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The death of Whitney Houston in some ways represents a medical "perfect storm" -- heart disease and a plethora of drugs that can accelerate or aggravate that condition, cardiovascular specialists told MedPage Today.
"A lot of people were surprised that Whitney Houston -- according to the coroner's report -- had cardiovascular disease, but that was not surprising to me, because we knew she had a least one major risk factor for heart disease, cigarette smoking," said John Gordon Harold, MD, the president-elect of the American College of Cardiology.
Harold, clinical professor of medicine at Cedars-Sinai Heart Institute, Los Angeles, and other cardiologists contacted by MedPage Today said there were several scenarios that could explain how Houston drowned in her hotel bathtub February 11.
- The 'hot tub syndrome' -- sedative drugs found in Houston's system might have caused her to fall unconscious and slide under the water. "We see this often in people who have been partying and have sedatives on board," Harold said.
- Cocaine also reported in her body could have caused vasospasm or arrhythmia that caused her to lose consciousness and drown.
- With some coronary arteries substantially blocked, a drug-induced spasm could have closed a diseased artery enough to occlude blood flow, causing a heart attack that caused her to drown.
Whatever the triggering event, the fact that Houston was alone and in a bathtub when she suffered a critical event, prevented timely resuscitation and emergency assistance, and turned the incident into a fatality.
In addition to finding blockages in Houston's coronary arteries, the Los Angeles County coroner said that toxicology tests indicated Houston was a chronic user of cocaine. He also reported that marijuana, the muscle relaxant Flexeril, the allergy medication Benadryl, and the anti-anxiety medication Xanax were found in her system. Fresh water was found in her lungs, indicating that the immediate cause of death was drowning, according to the autopsy report.
Houston's lifestyle also likely impacted development of cardiovascular disease, said several doctors interviewed by MedPage Today. None of those physicians treated the singer and actress who died at age 48.
"I think the take home message for young African American women is that they are not immune to heart disease, and smoking is a major risk factor," said Harold. "What we often see in women like Whitney Houston is unrecognized or undiagnosed high blood pressure and hyperlipidemia -- the same risk factors that we see in men."
"I was one of her fans," admitted Harold, who said that Houston's long-time smoking habit, her use of marijuana and cocaine all would have had increased the risk of cardiovascular disease.
"Smoking was her major risk factor for coronary artery disease," Harold said. "Marijuana smoking is known to increase the risk of heart disease. Acute administration of cocaine causes blood vessel constriction even in people with normal blood vessels. You can have cocaine-induced stroke or myocardial infarction.
"In fact, in young people who present with stroke or a myocardial infarction with no other cause, we almost always order a blood screen for possible illicit drugs, because it is a known risk," he said.
"We understand that with Whitney Houston there was chronic cocaine use," said Joanne Foody, MD, associate professor of medicine at Harvard Medical School and director of the Cardiovascular Wellness Center at Brigham & Women's Hospital, Boston.
"But even single use of cocaine can cause spasm of the arteries, can cause heart attacks, stroke, and sudden cardiac death," she told MedPage Today.
She said it is unclear whether cocaine can accelerate development of cardiovascular disease. "We think that cocaine does cause dysfunction of the arteries such that when an artery should normally relax it instead constricts. Chronic use may cause stressors on the heart such as hypertension, it can cause vasospasm that can cause damage the artery and allows for cholesterol-related atherosclerosis to develop," she said.
"Whitney Houston was relatively young, but people have to realize that coronary disease starts early in life -- even in the first two decades of life," Foody said. "Everyone has to understand the risk factors for heart disease, and particularly women have to recognize symptoms that could be responsible for heart disease."
Donna Arnett, PhD, president-elect of the American Heart Association, and chairman of epidemiology at the University of Alabama at Birmingham, told MedPage Today that numerous studies indicate that cardiovascular disease occurs as early as 8 years of age where fatty streaks -- the first signs of cardiovascular disease have been observed.
"So the finding of 60% blockages in the coronary arteries of a 48-year-old woman -- such as Whitney Houston -- is really not that surprising," she said. "The link between cocaine and atherosclerosis is not well defined, but there certainly is a link between cocaine and myocardial infarction. That has been reported as far back as the mid-1990s. These myocardial infarcts can be caused by arrhythmias, not necessarily by atherosclerosis."
Arnett suggested that if a person with atherosclerosis was using cocaine "it would be a bad combination." If a person has narrowed arteries and takes a drug that causes vasospasm, it would not take a major spasm, to occlude and artery, she suggested.
"Atherosclerotic disease remains the leading killer of men and women," said Gregg Fonarow, MD, director of the Ahmanson-UCLA Cardiomyopathy Center and associate chief of the UCLA Division of Cardiology. "Usually women in their 40s and 50s who present with coronary artery disease have traditional risk factors such as high blood pressure, obesity, smoking, diabetes or a family history of cardiovascular disease."
"But it is also known that chronic cocaine use can accelerate the cardiovascular disease process," Fonarow told MedPage Today. "And you can find much more extensive coronary artery disease than you would expect. There are multiple mechanisms by which cocaine can lead to sudden, unexpected sudden death. Arteries that are narrowed are more likely to have spasms."
Fonarow also said that amphetamines are also considered potential accelerators of cardiovascular disease. He said narcotics such as morphine and sedatives can affect the heart in other ways such as by suppressing respiration, causing respiratory arrest and subsequently cardiac arrest.
He said these drugs can also cause an irregularities in heart rate such as QTc prolongation.
He suggested that a patient with a 60% narrowing in coronary arteries would not likely be a candidate for a percutaneous coronary intervention, but would likely be treated with lifestyle changes or treatment with statin or other medications.
"In Whitney Houston's case, there a multiple potential contributors to her death, but how it all ties together and what was the actual mechanism still has not been determined," said Fonarow, a spokesperson for the American Heart Association. "It may never be fully sorted out."
"The lesson here is that these recreational drugs such as cocaine can cause serious damage to the heart, and even with single use can be fatal," Fonarow said. "There are risks to these drugs."
From the American Heart Association: