This is going to be an uncomfortable article for many of you to read. There will be some gruesome details. Morbid realities. And perhaps a few truths, that might make some of you wonder about your own health. And it should.

Also, it's very uncomfortable to write. Very personal. So, it is with sincere hope that the author, yours truly, can offer up some wisdom that might change, or even save, some lives among those reading.

Let's start with an irony…

Prelude: Gratitude Before A Cascade of Tragedy

In 2022, I remember sitting in bed, thinking, "Wow. I have a lot to be thankful for. I just got a nice job. Despite being separated from my other half because of global conditions, we managed the distance well. I have good friends… I can't remember the last time I cried about anything."

Then... life started hammering me:

• 1 month after, my Dad died in the US (heart attack)
  
• 4 months later, I broke my ankle
  
• 2 months later, I lost my job
  
• 6 months later, I was hit by a truck while riding my bike and broke my wrist
  
• 2 weeks later, I had a heart attack
  
• 1 week later, open heart surgery
  
• 5 months later, motorcycle accident, broke my ankle (again)
  
• 1 month later, I get stung by a bee (at this point...'when it rains... it pours')
  
• 4 months later (estimated), one of my arteries collapses.
  
• 2 months later, high blood pressure becomes a symptom so uncomfortable, I go in for a check-up. I need heart stents.
  

There is a tremendous amount of details in the above that we're going to skip. I do want to also say, before anyone thinks I am disaster-prone... the last time I went to the hospital for anything was 2012 (this... is actually a problem which I'll explain later).

What is Inside This Article Series:

• The symptom and triggers that lead to my heart attack (super important, DON'T skip this)
• The heart attack itself in Turkey: So you know what it feels like.
  
• The open-heart surgery in Turkey: All the gruesome details.
  
• Post-operation problems in Moldova: A big change in healthcare
  
• Bringing my healthcare back to China: An even bigger change in healthcare.

If just one person spots the symptoms I had and takes early action, if just one person gets a little smarter about navigating healthcare while overseas, or if more expats realize what's actually possible in China – so they stop skipping treatment or dodging check-ups over bad info – then sharing this is absolutely worth it.

PART ONE: THE SYMPTOMS AND TRIGGERS BEFORE THE HEART ATTACK

When I first came to China, I looked like this. I was 174 and around 64kg. I even had hair:

The Downward Spiral Context: 2018-2022

My life was upended in 2018 when my partner had to leave China. Personal circumstances required them to leave suddenly, and the declining health of family members prevented them from returning so quickly. A creeping psychological pain started impacting various parts of my life, and for all to see, I'll talk about my coping mechanisms:

- I stopped going out, because going out reminded me of my loneliness

- I started comfort eating

- I began consuming myself in work, working 12-16 hour days.

This is What Began to Happen to my Body:

Weight Gain: So, the young curly-haired boy didn't last long in China. I "matured" a bit, meaning I lost all my hair and evened out to a pleasantly plump 74kg. But as things progressed over my journey, I exploded to nearly 92kg. As I put on weight, other symptoms began to creep up.

Nose bleeds. Often. At first, I didn't think of them and just took it as an issue with "dry air." But this was a sign of Hypertension (High Blood Pressure). This shows you how silly a person can be when experiencing a seemingly benign symptom, and how we rationalize to make things seem "normal," or nothing to worry about.

You see, weight gain can contribute to high blood pressure. The extra weight makes your heart work harder because it has to pump blood to more body tissue, increasing the pressure on your artery walls. This extra pressure can strain the tiny, fragile blood vessels inside your nose, making them more likely to break and bleed. So this resulted in sudden nosebleeds, even without obvious triggers like injury or dry air. While not everyone with hypertension gets nosebleeds, frequent or unexplained ones were signs for me to check in on things. But I didn't. In my defense...people in Shanghai are way too busy to notice the frequency of nosebleeds, let alone go to a hospital because of a nosebleed. Right?

Another interesting tidbit: carrying extra weight is often linked with other issues like high cholesterol, insulin resistance, and inflammation, all of which can add to the strain on your heart and blood vessels. This brings me to my next issue.

