Sudden Cardiac Death - ccme.osu.edu - Sudden...  Sudden Cardiac Death ... Severity of Heart...

download Sudden Cardiac Death - ccme.osu.edu - Sudden...  Sudden Cardiac Death ... Severity of Heart Failure

of 23

  • date post

    21-Aug-2018
  • Category

    Documents

  • view

    214
  • download

    0

Embed Size (px)

Transcript of Sudden Cardiac Death - ccme.osu.edu - Sudden...  Sudden Cardiac Death ... Severity of Heart...

  • Sudden Cardiac Death What an electrophysiologist thinks a

    cardiologist should know

    Steven J. Kalbfleisch, M.D.

    Medical Director Electrophysiology Laboratory

    Ross Heart Hospital

    Wexner Medical Center

  • Sudden Cardiac Death (SCD) Death within 1hr of sx onset

    300,00-400,000 Victims Annually (0.1% of population)

    SCD accounts for 50% of all cardiac related deaths and

    15% of total mortality in US.

    Primary Cause is Arrhythmic

    Older data - VT/VF (75%), Asystole/PEA (25%)

    Newer data - Asystole/PEA (50%)

    Recurrence Rate is up to 30% annually among Survivors

  • Incidence of SCD in Specific Populations

    Myerburg RJ. Circulation.1998;97:1514-1521.

    GROUP

    300,000

    Patients with high coronary-risk profile

    Patients with previous coronary event

    Patients with ejection fraction < 35%, congestive heart failure

    Patients with previous out-of-hospital cardiac arrest

    Patients with previous MI, low EF, and VT

    General population

    200,000 100,000 0

    No. of Sudden Deaths Per Year

    30 25 20 15 10 0

    Incidence of Sudden Death (% of group)

    5

    Over half of

    SCA victims

    have no prior

    symptoms

  • Severity of Heart Failure Modes of Death

    LANCET. 1999;353:2001-07.

    12%

    24%

    64%

    CHF

    Other

    Sudden Death n = 103

    NYHA II

    26%

    15%

    59%

    CHF

    Other

    Sudden Death

    n = 103

    NYHA III

    56%

    11%

    33%

    CHF

    Other

    Sudden Death n = 27

    NYHA IV

  • Sudden Death Is Frequently Due To Ventricular

    Tachycardia Degenerating To Ventricular Fibrillation

    The rhythm recorded depends on the timing of the recording

  • 24 hr Holter on during CHF Event /

    Respiratory Arrest

    Just because asystole occurred doesnt

    mean that is what they died from!

  • III

    V1

    AVB An uncommon cause of SCD

    Torsades with High Grade AVB

    Infranodal CHB

  • Sudden Cardiac Death

    400,000/year

    Provoking Factor Underlying Heart Disease

    80% No Acute MI

    20% Acute

    MI

    80% CAD

    15%

    Other

    5%

    None

    Non-ischemic Cardiomyopathy

    Inherited Disorders

    LQTS, Brugadas, HCM, ARVD

  • Ventricular Arrhythmias as a Cause of

    Syncope / SCD

    Monomorphic Ventricular Tachycardia Scar related

    Polymorphic VT / Ventricular fibrillation Acute MI / ischemia / NICM

    Torsades de Pointes Congenital long QT

    Drug / Metabolic induced

  • 65 yo M with CAD, s/p CABG with syncope and WCT

    Sustained monomorphic VT = Scar related

    65 yo M with CP in ER PVMT / VF = think ischemia

  • 68 y/o woman, Hx PAF / CAD, LVEF 50%

    Rxd with Sotolol 120mg Bid

    Iatrogenic SCD!

    No mortality benefit with any antiarrhythmic

    in any patient group

  • Proven Treatment for SCD

    Bystander CPR

    External defibrillators (AEDs)

    Medications - BBs and ACEI in high

    risk groups (Post MI, CHF)

    ICD therapy (including CRT in select

    patients)

  • JACC 1997;30:1500-5.

    Out of Hospital Cardiac Arrest

    Home

    399

    On Street

    47

    Public Place

    31

    Other

    20

    Work

    4

    Site of Cardiac Arrest

    The Maastricht Study Holmberg et al,

    AJC 1999

    Time from Cardiac Arrest to

    First Defibrillation

  • ICD components

    Lead + Device Transvenous SICD

    ICD shock

  • ICD Indications Black / White

    OK to Implant Secondary Prevention (aborted SCD, Sustained VT,

    syncope in high risk group)

    EF < 30% / CAD / Prior MI

    EF < 35% / CHF (class II / III),

    CHF (class IV) if implanting with CRT

    Not OK to Implant (for Primary Prevention) MI < 40 days

    Revascularization < 3 months

    CHF < 3 months

    Class IV CHF or Class I Non-ischemic

    Life expectancy < 1 yr

  • Recorded 3 weeks after DC home

    65 yo M with VF / Aborted SCD

    Acute LAD Total Occlusion Rxd with PTCA

    EF = 25% post MI, NSVT x 25 beats

  • SCD in Young Athletes 1435 athletes 1980 - 2005

    Maron et al, Circ 2007

    Note: CAD is still the predominate cause of SCD in older athletes

  • What can you catch with an ECG?

    HCM The largest group in the USA

    ARVD the Largest group in Italy

    The Channelopathies

    Long QT

    Brugada Syndrome

  • 25 yo M had SCD event during

    basketball game

    Late gadolinium

    enhancement

    LV

    RV

    CMR

    HCM with septum 3cm

    and LGE

  • 26 yo athlete presented with LB WCT / Syncope ECG after conversion

    ARVD Episolon Waves / T Wave changes / CMR

    RV CMR

    RV dilation, RVEF = 40%, LVEF = 54%

  • 40 yo M presented after a syncopal episode ST-segment Elevation - V1 Through V3 Type I Brugada

    Family Hx of SCD Uncle died in sleep

  • The Evolution of SCD therapy Drug vs Device

  • Major ICD Trials

    Recent CABG

    < 40 days from MI

    *

    *

    *

    = secondary prevention *