Poison,Reynold's or a Broken Heart
Charles Ayanleke MD,MRCPI
65 yo AAM nursing home resident with PMH of HTN,DM,CHF(EF 10-15%),COPD and OSA admitted 2 months ago with COPD exacerbation and an incidental finding of mediastinal mass on CXR confirmed on CT.
During that previous admission,he underwent a Video assisted thoracoscopy(VATS) and biopsy which confirmed a benign thymolipoma.A small left pleural effusion was also noted at the time but was not pursued.
He drank ETOH only socially and denies IVDU. He has a 40 pack years history of tobacco use.
He was readmitted 3 weeks ago to ICU with a lower abdominal pain diarrhea and fever,postive stool for C-Diff and evidence of extensive colitis from the sigmoid to the splenic flexure on Abdominal CT scan.C-Diff colitis was managed with Vancomycin (par PEG and enemas) and with Flagyl IV.
He went into septic shock and grew GNB in urine,subsequently treated with Zosyn for UTI.He had hypokalemia and refractory hypophosphatemia which were aggressively replaced. EGDT was commenced for septic shock but pressor support could not be withdrawn for days.A subsequent cosyntropin stimulation test came back positive and he was placed on Hydrocortisone and Fludrocortisone.
He stabilized and was transfered to the regular nursing floor after 8 days in ICU.2 days after the transfer,the rapid response squad was called for a sudden chest pain and he was found to have an NSTEMI with troponins of 7.3.He was transfered back to ICU where conservative medical therapy was instituted with Argatroban,plavix and apirin as he had documented allergy to Heparin(??HITT) although the actual nature of the allergy was unclear.Cardiology later changed argatroban to Fondaparinux S/Q for hospital formulary and cost reasons.
Pulmonary had postponed any thoracentencis until after the patient is off anticoagulation.
He gradually developed deepening scleral icterus and his bilirubin rose to >10mg/dl predominantly conjugated.ALP steadily topped 9,000 with only high normal transaminases but his GGT was >5000.
His ALP was normal in April 2008.
He had complained of a vague general abdominal pain worse over the Right upper quadrant.
An Abdominal U/S suggested coarse liver architecture consistent with cirrhosis without biliary dilatation. Repeat CT abdomen and pelvis was normal.
Antimitochondrial antibodies and hepatitis profile were negative.
He was deemed too unstable for liver biopsy(even the transjugular approach).He was put back on pressors after dropping his BP prior to a planned CRRT for worsening CHF and anaserca.
Gastroenterology discontinued any medication started within the last 2 weeks due to concerns of toxic/med-induced hepatitis.These include his Fondaparinux,plavix,aldactone and seroquel (which was started for anxiety and panic attacks).
He frequently became intermittently lethargic and required intermittent CPAP treatment for episodes of desaturation.
A day after his code was reviewed to DNRccA(as defined under Ohio laws),he went into cardio-respiratory arrest.CPR was not done and he subsequently expired.
Discussion:
The key differential diagnosis here include Ascending cholangitis,Cardiac cirrhosis and toxic or medication induced liver injury.The acuity of onset and the characteristic Reynold's pentad favors Ascending cholangitis in this very sick patient.
Unfortunately,he was too sick for a potentially life-saving biliary drainage via ERCP.
ERCP was the natural next step especially with the lack of biliary dilatation on Ultrasound scan in view of the very suggestive clinical picture.
MRCP may have helped establish a diagnosis but will not enable a therapeutic drainage procedure.He however received appropriate antibiotic cover with Piperacillin-Tazobactam.
Friday, June 27, 2008
The bad good.
Arisekola, please don't open the gate
By Reuben Abati
ONE of the challenges arising from the recent death of Alhaji Lamidi Adedibu, the self-styled Godfather of Oyo State politics, speaks to the troubled dynamics of social and class relations in Nigeria as indicated by the present circumstances of the hordes of hangers-on who flocked to his home on a daily basis. Now with Adedibu dead, this strong army of poor people appears defeated.
In his lifetime, Alhaji Adedibu provided free food for the masses: everyday, a cow was slaughtered in his compound, soup was prepared and yam flour delicacies were rolled off a busy kitchen line. Anyone who felt the pangs of hunger could stop by and have a meal.
