Inhospital SCDInhospital SCD

Doc.Dr Emir Fazlibegović,ESC,FESCDoc.Dr Emir Fazlibegović,ESC,FESCProf.Dr Mustafa Hadžiomerović, Prof.Dr Mustafa Hadžiomerović,

ESC,FESCESC,FESC

5th International Congress of 5th International Congress of cardiologysts and angyologysts of cardiologysts and angyologysts of Bosnia and Herzegovina,Sarajevo Bosnia and Herzegovina,Sarajevo

2010.2010.

Time references in SCDTime references in SCD

Biological Model of SCDBiological Model of SCD

Magnitude of SCA in the U.S.Magnitude of SCA in the U.S.

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 Zheng Z. Circulation. 2001;104:2158-2163.

AIDS1

Breast Cancer2

Lung Cancer2

Stroke3

SCA4

SCA claims more lives each year than these other diseases combined

450,000

167,366

157,400

40,600

42,156

#1 Killer in the U.S.

Magnitude of SCA in the U.S.Magnitude of SCA in the U.S.

~450,000 per year~450,000 per year11

1,200 per day1,200 per day• 1 every 80 seconds1 every 80 seconds

Although SCA is the first presentation Although SCA is the first presentation of cardiac disease in 20-25% of of cardiac disease in 20-25% of patients, most cases occur in patients patients, most cases occur in patients with clinically recognized heart with clinically recognized heart disease.disease.22

1 Zheng Z. Circulation. 2001;104::2158-2163.

2 Myerburg RJ, Heart Disease, A textbook of Cardiovascular Medicine. 6 th ed. 2001. W.B. Saunders, Co.

SCA Different from MISCA Different from MI

SCASCA

Caused by heart electrical system Caused by heart electrical system problem.problem.

MIMI

Occurs when one or more ofOccurs when one or more of t thehe arteries arteries that supply blood to thethat supply blood to the heart muscle heart muscle becomes blocked.becomes blocked. The affected area loses The affected area loses blood supply (ischemia)blood supply (ischemia) and results in and results in damage to the heart tissue.damage to the heart tissue.

SCA and MI SymptomsSCA and MI SymptomsSCA Symptoms:SCA Symptoms: Collapse and Collapse and

loss of loss of consciousness consciousness

Cessation of Cessation of normal normal breathing breathing

Loss of pulse Loss of pulse and blood and blood pressure pressure

MI Symptoms:MI Symptoms: Uncomfortable pressure, fullness, Uncomfortable pressure, fullness,

squeezing, or pain in the center of the squeezing, or pain in the center of the chest lasting more than chest lasting more than ffew minuteew minutes s Pain Pain spreading to the shoulders, neck, or arms spreading to the shoulders, neck, or arms Chest discomfort with lightheadedness, Chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of fainting, sweating, nausea, or shortness of breath Atypical chest pain, stomach or breath Atypical chest pain, stomach or abdominal painabdominal pain Nausea orNausea or dizziness dizziness Shortness of breath and difficulty Shortness of breath and difficulty breathing Unexplained anxiety, weakness, breathing Unexplained anxiety, weakness, or fatigue Palpitations, cold sweat, or or fatigue Palpitations, cold sweat, or palenesspaleness

www.americanheart.org

SCA has few to no premonitory signs and death is usually rapid--within one hour.

SCA has few to no premonitory signs and death is usually rapid--within one hour. An impending MI typically has many premonitory signs

that may develop over the course of hours or days.

An impending MI typically has many premonitory signs that may develop over the course of hours or days.

Etiology of Etiology of SCDSCD--An estimated 13 million people had coronary heartAn estimated 13 million people had coronary heart disease (CHD) in the U.S. in 2002. disease (CHD) in the U.S. in 2002. 11

--Sudden death was the first manifestation of CHD in Sudden death was the first manifestation of CHD in 550% of men 0% of men and 63% of women. and 63% of women. 11

--CHD accounts for at least 80% of sudden cardiac CHD accounts for at least 80% of sudden cardiac deaths in Western deaths in Western cultures.cultures.33

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 Death2,32,3

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

80%Coronary

Heart Disease

15%Cardiomyopathy

5% Other*

Causes of in-hospital mortalityCauses of in-hospital mortality

The cause of death in hospital is most The cause of death in hospital is most often noncardiac, usually being due to often noncardiac, usually being due to anoxic encephalopathy or to respiratory anoxic encephalopathy or to respiratory complications from long-term respirator complications from long-term respirator dependence dependence

