Heart attack with normal angiography or normal post mortem

Dr KK Aggarwal

Recipient of Padma Shri

The death of actress Sridevi was due to accidental drowning in a bath tub following loss of consciousness in a hotel in Dubai. This was the conclusion of the post-mortem report and foul play has been ruled out. Dubai police said that the case has been closed.

However, the cause of unconsciousness has not yet been conclusively found. Traces of alcohol were found in blood, and it has been suggested that this may have led to the accidental drowning.

Though the post mortem has ruled out heart attack, it still remains the most likely initiating event for loss of unconsciousness or gasping, which may have been due to ventricular tachycardia/fibrillation.

So, can one have a normal angiography or normal post-mortem after a heart attack? The answer is yes.

There are two types of heart attacks: Type I versus type II heart attack.

Most patients with acute heart attack will have obstructive (blockages) atherosclerotic (cholesterol deposition) coronary artery stenoses (narrowing) with acute thrombosis (clot) as the underlying pathology.

However, some patients (up to 28%) will not have significant epicardial coronary artery disease when coronary angiography is performed or post mortem is done. These patients are defined as having a type 2 heart attack, which is defined as a heart attack consequent to increased oxygen demand or decreased supply (coronary endothelial dysfunction, coronary artery spasm, coronary artery embolus, tachy / bradyarrhythmias, anemia, respiratory failure, hypertension, or hypotension).

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Can accidental drowning occur medically?

Dr KK Aggarwal

Recipient of Padma Shri

Actor Sridevi died of accidental drowning in her hotel bath tub after losing consciousness, according to the forensic report by the Dubai govt. on Monday. However, the report, which carries the stamp of the "Ministry of Health UAE" and the director of preventive medicine, Dubai, Dr Sami Wadie, does not state the cause of unconsciousness.

Can accidental drowning occur medically? Yes. Medical conditions can cause accidental drowning. Seizure disorders, which can be first-onset episode, can cause accidental drowning. Alcohol and/or use of illicit drugs increases risk of accidental drowning as it may affect balance, coordination and judgment. Stroke, syncopal attack (heart attack) or undetected primary cardiac arrhythmia are other factors that can cause accidental drowning. A gasping patient with ventricular arrhythmia will end up with drowning.

If there are no signs of struggle, then ‘accidental drowning’ can be a medical opinion. It is up to the police to accept this opinion or find it as a case of ‘homicidal drowning’ and investigate any foul play.

Some salient facts on accidental drowning

Drowning is the third most common cause of accidental death. A victim of drowning can be revived by cardiopulmonary resuscitation (CPR) with rescue breathing. Prolonged resuscitation, up to many hours, has been known to revive patients with hypothermia and cardiac arrest.

Antemortem drowning can be identified by the presence of fine, white, leathery, copious froth or foam tinged with blood at the mouth and nostrils (Froth is of lasting nature and large in quantity), cadaveric spasms in hands, diatoms in tissues from brain, liver and bone marrow of long bones, presence of water in stomach and intestines, voluminous water logged lungs along with fine froth in lungs and air passages.

A bathtub drowning is a major cause of death in a bathtub. The bathtub is the most common site of seizure-induced drowning; hence, patients with epilepsy should be advised to take showers instead of baths. Heart attack leading to syncope and subsequent falling in the tub can cause drowning. Besides the causes discussed above, mutations in the cardiac ryanodine receptor (RyR)-2 gene, which is associated with familial polymorphic VT in the absence of structural heart disease or QT prolongation, have been identified in some individuals with unexplained drowning. Concomitant trauma, paralysis, heart attack or hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias are other factors for accidental drowning. Duration of submersion >5 minutes is the most critical factor.

Several studies have reported incidents of bath tub drowning with varying medical histories as follows:

·         A total of 268 victims were found unconscious or dead during tub bathing. After postmortem examination, the manner of death was judged as natural cause in 191 (71.2%) and accidental drowning in 63 (23.5%) cases. Drowning water inhalation, which was confirmed in 72% of victims, was absent in the others. Whereas, inhalational findings were more frequent in victims with other backgrounds such as alcohol intake, mobility disturbance, and history of epilepsy (Am J Forensic Med Pathol. 2013 Jun;34(2):164-8).

·         In a series of 14 cases of suicide by drowning in the bath in the Bristol area, England between 1974 and 1996, six cases had evidence of concomitant alcohol or substance use. Seven cases had a past psychiatric history and a history of previous deliberate self-harm. Most drowned at home, face down, fully clothed (Med Sci Law. 1999 Oct;39(4):349-53).

