Medicine For People!

February 2016

Heart Attack

Sudden Cardiac Death

The Diplomat

My cousin Arthur had a heart attack about 40 years ago. At the time he was working as a diplomat in South America. He survived that heart attack and took a less stressful job at a college in Maryland. He worked many years and now enjoys his retirement.

Arthur (not his real name; I have some 30 cousins) was among the two-thirds of people who survive their first heart attack. About one person in three doesn't. This is why we work so hard to prevent that first one.

Let's think now about all heart attacks, first, second, and so forth. A heart attack occurs when a blood vessel that feeds a part of the heart muscle becomes blocked. Without its blood supply, that region of the heart muscle dies. The dying heart muscle generates abnormal electrical signals. One-third of the time, these signals lead to a rhythm disturbance which permanently stops the heart from pumping effectively; the person dies. Other times, people have more luck.

The Man from Italy

An Italian man who came into my office long ago with chest pain illustrates this well. We ran an EKG which showed that he was having a heart attack. To my surprise, he didn't want me to call 911, nor did he take my fervent advice to go to the hospital for treatment—he just wanted to know what was going on. He walked out of the office with medication to prevent irregular heartbeat and called back a few weeks later to say he was doing fine. The little dying piece of his heart had behaved itself and set off no fatal rhythm disturbance. He was among the fortunate.

Also fortunate are those people who have no symptoms at all and survive. We discover years later on an EKG that they had had a heart attack. The name we give those is silent heart attacks.

But the heart doesn't always maintain silence. Many folks, usually in their sixties, develop the familiar warning symptom of angina pectoris, Latin for pain in the chest. The pain arises because their heart muscle is unhappy with a reduced but sufficient blood supply; doctors worry, patients worry, and yet five years later about 19 out of 20 of these folks are still alive.[1]

A Hand of Cards

At conception, nature deals each of us a hand of cards. For some, that hand includes the family history of heart disease card, the diabetes card, the high blood pressure card—you get the picture.

If you hold that kind of hand, then the issues raised here are important for you. There are times when attention to each of those cards can extend life and improve health. Modern medicine, while sometimes a little too enthusiastic in the enterprise, does fairly well with those who hold such cards. I am happy to help you with them.

Let's show you another card in the deck.

Sudden Cardiac Death

One-fifth of all deaths in the United States result from sudden cardiac death, meaning that the heart stops within an hour, sometimes with no symptoms at all. Half of these folks did not even know they had heart disease [2]. When you see those hearts routinely restarted in the emergency department on television shows, what you see is fiction. In real life, about one person in 50 will go home and resume normal life after entering the hospital in cardiac arrest. Forty-nine won't.

Preventing Sudden Cardiac Death

For a long time, we thought we could not predict these sudden deaths, hence the great emphasis on lowering high cholesterol and blood pressure, two factors that play a role in many cardiac arrests.

But now we know that about half of people who suffer sudden cardiac arrest had some kind of chest pain or difficult breathing a few hours or weeks before their heart stopped.[3] This means that if they had sought care earlier, quite a few of them would probably have survived.

Realism Doesn't Mean Pessimism

Paradoxically, accepting that we will eventually pass away can be lifesaving. If one death out of five is from sudden cardiac death, then you personally, dear Reader, have a 20% chance of dying from it too. Positive thinking doesn't change that number. Accept reality and you are more likely to live longer than you would otherwise. That's because if you accept reality, you will take appropriate action.

Take Action

Even if you feel generally well and vigorous, unusual chest pain and trouble breathing could signal the end of your life.

Yes, maybe the pain doesn't signal a threat to your life. Nine times out of ten, that's the case. But the emergency department docs would far rather see you those nine times rather than miss the real event. They know that if you can get to the hospital while your heart is still beating on its own, your odds of going home are way over 1 in 50.

Then, like my cousin Arthur, you can continue to make your contribution to our collective human enterprise.

So if you do experience an unusual chest pain or breathing problem, please accept that something unexpected could be happening to you. Call 911.

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Newsletter edited by Jody Bower



Appendix

What If It Isn't My Heart

Most chest pain does not signal a heart attack. Most people have various minor chest pains from young adulthood on, often arising in the chest wall or from the esophagus. You've probably discussed these with your doctor and understand what causes them. If you have a different kind of pain, especially if you are older and judged to be at risk for heart disease, then you need to take action. If your doctors decide that it didn't signal danger, then you've learned something valuable.

Estimating Risk

We can estimate your risk of myocardial infarction (the medical term for heart attack) with a standard cholesterol profile, a chemistry panel, a C-reactive protein level, and a cardiac risk focused examination.

More about Your Heart

Sudden cardiac death starts with damage within the arteries feeding the heart muscle, which permanently disrupts the rhythmic operation of the heart's electrical system. Together with the valves and muscle of the heart, these comprise the important parts of your heart. You can read more in our June 2008 newsletter

Cholesterol: Not What Most People Think

Navigate here and click on Cholesterol: The Inside Story. In a word, the "normal range" for cholesterol printed on every laboratory report in the United States is actually a recommended range. The average U.S. adult cholesterol is close to 220. How can someone call levels over 200 high? All it takes is money and a prestigious committee. If you don't have an hour to watch my video, cruise to here where you can find a 3-minute summary and a chart I don't have permission to reproduce here. The chart illustrates that about a third of people with heart disease have a cholesterol level under 200.

To be fair, newer cholesterol guidelines go beyond mere numbers and address individual risk. You can see a summary here .

Endnotes

[1] Despite the evidence to the contrary, we still perform far too many coronary artery bypass surgeries for this and other heart conditions.The Spanish perform just one of these procedures for every three we do, and still have a lower death rate from cardiovascular disease. See http://www.qualitywatch.org.uk/indicator/international-comparisons-surgical-procedures and https://www.bellevuecollege.edu/Artshum/materials/inter/Spring04/SizeMatters/InternatCardioDisSTATsp04.pdf

[2] European Heart Journal (2014) 35, 1642–1651

[3] Ann Intern Med. 2016;164(1):23-29. doi:10.7326/M14-2342

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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.