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Opinion article
A cataclysm in the myocardium
Un cataclismo en el miocardio
Hermes Ilarraza-Lomelí
Corresponding author
hermes_ilarraza@yahoo.com

Correspondence to: Juan Badiano 01, Colonia Sección XVI, Delegación Tlalpan, ZP 14080, Ciudad de México, Mexico. Tel.: +52 5573 2911x1214; fax: +52 5573 0994.
Cardiac Rehabilitation Service, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Atherothrombosis and earthquakes follow the power law&#46; This plot shows earthquakes occurrence according to their magnitude&#44; lower intensity&#44; higher frequency and vice versa&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Another autumn was coming on a Thursday morning when Mexico was browsing the newspaper and rushing the coffee before going to work&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It was September the 19th of 1985 at 7<span class="elsevierStyleHsp" style=""></span>am&#44; and news included the recent episode of the icy battle between Ronald Reagan and Mikhail Gorbachev about the Star Wars project&#44; the presidential tour of Miguel de la Madrid and the eternal delays of the stadiums preparation for the XIII Soccer World Cup&#44; that would take place eight months later&#46; However&#44; there was no information about the proximity of that earthquake&#44; greater than 8<span class="elsevierStyleHsp" style=""></span>M<span class="elsevierStyleInf">W</span> strong&#44; that would occur a couple of minutes later&#46; That day&#44; many people died as a result of huge landslides and other more because of an acute myocardial infarction due to panic&#46; In medical literature&#44; several authors have described the way how an earthquake is related with an increased incidence of myocardial infarction&#44; however this association appears to be stronger than we thought&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Occasionally and without any warning&#44; our planet suddenly sneezes and causes a cataclysm of colossal dimensions&#44; like the Krakatoa&#39;s volcano eruption&#44; the earthquake of almost 200<span class="elsevierStyleHsp" style=""></span>gigatons in Valdivia or the Tsunami in Indonesia&#46; Our human body&#44; as a faithful representative of Nature&#44; may also experience cataclysms that severely alter us&#44; but this time transformed into a vascular catastrophe&#44; secondary to a thrombus formation which generates a chain reaction within the affected territory&#44; usually the myocardium or encephalon&#46; A first similarity between major earthquakes and acute atherothrombosis is that both events have a very low occurrence rate&#44; and their consequences are immediate and catastrophic&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore&#44; geologists and physicians&#8217; concern focuses on predicting these types of events&#44; because when they have already occurred&#44; it is usually too late&#46; Ch&#225;vez-Dom&#237;nguez and colleagues demonstrated in 2003 that 92&#37; of patients who died due to a heart attack in Mexico did not received any attention from health services because they died at home&#44; at work or on the street&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Science of seismology studies the continuous movement of the earth&#39;s crust and records it&#44; minute by minute&#44; in the different centers located throughout our planet&#46; Earthquakes occur daily&#44; and when scientists plot their apparition over the years &#40;time domain&#41;&#44; it is very difficult to determine some dynamic pattern&#46; However&#44; if we change our perspective to a <span class="elsevierStyleItalic">frequency-domain</span> point of view&#44; using the Fourier transform&#44; we can observe that earthquakes faithfully obey the <span class="elsevierStyleItalic">Power Law</span>&#44; which is date independent&#46; This distribution shows us roughly&#44; that there will be an enormous amount of small quakes and a very low occurrence of great ones&#44; see <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; Now the problem is&#44; despite having collected and analyzed trillions of terabytes of information about it&#44; large earthquakes continue to appear unpredictably&#44; especially over time&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In other order of ideas&#44; atherothrombosis has been extensively studied since the first descriptions by von Rokintansky and Virschow&#44; concepts that later were taken up by Ross and that currently constitute the basis of vascular syndromes&#8217; treatment and prevention&#46; Atherosclerotic lesions accompany human beings since childhood&#44; and they can remain harmless for years&#44; as we see in subjects with multiple atheroma who never had a thrombotic event and who eventually died because of a non-cardiovascular etiology&#46; However&#44; some of these plaques are under a great metabolic and inflammatory stress that one day they can no longer resist&#44; suffering an intimal rupture and generating an imbalance between the pro- and antithrombotic mechanisms of the endothelium&#46; This process can produce a complete arterial occlusion and a wave of ischemia through the tissue at risk&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Atherothrombosis also follows the power law&#44; as far as many microscopic thrombi can