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Health Matters KK

A bolt from the blue…..

It is now less than a week since the young performer KK ( Krishnakumar Kunnath) with a wonderful voice died tragically after a concert in the latter day Black Hole of Calcutta, aka Nazarul Manch. He was not yet 54, much too young to die. The original black hole of course had Siraj Ud Daulah stuffing a room 14′ x 18′ in size with (according to some accounts) as many as 146 prisoners. The next morning, 23 were lucky enough to emerge alive. ( Another account speaks of 64 incarcerated and 43 dying out of these) . The local TMC riffraff allowed 7000 to get into a hall meant to accommodate around 2200. The AirCon broke down and some one got the brainwave of setting off fire extinguishers in the same enclosure to add to their “enjoyment” . K K collapsed under somewhat murky circumstances because after he collapsed, he was made to thoughtlessly walk/ rush to the vehicle which was to evacuate him to the hospital.

The incident just shocked everyone, as it came out of the blue about a well known celebrity singer, who was something of a youth icon. Have we really grasped the take home messages from the incident? Unfortunately not too much, I am afraid.

Even if the incident set off a public debate on training of first responders for life support and identification of risk of cardiovascular disease, it would serve a better purpose.

India, unfortunately enjoys the dubious distinction of being the World Leader in new cases of Type II Diabetes and Coronary Artery Disease. This is a metric we could have well done without and should never be proud of this one sad fact. Let us look at what is SCD (Sudden Cardiac Death) all about and what can each of us do individually and collectively to avert the next such a tragic death.

Sudden Cardiac Death (SCD) is an unexpected death due to cardiac causes that occurs in a short time period (generally within 1 hour of symptom onset) in a person with known or unknown (undiagnosed) cardiac disease. It has been estimated that the worldwide loss of life to SCD is between three-quarters to a million every single year. The exact statistics from India for this is lacking (as most medical statistics in this country) but a single set of inferences of a voluntary nonprofit organisation based in US,- but founded by an Indian Physician- Coronary Artery Disease in (Asian) Indians, Dr Enas Enas, are illustrative. He has shown by his elegant study that Indians suffer from a more malignant and dangerous form of coronary artery disease than the rest of the world does.

We suffer Coronary Artery Disease 3 decades earlier than the Western World.

We see 500,000 of our countrymen die every single year of Coronary Artery Disease : EVERY SINGLE YEAR. While this figure may not look frightening in a country of 1.3 Billion, where the annual death rate for the last documented year is approximately 10,073,480 in 2020 (Just over a Crore in this very populous country). So 500,000 out of these sounds a ridiculous 0.77 %. Let me add a qualifying statement for this number of deaths, THIS IS THE NUMBER OF INDIANS BELOW THE AGE OF 30 YEARS OF AGE DYING EVERY YEAR IN OUR COUNTRY OF CORONARY DISEASE.

That translates to around 1400 deaths every single day, of our people below the age of 30 years (people who haven’t even begun living their lives before that is snuffed out so cruelly by a killer that got into them for the most part undetected). That translates into something like 4 wide-bodied jet planes full of people crashing with fatal outcome every single day, with all the consequent catastrophic socioeconomic impact that one can well imagine. Yet you don’t find a single periodical or a media portal ever talking about it.

Sudden cardiac death occurs most frequently in adults in their mid-30s to mid-40s, and affects men twice as often as it does women. This condition is rare in children.

Major risk factors include conventional risk factors for Coronary Artery Disease, as Coronary Artery Disease is the best known (and easily preventable) contributor to the tragic catastrophe.

The two leading risk factors include:

  • Previous history of a Myocardial Infarction “Heart Attack” (75 percent of SCD cases are linked to a previous documented heart attack) -A person’s risk of SCD is much higher during the first six months after a documented heart attack.
  • Coronary Artery Disease (80 percent of SCD cases are linked with this disease) -Conventional Risk factors for coronary artery disease include smoking, family history of cardiovascular disease, Dyslipidemia (“high cholesterol“) or an enlarged (especially if weak) heart, Hypertension, Type II Diabetes Mellitus, High Homocysteine, High Fibrinogen Levels, Lack of exercise, Obesity and a positive family history.

