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Ventricular Tachycardia (VT) and Sudden Cardiac Arrest (SCA) -Epidemiology, Etiology and Evaluation Thomas J Dresing, MD Cleveland Clinic Objectives • • • • • • What is SCA Define incidence of SCA SCA and Post-MI patients SCA and HF patients Landmark trials How to identify patients for primary prevention Sudden Cardiac Arrest is one of the Leading Causes of Death in the U.S.1-3 335,000 SCA3 41,400 Breast Cancer1 1 14,000 AIDS2 American Cancer Society. Cancer Facts and Figures 2006. CIA. The World Factbook – rank Order – HIV/AIDS – deaths. Available at: http//www.cia.gov 3 American Heart Association. 2005 Heart and Stroke Statistics Update. 2 162,500 Lung Cancer1 Only ALL cancers combined causes more deaths each year than sudden cardiac arrest. Septicemia Nephritis Alzheimer’s Disease Influenza/Pneumonia Diabetes Accidents/Injuries Chronic Lower Respiratory Diseases Cerebrovascular Disease Other Cardiac Causes Sudden Cardiac Arrest (SCA) All Cancers National Vital Statistics Report, Vol 49 (11), Oct. 12, 2001. State-specific mortality from sudden cardiac death – United States 1999. MMWR. 2002;51:123-126. 20% 25% Cause of SCA 12% Other Cardiac Cause 88% Arrhythmic Cause Albert CM. Circulation. 2003;107:2096-2101. Underlying Arrhythmias of SCA Torsades de Pointes 13% Bradycardia 17% VT 62% Primary VF 8% B Adapted from Bayes de Luna A. Am Heart J. 1989;117:151-159. ayés de Luna A. Am Heart J. 1989;117:151-159. Who is at Risk for SCA? • • • • • A prior SCA Family history of SCA Congestive Heart Failure (CHF) Have had a Myocardial Infarction (MI) Ejection Fraction (EF) less than or equal to 35% Sudden Cardiac Arrest Risk How can we effectively identify patients at-risk? SCD-HeFT, MADIT II AVID, CASH MADIT I, MUSTT Myerburg RJ, et al. Circulation. 1998. 97:1514-1521. Epidemiology of VT & SCA Classification of Ventricular Arrhythmia By Disease Entity •Chronic coronary heart disease •Heart failure •Congenital heart disease •Neurological disorders •Structurally normal hearts •Sudden infant death syndrome •Cardiomyopathies ♥ Dilated cardiomyopathy ♥ Hypertrophic cardiomyopathy ♥ Arrhythmogenic right ventricular (RV) cardiomyopathy Audience Response Question #1 Who is at Risk for SCA? A. A patient with a prior SCA B. A patient with a family history of SCA C. A patient with Congestive Heart Failure (CHF) D. A patient who has had a Myocardial Infarction (MI) E. All of the above Audience Response Question #1 Who is at Risk for SCA? A. A patient with a prior SCA B. A patient with a family history of SCA C. A patient with Congestive Heart Failure (CHF) D. A patient who has had a Myocardial Infarction (MI) E. All of the above Epidemiology of VT & SCA Classification of Ventricular Arrhythmia By Electrocardiography •Nonsustained ventricular tachycardia (VT) ♥ Monomorphic ♥ Polymorphic •Sustained VT ♥ Monomorphic ♥ Polymorphic •Bundle-branch re-entrant tachycardia •Bidirectional VT •Torsades de pointes •Ventricular fibrillation Nonsustained Monomorphic VT Nonsustained Polymorphic VT Sustained Monomorphic VT Spontaneous conversion to NSR (12-lead ECG) Sustained Polymorphic VT Bundle Branch Reentrant VT VF with Defibrillation (12-lead ECG) Clinical Presentations of Patients with VT & SCA •Asymptomatic individuals with or without electrocardiographic abnormalities •Persons with symptoms potentially attributable to ventricular arrhythmias ♥ Palpitations ♥ Dyspnea ♥ Chest pain ♥ Syncope and presyncope •VT that is hemodynamically stable •VT that is not hemodynamically stable •Cardiac arrest ♥ Asystolic (sinus arrest, atrioventricular block) ♥ VT ♥ Ventricular fibrillation (VF) ♥ Pulseless electrical activity The most common mode of death in mild to moderate