Detecting signs of a silent killer

Daily News Staff Writer
Silence isn’t always golden. In some cases, it may be deadly.
Running guru Jim Fixx — who inspired millions to pound the pavement in health’s name —apparently had no warning of the heart attack that killed him while jogging in 1984.
Chicago Mayor Harold Washington had complained of chest pains in the weeks before he died of cardiac arrest Nov. 25. The mayor, who was overweight but otherwise appeared in good health, attributed the pains to congestion.
Just moments before dropping dead from a massive heart attack Jan. 5, former pro-basketball star Pete Maravich told friends he felt great. The 40-year-old had been playing an informal game of basketball in Pasadena.
With Maravich the latest high-profile death from heart disease — a coroner’s report last week concluded he died of a rare heart defect — attention again is being focused on heart disease. Doctors puzzled, amateur athletes worried, and others, shocked, read about someone who appeared healthy but died of an undetected heart problem.
Heart disease already claims the lives of about 700,000 Americans annually, and more than 5 million are being treated for it.
Yet, the American Heart Association estimates, 3 million to 4 million people could have a form of heart disease and not know it. This type of heart disease may not produce the symptoms of the more common coronary disease that causes chest pains, alerting victims to its presence.
What they might have is silent heart disease, or silent ischemia.
For years doctors considered chest pain to be a red flag. Pain, caused by a network of nerves, signaled ischemia (pronounced is-key-me-a), a condition when blood flow is reduced in coronary arteries that nourish the heart muscle.
But if the warning system fails, ischemia episodes pass silently. Silent ischemia may be responsible for the more than 100,000 people who die of heart attacks each year with no prior warnings of cardiovascular problems. A total of 540,000 people die annually — more than 1,500 daily — from heart attacks.

First sign may be the last

The first sign of heart disease in these instances might be the last.
“Unfortunately, the first manifestation — such as with Pete Maravich — may be death,” said Alan Rozanski, director of the cardiac rehabilitation program at Cedars-Sinai Hospital.
That doesn’t mean everyone who plays a pickup game of basketball after work or goes to aerobics twice a week should worry about heart disease, doctors caution.
Doctors have defined certain factors that increase the risk of heart disease. Among the risk factors are a family history of heart disease, high blood pressure, high blood cholesterol levels, diabetes and a smoking habit.
“A person should be concerned if he has reason to be concerned — does he have the risk factors? . . . If not, he has less reason to be concerned,” said Dr. Peter F. Cohn, a professor of medicine and chief of cardiology at the State University of New York at Stony Brook. He also has co-authored with his wife, Dr. Joan K. Cohn, the book “Heart Talk: Preventing and Coping with Silent and Painful Heart Disease” (Harcourt Brace and Jovanovich, $14.95).
The number of people affected by silent heart disease, however, the Cohns write, is so significant that it is a major health problem and “a challenge to contemporary therapeutic principles in cardiology.”
“Physicians are listening to what the heart says and what the patient says,” Peter Cohn added.

Better tools for diagnosis

As doctors recognize more and more the presence of silent heart disease, new tools are being developed and improved to diagnose it. Cardiologists debate the best way to screen for it but point to risk factors as the first step. Some experts say the risk of heart disease increases after a person turns 35. In American men ages 25 to 34, about 110,000 are estimated to have heart disease. The number jumps to about 160,000 among men ages 35 to 44, according to the American Heart Association.
Silent heart disease often escapes detection in a routine physical. Years of checkups failed to detect the heart defect in Maravich, who was born without one of the two artery systems that supply heart to the blood.
For people with risk factors, doctors recommend an exercise stress test, which can detect the disease. A person works out on a treadmill while doctors monitor his heart on an electrocardiograph. Still, doctors argue, the test may not always detect aberrations, or if it does, the aberrations may not confirm heart dis-ease.
Cardiologists recommend that test be cross-checked with one of several heart-imaging techniques. People — particularly men over age 35 — who plan to take up exercising after years of sedentary life also should have the stress test.
“It’s risky unless there’s medical clearance,” said Dr. Arthur J. Lazik, director of cardiology at Northridge Hospital.
While exercising is healthier than not exercising, it can carry some risks, especially for someone with silent heart disease. Sudden physical exertion some-times can trigger heart problems as the heart struggles to meet the physical demand.
Dr. Ronald Mackenzie, medi-cal director of the Centinela Na-tional Athletic Health Institute and a specialist in preventive sports medicine, noted that someone with silent heart disease may appear to be in great shape. Or, he may ignore any kind of warning signs, believing exercise will fix everything.

Less competition

“I often advise people who are good tennis players who get to age 50 and beyond to continue exercising, but don’t worry so much about whether you win or lose,” Mackenzie said. “Competition can get people in trouble … Pushing themselves to the limit, even among people in good condition, is not always prudent.” (See accompanying story.) Mackenzie also recommended physical exams and stress testing for anyone who exercises intense-ly, whether in competition or a class. “If you’re going to race your car, you’re better off testing it before the race,” he said.
Doctors also stress the psychological treatment of a patient who learns he has silent heart disease. For some, the diagnosis is akin to learning of cancer. A person can seem fine on the outside, but learn he has something life-threatening on the inside.
Depression, fear of exercising or moving and denial of the problem may occur in a person diagnosed with silent heart disease.
“You can change it into something positive,” said co-author Joan Cohn, an instructor in medicine and pediatrics at Stony Brook with her husband and a psychotherapist in private practice. “It’s like if you had a pot belly and can do exercise and cut down on fats. You can look at (the situation) and say, ‘What positive steps can I make out of this?’
“Experts recommend that a silent heart disease patient have a support group or family or friends he can talk with or seek professional counseling. Adjusting one’s lifestyle — possibly altering diet, changing an exercise program — can have an ego-enhancing effect, Cohn said.
A person should not be depressed if silent heart disease is detected in time, said Dr. Shahbudin H. Rahimtoola, the GeorGE C.Griffith professor of cardiology at USC.
“The way to deal with it is to be grateful to have found out before it’s too late — and that something can be done about it,” he said. “That’s better than finding out too late.”

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