"I think I'm having anxiety," Leonard Castro told his wife on a day back in September.
Some time in the days running up to Sept. 9, multiple factors that made 46-year-old Leonard Castro a prime candidate for a heart attack converged. His body was groaning: Blood pressure too high. Too much bad cholesterol. Too much sugar in the blood. Too much weight.
Over the years, the walls in the arteries of his heart had narrowed and stiffened with plaque. The cells in those arteries became inflamed, a medical term perfectly derived from the Latin word "inflammare": to set on fire.
Small clots of blood began to plug the arteries. Each time the flow of blood faltered, even for a few seconds, muscle cells died of lack of oxygen.
That was what was happening inside one man's chest. Simultaneously, lives were upended. A spouse began imaging herself a widow. A father feared he would outlive his son.
A middle-aged man wondered: How could this happen to me?
Someone has a heart attack every 34 seconds in the United States. For 785,000 people, it's a first heart attack. For 470,000, it's a second or perhaps third attack. Fewer people than ever suffer that "big, bad heart attack" that kills them or ruins their health, says Dr. C. Noel Bairey Merz, director of the preventive and rehabilitative cardiac center at Cedars-Sinai Medical Center in Los Angeles. "If you can get to the hospital, the death rate is very low now." More than 90% of heart attack patients who reach the hospital survive, according to a recent study.
And most people who survive heart attacks today are expected to fully recover. But that is not to say their lives don't change dramatically. They have to.
One minute Castro, an auto parts salesman, was a weekend golfer who changed the oil in his car, mowed his own lawn and trimmed the ivy.
The next minute, he was on disability, could barely walk across his house and needed help using the bathroom.
Hilda asked neighbors to keep an eye out so he didn't do anything stupid and strenuous, like start the lawnmower.
That is a heart attack for those who survive.
"I felt like a dead fish in the water," he said of those first weeks at home with a healing chest. "I couldn't bend down. I couldn't put pressure on the chest. When we brought groceries home, Hilda would bring in the bags. I would carry a loaf of bread or the eggs."
The Castros were hosting relatives for Labor Day weekend when it happened. On Saturday, Leonard and Hilda's cousin played golf. He joined a raucous game of volleyball in the pool. He manned the grill, flipping burgers and steaks.
On Sunday, they went to a swap meet. Leonard says that, while standing by the entrance gate, "I kind of lost my breath. It felt like a smog day, when it hurts when you breathe."
Leonard waved off Hilda's concern.
A heart attack? No way. But, in fact, he had been warned about such a day. Over the years, he had developed into a walking checklist of cardiac risk factors. He was 5 feet, 11 inches and weighed 318 pounds. He took blood pressure medication and had total cholesterol of about 250 — too high. His father had heart disease. Five years ago, Leonard was diagnosed with diabetes.
"Every time I'd see my doctors, they'd say, 'You need to lose weight. You're at risk for heart disease. We don't want you to have a heart attack,' " Leonard recalled. "I'd tell myself, I won't get to that point."
He would come home from the doctor and watch what he ate: skinless chicken breasts and salads instead of the pasta he loved. But never for more than a few days.
Over the next few days, Leonard had more bouts of shortness of breath, usually in the evening. Hilda, his wife of 18 years, insisted on calling the doctor Wednesday night. The doctor told him to go to the nearest emergency room. Leonard wouldn't go. It was anxiety, he insisted. Or maybe his new diabetes medication wasn't agreeing with him.
The next day, when Hilda found him lethargic, sweating and pale — still insisting he was OK — she erupted. "We call 911 or I'll drive you to the emergency room," she ordered.
Within the hour, an emergency room doctor told Leonard that he had had a heart attack.
Leonard's 81-year-old father burst into tears when he saw his son hooked to an electrocardiogram machine. "This shouldn't be happening to you," he cried.
Leonard was transferred to St. Joseph Hospital in Orange and two days later underwent a quintuple bypass surgery to re-establish blood flow in five completely or partially blocked blood vessels.
Family and friends filled three waiting rooms. Hilda asked them to be strong in front of Leonard. No tears.
He cried once, lying on the gurney just before surgery. He was afraid he would not survive. Hilda cried too. "I was crying because he had to go through this."
