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Everybody knows somebody who has had a sudden, fatal heart attack. More than 300,000 Americans die of heart disease each year without making it to the hospital, most of them from sudden cardiac arrest, according to the American Heart Association. In about half of those cases, the heart attack itself is the first symptom.

Deaths from cardiovascular disease in general have dropped dramatically in recent years, but it is still the No. 1 killer of men and women in the U.S. — claiming more lives than cancer, chronic respiratory diseases, accidents and diabetes combined.

That's in part because, for all the advances doctors have made in understanding risk factors, lowering cholesterol with statins and propping open narrowed arteries with stents, most heart attacks are caused when tiny bits of plaque break loose and burst like popcorn kernels, forming clots that block arteries. That prevents blood from reaching areas of heart muscle, which start to die. It's hard to predict when that might happen — which is why people who never knew they had heart disease, and people who thought it was under control, still have sudden heart attacks.

"We have terrific therapies that were unimaginable 25 or 30 years ago," says E. Scott Monrad, director of the cardiac catheterization lab at Montefiore Medical Center in Bronx, N.Y. "But one of the biggest risks is dying before you even get to see a doctor."

Since the death of NBC's Tim Russert, scores of commentators on health and political blogs have offered theories about what might have been done to save him. Few details were released, other than that the "Meet the Press" moderator was being treated for asymptomatic coronary artery disease, had diabetes and an enlarged heart, and had a stress test in April.

Many blog-posters argued that Russert should have had an angiogram — an invasive diagnostic test in which the coronary arteries are injected with dye and X-rayed to spot blockages. But even if he had had the procedure an hour before the attack, doctors might not have seen anything to be alarmed about. More than two-thirds of heart attacks occur in arteries that are less than 50 percent narrowed by plaque buildup — and those are often too small to show up on an angiogram or cause much chest pain.

Similarly, the stress test Russert had is better suited to detecting significantly narrowed arteries than the small, soft unstable kind of plaque that often causes fatal blood clots.

"Time and again we see examples of unexpected cardiac disease in people who didn't know they had it," says Prediman K. Shah, director of cardiology at Cedars-Sinai Heart Institute in Los Angeles, one of many experts who think wider use of coronary calcium CT scans could help spot more people at risk of soft-plaque blockages. The non-invasive procedure takes about 15 minutes and costs a few hundred dollars. But few insurers cover it because there is scant evidence that treating people on that basis saves lives.

At a minimum, seeing a picture of the calcium lining their arteries can be a wake-up call for patients to take their coronary-artery disease seriously and to be diligent in taking medication, exercising and making other healthy lifestyle changes.

Not all heart attacks are fatal. Most of the 1.2 million Americans who had one last year survived. If the area of oxygen-starved heart muscle is small, or in the right ventricle, the heart can often keep pumping, allowing the patient to make it to a hospital, where doctors can break up the blockage with a clot-dissolving drug or catheterization. The situation becomes rapidly fatal if the heart starts beating wildly, and ineffectively, as it struggles to keep pumping. Unless it is jolted back into a normal rhythm within a few minutes, the patient's brain will starve for oxygen and shut down.

Many airports, shopping malls, schools and offices have portable automatic external defibrillators, or AEDs, on hand as well. They're designed to automatically assess a victim's heart rhythm and administer an electrical jolt as needed.

"The earlier CPR is started, the higher the rate of success," says Monrad, who says he has had several cases in which vigorous CPR in the field bought precious time and saved a life. On average, however, only a small percentage of people in full cardiac arrest are successfully revived.

For those whose disease has been diagnosed or who got treatment in time, stents, angioplasty and bypass surgery are only stop-gap measures that don't do anything to halt the progress of the underlying disease.

"It's important that each person take responsibility for taking care of themselves," says Edmund Herrold, a clinical cardiologist in New York City and professor at the Cornell University Weill Medical College.

"Get a regular checkup. Watch your weight and your blood pressure and your cholesterol and if you have diabetes, keep that under control. Exercise. Take an aspirin every day. Eliminate meat. There's no guarantee, but you can dramatically lower the risk of a cardiac event if you pay attention to these issues."