1. SUDDEN CARDIAC
ARREST
DR. D. B. PAHLAJANI
MD,FACC,FSCAI
Consultant Cardiologist & Chief of Cardiac Catherization
Laboratory, Breach Candy Hospital Mumbai
2. 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,6th
ed.W.B. Saunders 2001:1
4. 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
5. 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.
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
6. 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
8. 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*
9. Arrhythmic Cause of SCD
Albert CM. Circulation. 2003;107:2096-2101.
12%
Other Cardiac
Cause
88%
Arrhythmic
Cause
10. Bayés de Luna A. Am Heart J. 1989;117:151-159.
Underlying Arrhythmias of
Sudden Cardiac Arrest
Bradycardia
17%
VT
62% Primary VF
8%
Torsades de Pointes
13%
12. 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 ejection
fraction <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
13. Heart Failure and Sudden Death
5
8
7
15
0
2
4
6
8
10
12
14
16
Age-adjustedannual
rate/1000
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.
14. Severity of Heart Failure
Modes of Death
MERIT-HF Study Group. Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomizedMERIT-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
SuddenSudden
DeathDeath
n = 103n = 103
NYHA IINYHA II
26%26%
15%15%
59%59%
CHFCHF
OtherOther
SuddenSudden
DeathDeath
n = 103n = 103
NYHA IIINYHA III
56%56%
11%11%
33%33%
CHFCHF
OtherOther
SuddenSudden
DeathDeath
n = 27n = 27
NYHA IVNYHA IV
The greatest opportunity for
SCD prevention is in patients
that have mild to moderate
CHF.
15. 1
Moss A, et al. N Engl J Med. 1996;335:1933–40.
2
Buxton, A, et al; N Engl J Med. 1999;341:1882–90.
3
AVID Investigators; N Engl J Med. 1997;337:1576–83.
4
Moss, 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
17. 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
18. 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
19. % Witnessed VF Patients Surviving to Hospital Discharge
49%
7%
74%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Receiving shock <3
min. after collapse
(26 / 35)
Receiving shock >3
min. after collapse
(27 / 55)
National average
Sudden Cardiac Arrest (SCA)
“Chain of Survival” Third link – Early
Defibrillation
20. SCD Rates in Post-MI Patients
with LV Dysfunction
21
19.8
14
10
7
16 16
12
9.4
28
18
20
28
0
10
20
30
TRACE CAPRICORN EMIAT MADIT MUSTT
Inducible
MUSTT
Registry
MADIT II*
ControlGroupMortalityat2years
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.
21. SCD Rates in CHF Patients with LV
Dysfunction
17
8
20
15
9
19
7
6
4
11
0
10
20
30
CHF-STAT GESICA SOLVD V-HeFT I MERIT-HF CIBIS-II CARVEDILOL-US
ControlGroupMortality
Total Mortality
Sudden Death
Total Mortality ~15-40%; SCD accounts for ~50% of the total deaths.
12 months 16 months41.4 months 27 months13 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.
Notes de l'éditeur
Death is universally arrhythmic sudden death
Focusing on cardiac arrest survivors is NOT the answer because these patients represent only a very small percentage of the total number of patients who experience SCA each year. To address the greatest number of patients, primary prevention therapies will be required. Today, we can effectively identify/treat a very small portion of the total number of patients who experience SCA. SCD-HeFT may significantly increase our ability to treat high-risk heart failure patients.
The proportionate contribution of SCD to total mortality in HF associated with reduced left ventricular function has not changed substantially between the Framingham data and now.
Kannel WB, Wilson PWF, D&apos;Agostino RB, Cobb J.
Sudden coronary death in women.
Am Heart J 1998 Aug; 136: 205-212
Interestingly, most patients who suffer from sudden cardiac death (64%) are the patients who are minimally symptomatic with Class II heart failure. The sickest, most symptomatic patient (Class IV) experience heart failure deaths (56%) from pump failure, rather than sudden cardiac death (33%).
It is important to remember that although it can be said that a heart failure patient in NYHA class II may have a higher risk of SCD, their relative annual risk of dying is less than the other NYHA classes.
The SCD-HeFT Trial (Sudden Cardiac Death in Heart Failure Trial) which enrolled NYHA class II and III patients, hopes to answer whether patients in these classes are truly at a higher risk for SCD and need protection.
TRACE: Kober L, et al. N Engl J Med 1995; 333: 1670-6.
CAPRICORN: The CAPRICORN Investigators. Lancet 2001; 357: 1385-90.
EMIAT: Julian DG, et al. 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. Journal of Interventional Cardiac Electrophysiology 9, 203-206, 2003. 3) 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.
CHF-STAT: Singh SN, et al. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. N Engl J Med 1995; 333: 77-82.
GESICA: Doval, HC. Lancet. 1994.
SOLVD: Cooper H, et al. Dirueticsand Risk of Arrhythmic Death in Patients with Left Ventricularl Dysfunction. Circulation. 1999; 100: 1311-1315.
V-HEFT I: Goldman S, Johnson G, Cohn JN, Cintron G, Smith R, Francis G. Mechanism of death in heart failure. The Vasodilator-Heart Failure Trials. The V-HeFT VA Cooperative Studies Group. Circulation. 1993 Jun;87(6 Suppl):VI24-31
MERIT-HF: Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL randomized intervention trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 353: 2001-07.
CIBIS II: The Cardiac Insufficiency Bisoprolol Study II (CIBIS II): a randomized trial. THE LANCET: 353: 9-13.
CARVEDILOL-US: The Effect of Carvedilol on Morbidity and Mortality in Patients with Chronic Heart Failure. N Engl J Med 1996; 334: 1349-55.