Only about 10 percent of patients die from Only about 10 percent of patients die from recurrent arrhythmia, while approximately recurrent arrhythmia, while approximately 30 percent die from a low cardiac output 30 percent die from a low cardiac output or cardiogenic shockor cardiogenic shock

PROVOKING FACTORSPROVOKING FACTORS

Electrolyte disturbancesElectrolyte disturbances • Any reversible metabolic abnormalities Any reversible metabolic abnormalities

should be identified and corrected, should be identified and corrected, particularly hypokalemia and particularly hypokalemia and hypomagnesemia which may predispose hypomagnesemia which may predispose to ventricular tachyarrhythmias to ventricular tachyarrhythmias

Antiarrhythmic drugsAntiarrhythmic drugs• Whenever possible, antiarrhythmic Whenever possible, antiarrhythmic

drugs should be discontinued prior to drugs should be discontinued prior to any diagnostic studiesany diagnostic studies

PROVOKING FACTORSPROVOKING FACTORS

Use of an Use of an illicit drugillicit drug such as cocaine such as cocaine can directly cause arrhythmia or can directly cause arrhythmia or produce coronary artery vasospasm produce coronary artery vasospasm and ischemia and ischemia

AA prolonged QT prolonged QT interval which may interval which may be acquired (due, for example, to a be acquired (due, for example, to a drug or electrolyte disturbance) or drug or electrolyte disturbance) or inheritedinherited

Arrhythmic Cause of SCDArrhythmic 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 Underlying Arrhythmias of Sudden Cardiac ArrestSudden Cardiac Arrest

Bradycardia17%

VT62% Primary VF

8%

Torsades de Pointes13%

SCD Rates for Males and SCD Rates for Males and FemalesFemales

0

100

200

300

400

500

600

Males Females

WhiteBlackAmerican Indian/Alaska NativeAsian/Pacific Islander

407.1

502.7

270.5

336.1

Per

100

,000

Sta

nd

ard

US

Po

pu

lati

on

258.8212.6

153.4

130.0

Zheng Z. Circulation. 2001;104(18):2158-2163.

Incidence of Sudden Death Increases Incidence of Sudden Death Increases with Agewith Age

During a 38 years follow-up of subjects in the Framingham Heart Study, the annual incidence of sudden death increased with age in both men and women.However, at each age, the incidence of sudden death is higher in men than women. (Am Heart J 1998; 136:205)

SCD genderSCD gender

232

150

8565

270

171

8586

257

143

6182

241

133

6172

275

162

8478

272

164

10064

209

122

6854

253

144

7272

242

174

9678

296

185

9392

0

50

100

150

200

250

300

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

No. Death

No. SCD

MEN

FEME

SCD ageSCD age

150

4

33

113

171

8

40

123143

1

28

114

133

2

30

101

162

2

27

133

164

1229

123122

2

23

97

144

121

122

174

4

33

137

185

523

157

020406080

100120140160180200

No. SCD

< 45

45-65

> 65

SCD in Clinical Hospital MostarSCD in Clinical Hospital Mostar (10 years) (10 years)

61%

0%

13% 14% 9% 8%1%

22%

1% 6%

24%

0%

10%

20%

30%

40%

50%

60%

70%

%MT SC

D

AORT. DISE

C.

SHCO

K CARDIOGEN

ES ICV

AHF-OED

EMA

CARDIAC ARREST FV AIM

THROM

BOSIS A

.MEZ

ENTERICAE

SUDDEN

DEA

THCHF

Clinical Substrates Associated with Clinical Substrates Associated with

VF ArrestVF Arrest

Congestive heart failureCongestive heart failure• The presence of CHF increases overall The presence of CHF increases overall

mortality and the incidence of SCD in mortality and the incidence of SCD in both men and womenboth men and women

• AIM ,cardiogenic shock , ICVAIM ,cardiogenic shock , ICV

CHF Predict Increased Sudden Death and CHF Predict Increased Sudden Death and Overall MortalityOverall Mortality

During a 38 years 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. *P <0.001.

