What May Have Killed James Gandolfini

James Gandolfini, the actor who made the violent Tony Soprano a strangely assuring presence, died suddenly in Italy on Wednesday. Details are lacking, but most reports suggest that he had a heart attack. He was 51 years old.

Given the numbers, a cardiac event is indeed the likeliest cause of Gandolfini’s sudden death. Other causes of sudden death, including a blood clot to the lung, a stroke, or a ruptured aneurysm, are possible as well, but for the sort of shocking speed that seems to have characterized this event, a heart attack is most likely—it is overwhelmingly the most common and the most swift.

In general, there are two related but distinct physiological ways in which one might die suddenly from a cardiac event. First, a person might, for a variety of reasons, develop a fatal rhythm, an “arrhythmia.” Usually the electrical conducting system of our heart, a framework of strategically placed nerves, bops along at its own sweet pace. Very rarely, though, that fastidious and precise pulse deteriorates into a disorganized scramble. Because no blood is pumped forward, a person passes out, and, if normal rhythm is not restored quickly, dies.

People at risk for this include those with previous cardiac problems—people like Dick Cheney who prior to his heart transplant wore an ICD, or implantable cardioverter defibrillator, to zap his scrambled rhythm back into organized productive beats. But for those who are not as lucky as Cheney and develop ventricular fibrillation but don’t recover, the result is sudden death.

In addition to rhythm problems, the heart, which supplies blood to the rest of the body, may have a problem with its own blood supply. The coronary arteries, which feed the heart muscle, may become narrow from atherosclerosis (bad genes, too much pizza, or both) and then suddenly close off. If the occluded artery is one of the main coronary arteries, a person might feel severe pain, look deathly and, as the heart muscle quickly dies off, die within a matter of moments. To remedy this, those who survive such an attack might have stents placed to pry open the coronary arteries or else undergo the more invasive coronary bypass graft (CABG) surgery.

The CDC tracks the impact of cardiac disease closely, and the numbers are staggering. According to their statistics, about 600,000 people in the U.S. die from heart disease each year, meaning heart attacks, heart failure, rhythm disturbances, and other problems. It’s the nation’s No. 1 killer. Of these deaths, coronary heart disease—the narrowing of the arteries that feed the heart—accounts for more than half the deaths. In addition, more than 700,000 Americans have heart attacks each year. “Heart attack” refers to loss of heart muscle from inadequate blood supply to the heart. About 500,000 are first heart attacks, and 200,000 occur in people who already have had a heart attack. In addition to the tragedy of the lives lost, this type of heart disease costs over $100 billion a year in health care and lost productivity.

A study in 2011 reported on a large group of persons who, possibly similar to Gandolfini, had their first heart attack. The study examined the impact of five established risk factors for cardiac disease—high blood pressure, smoking, high blood cholesterol, diabetes, and family history of heart disease—on the age of the first heart attack and on its outcome. Six out of seven people with a heart attack had at least one risk factor; the more risk factors, the earlier the first heart attack occurred. A person with all five risks had a first heart attack at age 57.

In addition, the researchers found that about 10 percent of patients who reach the hospital died of the first heart attack—a deceiving number in that many patients die of their heart attack before reaching the hospital at all. When the people who die at home are included, the fatality rate is about 40 percent, though improvements in on-site resuscitation have resulted in some reduction.

Gandolfini was a rare talent, truly a joy to watch no matter the role. But his apparent fate, sadly for him and for the 1,000 people in the U.S. who died the same day from a heart attack, was incredibly common. Advances in prevention, in genetic profiling, and in medical and surgical management have made cardiac disease a substantially less frightening diagnosis now than it was a generation ago. That said, as Tony Soprano’s sudden death exemplifies all too vividly, we are a very long way from truly controlling diseases of the heart.

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