Download Sudden Cardiac Death

Inhospital SCD
Doc.Dr Emir Fazlibegović,ESC,FESC
Prof.Dr Mustafa Hadžiomerović,
ESC,FESC
5th International Congress of
cardiologysts and angyologysts of
Bosnia and Herzegovina,Sarajevo
2010.
Time references in SCD
Biological Model of SCD
Magnitude of SCA in the U.S.
Stroke3
167,366
Lung Cancer2
157,400
Breast Cancer2
40,600
AIDS1
42,156
1
2
3
4
SCA claims
more lives
each year
than these
other
diseases
combined
450,000
SCA4
#1 Killer in
the U.S.
U.S. Census Bureau, Statistical Abstract of the United States: 2001.
American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.
2002 Heart and Stroke Statistical Update, American Heart Association.
Zheng Z. Circulation. 2001;104:2158-2163.
Magnitude of SCA in the U.S.
~450,000 per year1
 1,200 per day
• 1 every 80 seconds
 Although SCA is the first presentation
of cardiac disease in 20-25% of
patients, most cases occur in patients
with clinically recognized heart
disease.2

1 Zheng
2
Z. Circulation. 2001;104::2158-2163.
Myerburg RJ, Heart Disease, A textbook of Cardiovascular Medicine. 6th ed. 2001. W.B. Saunders, Co.
SCA Different from MI
SCA
Caused by heart electrical system
problem.
MI
Occurs when one or more of the
arteries that supply blood to the heart
muscle becomes blocked. The affected
area loses blood supply (ischemia)
and results in damage to the heart
tissue.
SCA and MI Symptoms
SCA Symptoms:
 Collapse and
loss of
consciousness
 Cessation of
normal
breathing
 Loss of pulse
and blood
pressure
SCA has few to no
premonitory signs
and death is usually
rapid--within one
hour.
www.americanheart.org
MI Symptoms:

Uncomfortable pressure, fullness,
squeezing, or pain in the center of the
chest lasting more than few minutes Pain
spreading to the shoulders, neck, or
arms Chest discomfort with
lightheadedness, fainting, sweating,
nausea, or shortness of breath Atypical
chest pain, stomach or abdominal pain
Nausea or dizziness Shortness of breath
and difficulty breathing Unexplained
anxiety, weakness, or fatigue
Palpitations, cold sweat, or paleness
An impending MI typically has many premonitory signs
that may develop over the course of hours or days.
Etiology of SCD
-An estimated 13 million people had coronary heart
disease (CHD) in the U.S. in 2002. 1
-Sudden death was the first manifestation of CHD in
50% of men and 63% of women. 1
-CHD accounts for at least 80% of sudden cardiac
deaths in Western cultures.3
Etiology of Sudden Cardiac Death2,3
5% Other*
15%
Cardiomyopathy
* ion-channel abnormalities, valvular or congenital heart disease, other causes
80%
Coronary
Heart
Disease
1
American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex.: American Heart Association; 2002.
2
Adapted from Heikki et al. N Engl J Med, Vol. 345, No. 20, 2001.
3
Myerberg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. P. 895.
Causes of in-hospital mortality


The cause of death in hospital is most
often noncardiac, usually being due to
anoxic encephalopathy or to respiratory
complications from long-term respirator
dependence
Only about 10 percent of patients die from
recurrent arrhythmia, while approximately
30 percent die from a low cardiac output
or cardiogenic shock
PROVOKING FACTORS


Electrolyte disturbances
• Any reversible metabolic abnormalities
should be identified and corrected,
particularly hypokalemia and
hypomagnesemia which may predispose
to ventricular tachyarrhythmias
Antiarrhythmic drugs
• Whenever possible, antiarrhythmic
drugs should be discontinued prior to
any diagnostic studies
PROVOKING FACTORS


