteries in his heart. An x-ray camera was used to project images of his arteries onto a television screen, helping Dr. Gandhi to guide the catheter to the blockage in the artery.
Like an artist using an Etch-a-Sketch, Dr. Gandhi snaked the tube through the twists and turns of the artery he saw on the screen. Unlike an Etch-a-Sketch, Dr. Gandhi was under extreme pressure to do it as quickly as possible – every second too long could result in damage to Tony’s heart. Interventional cardiologists have a saying: “Time equals muscle.” The longer it takes to reopen the artery, the more muscle of the heart could die. In this case, time equaled life – Tony’s life.
When the catheter was properly positioned, Dr. Gandhi injected a contrast dye through the catheter into the heart and its arteries. He found a two-inch long clot completely blocking the left anterior descending artery – aka, the widow-maker. He passed a tiny, thin guidewire through the clot, and then threaded the catheter with a small uninflated balloon at its tip through the guiding catheter, over the guidewire and into the artery to where the artery was blocked with plaque.
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|Arteries opened with angioplasty can become blocked again. To reduce the risk, many angioplasties are accompanied or followed by the insertion of a stent -- a small stainless steel mesh tube that helps prop open the artery at the point where the blockage was opened. Watch this short animation to see how a stent is placed, thus helping to restore blood flow through a previously blocked artery.
Once in position, Dr. Gandhi inflated the balloon that, as it inflated, flattened the plaque against the wall of the artery and allowed life-saving blood to start flowing again to the injured muscle. Using the catheter, he threaded a tiny, expandable metal mesh tube called a stent within the artery wall. Once in place, he expanded the stent to prop open the artery and prevent it from collapsing. The stent was coated with a slow-releasing medication that minimizes the body's propensity to form scar tissue around the stent. This is called a drug-eluting stent.
Once the artery was cleared and permanently propped open, blood flow was restored to the heart.
“You could just see the relief on Tony’s face as the pain resolved,” said Dr. Applegate.
Tony had survived the widow-maker. He had literally come back from the dead. No question, it was a tremendous relief. But it would not be long before a nagging concern entered Tony’s mind as he lay in his hospital bed.
Would he ever be a firefighter again?
Back at Fire Station 7, the expectations were pretty much unanimous, Emerson said.
No, he would not.
V. Recovery – The Way Back
It was Sunday, three days after the widow-maker. Emerson and some of the crew were outside the hospital ready to visit Tony. They were shocked by what they saw: Tony coming out the door.
He was going home.
“He had survived a major heart attack,” Emerson said. “He was clinically dead at one point. It was miraculous.”
No one was more surprised than Tony when Dr. Applegate said he was ready to be released from the hospital into cardiac rehabilitation. His left ventricular ejection fraction, a test that determined how well his heart pumps with each beat, was less than 35 percent. That means that 35 percent or less of the blood in his left ventricle was pumped out with each heartbeat, compared to a normal heart pumps more than half (55 percent to 70 percent) the blood volume with each beat. If Tony had just come in off the street with an EF of 35, he likely would have been assessed to be at risk for life-threatening irregular heartbeats.
“I was out of breath just getting out of bed to go to the bathroom,” Tony said.
But Tony’s good physical condition before the heart attack was a strong factor favoring strong recovery. Tony got started in a cardiac rehabilitation program, which help patients resume a healthy lifestyle after a cardiac event. The program included monitored exercise, education and counseling about cardiac risk factors, and psychosocial support.
|At the recommendation of Dr. Applegate and Dr. Gandhi, Tony participated in a cardiac rehab program and made changes to his lifestyle. He still sees Dr. Applegate for routine checks.
Based on information from Dr. Applegate and Dr. Gandhi, the cardiac rehab specialists prescribed an exercise program specifically for Tony. He was encouraged to attend two or three exercise sessions per week at the cardiac rehabilitation center and to supplement this at home with exercises such as walking. At the hour-long sessions, he also got information about nutrition, stress reduction and medications.
Tony took his second chance at life very seriously, making changes in his diet and sticking religiously to his new drug regimen, Allison said.
