John Ritter: how treatable was his condition a month ago?

Factual Questions
1

These heart-breaking stories of premature, sudden death always provoke the obvious questions: had his congenital heart condition been diagnosed, say, a month earlier in a physician’s office, might surgery have saved him?

Obviously there are many unknowns, such as the severity of the malformity at death, but what is your best guess anyway?

News reports say Ritter was rushed to Providence St. Joseph Medical Center shortly after 10 p.m. Thursday, but it seems likely he was dead on arrival. Obviously thedamage by then was too extensive.

Would an echocardiogram have likely detected what soon became “a dissection of the aorta”?

What exactly is dissection of the aorta? Likely warning signs?

2

Source: http://www.cnn.com/2003/HEALTH/conditions/09/12/aortic.aneurysm.ap/index.html

While the rest of the article really doesn’t answer your question, it appears that the condition is effectively a crap shoot. It’s an unknown condition, and when it strikes, the odds are stacked against you that you will survive.

3

An ultrasound or ct done a month ago probably would have shown an aneurism, and surgery could have saved his life.

4

Not necessarily. The flaw in the aortic wall could be microscopic up until the stresses are just right to make it dissect suddenly.

QtM, MD

5

That’s why I wrote probably, since it is usually the case.

6

And of course, there would have had to have been some reason to perform an echocardiogram as well. So unless he had some other cardiac complaint considered serious enough to order one for, it’s not likely at all that this would have been diagnosed.

7

Hmmm. You’d think that given John Ritter earned Big Money, no doubt had world-class health coverage, and also was an 800-lb. gorilla for a major network, you’d think the studios would insist a man in his mid-50 have a thorough medical workup.

Qadgop, what’s the down side of giving a rich guy an echocardiogram? Is that even the right test?

Are you saying that he had the equivalent of a cardiac blow-out, much like when a car’s tire suddenly blows out? Asymptomatic?

8

My Uncle had a congenital heart defect that appears to be similar to (or exactly the same as) this, and he knew he had it because all his brothers and sisters have it too, discovered when a couple of them died instantly (and I mean instantly) for no outside reason. Basically, I ain’t no expert, but it seems to be untreatable, happen without provocation, and be pretty much inevitable.

But no pain seems to be involved, and death is instant.

9

Ah, well, our hospital is apparently very good at these arterial dissections; so there’s been some local coverage of what this was. Of course, listening to it, I became convinced that I had the same flaw lurking in my body.

They don’t know how common this is, but they estimate maybe 5,000 people a year. Someone presenting with chest pain (which is the only sign that would tip anyone off) is many many times more likely to be having a heart attack. You have to rule out a heart attack before you’d even begin to guess it might be aortic dissection.

The guy they were talking to here said that once this gets serious, mortality riases about 1% per hour. Emergency surgery is needed. If the aorta blows, forget it, though–you’re going to bleed to death internally, and damned fast.

Some cardiologists up here have been hosting seminars for ER docs to help them know more about it, and apparently (coincidentally) two papers on this subject were published this week in medical journals.

It wasn’t clear to me how it might be found before the serious stage. However, they said when they are detected early and are occuring in the downward-running part of the aorta, they can treat it with medication. Otherwise, surgery.

10

Not meaning to hijack, but this reminds me of some trivia about one of my favorite diseases in medical school: Kawasaki Disease or Syndrome. The following ain’t medical advice no-how. I’m just sharing the kind of tidbit that I imagine the hardcore SDMB’er might find interesting.

