R.I.P. James "Tony" Gandolfini - What Can We Learn?

When I was living in Chicago, missing the brash Jersey attitudes and Italian delicatessens of my youth, The Sopranos provided me with a sixty minute journey back home every week. Whoever watched with us, as we hung on every word, would also be forced to endure my vocal alerts for every North Jersey sighting embedded in a TV drama that seemed so real. The Lincoln Tunnel exit, Route 3, Bloomfield Avenue, lots of cured meats and wet muzz - things that were unique to my home - Jersey.

The viewing of The Sopranos began to take on an event-like atmosphere, preceded by numerous pots on the stove, sausages and meat balls, gravy simmering, wine pouring, friends talking and congregating - until, that is, the intro began with its heavy baseline and Tony, arm out the window, cigar in hand, making all of us feel lucky to know him, and to not be on his bad side. The good bad guy.

The controversial fade-to-black finale without closure now takes on such a more profound tone - since we know what happens in real life. James Gandolfini's passing is sad for so many reasons - the term "untimely" hardly does it justice. The death of any young person - particularly from potentially preventable causes - is a tragedy. And events like this, because of their notoriety and widespread media coverage, have the opportunity to spur change.

 Gandolfini was such a young man at 51, leaving 2 young children and a wife behind; aborting a proud and accomplished acting career; and for those of us who hale from his home state of New Jersey, the former Rutgers grad's death cements his image in our minds as a small screen icon. Jersey has had so many famous residents (don't make me name them, 'cause I can) but none as "Jersey" as Gandolfini.

The fact that he was so famous/beloved and so young and didn't die of what so many young, famous people die of (addiction), makes the story so acutely interesting - not just in a Page 6 way, but more from a "what can I do to prevent that?" way.  The death of any young person is tragic and often engenders questions of how and why - yet the answers sometimes leaves us unsatisfied.

Objectively, Gandolfini was not the picture of health. He was likely technically obese and had a well-documented penchant for food and cigars - to the point that his last meal has been chronicled in every newspaper that reported his death - as if it had a direct relation to his sudden cardiac death. Which it very likely, did not. Would they have done that for a thinner man?

The fact is that out-of-hospital cardiac arrest occurs more than 380,000 every year in the United States alone - with the vast majority occurring inside the home. Many of those happen in people with no known heart disease. This is an incredibly strong argument for why ALL people should learn hands-only CPR - an unbelievably  simple skill that can literally make the difference between saving a life or watching someone die. This link will teach you all you need to know: http://www.heart.org/HEARTORG/CPRAndECC/HandsOnlyCPR/DemosandVideos/Demos-and-Videos_UCM_440561_Article.jsp.

 Less than one third of all cardiac arrest victims actually receive CPR - a shame when you can literally triple the likelihood of saving someone's life just by pushing on their chest to the tune of Staying Alive.

That said, how can you prevent a tragedy like this from happening to you or a family member? Knowing the obvious warning signs is  a good start: so, if you have chest discomfort that lasts more than a few minutes, or that goes away and recurs (particularly with exertional activity) - that's concerning and needs to be worked up by a doctor. Alternatively, some people may also develop left arm pain, jaw pain, nausea and/or diaphoresis (sweating) - equally concerning signs that merit a visit to your doc. Women and diabetics tend to present with somewhat atypical signs e.g. abdominal pain, back pain, shortness of breath. The take home message: if you are concerned with symptoms in or around your chest area and you have one or more of the risk factors described below: GO TO YOUR DOCTOR.

Once the event has occurred, damage has been done - so the real question is: who is at highest risk for having a cardiac arrest or heart attack at a young age? Contrary to popular opinion, early onset coronary disease has never been conclusively linked to a stressful job or life. In fact, it is more likely people's coping mechanisms (smoking, drinking, drugging, eating), triggered by their stress, that cause their cardiac events. Actual statistically proven risk factors for coronary artery disease include:

• Smoking
• High blood pressure
• Elevated cholesterol and/or triglycerides
• Family history in 1st degree relatives (father, mother, bro, sis) of CAD before 55 in males and 65 in females.
• Diabetes 
• Obesity

The above risk factors are vetted by numerous studies, but I will add one more that I feel likely contributes to a vast number of these cardiac embarrassments: lack of medical attention. Younger men in particular often veer away from medical attention despite the proverbial writing on the wall. They also tend to ignore symptoms that may herald an impending disaster. The fear of discovering something trumping the much less realistic seeming fear - that one may die from doing nothing. So, if you are one of these men (or women) - or live with one of them -  do not ignore your symptoms. Go see a doctor.

