Cardiovascular Applications in IME’s Jeffrey M. Friedel, MD

Topics Coronary Artery Disease Heart Attacks Irregular Heart Rhythms Heart Valve Disorders Heart Failure

Heart Attacks (Myocardial Infarction) - A sudden, potentially catastrophic event - About 790,000 people in the US have heart attacks each year. Of those, about 114,000 will die. - The estimated annual incidence of heart attack in the US is 580,000 new attacks and 210,000 recurrent attacks. Average age at the first heart attack is 65.3 years for males and 71.8 years for females. Approximately every 40 seconds, an American will have a heart attack. - The estimated direct and indirect cost of heart disease in 2012 to 2013 (average annual) was $199.6 billion.

Heart Attacks- Causality What leads up to a heart attack (risk factors) What triggers a heart attack (environmental / occupational factors) Old versus new concepts

Heart attack- traditional thinking

Heart attack- traditional thinking

Heart Attack – modern thinking Heart attack is a sudden, dramatic event in an individual at risk Caused by RUPTURE of the underlying plaque

Heart Attack – modern thinking

Plaque rupture

Heart attack- angiogram

Heart Attack Plaque Development Plaque RUPTURE Age Diabetes Smoking High BP High cholesterol Family History Physical inactivity Heavy exertion Intense heat / cold Emotional response (positive and negative) Pollution Heavy alcohol / caffeine use Drug use (especially cocaine) Sexual activity

Cases

Case 1 47 year old firefighter – history of high blood pressure otherwise healthy Shortly after live fire suppression training, feels poorly short of breath treated at site but collapses one hour after the training exercise Cardiac arrest shocked for irregular heart rhythm (VF) taken to hospital but subsequently dies Autopsy multiple areas in heart of plaque builup but evidence of blood clot in the main artery of heart

Case 1 (cont) Was the arrest, etc. related to activity? Time line Significance of pre-existing heart disease found at autopsy What triggers potentially involved? Activity significant talk about mets. Moving pallets, turnout gear, large heavy hoses

Case 2 68 year old bus driver Known history of heart disease but cleared to drive by recent physical and stress test While driving, suddenly becomes unconscious. Bus veers into guardrail  passengers safe but driver remains unconscious 911- medics arrive and perform CPR. Driver taken to hospital and subsequently dies Autopsy extensive plaque in all 3 arteries of heart Findings of old/remote heart attack. No findings of blood clot / recent heart attack

Case 2 (cont) Cause of death? Activity preceding and at the time of death– any triggers? Significance of pre-existing disease Testimony of passenegers no unusual activity. no close call with an accident, no potential trigger

Case 3 63 year old accountant By all accounts, enjoys his work. With current employer 20 years CEO calls meeting, informs him that he is being terminated with 2 weeks notice in the interim will be required to train replacement Returns to office- develops chest pain, shortness of breath- taken to hospital Suffers a heart attack. Appropriately treated and discharged 3 days later.

Case 3 (cont) ?? Emotional trigger Timing the heart attack Cardiac enzymes

QUESTIONS