Now, it’s a tragic condition, make no mistake, but it’s chock full of quirks that endeared it to me. Woe betide the student who failed to check a toddler rash or or fever for the classic ‘strawberry tongue’! In some cases it can evolve to a sudden dissecting aneurysm, and it’s one of those rare conditions where the old vaudeville joke “Take two aspirin and call me in the morning” could save a life - because ordinary-dose aspirin is actually a primary treatment to prevent the aorta from dissecting

It also happens to support a view I’ve had since they took children’s aspirin off the market. Remember those apricot colored, orange flavored St. Joseph’s Baby aspirins that once had a place in every family medicine cabinet? It was among the safest and most trusted medications for 100 years until an outbreak of Guillain Barre’ syndrome in the late 70’s. Guillain-Barre can present as something as mild as peripheral tingling, but the thing that scared the medical establishment was the possible progression to total paralysis, or even a collapse inheart rate and blood pressure. G-B strikes both sexes and all ages, and is pretty darn rare (1 in 100,000). It usually occurs after a respiratory or gastrointestinal virus, and during the late 70s outbreak, a study showed a link to the use of aspirin during certain viral infections.

Overnight, we all became terrified of giving our children St. Joseph’s. Tylenol (which is also pretty safe, but wasn’t usually given to children over 18 mos back then) took over in pediatric applications. The funny thing is that other countries continued to use baby aspirin with no dire effects, and St. Joseph’s Baby aspirin is now sold over the counter in the US as “coronary strength” aspirin (1/4th the aspirin at 4-10x the price or more) to decrease the risk or damage of heart attacks [even though Guillain Barre strikes all ages fairly equally]

My general impression of the literature from 1978-1992 (the last time I seriously checked) was that the switch from children’s aspirin to children’s acetominophen slightly increased the overall health risk to children. I can’t be absolutely certain because the net risks we’re discussing are in the parts-per-million range, and no one had done -much less repeated- a powerful enough study with millions of child subjects, but recall that the Guillain-Barre Syndrome that so scared us only occurs in 10 cases per million, and wasn’t noticed until aspirin, the most studied drug of all time, had been sold ver the counter for 100 years. The acetominophen which replaced it is known to be more toxic, causes more ‘accidental ingestion’ fatalities in children than aspirin did, and doesn’t help diseases like Kawasaki’s – but only a huge rigorous study could assess all the risks and benefits, and the difference is almost certainly tiny.

There’s no way I’d give kids aspirin for ordinary fevers. The legal standard is ‘prevailing local practice’ and since no other docs do it, I’d be sued out of my skivvies if anything (even an Easter Bunny mauling) happened to the kid afterward. I don’t lose sleep over it, since the risks are small, either way.

But I don’t put on blinders either. As far as aI can tell (and I’d welcome a journal cite of a suitably statistically powerful study from any of the other docs or medical types here), we panicked in response to a rather small risk, and ended up increasing the net risk slightly. Ironic, eh? And you can bet no one’s going to fund the giant study needed to confirm or disprove it (nor should they: the potential improvement would be tiny, and the money for such a large study would be better spent on other conditions/treatments)

11

To address this one better, one would have to know where the aorta dissected. Anybody hear? Ascending aorta? Descending thoracic or abdominal aorta?

The trouble with screening asymptomatic people with echocardiograms (besides the expense and tying up all the technicians and machines) is that there will be a significant number of false positive tests: Tests that show something that looks abnormal when it’s really not. To see if it’s really abnormal then you’ll need a cardiac catheterization. To pick up every early aortic aneurism by echo, you will probably pick up at least 100 normal people, subject them to cardiac cath, and have them go thru the risks of that test: Stroke, heart attack, bleeding, infection, death. Probably do more damage by screening for the uncommon disease of aortic dissection than not.

12

Last question, doc. Let’s look at the example provided by GuanaLad. In the case of serious family history–where uncles/aunts etc die prematurely from arterial dissection, what would your advice be for family members in their 20s and 30s?

No idea yet on location of dissection. Isn’t dissection medicaleze for a tear in the heart muscle???

13

With a strong family history of aortic dissection, I’d want to know why they had them (connective tissue disease, etc) and then decide how to do surveillance on the patient. This might well include echocardiograms.

Dissection means division or separation parts. Any parts. And the aorta runs from the heart to the pelvis. So an aortic dissection may not involve the heart at all.

