1. Sudden Cardiac Death Risks Khaled Hassan, MD Access Medical Emergent Devices ( AMED )

2. Defination Sudden cardiac death is an unexpected death due to cardiac causes that occurs in a short period of time ( within 1 hour of onset of symptom ) in a person with known or unknown heart disease. It is estimated that 7 million lives lost every year due to SCD world wide with 300 thousands in USA alone. a)

3. Factors behind the SCD 1) Coronary artery disease. 2) Dilated Cardiomyopathy. 3) Hypertrophic Cardiomyopathy. 4) Valvular heart disease. 5) Long QT syndrome. b)

4. SCD in adoloscents and young adults Sudden unexpected cardiac death (SCD) in a child or adolescent is a devastating event with serious impact on the family, the school, and the community. We will discuss in the next few slides the epidemiology of SCD in children and adolescents and includes a discussion of its incidence and etiologies. It also discusses strategies for prevention.

5. Epidemiology of SCD in Children and Adoloscents Each year SCD claims the lives of over 2000 children and adolescents in US and accounts for 3-5 percent of all death in children in 5- 19 years of age group. It is also responsible for 10-15 % of infant deaths. c)

6. Causes of SCD in children Structural cardiac abnormalities (congenital heart diseases and postoperative repairs, coronary artery anomalies, or Marfan syndrome) Abnormalities of the electrical system of the heart (also known as primary electrical diseases), such as long QT syndrome and Wolff-Parkinson-White syndromelong QT syndrome Abnormalities of the heart muscle structure or function, such as hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), or dilated cardiomyopathiescardiomyopathies Acquired heart disease (inflammation or infection in the heart/myocarditis) Arrhythmias, including atrial flutter/atrial fibrillation, ventricular tachycardia (VT), ventricular fibrillation (VF), sinus node dysfunction, and complete heart block Arrhythmias Atherosclerotic coronary disease Commotio cordis (caused by a blow to the chest) Drug-induced SCA Conditions causing SCD are typically not diagnosed prior to the arrest. In many cases, these conditions are inherited, but family members are unaware of their family history. d)

7. Risk factors of SCD Athletic activity: Two-thirds of the deaths caused by SCA in children occur during exercise or activity. SCA is the leading cause of death in young athletes, accounting for 75 percent of all athlete-related deaths. Known congenital heart disease or structural heart abnormalities. Known abnormal heart rhythms associated with congenital heart disease. Most commonly, these include ventricular arrhythmias or atrial arrhythmias. Known abnormal heart rhythms that are very rapid, even with a normal heart. For example, rapid ventricular tachycardia or atrial fibrillation with a rapid ventricular response. Undiagnosed cardiac conditions, especially those known to be associated with sudden cardiac arrest. Obesity and hypertension. Exposure to drugs, medications, toxins and infectious agents, including cocaine, inhalants, recreational or club drugs, and some prescription medications. Sudden blow to the chest directly over the heart (commotio cordis). e)

8. Hypertrophic Cardiomyopathy ( HCM ) Hypertrophic cardiomyopathy (HCM) is a condition of heart muscle disease in which the muscle is thickened (hypertrophic). This thickening typically occurs in the lower left chamber of the heart, called the left ventricle. Thickening of the heart muscle can occur at the septum (muscular wall that separates the left and right side of the heart), the posterior wall or free wall (outside wall of the left ventricle), the apex (the bottom of the heart) or throughout the entire left ventricle. When the muscle becomes thickened, it may make it difficult for an efficient amount of blood to flow into and out of the heart, especially during exercise. In some cases, the thickening of the muscle can block blood flow from the left ventricle to the aorta. This is called “outflow tract obstruction.” Hypertrophic cardiomyopathy affects an estimated 600,000 to 1.5 million Americans, or one in 500 people. f)

9. HCM g).

10. HCM ( Signs and symptoms ) The first signs of HCM may be fainting, exercise intolerance, or fatigue. HCM symptoms most commonly first occur in adolescence, but can appear at any age. h The first signs of HCM often include fainting, exercise intolerance, or fatigue. Young athletes with HCM most often complain of chest pain and shortness of breath during exercise. In some HCM patients, a doctor may hear a heart murmur.