·         A retrospective review of 92 deaths in the bathtub in Maryland found 71.7% incidence of bathtub drowning; 28.3% were the absence of bathtub drowning. Three leading contributory causes of death were cardiovascular disease, drug/alcohol-related death, and seizure disorder in both groups More than triple overlapped drowning-related signs (history of recovery from the water, foam in the air way, watery fluid in the sphenoid sinuses, hyperinflated lungs and watery fluid in the stomach contents) could be beneficial for the diagnosis of a bathtub drowning. (Forensic Sci Int. 2015 Aug;253:64-70).

·         In a retrospective analysis of 245 bathtub death cases between 1971 and 1988 carried out in the Institute of Legal Medicine in Hamburg, 66 cases proved to be natural deaths, 76 were classified as suicides, 39 as accidents and 13 as homicides, while 51 fatalities remained unclear with respect to one of these groups. About 50% of the victims were alcoholized.  (Arch Kriminol. 1991 Jul-Aug;188(1-2):35-46).

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Sridevi passes away: What factors contributed to her tragic death?

 Dr KK Aggarwal

Recipient of Padma Shri

Actress Sridevi passed away at the age of 54 years due to sudden cardiac arrest on Saturday. While her family (actor Sanjay Kapoor) has said that she had no history of heart disease, a Facebook post and Whatspp message is being circulated that blames her untimely death on plastic surgeries and other cosmetic procedures she may have undergone in an effort to ward off signs of aging and look young.

The post, whose authenticity cannot be verified says “Society demanded that she stay slimmer/look younger than a40-year-old and hence, the continuous surgeries. When I met her about 5 years ago, she was beautiful but a sad version of that self that we loved so much in a movie like Chandni. What a lot of pressure to keep her weight down, to make sure that her face had no wrinkle lines....continuous clinic visits in Southern California” (Read more at: https://www.oneindia.com/india/plastic-surgeries-desire-look-young-could-have-led-sridevi-s-death-claims-viral-post/articlecontent-pf31730-2648473.html)

Repeated plastic surgeries per se cannot cause sudden cardiac arrest, however, the associated stress can lead to such an adverse event. The stress of surgery and the recuperation process may result in some degree of depression. A person who is already insecure about their appearance may become severely depressed if the result of the surgery is not what he/she expected to be.

Job dissatisfaction and relational disharmony can be factors in a sudden adverse cardiac event. She ruled the Hindi film industry as the no. one female star in the 80s. She was also an acclaimed actress in the South film industry. Her elder daughter was to make her debut in Hindi films. So, she had something to look forward to.

It is being said that she was on a weight loss diet. A ketogenic diet is a diet which has low carbs, high fats and adequate proteins (1 gm/kg body weight). It is a type of starvation diet (starvation of carbohydrates), which puts the body into a metabolic state called ketosis, wherein the body derives energy from ketone bodies unlike a normal, higher carbohydrate diet, where glucose is the source of energy. And, the extra glucose is converted into fat, which is then stored. A ketogenic diet therefore burns fat rather than carbohydrates, resulting in weight loss.

Cardiac arrest in the setting of diet pill consumption has been reported. The American Journal of Emergency Medicine has published a case describing ventricular tachycardia/fibrillation arrest in an otherwise healthy 48-year-old woman who was taking no medications other than phentermine, a common appetite suppressant. It has been suggested that phentermine, which is a chemical analog of the potent amphetamine class of noradrenergic stimulants, may promote potentially fatal cardiac outcomes (Am J Emerg Med. 2008 Jul;26(6):732.e1-3). Vigorous physical activity also may be a potential trigger of sudden cardiac arrest in some patients (Int J Cardiol. 2009 Jan 24;131(3):345-9).

These factors may not have contributed to her death, as was being circulated on social media earlier.

However, yesterday, quoting the Dubai government's media office feed on Twitter, the PTI reported that “Following the completion of post mortem analysis, Dubai police headquarters stated that the death occurred due to drowning in her hotel apartment's bath tub following loss of consciousness.” The Dubai-based Gulf News said in a report that the actor was under the influence of alcohol. She fell into the bathtub and drowned. It also attached a copy of the UAE government's forensic report on its Twitter handle. The report, citing accidental drowning as the cause of death, has a stamp of the "Ministry of Health UAE" and the director of preventive medicine, Dubai, Dr Sami Wadie.

A normal person would not drown in a bath tub unless he/she is unconscious or is under the influence of alcohol, which was found only in traces.

Perhaps she had a cardiac arrest and she fell down in the bath tub or she became unconscious and fell down in the bath tub, leading to her accidental drowning.

The delay in handing over of the body and the forensic report is not because any foul play is suspected. The normal procedure in UAE takes about 4-5 days. This is usual.