They all suffered “heart attacks”. No details have been
provided on Mr. Botin’s (79) death but according to a media source “it was
totally unexpected” and “…it occurred a few hours before he would present a
painting by Velázquez that he helped restore…”. Mr Gandolfini (51), well known
for his role in the Soprano’s, was on vacation in Rome and planning to attend
the closing of the Taormina Film festival in Sicily when his 13 year old son
found him unconscious at their hotel’s bathroom. Resuscitation efforts at a
hospital were unsuccessful. My grandfather (68) died of acute pulmonary oedema (i.e.
acute heart failure) the day after he was planning to join a sports club…
Despite medical supervision (a cardiologist was “seeing”
my grandfather), it is an epidemiologic fact common to most people above 40
years of age to have at least an untreated or undertreated vascular risk factor.
Among the most common modifiable risk factors are inappropriate nutrition with
or without excess weight, a sedentary life, current or recent smoking, high
blood pressure (undiagnosed in 1 out of 3 people and uncontrolled in 80% of
diagnosed patients in developed countries), abnormal lipid levels or diabetes. Also,
Botín, Gandolfini and my grandfather shared a load of un-modifiable risk
factors such as male sex, age and, potentially, a spectrum of unfavorable genetic
traits. All these factors alter the normal arterial wall structure generating
plaques that progressively narrow the vessel’s lumen leading to a decrease in
blood flow to the heart, brain and other organs.
The vascular problem is complex and dynamic. It is definitely
not just a matter of clogged pipes. In fact, 80% of myocardial infarctions (MI’s)
-with a high mortality rate- occur due to arteries that are not previously
“stenotic” (i.e. narrowed). These patients will not be detected with a coronary
“stress” test which only identifies arteries that have advanced narrowing and
thus cannot supply enough blood to the heart muscle. Only 20% of MI’s occur in
patients with previously narrowed arteries and these are the ones that can be
detected by warning symptoms or a positive stress test. The concern, then, is
that the vast majority of people have “plaques” covering the arterial wall (as
dirt may accumulate in the walls of a plumbing system) which do not decrease
the vessel’s diameter and are thus difficult to detect with conventional
studies. The danger is that the so called “plaque accident” can unexpectedly occur
leading to a sudden plaque disruption that generates a clogging cascade ending
within minutes with a blocked artery… and an infarcted or dead person. A
similar mechanism underlies many strokes. We have all heard people saying: “…
how could this happen?… he/she was so healthy….”. In the case of James
Gandolfini, the New York Times quoted that, after receiving results of the
autopsy, a family member stated that he “…died… of natural causes”. Wrong!
These people are sick and the essential -the status of their arteries- was
invisible to the eye…
What Botín, Gandolfini and my grandpa did not know is
that almost 80% of vascular events
occur in people with few risk factors.
This is the reason why most people feel that a heart attack or stroke is
something that will happen “to others”. Yet, some people get health check-ups
with the hope that if “approved” they get a few years’ survival guaranteed. Disappointingly,
a Danish study on 180.000 people published recently in the British Medical
Journal showed that conventional health check-ups (including a chest Xray, EKG,
ultrasounds and blood tests among others) did not decrease total mortality or
death secondary to cardiovascular disease or cancer, the very reasons for
promoting and performing these evaluations (pap smear, mammogram, colonoscopy
and prostate exams were excluded). So, what are we missing?
Could an eye doctor give you the right glass prescription
without examining your eyes? The exact same rationale applies to disease of the
arteries irrespective of whether they are in the heart, brain, legs or kidneys.
Different methods can reliably evaluate arteries but most are expensive and
some are invasive such as catheterization and others, like multi slice CT, use
high doses of radiation precluding the repeated testing needed for disease
follow-up. Ultrasound is fast, reliable, non invasive and affordable. There are
ultrasound tests available that allow to objectively measure the atherosclerosis
load in the vessel’s wall. Atherosclerotic plaque quantification was originally
developed by David Spence in the 90’s and further studied by Valentin Fuster
and others more recently. A quantification of arterial “plaque” burden (expressed
in square or cubic millimeters depending on the technique) allows to accurately
measuring the individual’s risk of having a vascular event. Knowing a person’s
vascular risk factor profile (smoker, excess weight, hypertensive, etc) does
not provide accurate data on that individual person’s risk of suffering a heart
attack, stroke or other vascular event. In concordance with this notion, the
latest lipid therapy guidelines recommend treatment according to the person’s
vascular risk and not according to a specific cholesterol level. It is
impossible to accurately define the best medical treatment based only on a
person’s risk factor profile (or using “risk scores” which are derived from
risk factor data) without measuring the load of atherosclerosis that affects
the arteries. Vascular prevention should be based on a tailor made treatment.
Or, again, could the eye doctor give you the right glass prescription just
knowing you can’t see well (i.e. that you have vascular risk factors) without
examining your eyes (i.e. your arteries)?
From Galileo Galilei to the software metrics guru Tom de
Marco, many have stressed that one can only control what is measured. And
everything is measurable. We should not only be measuring the conventional risk
factors such as blood pressure, cholesterol, glucose, exercise and calories,
but also the amount of atherosclerosis in the arteries. Only then we will be
able to adjust the treatment of vascular risk factors “individually” according
to all findings. The World Health Organization and different research authorities
have shown that cardiovascular deaths could decrease by 80% if what we know
about vascular disease was applied effectively. Botín, Gandolfini and my
grandfather, no matter their wealth, social status or popularity were probably
not receiving the medications and other measures (exercise, nutrition) that
could have prevented their deadly vascular event. It is also unlikely that they
had their “atherosclerosis” burden measured to adjust treatment according to
their individual atherosclerosis load. There are millions more like them that every
year have fatal MI’s and strokes. Of the approximately 150,000 people that die
every day worldwide, almost one third dies of vascular related disease. Most of
these deaths are preventable. It is due time to declare “tolerance zero” to
unexpected vascular death.
Conrado J. Estol, M.D., Ph.D.
