Heart attacks aren't as fatal as they used to be | Hacker News Reader

Heart attacks aren't as fatal as they used to be

vox.com

83 pointslr083 comments

No doubt a decrease of smoking, availability of satins, cpr/defibrillators, and stents has led to a massive increase in prevention and survival.

However, the diagnostic and treatment side has improved considerably in that time too. Troponin assays became widely available in the late 1990s/early 2000s, and dual antiplatelet therapy (aspirin + clopidogrel) around 2000s. These are part of the standard toolkit for detecting and treating MIs that simply didn't exist when I was young and are part of the story of making MIs catastrophic events to a more survivable disease.

The article isn't wrong per se, but I do want to point out that it isn't comprehensive when it comes to listing the reasons. There are interesting advances that it left out.

Your point generalises. For instance, homicide rates have fallen in large part because many wounds that used to be fatal are now survived. Breast cancer death rates also are down because of better diagnosis and treatment.

And transportation, electronic communication, beta blockers, blood diluters...

*statins, not satins. Satin is nice though.

Good catch! Love it when the misspelling is also a word :D

My father didn't die of a heart attack, he died of an aneurysm. However, he had a massive "widow maker" heart attack and had to be revived from arrest in the ER, more than once.

He had a heart beat, unconscious, for a few days, before the blood thinners caused the aneurysm, I'm told.

So, is this a heart attack? Is this "less deadly?" No, it's a proximal classification. Maybe their cardiac care center has a metric to hit.

Anecdotally I worked in the emergency department and ICU for 2.5 years as a scribe and translator in undergrad (ending about 7 years ago) and never saw a single person successfully revived. In the sense that everybody who ever got revived to the point that your dad did, in my experience, died.

Off the top of my mind, I can think of two patients who I personally cared for in the days or weeks after CPR who had an outcome other than death or vegetative state. One patient walked out the door two weeks after admission. The other patient regained consciousness and was able to speak/communicate, but was bed bound, appeared to have sustained some degree of cognitive damage, and had to receive feeds through a gastric tube. She was in the hospital for about six months before being discharged to a nursing facility. That's the numerator. It's hard to quantify the denominator. 40 or 50 maybe? But that's a guess.

I had a patient who checked in the ED for chest pain (felt like indigestion but he was intelligent enough to know it wasn't). Arrested just as we were getting vitals. CPR and shock -> came back awake and asked what happened. EKG after ROSC indicated STEMI. Arrested again, this time we just shocked right away before CPR and he awakened with ROSC. Eventually the cath lab was no longer occupied (this was a small hospital) and he went and got taken care of. Even if he arrested once and awakened it would have been amazing. But twice, I had never seen that in my years working in various emergency departments. That story had a happy ending (or continuation, as life moves on to new seasons), something I don't see very often. Other than that, my experience matches up mostly with yours in that for patients who arrest, happy outcomes are rare. One medic called 911 for his wife who had arrested - luckily he had witnessed it and went straight to the chest while his teammates on duty came to bring her in. I can't remember if they got ROSC or if we did, but she had a fair outcome. She had a long rehab time but was able to live a mostly normal life after that. The ones who just don't have a good ending are too many to count.

Most studies of hospital resuscitation survival puts it at about a 1/4. Plenty of people survive and have good neurological outcomes lots of people do not [0].

Outside of diagnostically defined cohort it’s a bit of a silly idea as you can attempt on anyone without respect to readily identified odds of success [1] so the what of CPR isn’t readily untangled from the who of it.

Out of hospital is a similar story but with less ability to triage and thus the same pattern in which the fact of CPR [2] is less informative than the underlying problem [3, old but the best study I know of would be interested if someone knows of an update to it given in hospital trend since].

0. https://www.nejm.org/doi/full/10.1056/NEJMoa1109148

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC8118500/

2. https://ccforum.biomedcentral.com/articles/10.1186/s13054-02...

3. https://pmc.ncbi.nlm.nih.gov/articles/PMC1767484/

this is why american medical care is so expensive. Family’s and Law make doctors “do everything” even when the doctors know there is 0.01% chance such a person even makes it out of the icu and that’s not saying anything about brain function.

