[tomhoward]

It's a great post, but to me there's another message that Dustin - understandably - hasn't focused on: "perfect health" is often (usually?) an illusion.

Given what I've learned about health in recent years, I can't accept that this guy really was in perfect health; if he was, he wouldn't have suffered a major cardiac arrest while simply jogging on a treadmill.

I think it's mostly a failure of modern medicine and modern attitudes towards health that most of us walk around feeling and looking like we're in "perfect" health, only to find all too late that a severe condition was lurking undetected.

The answers may lie in fields like Quantified Self [1], or PG's suggestion of Ongoing diagnosis [2].

But whatever the case, we're only just starting to scratch the surface of an area that I think this post demonstrates is hugely important.

[1] http://quantifiedself.com/

[2] http://paulgraham.com/ambitious.html

[JshWright]

> I can't accept that this guy really was in perfect health;

I guess that depends on why you mean by 'perfect health.' He may very well have been in perfect health by every outward appearance. There are a large number of surprisingly minor things that can make you dead in an instant.

A brief primer on electrocardiology... Each heart beat is divided into several phases. An electrical impulse in generated in the two small chambers at the top of the heart (the atria), causing them to contract. This is the first small bump in an EKG, and is called the 'P' wave. After a brief pause, the impulse is conducted to the big chambers at the bottom of heart (the ventricles), causing them to contract. This is the big wave on an EKG, called the 'QRS complex.' After that, there's a period of time where the cells in the ventricles are recharging. This is the final bump in the EKG, called the T wave.

The Wikipedia article on this topic is very good. http://en.wikipedia.org/wiki/Electrocardiography#Waves_and_i...

If the heart is shocked (physically or electrically) during that recovery period, it can throw the heart into a fatal dysrhythmia where all the muscle cells in the heart are contracting chaotically. This is what happens when a baseball, lacrosse, or hockey player takes a blow to the chest and goes into sudden cardiac arrest... The blow happened during that very narrow window or time.

It's possible for your own heart to do that to itself though... It's very common for healthy people to have occasional 'premature ventricular contractions' where some random cell in the heart decides it's pissed off and wants to contract early. These are generally harmless, and happen all the time without anyone noticing. Every once in a while though, one of those PVCs occurs during that recharging phase, which can be very bad... So, a 'perfectly' healthy person _can_ throw a PVC, end up with an R-on-T contraction, and whamo... they're dead. Is it common? No, it's extremely rare. Does it happen? Sure does...

[tomhoward]

I guess that depends on why you mean by 'perfect health.'

I know :)

He may very well have been in perfect health by every outward appearance.

Exactly what I'm saying.

There are a large number of surprisingly minor things that can make you dead in an instant.

Yes, but my contention is that the likelihood of these things happening is influenced by the degree to which your health is "perfect".

some random cell in the heart decides it's pissed off and wants to contract early

Again, from my point of view, the likelihood of this happening, or the potential harm that can come of it, is influenced by the level of perfection in one's health.

Your comment is very informative btw, so thank you.

I know we're talking about areas of health that are not yet very well understood, which is why there is scope for discussion, and why there are no irrefutable facts that can close the debate.

But this is exactly what I'm taling about; I'm hoping for a time when medical science has progressed to a point where these issues are very well understood, and seemingly random cardiac arrests like this can be preempted and prevented. I believe it's possible.

[JshWright]

>But this is exactly what I'm taling about; I'm hoping for a time when medical science has progressed to a point where these issues are very well understood, and seemingly random cardiac arrests like this can be preempted and prevented. I believe it's possible.

This is simply a discussion of semantics, and I feel kind of silly for arguing it in the first place. You're absolutely correct that most of the 'random' sudden cardiac deaths that occur are in fact related to a previously unknown preexisting condition. Wolff-Parkinson-White, congenital long Q-T, and a variety of cardiomyopathies (most of them congenital as well) can easily predispose someone to dropping dead.

[mikestew]

Wolf-Parkinson's, that's me. I was a highly-trained and mostly-healthy bike racer and would occasionally get a rapid, arythmic heart beat under certain conditions that would last for sometimes hours. Finally went in to get it checked, and when I asked "doesn't that result in sudden death in athletes?" He said if it hadn't killed me by now it probably wasn't going to. One heart ablation and it hasn't bothered me since.

My rambling point is that, yeah, "perfect health" sometimes isn't. And a few pieces of heart tissue that grew just a little differently could have meant I'm not writing this despite being a life long endurance athlete. I can't say it's changed my outlook on life much, though.

[apr]

Did you feel anything during the ablation procedure?

[mikestew]

Sorry for the late reply, I don't have reply notifications set up. During the ablation itself, I felt nothing because I was drugged. However, they have to repro the problem in order to know what to zap. That was an interesting process with all kinds of non-painful (though not entirely pleasant) stuff to feel. The details are still up if you care: http://psychocross.blogspot.com/2007/10/next-in-continuing-s...

[carbocation]

Most commonly, this is going to be attributed to a ventricular arrhythmia, likely due to hypertrophic cardiomyopathy. This has nothing to do with cholesterol, lifestyle, diabetes, etc.

[tomhoward]

I wasn't referring to cholesterol, lifestyle, diabetes, etc - or at least not only those things.

I'm talking about any condition at all that diminishes one's health condition from being "perfect" - regardless of whether the cause is genetic or something else. Some of these can currently be understood and diagnosed (but usually aren't), whilst others may become understood, diagnosable and curable in the future.

To me, hypertrophic cardiomyopathy would disqualify someone from being described as having "perfect health".

BTW, this is interesting: http://med.stanford.edu/ism/2010/june/hypertrophy.html - and it includes a mention of epigenetics, which I think is highly relevant to what we're talking about.

[ryanwaggoner]

I can't accept that this guy really was in perfect health; if he was, he wouldn't have suffered a major cardiac arrest while simply jogging on a treadmill.

That may or may not be the case. I suspect that the vast majority of cases of sudden cardiac arrest are attributable to risk factors, but probably not all. Our bodies are pretty incredible, but not perfect. Sometimes they just malfunction.

[graeme]

Do you have any evidence for that? Cardiac arrest is a pretty major malfunction.

I'll grant that there may be a few cases of spontaneous malfunction among people with systems functioning optimally.

But I'd wager that given the knowledge someone had cardiac arrest, the odds of something being wrong with their system are higher than 99.999%.

Specifically, I'd be interested in cases of spontaneous cardiac arrest among hunter gatherers or other groups that largely avoid the 'diseases of civilization'.

[carbocation]

See my parallel comment. Aside from a possible genetic defect, it's quite possible that this person is healthy by all normally measured features. In the general case, a hunter gatherer lifestyle would likely have triggered this sooner, if anything.

[graeme]

A genetic defect, if not impacted by lifestyle, would do the trick. However, 'normally measured features' may not fully capture cardiac health.

I'd still like to see studies of cardiac arrest among hunter gatherers, or as another poster commented, primates. Lots of genetic problems can be impacted by lifestyle (epigenetics).

I don't know about about the condition you posted to say how lifestyle affects gene expression in that case.

Assuming the disease isn't strongly affected by gene expression, my statistics are likely off then. Wikipedia listed the condition as having a .2-.5% prevalence.

[tomhoward]

Specifically, I'd be interested in cases of spontaneous cardiac arrest among hunter gatherers or other groups that largely avoid the 'diseases of civilization'.

+1

It would also be interesting to know about any similar studies on the most advanced species of non-human primates.

[tomhoward]

I think we largely agree - differing only on the interpretation of the word "perfect".

In my interpretation, perfect health means this type of malfunction doesn't happen. But these days, such perfection is very rare, though it's possible with sufficient knowledge and access to diagnostics.

[skrebbel]

By that definition, perfect health doesn't exist.

[tomhoward]

False; it's just very unusual in modern times.

[davidw]

I had a good friend over for dinner recently, and learned that he had recently suffered a heart attack. Not a really bad one, but there aren't exactly 'good' ones either. Pretty scary, as he's still in his 30ies, like me, in good health, no smoking, not much drinking, some exercise, eats ok, and so on.

[tomhoward]

still in his 30ies, like me, in good health, no smoking, not much drinking, some exercise, eats ok, and so on.

This is the problem. In the absence of proper diagnostics, people look at popularly touted risk factors like age, alcohol/smoking/drugs, exercise, diet, etc. But these are highly generalised factors that don't take into account: genetic/congenital/epigenetic conditions, stress/emotional issues, environmental factors, and other factors that are difficult to understand by themselves, because the human body is so complex.

The only way to truly determine the extent to which someone's health really is perfect is with detailed individual diagnostics.

As I said in the initial comment, we're only just getting started in developing adequate approaches to diagnosis that may become widely accessible, but I think it's the key to preventing unexpected attacks in your friend and Dustin's friend.

[carbocation]

Not to be a downer, but I suspect that we are decades away from meaningful diagnostics that would get you anywhere close to being able to declare someone in "perfect health". In fact, I will say that we are 20 years away, and we always will be.[1] For someone who believes that "perfect health" is of little meaning in an adaptive evolutionary framework, this isn't a big issue, but it could be disquieting to some.

Let's say you sequence everyone's genome and can do it for $0 per person. Even if you could, having a genome sequence gets you only so far. We don't know what many genes do; even less so do we know what changes in their structure or in their regulatory elements may do. We have useful, powerful ideas coming from evolutionary biology, but these won't be enough to let one feel confident about health claims.

And this says nothing about infectious, environmental, and behavioral components to risk.

[1] = I know that the fusion "20 years away and always will be" actually refers to the fact that if insufficiently funded it will always be 20 years away. But most people don't know that part of the reference, so I will ignore it at will.

[tomhoward]

Optimal is perhaps a more useful term.

I'm more optimistic than you about how soon we might see major advances.

The emerging field of epigenetics seems very promising.

[carbocation]

I hope I didn't come off as pessimistic in the general case with regard to medical advances! We see important medical advances every year. I was referring to the notion of being able to verify "perfect health".

[marshallp]

I'll have to disagree with you on that. Genetics is the wrong approach to dealing with all this and was a wild goose chase. Regenerative medicine is the correct approach, the body has all the mechanisms already to regrow itself, after all, it did grow in the first. Regrowing the body and keeping it from being a cancerous growth is the actual challenge. Noninvasive surgery like radiosurgery, focused ultrasound, and photoacoustic surgery is the correct approach along with floating growth factors. This is not really biological engineering but electromechanical engineering and well within grasp. A proper effort would get this done within a year.

[jackylee0424]

We're in a culture of productivity. Here, a person in "good health" is like describing him a proper-functioning working machine.