A friend passed away recently. Actually, a few friends have passed away lately, but this one was particularly saddening. He was surfing in Cape Town at a big wave spot, and he didn't feel right. He paddled all the way in, made it to the land, but had a heart attack, and there was no one around to help him.
He was about my age, and maybe we both didn't have the most healthy of lifestyles in our youth, but it really rattled me.
I reached out to a good friend of mine who is a surfer and an Interventional cardiologist. Yep, he made better decisions than me back in the day when we left school, but that's another story. His official title is Dr Robin Van Lingen, MBChB, FRCP. Consultant cardiologist, and back in the day we travelled to Chile together, hunting perfect lefts and drinking pisco sours.
Heart attacks, they're becoming a thing. It seems that we are noticing them more now, mainly because we are getting older.
RVL: Yes, Andy Irons - the coroners report listed cause of death as a heart attack along with drug ingestion, at 32. Derek Ho at 55. Your friend Paul. There are also increasing numbers of middle-aged men taking up triathlons and often dying in the water during the swim segment - a dangerous place to have a heart problem, much like surfing.
Early warning signs?
Heart disease is one of the biggest killers on the planet. More than 800 000 Americans die every year from cardiovascular disease, more than in all their conflicts in the 20th century.
So more than COVID? Should we not just shut down the economy? That should work…
Moving on, classic warning signs will be chest pain, often a tightness or pressure in the chest, rather than a pain, on walking or exercising. This gets better with rest. Sometimes the discomfort can spread into the jaw or down the left arm. Or shortness of breath. But unfortunately, you can have heart disease without symptoms. 30-40% of people will have no warning before they have a heart attack.
If you get relatively predictable chest tightness on walking that ceases with rest, it is known as stable angina. If the pains are rapidly escalating and getting worse, this is known as unstable angina. You need to get help urgently. If you get severe discomfort that does not go within 15 minutes, often associated with sweating and a sense of impending doom, this may be a heart attack.
Impending doom? Reminds me of the time when we went surfing at Lobos in Chile. That paddle out was impending doom. Never been so scared in my life.
Ja bru – that and your rum and coke concoctions after. Well, the cause of all this, including the doom, is atheroma (a fatty build up in the arteries) that narrows the arteries. If this fatty plaque is causing a narrowing, it slows blood flow, and you get the chest pain from a lack of oxygen to the heart muscle. Hence why it is better at rest but worse on exercise as you need more oxygen.
But these fatty plaques can also rupture, or become unstable. They then grow rapidly in size, and blood clots form on them to try and heal them - so-called unstable angina. And if they block off entirely in this process, then that is a heart attack where no oxygen gets to the muscle, and the muscle dies.
You have a few hours to unblock the artery to restore blood flow and salvage some of the muscle to minimise the damage. You can use powerful blood-thinning drugs called thrombolytics. More increasingly these days primary angioplasty is used, where you unblock the arteries with balloons and stents.
Suppose you develop significant muscle damage after the heart attack. In that case then long term, you can be left with heart failure where your heart fails to pump properly.
It is common sense, really, but let's go through the risk factors.
Yes, most people know the risk factors - obesity, smoking, diabetes, hypertension, sedentary lifestyles, poor diet and high cholesterol.
Do people still smoke?
Unfortunately, yes. But there is also a genetic component to it which is still poorly understood. You can get other genetic diseases, like hereditary high cholesterol, that can, in turn, put you at increased risk. But I see lots of "healthy" people who still develop heart disease, and it becomes much more common as you get older.
Possible things that could help - I think you once told me to have aspirin on hand? (I have some genetic risk in my family).
Looking after yourself and choosing a healthy lifestyle is, of course, the starting point. A healthy diet, keep the weight down, exercise regularly and don't smoke.