Other risk factors for Sudden Cardiac Death include:

  • A weakened pumping of the heart: Left Ventricular Ejection Fraction of less than 40 percent, combined with (documented or risk factors that contribute to a risk for development of ) ventricular tachycardia,
  • Prior episode of sudden cardiac arrest ( a Survivor of SCD is at the highest risk of a repeat event and it is imperative that we get to the bottom of the causes and do everything we can to avert such an event)
  • Family history of sudden cardiac arrest or SCD (irrespective of the causes of these)
  • Personal or family history of certain abnormal heart rhythms, including underlying electrical abnormalities like Long QT Syndrome (an electrical abnormality where the heart takes unduly long to electrically recover from the previous heart beat and this coupled with an unfortunate earlier than expected occurrence of the next beat leads to the creation of a dangerous disorder of heart rhythm), Wolff- Parkinson-White or another similar Syndrome (an electrical “short circuit” in the conduction tissue of the heart that makes the person prone to dangerously fast rhythm disorders ), extremely low heart rates or a heart block (This refers to a block in the conduction of cardiac impulses so that the lower chambers do not beat in synchrony with the pacemaker of the heart)
  • Dangerous Rhythm Disorders (Ventricular Tachycardia or Ventricular Fibrillation where the circulation comes to a standstill and will kill in a short period of time)  after a heart attack usually contribute to most of the early deaths after a heart attack.
  • History of congenital heart defects or Congenital abnormalities of blood vessels that can lead to heart attack or rhythm disorders that endanger the life of the victim in a short span of time.
  • History of Documented Syncope (fainting episodes of unknown cause) especially if the same is inadequately evaluated and/or treated.
  • Heart Failure: is a condition in which the heart’s pumping is weaker than normal, or ineffective, as in the pumping can be performed at the cost of a rise in the filling pressures. Patients with Congestive heart failure are 6 to 9 times more likely than the general population to experience ventricular arrhythmias that can lead to sudden cardiac arrest and death.
  •  Dilated Cardiomyopathy: this is the underlying cause of SCD in about 10 percent of the cases: a decrease in the heart’s ability to pump blood due to an enlarged (dilated) and weakened left ventricle, as usually the contraction is dyssynchronous and also accompanied by abnormal heart rhythms including the dangerous ventricular rhythm disorders.
  • Hypertrophic Cardiomyopathy: a thickened heart muscle that affects the ventricles, and creates an altered state of contractility and higher filling pressures. There is also an association with electrical abnormalities like WPW syndrome and leaking heart valves.
  • Valvular Disease: Individuals with abnormalities of cardiac valves with either obstruction of blood flow and /or leaking valves. Those with severely stenotic valves (obstructed valves) are more prone to sudden death. Those with severe aortic stenosis are even more prone to this. Sometimes the first manifestation of the disease may be death (or a manifest threat to continuation of life)
  • Significant changes in blood levels of blood salts: like potassium and magnesium (from using diuretics, for example), even if there is no organic heart disease.
  • Obesity
  • Diabetes
  • Recreational drug abuse
  • Taking drugs that are “pro-arrhythmic” may increase the risk for life-threatening arrhythmias.

Sudden cardiac death (SCD) occurs rarely in athletes and individuals who were otherwise healthy, but when it does happen, it often affects us with shock and disbelief, as happened on 31st May.

Management

The old adage about prevention being better than cure could possibly have been designed specifically for this condition. It is especially true since many of the victims might actually present with the underlying disease when they die.

Disaster (or tragedy) walks in through the door left open by negligence.

Most populations are less receptive of the idea of preventive health evaluation ( “Why fix it if it isn’t broken?” ) – this is especially true of Indians. We are loathe to the idea of subjecting ourselves to a battery of tests that might show up an increased risk of disease (or worse) or of death. But there is just no getting away from the fact that this is the best method of detecting disease (and better still the risk of disease in others) in a population that does not realise the risk it is exposed to.

Consider it as an internal security agency manoeuvre that shows hidden/ embedded sleeper terror cells before they have ever had the opportunity to wreak devastation on an unsuspecting population. If one justifies the sleuths picking up and dealing (sometimes involving liquidation) with terrorists and subversives, how can we ever object to a periodic exercise that exposes the hidden factors that make us prone to disease or actual disease processes within our bodies, putting us at risk of severe , potentially debilitating and/or fatal disease?

Indians will come up with the most outlandish of arguments and come up with every conceivable line of (mistaken) thought that justifies their myopic, ill advised behaviour. I have stopped being surprised at the stupidity of individuals but there is really no place in my mind for any justification for a 60 year old person who doesn’t know s/he has diabetes and/or hypertension simply because s/he has never been evaluated for the presence/ absence of these. Ignorance isn’t bliss for these aspects.

