Nurture heart disease—stop cancer
BMJ 2001;322:1003 ( 21 April )
Can I choose the cause of my death? Death is an ultimate truth. It can only be postponed, not denied. Since the sum total of the probabilities of death by variouscauses is one, they end up competing with one another. If I donot die from tuberculosis I may die from cancer. This raises thequestion of whether medical science should focus on some specificcauses of death at the expense of the others.
Heart failure in old age need not be prevented but possibly promoted
If deaths cannot be prevented altogether are there any causes more desirable than others? In a survey in Japan old peopleexpressed a preference for heart disease as the cause of deathrather than dementia, cancer, or stroke. Most would agree thatsudden death is far more welcome than a slow, incapacitating,and painful death. It would be nice to see a day when everybodywould die suddenly in old age without suffering from infirmityor distress. Clearly, there is a case for identifying risk factorsof sudden death in old age, and to nurture them instead of controllingthem. Medical science seems not to have deliberated sufficientlywell on narrowing the spectrum of causes to a few desirable ones.
"Behold the signal of Od Time": scene from The English Dance of Death by William Combe, c1815
See the figure above
There is substantial evidence that acute myocardial infarction is the predominant cause of sudden death in old age, particularlywhen unnatural causes such as accidents are excluded. Consideringthat there is no escape from death, that sudden death is moredesirable in old age, and that acute myocardial infarction isthe predominant cause of sudden deaths in this age, the wholespectrum of research on risk factors for acute myocardial infarctionneeds a fresh look. The disease is increasingly affecting youngerpeoplethat certainly deserves full attention. Risk factors ofmyocardial infarction in young people should be delineated withfar more precision than is done so far, and everything possibleshould be done to controlthem.
But the point of my argument is just the reverse for factors of acute myocardial infarction in old age, especially when itcauses sudden death. The risk factors for these deaths also needto be delineated with the same degree of earnestness, not forthe purpose of their control but to cultivate them. Heart failurein old age need not be prevented but possibly promoted, lest increasinginfirmity takes its toll. Many physicians around the world mayabhor this idea but I am convinced. Mega-projects, such as Inter-heartstudy (www.ccc.mcmaster.ca/projects/interheart), need to focusnot just on finding treatment strategies but also on locatingmore cases of sudden death in old age that might be getting excluded,so that the factors leading to such deaths can be identified withgreater precision and granted respect in life. Treatment strategiesshould be focused on the youngerpatients.
What age is old enough to be considered old? Evidence suggests that the maximum attainable life expectancy is 85 years. Manypeople, however, spend a substantial part of old age in a debilitatingcondition. According to a recent calculation, the percentage ofremaining life at age 60 years lived with severity adjusted disabilityranges from 22 to 53 in different regions of the world. Untilsuch time as further success is achieved in adding life to thegain in years, the age of 80 and above can be arbitrarily consideredold enough for the purpose of identifying factors contributingto sudden death. Thus, in the case of acute myocardial infarction,risk factors for sudden death beyond 80 years of age can be consideredgood fornurturing.
As a corollary, this also underscores the need to increasingly target those ailments that cause long term and severe disabilitycompared with those that cause death in old age. Thus, there shouldbe an increasing focus on diseases such as cancer and AIDS ratherthan acute myocardial infarction. Deterioration in quality oflife after acute myocardial infarction is rarely as much as inadvanced stages of cancer orAIDS.
A Indrayan, professor, division of biostatistics and medical informatics.
© BMJ 2001