Dear Community ,
I am inviting you to have a look at Sudden Cardiac Death ( SCD ).
Below is an interesting case :
A 49 year old man of Asian descent was referred by his General Practitioner (GP) to clinic for further assessment and eventual preventive measures , following the death of this patient 's senior brother at the age of 51 , in October 2014.
Background of the patient : 49 year old man. He is a mechanic. Happily married with two children.
Risk factors. Diabetes, hypertension, familial hypercholesterolaemia, less than ten years ex cigarette smoker, positive family history for sudden cardiac death - father died suddenly at the age of 50. His senior brother died suddenly at the age of 51 last month.
Current medication. Metformin for diabetes and Gemfibrosil for cholesterol. Coversyl for hypertension
He is allergic to a wide spectrum of cholesterol lowering drugs.
He is completely asymptomatic in every respect.
Referral reasons : referred to the Chief Cardiologist at the upcoming Fako Heart for primary prevention of sudden cardiac death in view of his risk factors.
On clinical examination: He appreared well. His weight was 75 kg, Chest was clear, Normal heart sounds, Respiratory rate 20/min, Sats 98% on air, Temperature 37*c , ECG normal with a Heart rate of 70b/m.
Blood biochemistry satisfactory apart from total cholesterol level elevated at 7.2
HBA1c - Glycated haemoglobin elevated at 7,5.
Investigations : I performed EchoDoppler of the Carotid arteries ( neck ) . There were minor plaques at the left common carotid artery. Rationale : According to a recent article , there is an indirect link between coronary artery lesions and carotid lesions , and both could coexist in up to 20% of cases.
Echoardiographic images of the heart: Preserved funtion with no signs of wall motion abnormalities. EF 68%
Exercise Tolerance Test::Asymptomatic at a good work load after 15minutes on a mountain Bike style of stress test. However, during recovery there were abnormalities suggestive of probable ischaemia or poor blood supply to the heart muscle under high stress. This could be acceptable . But the crux here is that this gentleman has the most significant risk factors for sudden death. Therefore, I have to address the minor changes observed during his stress test. I could have been reluctant without such risk factors.
Plan of action/ conduit a tenir :
I explained my findings to the patient and stressed the importance of primary prevention of heart disease.
The difficulty in this situation is the role of Aspirin . Across our cardiology community, there is ongoing debate about the role of Aspirin in primary prevention of ishaemic heart disease - see heart attack. ( please be reminded that heart attack is different from heart arrest) In fact heart arrest is often due to a heart attack in Western countries. In Africans it is mostly but not soley due to hypertension and valve diseases which could lead to acute heart failure and subsequent heart arrest.
Treatment strategy: I optimised his medication with Aspirin 75mg daily based on the plaques in his carotid arteries in conjuction with the minor abnormalities of his stress test.
I then introduced a betablocker, bisoprolol 2.5mg daily. I opted for pravastatin 40mg daily and interrupted his fibrates given that his cholesterol was badly elevated.
I invited him to repeat another functional imaging modality without pharmacological washout in 3 months time. And will compare with previous stress findings.
Analysis : In patients presenting with symptoms , this should have been a straight forward case. I will operate on the patient straight away given his risk factors.
The challenges with asymptomatic( without symptoms) patients is based on- why did you operate on him/ her given that there could be complications when operating on the heart?
In the end I will explore the coronary arteries of this man within the next 90 days. My decision is based on international experience in the sense that up to 95% patients of Asian origin under my care, presenting with a similar picture have blocked arteries supplying blood to the heart muscle. Also, he is a male subject with two of his first degree relatives dying suddenly from unknown heart conditions.
This long email is intended for medics. And will be grateful if you could explain this case to your loved ones.
Apart from the clinical scenario, there is a cost implication issue here.
The upcoming Fako Heart in GRA , Buea , will offer a similar service without a Cath lab given that ishaemic heart disease is yet to be a burden in our country. Ours is high blood , heart valve diseases and malformations.
So far this patient has spent 1200 pounds /1500 euros/ 2800 dollars for his consultation and investigations.
Fako Heart will offer the same package and professionalism for just a 100.000cfa.
Comments welcome.
Have a nice sunday.
Fako Heart.
Centre of Excellence for Prevention of Cardiac Disorders & Stroke.
P..O Box 400
Buea-SW Region
Cameroon.
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