UPDATED — I think the real cause of death for Billy Mays was obstructive sleep apnea

I know the coroner’s report says that Billy Mays died on June 28 of a heart attack just shy of his fifty-first birthday. I know that the toxicology report released August 7 says that he had used cocaine a few days before his death and that cocaine use exacerbated his hypertensive heart disease and contributed to his death. I know statistics on heart disease from the American Heart Association show that the first sign of heart disease for one-third to half of people who have it is suddenly dropping dead. I know Mays went to bed the night he died saying he didn’t feel well.

However, I think the real cause of death for Billy Mays was obstructive sleep apnea.

Let me explain by starting with some background from the Miami Herald, which summarizes the coroner’s report released Aug. 7 as follows — I boldfaced the most important sentence:

While heart disease was the primary cause of his death, the medical examiner listed cocaine as a “contributory cause of death.”

The medical examiner “concluded that cocaine use caused or contributed to the development of his heart disease, and thereby contributed to his death,” the office said in a press release.

The office said Mays last used cocaine in the few days before his death but was not under the influence of the drug when he died. Hillsborough County spokeswoman Lori Hudson said nothing in the toxicology report indicated the frequency of Mays’ cocaine use.

Cocaine can raise the arterial blood pressure, directly cause thickening of the left wall of the ventricle and accelerate the formation of atherosclerosis in the coronary arteries, the release said.

The toxicology tests also showed therapeutic amounts of painkillers hydrocodone, oxycodone and tramadol, as well as anti-anxiety drugs alprazolam and diazepam. Mays had suffered hip problems and was scheduled for hip-replacement surgery the day after he was found dead.

Pill counts also showed Mays was using his prescription pain and anxiety medications as prescribed.

I am unaware of any autopsy test for death by obstructive sleep apnea, so I expect coroners do not look for it or consider it as a cause of death.

Here’s the thing: research shows obstructive sleep apnea contributes to heart disease even more than cocaine use. Specifically, it has been found to be a cause of intractable high blood pressure (= hypertension), atrial fibrillation and idiopathic congestive heart failure. OSA is not what made Mays’ heart atherosclerotic, but it could have contributed to its enlargement related to hypertension. The reason that obstructive sleep apnea affects the heart is that during an obstructive apnea, your body still goes through the motions of breathing, even though the airway has collapsed and is sealed shut — trying to breathe against this vacuum causes an enormous strain on the heart. (I started playing the bassoon again in 2003 three months after I was diagnosed with OSA. The pressure of playing long notes is comparable to trying to breathe against a sealed airway — it took five years from my diagnosis before I could play long notes without my heart going crazy the way it did during long apneas.)

Obstructive sleep apnea results in sleep deprivation, because it jars you slightly awake hundreds of times a night, usually without your being aware of it. But it also results in oxygen deprivation because the amount of time your airway is shut and you are not getting air can add up to almost half of every hour you are asleep. Oh, and by the way, the reason it doesn’t add up to a half hour OR MORE of every hour you are asleep is that once you reach that amount of time without air, you are circling the drain and could die any time. That’s because there’s a feedback system in the body between the level of oxygen and carbon dioxide and when the carbon dioxide level gets too high, the brain stops sending the signals to breathe.

When a person with undiagnosed obstructive sleep apnea takes therapeutic doses of medications for pain and/or anxiety — which means the normal dose on the correct schedule, not an overdose — they can die because those medications make it just hard enough to wake up that it is easy to cross that point of no return in the level of carbon dioxide in the blood that stops the brain from sending the signals to breathe — that is, which causes central apneas. (This situation is ditto for alcohol consumption or using recreational drugs, even in small or moderate amounts.)

In addition to his hypertensive heart disease, one of the things that convinces me that Billy Mays had obstructive sleep apnea is his use of cocaine a few days before his death. If he really had a drug problem, it would have been in his system when he died. No, the deprivation of sleep and oxygen from obstructive sleep apnea make you sleepy and foggy during activity. Billy Mays was famous for his energy and enthusiastic sales pitches. Cocaine perks you up. I think Billy Mays was self-medicating with cocaine to treat the sleepiness and fogginess resulting from his undiagnosed sleep apnea.

But the main reason that I think what really killed Billy Mays is obstructive sleep apnea is that just before I was diagnosed with obstructive sleep apnea one Percocet (acetominophen plus oxycodone) almost killed me. I took it for the worst sinus headache of my life. I woke up gasping for air, diaphoretic, with a thready pulse I could just barely detect and I vomited for several minutes — these are all signs of cardiac distress. My symptoms were bad enough that I called 911 and they took me to the hospital where my cardiologist did three days of tests, including an angiogram, before giving up on determining the cause of the problem (he doesn’t quite grasp the connection between heart disease and sleep disorders). I might have died if I hadn’t also had six cups of coffee that day.

What I hope will result from my writing this post are that more people who have daytime sleepiness will see a sleep specialist for an evaluation, and if needed, a sleep study. I also hope that more cardiologists will learn about the research connecting sleep disorders as a cause of various types of heart disease. And I hope that coroners will figure out a way to determine in an autopsy whether the cause of an unexpected death during sleep was caused or exacerbated by obstructive sleep apnea.

I also hope that the very real possibility that Mays was self-medicating due to symptoms of undiagnosed obstructive sleep apnea rather than addiction may restore some lustre to his reputation and comfort his fans and family.

P.S.

When someone is sleeping and stops making the sounds of breathing, the cause is most likely to be obstructive sleep apnea. You can see an animation here. Remember, the brain is still sending the signals to breathe, even though the airway has collapsed and no air can get through — which is why you do not hear breathe sounds — so you will see the motions of breathing. If the silence lasts longer than 10 seconds and happens more than 10 times an hour, or daytime sleepiness seems excessive, then it’s a good idea to consult a sleep specialist. Not your family doctor — sleep medicine is VERY new. A sleep SPECIALIST. Seriously.

Update, 8/10/09: The life-saving coffee was Hair Raiser, a proprietary blend from Caribbean Coffee Company in Santa Barbara, which is liquid alertness without any jitters: