Monday, April 25, 2016

Uncertain Health in an Insecure World – 82

“Dearly Beloved”

"We are gathered here today
To get through this thing called life"

When a mourning dove dutifully cares for its mate's lifeless body, it cries out in loneliness.

 Knowing the cause of a single death is less important than what our reactions say about the meaning of that life.

Today, there's no mysterious missing airplane, no sub-equatorial viral threat, and no refugees fleeing from the sound of gunfire. There is just a 57 year-old previously healthy Black male who died suddenly at home in an elevator.

Dumbstruck fans and the 24/7 global media demand to know, “Why? Under these unique conditions, a full autopsy and toxicology are undertaken to answer the world’s question. Eventually, medical investigators deliver an answer, but this does nothing to resolve the finality of such a loss for friends and family.

We are a curious tribe, with limited tolerance for ambiguity. It makes us go crazy...

But pending the outcome of the definitive studies into Prince Rogers Nelson’s death, we can develop a differential diagnosis that applies to 99% of his health risk profile. This probability analysis can be fit to the likeliest causes of sudden death in his cohort.

There’s an old saw among doctors and pathologists that “common things are common.” The most common cause of sudden death in previously healthy middle-aged men is coronary heart disease. A clot unexpectedly forms in a major coronary artery (above), without any previously known plaque blocking the vessel. This acutely reduces the downstream blood flow to heart muscle, creating an electrical instability in the heart rhythm. The heart muscle chokes, begins to die, and develops “bag of worms” dysrhythmia called ventricular fibrillation (above). Cardiac arrest is often followed by a full cardiac standstill (i.e., asystole).

If the above events are “witnessed”, a potentially lethal catastrophe can be salvaged in the field by effective CPR (above), and in medical facilities by clot-busting lytic drugs. If these are unavailable, the outcome is almost universally fatal (below) – yet another sudden cardiac death. For this reason, Prince’s post-mortem will include a careful examination of the heart for coronary artery blockages, blood clots and heart muscle damage (i.e., myocardial necrosis).

A person who dies suddenly is not available for doctors to obtain a medical history. Just as the police were called into Paisley Park rule out trauma and foul play (apparently, not the case with Prince), forensic investigations of previous life circumstances and habits, including recent medical conditions or related health events, can be highly revealing for contributing factors.

In Prince’s case, the press has revealed the following clues. First, he had been suffering from “flu-like” symptoms for several weeks, forcing him to cancel some appearances. Certain non-flu viruses (i.e., Coxsackie) can spread to infect the heart muscle, producing lethal viral cardiomyopathy, predisposing to a sudden cardiac death. Second, it is reported that Prince received naloxone (Narcan™) to reverse the effects of a narcotic (oxycodone?) when his airplane emergency landed in Moline Illinois. While he was not known to being suffering from drug addiction, a narcotic overdose could cause an acute respiratory collapse. However, stimulant drugs like cocaine are more likely to produce a lethal heart rhythm disturbance and/or coronary artery spasm. Third, if Prince had been physically inactive from long airplane flights or suffering from undiagnosed cancer, this might have caused a deep vein thrombus (DVT) in the legs or pelvis that could throw off a blood clot to the lungs. A resulting pulmonary embolism (PE), if massive, could have caused sudden death; the full autopsy included a careful look at the lungs.

Although Prince had access to the best medical care during his life, it is conceivable that he had an unknown medical illness. He could have been born with a congenital coronary blood vessel abnormality, or a genetic heart muscle condition called hypertrophic obstructive cardiomyopathy (HOCM) that is more common in Black males. But these conditions usually restrict physical activity early in life, causing warning symptoms like chest pain, shortness of breath, dizziness and/or fainting.

Prince had not recently traveled abroad (other than to Canada in March), so it’s unlikely that his sudden death was from a common South American heart muscle inflammation caused by T. Cruzi infection, called Chaga’s Disease. Another immune-mediated heart muscle inflammation (sarcoidosis) that is more common among Blacks could have created the flu-like symptoms and weight loss that some had observed in Prince.
The causal list is long… the possibilities are almost endless.

But “common things are common”, even among uncommonly talented people.

In the end, understanding things after death (i.e., through post-mortem examination) does not assure that death could have been prevented. A 2003 British Heart Foundation study showed that among 3,500 apparently healthy U.K. adults who die suddenly each year, in 4% no cause for death can be found despite a full autopsy. Like Sudden Infant Death Syndrome (SIDS), British experts coined the term “Sudden Adult Death Syndrome” (SADS) to characterize these mysterious, presumably electrical heart rhythm sudden deaths. Like SIDS parents, surviving SADS family members crave answers and deserve explanations.

Unfortunately, medical science is imperfect, without answers for every life & death circumstance. 


Prince was an exceptional artist, and an imperfect human organism.

Regardless of his musical greatness and personal legacy, he was just a man, and subject to the physical frailties of all middle-aged men.

We all rail against the unruly suddenness of The Artist’s unexpected passing.

And while his fans cry, they will eventually get past this natural death, whatever the cause. 

We in the Square do not have a favorite Prince song; his was a body of work from a soul that lives on.

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