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Inhospital SCD Doc.Dr Emir Fazlibegović,ESC,FESC Prof.Dr Mustafa Hadžiomerović, ESC,FESC 5th International Congress of cardiologysts and angyologysts of.

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Presentation on theme: "Inhospital SCD Doc.Dr Emir Fazlibegović,ESC,FESC Prof.Dr Mustafa Hadžiomerović, ESC,FESC 5th International Congress of cardiologysts and angyologysts of."— Presentation transcript:

1 Inhospital SCD Doc.Dr Emir Fazlibegović,ESC,FESC Prof.Dr Mustafa Hadžiomerović, ESC,FESC 5th International Congress of cardiologysts and angyologysts of Bosnia and Herzegovina,Sarajevo 2010.

2 Time references in SCD

3 Biological Model of SCD

4 Magnitude of SCA in the U.S. 1 U.S. Census Bureau, Statistical Abstract of the United States: American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures Heart and Stroke Statistical Update, American Heart Association. 4 Zheng Z. Circulation. 2001;104: AIDS 1 Breast Cancer 2 Lung Cancer 2 Stroke 3 SCA 4 SCA claims more lives each year than these other diseases combined 450, , ,400 40,600 42,156 #1 Killer in the U.S.

5 Magnitude of SCA in the U.S. ~450,000 per year 1 ~450,000 per year 1 1,200 per day 1,200 per day 1 every 80 seconds1 every 80 seconds Although SCA is the first presentation of cardiac disease in 20-25% of patients, most cases occur in patients with clinically recognized heart disease. 2 Although SCA is the first presentation of cardiac disease in 20-25% of patients, most cases occur in patients with clinically recognized heart disease. 2 1 Zheng Z. Circulation. 2001;104:: Myerburg RJ, Heart Disease, A textbook of Cardiovascular Medicine. 6 th ed W.B. Saunders, Co.

6 SCA Different from MI SCA SCA Caused by heart electrical system problem. MI MI Occurs when one or more of the arteries that supply blood to the heart muscle becomes blocked. The affected area loses blood supply (ischemia) and results in damage to the heart tissue.

7 SCA and MI Symptoms SCA Symptoms: Collapse and loss of consciousness Collapse and loss of consciousness Cessation of normal breathing Cessation of normal breathing Loss of pulse and blood pressure Loss of pulse and blood pressure MI Symptoms: Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest lasting more than few minutes Pain spreading to the shoulders, neck, or arms Chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath Atypical chest pain, stomach or abdominal pain Nausea or dizziness Shortness of breath and difficulty breathing Unexplained anxiety, weakness, or fatigue Palpitations, cold sweat, or paleness Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest lasting more than few minutes Pain spreading to the shoulders, neck, or arms Chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath Atypical chest pain, stomach or abdominal pain Nausea or dizziness Shortness of breath and difficulty breathing Unexplained anxiety, weakness, or fatigue Palpitations, cold sweat, or paleness 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.

8 Etiology of SCD -An estimated 13 million people had coronary heart disease (CHD) in the U.S. in disease (CHD) in the U.S. in Sudden death was the first manifestation of CHD in 50% of men and 63% of women. 1 -Sudden death was the first manifestation of CHD in 50% of men and 63% of women. 1 -CHD accounts for at least 80% of sudden cardiac deaths in Western cultures. 3 -CHD accounts for at least 80% of sudden cardiac deaths in Western cultures. 3 1 American Heart Association. Heart Disease and Stroke Statistics2003 Update. Dallas, Tex.: American Heart Association; Adapted from Heikki et al. N Engl J Med, Vol. 345, No. 20, Myerberg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6 th ed. P Etiology of Sudden Cardiac Death 2,3 * ion-channel abnormalities, valvular or congenital heart disease, other causes 80% Coronary Heart Disease 15% Cardiomyopathy 5% Other*

