The challenge of premature deaths


Managing Director,Kandy Diabetes Centre

A few days ago a neighbour of mine, 56 years old, died suddenly of a heart attack. I was surprised since he was a regular walker (whom I used to meet when I do mine), but at the funeral it was mentioned by his wife that he was a heavy smoker and an alcoholic. He has developed what sounded like gastritis (at least according to the wife) and when the pain became unbearable he was taken to hospital and passed away shortly. There are two issues here, the first being why he got the attack, and the misdiagnosis by his relatives that it was just a gastritis.

Let me deal with the latter first, namely misdiagnosis. It is mainly the patients and the relatives who are responsible for this but sometimes include some doctors too. They attribute the pain which is sometimes felt in the bottom of the chest to a pain arising from the stomach, the closest organ to the place where the pain is felt most. They also attribute the pain due to high acidity in the stomach brought on by a hot meal or alcohol. This is called an ‘attribution error’ which is quite prevalent in our society.

Then as to the first, as to why he got the heart attack? People just don’t get an attack in the absence of risk factors. These include diabetes, high blood pressure, high cholesterol, smoking, proteins in the urine (microalbuminuria) and a family history of such an illness. In addition, more recently it has been found that even the presence of fat in the liver (‘fatty liver’) too has been identified as a possible risk factor. So it is obvious that if one wants to avoid such deaths these conditions should be identified and treated properly. In an audit carried out at our Diabetic Centre, only about 30% of the doctors, including Consultants, attend to this aspect and are therefore indirectly responsible for these premature deaths!. However it should be mentioned here that some patients even in the presence of several risk factors do not succumb to premature deaths. Maybe their good Karma is playing a role!

How does one identify those who are at a particularly high risk?

In the more developed countries, doctors make use of what are called ‘risk engines’, which could be used as an app in their mobile phones. However, in a country, such as ours, we have to mainly go by the clinical observations aided by laboratory investigations. There are four categories of risk which could be used in clinical practice.

1. Very high risk:

Established heart disease or stroke, diabetes with organ damage such as the kidney. Such patients, in the presence of symptoms suggestive of a heart attack or a stroke, need urgent investigations and treatment

2. High risk

Markedly elevated single risk factors such as high blood pressure or cholesterol. This category also includes all other diabetic patients, except the very young.

3. Moderate risk

Family history of premature heart attacks, low HDL cholesterol (the good cholesterol), high triglyceride cholesterol.

4. Low risk

Presence of diabetes or high blood pressure in a young person.

In the author's opinion the first three categories need further investigations in the presence of symptoms such as chest pain, palpitations, difficulty in breathing and unexplained faintishness due to a ‘silent heart attack’. However, even in the absence of symptoms, screening should be carried out if the risk is high, particularly Risk categories 1 and 2. These screening tests include an ECG, ECHO cardiogram, exercise ECG, CT coronary angiography and calcium score. Among these the ECG and the ECHO cardiography are not of much use except when the patient has had an acute heart attack. The exercise ECG too has its limitations, and the author is aware of a few deaths when the patient undergoes this test. The exercise ECG is going out of fashion and as a screening test the best is the CT coronary angiography, which would enable one to decide whether to go for the ‘gold standard’ for heart disease, namely conventional angiography. In this instance the cardiologist could even decide on carrying out ‘stenting’ to allow the blood to pass through a blocked blood vessel.

What are the first aid measures that could be adopted in the case of a heart attack? The person should be kept flat and a cocktail of three drugs should be immediately administered at home. These drugs include aspirin 300mg, atorvastatin 40mg (a cholesterol lowering drug), and an antacid pantoprazole at a dose of 40mg. These drugs are packed in one container and is called a ‘heart pack’. This could be administered at home, since particularly in outstations the time taken to reach a larger hospital where facilities are available for further specialized care is considerable. Nevertheless the same three drugs are routinely administered to patients when they come to the Out Patients Department. So why not administer it at home? If one could reach the hospital within 90 minutes of the onset of the pain, the patient can undergo further life saving treatment. In our experience we find the ‘Heart Pack’ very useful and feel happy that we were able to save a few lives.

Of course, the final lesson is whoever who has these conditions should be aware of the factors mentioned above, and therefore could prevent a large number of such premature deaths.

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