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.

Time references in SCD

Biological Model of SCD

Magnitude of SCA in the U.S. 167,366 Stroke3 450,000 SCA claims more lives each year than these other diseases combined SCA4 Lung Cancer2 157,400 #1 Killer in the U.S. Breast Cancer2 40,600 AIDS1 42,156 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.

Magnitude of SCA in the U.S. ~450,000 per year1 1,200 per day 1 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 1 Zheng Z. Circulation. 2001;104::2158-2163. 2 Myerburg RJ, Heart Disease, A textbook of Cardiovascular Medicine. 6th ed. 2001. W.B. Saunders, Co.

SCA Different from MI SCA MI Caused by heart electrical system problem. 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.

SCA and MI Symptoms MI Symptoms: SCA Symptoms: Collapse and loss of consciousness Cessation of normal breathing 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 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. www.americanheart.org

Etiology of Sudden Cardiac Death2,3 Etiology of SCD -An estimated 13 million people had coronary heart disease (CHD) in the U.S. in 2002. 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 Etiology of Sudden Cardiac Death2,3 80% Coronary Heart Disease 15% Cardiomyopathy 5% Other* 1Myerburg, Robert. Sudden Death due to Cardiac Arrhythmias. NEJM, Vol. 345, No. 20; November 15, 2001. This slide reviews our best understanding of the causes of SCA. According to Dr. Myerburg, CAD is the underlying cause for 80% of SCA events. Either an acute ischemic event and/or a reentry pathway from a previous MI can cause an SCA event. According to this diagram, non-ischemic cardiomyopathy accounts for 10-15% of cases of SCA even though non-ischemics account for about 40% of CHF patients. Given that DEFINITE showed positive results in Class III patients with non-ischemic cardiomyopathy and we do not yet know the results of the non-ischemic arm in SCD-HeFT, our understanding of the etiology of SCA could change in the next several months. * ion-channel abnormalities, valvular or congenital heart disease, other causes 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.

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

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

PROVOKING FACTORS 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

Arrhythmic Cause of SCD 12% Other Cardiac Cause 88% Arrhythmic Cause Albert CM. Circulation. 2003;107:2096-2101.

Underlying Arrhythmias of Sudden Cardiac Arrest Torsades de Pointes 13% Bradycardia 17% VT 62% Primary VF 8% Bayés de Luna A. Am Heart J. 1989;117:151-159.

SCD Rates for Males and Females 502.7 407.1 336.1 Per 100,000 Standard US Population 258.8 270.5 212.6 130.0 153.4 Zheng Z. Circulation. 2001;104(18):2158-2163.

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)

SCD gender

SCD age

SCD in Clinical Hospital Mostar (10 years)

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

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.

SCD in CHF

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.

Clinical Substrates Associated with VF Arrest 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 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 hours

SCD Rates in Post-MI Patients with LV Dysfunction 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 Latebreaking Clinical Trials, March 2002. Total Mortality ~20-30%; SCD accounts for ~50% of the total deaths. References in slide notes. * MADIT-II mortality values at 20 months.

SCD in AIM

SCD IN ICV

SCD IN SCHOCK CARDIONGENES

SCD in AHF

SCD in CARDIAC ARREST

SCD on the road to Hospital

SCA Resuscitation Success vs. Time* 10 20 30 40 50 60 70 80 90 100 Chance of success reduced 7 - 10% each minute % Success *Non-linear The chance of a successful resuscitation declines by about 7–10% each minute. The actual relationship between defibrillation success and time is a non-linear one, with the best chance for success probably occurring in the first 3–4 minutes. 1 2 3 4 5 6 7 8 9 Time (minutes) Cummins RO. Annals Emerg Med. 1989;18:1269-1275.

SCA Chain of Survival Statistics 5% estimated SCA out-of-hospital survival2,3 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. 40% SCAs not witnessed or occur in sleep1 80% SCAs occur at home1 1 Swagemakers V. J Am Cardiol. 1997;30:1500-1505 2 Ginsburg W. Am J Emer Med. 1998;16:315-319. 3 Cobb LA. Circ. 1992;85:I98-102.

Sudden Cardiac Death Incidence 400,000 - 500,000/year in U.S. Only 2% - 15% reach the hospital Half of these die before discharge High recurrence rate

Risk of Sudden Death: Data from GISSI-2 Trial 1.00 1.00 0.98 p log-rank 0.002 0.98 0.96 0.96 0.94 0.94 Survival Survival 0.92 0.92 p log-rank 0.0001 0.90 0.90 0.88 0.88 A B 0.86 0.86 30 60 90 120 150 180 30 60 90 120 150 180 Days Days Patients without LV Dysfunction Patients with LV Dysfunction No PVBs 1-10 PVBs/h > 10 PVBs/h

People who’ve had a heart attack and have LV dysfunction (less than or equal to 40%) have a sudden death rate that’s similar to a CHF population.

“People who’ve had a heart attack have a sudden death rate that’s 4-6 times that of the general population.”1 1American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex.: American Heart Association; 2002.

Treatments to Reduce SCD Improving Pump Function ACE inhibitor Beta-blocker Prevention of Arrhythmias Amiodarone Terminating Arrhythmias ICDs AEDs Prevent Ventricular Remodeling and Collagen Formation Aldosterone receptor blockade Correcting Ischemia Revascularization Beta-blocker Preventing Plaque Rupture Statin ACE inhibitor Aspirin Stabilizing Autonomic Balance Zipes DP. Circulation. 1998;98:2334-2351. Pitt B. N Engl J Med. 2003;348:1309-1321.

Symptoms 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 4,05 4 4,04 0,005 p<0,05 General failure 2,42 5 3,35 1 1,01 1,113 p< 0,05 Nausea 5,05 0,639 Uncomfortable 0,41 1,005 Chest pressure 35 14,11 20 13,42 15 15,15 0,379 Palpitation 1,21 2,01 1,749 Dessines 7 2,82 2,68 0,159 Combined symptoms 37 14,93 24 16,1 13 13,13 0,656 Summary 248 100 149 60,08 99 39,92  

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

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. Review summary. Add any other summary comments that you think are relevant.

Detailed in ESC and ACC/AHA/HRS Device Guidelines for SCD/SCA Summary 3 Detailed in ESC and ACC/AHA/HRS Device Guidelines for SCD/SCA and VODIČ ZA SCD ESC UKBIH 2010 The next set of slides reviews all of the ICD and CRT-D guidelines from ACC/AHA/HRS. Epstein AE, et al. Circulation. 2008;117:e350-408.