sudden cardiac death - ccme.osu.edu - sudden... · sudden cardiac death ... severity of heart...
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Sudden Cardiac Death What an electrophysiologist thinks a
cardiologist should know
Steven J. Kalbfleisch, M.D.
Medical Director Electrophysiology Laboratory
Ross Heart Hospital
Wexner Medical Center
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Sudden Cardiac Death (SCD) Death within 1hr of sx onset
300,00-400,000 Victims Annually (0.1% of population)
SCD accounts for 50% of all cardiac related deaths and
15% of total mortality in US.
Primary Cause is Arrhythmic
Older data - VT/VF (75%), Asystole/PEA (25%)
Newer data - Asystole/PEA (50%)
Recurrence Rate is up to 30% annually among Survivors
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Incidence of SCD in Specific Populations
Myerburg RJ. Circulation.1998;97:1514-1521.
GROUP
300,000
Patients with high coronary-risk profile
Patients with previous coronary event
Patients with ejection fraction < 35%, congestive heart failure
Patients with previous out-of-hospital cardiac arrest
Patients with previous MI, low EF, and VT
General population
200,000 100,000 0
No. of Sudden Deaths Per Year
30 25 20 15 10 0
Incidence of Sudden Death (% of group)
5
Over half of
SCA victims
have no prior
symptoms
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Severity of Heart Failure Modes of Death
LANCET. 1999;353:2001-07.
12%
24%
64%
CHF
Other
Sudden Death n = 103
NYHA II
26%
15%
59%
CHF
Other
Sudden Death
n = 103
NYHA III
56%
11%
33%
CHF
Other
Sudden Death n = 27
NYHA IV
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Sudden Death Is Frequently Due To Ventricular
Tachycardia Degenerating To Ventricular Fibrillation
The rhythm recorded depends on the timing of the recording
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24 hr Holter on during CHF Event /
Respiratory Arrest
Just because asystole occurred doesn’t
mean that is what they died from!
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III
V1
AVB – An uncommon cause of SCD
Torsades with High Grade AVB
Infranodal CHB
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Sudden Cardiac Death
400,000/year
Provoking Factor Underlying Heart Disease
80% No Acute MI
20% Acute
MI
80% CAD
15%
Other
5%
None
• Non-ischemic Cardiomyopathy
• Inherited Disorders
– LQTS, Brugada’s, HCM, ARVD
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Ventricular Arrhythmias as a Cause of
Syncope / SCD
• Monomorphic Ventricular Tachycardia • Scar related
• Polymorphic VT / Ventricular fibrillation • Acute MI / ischemia / NICM
• Torsades de Pointes • Congenital long QT
• Drug / Metabolic induced
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65 yo M with CAD, s/p CABG with syncope and WCT
Sustained monomorphic VT = Scar related
65 yo M with CP in ER – PVMT / VF = think ischemia
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68 y/o woman, Hx PAF / CAD, LVEF 50%
Rx’d with Sotolol 120mg Bid
Iatrogenic SCD!
No mortality benefit with any antiarrhythmic
in any patient group
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Proven Treatment for SCD
• Bystander CPR
• External defibrillators (AEDs)
• Medications - BBs and ACEI in high
risk groups (Post MI, CHF)
• ICD therapy (including CRT in select
patients)
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JACC 1997;30:1500-5.
Out of Hospital Cardiac Arrest
Home
399
On Street
47
Public Place
31
Other
20
Work
4
Site of Cardiac Arrest
The Maastricht Study Holmberg et al,
AJC 1999
Time from Cardiac Arrest to
First Defibrillation
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ICD components
Lead + Device Transvenous SICD
ICD shock
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ICD Indications – Black / White
• OK to Implant – Secondary Prevention (aborted SCD, Sustained VT,
syncope in high risk group)
– EF < 30% / CAD / Prior MI
– EF < 35% / CHF (class II / III),
– CHF (class IV) if implanting with CRT
• Not OK to Implant (for Primary Prevention) – MI < 40 days
– Revascularization < 3 months
– CHF < 3 months
– Class IV CHF or Class I Non-ischemic
– Life expectancy < 1 yr
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Recorded 3 weeks after DC home
65 yo M with VF / Aborted SCD
Acute LAD Total Occlusion Rx’d with PTCA
EF = 25% post MI, NSVT x 25 beats
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SCD in Young Athletes 1435 athletes 1980 - 2005
Maron et al, Circ 2007
Note: CAD is still the predominate cause of SCD in older athletes
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What can you catch with an ECG?
• HCM – The largest group in the USA
• ARVD – the Largest group in Italy
• The “Channelopathies”
– Long QT
– Brugada Syndrome
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25 yo M had SCD event during
basketball game
Late gadolinium
enhancement
LV
RV
CMR
HCM with septum 3cm
and LGE
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26 yo athlete presented with LB WCT / Syncope ECG after conversion
ARVD – Episolon Waves / T Wave changes / CMR
RV CMR
RV dilation, RVEF = 40%, LVEF = 54%
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40 yo M presented after a syncopal episode ST-segment Elevation - V1 Through V3 – Type I Brugada
Family Hx of SCD – Uncle died in sleep
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The Evolution of SCD therapy Drug vs Device
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Major ICD Trials
Recent CABG
< 40 days from MI
*
*
*
= secondary prevention *