As a German-Italian descendant, Tony said he loved a slab of beef and potatoes, so it wasn’t easy cutting back portions, eating more fish, salad and kale. He also started taking fish oil (Omega-3), which may have benefits such as reducing triglycerides (a type of fat or lipid in the blood that may increase risk of heart disease), blood pressure, blood clotting, stroke and heart failure risk, and irregular heartbeats.
Perhaps the most important new routine was to follow the drug regimen prescribed for him. He knew it was crucial for at least a year after his stent procedure to take two antiplatelet medications. This helps prevent clotting of the stent. Tony also takes a statin to lower his cholesterol, and two drugs to treat high blood pressure, control the heart rate and improve survival post-heart attack.
Tony admits that he doesn’t like to be on these drugs, or any kind of drugs. But he also realizes the importance to his health of taking them. He has resigned himself to the fact that “I will be on heart medications for the rest of my life.”
| Reunited: Firefighter Tony Spagnoletti was saved by the cardiologists at Wake Forest Baptist Health after a major heart attack. There are 2 #unbrokenhearts in this hospital bed.
That acceptance came on the first night back at home after the heart attack. As they lay in bed together, Tony and Allison held hands. And they cried.
“From that time on, we felt that the only way was to just go forward, do what they tell us to do,” Allison said.
If being sent home three days after his massive heart attack surprised him, what his doctor had said next shocked him. He was told that, with cardiac rehabilitation, he would be back to work in 30 days.
“I thought he was crazy,” he said.
Had his doctors been forced to crack open his chest to repair his heart, Tony would have been recovering for months. But given the minimally invasive nature of angioplasty procedures, most stent patients can often go home within 24 hours or even the same day, said Dr. Applegate. Most of these patients are able to return to resume the lives, including the jobs, they had before their heart attacks.
Tony told his cardiac rehab team that before being released for duty as a firefighter, he wanted to do a heart stress test, which involves running on a treadmill hooked up to a heart monitor. A cardiac rehab nurse objected, telling Tony that “no one runs in cardiac rehab.” Tony replied that he would face much more stressful conditions when he returned to work, including climbing ladders loaded with gear or pulling heavy fire-hose – so he wanted to test himself in a controlled environment. “For firefighters, there is no light duty,” he said.
So, reluctantly, they let him do the test. “They watched me like a vulture – and they did intervene, because they wouldn’t let my heart rate get over 180,” he said.
Tony worked hard to get himself back into shape – and keep himself that way. Although he wasn’t overweight before, he dropped a few pounds (194 to 188) and has maintained a good weight. He does two workouts a week consisting of four miles on the elliptical and weight-lifting, and walks the dog two miles every day.
The first day back at work, there was a big fire. He had to pull hand-lines and help the rapid intervention team – pretty intense work. But Tony took it in stride. Some paramedic friends of Tony’s checked his EKG afterwards, and it was normal.
“For me as an officer, I tried to treat him no differently than I would treat anyone else,” Emerson said. “When it was time to fight fire, it was time to fight fire.”
Even so, there was speculation outside of his crew in the fire department that his crew members would have to pick up the slack left by Tony’s inability to perform some of the more strenuous firefighting duties.
Tony indirectly addressed those rumors at the fire department’s fitness test, part of which is running a mile. As he got ready to run the mile, Emerson brought over a portable defibrillator and stuck the cords through Tony’s shirt to his chest. Then he walked into a room full of fire fighters and fitness evaluators.
“I’m ready!” Tony told onlookers. Everybody laughed.
As it turns out, he didn’t need a defibrillator. In fact, Tony outran everyone, Emerson said. He recorded a mile faster than the last one he had done before his heart attack – a time that put him in the top 10 percent for his age among his fellow firefighters.
“I think that squelched any scuttlebutt that my guys were carrying me,” Tony said.
People who go through a major heart event are often not quite the same afterwards – even those who “fully recover.” It’s not a matter of becoming better or worse; it’s just a matter of being different. The changes may be subtle, perhaps not even detectable to those who are not intimates; but they are there, nonetheless.
That was certainly the case with Tony.
|Hamming it up with the girls. Tony and his family took his second chance at life very seriously, making changes in his diet and sticking to his new medication regimen.
