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

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

3. 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.

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

5. Heart attack- traditional thinking

6. Heart attack- traditional thinking

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

8. Heart Attack – modern thinking

10. Plaque rupture

11. Heart attack- angiogram

12. 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

13. Cases

14. 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

15. 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

16. 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

17. 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

18. 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.

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

21. QUESTIONS