The skeptical cardiologist has long been fascinated by sudden, mysterious deaths. Quite often these are ascribed initially to a “massive heart attack” without a shred of evidence to support the claim.
I’ve written about the unexpected death of actor and comedian Garry Shandling a few times on my blog as I think it provides tremendous teaching points for patients.
Initially, I wrote “Do You Know What is on Garry Shandling’s and Your Parent’s Death certificate?” and speculated that he did not die of a massive heart attack as initial reports had suggested but more likely a pulmonary embolism.
The teaching point for patients was not necessarily about pulmonary embolism but about not assuming that the sudden death of a parent or sibling is due to a heart attack.
More important than what is on Garry Shandling’s death certificate is what is on your parent’s death certificate, and whether it is accurate. If one of your parents died prematurely and suddenly, it is important to know with precision what caused it. If the cause was an heritable cardiovascular condition, hopefully, appropriate testing can determine if you have that condition, and steps can be taken to prevent your premature demise.
Thankfully an autopsy was performed and revealed that Shandling did die of a pulmonary embolism.
The Circumstances of Grant Wahl’s Death
The prominent soccer writer Grant Wahl collapsed a week ago while covering the Argentina-Netherlands World Cup soccer match. According to reports he received CPR and was “ubered” to a hospital where he died. A TMZ article strongly implied that it was related to a case of bronchitis that Wahl had mentioned on his podcast. Wahl’s brother issued a video saying he believed Grant had died from foul play related to wearing a rainbow-themed T-shirt into the stadium.
“My body finally broke down on me. Three weeks of little sleep, high stress and lots of work can do that to you… I could feel my upper chest take on a new level of pressure and discomfort.”
Per his newsletter, he went to a medical clinic and was given “heavy duty cough syrup” and felt a little better
According to one report, he received CPR immediately but there was no defibrillator in the press box.
A Ruptured Ascending Aorta
Fortunately, an autopsy was performed on Wahl, and according to his wife (Dr. Celine Grounder) it showed that he died from “the rupture of a slowly growing, undetected ascending aortic aneurysm with hemopericardium.”
The aorta is the larger artery that carries blood from the heart out to the rest of the body. In its first segment it travels towards the head (ascending) and from it come the large arteries that transmit blood to the arms and the brain.
Enlargement of this ascending portion of the aorta (aka aneurysm) increases the risk of a rupture (aka dissection). When a dissection occurs, massive bleeding occurs into the sac around the heart (hemopericardium.) The mortality rate of an ascending aortic dissection is very, very high and unless surgery is done immediately most patients die.
The chest pain that Wahl experienced may have been from the ascending aorta. The typical pain of aortic dissection is sharp, and severe and radiates to the back, typically between the shoulder blades.
However, patients can have very severe enlargement of the ascending aorta and have no symptoms whatsoever and no abnormalities on physical examination or ECG. Thus, especially for individuals who have a family history of aortic aneurysm or dissection or a genetic disorder like Marfan’s, screening with imaging is recommended. Patients who have bicuspid aortic valve are also at increased risk of aortic aneurysms.
Screening for Aortic Aneurysm and Other Causes of Sudden Cardiac Death
There are three imaging tests that can reliably identify enlargement of the ascending aorta: echocardiography, CT scan, or cardiac MRI. For most individuals, the standard echocardiogram (if performed by a high-quality sonographer with good equipment) can be used to identify and monitor the ascending aorta. If the ascending aorta is not visualized well by echo then CT is recommended.
Interestingly, I have had several cases where we ordered a coronary artery calcium scan to help stratify a patient’s risk of coronary artery disease and incidentally found an aortic aneurysm. Two of these patients went on to have surgical replacement of their ascending aorta within a year.
(While reviewing my prior posts for this article I realized I had a nearly completed draft post on the assessment of the ascending aorta by echocardiography. I’ll complete that and send it out soon.)
Currently, widespread screening for ascending aorta enlargement is not recommended because of the rarity of the disease. However, as I mentioned if it runs in your family you should insist on a screening echocardiogram. Also, if a parent or sibling has had sudden, unexpected death and an autopsy wasn’t done then you should strongly consider getting an echocardiogram (to identify ascending aortic aneurysm or hypertrophic cardiomyopathy) and a coronary artery calcium scan (aneurysm and advanced coronary atherosclerosis.)
Take Home Points
Unexpected celebrity deaths often lead to a transient rise in the public’s recognition of specific death-causing diseases. In the past, aortic dissection and aneurysm received a bump with John Ritter’s death. When the St. Louis Cardinal Darryl Kile was found dead in his hotel room at age 33 from advanced coronary artery disease, the importance of screening for early coronary disease was emphasized.
We should use these events also to focus on the importance of everyone knowing the medical history of their parents and siblings, whether alive or dead.
-When someone dies suddenly and unexpectedly it is not automatically due to a massive heart attack. Do not assume your family member or spouse or close friend who was found dead in bed suffered a myocardial infarction.
-Unless the victim was quite old or had advanced cancer consider asking for an autopsy to find out the true cause of death. Whatever disease caused the death could be inherited by the victim’s offspring.
N.B. Apologies for the clickbait title. Sources suggest it is tongue-in-cheek
N.B. 2 I sent this post out a week ago via my Substack newsletter.