sudden cardiac death in women briain macneill galway university hospital oct 6 th, 2012
TRANSCRIPT
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Sudden Cardiac Deathin Women
Briain MacNeill
Galway University Hospital
Oct 6th, 2012
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Women and Heart DiseaseMyths and Truths
• MYTH: Most women die from cancer.
• TRUTH: Heart disease is the leading cause of death of women in North America and Europe. Nearly five times as many women will die from heart attacks alone this year than will die from breast cancer.
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Women and Heart DiseaseMyths and Truths
• MYTH: Heart disease is a man’s problem.
• TRUTH: Since 1984, more women than men have died of heart disease each year. Women are 28% more likely than men to die within the first year after a heart attack.
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Women and Heart DiseaseMyths and Truths
• MYTH: Only older women have heart disease.
• TRUTH: The rate of sudden cardiac death of women in their 30s and 40s is increasing much faster than in men their same age - rising 21 percent in the 1990s.
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Women and Heart DiseaseMyths and Truths
• MYTH: Women and men with heart disease get the same care.
• TRUTH: Women are less likely to receive Aspirin, beta blockers, statins , ACE inhibitors and defibrillators. Men are 52% more likely to be referred for angiography
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SUDDEN CARDIAC DEATH
IN WOMEN
WELL VISITS
SPORTSCLEARANCE
PALPITATIONS
SYNCOPEFAMILY
SCREENING
CHEST PAIN
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SUDDEN CARDIAC DEATH
IN WOMEN
WELL VISITS
SPORTSCLEARANCE
PALPITATIONS
SYNCOPEFAMILY
SCREENING
CHEST PAIN
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Well Visit
Physical examination:BMI, Pulse and Blood pressure measurementHeart murmur (supine / sitting / standing)Peripheral PulsesStigmata of Marfans Syndrome
Personal History:Heart murmurSystemic hypertensionFatigabilitySyncopeExertional dyspnoeaExertional chest pain
Family History:Premature sudden deathHeart disease in relatives
Cardiac Risk Profile
Exercise Capacity
Cardiac Symptoms
Lipid Levels
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The #1 Preventable Risk - Smoking• A. 50% of heart attacks among women are
due to smoking. • Smokers tend to have their first heart
attack 10 years earlier than nonsmokers.• Smokers are 4-6x’s more likely to suffer a
heart attack • Women who smoke and take OCP’s
increase their risk of heart disease 30x• Smoking cessation was associated with a
36% reduction in mortality among patients with CHD
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Obesity and Coronary Heart Disease Mortality
0
1
2
3
4
5
6
<19 19.0-21.9
22.0-24.9
25.0-26.9
27.0-28.9
29.0-31.9
>32.0
Nurses’ Health Study: Women who never smoked
RelativeRisk of CoronaryHeart Diseasemortality
Body Mass Index (kg/m2)
P<0.001 for trendManson JR, et al. N Engl J Med. 1995;333:677-685.
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Who to TreatPractice Prevention
Low Risk Women <10%:
Intervention is useful and effective:
Lifestyle InterventionsSmoking CessationPhysical ActivityHeart Healthy Diet
Weight ReductionTreat Individual CVD risk factors
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Practice Prevention
Intermediate Risk Women (10-20%): Smoking Cessation
Physical Activity
Heart Healthy Diet
Weight ReductionControl BP and Lipids
Class Ila- most scientific evidence favors this type of therapy:
ASA Rx- as long as BP is controlled (hemorrhagic stroke) and low risk of GI bleed
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Practice Prevention
High Risk Women (>20%): Class ISmoking CessationPhysical Activity/cardiac rehabHeart Healthy Diet- DASH DietWeight ReductionControl BP and Lipids- StatinASA therapyGlycemic control in DM
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Croi My Action – 1 year results
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Croi My Action – 1 year results
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SUDDEN CARDIAC DEATH
IN WOMEN
WELL VISITS
SPORTSCLEARANCE
PALPITATIONS
SYNCOPEFAMILY
SCREENING
CHEST PAIN
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Chest Pain Algorithm
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Not so straightforwardChest pain is the presenting symptom in <50% of womenAlmost half of MIs in women present with SOB, nausea,
indigestion, fatigue and shoulder painAtypical symptoms contribute to later presentation and higher
rates of misdiagnosis.Women presenting with MI and CAD are more likely to be
older, have a history of DM, HTN, Hyperlipids, CHF, and unstable angina than male counterparts.
