Community Commentary -- BRIAN CHESNIE

I read of the sudden death of a fine young man named Brian Sweet while

he was exercising with a friend (“OCC rower’s death stuns family,

friends,” Aug. 18). It was about 15 minutes into the exercise routine. He

was running up and down the stairs at the stadium, and he died despite

the valiant efforts of his friend, who was well-trained in appropriate

response and cardiopulmonary resuscitation. Apparently, Brian was

physically fit and had no prior health problems.

There is an overwhelming sense of loss and grief when a person dies

suddenly and unexpectedly, especially when it is a young person. There is

also a sense of utter disbelief and confusion as to “how could this

happen?” We have been reading through the summer of the deaths of a

number of young athletes, some blamed on excessive heat, or in others,

the use of stimulants. However, in most instances, these factors are

unrelated.

The problem relates to the overwhelming public health problem of

sudden cardiac death. People of all ages die suddenly and often

unexpectedly in the United States, with an incidence of about 400,000 per

year or about 1,100 individuals per day. This is the equivalent of three

747s falling out of the sky on a daily basis, and I have always found it

astonishing that there is such little awareness of this among the public

or discussion of this in the media. It is the No. 1 cause of death in the

country. The numbers are stark and clinical, but in almost every

situation, there is a deeply sad human story.

The cause of it is mostly related to a sudden and catastrophic

derangement of the heartbeat whereby the heart is unable to beat and pump

in an organized manner. The lower chambers, which are the ventricles,

lose the ability to pump and actually go into a crazed, chaotic

turbulence called ventricular fibrillation. From the onset of this,

collapse will occur in about 10 seconds, and the window of opportunity of

survival requires defibrillation (shock paddles to the chest) within six

minutes.

The numbers are staggering. Of the more than 400,000 deaths per year,

about 75% of these people have some degree of underlying coronary artery

disease, and yet only a small percentage of them are having this occur in

the setting of an acute heart attack. Another 20% have other types of

heart diseases (often different types of heart muscle diseases, called

cardiomyopathies). Then, about 5% have no evidence whatsoever of anything

structurally wrong with their hearts. Autopsies reveal nothing in these

people. These people are usually young, in their teens and 20s, and there

are about 20,000 deaths a year (5% of 400,000). Many of them may have a

difficult to diagnose abnormality called Long QT Syndrome, which may or

may not show up as a subtle abnormality on an electrocardiogram. The

other group that tends to be in the younger age category is the

cardiomyopathy group of which there are several types, and they will

number in the many thousands.

An enormous problem is identifying these people. The sudden death

event is the first and only manifestation of a heart problem in 35% of

the entire group.

The issues of identification of risk and types of treatment are

complex and expensive. Implantable defibrillators are sophisticated

pacing devices that are capable of shocking this abnormal heartbeat back

to normal. These have been available for the past 16 years, and we routinely implant them in people (a small pacemaker type of surgery) who

have survived a cardiac arrest or whom we believe are at higher risk for

this potentially catastrophic problem.

An example is Vice President Dick Cheney’s recent surgery. Equally

important is the newer availability of external devices that are

available in public and private places for the emergency use of rescuing

someone who has collapsed. These defibrillators, are now being put on

board airplanes and also placed in stadiums, arenas, shopping malls and

office buildings with the hope that high availability will improve

someone’s chances of survival.

While we can identify many with underlying heart disease, it is very

difficult to do this in those whose first event is their last one and in

young, seemingly healthy people. While these catastrophic collapses may

be triggered by a preceding event, the fundamental problem is the

cellular abnormality affecting the heart muscle, and all too often there

is an unpredictable randomness to these tragedies.

Should young athletes be screened? Absolutely. The cost effectiveness

and extent of screening is the issue. At the very least, a questionnaire

for the family should be done, including family history of any heart

problems, heart rhythm problems, history of sudden death, history of

collapse, of fainting, or significant wooziness and the use of any

medications and supplements.

An electrocardiogram should be done, and a limited physical exam

should be done with careful listening of the heart by an appropriate

physician. Anything that raises suspicion should be referred to a

cardiologist for further testing, with consideration of an exercise

treadmill test and an echo cardiogram, as well as assessment of certain

blood tests.

These tests are expensive, and the overwhelming majority of young

people will have normal tests. And even then, a random and unpredictable

tragedy will occur. But there will also be those who will be identified

and helped.

We all wish to die peacefully, at an old age, suddenly and preferably

in our sleep. But when young people are cut down, or people at the prime

of their lives, or older people living well die suddenly, it is not the

end point of a terminal disease, but an electrical derangement of the

heart muscle that can be managed, protected against and corrected so that

life can continue.

* BRIAN CHESNIE lives in Newport Beach and is the director of

electrophysiology and pacing services at Hoag Hospital.