I'm pretty sure that in "socialized medicine" countries i.e. the rest of the civilized world pretty much, they also "do everything" even if chances are low. AND everyone involved (including family) can do their part in it without having to deal with papers, money, bills, proof of insurance, and the plethora of other likely speed bumps that exist in the US.

So no, I don't think that's why. If anything, the amount and quality of average care for the average US citizen is lower, if life expectancy and my anecdotal observation are valid indicators.

It's expensive because it's a business designed to make profit every step of the way, and over time has created many steps to feed.

I'm no expert but at least in the initial stages of resuscitation, the cost is relatively low. Paramedics doing CPR, defibrillation, some epinephrine, then in the ER they'll intubate, get some lines in, push more epi and maybe amiodarone - pretty basic stuff that's more about doing it fast than expensive equipment. I don't think it adds up to a ton… well yes American healthcare is absurdly expensive, but this particular aspect isn't extraordinary. The initial resuscitation steps are about timing, not fancy drugs

Even if they die, reviving them still opens the door for organ and tissue donation.

IMO it's still good that it's family's decision. Even if it is an incorrect one.

I think its good, but I also think that we don't have enough education in the US populace about what this means realistically. "Pulling out all the stops" means that your loved ones last time on this earth is either in agony or comatose, neither of which I would tolerate of my dog much less my mother.

Very sadly true. As someone who has done CPR probably 250-300 times, one of the most challenging parts was transitioning to the role where I'm talking to family, and explaining the realities of things, and when we should discontinue efforts.

The biggest reason is probably that you need to fit a medical insurance agent, a lawyer and a doctor all around the same hospital bed to give care.

what can happen is something like this

>have heart attack, which is when an artery clog prevents oxygen and blood from getting to the heart

>heart tissue impacted by clogged artery dies

>ED did revive person and get the heart beating again, but the dead tissue is still there and goes through the dying / fibrotic process over several days

>during the process the tissue is in a fragile state, so the heart can rupture

this is how carrie fisher died, a few days after the heart attack, for example

> heart attack and had to be revived from arrest

Worth pointing out that heart attacks and cardiac arrest are not the same. A heart attack (myocardial infarction) is insufficient supply of blood to the heart, which causes damage. Cardiac arrest is when the heart stops completely (and is much more serious).

Heart attacks can cause cardiac arrest (especially if not treated), but the most common outcome is not immediate death. With proper treatment maybe 95% of MCI patients will survive. The prognosis for cardiac arrest is much worse - ~90% of patients experiencing a cardiac arrest will not survive, even if temporarily revived.

Out-of-hospital arrests are that deadly. Those that occur in a hospital are somewhat more survivable.

Not a whole lot more, but if you're going to arrest you want to do it in a hospital with lots of nurses nearby.

Many heart attacks occur because people don't get enough exercise and overeat. This is often the result of clinical depression. Is the killer depression or is it heart disease?

Same with the hyperlipidemia. It leads to eventual plaques in the arteries, which leads to heart attacks. But that's a genetic abnormality in the liver. The liver is pulling the trigger, the heart is taking the bullet.

Preventative care also seems to be an issue. Medicare denied a test for my dad to check the state of his heart, because it wasn't really having any symptoms. When he found out the test was only about $100, he just paid for it himself. He'll be going in for a quintuple bypass next week. I guess Medicare was content to wait for a heart attack.

The article should really have a picture of a cath lab at the top, not an AED. Advances in catheterization technology are the key factor in reducing heart attack deaths, not AEDs

Critical care paramedic here. The answer is "both".

AEDs are a key factor in ensuring patient survival until we can get them to the cath lab and get them ballooned.

"High quality compressions, early access to defibrillation". For every minute you do not have an effective pulse, your chance of survival goes down about 10%.

Airway management takes a distant back seat. Most meds we give are only mildly, or questionably effective.

But being able to defibrillate a dysrhythmia early is the key to getting the heart working itself - chest compressions are the best we have, but still. It takes us minutes of compressions to get to a suitable arterial pressure for effective perfusion, but ten seconds or less to lose it.

AEDs won't improve volume and arterial flow, but it'll give you a fighting chance of getting to the lab. Compressions alone are not going to do that - they will just preserve tissue.

