Heart attack with normal angiography or normal post mortem

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Dr KK Aggarwal

Recipient of Padma Shri

The death of actress Sridevi was due to accidental drowning in a bath tub following loss of consciousness in a hotel in Dubai. This was the conclusion of the post-mortem report and foul play has been ruled out. Dubai police said that the case has been closed.

However, the cause of unconsciousness has not yet been conclusively found. Traces of alcohol were found in blood, and it has been suggested that this may have led to the accidental drowning.

Though the post mortem has ruled out heart attack, it still remains the most likely initiating event for loss of unconsciousness or gasping, which may have been due to ventricular tachycardia/fibrillation.

So, can one have a normal angiography or normal post-mortem after a heart attack? The answer is yes.

There are two types of heart attacks: Type I versus type II heart attack.

Most patients with acute heart attack will have obstructive (blockages) atherosclerotic (cholesterol deposition) coronary artery stenoses (narrowing) with acute thrombosis (clot) as the underlying pathology.

However, some patients (up to 28%) will not have significant epicardial coronary artery disease when coronary angiography is performed or post mortem is done. These patients are defined as having a type 2 heart attack, which is defined as a heart attack consequent to increased oxygen demand or decreased supply (coronary endothelial dysfunction, coronary artery spasm, coronary artery embolus, tachy / bradyarrhythmias, anemia, respiratory failure, hypertension, or hypotension).

Dr KK Aggarwal

Padma Shri AwardeeVice President CMAAOGroup Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Can accidental drowning occur medically?

Health Care Comments Off

Dr KK Aggarwal

Recipient of Padma Shri

Actor Sridevi died of accidental drowning in her hotel bath tub after losing consciousness, according to the forensic report by the Dubai govt. on Monday. However, the report, which carries the stamp of the “Ministry of Health UAE” and the director of preventive medicine, Dubai, Dr Sami Wadie, does not state the cause of unconsciousness.

Can accidental drowning occur medically? Yes. Medical conditions can cause accidental drowning. Seizure disorders, which can be first-onset episode, can cause accidental drowning. Alcohol and/or use of illicit drugs increases risk of accidental drowning as it may affect balance, coordination and judgment. Stroke, syncopal attack (heart attack) or undetected primary cardiac arrhythmia are other factors that can cause accidental drowning. A gasping patient with ventricular arrhythmia will end up with drowning.

If there are no signs of struggle, then ‘accidental drowning’ can be a medical opinion. It is up to the police to accept this opinion or find it as a case of ‘homicidal drowning’ and investigate any foul play.

Some salient facts on accidental drowning

Drowning is the third most common cause of accidental death. A victim of drowning can be revived by cardiopulmonary resuscitation (CPR) with rescue breathing. Prolonged resuscitation, up to many hours, has been known to revive patients with hypothermia and cardiac arrest.

Antemortem drowning can be identified by the presence of fine, white, leathery, copious froth or foam tinged with blood at the mouth and nostrils (Froth is of lasting nature and large in quantity), cadaveric spasms in hands, diatoms in tissues from brain, liver and bone marrow of long bones, presence of water in stomach and intestines, voluminous water logged lungs along with fine froth in lungs and air passages.

A bathtub drowning is a major cause of death in a bathtub. The bathtub is the most common site of seizure-induced drowning; hence, patients with epilepsy should be advised to take showers instead of baths. Heart attack leading to syncope and subsequent falling in the tub can cause drowning. Besides the causes discussed above, mutations in the cardiac ryanodine receptor (RyR)-2 gene, which is associated with familial polymorphic VT in the absence of structural heart disease or QT prolongation, have been identified in some individuals with unexplained drowning. Concomitant trauma, paralysis, heart attack or hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias are other factors for accidental drowning. Duration of submersion >5 minutes is the most critical factor.