CHF is SCA NYHA II 12% 24% 64% NYHA III CHF CHF Other 26% Other 15% Sudden Death 59% Sudden Death n = 103 n = 103 SCA Pump Failure NYHA Class II 64% 12% NYHA Class III 59% 26% People who’ve had a heart attack have a sudden death rate that’s 4-6 times that of the general population • • • Studies show that a previous MI can be identified in as many as 75% of SCA patients A previous MI raises the one-year risk of SCA by 5% as a single risk factor The five-year risk of SCA for patients with a previous MI, non-sustained, inducible, nonsuppressible VT, and a LVEF < 40% is 32% Reduced left ventricular ejection fraction (LVEF) remains the single most important risk factor for overall mortality and sudden cardiac arrest No PVCs Maggioni AP. Circulation. 1993;87:312-322. 1.00 1.00 > 10 PVCs/hr 0.98 p log-rank 0.002 0.96 Survival 0.96 Survival 1-10 PVCs/hr 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 Days 0 30 60 90 120 150 Days Patients without LV Dysfunction Patients with LV Dysfunction (LVEF >35%) (LVEF < 35%) 180 SCA in Heart Failure1,2 • 1 Despite improvements in medical therapy, symptomatic HF still confers a 20-25% risk of pre-mature death in the first 2.5 yrs after diagnosis. 50% of these premature deaths are SCD (VT/VF) Bardy G. The Sudden Cardiac Death-Heart Failure Trial (SCD-HeFT) in Woosley RL, Singh S. Arrhythmia Treatment and Therapy. Copyright 2000 by Marcel Dekker, Inc. , pp. 323-342, 2 Sweeney MO. PACE. 2001;24:871-888. Audience Response Question #2 True or False? The most common cause of death in a patient with mild to moderate CHF is “pump failure”. Audience Response Question #2 True or False? The most common cause of death in a patient with mild to moderate CHF is “pump failure”. FALSE Surviving SCA Urgency of Sudden Cardiac Arrest Resuscitation Success vs. Time Chance of success reduced 7-10% every minute 100 90 80 % Success 70 60 50 40 30 20 Adapted from text: Cummins RO, 1998. Annals of Emergency Medicine. 18:1269-1275.. 10 0 1 2 3 4 5 6 Time (minutes) 7 8 9 Sudden Cardiac Arrest SCA Survival = Early Defibrillation • • Only effective treatment for SCA is an electrical shock delivered by: - Automated external defibrillator (AED) or - Implantable cardioverter-defibrillator (ICD) Time is critical – each minute of delay before defibrillation reduces survival rates by about 10% Therapies for VT Antiarrhythmic Drugs • • • • ♥ Beta Blockers: Effectively suppress ventricular ectopic beats & arrhythmias; reduce incidence of SCD ♥ Amiodarone: No definite survival benefit; some studies have shown reduction in SCD in patients with LV dysfunction especially when given in conjunction with BB. Has complex drug interactions and many adverse side effects (pulmonary, hepatic, thyroid, cutaneous) ♥ Sotalol: Suppresses ventricular arrhythmias; is more pro-arrhythmic than amiodarone, no survival benefit clearly shown ♥ Conclusions: Antiarrhythmic drugs (except for BB) should not be used as primary therapy of VA and the prevention of SCD Therapies for VT Non-antiarrhythmic Drugs ♥ Electrolytes: magnesium and potassium administration can favorably influence the electrical substrate involved in VA; are especially useful in setting of hypomagnesemia and hypokalemia ♥ ACE inhibitors, angiotensin receptor blockers and aldosterone blockers can improve the myocardial substrate through reverse remodeling and thus reduce incidence of SCD ♥ Antithrombotic and antiplatelet agents: may reduce SCD by reducing coronary thrombosis ♥ Statins: have been shown to reduce life-threatening VA in high-risk patients with electrical instability ♥ n-3 Fatty acids: have anti-arrhythmic properties, but conflicting data exist for the prevention of SCD Therapies for VT ICDs: Results from Primary and Secondary