Cases like Gandolfini's and Tim Russert's death not too long ago, remind us that coronary disease and its sequelae can be devastating and without obvious preceding symptoms. In the interventional cardiology community we see these events fairly frequently, and most of them do not receive much fanfare. With the advent of so many new technologies and vastly improved treatment of heart attacks, we still are unable to save everyone. The key to better outcomes is better prevention.

The Truth About Shoveling Snow

With the snowiest weeks ahead, we thought it would be good to uncover the truth about shoveling snow. Slips and falls, not cardiac catastrophes, are the most commonly seen winter-related injuries - but heart problems account for almost every recorded death in reported studies.

It is quite possible that you have heard about the risks of shoveling snow on the news, or possibly from your doctor, and most likely from your spouse. However, it is very unlikely that anyonw has shown you the proof that it can be deleterious to your cardiac health.

 "It's a dangerous activity. People who are middle aged or older with a history of heart problems simply should not shovel snow," said Barry Franklin, director of Cardiac Rehabilitation and Exercise Laboratories at William Beaumont Hospital in Royal Oak, Mich.

But why? In an ABC News report, Franklin lays it out fairly well explaining that many people may not realize that a shovel full of wet snow can weigh as much as 15 to 16 pounds. So he said that if someone is shoveling snow at a rate of 12 shovelfuls per minute, they will have moved nearly a ton of snow if shoveling their driveway in just 10 minutes.

"So the physical demands are really, really substantial," said Franklin. When you couple that with the cold air that they are breathing, which causes the coronary arteries to constrict, in many respects you've got a perfect storm for heart trouble," said Franklin.

"Being out in the cold, some of the warning signs may be camouflaged," he added.

Cold weather and hard work can mask those symptoms, delaying people's responses and sometimes leading them into more trouble.

"We really encourage people beyond the age of 50 to try to hire a neighborhood kid to do it," he added.

Not everyone is at risk for a heart attack while shoveling, of course and people in cold climates often have "conditioning," according to Dr. Randal Thomas, director of the Mayo Cardiovascular Health Clinic in Rochester, Minn.

Studies published in the Lancet and the American Journal of Cardiology show that the incidence of heart failure goes up in the week after a blizzard. The Lancet study, based on death certificates in eastern Massachusetts after six blizzards from 1974-78, demonstrated that coronary artery disease-related deaths rose by 22 percent during the blizzard week and stayed elevated for the subsequent eight days, suggesting that the effect was related to storm-related activities, like shoveling, rather than the storm itself.

Similarly, the AJC article, based on medical examiner records from three Michigan counties, found that there were more exertion-related sudden cardiac deaths in the weeks during and after blizzards, and that 36 of the 43 total exertion-related deaths occurred during or shortly after snow removal.

Here are some tips from Brigham and Women's Hospital cardiologist, Daniel Forman M.D.,director of Exercise Testing Laboratory and Cardiac Rehabilitation.

Certain individuals should consult their doctor before shoveling snow:

• People who have previously had a heart attack or other cardiovascular disease.
• People with a history of chest pain or angina.
• People with medical histories of high blood pressure, diabetes or high cholesterol levels.
• People who smoke or who have other cardiovascular risk factors.
• People who do not exercise regularly.

For those who wish to shovel snow, follow these general tips to help stay healthy:

• Dress warmly and be sure to protect extremities such as your nose, ears, hands and feet. This is important because cold weather can reduce circulation, aggravating heart disease.
• Stretch your arm and leg muscles as you would before any exercise; this minimizes musculoskeletal injury and strain.
• Also warm up your cardiovascular system with a light activity such as marching in place or walking before shoveling. Warming up is an important means of modifying cardiovascular strain.
• Don’t eat a heavy meal or drink alcohol prior to shoveling (this is not a good way to work off a big meal!). Avoid stimulants such as caffeine or nicotine, which increase heart rate and cause blood vessels to constrict.
• Use a shovel with a small blade. It is safer for your heart as well as your back and joints to lift smaller and more frequent amounts of snow than to haul a few huge shovelfuls. Likewise, it is important to have a shovel that is suited for your height.
• Pace yourself. Start out shoveling slowly, and don’t try to clear the entire area at once.
• Take frequent breaks to give your heart a rest. Use the time off to drink plenty of water and stay hydrated. Also make sure you are eating normally and taking your routine medications. Push the snow rather than lifting and throwing it.
• If you must lift, do it properly. Spread your hands along the handle for more leverage, stand with your feet hip-width apart, and bend at the knees (not at the back).
• Do not twist or throw snow over your shoulder. Scoop in a forward motion and step in the direction you throw the snow to avoid lower back pain the day after shoveling.
• Know the warning signs of a heart attack. Stop immediately and seek emergency medical help if you experience heart attack symptoms such as chest pain, shoulder, neck or arm pain, shortness of breath, dizziness, fainting, sweating or nausea.