initially appear&#44; but finally they will be destroyed&#46; In contrast&#44; sometimes one or two large thrombi get stable and can cause acute and severe ischemia by occluding the artery that irrigates an important territory&#46; Although this cascade of events has been extensively studied by experts for decades and despite the in-depth analysis of all this information&#44; no method has been able to accurately predict the timing and location of a heart attack&#46; How many times has a patient suffered an acute myocardial infarction under the surprised eyes of his physician&#63;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Ironically&#44; large earthquakes are also caused by a structural rupture&#44; but of a tectonic plate&#44; which usually have their origin in pre-existing faults located in the earth&#39;s crust&#46; These quakes occur when the stress of a couple of tectonic plates&#44; which has gradually increased for years&#44; suddenly causes a huge plate-movement and the subduction of one plate under the other&#46; Thus&#44; that rupture in a small nucleation zone&#44; displaces the plates and radiates megatons of energy as seismic waves along the surface of the fault&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Therefore&#44; both earthquakes and heart attacks are the result of a continuous process of stress that under certain circumstances&#44; is liberated in an unpredictable&#44; irrepressible and irreversible way&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main shake of an earthquake causes the greatest structural damage&#44; especially if it is prolonged&#46; At the end of an earthquake several complications appear&#44; worsening situation&#58; landslides&#44; tsunami&#44; gas leaks&#44; fires&#44; blackouts&#44; loss of communication lines&#44; fractures in the streets and an imminent sanitary contingency&#46; Immediately&#44; emergency services take part&#44; particularly civil protection units that react by rescuing injured&#44; reducing collateral damage and housing the population&#44; by delivering humanitarian and financial support&#46; Finally&#44; everything ends when the affected area is rebuilt&#44; a task that partially lies on people&#39;s resilience that means how quickly a community can recover from earthquake damage&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Similarly&#44; coronary atherothrombosis damages the heart structure in several ways&#58; inflammation and cellular necrosis&#44; loss of heart rhythm&#44; conduction system blockage or the rupture of valvular and ventricular components&#46; If patient reaches hospital&#44; emergency services would be triggered to relieve ischemia&#44; limit damage and injured tissue will be finally repair with a scar&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In both cases&#44; events could not be precisely predicted and interventions were only reactive to catastrophe&#46; Although an earthquake cannot be avoided&#44; too many lives could be saved by evacuating the area well in advance&#44; only if we can predict it&#46; Unlike earthquake&#44; it is thought that heart attack could be avoided&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A group of seismological scientists are focused in earthquake prediction&#44; based on two methodology types&#58; analysis of diagnostic precursors&#44; widely studied because of its potential utility in the forecast of short-term earthquakes &#40;&#60;1 year&#41;&#46; Second type are trend methods&#44; useful for intermediate &#40;1&#8211;10 years&#41; or long-time prediction &#40;10&#8211;100 years&#41;&#46; Earthquake occurrence is an independent and probabilistic phenomenon that means it has no memory&#46; The International Commission on Earthquake Forecasting for Civil Protection &#40;ICEF&#41; published a very heterogeneous list of methods to analyze earthquake precursors&#44; including&#58; changes in deformation rates&#44; fluctuations in groundwater levels&#44; changes in radon concentrations &#40;soil&#44; groundwater and air&#41;&#44; electromagnetic variations of the Earth&#39;s surface&#44; thermal anomalies&#44; seismic waves patterns and abnormal animal behavior associated their perception of seismic P waves&#46; Trending methods study the statistical recurrence of quakes&#44; supported by the study of seismographic&#44; historical and paleontological records&#46; Temporal accuracy of this approach ranges from 500 to 2000 years&#46; Some faults on earth&#39;s crust present multiple modes of periodicity&#46; Our main problem is that earthquakes cannot be predicted with a time accuracy shorter than decades&#44; and therefore medium- and short-term forecasts&#44; have always a low probability to confer benefits in terms of civil protection&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Physicians have developed several coronary risk calculators&#44; based on statistical associations obtained from cohort studies &#40;Framingham&#44; etc&#46;&#41;&#44; models that promise to be a useful tool to predict cardiovascular adverse outcomes at medium and long-term follow-up &#40;10 years&#41;&#46; Predictive variables are usually considered as demographic&#44; nosological and biochemical risk factors&#44; according to atherosclerosis and atherothrombosis pathophysiology&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Similar