The money that Adedibu had collected from his clients in positions of power and authority, he gave a part of it to the poor, to pay their children's school fees and to attend to their other needs. Even if this was a self-serving method of gaining political relevance and popularity at the grassroots level, Adedibu sustained this twice-a-day free meal programme till the end. And this was the source of his reputation as a philanthropist, his appelation as Alaafin Molete and the description of his brand of politics as "amala politics". Every day of the year, a crowd gathered at his doorstep.
But since his death on June 11, that crowd of hungry men and women looking for food as fuel, has thinned out. The hungry mouths kept converging for a few days after the burial, but when they noticed that Adedibu's 19 children had resolved to close the kitchen, tie up the bags of yam flour, and sanitise the compound and put an end to their father's politics of food, the crowd had to disperse. Indeed, one of Adedibu's children speaking for the family had declared, clearly, that there will be no more free food for the poor in Adedibu's household.
The people were advised to "find their level." The children are not willing to step into their father's shoes. Amala politics is over. It is finished. Its author and exponent is dead; that chapter is closed. And so today, Adedibu's once busy compound has become quiet: no more drummers waking up the Alaafin and serenading him with praise-chants, no more thugs hanging by the gate providing protection for the Godfather; the women who used to cook all day in the kitchen have folded their bulbous wrappers and have hit the road in search of new patrons.
But since as they say, "nature abhors a vacuum", and the stomach is a god that can only be propitiated with food, the courtiers of Adedibu's palace have had to go in search of a new patron who can take care of their needs. And it is to the home of Alhaji Azeez Arisekola-Alao, that they have turned their gaze.
Arisekola is another prominent Ibadan citizen, a notable Nigerian businessman, the Aare Musulumi of Yorubaland (the generalissimo of the islamic faith in Yorubaland), and in a much quieter way, also a philanthropist. Besides, the late Adedibu reportedly chose Arisekola as the administrator of his estate and executor of his will.
In their simple understanding, the amala crowd may have concluded that this literally means Alhaji Arisekola is Adedibu's anointed successor and the man to inherit his public and social obligations. Last Saturday and Sunday, they gathered in front of his home at Ikolaba in Ibadan - women and youths looking for financial assistance and food. As reported in The Punch of June 23, 2008, p,10, "a 17-year old boy" wants Arisekola to feed him and pay his school fees. And a widow needs money to feed her children. But the gate to Arisekola's house was securely fastened.
The hungry men and women at the gate were told by guards that "they were not instructed to open the gates for anybody without prior appoitment". Undeterred, the able-bodied men and women begging for money and food, returned on Sunday but the gates were still locked.
Adedibu may have opened his own gates for the hungry and the poor, but the scenario at Arisekola's house is closer to reality.
There is a huge divide between the poor and the rich in Nigeria, standing within that divide are guards, gates, walls and barbed wires reaching the skies. In the home of every rich man, there is a crowd of beggars waiting to knock on the door, knocking on the gates, but the rich have learnt to keep the poor away.
You can't barge in on them unless you have an appointment. They have guards, they have dogs that have been trained to keep intruders and poor - looking people away. Their homes are in isolated parts of the city not in open neighbourhoods like Adedibu's Molete. They have electronic surveillance, some of our rich men even have mini-police stations in their houses, complete with cells and uniformed police men who can charge you for tresspass and lock you up immediately.
The only way the poor can gain entrance into those gilded cages where the rich live is as employees in the servants' quarters, or as armed robbers who break down the walls and force their way in with the help of guns. The reality is that the Nigerian rich are prisoners of their wealth. They cannot enjoy it because they are constantly afraid that the poor, looking for food and free money, may tear down the walls.
Can anybody blame Alhaji Arisekola-Alao for locking up his gates and instructing his guards to shut out uninvited and unwanted guests? The man may have been Adedibu's friend in his lifetime, but he is not a politician.
He is a businessman. And he probably doesn't like the idea of poor people messing up his well-manicured lawns and polluting his abode with their body odour. Nobody should be surprised if Alhaji Arisekola recruits armed guards to beef up security at his home or if he seeks police protection, and puts up a sign: "Intruders and tresspassers will be shot on sight, Be warned." With their desperation since their patron died, the Amala crowd of Ibadan has now helped to advertise a seemingly positive value of Adedibu's peculiar mess. But this is a comment on the state of the Nigerian society.
There is a growing crowd of poor people out there which feels shut out of the Nigerian system. The crowd exists nationwide, not just in Ibadan. Its members are worst hit by the failure of the Nigerian economy, the specter of galloping inflation, unemployment and the sheer incompetence and ineffectuality of government at all levels. It is government that should be blamed.