14

Jonathan Larson, the creator of the musical RENT, was having horrible stomach pains and went to two NYC hospitals. The first one diagnosed food poisoning and made him vomit. The second hospital took an X-ray that they said showed “nothing” and told him he had a major case of the flu.

He died two days later of an aortic aneurism that ripped a 12 inch tear in his aorta. This was when RENT was in dress rehersals for Broadway.

The X-ray clearly showed a bulge in the aorta, and the hospital is being sued by Larson’s estate. If they take into account loss of his potential future income and win, the hospital is busted.

15

More about dissection (to supplement Duckster’s link) from a layman who was fascinated by the local media coverage: the aorta’s three layers are basically a microscopically thin layer on the inside, a sticky layer in the middle (which basically holds the thin layer to the outside) and a thicker outer layer. When there is a tear in the thin inner layer, the flow of blood can start shearing it off, increasing the tear, forcing blood between the layers, and eventually causing an aneurism.

And here’s more U-M info about it: http://www.med.umich.edu/1libr/aha/aha_aortdiss_car.htm
http://www.umich.edu/~urecord/0001/Mar19_01/12.htm

This is such a lovely town to get deathly ill in. Really.

I think the key thing is that such things are damned hard to diagnose, and even when diagnosed people can die. A lot of 'em do.

16

This sounds like what killed a family friend about 10 years ago. He was 34, IIRC. He basically woke up in a jerk, waking up his wife, and she had barely enough time to look at him before he collapsed, already dead. They had a 3-4 year old child, too. Very sad for everyone, as he was a very friendly and well-loved man. Ritter’s death made me think of Daniel immediately. :frowning:

17

My hubby has Marfan’s Syndrome, a genetic connective tissue disorder that is earmarked by just such aortic dissections. In fact, aortic aneurisms and dislocating eye lenses are the only two truly diagnosing symptoms; the rest is observation and guesswork. (As my hubby has neither characteristic, but practically all of the other physical features, he is diagnosed, technically, with “probable” Marfans…but is treated the same as any other officially diagnosed patient, as his heart docs all agree that he almost certainly has it.)

I’ve wondered if Ritter was by chance an undiagnosed Marfans patient. Although the long and lean appearance is what most people think of when they hear the term (if they’re familiar with it at all), it’s actually only one form of a myriad of possible mutations. Some, like my hubby, are a practical physical archetype–but their aorta is fine. Others, sadly, have no outward characteristics–but their aorta is slowly swelling before taking their life prematurely.

To answer the OP, at least what is done with Marfan’s patients is a yearly (or so) echocardiogram. (Hubby’s is actually Tuesday.) They measure the size of the aorta, and prescribe medication when and if needed to keep both blood pressure down and the aneurism from growing. Eventually, surgical repair is needed. But as previously mentioned in the thread–a doc would need a reason to perform the echo in the first place. In Ritter’s case, there didn’t appear to be a need.

BTW, in the case of the 1984 Olympic volleyball player Flo, who dropped dead from an aortic dissection from undiagnosed and untreated Marfans, an autopsy revealed she’d actually had a smaller dissection in recent history that had healed, partially, before the one that took her life. I didn’t know it was possible for one to survive this (“minor aortic dissection” seems like an oxymoron)…anyone have details on how that could be? Would it have to be a really, really tiny tear?

18

Aspirin use has no relation to Guillain-Barré syndrome. Aspirin is associated with Reye’s Syndrome, a condition known to affect only those under 20 years of age, most often developing 3-7 days after onset of influenza or chickenpox infection with concomitant use of aspirin. Reye’s syndrome causes swelling in the brain and affects the liver. It most commonly affects children between 6-12 years old, and may result in permanent brain damage or death.

Guillain-Barré syndrome is an autoimmune disease that usually occurs after respiratory or intestinal viral or bacterial infections, and was associated with a flu vaccine used in 1977. It causes the body to attack its own nerves, and can cause weakness and paralysis. Fortunately, almost everyone recovers fully, although it may take up to one year. It does affect all ages equally, as you said.