9 Causes of in-hospital mortality The cause of death in hospital is most often noncardiac, usually being due to anoxic encephalopathy or to respiratory complications from long-term respirator dependence The cause of death in hospital is most often noncardiac, usually being due to anoxic encephalopathy or to respiratory complications from long-term respirator dependence Only about 10 percent of patients die from recurrent arrhythmia, while approximately 30 percent die from a low cardiac output or cardiogenic shock Only about 10 percent of patients die from recurrent arrhythmia, while approximately 30 percent die from a low cardiac output or cardiogenic shock

10 PROVOKING FACTORS Electrolyte disturbances Electrolyte disturbances Any reversible metabolic abnormalities should be identified and corrected, particularly hypokalemia and hypomagnesemia which may predispose to ventricular tachyarrhythmiasAny reversible metabolic abnormalities should be identified and corrected, particularly hypokalemia and hypomagnesemia which may predispose to ventricular tachyarrhythmias Antiarrhythmic drugs Antiarrhythmic drugs Whenever possible, antiarrhythmic drugs should be discontinued prior to any diagnostic studiesWhenever possible, antiarrhythmic drugs should be discontinued prior to any diagnostic studies

11 PROVOKING FACTORS Use of an illicit drug such as cocaine can directly cause arrhythmia or produce coronary artery vasospasm and ischemia Use of an illicit drug such as cocaine can directly cause arrhythmia or produce coronary artery vasospasm and ischemia A prolonged QT interval which may be acquired (due, for example, to a drug or electrolyte disturbance) or inherited A prolonged QT interval which may be acquired (due, for example, to a drug or electrolyte disturbance) or inherited

12 Arrhythmic Cause of SCD Albert CM. Circulation. 2003;107: % Other Cardiac Cause 88% Arrhythmic Cause

13 Bayés de Luna A. Am Heart J. 1989;117: Underlying Arrhythmias of Sudden Cardiac Arrest Bradycardia 17% VT 62% Primary VF 8% Torsades de Pointes 13%

14 SCD Rates for Males and Females Per 100,000 Standard US Population Zheng Z. Circulation. 2001;104(18):

15 Incidence of Sudden Death Increases with 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)

16 SCD gender

17 SCD age

18 SCD in Clinical Hospital Mostar (10 years)

19 Clinical Substrates Associated with VF Arrest Congestive heart failure Congestive heart failure The presence of CHF increases overall mortality and the incidence of SCD in both men and womenThe presence of CHF increases overall mortality and the incidence of SCD in both men and women AIM,cardiogenic shock, ICVAIM,cardiogenic shock, ICV

20 CHF Predict Increased Sudden Death and Overall 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.

21 SCD in CHF

22 In people diagnosed with CHF, sudden cardiac death occurs at 6-9 times the rate of the general population. 1 1 American Heart Association. Heart and Stroke Statistical –2003 Update. Dallas, Tex.: American Heart Association: 2002.

23 Clinical Substrates Associated with VF Arrest Myocardial ischemia and infarction Myocardial ischemia and infarction Acute myocardial infarction is associated with an approximate 15% risk of VF within the first 24 to 48 hours, with the incidence falling to only 3 percent over the next several daysAcute myocardial infarction is associated with an approximate 15% risk of VF within the first 24 to 48 hours, with the incidence falling to only 3 percent over the next several days When VF is provoked by an AMI, symptoms of the infarction are present for minutes to hours before sudden death occurs; over 80 percent of VF episodes occur within the first 6 hoursWhen VF is provoked by an AMI, symptoms of the infarction are present for minutes to hours before sudden death occurs; over 80 percent of VF episodes occur within the first 6 hours

24 References in slide notes. * MADIT-II mortality values at 20 months. SCD Rates in Post-MI Patients with LV Dysfunction Total Mortality ~20-30%; SCD accounts for ~50% of the total deaths.

