Sudden cardiac death after stenting

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Submitted by Dr T on February 19, 2013 – 11:22am

Question: 
Dear Dr. T,My father recently passed away one week before his 67th birthday in January 2013. He has always been a very healthy individual throughout his entire life with a strict diet, no junk food, regular exercise, and didn’t smoke, drink alcohol, or do drugs. Very healthy person. He was a college professor with a PhD degree and owned a small business. Indian-American descent. He was very happy, lighthearted, and always cracking jokes and smiling. No one in our entire or extended family has ever had any kind of heart disease, or heart problems, so this was a surprise.Suddenly, he had 3 heart attacks all within one month in October 2006. Left Anterior Descending (LAD), Circumflex (Circ) and Right Coronary Artery (RCA) were all blocked and he had 3 stents put in immediately. He was doing very well and put on a plethora of medications, lipitor, metaprolol, plavix etc and many others. His heart and ekg’s, troponin levels, etc all were constantly monitored.In summer 2011 he had all three stents replaced I believe and was doing very well. So from 2006 – 2013 he was doing absolutely great with regular checkups. The DAY before he died, he went to the cardiologist and he checked his heart, did all the battery of tests, and the cardiologist said the heart looked wonderful and was functioning very well, no blockages, no need of a bypass or anything like that. My father was very happy.The next morning, he told me he had chest pains and lost consciousness and died a few minutes later. Paramedics, ER docs, cardiologists, surgeons everyone tried everything for 1 hour straight, shocking him continuously, but it was no use. I am shocked how this can happen 12 hours after such a positive cardiologist appointment. On the death certificate, I see that he did not die from a heart attack, it was an electrical wiring problem. The ER doc wrote that he had ventricular fibrillation —-> left ventricular systolic dysfunction. The ER doc wrote that it was due to advanced coronary artery disease.Can you explain what could have happened here, and why so suddenly, seemingly out of the blue? How can one have such a great cardiologist appointment, but die of SA/AV node failure the next morning? Why didn’t that show up in the lab reports? I’m a medical student and would like to know. My dad died a week before my USMLE exam.Thanks, 

I am so sorry to hear about your father’s death. Re: what caused what in what order – this is the sequence:

Thus I disagree with the final diagnosis on the deatth certificate.

The “battery of tests” on the preceding day most likely did not include a stress test or CTCA since your father was asymptomatic. I suspect they would have shown a major stenosis. These are the options of what could have happened:

  • Stent thrombosis
  • New disease:
    • Local disease at or near one of the stented arteries
    • A new Left Main coronary artery stenosis during the interval, rather than a recurrence in one of the previously stented arteries.

While stenting is of course not responsible for the Atherosclerosis, it causes severe local damage to the artery involved; the result an inflammatory reaction that involves the area that is stented as well as a zone up – and down stream of the artery, thus the 10-15% yearly failure rate/stent.

In essence a stent produces a new disease and to prevent the built-in complications, all those drugs are given to suppress the inflammatory response. An acute event is usually the result of plaque hemorrhage with acute occlusion of the artery involved, which is what probably happened. He died before an examination of the heart would have shown actual necrosis. 

 

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