What are AEDs? Aspirin? Blood thinners? I'm from the UK, so probably a naming difference!

AED - Automated External Defibrillator. They're portable device defibrillator which can deliver an electric shock. As I understand it, it detects an abnormal heart rhythm and shocks the rhythm back to normal. Note that there are some situations where they will not work. (For example, Pulseless Electrical Activity or PEA is "non-shockable.")

Correct. The shockable rhythms are ventricular fibrillation and ventricular tachycardia (racing heart). Fortunately these rhythms occur in many heart attacks.

Unfortunately PEA and asystole (flatline) do too, and shocking won't fix those -- despite what movies and TV would often have you believe.

Precisely. Well, when you're talking about AEDs - VF and VT.

Defib is more like rebooting a malfunctioning heart, versus jump starting it.

Paramedics with a manual defibrillator can do other things with other rhythms, but AEDs are limited to those.

> despite what movies and TV would often have you believe.

Yeah, I found out the hard way, suffering PEA. AEDs are great; but, people should still learn CPR.

Thanks :)

AED: Automatic External Defibrillator, a defibrillator that doesn't need a trained operator

Aspirin: a blood thinner and painkiller

Blood thinners: given to people at risk of a heart attack to thin the blood and reduce the chance of blood flow being obstructed

IIRC in the King's English:

aspirin = acetylsalicylic acid

blood thinners = anticoagulants

They are called AEDs in the UK too

Explain

There is a procedure called a "catheterization" (hence "cath lab").

I have two stents in my heart. They went in with a catheter through an artery in my wrist. They found the places in my heart where the arteries were 80% to 90% blocked, and placed stents there. They said I was five years from a heart attack.

This was an outpatient procedure. I went home that night.

The worst part of it, for me, was that they put a serious tourniquet on my wrist, because once they took the catheter out, I had an open artery. My wrist felt like I lost a bar fight. It ached for a month.

This is so much better than having a heart attack.

How did they know I needed this? I talked to a cardiologist. He told me that, as you age, your athletic performance drops slowly, over decades. That's normal. What's abnormal is when you suddenly can't do something you were able to do a month ago.

So I paid attention when I realized, hey, a month ago I didn't get this winded playing ultimate frisbee. A month ago I recovered faster when I was winded.

So I told that to my GP. He ordered a cardiac stress test for me. This basically is hooking you up to an EKG, putting you on a treadmill, running the treadmill faster and harder until you drop, and watching what your EKG does. If the shape stays the same except faster, you're good. If the shape changes, that's part of your heart not getting enough blood under load. My shape changed. So they ordered the catheterization for me.

So cath labs are about preventing the heart attack, not keeping you from dying once you have one. Not dying is good. But not having it at all is better. I think that may have been the GP's point.

If someone told you you were "five years from a heart attack" they lied

that's not how it works

in a stable person (ie, not actually having a heart attack) stents help symptoms (a little better than medicines, but even that is debatable -- see Orbita trial). Medicines and lifestyle changes prevent heart attacks -- see Courage and Ischemia trials

cath labs are in fact about keeping you from dying once you have a heart attack. The other stents for stable disease like you had are nice -- you feel better faster with fewer medicines that without, but not main thing

source: not going to appeal to authority. See trials mentioned above, or ACC guidelines on management of CAD

Catheterization is the mode of access to the heart, not the entire procedure. Stenting is one procedure that can be carried out that way, but there are other procedures which can be performed that way as well, such as imaging, cardiac ablation, pacemaker or defibrillator installation, or valve replacement.

> So cath labs are about preventing the heart attack, not keeping you from dying once you have one.

Cath labs *are* (also) about keeping you from dying once you have one. Inserting a stent into someone with an active MI can restore blood flow and minimize tissue damage.

Which part needs to be explained? I think I understood the comment and I’m not in the industry. AED is an initialism for the electrical shock device you can use to (maybe) reboot the heart’s OS when it locks up. Catheters are some kind of tube that gets implanted to bypass a non-functional part of the heart. Catheter procedures improving caused the change, not AEDs (apparently), so it’s somewhat misleading to show an AED instead of something about catheters.

PCI (Percutaneous Coronary Intervention, performed in a catheterization laboratory) has become the usual first-line treatment for acute heart attacks.