The blame belongs to the leaders at all levels who loot the treasury and years after the fact, claim innocence. The villains are those in the positions of authority who fail the people only to erect walls around their homes.
It is so comical seeing the Nigerian rich not being able to enjoy their wealth: at the root of this is the failure of enlightenment on their part; in other societies, both the rich and governments help to create a welfare society so the fears of the poor may be addressed. It is so pitiable seeing that many Nigerians, living on less than one dollar per day, face the indignity of having to go to another man's home to beg for food.
The greater danger is that whoever provides that food can use the poor for any purpose at all, and this was the gap that a man like Adedibu took advantage of. He was in that sense as much a creation of the imperfections of the Nigerian state as those he fed were victims.
Also in this plane are the boys turned militants in the Niger Delta who are being used by Adedibu-like figures to wage war against Nigeria; also here are the almajiris of the Northern parts who can be asked to go out and cause mayhem by an influential master, whose purposes may not be noble. Perhaps when the rich can no longer sleep in their homes, when their gates and guards and their bullet proof cars can no longer protect them, Nigeria will be forced to address the crisis of poverty not as effect, but as the root-cause of much that is wrong with our politics and society.
In the Adedibu case, a Kano-based cleric, Alhaji Muyideen Ajani Bello, delivering a sermon at the eight-day fidau prayer session for the late Adedibu had advised the rich men and women in Ibadan and Adedibu's children "to open their gates for the jobless, downtrodden masses and feed them." He said: "if you are not careful, armed robbers will increase in Ibadan. Once those that are feeding in Adedibu's house realise that there is nowhere for them to feed again, they will go out and rob houses. For you to avert this situation, be ready to feed these hoodlums and the jobless. Open your houses for people to come and eat, if not armed robbers will begin to burgle your houses."
Why should anybody feed others if this were a well-organised society? Many of the people looking for food are not physically challenged ( even if they were?), many of them are educated or are skilful in some ways. They need jobs and opportunities, and guarantees that anyone who is willing to work will find something to do. The true challenge is in turning Nigeria into a land of opportunities where human dignity can be assured.
Nigerians also need a social security system that caters for both the vulnerable and the privileged and raises the quality of life. Because many hungry mouths exist, to be exploited and used for political purposes, that is why there has been so much unedifying talk about Adedibu's likely successors.
Institutions of state would still have to be strengthened to provide succour for the helpless, and to check the resort to criminality for either ideological or existential reasons. Leaders must stop stealing money and votes and focus on the people's welfare. It is the failure to do this that will produce the next Adedibu, and the effect on society would just be as bad as the menace of armed robbery that the cleric fears.
*Rueben Abati is my favourite social commentator and the editor of the leading Nigerian daily,The Guardian.
By Reuben Abati
ONE of the challenges arising from the recent death of Alhaji Lamidi Adedibu, the self-styled Godfather of Oyo State politics, speaks to the troubled dynamics of social and class relations in Nigeria as indicated by the present circumstances of the hordes of hangers-on who flocked to his home on a daily basis. Now with Adedibu dead, this strong army of poor people appears defeated.
In his lifetime, Alhaji Adedibu provided free food for the masses: everyday, a cow was slaughtered in his compound, soup was prepared and yam flour delicacies were rolled off a busy kitchen line. Anyone who felt the pangs of hunger could stop by and have a meal.
The money that Adedibu had collected from his clients in positions of power and authority, he gave a part of it to the poor, to pay their children's school fees and to attend to their other needs. Even if this was a self-serving method of gaining political relevance and popularity at the grassroots level, Adedibu sustained this twice-a-day free meal programme till the end. And this was the source of his reputation as a philanthropist, his appelation as Alaafin Molete and the description of his brand of politics as "amala politics". Every day of the year, a crowd gathered at his doorstep.
But since his death on June 11, that crowd of hungry men and women looking for food as fuel, has thinned out. The hungry mouths kept converging for a few days after the burial, but when they noticed that Adedibu's 19 children had resolved to close the kitchen, tie up the bags of yam flour, and sanitise the compound and put an end to their father's politics of food, the crowd had to disperse. Indeed, one of Adedibu's children speaking for the family had declared, clearly, that there will be no more free food for the poor in Adedibu's household.