to telluric movements&#44; predictions about acute myocardial infarction can be more reliable for long periods of time &#40;decades&#41;&#44; but when clinicians try to use it as a short term forecast&#44; these mathematical models lose accuracy&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Outcome prediction in cardiology and seismology accepts the epistemic basis that atherothrombosis and earthquake are a linear&#44; deterministic&#44; reductionist and probabilistic phenomena&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Predicting location of these kinds of events could be more accurate than forecasting time&#46; If adequate seismic and geological data are available&#44; particularly for those areas with a well delineated cortex faults pattern&#44; it is relatively easy to predict where the epicenter will take place&#46; Talking about ischemic heart disease&#44; CT-scan coronary calcium-score allows physicians to identify those arterial territories that are more likely to have an occlusive atherothrombotic event and a heart attack&#46; Other methods for establishing patient&#39;s prognosis include nuclear medicine&#44; stress echocardiography and coronary angiography&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Within time domain&#44; earthquakes tend to occur very closely one to another&#44; grouped in shaking sequences that gradually increase their magnitude &#40;foreshocks&#41; until the most intense earthquake occurs &#40;main shock&#41;&#44; followed by a series of aftershocks&#46; Seismology experts also assume that the clusters of foreshocks and aftershocks have a Poisson distribution&#46; When a rate of seismicity is high but without a clear main shock&#44; the sequence is called an earthquake swarm&#46; Geologists think that a better seismographic patterns understanding would improve the short-term quakes predictability&#44; particularly the study of foreshocks behavior&#46; However&#44; these ground waves are practically indistinguishable from the <span class="elsevierStyleItalic">background seismicity</span> of Earth&#39;s crust&#46; Researching teams are currently generating earthquake forecasting-models&#44; like Epidemic-Type Aftershock Sequence &#40;ETAS&#41;&#44; a combined tool that integrates three seismic scales&#58; Utsu&#44; Omori and Gutenberg-Richter&#46; Historically&#44; only a couple of earthquakes have been well predicted&#44; and the most famous case of an imminent prediction was the Haicheng earthquake &#40;China&#41; on February 4th 1975&#44; where a large population was safely evacuated several hours before the main shake of the earthquake&#46; Nevertheless&#44; this forecasting has been widely questioned and similar schemes of prediction have been unable to succeed&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Today&#44; when science is unable to predict earthquake&#39;s location&#44; timing or intensity&#59; all we have are specialized systems looking for a rapid and effective response to a cataclysm&#46; Alarm casting procedures should be standardized to take better decisions at different levels of government and among the public&#46; One strategy is called Seismic Alert and it has been designed to reduce potential complications due to massive structural destruction&#44; by timely evacuation of the population at risk&#46; Since 1986&#44; the Center for Instrumentation and Seismic Record &#40;CIRES&#41; has implemented this alert system based on the detection of large earthquakes&#44; using sensors located in the already recognized epicenters&#44; particularly at the Mexican southern coasts&#46; CIRES equipment sends a coded signal that is captured by the Personalized Seismic Alert System &#40;SASPER&#41; and it is subsequently re-transmitted to the population at risk using massive electronic information media&#46; Cities with this Anti-Seismic Accelerometer Network are mainly located in the Valley of Mexico&#44; Guerrero and Oaxaca&#46; This electronic warning provides Mexico City about 40<span class="elsevierStyleHsp" style=""></span>s for people evacuation to safety areas&#44; before the main shock arrives&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Something similar happens with acute coronary syndromes&#44; which initially emit their clinical alert &#40;angina&#44; syncope&#44; etc&#46;&#41; that is repeated through emergency systems activation&#46; The newest form of this action is known as Myocardial Infarction Code that has been structured using smartphone platform and social networks&#46; This biological alarm has been triggered when atherothrombotic process is irreversible&#44; and from then&#44; all attempts will be directed to relieve ischemia&#44; reduce collateral damage and treat complications&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Furthermore&#44; there is another reactive strategy to prevent or to treat life-threatening arrhythmias&#44; tightly associated with myocardial infarction&#44; a program called <span class="elsevierStyleItalic">cardio-protected areas</span>&#46; Electrical therapy for ventricular fibrillation or tachycardia has reduced dramatically short-term mortality due to malignant arrhythmias&#59; this effect has been reinforced with standardization of cardiopulmonary resuscitation maneuvers &#40;ACLS&#41;&#46; Those ancient defibrillators evolved into