The most stupid and self defeating act or excuse that I have heard in the four decades of my practice is “This level of Blood Pressure/ Blood Sugar/ Blood Cholesterol is ‘Normalfor me, I have had it for x years”. I am unable to really understand the self-destructive behaviour when an otherwise intelligent and educated person stops taking tablets for High blood pressure, High Blood Sugars and deranged lipids, despite coming across countless such people in the last 40 years. They don’t surprise me anymore, but I still don’t understand why they choose to play Russian Roulette with their own lives. Even more horrifying is the recurrent occurrence of physicians (In India, of various denominations) who indulge in such behaviour. At the very least, they ought to know the naked truth and the clear and present danger. Imagine the fate of the unsuspecting patient population who repose faith in the hands of such irresponsible people. I would strongly recommend every adult (male and female: women’s health is frequently disregarded in all societies) subject herself/himself periodically to a rigorous evaluation at the hands of a qualified (and hopefully an experienced ) physician who takes a detailed medical history and then orders a set of tests appropriate for the person to assess the risk of disease.

This process of periodic screening should ideally start at the age of no later than 35 years for an Indian male and 40 for the woman. In the presence of diagnosed abnormalities (like High Blood Pressure or Diabetes Mellitus) during a chance examination (during enrolment for an insurance plan or while seeking employment) the initiation of periodic examination for surveillance must necessarily begin at an earlier age. If no significant abnormality is discovered in an individual, the frequency of screening may be (especially for physically active younger individuals) once in 3-5 years, but would be necessarily at lesser intervals for those who are older or who already have a diagnosed health issue.

Obesity/ lack of physical exercise (Both sadly so very common in India) should be viewed at with greater concern, as both will greatly increase the risk of cardiovascular disease (obesity also increases the risk of various other disease processes including chronic lung disease, and even certain malignancies) and should be dealt with a certain degree of urgency and gravitas that is appropriate to the health risk both pose.

One of the arguments that everyone is fond of putting forth is the expense: however the economic impact of at the loss of productivity/life of a young breadwinner on the immediate family needs to be considered as a counter to this.

I would just like to quote three figures of risk of death from disease v/s treatment modalities relating to my primary speciality to highlight the point. Worldwide, the risk of death from a first heart attack is 12-13%. The risk of death or serious disability arising from a Coronary Artery Bypass Surgery in most good centres is less than 1%, while the risk of death from an angioplasty now is actually almost always the same as this (and most often much better than Bypass Surgery as technological advances and improvement in operator skills have meant better outcomes for the patient).

So the take homes for all should be: start preventing tragedies, don’t give an opportunity to someone else to hold a candlelight vigil for you. Adopt health friendly habits of diet, exercise, lifestyle and learn to adapt with stress and stressors (rather than live in the Utopian idea of a stress free existence) while carrying out an active Physician Guided (as against an industry driven, largely unscientific) Preventive program that involves early detection of risk factors and disease (if it unfortunately already exists).

The order should be history taking first, trying to understand the background, physical examination next, and then do the tests that are appropriate to the given individual.

Medicine is a science, and the practice of medicine is an art. Unfortunately these days Commerce has sidelined the science, and the art all but forgotten.

Stay safe, folks, look after yourself better. none of us are Supermen, we are mere Clark Kents in the (only too vulnerable) HUMAN form that makes us prone in the sad so-called modern “lifestyle” to various diseases. It is imperative we do something to try to save ourselves before falling a victim to the menaces of an euphemistically termed “modern lifestyle”.

By abchandorkar

Consultant Interventional Cardiologist, Pune, India

21 replies on “A bolt from the blue…..”

A great food for thought…… Beautifully written…….The lines I liked the most from your article…..” learn to adapt with stress and stressors (rather than live in the Utopian idea of a stress free existence)..”

Though difficult to implement….but one should try to follow to make one’s life happy and peaceful…

Indeed…. true….
Thanks for the wonderful share Aniruddha sir🙏🏻🙏🏻😊😊

Liked by 1 person

Although detailed functioning of the arteries is Latin to me, the way you’ve described it’s various aspects is beautiful . Your article should serve as an eye opener to the youth. Thank you..

Liked by 1 person

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