Assoc. Prof. Dr. Sotir Marchev, MD, was born in 1961 in Blagoevgrad. He graduated with a gold medal from English High School, and then, also with honors, the Medical University in Sofia. He has two specialities – internal medicine and cardiology. Specialized echocardiography and invasive cardiology and electrophysiology in Vienna, Osaka, Belgrade. He has Accreditation of Echocardiography of the European Society of Cardiology and is an honorary member. Associate Professor of Cardiology at the Medical University in Pleven.

– Assoc. Prog Marchev heart diseases are crucial for the individual, but sometimes also influence history. What is the Bulgarian example?
– Exactly 1000 years ago, on October 6, 1014 Tsar Samuil, seeing his blinded army, died suddenly. After his death, the First Bulgarian Kingdom fell quickly under Byzantine rule. And you can say that this changed the course of history.

– What are people dying from under sudden stress?
– This is a very exploited topic in television series and is a frequent source of fear in everyday life. Recently I saw my patient nervously treading outside his home. I asked him what he was doing. “My favorite football team is playing and now are the penalties. I came out, I do not want to watch and get another heart attack,” he explained. And indeed, during football games it has happened, someone from the spectators to be carried out on a stretcher. Recently a letter from a Mexican writer was broadcasted, whose grandfather died in 1994, after seeing Stoichkov score a goal against Mexico.

– Would he be alive today if he was not watching?
– From 1994 the contemporary cardiology knows the answer. On the 17th of January Los Angeles was shaken by a major earthquake – the richest city in the richest state (California) of the richest country (USA). Earthquakes are an example of the impact of sudden stress on health. During the earthquake, some patients carried Holters for blood pressure monitoring and ECG. The data from the devices shows how patients’ pulse from 85 per minute reaches 160 when the earthquake strikes. There are also records of blood pressure rising from 130/80 before the earthquake to 160/120 during the quake. Then the damages were large; buildings, bridges and trestles collapsed. Insurers and reinsurers went bankrupt. On the day of the earthquake the number of patients with infarction was significantly higher than that on the same day of previous years, when there was no earthquake. But in the weeks after the earthquake, the number of heart attacks appeared to be smaller than on those days in past years. The conclusion is that the heavy sudden stress from the earthquake has caused heart attacks of people who anyway would have had a heart attack in the coming weeks. The stress during the earthquake provoked these attacks.

– Are there other indisputable examples?
– The great earthquake (9th degree on the Richter scale) in Japan on March 11, 2012. The cases of acute coronary syndrome sharply increased after the earthquake at the expense of a decrease below the usual level in their number three months later. To put it bluntly, the answer to the above question is: angry or not – the difference is 3 months of life. The patients who died due to the stress of the football game would probably have had a heart attack in the coming weeks. Tsar Samuil was about 70, and even if the Battle of Klyuch had developed differently, most probably he would have had a heart attack shortly afterwards.

– In your practice have you personally observed the effects of stress?
– The most recent example is from May 24 this year when we had an earthquake in our country. We gathered the Holters of the patients from the hospitals of the Bulgarian Cardiac Institute during the quake. Each person reacts individually, according to his fear of earthquakes. In all the pulse rose, but the usual changes were for example: from pulse 65 per minute before the earthquake to 90 per minute during the quake.
Everything said so far applies, of course, only to the sudden stress and ischemic heart disease. The statistics of the earthquake in Japan in March 2012 showed that in contrast to the acute coronary syndrome, in which the initial increase in cases was offset by further reduction, the incidence of cardiac insufficiency observed only increased without compensatory decrease later.

– How the sudden stress causes cardiac insufficiency?
– We have more data on the effects of sudden stress on women. Usually elderly women on bad news get transient cardiac insufficiency and very few of them die. Most often, after 3-4 weeks almost all recover. This condition is called stress cardiomyopathy. It was first discovered in Japan in 1990. During the illness the left ventricle resembles an amphora.
But in the Japanese history there are no amphorae, nor pots, so they called the disease Taco-tsubo – a Japanese vessel, which most closely resembles the amphora. It is used to catch octopuses. “Taco” means octopus, “tsubo” – cup. We described this disease in Bulgaria for the first time in 2006 and since then it is diagnosed more widely. Most often the patients are elderly women, usually after negative news. For example, one of the patients received ultimative term to repay the loan, but no money. Another who had lost her daughter and herself took care of her granddaughter, was surprised by the 16-year-old girl with the message that she is pregnant. Third patient had suddenly lost her husband. Another patient’s husband was cheating and the whole village knew…

– Diagnosis in women?
– It occurs rarer in men and in young people. For example, a young tinsmith had received taco-tsubo cardiomyopathy, when his employer, rushing to complete the facility, sent him to work on a wet and slippery roof.
The ECG and the laboratory tests of the patient with stress cardiomyopathy are like with acute infarction, but the invasive examination shows that his/her blood vessels are passable. If the invasive tests are not carried, everyone will think it was an infraction. It is caused by stress hormones – adrenaline and noradrenaline, which directly affect the heart muscle. This stress in men, as in Tsar Samuil, can lead to sudden death. In women without coronary artery disease and clean coronary vessels a protective mechanism is triggered and muscle cells cease to respond to the stress hormones. Thus the taco-tsubo cardiomyopathy occurs.
The bad news is that stress can really break your heart, and good – that usually condition resolves in few weeks.

– The advice not to worry is easy to give but difficult to abide by. What else can the medicine offer?
– In 1988, the Nobel Committee awarded the Nobel Prize in Medicine to Sir James Black for the discovery of the first H2-blocker (cimetidine) and the first beta-blocker (propranolol). For these discoveries the Queen declared him a knight, and hence – the title sir. Beta-blockers are medicines that block the path of the nerves from the brain to the body.
The person is worrying, but this stress does not reach the organs. In all Olympic events associated with shooting (biathlon, shooting, etc.), the beta-blockers are considered doping and banned. The stress of the competition does not reach the shooter’s hand and he shoots more accurately (speaking in medical language beta-blockers reduce peripheral tremor). In young men, beta-blockers have a significant side effect. If they see a beautiful naked woman, the excitement in their brain does not reach their penis, i.e. beta-blockers can cause erectile dysfunction. Of course, women do not develop this side effect.
The beta-blockers reduce sudden death after myocardial infarction. But not all. The beta-blockers, which reduce sudden death, are fat-soluble and enter the central nervous system. Those, which have no preventive effect are water soluble and do not enter the central nervous system. In sudden deaths the modern cardiology considers the brain as the trigger and heart as the target. Or, as the saying goes, “all woes come from the head.”

Interview with Assoc. Prof. Dr. Sotir Marchev, MD (04/10/2014; Liubomira Nikolaeva, 24 hours)