The people were advised to "find their level." The children are not willing to step into their father's shoes. Amala politics is over. It is finished. Its author and exponent is dead; that chapter is closed. And so today, Adedibu's once busy compound has become quiet: no more drummers waking up the Alaafin and serenading him with praise-chants, no more thugs hanging by the gate providing protection for the Godfather; the women who used to cook all day in the kitchen have folded their bulbous wrappers and have hit the road in search of new patrons.
But since as they say, "nature abhors a vacuum", and the stomach is a god that can only be propitiated with food, the courtiers of Adedibu's palace have had to go in search of a new patron who can take care of their needs. And it is to the home of Alhaji Azeez Arisekola-Alao, that they have turned their gaze.
Arisekola is another prominent Ibadan citizen, a notable Nigerian businessman, the Aare Musulumi of Yorubaland (the generalissimo of the islamic faith in Yorubaland), and in a much quieter way, also a philanthropist. Besides, the late Adedibu reportedly chose Arisekola as the administrator of his estate and executor of his will.
In their simple understanding, the amala crowd may have concluded that this literally means Alhaji Arisekola is Adedibu's anointed successor and the man to inherit his public and social obligations. Last Saturday and Sunday, they gathered in front of his home at Ikolaba in Ibadan - women and youths looking for financial assistance and food. As reported in The Punch of June 23, 2008, p,10, "a 17-year old boy" wants Arisekola to feed him and pay his school fees. And a widow needs money to feed her children. But the gate to Arisekola's house was securely fastened.
The hungry men and women at the gate were told by guards that "they were not instructed to open the gates for anybody without prior appoitment". Undeterred, the able-bodied men and women begging for money and food, returned on Sunday but the gates were still locked.
Adedibu may have opened his own gates for the hungry and the poor, but the scenario at Arisekola's house is closer to reality.
There is a huge divide between the poor and the rich in Nigeria, standing within that divide are guards, gates, walls and barbed wires reaching the skies. In the home of every rich man, there is a crowd of beggars waiting to knock on the door, knocking on the gates, but the rich have learnt to keep the poor away.
You can't barge in on them unless you have an appointment. They have guards, they have dogs that have been trained to keep intruders and poor - looking people away. Their homes are in isolated parts of the city not in open neighbourhoods like Adedibu's Molete. They have electronic surveillance, some of our rich men even have mini-police stations in their houses, complete with cells and uniformed police men who can charge you for tresspass and lock you up immediately.
The only way the poor can gain entrance into those gilded cages where the rich live is as employees in the servants' quarters, or as armed robbers who break down the walls and force their way in with the help of guns. The reality is that the Nigerian rich are prisoners of their wealth. They cannot enjoy it because they are constantly afraid that the poor, looking for food and free money, may tear down the walls.
Can anybody blame Alhaji Arisekola-Alao for locking up his gates and instructing his guards to shut out uninvited and unwanted guests? The man may have been Adedibu's friend in his lifetime, but he is not a politician.
He is a businessman. And he probably doesn't like the idea of poor people messing up his well-manicured lawns and polluting his abode with their body odour. Nobody should be surprised if Alhaji Arisekola recruits armed guards to beef up security at his home or if he seeks police protection, and puts up a sign: "Intruders and tresspassers will be shot on sight, Be warned." With their desperation since their patron died, the Amala crowd of Ibadan has now helped to advertise a seemingly positive value of Adedibu's peculiar mess. But this is a comment on the state of the Nigerian society.
There is a growing crowd of poor people out there which feels shut out of the Nigerian system. The crowd exists nationwide, not just in Ibadan. Its members are worst hit by the failure of the Nigerian economy, the specter of galloping inflation, unemployment and the sheer incompetence and ineffectuality of government at all levels. It is government that should be blamed.
The blame belongs to the leaders at all levels who loot the treasury and years after the fact, claim innocence. The villains are those in the positions of authority who fail the people only to erect walls around their homes.
It is so comical seeing the Nigerian rich not being able to enjoy their wealth: at the root of this is the failure of enlightenment on their part; in other societies, both the rich and governments help to create a welfare society so the fears of the poor may be addressed. It is so pitiable seeing that many Nigerians, living on less than one dollar per day, face the indignity of having to go to another man's home to beg for food.
The greater danger is that whoever provides that food can use the poor for any purpose at all, and this was the gap that a man like Adedibu took advantage of. He was in that sense as much a creation of the imperfections of the Nigerian state as those he fed were victims.
