sudden cardiac death in women

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Sudden Cardiac Death in Women. Briain MacNeill Galway University Hospital Oct 6 th , 2012. Women and Heart Disease Myths and Truths. MYTH: Most women die from cancer. - PowerPoint PPT Presentation


  • Sudden Cardiac Deathin WomenBriain MacNeillGalway University HospitalOct 6th, 2012

  • Women and Heart DiseaseMyths and TruthsMYTH: 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.

  • Women and Heart DiseaseMyths and TruthsMYTH: Heart disease is a mans 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.

  • Women and Heart DiseaseMyths and TruthsMYTH: 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.

  • Women and Heart DiseaseMyths and TruthsMYTH: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



  • Well VisitPhysical examination:BMI, Pulse and Blood pressure measurementHeart murmur (supine / sitting / standing)Peripheral PulsesStigmata of Marfans SyndromePersonal History:Heart murmurSystemic hypertensionFatigabilitySyncopeExertional dyspnoeaExertional chest pain

    Family History:Premature sudden deathHeart disease in relatives

    Cardiac Risk Profile

    Exercise Capacity

    Cardiac Symptoms

    Lipid Levels

  • The #1 Preventable Risk - SmokingA. 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 4-6xs more likely to suffer a heart attack Women who smoke and take OCPs increase their risk of heart disease 30xSmoking cessation was associated with a 36% reduction in mortality among patients with CHD

  • Obesity and Coronary Heart Disease MortalityNurses Health Study: Women who never smokedRelativeRisk of CoronaryHeart DiseasemortalityBody Mass Index (kg/m2)P
  • Who to TreatPractice PreventionLow Risk Women
  • Practice PreventionIntermediate Risk Women (10-20%):Smoking CessationPhysical ActivityHeart Healthy DietWeight ReductionControl BP and LipidsClass 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

  • Practice PreventionHigh Risk Women (>20%): Class ISmoking CessationPhysical Activity/cardiac rehabHeart Healthy Diet- DASH DietWeight ReductionControl BP and Lipids- StatinASA therapyGlycemic control in DM

  • Croi My Action 1 year results

  • Croi My Action 1 year results


  • Chest Pain Algorithm

  • Not so straightforwardChest pain is the presenting symptom in
  • CHD Mortality in Younger WomenWomen under 65 suffer the highest relative CHD mortality

    Slide 28










    Figure 1. Rates of death during hospitalization for Myocardial Infarction among women and men, according to age. The interaction between sex and age was significant (P


  • Palpitations Algorithm


  • .Eur Heart J 2009;30:2631-2671

  • Cardiac SyncopeBradycardiaSA Node Dysfunction

    AV Conduction Defect

    Medication RelatedTachycardiaSupraventricular

    Ventricular- Preserved LV- Reduced LV


    Reflec Mediated

    Medication Related


  • Causes of SCDOver 35 yrs of age Coronary Heart Disease

    Under 35 yrs Cardiomyopathies Congenital Heart Disease Structurally Normal Heart (ion channel disorders, conduction disease) = SADSAnomalous coronaries Myocarditis

  • 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

  • HOCMSymptoms include :Shortness of breath with exercisechest pain (usually with exercise) Diziness (at rest or with exercise) blackouts PalpitationsNo symptoms

    Risk of sudden death ~ 1% per yearIntensive exercise can increase riskUsually identifiable on ECG and Echo

  • Other Cardiomyopathies- DilatedMay be inherited, much less commonOther causes include viral illness, drugs, alcoholMay cause shortness of breath, palpitations, blackout, sudden deathECG and echo usually identifiesOther tests may be necessaryTreatment: Medications, pacemakers and/or ICDRisk of SCD usually highest in those with poorest pump function, who usually have symptoms

  • Other Cardiomyopathies Arrhythmogenic (ARVC or ARVD)Heart may become enlargedScarring develops in heart Causes palpitations, dizzy spells, blackouts, shortness of breath, sudden deathOften inheritedMay need several tests to diagnoseECG, echo, Exercise test, Holter, Cardiac MRIMilder cases can be missed TreatmentMedicationsLifestyle modificationIf high risk, recommend ICD

  • Other inherited conditionsMarfans syndromeWeakness of walls or large blood vesselsMay be associated with tall stature and hyperflexibility, eye problemsIdentified on physical exam, echo and X-ray scansCongenital heart diseaseAbnormal development of cardiac structure(s) in the wombMilder forms generally not life-threatening< 10 % inherited, most occur spontaneouslyMitral valve prolapse1% of population have at least mild caseSevere cases may be associated with sudden deathMay be over-estimated as cause of sudden death

