It was sweltering hot that day. The 61-year-old woman encouraged the donkey to trot. She loved riding around the ring on her beautiful white beast. The order was walk, trot, and canter. Suddenly, she noticed a tingling in her hands and feet that was spreading towards her torso. She was aware of the feeling, but was going to ignore it. It didn't work. Her strength seemed to melt away, and before I could say or do anything, I felt myself falling forward. When the world turned gray, the donkey stopped. Her arms, then her body, slipped down the animal's sweaty neck and fell to the ground. Then everything went black.
She woke up to see the white belly of the donkey. He bent down, smiled softly, then yelled at the approaching instructor. OK? the instructor shouted in alarm. Should I call an ambulance? She assured the instructor that she would be fine. It was just that the hot weather could get to her. She let the cool darkness of the barn help her. Warm tears streamed down her face as she lay on the damp concrete floor. She couldn't go on like this, she thought.
The first time she passed out was probably four years ago. She was finishing up a brisk walk on the treadmill at the gym when she felt a strange tingling. A black dot swam before my eyes and I heard my head hit the wall of the window in front of me. Then black people took over. She woke up surrounded by worried faces. Strangely enough, she was an active person. Her work as a field geologist kept her hiking and climbing regularly.
She went to her doctor, a nurse. According to the NP, she had high blood pressure but was otherwise healthy. The woman was taken to a local cardiologist. Yes, she told the doctor that she was now more short of breath than before. And, admittedly, she was sometimes more tired than expected. But no, she never felt any pain or pressure in her chest. Most of the time she felt good. And she didn't faint often, only a few times a year, mostly when she was exercising in the summer heat. She underwent an exercise stress test and, if it was normal, a scan that used a radioactive dye to outline how effectively her heart was beating. That was also normal. The same was true for echocardiography.
Therefore, the female NP focused on improving blood pressure and diet. But even if her blood pressure seemed perfect, she would occasionally find herself on the ground looking up at worried faces.
look into her heart
It was after falling off a donkey that the woman decided she needed a new perspective on her problems. She made an appointment with Dr. David Ramos, a cardiologist at Columbia New York Presbyterian in Monroe, New York, near her home in Piermont Village. It took many months before I was admitted to the hospital. But when she finally met Ramos, he listened carefully as she described her worsening shortness of breath, increased fatigue with even mild exertion, and frequent blackouts. There were no particular problems with the test. Ramos reviewed his record. Syncope, medically known as syncope, is a common problem caused by decreased blood flow to the brain. 40% of us will faint at least once in our lives. And for most of us, it's a one-time occurrence, often caused by a sudden change in blood pressure or heart rate, often in response to medication or some type of mental or physical stress.
Repeated fainting suggests a heart problem. The woman's NP and cardiologist looked at her heart closely but found nothing. There was no evidence of coronary artery disease or heart failure. There were no signs of abnormal rhythms that could block blood flow. There was nothing wrong with her heart structure. At least the last echocardiogram she had a few years ago was fine. Ramos sent her to another one.
The photo showed that the wall of the left ventricle, the part of the heart that pumps blood into the circulation, was thicker than normal. This can occur in people with high blood pressure. The heart becomes more muscular as it pumps blood through a system with higher pressure. The thicker the wall, the harder it is, making it harder for the heart to relax and expand to completely fill with blood. Could it be that when a woman exerted herself, her heart was unable to pump enough blood to meet the demands of her body and brain? He increased his time and prescribed medication to lower his blood pressure.
Still, she continued to faint, now more frequently. During the summer, she may faint once or twice a month. She passed out on the steps of the Leaning Tower of Pisa. As she hurried up the great stone stairs of New York's Grand Central Terminal, she felt a tingling that warned her another episode was coming. She climbed the stairs and lay down on the stone floor. It felt silly, but she didn't pass out. Ramos increased the dosage and added another drug. She regularly fainted or was on the verge of fainting.
Small changes and clear answers
After two years of tweaking the woman's medications without seeing any improvement, Ramos underwent repeat echocardiograms. The thickening worsened, but only in the wall separating the left and right ventricles. It was a small change, but enough for Ramos to recognize the problem. The woman had a disease called hypertrophic obstructive cardiomyopathy (HOCM).
Ramos sat across from the patient with a model of the heart and a piece of paper and helped show the patient how this small change in the structure of the heart can cause a fainting attack. The wall between the ventricles, known as the septum, plays a unique and important role in blood flow through the heart. When increased demand sends more blood to the left side of the heart, for example when you're exercising in the heat, its walls have to bulge outward to accommodate the larger volume. If it gets thick and hard, you can't do that. The thickening also changed the way the ventricular valves opened, partially blocking outward flow with each beat.
The patient indicated that he had been experiencing syncope for many years. Why wasn't her echocardiogram normal before? Ramos explained that HOCM affects how the heart pumps long before any changes are visible. And over time, the thickening of the septum becomes even more exaggerated.
HOCM is a mostly inherited genetic disease that affects 1 in 500 people. The most severe symptoms occur in young athletes who die unexpectedly, but in most people the disease begins late and progresses more slowly. Eventually, most people with the condition will need surgery to thin the overstretched septum and repair the valve, Ramos said. She wasn't at that point, but she'll probably get there.
This diagnosis changed the medications she had to take. Some of the things recommended for high blood pressure can worsen the symptoms of HOCM. And Ramos must have his heart monitored every year with an echocardiogram.
Ramos referred to it by an acronym when describing the disease. He pronounced it HOE-come. The patient smiled when he heard this. Ramos looked at her quizzically. “Where I'm from,” she said with a laugh. “Hokum means nonsense, fool.”
The woman responded well to the new drug, but as Ramos expected, the blockage in her heart worsened. She finally underwent surgery in 2021. She hasn't fainted since. She exercises regularly, but not as intensely as before. No more wind blowing on the stairs or when it's hot. Since being diagnosed, she researched her family history. She had two uncles who suffered from heart disease. One died young, and the other lived into his 70s, but was housebound most of his life. Recently, a great-nephew and cousin were diagnosed with HOCM, and the patient continues to encourage others to get tested for the disease.
As it turns out, despite its name, HOCM turns out to be no nonsense after all, she told me.
