Silent Heart Disease in Diabetes: "Why Don't I Feel it?"
Whenever something bad happens there is an irrational thought process that causes each of us to try to assess “blame”. This is no different for doctors than it is for other people. I can’t think of anything much stranger than the discussion I hear from physicians after a young patient comes in with a heart attack. You can almost see the gears turning in each doctor’s head. The first thought is that the patient has a family history, high blood pressure, uses cocaine or alcohol or tobacco, has high cholesterol, is diabetic, has congenital heart disease or rheumatic fever or any other problem that differentiates him/her from the doctor. After all, the doctor doesn’t want to feel that this could happen to him/her. The next thought is that the patient must have been doing something to cause this catastrophe (not like the doctor), and certainly the patient should have known that something was wrong. These are common thoughts that people have (doctors included). We don’t want to think that heart attacks can just sneak up and hit us.
Unfortunately, not every heart attack is preceded or accompanied by symptoms. This is often not because the patient is ignoring the problem (though sometimes people do this or hide their symptoms from everyone). Approximately 15% of heart attacks are “silent”, meaning that they are discovered during a time when the patient has an electrocardiogram or echocardiogram for another reason. In diabetics, the percentage of heart attacks that are “silent” is somewhat higher (25%). It is thought that this is because there is a problem with the nerves that carry the symptoms of pain to the brain due to the diabetes.
Why should we be surprised that a blood vessel can get blocked without a warning? Strokes often happen the same way. No warning, and yet all of a sudden the arm doesn’t work Such a stroke is obvious to everyone. But there are also “silent strokes” that we can see on an MRI or CAT scan (magnetic resonance imaging or computerized axial tomography are long words so we almost never say them) for which the patient hasn’t felt or noticed anything. These are what we also call “silent” strokes.
When heart attacks and strokes are “silent” it is very difficult for a patient to know what to “watch out for”. For this reason it becomes extremely important to use every preventive measure that we have at our disposal to protect the heart and the brain. This involves more frequent physical examinations (an electrocardiogram at every visit if that was the test that gave us information) and laboratory tests (often repeated echocardiograms or stress tests). A history of silent heart attacks or strokes will require the use of medications that prevent recurrence and loss of function. These include platelet inhibitors (aspirin is the most common but clopidogrel and dipyridamole are frequently used), anti clotting drugs (warfarin), drugs that lower cholesterol, lower heart rate and/or blood pressure.
It is often difficult for both the patient and family to cope with the fact that there is little warning of problems in the diabetic patient, for this reason it is a good idea for the health care professional to meet with the family to talk about early warning signs of problems. It is certainly never a bad idea for a family to be aware of what to do in an emergency. A family member that is “enabled” by a Red Cross first aid or CPR course is always a welcome helper in medical care.
Larry Weinrauch is a cardiologist in Watertown, Massachusetts and is affiliated with Mount Auburn Hospital. He wrote for HealthCentral as a health professional for Heart Health, High Blood Pressure, and High Cholesterol.