One of the many perquisites of practicing medicine at Saint Louis University has been the opportunity to participate in a medicine and literature program. Roughly once per month, the participants are gifted a book to read and subsequently discuss at a zoomgregation.
Last month’s book was “The Body: A Guide for Occupants” by Bill Bryson (BB.) Now I’m a big fan of BB, especially his early work and, in particular, “Notes From a Small Island,” having spent the first five years of my life on a small island; I consider myself a human body aficionado but the idea of reading a layperson’s guide to the body, even one with the wit and humor of BB did not initially appeal to me.
Consequently I decided to only read the portion dealing with the heart and critique it viciously. The process did not take long as Bryson shockingly only devoted 13 of the book’s 450 pages to, in my totally unbiased opinion, the most interesting, best understood, and most important body organ on the planet. Cardiac disease is the biggest killer of men and women in the US and the amazing treatments ranging from drugs to devices that cardiologists have developed to dramatically cut heart disease death are nothing short of astounding.
Surely, I thought, the heart deserved more than 2.89% of BB’s total body dissection.
After completing my critical mission, I must admit, however, that he did a decent job of relating some of the fascinating history of cardiovascular medicine without giving out horribly bad advice. He gets off on a good foot for me when he brings up, the man I like to call “The Torturer of Teddington.”
The Reverend Stephen Hales (1677-1761)
Bryson spends a paragraph describing the early work of this fascinating Anglican curate who greatly advanced understanding of cardiovascular physiology with various “gruesome” animal experiments.
Bryson also describes in some detail the self-experimentation of Werner Forssman who was one of three to be awarded the Nobel Prize in 1956.
In his Nobel acceptance speech Forssman summarized the contribution of Hales to heart catheterization thusly:
As far as I know, the credit for carrying out the first catheterization of the heart of a living animal for a definite experimental purpose is due to an English parson, the Reverend Stephen Hales. This scientifically interested layman undertook in Tordington in 1710, 53 years after the death of William Harvey (1578-1657), the first precise definition of the capacity of a heart. He bled a sheep to death and then led a gun-barrel from the neck vessels into the still-beating heart. Through this, he filled the hollow chambers with molten wax and then measured from the resultant cast the volume of the heart-beat and the minute-volume of the heart, which he calculated from the pulse-beat. Besides this, Stephen Hales was also the first, in 1727, to determine arterial blood pressure, when he measured the rise in a column of blood in a glass tube bound into an artery.
As BB notes Hales “had the double distinction of advancing science while at the same time giving it a bad name.”
The difference Between a Cardiac Arrest and a Heart Attack
I salute Bryson for spending several paragraphs highlighting the important distinction between two cardiac events which are often used interchangeably by laypeople: a cardiac arrest wherein the heart suddenly stops beating due to an abnormally fast or slow rhythm and a heart attack wherein a portion of heart muscle loses its blood supply and begins to infarct or die.
Immediate action is needed for both these conditions and is often life-saving: CPR and defibrillation for the first and catheterization with stenting for the second
The distinction between the two is medically important because they require diffferent treatments, though the distinction may be a touch academic to the sufferer
Ironically, it turns out, this distinction is quite important to BB himself.
Unexpected Death During Sleep
Bryson begins one paragraph with a discussion of the different ways heart attacks manifest in women versus men, moves on to mention angor animi (a sense that one is about to die sometimes noted in patients with heart attacks), and ends with a discussion of the high prevalence of sudden unexplained death syndrome in the Hmong people of Southeast Asia.
In the middle of this wide-ranging paragraph he tucked a sentence which simultaneously intrigued and alarmed me
My own father went to bed one night in 1986 and never woke up.
As I’ve discussed in numerous previous posts (on Garry Shandling here and here) it is really important to know what is on your parent’s death certificate: it is even more important if your mom or dad died suddenly, unexpectedly and/or at a youngish age. The more unexpected and the younger the death, the greater is the need to obtain an autopsy to inform what ends up on the death certificate.
Often, a parent’s sudden death during sleep is due to coronary artery disease with an acute heart attack and subsequent cardiac arrest. If this is documented, then children of the deceased need to engage with a good preventive cardiologist as soon as possible
Other causes of death, however, can also be inherited including aortic aneurysms and certain inherited arrhythmias
A recent review of the “Impact of Sleep on Arrhythmogenesis” notes that “15% of sudden cardiac deaths occur at night or 48,750 cases annually in the United States alone.” Such deaths might be related to sleep-state dependent changes in autonomic nervous system activity or obstructive sleep apnea.
Studies show the rate of nocturnal cardiac events is nonuniform:
The peak incidence of myocardial infarction and AICD discharge occurred between midnight and 0:59 am, whereas the peak incidence of sudden cardiac death was between 1:00 and 1:59 am.
If Bill Bryson’s dad had a normal autopsy we might consider his failure to wake up was a consequence of the Brugada syndrome:
The striking phenomenon of sudden death during sleep due to ventricular arrhythmia has been reported in Western adults diagnosed with the Brugada syndrome, which strikes men almost exclusively, and in young, apparently healthy Southeast Asian men with the sudden unexplained nocturnal death syndrome (SUNDS). The latter syndrome is named lai-tai (“sleep death”) in Laos, pokkuri (“sudden and unexpected death”) in Japan, and bangungut (“to rise and moan in sleep”) in the Philippines. These syndromes probably represent the same disorder, which is characterized by right precordial ST segment elevation.
In which case BB should get an ECG.
In any event, whether BB’s dad died during his sleep from a massive heart attack or a cardiac arrest from another mechanism is well beyond mere academic concerns.
A Message to Bill Bryson
I was able to get this email to Mr. Bryson via Penguin his publisher:
I’m a cardiologist and Bryson fan. As part of the Saint Louis University School of Medicine 2020-2021 Literature & Medicine program (basically a book club which, during the pandemic has been conducted via Zoom) your book, The Body, was selected. Due to time constraints and my feeling that other organs are not important, I focused on the 13 pages you spend on the heart. I became concerned for your wellbeing when I read that your father went to bed in 1986 and never woke up. The sentence on your dad is tucked into a paragraph between sentences on gender-related differences in heart attacks and the Hmong risk of SUNDS and could be easily overlooked but it is of immense significance. In both my writing as the skeptical cardiologist (see here and in discussion with my patients I emphasize the importance of knowing what is on your parent’s death certificate, especially if they died suddenly or at a youngish age. Sudden death is commonly assumed to be due to a “massive heart attack” but as you point out in your chapter on the heart there is a big difference between cardiac arrest and heart attack and with unexpected death during sleep, a heart attack may not be involved. Anyway, I am primarily writing this to encourage you to consider undergoing evaluation if you haven’t already for any evidence of premature atherosclerosis which might put you at risk for the same fate as your father.
I suspect you have access to the best and brightest doctors in the world and I hope you’ve had discussions with them on your dad’s fate and what you can do to avoid it but lately, I feel compelled to spread the word on the inherited risk of sudden death and coronary atherosclerosis to anyone I come into contact with, even if, as in your case, I only know you from your outstanding literary output. My most recent post on inherited coronary heart disease risk and how to better identify it is on my blog here.
We can all breathe a sigh of relief as Mr. Bryson did respond and assures me that his doctors believe he is in tip-top shape.