It's much more effective than previous treatments (essentially clot-busting drugs, blood thinners, and bedrest), particularly since Drug-Eluting Stents arrived in the early 2000s.

CAC tests are not without risk. Every CAC test is a CAT scan which means X-ray radiation.

It is certainly the case that for a great many people the benefits of a CAC test outweigh the risks, but talk to your doctor before you rush out and get one.

I wish it were possible to do a CAC test using MRI (and thus without ionizing radiation) but to the best of my knowledge it's not.

I would just like to recommend this excellent Radiolab episode about saving lives during heart attacks: https://radiolab.org/podcast/how-to-save-a-life

"[…] people who undergo CPR outside of a hospital setting survive only 10 percent of the time. Within a hospital setting, CPR survival rates are only a bit higher — about 17 percent."

https://www.discovermagazine.com/health/contrary-to-popular-...

So it seems CPR has contributed little to the survivability of heart attacks.

This varies hugely around the country. The Utstein criteria are only a subset of cardiac arrests, but while in NY you might have 11% chance of survival, Detroit, 8%...

Rochester County, MN, King, Pierce and Thurston Counties in WA regularly battle each other for highest survival rates in the country, from high 30s, often in the 40s, even 49% survival.

-- paramedic in Washington

> 2.1 percent doesn’t sound high — it’s a little higher than the chance of pulling an ace of spades from a card deck — but when it comes to major adverse cardiovascular events, 2.1 percent is approximately 100 percent higher than I’d like.

That says something about the excesses of American medicine

Yeah cancer is the big killer nowadays. Survival rates for stage 4 cancer still poor after many decades of research. Worse yet, in many instances there are no obvious risk factors, such as people in their 30s or 40s who get colon cancer and were not eligible for screening .

Would screening improve the outcomes or just create more patients getting unnecessary treatment?

Yes, colorectal cancer screening is estimated to reduce colorectal cancer mortality by 50% to 73%.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10093633/

https://www.nejm.org/doi/full/10.1056/NEJMoa2208375

Progressive screening using non-invasive assays like Cologuard and FIT is a valuable screening mode. The non-invasive assays are not perfect but they are improving.

What about overall mortality?

Catching colorectal cancer at an early stage improves survival rates tremendously. You have to weigh the risk of complications from the colonoscopy (primarily bowel perforation) with the improved outcomes. There's a cost element as well, since colonoscopies (without complications) can be several thousand dollars.

That's the calculations that go into screening guidelines. It's a lot of weighing now much benefit early detection provides vs how much harm testing and false positives do.

Guidelines do change however. When I first was diagnosed at age 41, my doctors were all pretty surprised due to my age. Not shocked, just surprised. Five years later, they were all pretty consistent in their views that the age guidelines should be lower, and that viewing colorectal cancer as something primarily limited to 50+ was outdated.

> not eligible for screening

Is this a thing? I thought I could walk into my PCP's office and schedule a screening any time, provided I may need to pay more out of pocket or something.

PCP is certainly not going to be the one doing the colonoscopy.

maybe they’d do the stool sample or some silly blood test if you are extremely insistent and can somehow demonstrate a risk factor.

I’ve dealt with a few PCPs and they seem less informed about their own area than a 30 sec google search.

They’re basically L6 tech support…

I read here (on Hacker News) that the stool test is actually really valuable and cheap enough to pay out of pocket prior to trying to justify an out-of-schedule colonoscopy.

Is it at home ones or ones that you send sample to get sequenced?

Not to mention the prepare for a colonoscopy is not pleasant.

And colonoscopies are invasive procedures that have their own risks. Perforated bowel can turn this "routine" procedure into an emergency.

Gentle reminder for Australian folks here, you can get a bowel screening test kit for free, if you're between 45 - 74 years of age.

https://www.health.gov.au/our-work/national-bowel-cancer-scr...

Grandfather died of colon cancer at 43.

Went into my PCP at 40 asking for a colonoscopy, he said insurance wouldn’t cover it until I was 50.

…

Ask him to do a hemoccult (done in the office - doc sticks his finger up your a** and dabs it on a test material) or request a cologuard test (shit in a box at home and mail it to the lab! - loads of laughs driving cautiously to FEDEX!)

