Sunday, June 7, 2009
Heart disease, prevention - A Treadmill Death
Randy Smith, a speedy, high-scoring guard who set a National Basketball Association record by playing in 906 consecutive games over 12 seasons, died Thursday in Norwich, Conn. He was 60.
He was pronounced death at William W. Baukus Hospital. He had a heart attack while on a treadmill at the Mohegan Sun Casino in Uncasville, where he worked in promotion.
Richard Goldstein, “Randy Smith, 60. N.B.A. Iron Man Dies,” New York Times, June 6, 2009
This obituary notice reminds us that treadmill exercise has risks. In the case of Randy Smith, we have conflicting information about the circumstances of his death. One report says he was working out as part of a usual exercise routine on a treadmill in his home. The other says he was working out on a treadmill at the Mohegan Sun Casino. The Mohican Sun declined to comment, citing medical confidentiality.
Apparently Smith had no history of cardiac symptoms. He was not exercising under medical supervision. His death is a vivid reminder that sudden death is the first symptom of coronary artery disease in 30% of patients and that cardiac defibrillators may be important devices to have around in health fitness facilities and in public places like the Mohegan Casino. Smith’s sudden death reminds us that exercising on a treadmill carries risks.
However, when cardiac stress treadmill tess are carried out under the supervision of a cardiologist with close ECG mentoring, risks of death are miniscule, less than 1 in a 1000. And there is no question, cardiac treadmill tests are indicated in many situations. A physician may recommend an exercise stress test to.
• Diagnose coronary artery disease in patients with significant risk factors
• Diagnose heart-related cause of symptoms such as chest pain, shortness of breath or lightheadedness
• Determine a safe level of exercise
• Evaluate exercise tolerance in patients with unexplained fatigue
• Check the effectiveness of procedures done to improve coronary artery circulation in patients with coronary artery disease
• Predict risk of dangerous heart-related conditions such as a heart attack
• Evaluate blood pressure response to exercise in patients with borderline hypertension
• Look for exercise-induced serious irregular heart beats
I’m sensitive to sudden death from coronary artery disease because I recently had a heart attack. Following a recent myocardial infarction, I’ve been cathed twice, stented three times, and have undergone a cardiac stress test which I found stressful.
As a result of this experience, it strikes me, in certain circumstances, a supplement or a substitute for the traditional stress test, with less stress and more precise prognostic information, such as the risk of sudden death, is worthy of consideration, particularly if the patient has had symptoms or is at high risk.
Doctors in general and cardiologists in particular have known or sensed the following for a long time
• Shortness of breath is the most common presenting symptom in patients with underlying heart and pulmonary disease.
• Shortness of breath is a sign of underlying disease rather than of normal aging.
• It’s difficult to differentiate whether the cause of dyspnea is cardiac or pulmonary or a combination of both.
• Heart and lung function are interrelated but no devices are conveniently available to evaluate both this functional relationships.
• An early warning device to spot heart and/or pulmonary disease would be useful before either disease reaches chronic, and progressive and, in many cases, irreversible stages.
• The traditional coronary treadmill stress test is useful for evaluating cardiac ischemia but is complicated, largely not routinely available, and carries enough risk to require the presence of a cardiologist.
• Devices for measuring functional heart and lung capacity and producing reproducible data are not generally available in cardiologists’ offices, and do not lend themselves to testing in primary care offices, fitness centers, or in the home.
• Most criteria for staging heart failure are either primitive or subjective - seeing how far one can walk in 6 minutes or even the New York Heart Association’s functional classification (NYHA) – I – No symptoms, II- Mild symptoms, III Marked limitation, IV Severe limitation- are largely subjective and not reproducible between cardiologists.
• Despite sophisticated programming and cost of current cardiac pacemakers ($50,000 to $65,000 per pacemaker) not including cardiologist placement costs), it’s still not possible to predict whether a patient’s rhythm disorder will respond to pacing – the non-responder rate is in neighborhood of 30%.
SHAPE Medical Systems
The device developed by Shape Medical Systems, Inc., a Saint Paul, Minnesota -based company, helps meet these evidence-based criteria,
• reproducible data,
• objective measurement of what works and doesn’t work,
• early data of preventable and reversible disease,
• portability to different settings.
Among other things, Shape-HF™ device – consisting of a small gas analyzer, a one step stair, a face fitting mask to capture expelled air, and a laptop computer to analyze collected data – produces reproducible, easy-to-interpret results that objectively,
1)assesses the risk of hospitalization or death;
2) measures subtle changes in breathing efficiency that signals early or late stages of disease and need for further evaluation;
3) quantifies shortness of breath and cardiac and pulmonary function;
4) does so in six minutes using a very low intensity exercise protocol that does not stress or risk the patient;
5) determines how well a patient responds to different pacemaker programming options and provides an objective basis for defining response to therapy;
6) can serve as a supplement to traditional treadmill stress testing;
7) can be used at least four times a year to responses to drugs, medical device or exercise therapy.
In addition to these features, the device is small (components can be carried in an ordinary briefcase ), can be set in any setting (primary care office, home, or fitness center) with electrical outlets, is cost-effective, has received FDA approval, has been validated at the Mayo Clinic, can be deployed on the frontlines of medicine by primary care physicians, who badly need a device for objectively evaluating early symptoms of heart and lung disease (the number 1 and number 4 killers of Americans), and shows the power of innovation for rationally transforming health care based on both anatomical and functional criteria.