11. Long QT syndrome Long QT syndrome is a genetically transmitted cardiac arrhythmia caused by ion channel protein abnormalities. It is characterized by electrocardiographic abnormalities and a high incidence of syncope and sudden cardiac death. The frequency of long QT syndrome is unknown (possibly about 1 per 5000 population). Long QT syndrome is responsible for approximately 1000 deaths each year in the United States, most of which occur in children and young adults. i)

12. Screening for sudden cardiac death Study findings — ECG outperformed history and physical examination "In our study, using ECG outperformed the history and physical examination and found previously unidentified potentially serious abnormalities that would not have been identified by history and physical examination alone," the study authors wrote. Regular physical examinations by primary care physicians had not detected the cardiac conditions found in the current study Italy and Japan have compulsory screening of all athletes or schoolchildren. This study was done by Dr. Vetter. He is the Medical Director of Youth Heart Watch at The Children’s Hospital of Philadelphia. The mission of Youth Heart Watch is to prevent sudden cardiac death among children and adolescentsYouth Heart Watch

13. Diagnosis EKG. 2 D Echocardiograph. 24 hour holter. Electrophysiologic study. Genetic testing

14. High risks groups in children As mentioned before regular annual physical exam most of the time can not diagnose high risks children. Football player. Track and field athlete. Swimmer. Any competitive athlete are at high risks if they have underlying deformity.

15. Barriers in mass screening Complexity of current conventional EKG ( big machine ) Difficulties in lead placement and time required. Reading of EKGs and proper follow up.

16. Conventional EKG

17. New Technology (Made for each other) Paradigm shift in the practice of clinical electrocardiography. E – Gloves or EKG gloves. The EKG‐Glove is a mitten‐like biomedical device that utilizes a “peel and s tick” printed circuit to place electrodes on the chest of a patient in under 60sec. Spaulding EKG device is small and round that record and able to transmit crystal clear EKG using wireless network to apple, android and Microsoft devices.

18. EKG Gloves The glove is a single use, disposable apparatus. Designed to obtain a 12lead electrocardiogram /EKG) usi ng pre‐positioned electrod es. The EKG Glove comes in 2 sizes. Adult Medium: Greater than 97‐ 104cm Adult Large: Greater than 1 04 cm The glove can wirelessly tra nsmit information with a different reader.

19. Comparison of EKG Glove vs. Current ECG

20. Benefits of EKG gloves The lowest error rate. Less than 60 seconds or less to do and read EKG. Minimized risk of infection. Compact size. Bluetooth connectivity and mobile application allows seam less use anywhere. Decrease overall hospital costs. Radiolucent ( does not require to remove for a CT scan or CXR.)

21. Time comparison

22. Time Comparison

23. Spaulding EKG device The revolutionary 12-lead Spaulding Electrocardiograph uses biometric voice print technology to virtually eliminate demographic errors. Spaulding Clinical software application, automatically uploads up to 5 minutes of 12-lead ECG data – not the limited 10 second sample that is common in all other devices Automated measurements and interpretation are available on your site PC immediately after uploading data, including a full 12-lead unconfirmed report. Cardiology expert over-read available within minutes or hours The complete Spaulding Electrocardiograph system includes the Spaulding ECG Acquisition Module, the Spaulding ECG 12-lead Patient Cable, and the Mason Protocol software...application.

24. Other benefits of Spaulding ekg device Option of reading the EKG by cardiologist 24/7 either stat or regular. Very minimum charge for this service. Storage of old EKG up to 5 years or more for future comparison. It is like having your own cardiologist 24/7 !!!!

25. At the end …………. Please remember EKG is not a substitute of annual physical exam. It is an add on preventive cardiac monitoring.

26. Bibliography a) b) Ali A Sovari, MD, FACP, Fellow in Clinical Cardiac Electrophysiology, Cedai Sinai Medical Center/ Heart Institute. c) d) e)The Children’s Hospital of Philadelphia ( www.chop.edu)www.chop.edu f) g ) www.cincinnatichildren’s.orgwww.cincinnatichildren’s.org h) Maron BJ, Seidman JG, Seidman CE (2004) Proposal for contemporary screening strategies in families with hypertrophic cardiomyopathy. J Am. Coll. Cardiol. 44:2125-2132. i)pediatric long QT syndrome. Sreekanth S Raghavan, MBBS,, FACC Consulting Pediatric Cardiologist, Head and Director of Pediatric Cardiac Services, Manipal Heart Institute, India

27. End of conventional EKG Let’s welcome the Disruptive technology…….. Few slides were the courtesy of INEEDMD, Dr. Gopinathan and Spaulding Medical Device.