SUDDEN CARDIAC ARREST

DR. D. B. PAHLAJANI MD,FACC,FSCAI

Consultant Cardiologist & Chief of Cardiac Catherization Laboratory, Breach Candy Hospital Mumbai

Sudden Cardiac Death: Definition

• “Sudden cardiac death is natural death due to cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of acute symptoms, as in an individual with or without known pre-existing heart disease, but in whom the time and mode of death are unexpected”.

Gaziano JM in Braunwald Zipes Libby Heart Disease,6 th ed.W.B. Saunders 2001:1

The Epidemic of Sudden Cardiac Arrest

Sudden Cardiac Arrest• Accounts for 63% of all cardiac related deaths in the US1. • One of the most common causes of death in developed countries:

1 MMWR. Vol 51(6) Feb. 15, 2002. 2 Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th Ed. New York: WB Saunders. 1997: 742-779. 3 Zheng Z. Circulation. 2001;104:2158-2163. 4 Vreede-Swagemakers JJ et al. J Am Coll Cardiol 1997; 30: 1500-1505.

GeographyGeography IncidenceIncidence SurvivalSurvival

Worldwide 3,000,0002 <1%2

US 450,0003 ~5%2

W. Europe 400,0004 <5%4

Magnitude of SCA in the US

42,156

450,000

40,600

157,400

167,366

1 U.S. Census Bureau, Statistical Abstract of the United States: 2001.2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.3 2002 Heart and Stroke Statistical Update, American Heart Association.4 Circulation. 2001;104:2158-2163.

AIDS1

Breast Cancer2

Lung Cancer2

Stroke3

Sudden Cardiac Arrest 4

SCA claims more lives each year than these other diseases combined

The #1 Cause of Death

Resuscitated Cardiac Arrest-Prognosis

• 48749 STEMI• 5308 (10.9%) CA• 157 (29.3%) died on the day of admission• Increased risk of death during index hosp (HR

3.69 • 30 days HR 1.5• Following 30 days HR 1.1

Albert Alahmar et al,Heart,April 24,2014

Etiology of Sudden Cardiac Death

Coronary Heart Disease• An estimated 13 million people had CHD in the U.S. in 2002. 1

• Sudden death was the first manifestation of coronary heart disease in 50% of men and 63% of women. 1

• CHD accounts for at least 80% of sudden cardiac deaths in Western cultures.3

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.

Etiology of Sudden Cardiac DeathEtiology of Sudden Cardiac Death2,32,3OTHERS

* ion-channel abnormalities, valvular or congenital heart disease, other causes

80%Coronary

Heart Disease

15%Cardiomyopathy

5% Others*

Arrhythmic Cause of SCD

Albert CM. Circulation. 2003;107:2096-2101.

12%Other Cardiac

Cause

88%Arrhythmic

Cause

Bayés de Luna A. Am Heart J. 1989;117:151-159.

Underlying Arrhythmias of Sudden Cardiac Arrest

Bradycardia17%

VT62% Primary VF

8%

Torsades de Pointes13%

Heart Failure and Sudden Cardiac Death

Incidence of SCD in Specific Populations and Annual SCD Numbers

Adapted from: Myerburg RJ. Sudden Cardiac Death: Exploring the Limits of Our Knowledge. J Cardiovasc Electrophysiol Vol. 12, pp. 369-381, March 2001.

300,000200,000100,0000

Incidence of Sudden Deaths Per Year

(number)

Multiple risk subgroups

Patients with any previous coronary event

Patients with ejectionfraction <35% or CHF

Cardiac arrest, VT/VF survivors

High-risk post-MI subgroups

General adult population

3025201050

Incidence of Sudden Death(% of group)

MADIT, MUSTT, MADIT II

AVID, CASH, CIDS

SCD-HeFT

Heart Failure and Sudden Death

5

87

15

0

2

4

6

8

10

12

14

16

Age

-adj

uste

d an

nual

ra

te/1

000

Women Men

SCD-NoCHF SCD-CHF

During a 39-year 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.1

1 Redrawn from Kannel WB, Wilson PWF, D'Agostino RB, Cobb J. Sudden coronary death in women. Am Heart J 1998 Aug; 136: 205-212

60-115% increase in sudden death if

CHF present.