Also in this plane are the boys turned militants in the Niger Delta who are being used by Adedibu-like figures to wage war against Nigeria; also here are the almajiris of the Northern parts who can be asked to go out and cause mayhem by an influential master, whose purposes may not be noble. Perhaps when the rich can no longer sleep in their homes, when their gates and guards and their bullet proof cars can no longer protect them, Nigeria will be forced to address the crisis of poverty not as effect, but as the root-cause of much that is wrong with our politics and society.
In the Adedibu case, a Kano-based cleric, Alhaji Muyideen Ajani Bello, delivering a sermon at the eight-day fidau prayer session for the late Adedibu had advised the rich men and women in Ibadan and Adedibu's children "to open their gates for the jobless, downtrodden masses and feed them." He said: "if you are not careful, armed robbers will increase in Ibadan. Once those that are feeding in Adedibu's house realise that there is nowhere for them to feed again, they will go out and rob houses. For you to avert this situation, be ready to feed these hoodlums and the jobless. Open your houses for people to come and eat, if not armed robbers will begin to burgle your houses."
Why should anybody feed others if this were a well-organised society? Many of the people looking for food are not physically challenged ( even if they were?), many of them are educated or are skilful in some ways. They need jobs and opportunities, and guarantees that anyone who is willing to work will find something to do. The true challenge is in turning Nigeria into a land of opportunities where human dignity can be assured.
Nigerians also need a social security system that caters for both the vulnerable and the privileged and raises the quality of life. Because many hungry mouths exist, to be exploited and used for political purposes, that is why there has been so much unedifying talk about Adedibu's likely successors.
Institutions of state would still have to be strengthened to provide succour for the helpless, and to check the resort to criminality for either ideological or existential reasons. Leaders must stop stealing money and votes and focus on the people's welfare. It is the failure to do this that will produce the next Adedibu, and the effect on society would just be as bad as the menace of armed robbery that the cleric fears.
*Rueben Abati is my favourite social commentator and the editor of the leading Nigerian daily,The Guardian.
Saturday, June 21, 2008
Tim Russert's CAD Post-Mortem
Media Mulls Russert's Death as Cardiologists Weigh In
Shelley Wood
June 19, 2008 — Media reports in the wake of Tim Russert's sudden cardiac death last week at age 58 have moved on from lamenting the passing of a respected political journalist to questioning whether his death was preventable.
According to information his doctors have provided to the media in statements and in interviews, Russert was known to have asymptomatic coronary artery disease, and he was being treated for hypertension, high LDL and triglycerides, and low HDL. Most recently, Russert's LDL was 68 and his HDL had been raised from in the 20s to 37: an "acceptable lipid profile," according to his doctors. Russert had minimally elevated blood glucose but did not have diabetes; a stress test in late April was normal. Media reports, including a New York Times story on Tuesday , note that Russert had even had a calcium scan in 1998, which yielded a calcium score of 210, signaling intermediate risk. A subsequent autopsy has confirmed that Russert had left ventricular enlargement and died of ventricular fibrillation following plaque rupture in his left anterior descending artery.
Journalists reporting on Russert's death are turning to the cardiology community to make sense of it. Most experts are emphasizing that Russert's case, while high profile, is not that unusual.
"More than 300 000 people die each year in the US from out-of-hospital sudden cardiac death, and Russert had the classic symptoms," Dr Prediman K Shah (Cedars-Sinai Medical Center, Los Angeles, CA) told heartwire. "This is a very common scenario that plays out 90 times per day, every single day of the year."
Could Russert's death have been prevented?
Stories like the one in the Times and the Wall Street Journal the same day point to Russert's risk factors and his attempts to manage them. While his weight had crept upward during the US primary season, he seemed to have his cholesterol and blood pressure under control and was exercising regularly. The logical question being asked by reporters of cardiologists is: could Russert's death have been prevented?
Dr Douglas P Zipes (Indiana University Medical School, Indianapolis) agrees that much of the media coverage has tilted toward the possibility that Russert's death was inevitable. "That's been a real aspect of the media coverage," he acknowledged to heartwire. "But when I've been presented with that point of view from the media, my questions have been: what heart rate did he achieve in his stress test? Was it an adequate stress test? Was radionuclide or echo imaging done, which increases the sensitivity of the test? What medications was he taking, what were the doses, and did he take them on a regular basis? What was his cholesterol despite apparently taking a statin? What exercise program did he really participate in? I have no answer to any of those questions."
