The recent death of Tim Russert prompts an analysis of cardiac health and treatment

The New York Times published a thorough article examining the issue of coronary artery disease (CAD), prompted by Russert's recent sudden death. The newspaper pointed out that CAD is the leading cause of death in the U.S., killing 650,000 people each year.   It examined the various risks associated with CAD and the treatment options.

The Times noted that 16 million Americans have CAD and that about 300,000 die suddenly from CAD each year.  About half, like Mr. Russert, display no symptoms prior to the sudden event.

Mr. Russert died as a result of a plaque rupture, when a "fatty, pimple-like" inflammation in a coronary artery bursts, creating a clot that stops the circulation of blood and oxygen to the heart.  This, in turn, causes a myocardial infarction (MI), an event that happens about 1.2 million times each year in the U.S., killing nearly half a million people.  In Russert's case, the MI was fatal because it caused an abnormal heart rhythm, resulting in a complete shutdown of the pumping of his heart.  Had he been defibrillated immediately, it is possible that he would have survived the event if a normal pumping rhythm had been re-established.

Researchers are looking for bio-markers that would inform doctors when someone, like Russert, has plaque formations and is vulnerable to a clot.  Unfortunately, no reliable indicator has been identified.  On autopsy, it was apparent that Russert had significant CAD or plaque formation--enough to warrant a bypass if it had been identifed before his fatal event.  His doctors said that he did not present with enough symptoms or markers to warrant an invasive cardiac catheterization--the only procedure which would have allowed them to assess his CAD risk.

Russert had high blood pressure but no family history of heart disease.  His total cholesterol was normal, as was his LDL (or "bad") cholesterol.  His C-reactive protein, a measure of inflammation, did not provide any warning, and he did not smoke.  He was following an exercise regimen and had recently passed a stress test.  His estimated risk of a heart attack in the next ten years was under five percent.  On the other hand, his protective cholesterol (HDL) was low and he had high triglycerides.  He was overweight with a waist above the recommended 40 inches. A CT scan of his coronary arteries in 1998 resulted in a calcium score of 210--highly suggestive of CAD and heart attack risk.  An echocardiogram in April found that his heart wall had thickened-another danger sign.

While some critics have suggested that Russert should have undergone a cardiac catheterization, other physicians have resorted to the well-known axiom that cardiac care is "an art, not a science".  Either way, it is unfortunate that we still don't have a more reliable standard to predict who needs to undergo invasive treatment, and who does not.