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Actor James Gandolfini may have been larger than life to his fans, but "The Sopranos" star's sudden death from a heart attackwas all too ordinary.

If a 50-something man dies, heart disease is the No. 1 suspect.

“A quarter million Americans experience sudden cardiac death each year,” says Dr. Michael Miller, director of the University of Maryland Medical Center’s Center for Preventive Cardiology. “Half of them experience sudden death as the initial symptom.”

In other words – there were no symptoms, no warning.

Gandolfini, 51, was discovered by his teenage son after he collapsed in a bathroom in a Rome hotel Wednesday evening. Gandolfini was given first aid at the hotel and an ambulance took him to a hospital where the emergency room chief, Dr. Claudio Modini, said the actor arrived in cardiac arrest. Staff tried for 40 minutes to revive him but he was finally declared dead.

While Gandolfini's death in Italy was sudden, it shouldn't have been completely unexpected. Heart disease and stroke are by far the biggest killers of Americans. The two-thirds of Americans who overweight or obese all have a higher risk of heart disease including high blood pressure, clogged arteries and irregular heart rhythm, not to mention stroke.



“Most of us in the United States, especially men over the age of 50, show evidence of hardening of the arteries,” Miller tells NBC News.

But they often have no idea. “In people that have blockages that are less than 70 percent, they will generally not experience any symptoms. You can have a 30-40-50 percent blockage, feel great, even run a marathon one day and drop dead the next day,” Miller says.

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All it takes is a small blood clot getting stuck in an artery that’s halfway blocked.

That’s what happened to NBC News’ Washington bureau chief and “Meet the Press” host Tim Russert, who died at age 58 in 2008, says Dr. John Harold, president of the American College of Cardiology and a heart specialist at Cedars-Sinai Medical Center in Los Angeles.

Russert died at work, suddenly, quietly and without warning. He had been taking heart drugs, exercising and had a recent physical exam.

“In many patients who have a heart attack, the first symptom is sudden death and they don’t even make it to a hospital,” Harold says. “When (Russert) was autopsied, doctors found that some of the plaque that had built up in an artery broke off, causing a heart attack.”

It was in an artery known as the “widowmaker”, Harold says: the left anterior descending coronary artery. A clot there can cause the heart to stop beating normally and instead vibrate frantically in what’s called fibrillation. Quick use of a defibrillator can save people, but it has to be quick.

“This is not all that unusual,” Harold says. “We hear about it with famous media reporters and actors, but we see it every day in hospitals across the country.”

Heart disease deaths have actually decreased in recent years, thanks in part to drugs that lower blood pressure and cholesterol, and also because of a huge reduction in smoking, from 40 percent of the adult population in the early 1960s to 18 percent now. Implanted defibrillators can reduce the death rate by 25 percent, but they are pricey.

And there are better tests for heart disease risks, but they are far from perfect, Harold says

“You could have had a stress test the day before, passed it, and have a heart attack or stroke the next day,” he says.

“It sometimes is so perplexing. We can’t always diagnose those individuals that seemingly are in a state of excellent health and then die suddenly. We don’t have all the tools at present time.”

While a lack of exercise and a fat-and-meat laden Western diet add a huge amount of risk, heart disease can affect people who are not overweight, who exercise and who do not overeat. Harold says he is at meeting of cardiologists who are discussing a recent study that showed 4,000-year-old mummies had hardening of the arteries when they died.

“It’s no new disease. It has been around here for millennia,” Harold says.

There are some symptoms that people and their loved ones should look for, Miller and Harold advise.

They include:

Any type of chest pain that lasts for more than a few seconds



A general feeling of fatigue that doesn’t have an obvious cause



In women, a sudden stomach upset or nausea



Pain that spreads to either arm



The American Heart Association also advises that a feeling the heart is skipping or labored breathing means a trip to the emergency room could be in order.