  • Other conditionsValve diseaseUsually causes a murmurMay cause reduction in exercise toleranceAnomalous coronariesAnatomical variant in placement of blood vesselsSome may reduce blood supply during stress or exercise but most probably dont cause problem and may be over-estimated as cause of SCDMyocarditisInflammation of heart muscleUsually thought to follow viral infection1/8 people with virus + fever have ECG changeProbably should avoid exercise during viral infectionPossible genetic predisposition to being affected by virus

  • 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-mortemSudden death occurs, and is consistent with cardiac rhythm disturbance, but post-mortem examination finds no abnormalityIf 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

  • Electrical problems ChannelopathiesElectricity in heart is generated by pump channels in walls of each cell in heart pump salts (Na, K, Ca) in and out of cellPump channel = ion channelIf pump malfunctions (under or over-active) changes electrical activation of heart which causes electrical instability and increases chance of arrhythmiaMay not cause symptoms unless palpitations, dizzy episodes or blackoutsUsually detectable on ECG (if looking for it) Different genes code for different pumps and mutations cause different conditions : Long QT syndromeBrugada SyndromeCatecholaminergic Polymorphic Ventricular Tachycardia (CPVT)Not identifiable on PMCan be identified on ECG (+/- exercise test and rhythm monitor) in living40% of families of those who die of SADS have inherited cause identified (mostly LQT syndrome and Brugada syndrome)


  • Etiology based on largest US data setHCM 36%Coronary Anomalies 17%Increased Cardiac Mass (possible HCM) 10%Ruptured Aorta/Dissect 5%Tunneled LAD 5%Aortic Stenosis 5%Myocarditis 3%Dilated CM 3%Idiopathic Myocdardial scarring 3%Arrhythmogenic RV dysplasia 3%OTHERSMVPCADASDBrugada SyndromeCommotio CordisComplete heart blockQT prolongation syndromeEbsteins anomalyMarfans SyndromeWolff-Parkinson White Syndrome WPWRuptured AVMSAH

  • Sports Screening Italian Protocol

  • Results of Screening in Veneto Italy

  • Conditions Screened

  • Will This Work in IrelandWe'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

  • Sudden Cardiac Deathin WomenBriain MacNeillGalway University HospitalOct 6th, 2012

    *This data supports the premise that the greater the BMI, the higher the risk of CHD mortality. This study examined nurses who never smoked. As the BMI increased beyond 26.9, the relative risk increased sharply.

    *asa risk of bleed ing from pud and hemorrhagic bleed from elevated bp*HPS says women at high risk should be on a statin regardless of LDLArbs for high risk women with clinical evidence of chf or decrease in lvef or intolerant to aceisHDL level should be greater than 50 for high risk women and use niacin or fibrate only after ldl at goal with statinContext of transient loss of consciousness (T-LOC). SCD = sudden cardiac death.Pathophysiological basis of the classification (see text). ANF = autonomic nervous failure; ANS = autonomic nervous system; BP = blood pressure; low periph. resist. = low peripheral resistance; OH = orthostatic hypotension.Luc Oliver Merson painter - According to Herodotus, an Athenian runner named Pheidippides was sent to run from Athens to Sparta to ask for assistance before the battle. He ran a distance of over 140 miles, arriving in Sparta the day after he left.[111] Then, following the battle, the Athenian army marched the 25 or so miles back to Athens at a very high pace (considering the quantity of armour, and the fatigue after the battle), in order to head off the Persian force sailing around Cape Sounion. They arrived back in the late afternoon, in time to see the Persian ships turn away from Athens, thus completing the Athenian victory.[112 Low prevalence diseases so prior probability lowQuestionnaire aloneFamily history may not be knownConditions can occur without SCDSymptoms not recognised or suppressed+ Physical examinationAllows potential pick-up cardiac murmurs (HCM, bicuspid aortic valve, MVP) and coarctation, MarfansHCM may be present without murmur, misses other cardiomyopathies+ ECGImproves pick-up of cardiomyopathies, LQT etcChanges may be subtleWill not identify anomalous coronaries

    Screening by law since 1982Everyone 12 yrs of age or older engaged in formal competitive sportRepeated every 2 yearsPerformed by Sports CardiologistPublished review of athlete screening, and causes of SCD in athlete and non-athlete population in 20069% of athletes required further screening2% of athletes disqualifiedTo insert this slide into your presentation Save this template as a presentation (.ppt file) on your computer. Open the presentation that will contain the quote slide. On the Slides tab, place your insertion point after the slide that will precede the quote slide. (Make sure you don't select a slide. Your insertion point should be between the slides.) On the Insert menu, click Slides from Files. In the Slide Finder dialog box, click the Find Presentation tab. Click Browse, locate and select the presentation that contains the quote slide, and then click Open. In the Slides from Files dialog box, select the quote slide. Select the Keep source formatting check box. If you do not select this check box, the copied slide will inherit the design of the slide that precedes it in the presentation. Click Insert. Click Close.