Women were less likely have an ECG, antianginal therapy or invasive mangaement.
Women were less likely to enroll in cardiac rehabilitation after an MI or bypass surgery.
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CHD Mortality in Younger Women
2.94.1
5.7
8.2
10.7
14.4
18.4
21.8
25.3
6.17.4
9.5
11.1
13.4
16.6
19.1
21.5
24.2
0
5
10
15
20
25
30
< 50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Dea
th d
urin
g H
ospi
taliz
atio
n (%
) Men
Women
Figure 1. Rates of death during hospitalization for Myocardial Infarction among w omen and men, according to age. The interaction betw een sex and age w as signif icant (P<0.001).
Women under 65 suffer the highest relative CHD mortality
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SUDDEN CARDIAC DEATH
IN WOMEN
WELL VISITS
SPORTSCLEARANCE
PALPITATIONS
SYNCOPEFAMILY
SCREENING
CHEST PAIN
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Palpitations AlgorithmHistory, Physical, ECG
Structural Heart Disease Unlikely Structural Heart Disease Suspected
ECHO, Holter, Cardiac ReviewLabs including TFTs, Drug Screen
Daily Symptoms?
24 or 48 hour Holter Event Monitor / LoopYes No
Palpitations During NSRReassurance
Consider alternatives
NonVentricular ArrhythmiaTreat Cause
Routine cardiac evaluation
Ventricular ArrhythmiaUrgent Cardiac ReviewAngio, MRI, EP study
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SUDDEN CARDIAC DEATH
IN WOMEN
WELL VISITS
SPORTSCLEARANCE
PALPITATIONS
SYNCOPEFAMILY
SCREENING
CHEST PAIN
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.Eur Heart J 2009;30:2631-2671
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Cardiac Syncope
Bradycardia
SA Node Dysfunction
AV Conduction Defect
Medication Related
Tachycardia
Supraventricular
Ventricular- Preserved LV- Reduced LV
Hypotension
Hypoperfusion
Reflec Mediated
Medication Related
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SUDDEN CARDIAC DEATH
IN WOMEN
WELL VISITS
SPORTSCLEARANCE
PALPITATIONS
SYNCOPEFAMILY
SCREENING
CHEST PAIN
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Causes of SCD• Over 35 yrs of age
– Coronary Heart Disease
• Under 35 yrs – Cardiomyopathies – Congenital Heart Disease – ‘Structurally Normal Heart’ (ion channel
disorders, conduction disease) = SADS– Anomalous coronaries – Myocarditis
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Hypertrophic cardiomyopathy (HOCM)
Increased thickness of heart muscleMost common inherited cardiac diseasePrevalence
> 1 in 500 people carry gene>11000 in 32 counties90% of cases thought to be inherited (runs in family)10% ‘sporadic’ – pass on to their children?Approx 50% who inherit genetic change develop full-
blown condition (‘incomplete penetrance’)
Inheritance pattern Autosomal Dominant= 50% risk of inheriting gene if parent affected
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HOCM
• Symptoms include :– Shortness of breath with exercise– chest pain (usually with exercise) – Diziness (at rest or with exercise) – blackouts – Palpitations– No symptoms
• Risk of sudden death ~ 1% per year• Intensive exercise can increase risk• Usually identifiable on ECG and Echo
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Other Cardiomyopathies- DilatedMay be inherited, much less common
Other causes include viral illness, drugs, alcohol
May cause shortness of breath, palpitations, blackout, sudden death
ECG and echo usually identifies
Other tests may be necessary
Treatment: Medications, pacemakers and/or ICD
Risk of SCD usually highest in those with poorest pump function, who usually have symptoms
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Other Cardiomyopathies – Arrhythmogenic (ARVC or ARVD)
• Heart may become enlarged• Scarring develops in heart • Causes palpitations, dizzy spells, blackouts,
shortness of breath, sudden death• Often inherited• May need several tests to diagnose
– ECG, echo, Exercise test, Holter, Cardiac MRI• Milder cases can be missed • Treatment
– Medications– Lifestyle modification– If high risk, recommend ICD
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Other inherited conditions• Marfan’s syndrome
– Weakness of walls or large blood vessels– May be associated with tall stature and hyperflexibility, eye
problems– Identified on physical exam, echo and X-ray scans
