EN
Sudden cardiac arrest frightens people precisely by its suddenness: the person looked healthy, complained of nothing — and then it was over. Hence the particular sensitivity to any headline on the subject. One such headline went round the whole press a few years ago: ordinary painkillers supposedly raise the risk of cardiac arrest. The story is instructive — and a good occasion to work out who is actually at risk and what is done about it.
The story about the painkillers
In 2017 Danish researchers published a study in which they matched ten years of data from the national registry of out-of-hospital cardiac arrests against data from the registry of dispensed prescriptions. It emerged that in people who in the preceding month had received non-steroidal anti-inflammatory drugs — diclofenac and ibuprofen above all — the probability of such an event was higher. The press carried the figures round the world instantly.
The German pharmacologist Professor Kay Brune published a detailed criticism at the time. The substance of the objections is simple. The data showed that a prescription had been filled, but not why the drug had been prescribed, at what dose, or for how long it had been taken. And the difference between a single tablet after a sprain and a high daily dose in a rheumatic disease is fundamental. Besides, the very fact that a painkiller was prescribed often means that the person was unwell at that moment — which is a different story again. It is also telling that the drugs for which cardiovascular risks are in fact known came out of that same study free of suspicion — something the authors were unable to explain.
What is known about these drugs now
That publication did not change practice, and this is an important detail: the regulators considered it together with other studies and concluded that the available data do not allow non-steroidal anti-inflammatory drugs to be ranked by individual cardiovascular risk.
At the same time the restrictions introduced by the European regulator earlier, and in force to this day, have not gone anywhere. For systemic diclofenac the same precautions have applied since 2013 as for the selective drugs of this group: it is not used in people with established coronary heart disease, a previous stroke, peripheral arterial disease or marked heart failure. For ibuprofen it was clarified in 2015 that the increase in cardiovascular risk is associated with high daily doses, whereas no such increase has been shown for over-the-counter doses.
The practical conclusion has remained the same and is rather dull: the lowest effective dose, for the shortest necessary time, and a separate conversation with the doctor if you already have a disease of the heart or the vessels.
Who really is at risk
The overwhelming majority of cases of sudden cardiac arrest in adults are connected not with medicines but with disease of the heart itself — most often with coronary disease and its consequences. The key factor here is a previous heart attack and reduced pumping function of the left ventricle. That is precisely why after a heart attack it matters so much to measure this function and to follow it over time.
The second group is disease of the heart muscle (the cardiomyopathies), including the inherited forms. The third is congenital disorders of the heart’s electrical system, in which the heart is structurally normal: long QT syndrome, Brugada syndrome and related conditions. These appear more often at a young age, and it is they that lie behind most cases in which an adolescent or an athlete dies suddenly.
There are several signs worth taking seriously rather than putting down to tiredness: a faint during physical exertion or in the course of a strong emotion; attacks of a very fast heartbeat with the vision darkening; and a case of sudden death in a close relative at a young age, particularly an unexplained one or one occurring in a drowning or a road accident without an evident cause.
How this is checked
The assessment starts with the simple things: a detailed conversation about the symptoms and the family history, an ECG, an ultrasound of the heart, 24-hour monitoring. After that it depends on the situation: an exercise test, cardiac MRI where changes in the heart muscle are suspected, genetic testing with a geneticist’s consultation if the picture points to an inherited syndrome. Relatives are then examined too: a diagnosis here concerns not one person but a family. On the basis of the results it is discussed whether medicines, a limit on exertion or an implantable defibrillator are needed.
What this does not yet mean
Having a risk factor does not mean that the event will happen — what is at issue is a probability within a group, not a prediction for an individual. A normal ECG does not exclude all the conditions listed, so where the symptoms are worrying the assessment does not stop at a single tracing. And the other way round: palpitations, the feeling of the heart “missing” and occasional extra beats occur in healthy people and in most cases mean nothing. It is worth going into all this calmly and in order, rather than by the headlines in the news.
This material is for information only and does not replace a consultation with a doctor. No medicine should be started or stopped on the basis of this text. Which examinations are needed can be determined only after an examination in person.