Category Archives: heart attack

Two Three Letter Words For Saving Lives: CPR and AED

Every two years the skeptical cardiologist has to get recertified in Basic Life Support for medical personnel. This involves a review of what, the American Heart Association has decided, are important changes in guidelines for Emergency Cardiac Care and cardiopulmonary resuscitation (CPR).

I highly recommend all of you undergo such training. Although the survival rate of patients with “out of hospital cardiac arrests” is very low, your appropriate actions could be crucial in saving the life of a stranger or a loved one.

About a year ago one of my patients suddenly, and without any warning symptoms, collapsed at work. Fortunately for him, a co-worker had undergone CPR training and initiated chest compressions right away. When paramedics arrived 15 minutes later he was defibrillated from ventricular fibrillation and taken to a nearby hospital.

Our best information on cardiac arrest suggests that without CPR, irreversible brain damage (due to lack of oxygen) develops in about four minutes after the heart stops beating. Even with good CPR, the longer the time interval from arrest to defibrillation, the less likely the patient is to survive with good brain function.

Thus, the two keys to helping someone who drops dead next to you are beginning effective CPR (and compression only is OK) and defibrillating a fibrillating heart as soon as possible.

My patient was comatose on arrival to the hospital and was put into a hypothermic state, a process which has been shown to improve neurological outcome in cardiac arrest victims. Doctors informed his wife that they thought his prognosis was bad-less than 5% chance of surviving with intact brain function.  After three days he awoke from his coma and was transferred to my hospital.

I visited him in the ICU and other than a sore chest and an inability to remember the events surrounding his cardiac arrest, he was mentally normal and felt great. He continues to do very well to this day, but without the bystander CPR that he received (followed by the defibrillation) he would be one of the 350,000 who die of cardiac arrest in the US each year.

If the co-worker had not initiated CPR for the many minutes it took for EMRs to arrive, my patient’s brain would have been dying from lack of oxygen and it is most likely he would have suffered severe encephalopathy or brain death.

Recognizing Cardiac Arrest

Recognizing when someone needs CPR is a critical first step in the chain of events that can improve survival in cardiac arrest.

You are looking for two things before starting CPR:

  1. Unresponsiveness. The victim  does not move and does not respond at all to either verbal or physical stimulation.
  2. Breathing is absent or atonal (meaning ineffective , intermittent gasps).

Agonal respirations have also been described as “snoring, snorting, gurgling, or moaning or as barely, labored, noisy, or heavy breathing.”  Studies have shown that agonal respirations are common in the early minutes after cardiac arrest and are associated with good outcomes.

Two Steps To Save A Life

The two key components of resuscitation are CPR and defibrillation.

Performing these steps is simple and straightforward.

The earlier they are started, the more likely the victim is to survive.

If someone collapses near you and they are unresponsive and not breathing, they need CPR and an AED. Call for help as you are starting CPR.

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Cardiopulmonary Resuscitation (CPR)

CPR consists of repeated compressions of a victim’s chest.

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I came across this machine recently. You can learn and practice hands-only CPR using it.

Everyone has seen dramatizations of CPR and it is quite simple to do even without training. Basically, you want to “push hard and fast in the center of the chest.”

CPR training undergoes some tweaking over time as more scientific data is obtained but the fundamentals remain the same. The changes that the AHA is emphasizing in their current CPR courses are:

-depress the chest at least 2 inches

-depress the chest 100-120 times per minuCPR-Certificationte (as opposed to just >100 time per minute).

Of note, the recommended sequence has changed from A, B, C, to C, A, B. Compressions right away followed by assessment of airway and then mouth-to-mouth breathing.  In fact, because compressions without breaths have been shown to be as effective as with breaths, if you are uncomfortable giving breaths, recommendations now are to just do CPR.

 

Initiating CPR and calling 911 are the greatest initial things you can do for the person who collapses next to you.

However, the earlier you can defibrillate that person from ventricular fibrillation, the better their chance of survival.

Ambulatory electronic defibrillators or AEDS , if available, are very easy to use devices that can shorten the time to defibrillation and are the second key to successful resuscitation of cardiac arrest victims in the community.

I’ll talk about using them in a subsequent post.

antimortatorially yours

-ACP

 

Do You Know What’s On Garry Shandling’s And Your Parent’s Death Certificate?

