It was hot August day in South Carolina, when we returned to the club house after an evening deer hunt. All the hunters were gathered around the skinning shed when one of our friends collapsed without any warning. CPR did no good and at 54 years old, he had passed in mere moments. No previous symptoms and no warning. Ironically he had just been to his doctor a few weeks back for his annual physical.
We are going to digress a little from outdoor related health issues to look at a killer that is lurking about for a great many of us. This killer is silent and we don’t even know it is there. It bides it’s time, and attacks us suddenly and forcefully at a most inopportune time. This hidden danger is coronary artery disease (CAD). What follows is not a medical lecture and dissertation on treatment, since there are hundreds of textbooks written on the subject. We will focus on the risk factors and the ways to detect CAD before it causes you a huge problem. We highly encourage you to give your own situation some thought since CAD kills more Americans then any other disease process period, end of discussion. We are not big “told you so” fans so this really is important stuff, potentially lifesaving.
As awful as that experience was, fatal CAD is not a stranger to hunting camps. A few years later, we had an experience not soon forgotten. This is what happened; it began with a routine pack-in wilderness elk hunt: There were six hunters in our party, four were strangers. As most of you know, in this type of hunt you are up way before first light and head out on your trusted steed to navigate the wilderness in total darkness. You are gone all day and return well after dark. On the return one late evening, there was a huge commotion in camp with a lot of confusion and anxiety in camp.
One of the hunters had left out just as we did and traveled for hours to reach a predetermined ridge overlooking a large heavily wooded basin well below them. After quickly locating a bugling bull deep down in the dense timber below, he and his guide had tied up the horses and made their way down the steep incline to the base of the mountain. The going was slow but they finally made it. The guide, knowing he could locate the bull easier and quicker if he went out ahead alone, decided to leave the hunter at the base of a large tree so he could rest a little. The plan was to return shortly, collect the hunter and go and kill the bull. Unfortunately, the guide became disoriented in the thick underbrush and it took him some time to find his way back. When he finally made it back, the poor soul was lying on his back: dead. Again, another heart attack victim but by this time rigamortis had set in and the corpse was rigid as a board.
Trying to stay calm, he went to collect the horses to transport him out since there was nothing he could otherwise do. When he returned and despite all his efforts, he found it impossible to secure the stiffened body onto the horse. The gruesome part is that he had to make a circumferential cut around the waistline in order to be able to bend the body in a U shape so as to fit him onto the horse. We arrived in camp after the guide and the deceased hunter and hence the confusion and anxiety was self explanatory. The guide ended up becoming a good friend of ours and later told us that telling the family what happened and what he had to do was ten times worse then doing it.
CAD most commonly occurs in the setting of concrete risk factors. Be cautious about the amount of comfort you draw if you find yourself with few of these risk factors. CAD can strike, and often does strike those with “no risk factors”. Obesity, family history of CAD, smoking, diabetes, high blood pressure, vegetative life style, high cholesterol levels, elevated homocysteine and some connective tissue disorders (i.e. rheumatoid arthritis) have all been linked to CAD. Our guess is that if you have these risk factors your doctor has probably talked to you about reducing your risk. Take it upon yourself to have a CAD risk factor discussion with your doctor. Some of these you can do something about and some you can’t so you know what you need to do. Get these easy things checked and alter your lifestyle. Talking about getting healthier isn’t the same as getting healthier.
There is a dangerous big misconception about heart disease. Most folks think that they need to have a significantly blocked artery before sustaining a myocardial infarction (fancy for heart attack). Another myth is that you will also have warning chest pains first. To set the record straight depending on which medical journal you read, only 50% of the people that sustain a heart attack do so because they have an artery in their heart that is significantly ( >80% ) occluded by a plaque. This 80% occlusion number isn’t magic but reflects physical principles related to flow through a tube as elucidated hundreds of years ago by an Italian named Bernoulli. Pressures in the blocked artery change but flow does not reduce enough to make much difference until this extent of blockage. By the time folks have over 80% blockages they “usually” have chest pain or some type of symptom when they exert themselves to a certain degree. Thus they most often have a warning.
If you have a significant blockage in your coronary arteries, most likely you will have some type of symptoms when you exert yourself past a critical point. Realize though that the symptom may not always be chest pain. Become familiar with these atypical symptoms. These blood flow restrictive blockages are what the exercise stress test and nuclear stress test was designed to pick up. Hence this is what is ordered by our doctor for most of us when we get our heart screened by our doctors. Again, the thing to remember is that those tests only catch the first 50% of the potential dangerous cases of CAD.
Now, let’s focus on the other 50% that have heart attacks. These are the people we all know of that had no warning, were in apparent great health and had normal yearly checkups with their doctor. Then one day, without warning, they are stricken and all too often, die. This is a different situation all together. These people have smaller plaques that are not critical enough to cause a lack of blood flow no matter how hard they exert themselves. This is why they so readily pass their exercise stress tests that their physician requests on their annual physical exam. But these smaller plaques are ragged, brittle and unstable which makes them prone to crack or fracture.
How this leads to a sudden unexplained heart attach is best understood as follows. When you cut yourself, your body recognizes that it is bleeding and immediately forms a clot to stop the blood loss. The same process occurs within the vessel once a plaque ruptures or cracks. When the plaque ruptures it also cracks the inside lining of the vessel and now the vessel acts like it is bleeding so it also immediately sets up a clot. Unfortunately the clot blocks the whole vessel off so no blood flow is possible. The results are an immediate and potentially deadly heart attack. Because of the lack of typical symptom warning and inability of “routine” testing to detect these smaller plaques, specialized risk assessment is absolutely in order. Our buddy who died in hunting camp that August had recently passed a stress test; he fell into this category of CAD.
For those with sub-critical occlusions, but at risk, there are new diagnostics well worth the minimal effort they require. This new screening test literally takes 10 seconds to do and involves no exercise and no needles. Now, no test is fool proof but we have found that if you are in your forties (and older) and if you have plaque in your coronary arteries, this test will reliably pick it up. It is called a Cardiac Calcium Score. It is performed on a very advanced CAT scan and the cost (in Columbia SC) ranges anywhere from $99 to $150. It looks for any calcium deposits in the plaque in your coronary arteries (independently of the degree of occlusion) then quantifies it. This process results in a score telling you how much calcified plaque mass is contained within your coronary vessels. This number correlates with degree of CAD in that the higher the number the worse the disease. This is definitely one test you want to fail with a big fat zero. Both of us have personally passed repeated nuclear stress tests yet have lots of plaque in our coronary arteries based on this test and further diagnostics. We are on aggressive treatment that has been shown to be life prolonging. Absent this test, neither of us would be on any of these treatments and we would be in the 50% bad surprise group. We strive to never be that “other guy”.
CAD treatments really need to be individualized. We prefer a Cardiologist or Internist. Most of the time the Cardiac Calcium Score test can be obtained without an order from your doctor. You can go to any facility that performs them and have it done. Be pro-active! Then take the results to your physician so that a comprehensive and individualized treatment plan can be worked out.
One thing almost all of us can do is remember that an aspirin a day is recommended if there are no contraindications for you to take it. The reason it is so effective in preventing MIs is the fact that it inhibits the clotting process which helps to prevent the clot from forming in the vessel if you rupture a plaque. Naturally check with your doctor before beginning on aspirin therapy. Do yourself, your family, all those who care about you a favor and find out about your risk for CAD. Then follow the treatment plan to reduce the risk and keep you hunting longer. This isn’t a debating exercise like cartridge choice; this is a very strong medical recommendation.
As usual, we wish you safety and good health in all your outdoor adventures.