Needing to Pee More: I began to pee more, especially in the middle of the night. Every single night, I'd have to get up in once or twice and unleash the damn. But, I also was getting thirsty. Soooo thirsty, that I ended up putting a refrigerator in my room to keep chilled water and tea. Now… again, I thought this was just "dry air"… I mean, nosebleeds right? It's all dry. And I thought to myself "Well, I'm drinking lots of water. So healthy!"

But here's the thing – frequent urination and constantly feeling thirsty are classic signs of high blood sugar, and in my case pre-diabetes. When your blood sugar is too high, your kidneys work overtime to get rid of the extra sugar through your urine, which makes you pee more. As you lose more fluid by urinating frequently, your body gets dehydrated, making you feel really thirsty to replace what you're losing. This has direct effects on heart health.

I had this explained to me here in China by Dr. Fei, the Associate Chief of Cardiac Center at Jiahui Hospital (where eventually I moved my heart healthcare too).

Pre-diabetes, diabetes, and insulin resistance all increase the risk of cardiovascular disease (CVD) because they cause damage to the blood vessels over time. When blood sugar stays too high, it can make the walls of your arteries stiff, inflamed, and more likely to collect plaque (a fatty buildup), which can block blood flow and lead to heart attacks or strokes. Insulin resistance (when the body doesn't respond well to insulin) also increases harmful substances in the blood like triglycerides and "bad" cholesterol, while lowering "good" cholesterol, which adds even more stress to the heart and arteries. Altogether, these conditions create a perfect storm of high blood sugar, unhealthy cholesterol, and inflammation that puts a lot of extra strain on your heart and circulation.

If you've ever wondered why sometimes diabetes impacts heart health there's your answer.

Changing Health Habits Might Not Be Enough: 2023

After reuniting with my better half after time away from each other. I was told point blankly, I had gotten into a physical condition that... needed to change ("Jacob, you got fat"). So I started exercising. It was... really really difficult. But I was in an absolutely beautiful place, Antalya, which is a city on the southern coast of Turkey, in an area called the Turquoise Coast. Little did I know that this beautiful city would be a place that would break my body and spirit in so many ways. But it also rebuilt, and transformed me.

For the majority of my life, physical exercise was always laborious. If you are reading this and dislike exercising, kindred spirit here. More often than not, I would experience chest pain, and would run out of breath easily. I always thought this was just a condition of my natural state: not keeping up my stamina by being inconsistent with exercise.

I should mention that a lot of my knowledge about my condition has come from treatment here in China, ironically, given that despite living here, I always avoided going to the hospital here. There were huge contrasts in medical care across my journey, but a vast enlightenment regarding my condition didn't really occur until I came back to Shanghai. I'll explain this throughout.

In relation to exercise, I asked Dr. Wei at Jiahui if the pain and discomfort I felt from exercise was an indication of what may have been happening underneath. Here is his answer in full:

I'd like to summarize the step-by-step approach to your question about experiencing symptoms like chest discomfort, fatigue and feeling unwell during exercise, especially at your age.

The first step is to figure out what's causing the symptoms. We need to determine whether your symptoms are due to reduced blood flow to the heart (ischemia), or if they're simply the result of low physical fitness from not exercising regularly.

Cardiologists are trained to tell the difference between these two situations because ischemia tends to have specific symptoms, often referred to as "typical chest pain." This usually feels like pressure, tightness, or squeezing in the chest, especially during exertion, and it may radiate to areas like the arm, neck, or jaw.

On the other hand, people who are just deconditioned (not used to exercise) tend to experience general fatigue and shortness of breath during physical activity. These symptoms happen due to poor exercise tolerance and are not necessarily caused by reduced blood flow to the heart.

In hindsight. I definitely had the conditions of ischemia. I talked to a relatively healthy friend of mine after walking up a hill together. He noticed I was uncomfortable and explained how I felt. We were both out of breath. But his chest didn't feel tight.

I continued to build up my tolerance and endurance. Regularly exercising, and going to the gym for the next three months after arriving in Antalya. Eventually, I was able to do 3-hour bike rides along the coast of Antalya bay. This improving of my condition didn't matter in the end.

