When I met with the Emergency Room doctor after Doug's sudden death that occurred while running, I asked him what happened. He said that most likely Doug suffered a malignant arrhythmia that caused sudden cardiac arrest. My first reaction was "What the f**k is a malignant arrhythmia?"

He explained that it is not a stroke or a heart attack. It is a powerful electrical impulse that stops the heart suddenly. (In contrast, a heart attack occurs when the blood supply to part of the heart muscle is blocked. A stroke is sudden death of brain cells caused when blood flow is interrupted to part of the brain - often by a blood clot.)

As I understand it, there are hundreds of different types of cardiac arrhythmias. Some types of irregular heartbeats are common and not dangerous. Others can kill you. The bad kind (which include malignant arrhythimias (MA) may not show up on a brief EKG (which Doug had less than 24 hours before he died because he was getting cleared for shoulder surgery.)

Cardiac MA's are often associated with coronary heart disease, cardimyopathy or valvular heart disease. Doug was being treated for high blood pressure and high cholesterol. ECG's indicated he had bradycardia (a slow heart beat) and also had Left Ventricular Hypertrophy (an enlarged left chamber of the heart.)

An MA does not show up on an autopsy - you would have to be monitoring the beating heart at the time it occurred. The autopsy did reveal that Doug had a significantly enlarged heart.)

But they can also happen to people who don't have any history of heart disease. The nasty kind of MA's can be associated with a variety of syndromes, including genetic defects that cause Long and short QT, Wolff-Parkinson-Whiteand Brugada syndromes, causing polymorphic ventricular tachycardia (VT) or ventricular fibrillation that can result in sudden death.

An MA can happen to people who look and feel healthy - in fact they could be standing there talking to you, feeling nothing, and suddenly keel over.

When an MA is sustained, it can result in loss of consciousness, and if the arrhythmia continues for more than 5 minutes, the person dies.

Many people do not survive sudden cardiac arrest, even with professional medical attention shortly after they occur. Thanks to a 911 call from a passerby who saw Doug on the ground, Emergency Medical Technicians (EMTs) reached Doug within three to five minutes after he collapsed while jogging. The first EMT team had an Automatic Electronic Defibrillator (AED). They put it onto Doug's chest. It read some kind of electrical cardiac rhythm - either ventricular fibrillation or pulse less ventricular tachycardia. This may have been Doug's heart quivering - it was not beating at the time. The AED "recommended" or advised a shock. After one shock, his cardiac rhythm converted to a Pulseless Electrical Activity or PEA (a few electrical beats not producing a pulse), which is not shockable. Unlike what you see on TV, a flat-lined heart (called an asystole) can not be shocked into restarting. At that point, medication is required.

The paramedics then switched to a full cardiac monitor. They interpreted the rhythm as continuing to be PEA. At 12:48, they noted that Doug's pupils were fixed and dilated. They treated him with medications indicated in protocols, including Atropine, Epinephrine. They continued giving CPR while transporting him to the Hartford Hospital Emergency Room. The medical team continued to try to revive him. Their efforts were futile. The diagnosis listed on the hospital report was "sudden death."

Although we didn't know it, Doug's heart was not normal (see autopsy results.) His death also could have been related to a high blood pressure medication he was taking - Benicar HCT. Read more about sudden cardiac arrest and Benicar.

Some statistics on sudden cardiac arrests that occur OUTSIDE of a hospital setting.

• 300,000 Americans suffer cardiac arrest in a non-hospital setting each year.
  • The survival rate for those who suffer outside the hospital is less than 7 or 8 percent.
  • Only 1 in 20 people usually survives a sudden cardiac arrest event. (Source: AHA. Heart and Stroke Statistics - 2010 Update, American Heart Association.) With an ICD device, 19 out of 20 people will survive SCA. ICD therapy has been shown to effectively stop 95% or more of dangerously fast heart rhythms. (Source: Himmrich E, et al.)
• Two thirds of survivors have severe brain damage.
• Cardiopulmonary Resuscitation or CPR cannot restart a heart that has stopped beating for electrical reasons. However, effective bystander CPR provided immediately after sudden cardiac arrest can double or triple a victim's chances. Still, the numbers aren't great - but every one matters to someone, somewhere.

Even when cardiac arrest occurs in a hospital setting, short-term survival and long-term prognosis are not very good. Research continues on how to improve survival rates and prognosis.

I wish they could have re-started Doug's heart. I wish he had been given a chance to live a long, healthy life. However, I do not wish that they had resuscitated him to leave him with severe brain damage or serious physical handicaps. I think that would have been torture for Doug, and I probably would not have handled it well either.

But, as they say, wishing ain't gittin. We don't get to choose. We cannot control all outcomes. I guess the only alternative is to learn to accept and come to terms with what did happen. Fourteen months later, I'm still working on that part.

(10/25/2011)

MORE

• First responders - paramedics/ambulance crew
• The end - what happened
• Hypertension and Benicar HCT
• Sudden death and running
• Arrhythmias - causes, symptoms and treatment (good description by NIH)
• Arrhythmias and Sudden Cardiac Death, American Medical Association
  • "....probably everyone at one time or another develops premature atrial or ventricular beats. In fact, during a 24-hour period about one-fifth of healthy adults are likely to have frequent or multiple types of ventricular premature beats....Still, acquired heart disease is the most important factor predisposing a person to arrhythmias. The main causes are atherosclerosis, hypertension and inflammatory or degenerative conditions. The scarring or abnormal tissue deposits found with these diseases can cause bradycardias; they do this by interfering with the work of the sinus node or overall AV conduction. Likewise, they can cause tachycardias (originating in either the atria or ventricles) by causing cells to fire abnormally or by creating islands of electrically inert tissue. (impulses circulate in a reentrant fashion around these areas.)"
• Olmesartan (Benicar) may be associated with a severe form of spruelike enteropathy
• Sudden death - what it is like for those left behind
• Searching for answers
• CPR statistics - American Heart Association
• Atrial Fibrillation - what is it (Cleveland Clinic)
• Dealing with a death that was preventable
• Overview of arrhythmias - Merck Manual