Shah agreed, pointing out that many of the specifics about Russert's management are "still sketchy."
"So whether this was preventable or inevitable is difficult to say," Shah observed. "We can't be critical of his doctors since we don't really know the full extent of the medical background. Maybe he was doing everything that it was humanly possible to do and still died, which is not impossible. We still lose people in spite of the best available treatment."
Shah believes if anything good could come out of Russert's untimely death, it is the reminder to the public, to physicians, and to policy-makers that "the battle has not been won."
"We obviously need, in addition to screening, widespread attention to cardiac health through lifestyle modification and probably much earlier detection of the disease at a stage where you can actually arrest its progress," Shah said. "If you detect disease in a 58-year-old, it's a different ballgame than if you detect it in the 30s or 40s. The later you detect it, the less effect therapy will have in halting the progression."
Uncontrolled factors and unknown risk
Dr Eric Topol (Scripps Translational Science Institute, La Jolla, CA) pointed out to heartwire that Russert's weight was a major uncontrolled risk factor; he was also under considerable stress and acknowledged being sleep-deprived. These are "major factors," Topol suggests, but they don't explain everything. He believes a CRP test and newer genetic tests would have gone a long way toward to illuminating just how high Russert's MI risk indeed was. It is not clear whether Russert had had his CRP measured on a regular basis.
"We are reasonably good at treating heart attacks when people get to the hospital, but they don't always get there, and we don't know how to predict plaque rupture," Topol said.
Topol believes genomic testing in the future, and even some of the tests available today, might have helped doctors get a better idea of the risks Russert was facing. "I wouldn't be at all surprised if Russert had 9p21 homozygote, and his son Luke should be tested," Topol said.
Much has been made of Russert's abdominal obesity as a risk factor, something Topol does not discount. But he points out: "There are a lot of people walking around with obesity, but only a fraction have plaque-rupture events that are fatal, so we need to pick out that tiny fraction who are at increased risk and we need better means to do that."
A stress test, Topol points out, is of no value for identifying arteries at risk of causing sudden cardiac death. "The cardiology community still doesn't get it, that stress testing isn't the way to pick up plaque ruptures. There's a classic study that shows that CRP is complementary, and obviously CRP is a very crude test, and we could do much better with genes and proteins, even with what we know today. But I think that the medical community's problem is thinking that stress testing is such a great thing and it simply isn't."
Russert's physicians clarify some points.
Several media outlets and bloggers also reported erroneously on Tuesday that NBC's studio did not have an automatic external defibrillator on site, something that one of Russert's physicians clarified on Larry King Live.
According to Dr Michael Newman, Russert's physician, Russert's resuscitation was initiated immediately at NBC and Russert was ultimately defibrillated three times before his arrival at Sibley Memorial Hospital. But how and to what extent resuscitation efforts were conducted appropriately before emergency personnel arrived is still unclear. USA Today has reported that emergency crews arrived at NBC to find someone trying to perform rescue breathing on Russert using a mask, but that this person was not doing chest compressions . USA Today also reported that it was paramedics who, presumably using their own defibrillator, delivered the three shocks to Russert without success.
*culled from MEDSCAPE.
Shelley Wood
June 19, 2008 — Media reports in the wake of Tim Russert's sudden cardiac death last week at age 58 have moved on from lamenting the passing of a respected political journalist to questioning whether his death was preventable.
According to information his doctors have provided to the media in statements and in interviews, Russert was known to have asymptomatic coronary artery disease, and he was being treated for hypertension, high LDL and triglycerides, and low HDL. Most recently, Russert's LDL was 68 and his HDL had been raised from in the 20s to 37: an "acceptable lipid profile," according to his doctors. Russert had minimally elevated blood glucose but did not have diabetes; a stress test in late April was normal. Media reports, including a New York Times story on Tuesday , note that Russert had even had a calcium scan in 1998, which yielded a calcium score of 210, signaling intermediate risk. A subsequent autopsy has confirmed that Russert had left ventricular enlargement and died of ventricular fibrillation following plaque rupture in his left anterior descending artery.
Journalists reporting on Russert's death are turning to the cardiology community to make sense of it. Most experts are emphasizing that Russert's case, while high profile, is not that unusual.