modern semi-automatic devices&#44; that have left intensive care units and came out into out-of-hospital setting&#46; Defibrillation is one of the most effective therapies when is applied rapidly and appropriately&#46; Now&#44; the question is&#58; how to provide the required number of devices to assure that people at risk&#63; The main trouble is that population&#39;s distribution also obeys power law&#46; Thus&#44; there are very few places where a lot of people are together&#44; often only for short time &#40;football stadium&#44; airports&#44; etc&#46;&#41;&#44; while almost all individuals are not concentrated&#44; but dispersed over several square kilometers &#40;houses&#44; cars&#44; etc&#46;&#41;&#46; Recently&#44; a new strategy came out&#44; based on coupling small defibrillators with an unmanned aerial vehicle &#40;UAV&#41;&#44; commonly known as a drone&#46; This hybrid device could arrive very quickly into a cardiac-arrest site&#44; almost wherever the patient is&#46; All these new technologies could resolve some troubles around myocardial infarction&#44; but in a very limited way&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Scientists have developed several theories and statistical tools to predict earthquakes or heart attacks&#46; Although these models seem to have plausible arguments to forecast&#44; in practice they have been unable to fulfill their task&#46; Geophysics believes that earthquake prediction is possible&#44; based on non-seismic physical precursors&#46; On the other hand&#44; cardiologists also think that a myocardial infarction could be even avoidable&#44; if we identify and reduce patient&#39;s risk factors&#46; Nevertheless&#44; other colleagues are pessimistic about these considerations and they think that these predictions are intrinsically erroneous&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">This discrepancy led researchers to look for new manners of data interpretation and to postulate more realistic theories&#46; Several decades ago&#44; scientists have described how nature does not have a linear&#44; deterministic&#44; reductionist or closed behavior&#46; Natural phenomena follow an intricate path&#44; composed of innumerable interactions&#44; trending lines that sometimes go together and some other they diverge in an apparently capricious way&#44; but finally they weave a dense tissue of probabilities&#44; facts and conjectures&#46; Edgar Morin calls this type of interactions <span class="elsevierStyleItalic">complexity</span>&#44; from Latin&#58; complexus &#40;interlaced&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">One of the most accepted theories for earthquake onset describes how continental-drift dynamics presents several types of fluctuations in tectonic plates load&#44; which generate self-organization and resonance phenomena&#46; This mechanical behavior can result in emergent properties&#44; such as an earthquake&#46; Seismic pattern has a clearly complex and non-linear behavior&#44; which needs to be studied with appropriate methods and new mathematics&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Earthquake-prediction experts note that&#44; if we use forecasting models in a incorrectly way&#44; they can introduce epistemic uncertainty&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Analogously&#44; there are cardiology study-groups interested in non-linear dynamics&#44; and they are researching topics like&#58; atherosclerotic plaque formation&#44; circulation patterns of blood elements and life-threatening arrhythmias genesis&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Earthquakes and atherothrombosis are irreversible phenomena and this fact suggests that both could present&#44; thermodynamically&#44; high levels of entropy&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The lack of accurate forecasting-models forces us to take a more realistic approach&#46; Thus&#44; the most accurate and effective way to deal with this problem&#44; whether it be an earthquake or a heart attack&#44; is to implement a specific and fast intervention&#44; once the event just happened&#46; Engineers are already designing seismic-resistant buildings&#44; based on their complex and non-linear behavior during an earthquake&#46; Physicians have by now&#44; emergency systems like Myocardial Infarction Code or cardio-protected areas&#46; However&#44; these interventions are only symptomatic and palliative&#58; we cannot yet establish any relevant measure to prevent a natural disaster&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In summary&#44; earthquakes and atherothrombosis are more similar than we thought&#44; because they are unpredictable&#44; irrepressible and irreversible&#46; We need a new approach&#44; like complexity sciences&#44; for studying these problems in a transdisciplinary teamwork that could bring us a brightly light in this dark scenario&#46; Just imagine what could happen if physicists and physicians join their efforts in an interactive research to accurately predict a natural cataclysm&#44; whether it be an earthquake or a heart attack&#8230;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">No endorsement of any kind received to conduct this study&#47;article&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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