Sudden Death

by Paul Dudley White, M.D

A FEW months ago a widow in the Carolinas wrote me to ask: “What can I do to protect my sons, aged eighteen and sixteen, to escape death in their thirties from heart attacks, which killed their father’s grandfather at fifty-nine, their father’s father at fifty-one, and their father at forty-two, each generation about a decade earlier?” This is a perfect illustration of the great challenge that faces us today.

In an article entitled “Angina Pectoris in Father and Son” in the July, 1963, issue of the American Heart Journal, Dr. Samuel A. Levine wrote as follows: “Angina pectoris or coronary thrombosis was personally observed in 20 fathers and 21 sons. The first evidence of coronary disease in the sons appeared at an age 13.1 years younger (48.1 years) than that of the fathers (61.2 years). The average age at death of 8 sons was 54.8 years, and that of 14 fathers was 68.7 years. . . . The evidence suggests that some factors are at work which cause coronary artery disease to appear at a younger age and to run a more severe course in the present than in the previous generation.”

Sudden, especially instantaneous, deaths and heart attacks are commonplace in the United States. The laborer with his “improved” way of life is nowadays, in contrast to a generation ago, just as liable, or even more so, to sudden death as is the professional or business man. And racial origin does not seem to matter; once you come to the United States and live our way of life, you expose yourself to this hazard. Back in the old country, those who prosper most and own automobiles and are overnourished with rich food run the same risk, but they are generally far fewer in number. In fact, in this country we are witnessing what seems to be an epidemic of coronary atherosclerosis and sudden death, and we take it for granted that there is no way out except to cut down the physical and emotional strain which is, or should be, more or less normal to a healthy population — at least to a population with healthy arteries. Dr. Samuel A. Levine sounded a note of warning about these hazards in his article in the July issue of the Atlantic. Certainly for an unknown number of men, whether of middle age, older, or younger, the warning is appropriate, but we must not stop there.

The first imperative challenge is for us to do something about the causative factor of coronary atherosclerosis. We must not be fatalistic about instantaneous death, just sensibly careful for the time being. Even as recently as my own early years in medicine, a high infant mortality was considered inescapable — that is, it was attributed to God’s will — but since then we have found that it was our fault. And so I believe that we should develop a more hopeful attitude toward this present epidemic of presenile coronary atherosclerosis. What can and should we do to justify this optimism? Let me begin by discussing the mechanism of sudden death and the pathology and possible causes of atherosclerosis itself.

Sudden death due to so-called natural causes is probably as old as the hills, at least as old as the hills formed at the time that humankind evolved. However, the novelty of it today is its greatly increased prevalence, which has reached truly alarming proportions.

A most interesting presentation of sudden death can be found in the writings of Pliny the Elder, who, in the first century after Christ, included in his book on natural history a chapter entitled “Sudden Death.” He wrote as follows:

But the most miraculous, and also frequent, are sudden deaths (this is life’s supreme happiness), which we shall show to be natural. Verrius has reported a great many, but we will preserve moderation with a selection. . . .

Cases of men dying from no obvious cause are: while putting on their shoes in the morning, the two Caesars, the praetor and the ex-praetor, father of the dictator Caesar, the latter dying at Pisa and the former at Rome: Quintus Fabius Maximus on 31 December in the year of his consulship, in whose place Gaius Rebilus obtained the office for only a few hours; also the Senator Gaius Volcatius Gurges — all of these men so healthy and fit that they were thinking of going out for a walk. . . . Also an envoy who had pleaded the cause of Rhodes in the Senate to the general admiration, just as he was to leave the Senate house, expired on the threshold; Gnaeus Baebius Tamphilus, who had himself also held the praetorship, died just after asking his footman the time; Aulus Pompeius died on the Capitol steps after paying reverence to the Gods; Manius Juventius Thalna, the consul, while offering sacrifice; Gaius Servilius Pansa, while standing at a shop in the marketplace, leaning on his brother Publius’ arm, at seven o’clock in the morning; Baebius the judge, while in the act of giving an order for enlargement of bail; Marcus Terentius Corax, while writing a note in the marketplace; and moreover, last year, a Knight of Rome died while saying something in the ear of an ex-consul, just in front of the ivory statue of Apollo in the Forum of Augustus.

It should be noted that Pliny does not mention any women who died suddenly, or any menials, perhaps because he did not consider them of sufficient importance. The names that he does mention are those of more important citizens, in all probability prosperous possessors of their own chariots and charioteers, and accustomed to a rich diet and to the stresses of a competitive society. But they had no tobacco.

In 1706, two and a half centuries ago, there appeared on the scene a most notable volume, still unique in medical history, entitled De Subitaneis Mortibus (On Sudden Deaths) by Giovanni Maria Lancisi (1654-1720), physician to the Vatican during the incumbency of Pope Clement XI. Because of its importance as a milestone in medicine, Professor Alfred Boursy of Holy Cross College and I are in the process of translating it. Beginning in the summer of 1705 and on into the following winter, there had been a wave of sudden deaths in Rome, and Pope Clement ordered a series of autopsies under the supervision of Dr. Lancisi. As a result of these studies, Dr. Lancisi reached a number of conclusions which coincide with what we know today, as these excerpts show:

No one will have any doubt but that indications of a sudden death ought also to be deduced from an athletic constitution, whenever such athletic persons . . . become ever more obese through a sumptuous table, through sleep, and leisure. This very plump and more colorful condition of the body Celsus rightly called a questionable advantage. . . .

It happens (as had been my own belief) that these sudden cases were to a large extent not deaths of healthy people but represented some sort of scumming of human nature, or that, in the case of those who openly or secretly had been for a long time in a state of health both enfeebled and diseased, a bad crisis had occurred. . . .

To the above must still be added the observation that the maladies which in the course of the past months paved the way to death did not in any way contagiously affect the neighbors, the relatives, or those who dissected the bodies — a clear indication that in these maladies no virus was flourishing because of which we need to fear some epidemic or pestilential disease.

In May two years ago, sudden death was one of the most challenging and interesting problems discussed in Moscow by the American team of cardiologists with their Soviet colleagues at their annual meeting. These conferences were officially established as annual events when the United States and the U.S.S.R. signed an agreement in November, 1959, to join forces in the struggle against heart disease, cancer, and polio.

Probably the most important question discussed in 1961 was that of the degree of suddenness of death. In the case of long and lingering illnesses, such as cancer or tuberculosis, the heart is the last organ to fail, and the pacemaker of the heart — the sinoatrial node — is the last to die. Death is often very slow in such cases. There are those who die more rapidly, but still slowly, in the course of a few days, as from a virulent uncontrolled infection, or a stroke, or heart muscle failure, or an injury. Then we come to deaths within hours, which may be the first category of sudden ones; here belong many of the patients with typical severe heart attacks (coronary thrombosis), severe strokes, hemorrhage from dissection of the wall of the aorta or from other source of bleeding, or pulmonary embolism. We have also the deaths that come in minutes, again from heart attacks, strokes, and pulmonary embolism.

Finally, there are the truly instantaneous deaths that fell the victims at once. Here belongs the man who “drops dead.” His heart, which may be beating normally, suddenly stops, owing, in the great majority of cases, to what we call ventricular fibrillation, or an incoordinated ineffective contraction of the squirming muscle mass of the ventricles, or pumping chambers of the heart. Sudden total standstill of the entire ventricular muscle, which is found by electrocardiographic study to be the mechanism of death in some individuals who die more slowly, probably does not apply to cases of instantaneous death. There are on record rare instances of recovery from instantaneous death where it has been possible in a hospital to defibrillate the heart by electrical shock and then to start it beating again within a relatively few minutes after “death” and before the delicate cells of the brain have been irretrievably damaged. Massaging the fibrillating heart, either with the thorax closed or opened, in the street or out of reach of expert aid is futile, except in cases where the patient can be quickly transported to a hospital or a special clinic for defibrillation while circulation by cardiac massage and respiration by artificial means can be maintained. In the future, first-aid training and greater availability of defibrillators in first-aid centers outside hospitals may, under medical supervision, enable some victims of ventricular fibrillation to survive. As of today, drug treatment, including oxygen, is ineffective except as a supplement.

It is agreed by all that the vast majority of these instantaneous deaths are due to the effect of ischemia, or lack of oxygen, in the heart muscle itself, which sets off the abnormal rhythm of ventricular fibrillation. The ischemia is, in the vast majority of cases, due to insufficiency of the coronary circulation — that is, of the blood supply through the coronary arteries, which have become blocked to a greater or lesser degree by a rusting process in their walls labeled atherosclerosis. It is not necessary for a thrombus, or clot, to form in the coronary arteries to cause serious ischemia of the heart muscle and instantaneous death. In fact, Dr. Milton Helpern, coroner of New York City, has found in a very extensive experience over many years that at least three quarters of the thousands of victims of instantaneous death that he has investigated do not have coronary thrombosis, but they all have significant degrees of coronary atherosclerosis. I myself have heard of only one case of instantaneous death unexplained at autopsy; this was a young man in a hospital dispensary who literally died of fright — an exception that proves the rule.

WHAT can and should we do? In the first place, we should support to the full the many researches into the cause of early coronary atherosclerosis now in progress all over the world, both in animals and, more important, in man, as an individual and in populations — for example, in epidemiological teamwork in many countries. We should do this by private initiative and support of the American Heart Association and the International Cardiology Foundation and by public funds allocated by Congress to our National Heart Institute and, internationally, to the World Health Organization.