Use of an illicit drug such as cocaine
can directly cause arrhythmia or
produce coronary artery vasospasm
and ischemia
A prolonged QT interval which may
be acquired (due, for example, to a
drug or electrolyte disturbance) or
inherited
Arrhythmic Cause of SCD
12%
Other Cardiac
Cause
88%
Arrhythmic
Cause
.
Albert CM. Circulation. 2003;107:2096-2101
Underlying Arrhythmias of
Sudden Cardiac Arrest
Torsades de Pointes
13%
Bradycardia
17%
VT
62%
Bayés de Luna A. Am Heart J. 1989;117:151-159.
Primary VF
8%
Per 100,000 Standard US Population
SCD Rates for Males and
Females
White
Black
American Indian/Alaska Native
Asian/Pacific Islander
600
502.7
500
407.1
400
336.1
300
270.5
258.8
212.6
200
130.0
100
153.4
0
Males
Females
.
Zheng Z. Circulation. 2001;104(18):2158-2163
Incidence of Sudden Death Increases
with Age
During a 38 years follow-up of subjects in the Framingham Heart Study, the annual
incidence of sudden death increased with age in both men and women.However, at
each age, the incidence of sudden death is higher in men than women. (Am Heart J
1998; 136:205)
SCD gender
300
270 257
250 232
296
275 272
253 242
241
209
200
150 150
100
50
171
143 133
162 164
174 185
144
122
100
96 93
92
86 82
85 85
84
78
78
72
72
72
65
64 68
61 61
54
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
0
No. Death
No. SCD
MEN
FEME
SCD age
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
200
185
174
171
180
162 164
157
144
160 150
143 133
137
133 122
140
122
123 114
123
113
120
101
97
100
80
60
40 33 40
28 30 27 29 23 21 33 23
20
12
8
5
4
4
2
2
2
1
1
0
No. SCD
< 45
45-65
> 65
30%
8%
1%
1%
CH
F
0%
A.
AI
M
M
EZ
EN
TE
RI
SU
CA
DD
E
EN
DE
AT
H
10%
9%
FV
13% 14%
BO
SI
S
20%
TH
RO
M
70%
IC
AH
V
FOE
DE
CA
M
RD
A
IA
C
AR
RE
ST
SC
D
AO
RT
SH
.D
CO
IS
K
EC
CA
.
RD
IO
GE
NE
S
M
T
%
SCD in Clinical Hospital Mostar
(10 years)
61%
60%
50%
40%
22%
24%
6%
0%
Clinical Substrates Associated with
VF Arrest

Congestive heart failure
• The presence of CHF increases overall
mortality and the incidence of SCD in
both men and women
• AIM ,cardiogenic shock , ICV
CHF Predict Increased Sudden Death and
Overall Mortality
During a 38 years follow-up of subjects in the Framingham Heart Study, the
presence of CHF significantly increased sudden death and overall mortality in
both men and women. *P <0.001.
SCD in CHF
80%
72%
70% 63%
60%
59% 60% 58% 57%
56% 55%
63% 65%
50%
40%
30%
20%
10%
%MT SCD
29,32%
28,40%
27,97%
25,15%
23,17%
26,49%26%
22,22%
13,93% 14,37%
20
00
g
20
01
g
20
02
g
20
03
g
20
04
g
20
05
g
20
06
g
20
07
g
20
08
g
20
09
g
0%
CHF
In people diagnosed with
CHF, sudden cardiac death
occurs at 6-9 times the rate
of the general population.1
American Heart Association. Heart and Stroke Statistical –2003 Update. Dallas, Tex.: American
Heart Association: 2002.
1
Clinical Substrates Associated
with VF Arrest