Heart disease remains the leading cause of death among Americans despite numerous advances to keep patients alive. But it used to be far worse three decades ago. Heart attack patients were treated very differently from now, Bairey Merz, of Cedars-Sinai, recalled.
"They were identified, placed in a room — sometimes not even an intensive care unit — and given morphine and nitroglycerin," she said. "Then we would close the door and hope they would be there in the morning. We didn't have the understanding and the therapies to abort, interrupt or treat the heart attack."
Before the advent of coronary bypass surgery, clot-busting therapies and angioplasty, a procedure to open a clogged artery, survivors were left with heart failure, Bairey Merz says. "They didn't go back to work. They were weak."
Cardiac rehabilitation also changed, turning into a comprehensive program called secondary prevention that starts right after release from the hospital.
Secondary prevention is Life Overhaul 101. Patients learn about nutrition, exercise, stress reduction and how to manage multiple medications: aspirin, statins, beta-blockers and ACE inhibitors. They are screened for depression and treated if necessary. Smokers are urged to begin cessation classes.
Studies show that the more patients adhere to their program, the better they do.
"If, a year after a heart attack, a patient is taking all of these medications, they have a 90% reduction in recurrent risk," Bairey Merz said. "If they then do some exercise and go to a cardiac rehab program, they basically become immortal."
Leonard Castro doesn't feel immortal.
When he awoke from surgery, his chest felt heavy and numb. When he arrived home, he was confined to the upstairs of his house and a schedule of 10 five-minute walks a day.
Later, he would sit in a chair and watch Hilda clean the pool, and he'd simmer with frustration that he couldn't help.
"I would get up and try to sweep some leaves, and she would get so mad at me," he recalls.
His worst day occurred a couple of weeks after the heart attack, when he looked up information on quintuple bypass on his home computer. One article said his life expectancy was 15 years.
"I'm sitting there doing the math," he recalled. "So they're telling me I'm not going to make it to retirement age." He thought of his finances. They weren't in shape for Hilda. He thought about the travel he and Hilda had planned but never done: Yellowstone, Washington, D.C.
Forget that, said his cardiologist, Dr. Maged Azer. "Those are averages. What you want to do is not wait for the second heart attack."
As the half-dozen men and women work out in the cardiac rehab gym at St. Joseph Hospital, they watch a fast-paced world going by outside the floor-to-ceiling windows. Inside, each individual's pace is monitored by a nurse to make sure it remains within a permitted window of beats-per-minute in rhythmic uniformity.
The cardiac rehab patients greet each other and chat as they exercise. A priest, a businessman, a retiree. Leonard, working out on a stationary bike at 119 beats per minute, is the youngest.
"We're going to miss you, Leonard," Deborah DiGennaro, a nurse, calls out. It is four months after the heart attack, and today is his 24th, and final, rehab session.
Since the surgery, he has lost 35 pounds and his blood sugar has improved. He and Hilda, who has lost 10 pounds herself, walk every day around the neighborhood or at Disneyland, one of their favorite places. If it's raining, they grab umbrellas and go anyway.
Hilda was laid off from her job as a legal secretary a few weeks after Leonard's surgery. But, while looking for employment, she has learned to shop and cook in a new way, focusing on recipes from a cookbook for diabetics and avoiding meals high in carbohydrates.
The hardest part, she says, is setting aside her fear of the future. "In the weeks after the surgery, I'd wake him up in the middle of the night to make sure he was breathing. He'd say, 'Hilda! I'm asleep!' "
Leonard finishes his workout, turns in his heart monitor and receives a paper certificate attesting to completing cardiac rehab. It's decorated with hearts.
Cheers go up as Leonard holds the certificate aloft, a brief flash of pride. Hilda tears up.
They plan to travel more: Yellowstone and Washington. He aims to lose about 50 pounds more and can't wait to wrest the lawn chores away from his wife. He knows he's been given a second chance.
"I'm still sort of in shock that it happened," he said. "But every day I go in the bathroom to shave and I look in the mirror and see my scar. I'll see that scar every day."
At the first visit with Azer after bypass surgery, the doctor was straightforward. "You're young," he told Leonard. "You have a fresh heart. Now it's up to you to make the decisions to make this work."
Leonard nodded. Hilda smiled. "A fresh heart," she said. "I like that."