SCD in CHFSCD in CHF

63%

25,15%

56%

27,97%

55%

29,32%

59%

28,40%

60%

23,17%

58%

13,93%

57%

22,22%

72%

14,37%

63%

26,49%

65%

26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

%MT SCD

CHF

In people diagnosed with In people diagnosed with CHF, sudden cardiac death CHF, sudden cardiac death occurs at 6-9 times the rate occurs at 6-9 times the rate of the general population.of the general population.11

1 American Heart Association. Heart and Stroke Statistical –2003 Update. Dallas, Tex.: American Heart Association: 2002.

Clinical Substrates Associated Clinical Substrates Associated with VF Arrestwith VF Arrest

Myocardial ischemia and infarctionMyocardial ischemia and infarction • Acute myocardial infarction is associated Acute myocardial infarction is associated

with an approximate 15% risk of VF within with an approximate 15% risk of VF within the first 24 to 48 hours, with the incidence the first 24 to 48 hours, with the incidence falling to only 3 percent over the next falling to only 3 percent over the next several days several days

• When VF is provoked by an AMI, symptoms When VF is provoked by an AMI, symptoms of the infarction are present for minutes to of the infarction are present for minutes to hours before sudden death occurs; over 80 hours before sudden death occurs; over 80 percent of VF episodes occur within the first percent of VF episodes occur within the first 6 hours6 hours

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

References in slide notes. * MADIT-II mortality values at 20 months.

SCD Rates in Post-MI SCD Rates in Post-MI Patients with LV DysfunctionPatients with LV Dysfunction

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

SCD in AIMSCD in AIM

63%

0,2339

56%

0,1119

55%

0,1729

59%

0,2469

60%

0,2317

58%

0,1967

57%

0,2917

72%

0,2529

63%

0,2649

65%

0,1867

0%

10%

20%

30%

40%

50%

60%

70%

80%

%MT SCD

AIM

SCD IN ICVSCD IN ICV

63%

22,80%

56%

16,08%

55%

10,53%

59%

13,58%

60%

13,41%

58%

9,02%

57%

2,08%

72%

17,82%

63%

14,05%

65%

14%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2000g

2001g

2002g

2003g

2004g

2005g

2006g

2007g

2008g

2009g

%MT SCD

ICV

SCD IN SCHOCK SCD IN SCHOCK CARDIONGENESCARDIONGENES

63%

7,60%

56%

16,08%

55%

17,29%

59%

12,35%

60%

14,63%

58%

18,03%

57%

18,75%

72%

8,62%

63%

7,57%

65%

12,67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

%MT SCD

Schockcardiogenes

SCD in AHFSCD in AHF

63%

10,53%

56%

9,09%

55%

14,29%

59%

8,02%

60%

8,54%

58%

10,66%

57%

13,19%

72%

15,52%

63%

6,49%

65%

10,67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

%MT SCD

AHF-OEDEMA

SCD in CARDIAC ARRESTSCD in CARDIAC ARREST

63%

7,02%

56%

10,49%

55%

7,52%

59%

8,64%

60%

3,66%

58%

9,84%

57%

3,47%

72%

8,05%

63%

9,19%

65%

10,67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

%MT SCD

CARDIAC ARREST

SCD on the road to HospitalSCD on the road to Hospital

63%

2,34%

56%

4,20%

55%

2,26%

59%

2,47%

60%

10,37%

58%

16,39%

57%

9,72%

72%

6,90%

63%

3,24%

65%

2%0%

10%

20%

30%

40%

50%

60%

70%

80%

%MT SCD

SUDDEN DEATH

Cummins RO. Annals Emerg Med. 1989;18:1269-1275.

SCA Resuscitation Success vs. SCA Resuscitation Success vs. Time*Time*

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9

% Success

*Non-linear

Time (minutes)

Chance of success reduced 7 - 10% each minute

SCA Chain of Survival StatisticsSCA Chain of Survival Statistics

5% estimated SCA out-of-hospital survival5% estimated SCA out-of-hospital survival2,32,3

Even in the best EMS/early defibrillation Even in the best EMS/early defibrillation programs programs it is difficult to have high survival times due to it is difficult to have high survival times due to many SCA events not being witnessed and the many SCA events not being witnessed and the difficulty of reaching victims within 6-8 minutes.difficulty of reaching victims within 6-8 minutes.• 40% SCAs not witnessed or occur in sleep40% SCAs not witnessed or occur in sleep11

• 80% SCAs occur at home80% SCAs occur at home11

1 Swagemakers V. J Am Cardiol. 1997;30:1500-15052 Ginsburg W. Am J Emer Med. 1998;16:315-319.3 Cobb LA. Circ. 1992;85:I98-102.

Sudden Cardiac DeathSudden Cardiac Death

IncidenceIncidence 400,000 - 500,000/year in 400,000 - 500,000/year in U.S.U.S.

