Sudden Death 

Two more recent sudden deaths, a 41 year old female and a 54 year old NUS Associate Professor, both apparently healthy individuals. The newspaper reporter did well, highlighting what Dr. Low a cardiologist said that in reality there are more than 300 cases a year of sudden deaths and we are now aware of it because more of such cases are being reported to the press.

Without direct access to post mortem results, it would not be surprising that the majority of cases are due to cardiac (heart related) causes. Valvular problems used to be the predominant cause of cardiac deaths before the widespread use of antibiotics decreased a condition known as bacterial endocarditis. Today atherosclerosis (thickening and blockage of blood vessels), is believed to be the more likely cause of sudden cardiac deaths.  Another heart condition which can cause sudden death is myocarditis (where the heart muscle becomes inflamed and does not work efficiently) usually because of viral infection. This can happen when someone exerts himself when he is unwell. It is therefore very important to get this message across, when you are unwell, rest. There is no such thing as running off a cold or a fever.

How do we prevent atherosclerosis, a process which doctors are only now beginning to unravel and understand? High Blood Pressure, Diabetes, Hypercholesterolaemia, smoking and a yet unnamed condition now loosely termed as the vulnerable individual; (someone whose blood has a predilection to clot), are commonly associated with increased cardiac risks. If you have been diagnosed with any of the conditions above you will do well to adhere to the medication that your doctor has prescribed for you and change your lifestyle such as by stopping smoking, exercising at least 30 minutes preferably everyday or at least 5 times a week, bring your weight down to a lower risk level ( BMI between 18.5 to 23, refer to our article on BMI and use the Healthtools in this portal to access your diet and manage your weight), eat healthily by avoiding fatty foods and increase intake of fruits and vegetables. If you have a family history of these conditions but have yet to show any signs or symptoms, a routine health check is advisable as many individuals with High Blood Pressure and increased cholesterol levels do NOT feel unwell. The first symptom may well be the last symptom! A very well written article on Diabetes Mellitus is located within this portal and everyone should familiarize themselves with its signs and symptoms.

I will not expound on the various treatments for the different conditions here but suffice to say that controlling High Blood Pressure is very important and as long as medications are required to keep the BP at acceptable levels, it should not be stopped without medical advice.  What about those with high cholesterol, what should they do? Other than diet and exercise, your doctor will likely prescribe a cholesterol lowering drug and like blood pressure treatment, therapy should be life-long. Treatment of high cholesterol in susceptible individuals can reduce the risks for coronary heart disease (CHD) by as much as 35%. Individuals with high risk may need to have their cholesterol levels lowered to a much lower target than those with low to moderate risk.

High Risk Patients are individuals who are already known to have Coronary Heart Disease and patients with diabetes mellitus or multiple other risk factors. They have a 10 year CHD risk of greater than 20%. Moderate or Intermediate risk individuals have a 10 year CHD risk of between 10-20% and Low risk individuals have a 10 year CHD risk of less than 10%. For this purpose of assessment, the 10 year CHD risk means the risk of having a heart attack or coronary death in the next 10 years. As an example, if your score gives you a % of 11, it means that 11 people out of 100 with this score are likely to have a Heart Attack within the next 10 years. For an individual who has two or more risk factors, this estimation of the 10 year CHD Risk Score is therefore important.

The Major Risk Factors thus are:

• Total cholesterol = 240 mg/dl (6.2 mmol/L) or

LDL cholesterol = 160 mg/dl (4.1 mmol/L)

• Cigarette smoking
• Hypertension (BP = 140/90 mmHg or on anti-hypertensive treatment)
• Low HDL cholesterol (< 40 mg/dl [< 1.0 mmol/L])
• Family history of premature CHD (CHD in male first degree relative < 55 years; CHD in female first degree relative < 65 years)
• Age (men = 45 years; women = 55 years)
• Indian ethnicity

In part 2, we will discuss more on the relevance of the 10 year risk score and what it implies in terms of getting our LDL Cholesterol (Bad cholesterol) down.

Sudden Death – Part 2

The risk score is based on measurements determined by age, sex, total cholesterol and HDL cholesterol (good cholesterol), smoking status, Systolic Blood pressure whether treated or untreated and ethnic origin (Indians have a higher risk).

We have simplified the calculation process. All you need to do is go to our HeART Calculator and fill in the blanks and it will automatically count your score for you.

With the exception of age, all the above will need to be treated if abnormal and will in turn determine the LDL (bad cholesterol) target; for the prevention of CHD. The most important priority is to optimize the LDL cholesterol level. In the latest guidelines, if you are at High Risk, the gold target for LDL is below 100mg/dl (2.6 mmol/L), if you are at Moderate Risk, it is below 130mg/dl ( 3.4 mmol/L) and if Low Risk, it is 160mg/dl (4.1 mmol/L). Most doctors however believe that the lower the LDL-C achieved, the better and some American doctors are targeting levels of 70mg/dl (2.0 mmol/L). By the way, mg/dl or mmol/L are just different ways of describing concentration; mg/dl is the traditional format whereas mmol/L is the newer SI format. Stick to one, its easier to remember, I believe most doctors use mg/dl and any reduction is more prominent eg. from 160 to 100, rather than 4.1 to 2.6. To convert from mg/dl to mmol/L, just multiply by 0.0259. eg. 160 x 0.0259 = 4.1

So let’s summarize. If you have any of the following: Established Coronary Heart Disease, High Blood Pressure, Diabetes Mellitus, Atherosclerotic Cerebrovascular Disease, Peripheral Artery Disease, Abdominal Aortic Aneurysm, a strong family history of premature CHD, if you are an Indian, if you are obese or those with high risk BMI (see our article on BMI), if you smoke, if you leave a sedentary life-style, if you are stressed, you should count the number of risk factors that you have. If you have 0 – 1 Risk Factor, you automatically belong to the Low Risk group. If you have more than 2, you should obtain a base line record for your blood pressure, fasting glucose and fasting lipid levels. Using these results and apply it to the HeART Calculator to get your 10 year Risk Score. This should give you a reasonable indication of your level of risk. Consult with your doctor for further advice or treatment as required.

Sudden death causes are not limited to coronary (heart) events although it is reasonable to assume that it is probably the major cause. As mentioned, these are all guidelines to enable patients to have a better understanding of their condition and to assist doctors in making clinical decisions. Do remember that your well being begins with you and you can do much to reduce illnesses and diseases. Start with simple lifestyle changes; stop smoking, eat wisely and manage your weight intelligently, exercise regularly, take time off to rest and relax and if required, take your doctor’s advice and medications as prescribed.

Sudden deaths will occur but we can do a lot to stop it from including us in its statistics!

Data and information used above and those applied to the HeART calculator are provided by The Ministry of Health, Singapore. Clinical Practice Guidelines 2/2006. Lipids. May 2006.
Available from: http://www.moh.gov.sg/corp/publications/list.do?id=pub_guide_clinics