Is it a Heart Attack or a Snow-Shoveling Injury?
All symptoms pointed to a dangerous situation… or just a muscle strain
I was the doctor on call for my internal medicine practice one February week many years ago. It had been bitter cold, unusually snowy, and crazy busy.
I got a page from a patient (we’ll call her Ms. Jones): “I’m sorry to bother you on a Sunday morning, but I’m having some chest pains, after shoveling my driveway.”
I’d been catching up on charting, but hearing her say the words “chest pains” and “shoveling” in the same sentence snapped me right to full attention.
“It’s like an uncomfortable tightness across my chest, and it hurts more when I move in a certain way, so at first I thought it was muscle strain, but I Googled it and now I’m worried…” In a near-whisper, she asked: “Could this be a heart attack?”
Shoveling snow can be a high-risk activity
It is true that shoveling snow is a classic trigger for heart attacks. The American Heart Association publishes an annual warning for the general public explaining that the exertion and mechanics of lifting a load in cold weather can be even more intense than a treadmill stress test.
For people who are not in great cardiovascular shape, and who may have underlying heart disease without knowing it (which is common), getting out there to clear the driveway after a snowstorm could be deadly.
According to a 2020 scientific report published in Circulation, shoveling snow is not only significantly associated with heart attacks, but also major cardiac events such as arrhythmias and sudden cardiac death.
So of course, I was concerned. But the more I talked to Ms. Jones about her symptoms, the more I agreed with her own initial assessment that it seemed more like a bad muscle strain than a problem with her heart.
But, what if we were both wrong?
It is well-known that women’s heart attack symptoms are often missed, misunderstood or misdiagnosed, by both patients and doctors.
Indeed, I had had other female patients whose heart attacks presented with symptoms that sounded like something else entirely. In one case, my patient had had heartburn symptoms which she basically ignored. She thought it was nothing more than bad acid reflux. As a result, her heart attack never had a chance to be diagnosed, and she had permanent damage to the heart muscle and chronic heart failure.
Variations of that scenario are not uncommon. Heart disease in women “remains understudied, underrecognized, underdiagnosed and undertreated,” according to an expert commision’s call to action published in The Lancet.
This is a huge problem, because per the Centers for Disease Control and Prevention (CDC) 44% of women in the U.S. have some form of heart disease and it is the cause of 1 out of every 5 deaths of women.
Should she stay or should she go?
As I spoke with Ms. Jones, I learned that she was in her 60s and had high blood pressure, which are two major risk factors for heart disease.
On the face of it, my patient had a classic presentation for a heart attack (chest pain after snow shoveling in the cold) as well as major risk factors (her age and high blood pressure).
Still, the details of her pain made it sound more like a muscle strain to both me and her. Adding complication to the scenario was that, of course, another major winter storm was just rolling in, and she didn’t want to be out in it.
If we were cautious and sent her in to the emergency room, and it turned out to be just a muscle strain, I’d look stupid.
But if we were conservative and let her stay home to treat it as muscle strain, and it turned out to be a heart attack, I’d look even more stupid AND the patient could have a bad outcome. A very bad outcome.
That was that — decision made.
“The safest thing,” I told her, “is to make sure it’s not a heart attack. This requires you to be examined, and to have things like an EKG and labs done. It’s Sunday and our office isn’t open. So, you need to be seen in the emergency room.”
She was not too excited to be going to the hospital on the day of a huge snowstorm, but she was sufficiently scared, and so she did go.
What’s the diagnosis?
I called the ER right away and let them know what I was concerned about, and what I expected for her evaluation.
Of course, whether or not they took her chest pain seriously and did the evaluation depended on the doctor who saw her. There was always a chance that they would disagree with my assessment and plan, and blow her off. It didn’t happen that often, but it did happen.
I had to drive through the snow into the hospital to round on all of our inpatients anyways, so I made a plan to check in on her.
By the time I had finished rounding, hours had passed. I went to see Ms. Jones, and I was pleased to see that the emergency room doctors had done a full evaluation. I found the physician in charge of her case, an older guy with graying temples. Her tests were all back, and the diagnosis was:
Muscle strain, likely provoked by poor form in shoveling.
I expected him to chew me out for sending a minor outpatient issue to the ER. I started to explain my thinking: “I’m sorry, but it was impossible to be sure of the diagnosis, over the phone…”
He waved my apology away. “Oh, this was the appropriate evaluation,” he said. “She had real pain, and real risk factors. Of course she had to come in. We were happy to see her.”
As for Ms. Jones, she was reassured and relieved. Even though it wasn’t her heart that was the problem that day, she was motivated to make some healthy lifestyle changes that could help ensure it was never the problem.
A version of this case was originally published on my own blog at DrMoniqueTello.com. For science-based tips on how to lower your risk of high blood pressure and heart disease, check out my book, Healthy Habits for Your Heart.
