The following as an Appeal from Physicians who are Deputies of the Federal and Republican Parliaments, to the authorities of the Republic of Serbia and the Federal Republic of Yugoslavia, and to the medical and general public, urging adequate therapy for treating Slobodan Miloševic and the provision of proper conditions in which treatment can take place.
PREVENT THE FATAL OUTCOME OF MILOSEVIC`S HEART DISEASE
DO NOT PARTICIPATE IN HIS TACIT MURDER
The severely ill Slobodan Miloševic can be effectively treated only by highly competent, highly specialized staff in conditions in which exacerbation such as sudden cardiac death, stroke or other complications, unavoidable in current conditions, can be avoided.
We, medical doctors, members of the National Assembly of the Republic of Serbia and the Parliament of the Federal Republic of Yugoslavia, had access to the medical records of Slobodan Miloševic and having obtained the opinion of a competent team of experts, herein address the medical and general public by this appeal devoid of political bias, based exclusively on the principles of the medical profession and of science.
We describe his health conditions as follows:
1. Psychological aspects of heart disease
2. Symmetrical hypertrophic cardiomyopathy
3. Hypertensive crisis (malignant hypertension)
4. Conclusion
1. Psychological aspects of heart disease:
Stress is defined as an experience in which the circumstances exceed the capacity of the person to cope, resulting in excessive excitement of the person.
For more than fifty years now it has been widely known that conditions such as hypertension and asthma may reflect unconscious conflicts manifested in somatic symptoms.
Emotions are experienced both psychologically and physiologically. Although the forms of these cognitive manifestations of emotions may vary a great deal (anger, fear, anxiety, joy), the somatic repertoire of autonomous responses is limited. Emotional excitement, via the centrally induced sympathetic discharge, is manifested in the cerebrovascular system similarly to physical stress or strain: by tachycardia, elevated blood pressure, increased oxygen consumption, accelerated muscular flow and fall of splenic and renal flows. Cardiovascular consequences of emotion, as opposed to physical strain, may be more harmful because of absence of accompanying muscular activity and metabolic vasodilatation. Thus, the emotional stress accelerates the heart rate increasing the heart load. Accumulation of small stresses resulting from long-term conflicts promotes development of essential hypertension and coronary atherosclerosis.
Increased neurohumoral activity (adrenocortical, sympathetic, rennin-angiotensin) resulting from stress contributes to dysfunction of endothelial cells. Increased activity of the sympathic system influences the lipid metabolism, as well. The cholesterol level correlates with depression and emotional instability in a positive manner, while it is negatively correlated with motivation and joy. Therefore, both atherosclerotic plaques and clots and vasospasm are related to stress reaction.
Stress may result in elevated blood pressure, but there is no evidence that it may maintain hypertension. In absence of other promoters, stress may act as a trigger. It is frequently accompanied with numerous arrhythmias that may result in sudden cardiac death. Norepinephrine and isoproterenol (endogenous catecholamines) may lead to development of “contraction bands”, myocardial lesions similar to skeletal lesions that burst upon excessive contraction. Such lesions are associated with 80% victims of sudden death, including those in whom atherosclerosis has not been previously diagnosed. These changes were recorded in pilots who lost control over their planes, patients with pheochromocytoma, cocaine-induced death. The changes in the cell wall permeability permitting excessive Ca2+ influx may be the underlying mechanism of this phenomenon.
[back to top]
2. Symmetrical hypertrophic cardiomyopathy
From the hemodynamic point of view, these patients have hyperdynamic systolic function with high ejection fraction (estimated at 70% on coronarography and shown in the form of a banana-shaped cavity in the systole). This “supernormal” systolic function leads to increased O2 consumption that, together with abnormal blood flow through the myocardium may result in symptoms of ischemia. The basic difference between this and hypertensive heart disease is absence of history of hypertension in the former.
[back to top]
3. Hypertensive crisis (malignant hypertension)
This is an emergency conditions necessitating prompt therapy. It is characterized with one or more of the following signs:
· Acute or prolonged elevation of diastolic blood pressure to >120 mm Hg.
· Papillary edema (not necessarily),
· Signs of progressive renal failure,
· Signs of CNS dysfunction,
· (two of these signs are required to establish the diagnosis).
The absolute level of blood pressure is of lesser importance than the rate of elevation and absolute difference between the usual values and those measured in crisis.
