The death of Baltimore County Executive Kevin Kamenetz surprised many people in part because he was healthy and fit with no history of heart disease.
But doctors said even people in the best of health with no signs of cardiovascular disease can suffer a deadly attack that stops the heart. Sometimes it is the first sign of heart problems.
Doctors believe Kamenetz, 60, had a heart attack that led to cardiac arrest.
"Some people just come in out of the blue having been seemingly perfectly healthy," said Dr. Gail Cunningham, chief medical officer at University of Maryland St. Joseph Medical Center in Towson, where Kamenetz was taken for treatment and later pronounced dead.
Cunningham said this happens when a blood vessel suddenly becomes blocked, starving the heart of blood and oxygen. The organ then stops working. Damage can begin in minutes, doctors said.
"It is actually very common for the first manifestation of underlying heart disease to be a major heart attack," said Dr. Roger Blumenthal, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease.
In 2017, Maryland emergency medical services reported 6,888 sudden out-of-hospital cardiac arrests, according to the Greater Maryland American Heart Association and American Stroke Association.
Kamenetz woke up early Thursday morning feeling tightness in his chest. Rather than call 911 for an ambulance, he and his wife chose to drive about two miles away to the Chestnut Ridge Volunteer Fire Company, but his condition deteriorated quickly.
Kamenetz lost consciousness, his pulse and his heart stopped beating, so two volunteer EMTs provided CPR manually and then used a Lucas CPR device, a piece of equipment that sits above the body and provides chest compressions, said Elise Armacost, a Baltimore County public safety spokeswoman.
While this keeps some blood flow throughout the body, it is not the same as the heart beating on its own, Cunningham said.
Fire Department personnel there also tried to jump start Kamenetz's heart three times with a defibrillator. Medical personnel from Baltimore County's Garrison fire station arrived a short time later and administered CPR, gave Kamenetz cardiac drugs and performed "airway management," before transporting him to St. Joseph.
It is unclear which of Kamenetz's arteries was blocked and the family has chosen not to have an autopsy performed.
"I don't know what his underlying pathology was, so I don't know if this was one vessel or maybe he had several that were borderline and one was suddenly blocked," Cunningham said. "I just don't know."
While it's critical to receive treatment immediately with a heart attack, Cunningham said she couldn't say whether the decision to drive to the fire station instead of calling 911 had any impact on the outcome.
She also said it is also hard to tell if the stress of a gubernatorial campaign, which involves a grueling schedule of debates, meet-and-greets and other activities could have put too much pressure on his heart.
"Stress can be a contributor to heart problems, but not necessarily," Cunningham said.
Kamenetz was a healthy eater who liked granola and yogurt, Armacost said. He wasn't overweight and visited a doctor regularly. Just last week he signed an executive order for healthy vending in county office buildings. Every year, he planted a vegetable garden with his sons. Last year they planted pumpkins.
"He did not have any health issues that anyone was aware of," Armacost said. "That makes this even more than a shock to deal with."
In other cases of heart attack and cardiac arrest, people often have symptoms, such as breathlessness, fatigue or tightness in the chest.
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The sooner a person can get CPR the better the chances of survival, but the odds start going down quickly after the first five minutes, Blumenthal said.
People with a family history of heart disease and other conditions such as high cholesterol and diabetes are also more at risk. Smoking also can put more people at risk. Exercise and healthy eating can help reduce people's chances of a heart attack.
Sometimes people might not know they are at risk. Doctors said that is why people need to see their doctor regularly to get assessed and live a healthy lifestyle.
"We all think we have a healthy heart," said Dr. Ali Tabrizchi, an interventional cardiologist at the LifeBridge Health Cardiovascular Institute. "Then we have an unfortunate event and realize we really don't."
Baltimore Sun reporters Alison Knezevich, Jessica Anderson and Pamela Wood contributed to this article.