25 SCD in AIM

26 SCD IN ICV

27 SCD IN SCHOCK CARDIONGENES

28 SCD in AHF

29 SCD in CARDIAC ARREST

30 SCD on the road to Hospital

31 Cummins RO. Annals Emerg Med. 1989;18: SCA Resuscitation Success vs. Time* % Success *Non-linear Time (minutes) Chance of success reduced % each minute

32 SCA Chain of Survival Statistics 5% estimated SCA out-of-hospital survival 2,3 5% estimated SCA out-of-hospital survival 2,3 Even in the best EMS/early defibrillation programs it is difficult to have high survival times due to many SCA events not being witnessed and the difficulty of reaching victims within 6-8 minutes. Even in the best EMS/early defibrillation programs it is difficult to have high survival times due to many SCA events not being witnessed and the difficulty of reaching victims within 6-8 minutes. 40% SCAs not witnessed or occur in sleep 140% SCAs not witnessed or occur in sleep 1 80% SCAs occur at home 180% SCAs occur at home 1 1 Swagemakers V. J Am Cardiol. 1997;30: Ginsburg W. Am J Emer Med. 1998;16: Cobb LA. Circ. 1992;85:I

33 Sudden Cardiac Death Incidence 400, ,000/year in U.S. Incidence 400, ,000/year in U.S. Only 2% - 15% reach the hospital Only 2% - 15% reach the hospital Half of these die before discharge Half of these die before discharge High recurrence rate High recurrence rate

34 Risk of Sudden Death: Data from GISSI-2 Trial Patients without LV Dysfunction Patients with LV Dysfunction No PVBs 1-10 PVBs/h > 10 PVBs/h 0.86 A Days Survival p log-rank Days Survival B p log-rank

35 People whove had a heart attack and have LV dysfunction (less than or equal to 40%) have a sudden death rate thats similar to a CHF population.

36 People whove had a heart attack have a sudden death rate thats 4-6 times that of the general population. 1 1 American Heart Association. Heart Disease and Stroke Statistics2003 Update. Dallas, Tex.: American Heart Association; 2002.

37 Treatments to Reduce SCD Correcting Ischemia RevascularizationRevascularization Beta-blockerBeta-blocker Preventing Plaque Rupture StatinStatin ACE inhibitorACE inhibitor AspirinAspirin Stabilizing Autonomic Balance Beta-blockerBeta-blocker ACE inhibitorACE inhibitor Improving Pump Function ACE inhibitor Beta-blocker Prevention of Arrhythmias Beta-blocker Amiodarone Terminating Arrhythmias ICDs AEDs Prevent Ventricular Remodeling and Collagen Formation Aldosterone receptor blockade Zipes DP. Circulation. 1998;98: Pitt B. N Engl J Med. 2003;348:

38 Symptoms in terminal episodes Type of symptomsSumm.%Men%Feme%tp Without symptom93,6364,0233,030,422p < 0,05 Chest pain13052, ,540,547p <0,05 Dyspnea104,0364,0544,040,005p<0,05 General failure62,4253,3511,011,113p< 0,05 Nausea104,0353,3555,050,639p <0,05 Uncomfortable10,410011,011,005p< 0,05 Chest pressure3514,112013,421515,150,379p< 0,05 Palpitation31,2132,01001,749p< 0,05 Dessines72,8242,6833,030,159p< 0,05 Combined symptoms3714,932416,11313,130,656p<0,05 Summary ,089939,92

39 Summary 1 Defibrillation is the only effective treatment for SCA. Few SCA victims are treated quickly enough to survive.

40 Summary 2 High risk SCA patients can be identified: low LVEF, HF, prior MI, and prior SCA or VT/VF event. ICD and CRT-D therapies can prevent SCA. Most eligible patients are not receiving device therapy. Some healthcare organizations have developed care pathways to identify and treat patients at high risk of SCA.

41 Summary 3 Detailed in ESC and ACC/AHA/HRS Device Guidelines for SCD/SCA and VODIČ ZA SCD ESC UKBIH 2010 Epstein AE, et al. Circulation. 2008;117:e


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