Could Tim Russert's Death Have Been Predicted or Prevented?

The question posed in the tile is unanswerable, but I put it to William Bestermann, MD anyway. Doctor Bestermann is medical director of the Vascular Medical Center for the Holston Medical Center in Kingsport, Tennessee. He has a long and deep interest in preventing vascular deaths and is considered an authority on the subject.

Through his work at Holston Medical Center and at COSEHC (Consortium for Southeastern Hypertensive Control), he has shown doctors using protocols to prevent, monitor, and minimize metabolic risk factors producing the vascular death epidemic can dramatically reduce the rate of sudden deaths in patients with diabetes, hypertension, and lipid disorders.

Bestermann believes diabetes, hypertension, and the various dyslipidemias are closely related and inhabit the same vascular universe, and simultaneous control of metabolic factors ( Hemoglobin A1c of less than 7.0, BP under 130/80, and LDL of 70 or less) sharply reduces vascular deaths. Further, he thinks this reduction can be implemented in any community with physicians willing to follow protocols focusing on metabolic control.

He expresses his philosophy and its results in my book Innovation-Driven Health Care in a chapter in a chapter entitled “New Practice Paradigm for Preventing Vascular Deaths.”

Here is what he said in response to my question: Could Tim Russert’s death have been prevented?

“I can’t say absolutely about prevention in his case,
But I can say chances can be minimized in similar patients.

A heart attack is not about blockage. It’s about plaque rupture. When the plague ruptures, it kicks off the clotting process. Russet’s autopsy showed fresh clot. He had a stress test six weeks before. A stress test is not a good predictor of sudden death. But Russet was diabetic, and have a high risk of sudden death from heart attack or stroke.

You can’t predict a heart attack based on a stress test. But you can anticipate a plaque rupture if blood pressure and metabolic factors like glucose and lipids is out of control. Only 7% of diabetics have excellent control of these factors.

Stabilizing those plaques so they don’t rupture involves precise control of blood pressure, diet, and medication. An article in JAMA in 2004 showed simultaneous control of blood pressure, diabetes, and cholesterol occurred in only 7% of patients.1A type II diabetic, like Russet, has an 82% chance of heart attach or stroke. Each of those things you control, you lower the risk by roughly half.

In a study reported in the New England Journal in February, a Danish group split 160 patients into two groups – 80 under tight control of blood pressure and metabolic factors, the other 80 uncontrolled.2After 7 years, there was a 54% reduction in heart attack and stroke. and a 60% reduction in other complications. So ethically, th Danes had to bring the usual care group into the tightly controlled group.

At 13 years, half the people in the usual care group were dead, twice as many as in the aggressive care group. In the group under usual care, there were 4 times as many heart attacks, 5 times as many strokes. 11 times the number of stents, 3 times as many amputations, and 6 times the number of dialyses. In the patients under usual care, there were 158 catastrophes, or two apiece, and there were a 1/3 that many in aggressive care.

Doctor Bestermann emphasized he did not know the details of how well Tim Russet’s vascular risk factors were controlled. He added you can not absolutely prevent, or even, predict a plaque rupture but you can “stabilize the plaque” through blood pressure, glucose, and LDL control, and vastly decrease the odds of rupture.

References

1. Sedan, et al, Poor Control of Risk Factors for Vascular Disease with Previously Diagnosed Diabetes, JAMA, Jan 21, 2004.
2. Geed, P, et al, “Effect of Multifactorial Intervention on Mortality in Type 2 Diabetes, NEJM, Feb 8, 2008