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Better Call Saul’s Bob Odenkirk and Kathy Griffin “hanging” with an apparently healthy Larry Sanders on March 20. These two appeared on Shandling’s brilliant Larry Sanders TV show.

When someone who had appeared to be healthy dies suddenly, it is often assumed that he/she died of “a massive heart attack.” Certainly, this was the case in the recent unexpected sudden death of Garry Shandling, the actor and comedian.  Shandling, aged 66, died March 24 of this year.

ET online reported:

“His publicist Alan Nierob told the ET that Shandling had no history of heart problems, but that doctors believe he died as the result of a heart attack.”

Although a heart attack resulting in ventricular fibrillation is the most common cause of a sudden, unexpected death in individuals over the age of 40, it is not the only one.

In fact, People  magazine reported that Sanders experienced shortness of breath and pain in his legs just a day before his death, and that he spoke to a doctor friend about his symptoms, who stopped by that night to check on him,

Shortness of breath and pain in the legs raise the possibility of a clot or DVT in the leg, which can break loose and embolize into the pulmonary arteries. Such a pulmonary embolism, if massive, can result in swift and sudden death.

The LA Coroner’s office could not get Sanders’ physician to sign his death certificate and the cause of death has still apparently not been determined, pending toxicology testing which typically takes 6 weeks.

What’s On Your Parent’s Death Certificate

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.

Examples of inherited cardiovascular conditions (in addition to heart attack (myocardial infarction) or pulmonary embolism) that can cause sudden and unexpected death include aortic aneurysm dissection, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasis, and long QT syndrome.

Unfortunately I find that, at least in my patients, uncertainty about the cause of death of one’s parents is the norm.

Many of my patients, for example, tell me one of their parents died of a “massive heart attack” and they assume that they are at increased risk of the same fate. When I press for details, typically no autopsy was performed.  Mom or dad may have been found dead at home, or they may have suddenly keeled over but not survived to make it to the hospital for a definitive diagnosis.

Without an autopsy in such circumstances, it is not possible to be sure of the cause of death.

Even if you have a cause of death listed on your parent’s death certificate, there is no guarantee that it is accurate.  The doctor that filled it out, without an autopsy in many circumstances, is just speculating on the cause based on what he/she knew about prior medical conditions and the circumstances surrounding the death.

I was recently asked to fill out the death certificate of an elderly patient of mine who had atrial fibrillation and congestive heart failure and was living in a nursing home.

One night she was noted by the staff to be very short of breath and was taken to a local  emergency room where she was pronounced dead.

Based on the information available to me, I had no idea what caused her death. Although she had quite signifiant cardiac problems, when I last saw her she was stable and I have numerous patients with the same conditions who live for decades.

I filled out the death certificate, listing all of her conditions, and entered in that the cause of death was unknown.

Although the CDC guide for physicians filling out death certificates clearly states that this is acceptable, I was subsequently informed that the funeral home did not accept unknown cause of death and that they had found another doctor to fill in a cause  of death.

I guarantee you, whatever he put on as the cause of death was total speculation.

Jerry Seinfeld was good friends with Garry Shandling and, oddly enough, not too long ago, featured him in an episode of his internet series “Comedians in Cars Getting Coffee” entitled “It’s Great That Garry Shandling Is Still Alive.

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Shandling mentions “I had hyperparathyroidism,” making a joke that “the symptoms are so much like being an older Jewish man, no one noticed!”

James Fallows, the excellent The Atlantic writer, highlights his own experience with hyperparathyroidism (a disease that leads to high calcium levels and is easily treated with surgery), in a recent Atlantic article. The subtitle of this article, “a rare and under-publicized condition that can sometimes be fatal,” suggests that hyperhyperparathyroidism might have led to Shandling’s death.

I don’t think this is likely because Shandling suggests that the disease is in the past tense (i.e. he has already had the surgery), and sudden death from hyperparathyroidism would be extremely unlikely.

Fortunately, Shandling is getting a full examination and autopsy to fully determine the cause of his death. If he has offspring, this will be extremely helpful to them in understanding what medical conditions they can expect later in life.

If he was not a celebrity, his death, like many of your parents’, most likely would have been ascribed to a “massive heart attack.”