• Congenital heart disease– Abnormal development of cardiac structure(s) in the womb– Milder forms generally not life-threatening– < 10 % inherited, most occur spontaneously
• Mitral valve prolapse– 1% of population have at least mild case– Severe cases may be associated with sudden death– May be over-estimated as cause of sudden death
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Other conditions
• Valve disease– Usually causes a murmur– May cause reduction in exercise tolerance
• Anomalous coronaries– Anatomical variant in placement of blood vessels– Some may reduce blood supply during stress or exercise but
most probably don’t cause problem and may be over-estimated as cause of SCD
• Myocarditis– Inflammation of heart muscle– Usually thought to follow viral infection– 1/8 people with virus + fever have ECG change– Probably should avoid exercise during viral infection– Possible genetic predisposition to being affected by virus
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Sudden Arrhythmic (Adult) Death Syndrome (SADS)
‘Diagnosis of exclusion’ - Electrical problem is cause of death, but no electrical activity after death so not detectable at post-mortem
Sudden death occurs, and is consistent with cardiac rhythm disturbance, but post-mortem examination finds no abnormality
If post-mortem not carefully doneStructural cause of death may be missedMinor abnormalities may be incorrectly recorded as
cause of sudden death True number of SCD which are actually due to SADS
probably under-estimated
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Electrical problems – ‘Channelopathies’• Electricity in heart is generated by pump channels in walls of each cell in
heart – pump salts (Na, K, Ca) in and out of cell– Pump channel = ion channel
• If pump malfunctions (under or over-active) changes electrical activation of heart which causes electrical instability and increases chance of arrhythmia
• May not cause symptoms unless palpitations, dizzy episodes or blackouts
• Usually detectable on ECG (if looking for it) • Different genes code for different pumps and mutations cause different
conditions : – Long QT syndrome– Brugada Syndrome– Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
• Not identifiable on PM• Can be identified on ECG (+/- exercise test and rhythm monitor) in living• 40% of families of those who die of SADS have inherited cause identified
(mostly LQT syndrome and Brugada syndrome)
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SUDDEN CARDIAC DEATH
IN WOMEN
WELL VISITS
SPORTSCLEARANCE
PALPITATIONS
SYNCOPEFAMILY
SCREENING
CHEST PAIN
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Piermario Morosini Fabrice Muamba
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Etiology based on largest US data set
1) HCM – 36%2) Coronary Anomalies 17%3) Increased Cardiac Mass
(possible HCM) 10%4) Ruptured Aorta/Dissect 5%5) Tunneled LAD 5%6) Aortic Stenosis 5%7) Myocarditis 3%8) Dilated CM 3%9) Idiopathic Myocdardial
scarring 3%10)Arrhythmogenic RV dysplasia
3%
•OTHERS…•MVP•CAD•ASD•Brugada Syndrome•Commotio Cordis•Complete heart block•QT prolongation syndrome•Ebstein’s anomaly•Marfan’s Syndrome•Wolff-Parkinson White Syndrome – WPW•Ruptured AVM•SAH
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Sports Screening – Italian Protocol
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Results of Screening in Veneto Italy
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Conditions Screened
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Piermario Morosini Fabrice Muamba
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Will This Work in Ireland
“We're taking this match awful seriously.We're training three times a week now, and some of the boys are off the beer since Tuesday.”Offaly hurler,In the week before a Leinster hurling final vs. Kilkenny.
“The stopwatch has stopped. It's up to God and the referee now. The referee is Pat Horan. God is God.”Micheal O Muircheartaigh
“Sean Og O'Hailpin... his father's from Fermanagh, his mother's from Fiji, neither a hurling stronghold.”Micheal O Muircheartaigh
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Sudden Cardiac Deathin Women
Briain MacNeill
Galway University Hospital
Oct 6th, 2012