James Gandolfini’s Killer Has Powerful Accomplices: Misinformation and the Status Quo

James Gandolfini, well known to many of us as the likeable, yet brutal and sociopathic, family man, modern-day don of the HBO drama, The Sopranos, collapsed suddenly last Wednesday night in his Rome hotel bathroom.  His thirteen-year-old son, who was his only travel companion on their father-son Italian vacation, found him initially conscious on the bathroom floor and quickly called the hotel lobby desk for help.  The Italian paramedics arrived, collected him and transported him to the nearest hospital where subsequent heroic efforts – including open-chest cardiac massage -- were administered in an ultimately unsuccessful attempt to revive him.  Mr. Gandolfini was 51 years old and, according to a family spokesman, Michael Kobold, he had no known prior cardiovascular history, nor had he any prior symptoms to suggest his impending, catastrophic cardiac event.  While the general public, as well as the overwhelming majority of today’s physicians and healthcare providers will process Mr. Gandolfini’s premature death as an unfortunate and incomprehensible tragedy that could not have been reliably predicted and thus averted; there are a few physicians practicing today, like myself, who know that Mr. Gandolfini’s short and long-term cardiovascular risk could have been accurately determined and successfully addressed, and had this early detection and treatment approach been used, his irreversible sudden cardiac death could have been prevented!  How many more tragic, premature cardiac deaths must we be obliged to witness before we fully realize that our continued, misguided reliance on traditional cardiovascular risk factors – such as age, gender, tobacco use, blood pressure, cholesterol and obesity – as predictors of an individual’s personal risk for a future heart attack or stroke is simply not good enough; and that only through proper utilization of safe and innovative technologies and personalized medicine can we effectively prevent virtually all heart attacks and strokes?

Cardiovascular disease continues to reign as the leading cause of death and disability in men and women around the world.  Each year, close to 1.4 million people in the United States suffer a heart attack, and over 500,000 are killed by it.  Worldwide, more than 19 million people are killed by heart attack each and every year.  Unbelievably, over 1000 sudden cardiac deaths (SCDs) occur each and every day in this country; and according to the American Heart Association (AHA), more than 2150 people die each and every day from a heart attack.  Fully 50% of us will eventually succumb to a heart attack or stroke, and for half of that gigantic group of unfortunate people, their very first symptom will be sudden cardiac death (SCD) – as it was for Mr. Gandolfini.  And to better appreciate the utter impotence of the current healthcare approach to risk assessment, one need only recognize that the vast majority – 86% to be precise – of heart attacks occur in people who have heart artery blockages that are less than 70% in severity, and therefore cannot be detected on any form of cardiac stress test, nuclear or otherwise. So, you are probably asking yourself -- how can this possibly be with all of the medical advances, innovations and myriad tests available to physicians today? The answer is complicated, but can be simplified for the sake of brevity here: 

Our healthcare system woefully fails to accurately assess each unique individual’s personal cardiovascular risk, and the current energy, investment and cardiovascular care delivery methods are devoted to after-the-fact (reactive rather than proactive) acute, in-hospital care rather than effective, innovative and truly preventive, outpatient care. 

I believe that the fundamental problem is that the current cardiovascular healthcare system continues to deliver care and recommendations based on inaccurate, population-based measures of cardiovascular risk.  The Framingham Risk Score, developed in the 1960’s, is still used today by cardiovascular specialists everywhere, despite its widely acknowledged limitations and failings at predicting any one individual patient’s future cardiovascular risk.  Its limitations and inadequacies are especially misleading for those in the younger age groups, like Mr. Gandolfini, as it is heavily weighted toward chronological age.  As an example, it is a statistical fact that nearly 50% of heart attack patients have 2 or fewer traditional risk factors, and that nearly 50% of individuals labeled “low or intermediate risk” (based on the Framingham Risk Score) in reality harbor potentially life-threatening arterial plaque within their heart arteries.  Notwithstanding the many scientific advances in cardiovascular risk assessment technologies, your doctor’s approach to predicting and stratifying your personal risk for a future heart attack or stroke is very likely antiquated and based on the accepted status quo, and will almost certainly leave you vulnerable.  It is almost indisputable – and scarier yet, accepted -- that heart attack and stroke prevention efforts have not been successful to date, and a quick review of the tragic statistics cited above will attest to this.  Ironically, while millions of dollars are spent every year on reducing serum cholesterol, having a “normal” cholesterol level does not ensure that you are not at risk for a heart attack.  Analyses of patients hospitalized for heart disease reveal that more than 75% of them had “normal” cholesterol levels.  In my practice, and a few other similarly proactive ones around the country, relatively new non-invasive screening tests permit me to look inside a patient’s arteries and accurately assess their personal risk for future (imminent or more distant) heart attack or stroke.  Using either a Carotid Intima Media Thickness (CIMT) scan or a Coronary Artery Calcium (CAC) scan, I am able to identify and accurately quantitate the extent of subclinical atherosclerosis (plaque) present in an individual patient’s arteries.  Because this atherosclerosis or plaque is the absolutely essential and necessary first ingredient in any future heart attack or stroke, I am now able to provide to each unique patient an accurate risk assessment based on their respective arterial anatomic measures of risk rather than flawed population-based measures of risk.  This can be seen as analogous to the use of the mammogram for breast cancer screening, or the colonoscopy for colon cancer screening.  After identifying and quantitating the extent of an individual patient’s atherosclerotic burden, I then determine through the use of advanced cardiovascular blood testing whether or not the resident plaque is “vulnerable” – the type of killer plaque that is prone to rupture and cause a heart attack, as it did in Mr. Gandolfini.  If the harbored plaque proves “vulnerable”, aggressive therapeutic measures are then taken to mitigate and extinguish the imminent cardiovascular risk and thereby effectively eliminate any future risk of heart attack or stroke.  Amazingly, and despite the one-strike-and-your-out high stakes, our current healthcare system appears unable or unwilling to evolve in a manner that would allow for personalized and accurate cardiovascular risk assessment and cardiovascular event prevention, even though the handful of tools and techniques required to implement such an accurate risk assessment program have been readily available for more than a decade now.

The heart attack epidemic that began in the early 20th century and that continues to accelerate unabated today will undoubtedly make it difficult for most people to envision a future where heart attacks and strokes are no longer a threat.  As an interventional cardiologist who worked within our current cardiovascular healthcare system for the past 14 years, I have recognized, and can no longer ignore, the fatal flaws embedded in the current misguided approach to cardiovascular risk assessment end event prevention.  In order to provide a heart attack-free future for my patients, I chose to break from the conventional healthcare system and open a concierge cardiovascular medicine practice where I would be free to use the most accurate risk assessment methods available and to provide the most effective preventive therapy to each of my unique patients.  Having thus far achieved my vision of a heart attack-free future in my concierge practice pilot project, I firmly believe that we can achieve the same cardiac event-free reality on a national scale if the healthcare community – including academia, industry and healthcare policymakers – redirect their energy and investment from acute, inpatient care to preventive, outpatient care.  Let’s begin by eliminating the accomplices used by mankind’s #1 killer -- misinformation and the status quo -- in favor of improved cardiovascular risk assessment through early detection of subclinical atherosclerosis combined with an effective, personalized and proactive, preventive approach.