 

 

Are We Springing Forward to Death?: Daylight savings time and myocardial infarction

Tonight we will lose an hour of our lives when we observe Daylight Savings Time (DST).

Media reports suggest that DST, beyond robbing of us that nocturnal hour in the spring are also increasing our risk of heart attack (myocardial infarction or MI) and death.

Is this a valid concern or just media hype on a slow news day?

Scientific studies on this topic are mixed.

A recent study from Finland found MI rates increased 16% on the Wednesday after spring DST time change and dropped by 15% on the Monday after fall DST time change.

A 2015 German study found no difference in MI rate in the 3days or 1 week after spring or fall DST transitions.

However, some American studies have detected a bump in MI rate on the day after DST transition in the spring and a similar drop in MI rate on the day after the fall DST change.

A study of 42000 patients undergoing acute PCI for MI in Michigan found that

“The Monday following spring time changes was associated with a 24% increase in daily AMI counts (p=0.011), and the Tuesday following fall changes was conversely associated with a 21% reduction (p=0.044). No significant difference in total weekly counts or for any other individual weekdays in the weeks following DST changes was observed.”

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They concluded:

Our data argue that DST could potentially accelerate events that were likely to occur in particularly vulnerable patients and does not impact overall incidence. There is considerable controversy over the health and economic benefits of DST, and some authorities have argued that this practice should be abandoned.17 Although we are unable to comment on the merits of these arguments, our data suggest that while such a move might change the temporal fluctuations in AMI, it is unlikely to impact the total number of MIs in the broader population.

Mondays, in general, are the days of the week on which most MIs occur. This has been attributed to an abrupt change in the sleep–wake cycle and increased stress in relation to the start of a new work week

Manipulations of the sleep–wake cycle have been linked to imbalance of the autonomic nervous system, rise in proinflammatory cytokines and depression so presumably the additional disruption created by DST adds to this effect.

However, the data suggest that this very weak effect means only that if you were going to have an MI in the next week, after DST it is more likely to occur on the Monday of that week than on another day. Your overall risk of MI is not changed.

From a public health standpoint the major conclusion is that emergency rooms and cath labs should consider increasing staffing by 24% on the Monday after the spring DST time change.

I don’t think this is a significant factor for my patients. We have to deal with events and stressors that influence our sleep-wake cycle constantly. Good planning and sleep hygiene are the keys to success and reducing stress.

So, fear not the grim reaper as you set your clocks forward tonight.

Circadianly yours,

-ACP

PHOTO: PAVEL ŠEVELA/WIKIMEDIA COMMONS

 

I’m Having Chest Pain: Is It a Heart Attack?

IMG_4219I can tell you exactly when the pain started. I was riding  my bike in Forest Park, the great urban park of St. Louis. Ordinarily, I cycle from my house to the park, cutting across the  ivy-covered semi-Ivy league campus of nearby Washington University and circling its beautiful acres on a recently refinished bike path.

As I started the slow incline that parallels Skinker Avenue just West of Forest Park, a cyclist flashed past me. I could swear he said “Oh dear, oh dear. I shall be late.”

Instead of continuing straight along the bike path, the late cyclist suddenly veered to the left, following a heretofore untraveled spur that led up into the dark, impenetrable forests of the park.

At this point, the sensible, sixty-something portion of my psyche should have taken over and had me continue on the relatively straight, flat and well-traveled road that I had grown accustomed to. Alas, it was the teenage boy who took control and insisted on us taking the road less traveled.

The spur of the bike path had not been regularly maintained and there were numerous rough spots: ridges and chasms emerged with disconcerting frequency as I progressed.

The lure of exploration pulled me on. I kept my speed up as I descended a hill with the path turning sharply to the right. Suddenly an even sharper right turn emerged with a particularly uneven section of path. I lost control of the bike and landed heavily on my left side.

I felt a sudden sharp pain just to the left of my breastbone about midway in my chest.

As a cardiologist I spend a lot of time talking to people about chest pain and thinking about what is causing it.

The heart is in the chest and it is natural to believe that pain that comes from this area could be a manifestation of the dreaded heart attack. Since heart attacks are the #1 killer of both men and women  and they can very quickly lead to life-threatening arrhythmias it is wise to take seriously  any pain in the chest.

Three Types of Chest Pain

I was trained to sort what patient’s described to me about their chest pain  into three bins: Typical anginal pain, atypical anginal pain and non cardiac pain.