Myocardial ischemia and infarction
• Acute myocardial infarction is associated
with an approximate 15% risk of VF
within the first 24 to 48 hours, with the
incidence falling to only 3 percent over
the next several days
• When VF is provoked by an AMI,
symptoms of the infarction are present
for minutes to hours before sudden
death occurs; over 80 percent of VF
episodes occur within the first 6 hours
Control Group Mortality at 2 years
SCD Rates in Post-MI
Patients with LV Dysfunction
30
28
Total Mortality
Arrhythmic Mortality
28
21
20
20
18
16
14
16
12
10
10
19,8
9,4
7
0
TRACE
CAPRICORN
EMIAT
MADIT
MUSTT
Inducible
MUSTT
Registry
MADIT II*
Total Mortality ~20-30%; SCD accounts for ~50% of the total deaths.
References in slide notes.
* MADIT-II mortality values at 20 months.
SCD in AIM
80%
72%
70% 63%
63% 65%
59% 60%
58% 57%
56% 55%
60%
50%
40%
0,2917 0,2649
0,2529
0,2469
0,2339
0,2317
0,1967
20%
0,1867
0,1729
0,1119
10%
30%
20
00
20 g
01
20 g
02
20 g
03
20 g
04
20 g
05
20 g
06
20 g
07
20 g
08
20 g
09
g
0%
%MT SCD
AIM
SCD IN ICV
80%
72%
65%
58%
70% 63%
59%
63%
60%
56% 55%
57%
60%
50%
40%
30%
20
00
20 g
01
20 g
02
20 g
03
20 g
04
20 g
05
20 g
06
20 g
07
20 g
08
20 g
09
g
22,80%
20%
17,82%
16,08% 13,58%
14,05%
14%
13,41%
10,53%
9,02%
10%
2,08%
0%
%MT SCD
ICV
SCD IN SCHOCK
CARDIONGENES
80%
70% 63%
60%
72%
60%
59%
58%57%
56% 55%
63%
65%
50%
40%
30%
20%
18,75%
18,03%
17,29% 14,63%
16,08%
12,35%
12,67%
10% 7,60%
8,62%
7,57%
20
00
20 g
01
20 g
02
20 g
03
20 g
04
20 g
05
20 g
06
20 g
07
20 g
08
20 g
09
g
0%
%MT SCD
Schock
cardiogenes
SCD in AHF
80%
72%
70% 63%
60%
59%
55%
56%
60%
58%57%
63%
65%
50%
40%
%MT SCD
30%
AHF-OEDEMA
20%
20
00
20 g
01
20 g
02
20 g
03
20 g
04
20 g
05
20 g
06
20 g
07
20 g
08
20 g
09
g
15,52%
14,29%
13,19%
10,53%
10,66%
10,67%
9,09% 8,02%
10%
8,54%
6,49%
0%
SCD in CARDIAC ARREST
80%
70% 63%
60%
58%
59%
56%
55%
57%
60%
72%
63% 65%
50%
40%
%MT SCD
30%
CARDIAC ARREST
20%
20
00
20 g
01
20 g
02
20 g
03
20 g
04
20 g
05
20 g
06
20 g
07
20 g
08
20 g
09
g
10,67%
10,49%
9,19%
10% 7,02%
8,64% 9,84% 8,05%
7,52%
3,66% 3,47%
0%
SCD on the road to Hospital
80%
72%
70% 63%
60%
59%
58% 57%
56% 55%
60%
63% 65%
50%
40%
%MT SCD
30%
SUDDEN DEATH
20%
20
00
20 g
01
20 g
02
20 g
03
20 g
04
20 g
05
20 g
06
20 g
07
20 g
08
20 g
09
g
16,39%
10,37% 9,72%
10%
6,90%
4,20%
3,24%2%
2,34%
2,26%
2,47%
0%
SCA Resuscitation Success vs.
Time*
100
90
Chance of success reduced
7 - 10% each minute
80
70
60
%
Success
*Non-linear
50
40
30
20
10
0
1
2
3
4
5
6
Time (minutes)
Cummins RO. Annals Emerg Med. 1989;18:1269-1275.
7
8
9
SCA Chain of Survival Statistics
5% estimated SCA out-of-hospital survival2,3
 Even in the best EMS/early defibrillation
programs
it is difficult to have high survival times due to
many SCA events not being witnessed and the
difficulty of reaching victims within 6-8
minutes.
• 40% SCAs not witnessed or occur in sleep1
• 80% SCAs occur at home1