Then... I Got Hit By A Truck

So… while I'm starting to live a re-vamped life along the turquoise coast, some unexpected "life" happened. One evening, riding home from a beach picnic, I began crossing the road on my bike. BAM! I got hit by a big black TRUCK! (Technically, an SUV, but truck is more fun to say). It sent me flying off my bike, plunging into the road. They offered to take me to the hospital, but not wanting to cause a fuss, and feeling like I was fine, I just went home. Silly of course, but not because of the heart attack… but because I had broken my wrist. 2022 – 2023 is turning out to be amazing.

Strangely, it wasn't a painful experience, but doctors have said that was likely due to the numbing effect of shock.

What I remember most, however, was the full force of my body landing on the pavement. Why do I mention this? Well.. the question of "Why did I have a heart attack" was always on my mind. Especially after I started to change my diet and exercise more. I had mentioned to Dr. Wei, that this incident had occurred not too long before my heart attack. I asked if this could have been part of the equation.

Dr. Wei: Yes, the answer is yes. It's possible, and actually, it's a recognized occurrence. An acute myocardial infarction (heart attack) can happen in arteries that don't have severe lesions (significant narrowing or damage inside the artery caused by plaque buildup).

While severe lesions (major blockages) can cause heart attacks, more than 30 percent of myocardial infarctions (heart attacks) are actually caused by non-obstructive plaques (plaque buildups that don't block much of the artery).

Why can these plaques cause a heart attack? It's exactly as you mentioned. Plaques (fatty buildups in the artery walls) can rupture (break open). We generally classify plaques into two types:

• 1. Stable Plaque – This type has a very thick fibrous cap (the protective covering over the plaque), making it less likely to rupture.
  
• 2. Vulnerable (or Unstable) Plaque – This type has a very thin fibrous cap (protective layer), so it's much easier for it to rupture.
  

If there's high pressure, strong heartbeats, or sudden physical force, vulnerable plaques (the ones with the thin covering) are more likely to rupture. So in your case, the blunt force trauma of being hit by a truck a few weeks earlier, likely may have weakened vulnerable plaques, which then ruptured during your period of physical exertion from your increased heart rate. If you had an unstable plaque (a fatty deposit with a thin cap), the force of getting thrown from a bike onto the pavement, strong enough to break your wrist, could have weakened or partially cracked, even if it didn't rupture immediately.

In fact, blunt trauma is known to sometimes cause heart attacks immediately. I've seen many cases. For example, there was an incident where two men were arguing, and one punched the other in the chest. Hours later, the man who was punched had a heart attack. I was asked to assess whether the punch caused it – and yes, trauma like that can absolutely be a cause.

---

It turns out, that blunt force trauma can weaken or even rupture the walls in your arteries. Car accidents, physical assaults, even sports injuries, can cause serious cardiac complications in otherwise healthy individuals.

The Heart Attack

There was a time in the morning when I had started some "exercise" that got my heart rate up. This was Wednesday, we were scheduled to fly to Barcelona on Friday. After exerting myself, I felt a slight, dull-ish pain in my chest. I was breathing quite heavily, and at first just thought what I was feeling would subside.

How Would I Describe the Pain?

At first, it felt like precordial catch syndrome (PCS). Have you ever felt a sudden, sharp, stabbing pain, often near your ribs or slightly under them on either side? It feels like something is "stuck", pinched, or caught, and it worsens when you take a deep breath. It often "releases" suddenly with movement or even a deep breath, and then the pain is gone (I bet a lot of you have wondered what that was). So at first, I thought this was what I was experiencing because the pain was somewhat similar.

But then… I noticed something different. The pain wasn't exactly near or under my ribs. The pain was similar, but it felt…deeper, like inside of my heart on the left side. The next thing I noticed… is that the pain wasn't subsiding. It was very slowly… subtlety growing… into something else. I was still breathing heavy. Something was wrong.

I sat down, pulled out ChatGPT and briefly described my symptoms. As I was typing, my left arm started getting tingly. I remembered a movie that my better half made me watch six years ago about the human body from birth till death. In that movie, the person died of a heart attack. ChatGPT outlined exactly what I was feeling and what I was about to feel.

In the space of 5-ish minutes, I said "I need to go to the hospital, now."

My flatmates helped me get downstairs (we were living in a duplex). I sat on the couch, waiting for an ambulance. Out of nowhere, I started sweating profusely. I wasn't hot; I was freezing cold, and I was sweating. At this point, I told myself that it's important to stay calm and started giving my bank account passwords to my significant other because I knew what was happening… just in case.

One thing about my preconceptions (and perhaps many of you may think this as well) is that I thought: when you have a heart attack,… it's like… 3-5 minutes of feeling a pain in your chest and arm, then you keel over and you're DEAD, like in the movies. It's not like that. It's worse because the experience can last much longer.

Now the time varies depending on how severe the heart attack is, which artery is blocked, and how much heart muscle is affected. Dr. Wei was able to explain to me that "In my case, you were suffering from a left anterior descending artery (LAD) myocardial infarction. These types of heart attacks are particularly dangerous and are sometimes called the widowmaker". Yikes.

So the ambulance arrives in about 5-minutes (impressive). I'm driven over to the hospital, about 10 minutes (not bad). I'm admitted to the hospital, they take my vitals, give me some crushed aspirin. I wait for another 5 minutes, then I am taken into a Cath Lab (Cardiac Catheterization Laboratory) for an emergency angioplasty (a procedure to open blocked heart arteries using a balloon and often a stent). Now, I didn't know what was going on. I'm in Turkey and people aren't speaking a lot of English.

Things had been more than 5 minutes, and I wasn't already dead, so I wasn't even sure I was having a heart attack. The angioplasty was interesting. They inserted a catheter through my leg (using the femoral artery… it's a big vein in your leg that goes to your heart).

An Angioplasty Feels Like Aliens Poking Around Inside Your Heart

So, what is an angioplasty and why is it being done? Using live X-ray imaging, and technique called fluoroscopy, doctors are able to see what's going on inside you. First, they inject you with a special dye to create contrast, the dye flows through the catheter directly into your heart to make your blood vessels visible on X-Ray. A continuous X-ray machine takes real-time images so they can see where the blockage has occurred. Once they identify the blockage, they will perform an emergency angioplasty.

Eventually the pain subsided, and I started to feel fine while they were digging around in me. It wasn't clear if they had inserted a stent, or a balloon to open up my artery again, this part was a blur. One thing to note: When they take the catheter out of your your leg vein, you need to keep your leg flat and extended. DO NOT BEND IT. Unfortunately, the nursing staff wasn't able to speak English, and I misunderstood what they had meant, when they were pointing at my leg and giving me instructions. This reduced pressure at the puncture sight and prevents things from excessive bleeding and/or complications. I lifted my leg, and ended up bleeding myself a huge bruise that lasted for weeks.

But they discovered something during this procedure. Most of my primary arteries had between 70% - 90% stenosis (meaning, they were blocked). I wasn't off the hook.

The Bad News

"You are at high risk of having another heart attack. And it could be worse next time. You should have open heart surgery so we can replace some of the arteries; if you want to do this, we can schedule you for next week. If you can't commit now, we can schedule you in a few months."

A-mazing. All this is happening, by the way, while transiting through Turkey, without health insurance. Double A-mazing. I'll kill the suspense and just say now that I opted in to have the quadruple bypass, but this utterly gruesome part of my journey will be in the next installment of this little mini-series.

This Can Happen to Anyone:

I was 39 when this happened. And before anyone says "Oh well, he's closer to 40, the article title is clickbait". One thing that every doctor had said was "you are too young to have this happen to you." 7 months after this happened to me, one of my best friends in Shanghai, had a heart attack, and did. He was 35 years old. This can happen to anyone.

Now The Most Gruesome Part of This Story

The most gruesome part of my story comes with the open heart surgery. But we'll save that. We have to end this article here, because... it's already long enough. If you've read this far, then at the very least I hope to have given some of you food for thought with regards to your own health, and at least armed you with a bit of knowledge on how to be a bit more self-aware with our bodies.

One final and important point that is really surmised by the totality of this mini-series: If you are here, don't hesitate to go to the hospital in Shanghai. After having spent time in healthcare systems in Turkey, Eastern Europe, and now Shanghai, I can say that the healthcare system in this city is outstanding. Innovation and global-leading research take place here, so don't, under any circumstances, let preconceptions or outdated ideas stop you from getting things checked out if warning signs crop up.