That’s When the Light Went On
Tim Russert’s surprising death
Tim Russert, a noted journalist and political commentator, died suddenly last summer of a heart attack. The autopsy demonstrated extensive blockage in the coronary arteries. Many people have wondered if Mr. Russert’s death could have been prevented. From the articles I have read I have learned that he had good physicians—both an internist and a cardiologist—and presumably adequate insurance and finances to pay for medication and medical tests. He was intelligent, educated and an undoubtedly very motivated individual who most certainly had a solid knowledge of what constitutes a heart-healthy lifestyle. So how could this have happened? This question has been debated in the news and on-line my many experts and we may never have a consensus on this issue. One thing is certain, however: heart disease is back in the spotlight and this can’t be a bad thing.
What we don’t know about Mr. Russert’s case is whether he had any symptoms that would have suggested a recent instability in his coronary disease. Sure, the news reports cite his doctors’ claims that Mr. Russert was free of symptoms and I imagine his family had no suspicion that something was wrong. What I wonder is whether he had some of the vague, nonspecific, or mild symptoms that people sometimes get prior to a heart attack that he perhaps disregarded as irrelevant.
I see it all the time. After I finish caring for someone with a heart attack I go into further detail about their recent experience. I often hear them say “Come to think of it, I have had more indigestion than usual,” or “Now that you mention it I do remember getting more winded walking up a flight of stairs.” I don’t think this is intentional neglect—most people are not conditioned to think of any change in chest symptoms as a marker for an impending heart attack.
It’s also possible Mr. Russert truly had no premonitory symptoms. It is unfortunately not uncommon for death to be the first and only symptom of a large heart attack. Still, if any good comes from Mr. Russert’s untimely demise it is that the issue of heart disease finds its way onto the front page of the newspapers again. Who knows how many middle-aged men with early heart attacks have allowed themselves to be brought to the hospital simply because they read about Tim Russert. One such example was published in the New York Times. The article is written in first person by a producer for ABC news who became more short of breath than usual as he was out for a bike ride with friends. The author writes:
“That’s when Tim Russert popped into my head. In the last couple of weeks, like almost every middle-age man, I had taken a very personal interest in every detail of his story. Yes, he was overweight. But hadn’t he just passed a stress test?
“That’s when the light went on.”
The author went to the ER, was diagnosed with a heart attack, and a couple hours later was in stable condition and the owner of a new stent in his heart.
As sad as it is to lose anyone to heart disease I’m grateful the general population pays attention to it every now and again—it just might save a few of them.
The accuracy of a regular treadmill without imaging varies from around 65-80%. A large part of how good a test of this type is depends on how likely the patient had a problem to begin with. There are both false positive (the test is abnormal and the patient doesn't really have a problem) and false negative (the test is normal and the patient does have a problem) considerations. The tests are generally best for people whom you have an intermediate suspicion. A 65 year old obese, diabetic, hypertensive, hyperlipidemic, smoking male with chest tightness that reliably occurs with exertion and goes away with rest is so likely to have obstructive coronary disease that a stress test doesn't offer much except the likelihood of confusion associated with a false negative test. Similarly a 20 year old woman with no risk factors and no family history of coronary disease who has intermittent sharp stabbing chest pains at rest that last only a few seconds at a time is at higher risk for having a false positive test that will lead to further unnecessary cardiac workups. Mr. Russert was likely in the intermediate category where stress testing can be appropriate but it still remains imperfect and unable to detect the likelihood of a heart attack.
Dr. Van De Graaff
Ron, You're asking a question that continues to vex us as cardiologists. The story of Mr. Russert is unfortunately all too common. His doctor states that Mr. Russert had known coronary disease but had recently done well on a stress test. Despite this he passed away a short time later from a heart attack involving ruptured plaque in the left anterior descending artery. This raises the question I refer to: How can we determine who is at most risk of an imminent heart attack, and what sort of testing do we have that will guarantee against a heart attack? I'll go into this in more detail on my next blog post (I've been wanting to address this anyway), but suffice it to say that stress testing is most useful for detecting flow-limiting coronary blockage (>70-80% narrowing), but does little to detect the less severe stenoses that are nonetheless unstable and prone to plaque rupture. The answer in these individuals is to focus on medical prevention, such as the use of aspirin and tight, aggressive control of blood pressure and cholesterol. The patient needs to do his/her part as well with improved diet, exercise, and smoking cessation. Once you've done all this, the most you can do is cross your fingers. We don't know if Tim Russert had his LDL at goal (in his case < 70mg/dL) or if he could have improved his chances with exercise and diet. We do know that he did not have a blockage of greater than 70% on the day he did his stress test. One last thing to remember. Despite our most diligent efforts patients will still have heart attacks. We just keep doing our best.
I did a radio interview not too long after the unfortunate deaths of Tim Russert and George Carlin. While Carlin had well established heart problems, Russert did not. Reminds me some of the death of John Ritter. Your point is excellent. Too many times people put off seeking medical attention because they do not want to believe that anything could be seriously wrong with them. As the saying goes, "Denial is not just a river in Egypt".
If Mr. Russert just passed a stress test, could you comment on the accuracy of stress testing? Should more stress tests be done? I try to screen asymptomatic patients that have risk factors with at least a routine treadmill. Not everyone needs the expensive perfusion scans. I have picked up many asymptomatic patients that actually have significant CAD.
Dr. Van De Graaff
Jackie: Good question. High cholesterol represents only one of many risk factors for coronary artery disease and heart attack. Others include age, gender, and family history (things you cannot influence); and smoking, high blood pressure, and lifestyle habits (things you can influence). We know that a not-so-small fraction of patients with heart attacks have normal cholesterol. Most of these are individuals who tip the risk scale with other poor lifestyle choices such as smoking and lack of exercise, although every now and again we'll see someone with a heart attack who has no identifiable risk factors. You are absolutely right that an overweight, sedentary individual should not expect that a normal cholesterol panel would protect him or her from a heart attack or stroke. Additionally, there is a myriad of other problems that can arise as a result of untreated stress and obesity. Good luck.
If one's cholesterol and other lipids test ok, can they assume they are safe from a heart attack even if they have visible risk factors like being stressed, overweight and not exercising? Or is that a false sense of safety?