Several studies have reported incidents of bath tub drowning with varying medical histories as follows:

  • A total of 268 victims were found unconscious or dead during tub bathing. After postmortem examination, the manner of death was judged as natural cause in 191 (71.2%) and accidental drowning in 63 (23.5%) cases. Drowning water inhalation, which was confirmed in 72% of victims, was absent in the others. Whereas, inhalational findings were more frequent in victims with other backgrounds such as alcohol intake, mobility disturbance, and history of epilepsy (Am J Forensic Med Pathol. 2013 Jun;34(2):164-8).
  • In a series of 14 cases of suicide by drowning in the bath in the Bristol area, England between 1974 and 1996, six cases had evidence of concomitant alcohol or substance use. Seven cases had a past psychiatric history and a history of previous deliberate self-harm. Most drowned at home, face down, fully clothed (Med Sci Law. 1999 Oct;39(4):349-53).
  • A retrospective review of 92 deaths in the bathtub in Maryland found 71.7% incidence of bathtub drowning; 28.3% were the absence of bathtub drowning. Three leading contributory causes of death were cardiovascular disease, drug/alcohol-related death, and seizure disorder in both groups More than triple overlapped drowning-related signs (history of recovery from the water, foam in the air way, watery fluid in the sphenoid sinuses, hyperinflated lungs and watery fluid in the stomach contents) could be beneficial for the diagnosis of a bathtub drowning. (Forensic Sci Int. 2015 Aug;253:64-70).
  • In a retrospective analysis of 245 bathtub death cases between 1971 and 1988 carried out in the Institute of Legal Medicine in Hamburg, 66 cases proved to be natural deaths, 76 were classified as suicides, 39 as accidents and 13 as homicides, while 51 fatalities remained unclear with respect to one of these groups. About 50% of the victims were alcoholized.  (Arch Kriminol. 1991 Jul-Aug;188(1-2):35-46).

Dr KK Aggarwal

Padma Shri AwardeeVice President CMAAOGroup Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

People with influenza stand the risk of a heart attack

Health Care, Heart Care Foundation of India Comments Off

Vaccination can go a long way in preventing the onset of flu

New Delhi, 25 January 2018: Statistics indicate that people who get flu may be at a six-fold higher risk of heart attack in the week following infection. The risk of heart attack — or myocardial infarction — is particularly acute in older adults. These findings assume importance as an association between influenza and acute myocardial infarction reinforces the need for vaccination. While other respiratory viruses were also seen to raise the risk of heart attack, the incidence was not as high as the flu virus.

Influenza or ‘the flu’ is a highly contagious disease caused by infection from influenza type A or B (or rarely C) virus. These viruses infect the upper airways and lungs. Flu is not similar to a common cold and can be a serious illness. It is particularly of harm to the elderly and those with underlying medical conditions.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, President Heart Care Foundation of India (HCFI) and Immediate Past National President Indian Medical Association (IMA), said, “During flu illness, our body is under a lot of stress and inflammation is up. Further, the oxygen levels and blood pressure can drop which can lead to an increased risk of blood clots in the vessels that serve the heart. All of these can cause heart attack. Vaccination is the best way to reduce the risk of getting flu. Being vaccinated gives you protection against flu by building immunity to the virus and preventing transmission of the virus to other people.”

The initial symptoms of flu include headaches, chills, and a cough. Other signs such as fever, loss of appetite, and muscle aches follow late. Apart from this, nausea, vomiting, and diarrhea are rare in adults but more common in children.

Adding further, Dr Aggarwal, who is also Group Editor of IJCP, said, “There are other complications of a flu such as bacterial pneumonia, ear infections, sinus infections, and worsening of chronic medical conditions, such as asthma, or diabetes. It is, therefore, important to not ignore symptoms of a flu. Chest pains and shortness of breath might indicate a lot more.”

The following tips can help prevent influenza.

  • Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
  • If possible, stay home from work, school, and errands when you are sick. This will help prevent spreading your illness to others.
  • Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
  • Washing your hands often will help protect you from germs. If soap and water are not available, use an alcohol-based hand rub.
  • Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
  • Clean and disinfect frequently touched surfaces at home, work or school, especially when someone is ill. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

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