Prevention Trials Hazard ratio Trial Name, Pub Year LVEF, other features N = 196 MADIT-I 1996 0.35 or less, NSVT, EP positive 0.46 AVID 1997 N = 1016 Aborted cardiac arrest 0.62 CABG-Patch 1997 N = 900 0.35 or less, abnormal SAECG and scheduled for CABG 1.07 N = 191 CASH* 2000 Aborted cardiac arrest 0.83 CIDS 2000 N = 659 Aborted cardiac arrest or syncope 0.82 MADIT-II 2002 0.30 or less, prior MI N = 1232 0.69 DEFINITE 2004 0.35 or less, NICM and PVCs or NSVT N = 458 0.35 or less, MI within 6 to 40 days and impaired cardiac autonomic function 0.65 N = 674 DINAMIT 2004 1.08 0.35 or less, LVD due to prior MI and NICM N = 1676 SCD-HeFT 2005 0.77 0.4 0.6 ICD better 0.8 1.0 1.2 1.4 1.6 1.8 Major Implantable Cardioverter-Defibrillator Trials for Prevention of Sudden Cardiac Death Trial Year Patients (n) Additional Study Features LVEF Hazard Ratio* 95% CI p MADIT I 1996 196 < 35% NSVT and EP+ 0.46 (0.26(0.26-0.82) p=0.009 MADIT II 2002 1232 < 30% Prior MI 0.69 (0.51(0.51-0.93) p=0.016 CABGCABG-Patch 1997 900 < 36% +SAECG and CABG 1.07 (0.81(0.81-1.42) p=0.63 DEFINITE 2004 485 < 35% NICM, PVCs or NSVT 0.65 (0.40(0.40-1.06) p=0.08 DINAMIT 2004 674 < 35% 6-40 days postpost-MI and Impaired HRV 1.08 (0.76(0.76-1.55) p=0.66 SCDSCD-HeFT 2006 1676 < 35% Prior MI of NICM 0.77 (0.62(0.62-0.96) p=0.007 AVID 1997 1016 Prior cardiac arrest NA 0.62 (0.43(0.43-0.82) NS CASH† CASH† 2000 191 Prior cardiac arrest NA 0.766 ‡ 1-sided p=0.081 CIDS 2000 659 Prior cardiac arrest, syncope NA 0.82 (0.60(0.60-1.1) NS * Hazard ratios for death from any cause in the ICD group compared with the non-ICD group. Includes only ICD and amiodarone patients from CASH. ‡CI Upper Bound 1.112 CI indicates Confidence Interval, NS = Not statistically significant, NSVT = nonsustained ventricular tachycardia, SAECG = signal-averaged electrocardiogram. Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Table 5. Implantable Cardioverter Defibrillators (ICDs) Restore Heart Rhythm First-line therapy for patients at risk for SCA • ICD therapy consists of pacing, cardioversion, and defibrillation therapies to treat tachyarrhythmias. ICDs also have programmable diagnostic functions. • An ICD system includes the device, and the pacing, sensing and defibrillation lead(s). SCA Can Be Prevented… • • • The majority of cases are in patients with: – Coronary artery disease, previous MI – Low left ventricular ejection fraction – Dilated cardiomyopathy and heart failure Defibrillation is the only effective treatment option High-risk patients can be evaluated for known risk factors before they experience a Sudden Cardiac Arrest • EF remains a key indicator Audience Response Question #3 In which of the following patients is a defibrillator indicated? A. A 74 YO female with a history of coronary artery disease and a severely reduced ejection fraction (EF) B. A 25 YO male with vasovagal syncope and PVC’s C. A 82 YO male with metastatic lung cancer and CHF with an EF of 35% D. A 65 YO female with CAD and EF 45-50% who cannot take beta blockers due to fatigue or ACE-I due to cough Audience Response Question #3 In which of the following patients is a defibrillator indicated? A. A 74 YO female with a history of coronary artery disease and a severely reduced ejection fraction (EF) B. A 25 YO male with vasovagal syncope and PVC’s C. A 82 YO male with metastatic lung cancer and CHF with an EF of 35% D. A 65 YO female with CAD and EF 45-50% who cannot take beta blockers due to fatigue or ACE-I due to cough Conclusions The key to SCA prevention is to identify high risk patients BEFORE they have a SCA event. The majority of cases are in patients with: Coronary artery disease, previous MI Low left ventricular ejection fraction Dilated cardiomyopathy and heart failure