Qualy #82 - What is the most common first presentation of heart disease?

**Peter Attia** (0:05)
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Now, when I was in medical school, I remember in first year pathology lecture, the pathologist said, let's see a show of hands, what is the most common first presentation of heart disease? And, you know, everybody puts up their hands and says chest pain, left shoulder pain, shortness of breath. And he said, no, it's sudden death. That was a little over 20 years ago. Is that still true today?

**Ron Krauss** (1:28)
The estimates I've heard, and I think this is arguable because these are really rough rule of thumb calculations, somewhere in the range of 30%, possibly upwards of 30%, which is still a huge number.

**Peter Attia** (1:39)
It's staggering. It means that one third of people's first brush with the knowledge that they have atherosclerosis is death.

**Ron Krauss** (1:45)
And I have patients, and I'm sure you do as well, who have died and come back. And so there is this process where there's an acute event that causes an irreversible change, but for some people, fortunately, we can bring them back. But together, that represents really the basis for calling this disease the silent killer.
Because, as you were saying, we don't, and those patients have premonitory symptoms. Sometimes in retrospect, they are there. And I think that's the important reason for educating the public, as organizations like the American Heart Association does, as to the first signs of heart disease, because it may be, and it probably is true, that a significant component of that 30%.

**Peter Attia** (2:27)
Right, upon further querying, there was some exercise in tolerance.

**Ron Krauss** (2:31)
Didn't recognize it, yeah. And it's very hard sometimes. One of the things that we'll be talking about is ways of assessing risk.
And those are still imperfect. I mean, we can't, with 100% certainty, use any kind of risk predictor to know if somebody's destined to have a heart attack with certainty.

**Peter Attia** (2:46)
Yeah, you said something at the outset, which is this is a disease that begins in infancy. And I have very few textbooks and or papers that I refer to so frequently that they actually sit on my desk in my office so that every time I'm with a patient, I can pull them out. But one of them was a book that was given to me by one of my mentors. I consider you a great mentor, Tom Dayspring a great mentor, Alan Snyderman a great mentor. And Alan gave me this textbook of pathology. I think I believe it's Starry is the author.
And while I believe the data represented, they were somewhat dated because it was largely based on the Vietnam cohort.

**Ron Krauss** (3:21)
And Koreans.

**Peter Attia** (3:22)
Yes, where obviously smoking would have been a higher prevalence than today.
The fact remains that when you look at autopsies of young people who died of unrelated reasons, homicides, accidents, et cetera, and you look at the histologic sections of their coronary arteries, it's amazing how many of them have lesions that are type three or beyond. Type three meaning obviously a type of pathological region where you go beyond fatty streak.

**Ron Krauss** (3:49)
Yes, indeed. That's right. So a subset of these youths will have more advanced lesions. And the studies that have been done have linked all of the usual risk factors, smoking, certainly diabetes, hypertension, and dyslipidemia, and a lipid disorder. All of those have been associated with the more advanced lesions in those individuals.
So as you're pointing out, even a more significant plaque development can occur in childhood.

**Peter Attia** (4:17)