Angina is doctor-speak for chest pain that is due to the heart muscle not getting enough blood (usually due to a blocked coronary artery)

Cardiologists consider any discomfort from the lower ribs up to the bottom of the neck as chest pain although patients often don’t perceive it as a pain.

Heart attack pain often feels like a pressure, a heaviness or a burning and in addition to somewhere in the anterior chest region it can manifest in the neck or jaw or one or both of the upper arms.

My chest pain was  worse  when I took a deep breath (pleuritic) and this almost always indicates a lung cause or inflammation in the muscle/bones/joints that are related to breathing. Furthermore, pushing on the ribs  made it worse making it virtually certain that it was musculoskeletal.

A brief (well done) history and physical exam therefore would assign my chest pain to the “non cardiac” bin.

Typical anginal pain is brought on by exertion, lasts 3-15 minutes and is relieved by nitroglycerin or rest.

pretest likelikhood cadThe probability of a patient with non cardiac chest pain having significantly blocked coronary arteries is generally lower than that of a patient with typical anginal pain. However, as this chart demonstrates, patients (generally those with significant risk factors) can have severely blocked coronary arteries and have non cardiac chest pain.

For example, I have risk factors of age (>55 years), being male, hyperlipidemia and hypertension. A cardiac catheterization done on me at the time of my non cardiac chest pain might well show significantly blocked coronary arteries. Of course, these blocked arteries would have absolutely nothing to do with my pain.

This fundamental paradox is the source of a lot of the overtesting and over treatment that occurs in cardiology. Most of the time, chest pain that prompts a patient to come to the ER or doctor’s office does not fall easily into the non cardiac category or the typical anginal category: these are the atypical anginal patients.

Additional testing is required , progressing from EKGS and cardiac enzymes to stress testing to cardiac catheterization. If there are elevation of the cardiac enzymes or abnormalities of the EKG that indicate a recent or active heart attack then a cardiac catheterization is warranted because it is very highly likely that a tightly blocked coronary artery is the cause and opening that artery will be beneficial.

However, most patients have normal cardiac enzymes and unremarkable EKGS and can end up getting catheterizations (due to either  inaccurate stress tests or cardiologist’s recommendation) that they don’t need.

Once a catheterization is done, patients may then get a stenting procedure on a blocked coronary artery that wasn’t causing any problems. Not uncommonly, multiple blocked coronary arteries are found and the patient is rushed off to have a bypass operation. If the blocked arteries weren’t the cause of the patient’s chest pain (i.e. the pain was non cardiac) these procedures are likely doing more harm than good.

When To Go To ER With Chest Pain

I’ve spent thirty years fielding after hours telephone calls from patients who are having  chest pain.

It is not easy to make a reliable determination of who is likely having a heart attack or other potentially dangerous cardiac problem and who is not just based on the history.

If a patient called me describing what I described above I would likely advise him to go to the ER for evaluation (although I would be pretty sure it wasn’t a heart attack: sometimes rib fractures are associated with collapsed lungs or hemorrhage into the pleural space and sometimes trauma to the chest can cause heart damage). It’s always better to err on the side of caution when were’ dealing with potentially life-threatening problems.

After office hours, the only way to get an electrocardiogram and cardiac enzymes to be sure that the chest pain is or is not a heart attack is to go to an ER. Generally, if the patient has escalated the level of concern to calling the on call cardiologist, the symptoms are worrisome.

The bottom line for me is that you only get one chance to die (You only die once (YODO)

If you’re having a heart attack at any second your heart can go into ventricular tachycardia or ventricular fibrillation and you will die within minutes.

Thus, I have to have a very low threshold for advising trips to the ER. If I’m wrong, the patient  could die.

I didn’t go to the ER because I was 100% certain that my chest  pain was non cardiac. I’m also a doctor and therefore a very bad patient. I survived, however, and over several weeks the pain gradually subsided.

As a result of this fall (and several other bike falls I’ve had in the last few years) I’ve re-evaluated my cycling. I’m going to stay on very well-maintained paths and slow way down when the going gets rough.

Hopefully, this will allow me to continue the cycling which I’m convinced is helping to prevent me from visiting the ER with a true heart attack!

Skeptically Yours

-ACP