Only 2% - 15% reach the hospitalOnly 2% - 15% reach the hospital Half of these die before dischargeHalf of these die before discharge High recurrence rateHigh recurrence rate

Risk of Sudden Death: Data from Risk of Sudden Death: Data from GISSI-2 TrialGISSI-2 Trial

Patients withoutPatients withoutLV DysfunctionLV Dysfunction Patients with

LV DysfunctionNo PVBs

1-10 PVBs/h

> 10 PVBs/h

0.86

A

0.88

0.90

0.92

0.94

0.96

0.98

1.00

0 30 60 90 120 150 180

Days

Su

rviv

al

p log-rank 0.002

0.88

0.90

0.92

0.94

0.96

0.98

1.00

0 30 60 90 120 150 180

DaysS

urv

ival

B

p log-rank 0.0001

0.86

People who’ve had a heart People who’ve had a heart attack and have LV dysfunction attack and have LV dysfunction

(less than or equal to 40%) have (less than or equal to 40%) have a sudden death rate that’s a sudden death rate that’s

similar to a CHF population.similar to a CHF population.

““People who’ve had People who’ve had a heart attack have a a heart attack have a

sudden death rate that’s sudden death rate that’s 4-6 times 4-6 times

that of the general population.” that of the general population.”11

1American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex.: American Heart Association; 2002.

Treatments to Reduce SCDTreatments to Reduce SCDCorrecting IschemiaCorrecting Ischemia

• RevascularizationRevascularization

• Beta-blockerBeta-blocker

Preventing Plaque Preventing Plaque RuptureRupture

• StatinStatin

• ACE inhibitorACE inhibitor

• AspirinAspirin

Stabilizing Autonomic Stabilizing Autonomic BalanceBalance

• Beta-blockerBeta-blocker

• ACE inhibitorACE inhibitor

Improving Pump FunctionImproving Pump Function

• ACE inhibitorACE inhibitor

• Beta-blockerBeta-blocker

Prevention of ArrhythmiasPrevention of Arrhythmias

• Beta-blockerBeta-blocker

• AmiodaroneAmiodarone

Terminating ArrhythmiasTerminating Arrhythmias

• ICDsICDs

• AEDsAEDs

Prevent Ventricular Prevent Ventricular Remodeling and Collagen Remodeling and Collagen FormationFormation

• Aldosterone receptor Aldosterone receptor blockadeblockade

Zipes DP. Circulation. 1998;98:2334-2351.Pitt B. N Engl J Med. 2003;348:1309-1321.

Symptoms in terminal episodesSymptoms in terminal episodes

Type of symptoms Summ. % Men % Feme % t p

Without symptom 9 3,63 6 4,02 3 3,03 0,422 p < 0,05

Chest pain 130 52,42 76 51 54 41,54 0,547 p <0,05

Dyspnea 10 4,03 6 4,05 4 4,04 0,005 p<0,05

General failure 6 2,42 5 3,35 1 1,01 1,113 p< 0,05

Nausea 10 4,03 5 3,35 5 5,05 0,639 p <0,05

Uncomfortable 1 0,41 0 0 1 1,01 1,005 p< 0,05

Chest pressure 35 14,11 20 13,42 15 15,15 0,379 p< 0,05

Palpitation 3 1,21 3 2,01 0 0 1,749 p< 0,05

Dessines 7 2,82 4 2,68 3 3,03 0,159 p< 0,05

Combined symptoms 37 14,93 24 16,1 13 13,13 0,656 p<0,05

Summary 248 100 149 60,08 99 39,92    

Summary Summary 11

Defibrillation is the only effective Defibrillation is the only effective treatment for SCA. treatment for SCA.

Few SCA victims are treated quickly Few SCA victims are treated quickly enough to survive.enough to survive.

Summary Summary 22

High risk SCA patients can be identified: low High risk SCA patients can be identified: low LVEF, HF, prior MI, and prior SCA or VT/VF LVEF, HF, prior MI, and prior SCA or VT/VF event. event. ICD and CRT-D therapies can prevent SCA.ICD and CRT-D therapies can prevent SCA.Most eligible patients are not receiving Most eligible patients are not receiving device therapy.device therapy.Some healthcare organizations have Some healthcare organizations have developed care pathways to identify and developed care pathways to identify and treat patients at high risk of SCA.treat patients at high risk of SCA.

SummarySummary 3 3

DetailedDetailed in ESC and in ESC and ACC/AHA/HRS ACC/AHA/HRS Device GuidelinesDevice Guidelines for SCD/SCA for SCD/SCA

andandVODIČ ZA SCD ESC UKBIH 2010VODIČ ZA SCD ESC UKBIH 2010

Epstein AE, et al. Circulation. 2008;117:e350-408.