1 Swagemakers
V. J Am Cardiol. 1997;30:1500-1505
2 Ginsburg W. Am J Emer Med. 1998;16:315-319.
3 Cobb LA. Circ. 1992;85:I98-102.
Sudden Cardiac Death




Incidence 400,000 - 500,000/year in
U.S.
Only 2% - 15% reach the hospital
Half of these die before discharge
High recurrence rate
Risk of Sudden Death: Data from
GISSI-2 Trial
1.00
1.00
0.98
p log-rank 0.002
0.96
Survival
Survival
0.96
0.98
0.94
0.92
0.94
0.92
0.90
0.90
0.88
0.88
p log-rank
0.0001
A
B
0.86
0.86
0
30
60
90
120
150
180
0
Days
Patients without
LV Dysfunction
30
60
90
120
Days
No PVBs
1-10 PVBs/h
> 10 PVBs/h
Patients with
LV Dysfunction
150
180
People who’ve had a heart
attack and have LV dysfunction
(less than or equal to 40%) have
a sudden death rate that’s
similar to a CHF population.
“People who’ve had
a heart attack have a
sudden death rate that’s
4-6 times
that of the general population.”1
1American
Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex.:
American Heart Association; 2002.
Treatments to Reduce SCD
Correcting Ischemia
• Revascularization
• Beta-blocker
Preventing Plaque
Rupture
• Statin
• ACE inhibitor
• Aspirin
Stabilizing Autonomic
Balance
• Beta-blocker
• ACE inhibitor
Zipes DP. Circulation. 1998;98:2334-2351.
Pitt B. N Engl J Med. 2003;348:1309-1321.
Improving Pump Function
• ACE inhibitor
• Beta-blocker
Prevention of Arrhythmias
• Beta-blocker
• Amiodarone
Terminating Arrhythmias
• ICDs
• AEDs
Prevent Ventricular
Remodeling and Collagen
Formation
• Aldosterone receptor
blockade
Symptoms in terminal episodes
Type of symptoms
Without symptom
Summ.
%
Men
%
Feme
%
t
p
9
3,63
6
4,02
3
3,03
0,422
p < 0,05
130
52,42
76
51
54
41,54
0,547
p <0,05
10
4,03
6
4,05
4
4,04
0,005
p<0,05
6
2,42
5
3,35
1
1,01
1,113
p< 0,05
10
4,03
5
3,35
5
5,05
0,639
p <0,05
Uncomfortable
1
0,41
0
0
1
1,01
1,005
p< 0,05
Chest pressure
35
14,11
20
13,42
15
15,15
0,379
p< 0,05
Palpitation
3
1,21
3
2,01
0
0
1,749
p< 0,05
Dessines
7
2,82
4
2,68
3
3,03
0,159
p< 0,05
37
14,93
24
16,1
13
13,13
0,656
p<0,05
248
100
149
60,08
99
39,92
Chest pain
Dyspnea
General failure
Nausea
Combined symptoms
Summary
Summary 1
Defibrillation is the only effective
treatment for SCA.
Few SCA victims are treated quickly
enough to survive.
Summary 2
High risk SCA patients can be identified:
low LVEF, HF, prior MI, and prior SCA or
VT/VF event.
ICD and CRT-D therapies can prevent
SCA.
Most eligible patients are not receiving
device therapy.
Some healthcare organizations have
developed care pathways to identify and
treat patients at high risk of SCA.
Summary 3
Detailed in ESC and ACC/AHA/HRS
Device Guidelines for SCD/SCA
and
VODIČ ZA SCD ESC UKBIH 2010
Epstein AE, et al. Circulation. 2008;117:e350-408.