It is not a simple problem. There are a multitude of causes, probable and possible, that must be investigated intensively and extensively. These include heredity, diet in all its aspects, muscular metabolism, emotional stress, and causes yet unknown. But we have made a start, and some things we do know.

Second, we need to do much more than we are doing now to pick out the candidates for early atherosclerosis. This we can begin to do through an appraisal of the family history and the levels of serum cholesterol and other lipides, of blood sugar and uric acid, and type of body-build, as initiated in a volume entitled Coronary Heart Disease in Young Adults, published by the Harvard University Press ten years ago. It is to these candidates, while still young, that we should first apply the protective measures, as soon as we find out what they are.

And third, there are commonsense measures, reasonably scientific too, that we may apply at once, not only to the young candidates but also even to older men, whether or not they have become coronary patients.

And now we come to the widow’s question. The first part of my answer was easy — namely, to support to the full the research on atherosclerosis until we have the answers. I am sure that we shall find the answers if enough well-trained investigators are put to work on every phase of the problem — basic, clinical, and epidemiological. The second part of my answer was not so easy, but, from the evidence at hand, young people should avoid obesity, eat lightly of animal fats, and work hard physically all their lives.

Such use of our muscles, especially those of the legs, which make up about forty percent of our body weight and are meant to be used, aids the circulation physiologically in pumping blood up to our hearts against gravity, the valves in our veins preventing the blood from flowing the wrong way. This is incidentally helpful in supplying an optimal oxygenation of the cells of our brains, which are responsible for both our mental acuity and our spiritual health. It has been found in open-heart surgery that the best index of an adequate oxygen content in the blood is the electroencephalogram (brain-wave tracing).

A second advantage of vigorous muscular activity is psychological and is due to its tranquilizing effect. One does not need sedatives or tranquilizers if one becomes physically, muscularly weary. Other antidotes for stress, in addition to the relaxation that comes from the delicious weariness of the muscles, are absorption in the arts — whether music, painting, sculpture, or reading — or just plain philosophical conversation, an art that in these days of television has gone out of fashion but could with pleasure be revived. And, of course, listening to and viewing good programs on radio and television can be relaxing too, if they do not absorb too much of one’s time and become entirely a substitute for more cultural pursuits and for essential muscular exercise.

Finally, in some way not yet elucidated, vigorous muscular metabolism acts, probably biochemically, to delay the onset and the rapid progression of atherosclerosis, as indicated by certain recent investigations, including those of Brunner on the populations of kibbutzim (collective farms) in Israel and of Henry Taylor of Minneapolis on the employees of several of the Western railroads in the United States.

I HAVE presented the problem as it concerns the young candidate for early coronary heart disease and sudden death. Let me turn now to the second challenge — namely, that of the older man or woman who may have a serious degree of atherosclerosis, whether he knows it or not. To be sure, he may drop dead if he runs for a train or shovels snow, but very often he has warning enough in the form of angina pectoris, a symptom of coronary insufficiency, or in his electrocardiogram (which should be taken annually) before he undertakes such undue exertion. With sufficient time to develop a more adequate coronary circulation, he may recover from his angina pectoris, so that he can become more active again, though he should avoid extreme effort and stress. Herman Hellerstein, a cardiologist at Western Reserve, has been able carefully to retrain a good many coronary heart patients who have not been too hard hit, so that they can live not only a normal life but an unusually physically active one too. Indeed, exercise in moderation probably promotes the collateral coronary circulation which nature usually supplies us with in order to bypass the points of much narrowing of the bore of our coronary circulation when we get older and acquire variable degrees of coronary atherosclerosis.

Incidentally, it hardly seems reasonable to sentence to a life of physical inactivity the millions of older men who will not drop dead if they shovel snow because a few thousand men, some of whom are already ill or untrained physically and should know better, die when they do shovel snow. It is a bit like advising us not to drive our cars on the highways because some careless or unlucky individuals are hurt or killed while doing so. There is also truth in the old maxim that it is better to wear out than to rust out, and most people are happier in the process.

Thus, we should view with mixed feelings the sudden death that results from ischemia of the heart muscle from severe coronary atherosclerosis. If it occurs at a very advanced age after a lifetime of Health and enjoyable activity, it comes as a blessing, or, as Pliny said, “life’s supreme happiness.” If, on the other hand, it cuts down a man or a woman in youth or middle age it is a mistake and a challenge to us to do something about it. The old idea of a short life and a gay one is in essence the acme of selfishness. A person owes it to his family as well as to his own community, and sometimes to the nation and even to the world, to live as long as he can, unless he is a hopeless invalid. We can, I believe, protect the familial candidate somewhat even now, but we have hardly begun to think of doing so. By a better health program for our teenagers and those in their twenties, we may reduce the sudden deaths in middle age and thereby have healthier octogenarians, even though perhaps no greater number of centenarians. It is health, not simply longevity, we want to promote, but if we succeed in the former, the latter will follow.