New York, NY — 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.
Heartwire from Medscape © 2008 Medscape
Cite this: Shelley Wood. Media Mulls Russert's Death as Cardiologists Weigh In - Medscape - Jun 19, 2008.