The hemoccult (FIT or FOBT) tests are <$100 and the cologuard ~$700. Your insurance will likely cover (esp. the hemoccult test) all the more if you tell doctor of your family background. Hemoccult tests were part of my routine annual physical for decades and there are no familial tendencies.

There are some caveats: e.g., avoid bloody foods in the days preceding these test (Chinese pigs' blood cubes, yummm!)

You shouldn't have to do this, but have you tried calling the colonoscopy practice and asking for a cash price? It might not be as expensive as you think.

Screenings are not risk-free. There are always some false positives which then may lead to more invasive and unnecessary tests or treatment. There are a lot of rare conditions (based on age and/or history) that we don't screen for on a routine basis.

Colonoscopies here (midwestern US) are upwards of a couple thousand outside of the usual schedules enforced by insurance companies.

If there’s a complication they can easily skyrocket into the tens of thousands.

Most people around here can’t soak that.

that’s to be expected, after we do the adequate screening for one older population and mitigate many of the advanced versions of that, then the previously edge case becomes more prevalent amongst all cases

there is still a limited resource for the screening at this point, so that’s a friction to expanding screening

It's not just a question of scaling up the screening effort. Doctors are also concerned with potential harms caused by false positives.

What false positive would come out of a colonoscopy? You are visually looking for masses, and removing suspect polyps that are sent in for evaluation. The major potential harm of a colonoscopy is a bowel perforation. Serious complications occur roughly 0.3% of the time.

> Serious complications occur roughly 0.3% of the time.

https://www.cancer.org/cancer/types/colon-rectal-cancer/abou..., “the lifetime risk of developing colorectal cancer is about 1 in 24 for men and 1 in 26 for women.”

So, it’s a 4% lifetime risk versus a 0.3% per colonoscopy risk. The outcomes for the two risks also are different, but I would think that for many healthy people (e.g. those under 40 years old), the risk of doing such a check are greater than that of not taking it.

Reading https://en.wikipedia.org/wiki/Colorectal_cancer#Screening, that’s one of the reasons frequent colonoscopies aren’t advised.

As you said, the outcomes are wildly different. A 0.3% risk of colonoscopy complications vs missing out on catching a mass when it's relatively easy to treat.

No, heart disease still #1 (it's closer, like 680K vs 600K deaths)

Wish it was the case for some of my family :(

Also as result of long covid, more young healthy people get hearth attack. They have better chance to survive hearth attack, than older people. It improves survival stats!

But was the “Long Covid” caused by SARS-CoV-1 or decreased physical activity as a result of life fully coming to a stop for a few weeks/month and not fully resuming for years (and for some people never has)?

I as a relatively young man also hate it when my hearth is attacked. One can't even be secure before their own fireplace, in their own home any more.

Hearth= area in home where fire is kept, usually for cooking.

Heart= that sometimes unfortunate little knot of pumping muscle under your rib cage.

no, healthy young people have more heart attacks with acute covid. And die (or at least did in 2020-2021 time frame)

Long covid isn't really associated with increased heart attack rates

> A sudden cardiac death is the disease equivalent of homicide or a car crash death. It meant someone’s father or husband, wife or mother, was suddenly ripped away without warning.

Now ever increasing numbers of people avoid an abrupt death and live long enough that misery and terrible quality of life extend for decades. Hooray for all of those who emphasize preventing death above all else, whether they are motivated by extracting medical fees during life's long slow twilight, or by more pure considerations.

Most people who recover from a heart attack will not suffer a terrible quality of life. Depending on the severity and the treatment many will live quite normal lives for decades, and die from something completely unrelated.

The point stands — it’s not that the heart attack leaves you infirm, but that surviving it lets you live long enough to die of Alzheimer’s or cancer or depression.

Causes of abrupt death are being winnowed down, which the author regards with horror. I hope that they never experience the prolonged agony to which modern medicine has consigned so many, and that they are never forced by suffering to change their mind.

This is true. In fact if you have a heart attack and are treated relatively quickly, with no major injury and decreased function of the heart muscle, and continue to have regular follow up care and address risk factors, your mortality risk normalizes to those without history of a heart attack (but with CAD) and should have no functional limitations

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