The sudden death of Kannada actor-producer Dileep Raj at 47 after a reported massive heart attack has once again drawn attention to a troubling trend: seemingly active men in their 40s and 50s collapsing without warning from cardiac events.

Raj, known for films like Milana and U-Turn, was reportedly rushed to hospital after suffering the attack early Wednesday but could not be revived. His death has shocked the Kannada film industry and reignited concerns over the suddenness of massive heart attacks.

But according to Dr Ranjan Shetty, lead cardiologist and medical director at Sparsh Hospital, Bengaluru, what often looks like an unexpected collapse is usually the endpoint of years of silent plaque build-up inside coronary arteries. “The event is sudden but the blockage is not, it has been building up. There could have been undiagnosed underlying conditions, a family history which most patients may not be aware of or even the cholesterol history in their genetic tree,” he says. Excerpts:

A massive heart attack seems sudden because the final event happens in minutes, even though the disease process usually builds silently over years. Fatty plaque gradually accumulates inside the arteries of the heart over time due to factors like high cholesterol, smoking, diabetes, high blood pressure, chronic stress, poor sleep, sedentary behaviour or genetic predisposition. These trigger inflammation which weakens the arteries and speeds up fat deposition. While this process goes on, there are no symptoms at all, which is why many people feel completely fine.

The sudden part usually begins when one of these plaques, even a smaller one, becomes unstable and ruptures. The body treats this rupture like an injury and rapidly forms a blood clot at the site. If the clot completely blocks the artery, blood flow to part of the heart muscle stops abruptly. Without oxygen, heart muscle cells begin dying within minutes.

If the blocked artery is a major one, like the left anterior descending artery, the damage can be extensive and fast, which is why people refer to it as a “massive heart attack.”

Dangerous plaques are always not the biggest ones. So a person may not have severe artery narrowing that causes warning symptoms like exertional chest pain. Smaller, unstable plaques are actually more likely to rupture, making the first sign of heart disease a sudden collapse. There are also triggers that can tip a vulnerable plaque over the edge: Sudden intense physical exertion, extreme emotional stress that keeps stress hormones elevated, sleep deprivation, dehydration, uncontrolled blood pressure, smoking and drinking alcohol.

By then, silent plaque may have been building for decades, while work stress, metabolic strain and lifestyle pressures peak. This age bracket is often when multiple risk factors converge. By the time many men reach their mid-40s, they have spent two decades accumulating the effects of chronic stress, erratic sleep, sedentary routines, poor diet, smoking, alcohol consumption and untreated metabolic issues such as high blood pressure or insulin resistance.

This means damage can begin silently in the 30s, while symptoms often surface in the 40s or 50s. A normal-looking cholesterol report can create false reassurance. It cannot show that vulnerable plaque had already formed in his arteries.

An actor in the entertainment industry would be affected by long shoots, disrupted circadian rhythms, stress and irregular eating patterns.

One reason these deaths are so unsettling is that many victims appear outwardly healthy. They may not be visibly overweight. They may exercise occasionally. Some may have no diagnosed illness.

But cardiovascular risk in Indian men is often driven by what we call “metabolically unhealthy normal weight.” The person may look fit but carry visceral fat, inflammation and hidden arterial plaque.

Many men in this age group dismiss early symptoms. Chest tightness gets blamed on acidity. Shortness of breath is attributed to fatigue. Jaw discomfort or back pain is ignored. In some cases, the first warning may not even be chest pain but unexplained sweating, nausea, breathlessness or sudden exhaustion.

By the time medical help is sought, the artery may already be critically blocked. Calcium score testing and advanced imaging often reveal plaque long before symptoms appear.

Indian men should go for regular cardiac risk profiling, including lipid studies and blood pressure checks from their 20s and 30s depending on early markers. Regularly screen for diabetes and insulin resistance and study your family history for cholesterol and deaths of family members in their 40s and 50s. That is an automatic alarm call to get tested and monitored from your 20s.

If risk factors exist, tests such as coronary calcium scoring (a quick, affordable, non-invasive CT scan of the heart) can detect silent plaque.

A heart attack at 47 is often not about what happened that morning. It reflects what the body has been signalling and what has been ignored for years.