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Brian Ditto

Roger Ditto, left, talks about his heart attack during an interview with Dr. Brian Rah, a cardiologist and chair of the Cardiology Department at Billings Clinic.

A heart attack was the last thing Roger Ditto figured he was suffering last fall.

“I had about a week of early warning and I refused to listen to it,” Ditto, 65, said in an interview with Dr. Brian Rah, a cardiologist at Billings Clinic.

The Billings man didn’t think he fit the profile. He’s active, doesn’t smoke, doesn’t drink much alcohol, has good cholesterol numbers and a low resting heart rate.

About a week before, toward the end of playing 36 holes of golf with a friend, Ditto felt like he was breathing cold air, “like I had something going on with my lungs.” A visit to a physician assistant didn’t reveal anything out of the ordinary.

Then he developed heartburn, and at one point he vomited bile.

“The wife and I were looking on the internet and thought maybe this is an ulcer,” he said. “I’d eat an apple and it would calm down completely.”

He also took Prilosec, a medication that helped relieve the burning pain. Ditto finally scheduled an appointment with his longtime family physician, Dr. Daniel Gall, at Billings Clinic West.

On Oct. 30, the day before the appointment, Ditto played another round of golf. He almost talked his wife, Phyllis, into canceling his meeting with Gall.

Instead, he saw the physician, who insisted on an EKG. It revealed one artery was 100 percent blocked.

“He comes in the room, puts his hand on my shoulder and he says, ‘you’re having a heart attack right now,’” Ditto said. “I thought he was kidding. The next thing I knew I was in the cath lab with Dr. (Brian) Rah.”

Dr. Brian Rah

Dr. Brian Rah, a cardiologist and chair of the Cardiology Department at Billings Clinic, shows images of patient Roger Ditto's heart.

Gall had already called for an ambulance. Then he notified the hospital that Ditto was on his way so he could be taken directly to the catheterization lab.

That’s a good thing, said Rah, a cardiologist and chairman of the Cardiology Department at Billings Clinic. Time is of the essence in treating a patient having a heart attack.

The heart is a muscle, Rah explained, and if its blood flow decreases, it eventually dies.

“We actually call the first hour the golden hour,” he said. “The greatest advantage is getting the artery open in the first hour. After that, the outcome gets worse and worse.”

Rah, who wore red to the interview in honor of American Heart Month, threw out some startling statistics. Every 40 seconds in the United States, a person has a heart attack. Every minute, someone dies of a heart disease-related event.

“More people die of heart attacks than all kinds of cancer combined, even women,” Rah said.

Montana is a snapshot of the timing problem, the cardiologist said. Only about half the people in Billings — and 20 percent across the state — call 911 if they think they’re having a heart attack.

Instead, like Ditto, they tend to ignore the symptoms. Or they drive themselves to the hospital or ask someone to give them a ride.

“I think a lot of people don’t know for sure they’re having a heart attack,” Rah said. “They don’t want to bother people or waste resources.”

Brian Ditto

Roger Ditto, left, talks about his heart attack during an interview with Dr. Brian Rah, a cardiologist and chair of the Cardiology Department at Billings Clinic.

In Ditto’s case, because Gall called ahead, Ditto bypassed the emergency room and was taken directly to Rah. From the time he got to the hospital to the moment Rah opened the artery with a balloon angioplasty and placed a stent was 23 minutes.

“We can’t really improve on that,” the cardiologist said. “What can be improved is the patient getting here faster. That’s why we do so much education.”

The rural nature of Montana can make getting the balloon angioplasty more difficult. Only the larger hospitals around the state have catheterization labs.

At smaller hospitals, physicians rely on thrombolytics, or clot busters, to begin treatment. Then the patient is flown to a hospital where the stent procedure can be done.

“In a rural area, it’s even more valuable if they can notify the hospital they’re coming,” Rah said. “The hospital can notify the med flight so the plane is already there.”

Dr. Brian Rah

Dr. Brian Rah, a cardiologist and chair of the Cardiology Department at Billings Clinic, talks about patient Roger Ditto's heart attack.


As for symptoms, there are the typical signs associated with heart attacks, according to the American Heart Association. They include:

  • Chest pain.
  • Pain in other parts of the upper body, including the arms, back, neck, jaw or stomach.
  • Shortness of breath.
  • Breaking out in a cold sweat.
  • Nausea.
  • Light-headedness.

“About one-third never realize they’re having a heart attack,” Rah said. “They have nausea or vomiting, and a lot of people think they have a GI (gastrointestinal) illness.”

As for what happens to the body during a heart attack, the cardiologist explained the artery is like a pipe. Plaque builds up in the artery, which may create a small blockage.

A lot of people think it builds up and eventually occludes the artery, but that isn’t the case, Rah said.

“You’ve got the plaque, and some of it leaks out, usually in the corners,” he said. “Then all of a sudden it ruptures, stuff leaks out and tends to clot.”

Cholesterol medication can stabilize the plaque, making the plaque wall thicker, preventing it from leaking out the sides. Rah tells patients it’s like having a bowl full of JELL-O and covering it in Tupperware.

“It makes the plaque less likely to rupture,” he said.


There are some obvious ways to reduce the risk of a heart attack.

  • One is to stop smoking.
  • For people with diabetes, maintaining good blood-sugar control is important.
  • Regular exercise and heart-healthy eating both help, Rah said.
  • Taking medication, such as statins, to combat high cholesterol helps.

Next steps

After a patient receives a stent and before they're released, they have a few things to learn, said Kierra Knox, Chest Pain Clinic coordinator. She'll talk about modifiable risk factors, including tweaking the diet.

Kierra Knox

Kierra Knox, Chest Pain Clinic coordinator at Billings Clinic, talks about heart health.

"You don't have to give up red meat completely, but focus more on those lean proteins," she said. 

She invites them to spend time in cardiac rehab, where they'll get a customized exercise routine. And she talks to them about medications they will need to take for up to a year.

All of that together "should help reduce the risk of having another heart attack," Knox said. 



General Assignment and Health Care Reporter

General assignment and healthcare reporter at The Billings Gazette.