"More than 300 000 people die each year in the US from out-of-hospital sudden cardiac death, and Russert had the classic symptoms," Dr Prediman K Shah (Cedars-Sinai Medical Center, Los Angeles, CA) told heartwire. "This is a very common scenario that plays out 90 times per day, every single day of the year."
Could Russert's death have been prevented?
Stories like the one in the Times and the Wall Street Journal the same day point to Russert's risk factors and his attempts to manage them. While his weight had crept upward during the US primary season, he seemed to have his cholesterol and blood pressure under control and was exercising regularly. The logical question being asked by reporters of cardiologists is: could Russert's death have been prevented?
Dr Douglas P Zipes (Indiana University Medical School, Indianapolis) agrees that much of the media coverage has tilted toward the possibility that Russert's death was inevitable. "That's been a real aspect of the media coverage," he acknowledged to heartwire. "But when I've been presented with that point of view from the media, my questions have been: what heart rate did he achieve in his stress test? Was it an adequate stress test? Was radionuclide or echo imaging done, which increases the sensitivity of the test? What medications was he taking, what were the doses, and did he take them on a regular basis? What was his cholesterol despite apparently taking a statin? What exercise program did he really participate in? I have no answer to any of those questions."
Shah agreed, pointing out that many of the specifics about Russert's management are "still sketchy."
"So whether this was preventable or inevitable is difficult to say," Shah observed. "We can't be critical of his doctors since we don't really know the full extent of the medical background. Maybe he was doing everything that it was humanly possible to do and still died, which is not impossible. We still lose people in spite of the best available treatment."
Shah believes if anything good could come out of Russert's untimely death, it is the reminder to the public, to physicians, and to policy-makers that "the battle has not been won."
"We obviously need, in addition to screening, widespread attention to cardiac health through lifestyle modification and probably much earlier detection of the disease at a stage where you can actually arrest its progress," Shah said. "If you detect disease in a 58-year-old, it's a different ballgame than if you detect it in the 30s or 40s. The later you detect it, the less effect therapy will have in halting the progression."
Uncontrolled factors and unknown risk
Dr Eric Topol (Scripps Translational Science Institute, La Jolla, CA) pointed out to heartwire that Russert's weight was a major uncontrolled risk factor; he was also under considerable stress and acknowledged being sleep-deprived. These are "major factors," Topol suggests, but they don't explain everything. He believes a CRP test and newer genetic tests would have gone a long way toward to illuminating just how high Russert's MI risk indeed was. It is not clear whether Russert had had his CRP measured on a regular basis.
"We are reasonably good at treating heart attacks when people get to the hospital, but they don't always get there, and we don't know how to predict plaque rupture," Topol said.
Topol believes genomic testing in the future, and even some of the tests available today, might have helped doctors get a better idea of the risks Russert was facing. "I wouldn't be at all surprised if Russert had 9p21 homozygote, and his son Luke should be tested," Topol said.
Much has been made of Russert's abdominal obesity as a risk factor, something Topol does not discount. But he points out: "There are a lot of people walking around with obesity, but only a fraction have plaque-rupture events that are fatal, so we need to pick out that tiny fraction who are at increased risk and we need better means to do that."
A stress test, Topol points out, is of no value for identifying arteries at risk of causing sudden cardiac death. "The cardiology community still doesn't get it, that stress testing isn't the way to pick up plaque ruptures. There's a classic study that shows that CRP is complementary, and obviously CRP is a very crude test, and we could do much better with genes and proteins, even with what we know today. But I think that the medical community's problem is thinking that stress testing is such a great thing and it simply isn't."
Russert's physicians clarify some points.
Several media outlets and bloggers also reported erroneously on Tuesday that NBC's studio did not have an automatic external defibrillator on site, something that one of Russert's physicians clarified on Larry King Live.
According to Dr Michael Newman, Russert's physician, Russert's resuscitation was initiated immediately at NBC and Russert was ultimately defibrillated three times before his arrival at Sibley Memorial Hospital. But how and to what extent resuscitation efforts were conducted appropriately before emergency personnel arrived is still unclear. USA Today has reported that emergency crews arrived at NBC to find someone trying to perform rescue breathing on Russert using a mask, but that this person was not doing chest compressions . USA Today also reported that it was paramedics who, presumably using their own defibrillator, delivered the three shocks to Russert without success.
*culled from MEDSCAPE.
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