Looking after yourself and choosing a healthy lifestyle is, of course, the starting point
Once you have coronary artery disease, the usual therapies are aspirin, which is an anti-platelet that stops blood clotting too quickly. You can see above that heart attacks are caused by ruptured plaque clotting and "thrombosis" in the artery, and this is why aspirin is so useful - it reduces this risk. Cholesterol-lowering drugs (usually statins - they seem to calm these fatty plaques down too in addition to stopping new ones forming), drugs called b-blockers and ACE-I to lower BP and slow the heart rate down, and good diabetic and blood pressure control.
Ok, then the hard bit. What to do if a surfer collapses and you're on the spot.
Although we are very good at treating people if they present to the hospital with a heart attack, unfortunately, a significant number of people still don't make it to the hospital as they collapse and die suddenly at home, or at the beach in the case of your friend.
The reason for this is that when you develop the lack of oxygen to the heart, it changes the electrical conduction to the heart and can set up a dangerous rhythm abnormality. Ventricular fibrillation or ventricular tachycardia is the heart beating so fast it doesn't generate any cardiac output, and you collapse with no blood pressure. The treatment for this is an electric shock through the heart to "cardiovert" the heart back to a normal rhythm. The classic "stand clear" you see in movies with the electric paddles.
Once you collapse with no blood pressure, you have a few minutes before you start developing brain damage from lack of oxygen. So ambulance response times to collapsed people should be less than 8 minutes to provide the ability to rapidly cardiovert people should they be in this dangerous arrhythmia. Then you can concentrate on getting them to the hospital to unblock the artery, where you have a bit more time. Increasingly AED's (Automatic External Defibrillators) are seen in airports and supermarkets to do this job while waiting for the ambulance.
What about mouth to mouth?
The role of CPR (Cardio-Pulmonary Resuscitation) in these situations is to keep oxygen flowing to the brain while you wait for the ambulance. So you perform chest compressions to circulate the blood to the brain, and if you can mouth to mouth to improve the oxygen concentration. Increasingly mouth to mouth is not advised as it puts too many people off - just concentrate on the chest compression. It doesn't treat the underlying condition - only buys you time until the right treatment arrives.
You can thump the chest to see if this "cardioverts" the dangerous rhythm - but it delivers very little energy (about 6-8 joules) and so is rarely effective. The external electrical shock delivers about 150-360 joules in comparison.
Increasingly mouth to mouth is not advised as it puts too many people off - just concentrate on the chest compression. It doesn't treat the underlying condition - only buys you time until the right treatment arrives
Anybody can be trained in resuscitation. Different levels are Basic Life Support (BLS), Intermediate Life Support (ILS) or Advanced Life Support (ALS).
Here is a link to the UK's resuscitation council with information - they often have initiatives to treat members of the public. Other organisations, like the ambulance services or lifeguards, also sometimes run courses. (See HERE) But the usual Basic Life Support scenario is DRS ABCD.
You see a collapsed person;
D - assess for Danger before approaching (like electric power lines that are down and will kill you too if you touch them)
R - check for a Response, ask them if they are ok, shake them, see if they respond
S - Shout for help. This is the most important - the sooner you get help, the better. There are very few things you will be able to fix on the scene - remember you are buying time to get the right people and equipment there.
If there is no response, and they are not breathing with no pulse
A - Airway, check the airway is open and clear blocks, foreign bodies, vomit
B - Breathing, if they are not spontaneously breathing you can provide rescue breaths ("mouth to mouth")
C - Circulation, chest compressions - the rate of 30 compressions to 2 breaths, at a rate of 100-120 beats per minute - which is the rate of "Staying Alive"!
So then, in closing, heart disease is common, and knowing some basic principles of resuscitation and life support can be really helpful. Surfers should have some basics if something does go down. We hear of surfers saving lives, and of paramedics on beaches saving surfers lives, but we also hear of people who didn't make it, like your friend Paul. Sadly heart disease often doesn't give us any warning before it presents catastrophically. This is why it is still such a big killer in the world today.
For more info, visit Surfing Doctors, HERE.
Cover shot; never mind a heart attack in the water, seeing Nazare loom like this is enough to pump it through your chest. Pic by Helio Antonio.