Severity of Heart FailureModes of Death

MERIT-HF Study Group. Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomized MERIT-HF Study Group. Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomized intervention trial in congestive heart failure (MERIT-HF). intervention trial in congestive heart failure (MERIT-HF). LANCET. LANCET. 1999;353:2001-07.1999;353:2001-07.

12%12%

24%24%

64%64%

CHFCHF

OtherOther

SuddenSuddenDeathDeathn = 103n = 103

NYHA IINYHA II

26%26%

15%15%

59%59%

CHFCHF

OtherOther

SuddenSuddenDeathDeathn = 103n = 103

NYHA IIINYHA III

56%56%

11%11%

33%33%

CHFCHF

OtherOther

SuddenSuddenDeathDeath

n = 27n = 27

NYHA IVNYHA IV

The greatest opportunity for SCD prevention is in patients that have mild to moderate CHF.

1Moss A, et al. N Engl J Med. 1996;335:1933–40.2Buxton, A, et al; N Engl J Med. 1999;341:1882–90.3AVID Investigators; N Engl J Med. 1997;337:1576–83.4Moss, A. et al; N Engl J Med. 2002;346:877–83.

MADIT1

(n=196)

MADIT-II2 (n=1232) MUSTT3 (n=704)

Age 63 64 68

LVEF 0.26 0.23 0.30

NYHA I 37% 39% 37%

NYHA II or III 63% 57% 63%

NYHA IV Excluded 4% Excluded

CAD (%) 100 100 100

Previous CABG/PTCA (%) 73/27 60/45 56/23

Post-MI trials are not heart failure trials but…… there’s a high % of symptomatic heart failure and

LV dysfunction in the post-MI trials

150 Sudden Cardiac Deaths per 100,000 persons annually in industrialized world.

40% of SCDs occur in people with no prior history of heart disease.

SCD accounts for more than 50% of cardiac mortality.

Autopsies revealed 90% victims have CAD.

Age above 40 yrs.

Incidence of Sudden Cardiac Death

Prior Episode of V.TACH

Low LVEF.

Previous Myocardial Infarction.

Coronary Artery Disease

Family History of SCD.

Cardiomyopathy

Congestive Heart Failure

Long QT Syndrome.

Right Ventricular Dysplasia.

Risk Factors of Sudden Cardiac Death

% Witnessed VF Patients Surviving to Hospital Discharge

49%

7%

74%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Receiving shock <3min. after collapse

(26 / 35)

Receiving shock >3min. after collapse

(27 / 55)

National average

Sudden Cardiac Arrest (SCA)

“Chain of Survival” Third link – Early Defibrillation

SCD Rates in Post-MI Patients with LV Dysfunction

2119.8

14

10

7

16 16

129.4

28

1820

28

0

10

20

30

TRACE CAPRICORN EMIAT MADIT MUSTTInducible

MUSTTRegistry

MADIT II*

Con

trol

Gro

up M

orta

lity

at 2

yea

rs

Total Mortality

Arrhythmic Mortality

N Engl J Med 1995; 333: 1670-6. CAPRICORN: Lancet 2001; 357: 1385-90.Lancet 1997; 349: 667-74. MADIT: Moss AJ. N Engl J Med. 1996;335:1933-40.MUSTT: 1) Buxton AE. N Engl J Med. 1999;341:1882-90. 2) Buxton AE, et al. N Engl J Med 2000; 342: 1937-45. MADIT-II: 1) Moss AJ. N Engl J Med. 2002;346:877-83, 2) Arrhythmic mortality data from: Moss AJ. Presented at ACC Late Breaking Clinical Trials, March 2002.

Total Mortality ~20-30%; SCD accounts for ~50% of the total deaths.

SCD Rates in CHF Patients with LV Dysfunction

17

8

20

15

9

19

76

4

11

0

10

20

30

CHF-STAT GESICA SOLVD V-HeFT I MERIT-HF CIBIS-II CARVEDILOL-US

Con

trol

Gro

up M

orta

lity

Total Mortality

Sudden Death

Total Mortality ~15-40%; SCD accounts for ~50% of the total deaths.

12 months 16 months41.4 months 27 months 13 months45 months 6 months

N Engl J Med 1995; 333: 77-82. GESICA: Doval, HC. Lancet. 1994. Circulation. 1999; 100: 1311-1315.Lancet 1999; 353: 2001-07. N Engl J Med 1996; 334: 1349-55.