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Warning! This article contains spoilers to the film Kal Ho Na Ho. Please do not continue reading if you do not want to know the ending.
Sharukh Khan has showcased some dramatic deaths across his acting career. So much so that there is actually an article by the Times of India listing these films. The most dramatic of which I think is the one in Kal Ho Na Ho where he plays the character Aman Mathur. Even amongst the light-hearted Ramdayal and Kantaben jokes, this impending death is hinted towards as Naina initially narrates, speaking about Aman in the past tense. These suspicions are confirmed midway when his mother confronts him about his feelings towards Naina and he says “the heart itself is very weak…I am dying.” Which heart condition does he have, I hear you say? Let’s work through it together!
You are a junior doctor working in A&E and are asked to see a 30 year old man who presents after collapsing at his friends’ engagement party. He presents clutching his right arm and chest, unable to speak in full sentences owing to difficulty breathing and has sweat pouring down his face. He complains of central chest pain and dizziness. He was dancing and singing when the pain began. He has had similar episodes in the past however is unable to identify a trigger to these events. He was exerting himself during this episode but he is a professional dancer and has not had this problem during a recent performance at a Disco Club (#It’s the time to disco). He tells you that he is awaiting a heart transplant. His parents are aged 60 and 70 and are in good health. He is not aware of any sudden deaths in his family. When you ask him about previous investigations he has had for his heart problem, he mentions that he has had a stress test and echocardiogram. He does not know the results of these. His previous ECG, has ripped and unfortunately only shows a section of the V4 lead.
Kal Ho Na Ho
There appears to be a bradycardia. The rest of the ECG, from what you can make out, looks normal. You note some slight medico-legal issues with his best friend Priya doubling up as his Doctor. You let it slide. Based on this, what are your top differentials?
The sweating and chest pain are suggestive of cardiac ischaemia. Repeated episodes of ischaemia can lead to heart failure. The shortness of breath and the multiple pillows he uses in hospital could be suggestive of left ventricular failure. He also looks cyanotic. There is no explicit mention of palpitations throughout the film but Aman may have also had increased awareness of his heart beats, demonstrated by the dramatic ‘lub dub’ noises in the background as he falls to his knees. The indications for a heart transplant are those with advanced heart failure. A cause of heart failure in a male of his age could be dilated cardiomyopathy. Dilated cardiomyopathy is a progressive condition and survival is poor without a heart transplant. It is characterised by dilatation of the ventricles resulting in impaired contractility and reduced left ventricular ejection fraction. It presents with symptoms of heart failure and can also present with sudden onset arrhythmia. Dilated cardiomyopathy can be congenital or acquired and is associated with alcohol, recreational drugs such as cocaine, auto-immune disease and viral infections. The majority of cases of dilated cardiomyopathy are idiopathic. The cause of Aman’s dilated cardiomyopathy is difficult to identify, given that risk factors for dilated cardiomyopathy are not hinted towards in the film. The other cardiomyopathies (disease of the cardiac myocardium) also present with similar symptoms. Hypertrophic cardiomyopathy (HOCM) is believed to be the most common cause of sudden cardiac death in the young and can present at any age. Restrictive cardiomyopathy is when the myocardium is rigid which restricts ventricular filling during diastole. This is rarer than HOCM and dilated cardiomyopathy. This can be idiopathic or acquired in amyloidosis, haemochromatosis and scleroderma to name a few.
Another differential could be Eisenmenger Syndrome, a rare cyanotic heart disease which can present in adulthood. This arises due to an uncorrected left-to-right shunt in early life, resulting in pulmonary hypertension. This causes reversal of the shunt in later life, forming a right-to-left shunt in later life. As deoxygenated blood is able to enter the systemic circulation this causes cyanosis. Complications of this include heart failure and so could be in keeping with Aman’s presentation. There aren’t very many clues in the film, with greater focus on the emotional role of a heart rather than the physical one. However, based on what has been presented my top differential would be dilated cardiomyopathy. Please let us know if you have any other differentials and if you enjoyed reading this article, please suggest other films we could do case presentations on!
Further reading:
Please see
- https://clumsylostmedicalstudent.wordpress.com/2017/03/19/cardiomyopathy/ for more information on the different cardiomyopathies discussed in this article.
-https://www.amboss.com/us/knowledge/Cyanotic_congenital_heart_defects for more information on the different cyanotic congenital heart defects!