The ‘Whys’ of Sudden Cardiac Death Are Unknown ; Best Advice is to Exercise, Take Medicine

By Ask Dr. Ramo BARRY RAMO For the Journal

Three weeks ago, I got a call from the wife of one of my longtime patients telling me that her 60-year-old husband had died suddenly at home while reading the newspaper. After Tim Russert died suddenly under similar circumstances, every patient in my cardiology practice asks “how could that happen” and “how can I keep it from happening to me?”

Russert passed a stress test two months ago. He was taking blood pressure medication and a cholesterollowering medicine.

The sad answer is that we know what happened but we don’t know why it happened when it did or what triggered it. Russert’s coronary arteries contained a cholesterol-filled plaque that ruptured, formed a blood clot and closed off the blood supply that artery provided to the front of his heart. His autopsy showed an “enlarged heart.” That scenario occurs more than 1 million times a year, but most people with a heart attack survive if they make it to the hospital.

Russert had risk factors for heart disease. He had metabolic syndrome: abdominal obesity, high blood pressure and a particular cholesterol pattern characterized by low HDL cholesterol and high triglycerides. The syndrome often leads to diabetes, which Russert also had. But what triggered the plaque rupture that day isn’t known.

The first symptom of coronary artery disease in men is either a heart attack or sudden cardiac death. The absence of a warning is all too common because the plaques that rupture most often aren’t narrowing the artery enough to cause chest pain or shortness of breath, providing an advance clue to impending trouble. For that same reason, a stress test can be normal because an artery has to be more than 80 percent narrowed to produce a positive test.

So what am I telling my patients who ask if they are candidates for what happened to Russert? First, know and act on your numbers: your waist size, blood pressure, cholesterol, blood sugar and the number of steps you take a day (5,000 or more should be the minimum goal). But that doesn’t really tell us with any accuracy who is at risk for sudden cardiac death (except for people who have severely damaged hearts who are at very high risk for cardiac arrest).

We are looking at blood tests like C reactive protein that are markers of inflammation, the apparent cause of plaque rupture. For some patients at risk, I often recommend a coronary calcium score, which Russert had 10 years ago that showed he had calcium and therefore plaque in his coronary arteries. But for now we don’t have the equivalent of a biopsy that says sudden death is likely in your future, nor do we know yet how to prevent the rupture.

Automatic external defibrillators, or AEDs, are now routinely placed in airports, office buildings and sports stadiums. The studies in casinos have shown that the devices when used promptly can save lives. They should be as common as fire extinguishers where large numbers of people congregate.

A recent study suggests they aren’t worth buying for home use. However, learning CPR and calling 911 can make some difference although sadly, most patients who have a full cardiac arrest out of hospital die.

I feel very sad about my patient’s and Tim Russert’s deaths because they underscore how little we know about absolutely preventing the nations No. 1 killer. But your risk is clearly lowered if you act aggressively on the risk factors. And doctors must not just pat people on the head who are obese, who smoke and who don’t exercise. Here is the lesson for now: Get thinner, get fitter and take your medicine. Being passive for doctors and patients is dangerous.

Dr. Barry Ramo is a cardiologist with the New Mexico Heart Institute and medical editor for KOAT-TV. Send questions to Albuquerque Journal Boomer, P.O. Drawer J, Albuquerque, NM 87103, or e-mail them to htaylor@abqjournal.com.

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