Tony was thankful. He was thankful the system worked. He was thankful for taking the aspirin and the nitro. He was thankful for the speed with which the emergency response system got him to the hospital, where they were waiting for him. He was thankful for the heart tests, angioplasty and stents, and for the doctors who knew how and when to use them.
He knew how lucky he was, too. What if the ambulance had not been so close at the moment he needed it? What if he had been sleeping at home that night, 50 miles from the nearest cath lab?
Perhaps as a result of his gratitude, Tony wanted to do something with his second chance at life. He wanted to help others, especially other cardiac patients.
Even though he has always shied away from public speaking, Tony has accepted numerous requests to talk about his experience. He advises people to know their numbers, such as heart rate and blood pressure.
He urges people to know the warning signs of a heart attack. For instance, while Tony had classic heavy chest pain, even that can vary from person to person: some feel an uncomfortable pressure or a squeezing in their chest, while others feel a fullness, and still others sense a stabbing pain. Oftentimes there is no chest pain – the only signs may be a pain in the neck, shoulder, back, arm or jaw; or a pounding heart, difficulty breathing, cold sweats, dizziness or heartburn, nausea or abdominal pain. Warning signs for women are especially subtle, such as sudden onset of weakness, body aches, anxiety or difficulty sleeping.
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In this video, Dr. Mark Turco stresses the importance of seeking medical care when something doesn’t feel right.
Finally, he urges people who think they may be having a heart attack to chew an aspirin and call 911. Don’t stay home. Don’t try to drive yourself to the hospital.
But “staying alive” isn’t the only topic Tony has been giving talks about recently – he has also been talking about “near death.” Tony, a devoted Christian, has been described his near death experience at churches, and even at a funeral.
“I was probably only gone for three to five seconds,” Tony said. “But I saw that beautiful light. The pain that had been at a 10 was gone. I couldn’t hear anything. It was so relaxing, like I was in a dream. I talked about near death and perfect peace. People like to hear that.”
Tony said he still gets emotional when he talks about those experiences.
Going through an experience like a massive heart attack, however, is often accompanied by two feelings: sadness or depression that it had to happen at all, and fear that it may happen again. Although staying in shape, eating right and taking your medications can reduce the chances of that happening, people who have had heart attacks are more likely to have another one than those who have never had one.
About six months after the heart attack, Tony felt chest pain. He took two doses of nitroglycerin, but that didn’t help. He went to the hospital. They took his blood pressure, and it was good. But the only way they would know for sure if there was a blockage was to run a catheter into his artery. Fortunately, it looked fine.
“Until then, there had been nothing bad,” Tony said. “But that day startled me.”
|Tony with Allison and their girls, after speaking at a church during a medical mission. Tony wants to help others, especially other heart patients. He has accepted requests to talk about his experience. He advises people to know their numbers, such as heart rate and blood pressure, and to know the warning signs of a heart attack.
Since then, Tony has felt a twinge now and then. It could be gas, or something else, he said. But the pain was not significant, and it went away.
He knows that some people who have had heart attacks end up with angina, which is chest pain due to the heart not getting enough oxygen from the blood, often due to constricted blood flow in an artery. Angina can be debilitating, making it difficult for people to perform simple physical tasks such as walking upstairs or playing with their grandchildren.
“If I’m diagnosed with angina, they (the city of Winston-Salem) will retire me,” Tony said. “I love my job. I won’t lie about it, but angina is something I want to avoid.”
Any depression or anxiety Tony has had about his heart attack has been more than offset by his thankfulness that he came through it about as well as possible. Besides benefiting from an efficient emergency system and a few lucky breaks, Tony is also mindful he was saved by a procedure that is barely 30 years old and skills and technology that are the best in the world.
“Interventional cardiology, and all of the incredible technology and training of the doctors, saved my life,” Tony said. “It has saved a lot of lives.”
It wasn’t long ago Tony went back to the cath lab because of his heart. Not the physical heart, but the emotional one.
“I gave everyone in the entire cath lab a hug,” he said.
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1 American Heart Association. Heart Disease and Stroke Statistics 2014 Update. Circulation. 2014; 129: e28-e292.