Emergency therapy is necessitated since hypertensive encephalopathy, acute dissection of aorta, pulmonary edema, pheochromocytoma-related crisis, intracranial hemorrhage may develop.
Therapy: In the acute phases the patient should be strictly immobilized with headrest at 30o. These are acutely ill people, usually extremely anxious. It is of utmost importance to provide peaceful, supportive environment. Admission to intensive care unit is crucial, 12-lead EEG, intravenous therapy (with measurements of central venous pressure, if possible), arterial line of nitropruside is administered, all laboratory analysis, (accompanied with fundus oculi examination as well as neurological and nephrological consultation) are required.
Interestingly:
· The first echoardiographic examination was made on the day of admission to the coronary unit when the patient manifested ischemia of the apico-lateral part of the heart accompanied with ECG changes. Thus, the patients had objective confirmation of his condition during the reported pain. Since coronarography findings were normal, the pressure of the muscular bridge on the anterior descending coronary artery (more so because it was seen before the actual branching) or microvascular angina (small vessels were diagnosed as very poor) were suspected. This means that the patient should be treated as a cardiac patient in spite of the fact that his major vessels are patent.
· Since ventriculography shows marked wall hypertrophy (echography contradicts these findings, since echo images showed only mild hypertrophy) with typical banana-like image in the systole, he probably has a history of HCM, particularly in the light of the fact that his blood pressure used to be controlled well. Therefore, one cannot draw a conclusion that he has had history of severe hypertension for 20 years resulting in the ventricular thickness. In order to rule out this condition, heart biopsy should be performed.
STRESS – risk for sudden heart death.
[back to top]
4. Conclusion
On April 11th, at the initial examination, the prison physicians suspected the development of acute coronary syndrome and asked for cardiological consultation.
A multidisciplinary team (headed by Dr. Neškovic) suspected acute cardiac ischemia because of typical echographic findings (akinesia, i.e. completely static cardiac apex, together with apical part of the anterior, lateral wall and the septum) and ECG findings (2 mm ST segment depression, negative T waves) and asked for emergency coronarography!
If any other patient had had such findings and if the multidisciplinary team had met in Bujanovac where no conditions for invasive diagnostic procedures were available, the patient would have been placed in a coronary unit, where strict rest would have been prescribed with nitroglycerin and heparin infusion, as in the case of Miloševic!
His family would have been advised that he had had an infarct and all protective measures would have been introduced. Even if no typical ECG evolution of acute infarction (Q tooth formation) developed, it would have been defined as a case of non-Q infarction (subendocardial) where reperfusion of the surrounding tissues ensued.
Had this happened to Miloševic in Niš or any other major town, he would have received streptokinase in the first six hours after the occurrence of pain (because of the accompanying echographic and ECG findings)!
Dr. Neškovic and late Dr. Popovic wrote to Miloševic, while he was in office, describing him the nature of coronary disease, elevated blood pressure … substantiating longer history of these symptoms.
After coronarography, the patient has recovered, although his discharge summary says that 24 after the procedure no ECG or echographic abnormalities are present (the same as on admission). They even contemplated discharging him a few hours after coronarography.
He will be the first patient cured by this procedure!
Incompatibility of his echographic findings and ventriculography is another problem. Ventriculography shows typical image of HMC, while the echography is suggestive of simple hypertensive hypertrophy.
Also, the presence of the muscular bridge before the branching of the anterior descending artery and denuded microcirculation provide the basis for the diagnosis of microvascular angina.
The blood pressure variations occurring abruptly and acutely, substantially aberrant from the normally recorded ones, make us ask: Is there any other place in the world where hypertensive crisis is managed with a tablet of presolol and prilazide?
Complete investigation was ordered as early as April 23rd, but what has been done so far?
How can such a serious condition be diagnosed in prison conditions that require a multidisciplinary approach?
The warning and our appeal suggest the only possible conclusion: the severely ill Slobodan Miloševic can be effectively treated only by highly competent, highly specialized staff in conditions in which exacerbation such as sudden cardiac death, stroke or other complications unavoidable in current conditions can be avoided.
We also warn the public that even well regulated blood pressure, according to the referential data, may cause stroke in 38% of cases so that in this particular case we wonder what one can expect knowing the conditions in which Miloševic is treated.
In Belgrade, May 9th 2001.
