The death of Broward Health's president and CEO less than two weeks after undergoing triple bypass surgery may draw attention to a complication related to heart procedures, and the need for cardiologists to treat the mind along with the heart.
Dr. Nabil El Sanadi, 60, was found dead Saturday of a self-inflicted gunshot wound, according to the Broward County Medical Examiner's Office. Since then, friends and colleagues have recalled El Sanadi as having “an infectious laugh” and a true passion for his work.
And while there are no signs that his surgery played a role in El Sanadi's suicide, the fact that those close to him are in utter disbelief over his death raises questions as to whether he might have suffered from cognitive impairment known to occur after heart surgery. The procedure has been associated with sudden changes in personality and mood and in some cases depression.
“We do see depression as a big part of increasing the mortality in these patients, but it's not usually so overt that it (causes) suicide,” said Dr. Annabelle Volgman, a cardiologist at Rush University Medical Center in Chicago.
A more common postoperative condition known colloquially as “pump head,” causes short attention span, difficulties concentrating, short-term memory loss and slowed response. The condition was famously credited with President Bill Clinton's uncharacteristic remarks after his 2004 quadruple bypass surgery.
A 2001 New England Journal of Medicine study first brought to light this kind of cognitive impairment. Researchers then found that 53% of 261 patients tested had at least a 20% decline in cognitive test scores after undergoing coronary artery bypass surgery, with 42% still experiencing cognitive decline after five years.
The findings did not show causation.
But air bubbles or impurities could enter the blood as it's traveling through a cardiopulmonary pump during coronary artery bypass grafting procedures. That debris could float to the brain and cause small strokes. Concern over that complication has led to the development of other techniques that allow surgeons to operate while the heart is still beating. It also has driven some patients to opt for stents or medications.
And in 2009, researchers from Johns Hopkins Medicine found that cognitive impairment over a six-year period was no different among patients who had bypass surgery with a heart-lung pump compared with those who had the same procedure without the device, or even those who opted out of surgery in favor of arterial stents.
Volgman said cardiac surgery can at times exacerbate depression in a patient who already had underlying issues. Some patients say facing mortality has made them slip into depression.
She added that depressed patients usually stop taking medications after surgery or fail to participate in cardiac rehabilitation.
Volgman acknowledges cardiologists are not trained to measure cognition. There's been a push for cardiologists to consider cognitive impairment as affecting cardiac patients' health outcomes. And in 2008, the American Heart Association recommended that cardiologists screen patients for depression, believing the two were comorbid.
When seeing patients who complain about cognitive decline, Volgman partners with a neurologist and they communicate on their separate treatments to make sure they align.
“It is something that we (cardiologists) should know and so the more people we educate about it the better,” Volgman said. “Doctors should be receptive to complaints from patients about feeling fuzzy and do something about it instead of ignoring it.”