Sudden Cardiac Deathin Women

Briain MacNeill

Galway University Hospital

Oct 6th, 2012

Women and Heart DiseaseMyths and Truths

• MYTH: Most women die from cancer.

• TRUTH: Heart disease is the leading cause of death of women in North America and Europe. Nearly five times as many women will die from heart attacks alone this year than will die from breast cancer.

Women and Heart DiseaseMyths and Truths

• MYTH: Heart disease is a man’s problem.

• TRUTH: Since 1984, more women than men have died of heart disease each year. Women are 28% more likely than men to die within the first year after a heart attack.

Women and Heart DiseaseMyths and Truths

• MYTH: Only older women have heart disease.

• TRUTH: The rate of sudden cardiac death of women in their 30s and 40s is increasing much faster than in men their same age - rising 21 percent in the 1990s.

Women and Heart DiseaseMyths and Truths

• MYTH: Women and men with heart disease get the same care.

• TRUTH: Women are less likely to receive Aspirin, beta blockers, statins , ACE inhibitors and defibrillators. Men are 52% more likely to be referred for angiography

SUDDEN CARDIAC DEATH

IN WOMEN

WELL VISITS

SPORTSCLEARANCE

PALPITATIONS

SYNCOPEFAMILY

SCREENING

CHEST PAIN

SUDDEN CARDIAC DEATH

IN WOMEN

WELL VISITS

SPORTSCLEARANCE

PALPITATIONS

SYNCOPEFAMILY

SCREENING

CHEST PAIN

Well Visit

Physical examination:BMI, Pulse and Blood pressure measurementHeart murmur (supine / sitting / standing)Peripheral PulsesStigmata of Marfans Syndrome

Personal History:Heart murmurSystemic hypertensionFatigabilitySyncopeExertional dyspnoeaExertional chest pain

Family History:Premature sudden deathHeart disease in relatives

Cardiac Risk Profile

Exercise Capacity

Cardiac Symptoms

Lipid Levels

The #1 Preventable Risk - Smoking• A. 50% of heart attacks among women are

due to smoking. • Smokers tend to have their first heart

attack 10 years earlier than nonsmokers.• Smokers are 4-6x’s more likely to suffer a

heart attack • Women who smoke and take OCP’s

increase their risk of heart disease 30x• Smoking cessation was associated with a

36% reduction in mortality among patients with CHD

Obesity and Coronary Heart Disease Mortality

0

1

2

3

4

5

6

<19 19.0-21.9

22.0-24.9

25.0-26.9

27.0-28.9

29.0-31.9

>32.0

Nurses’ Health Study: Women who never smoked

RelativeRisk of CoronaryHeart Diseasemortality

Body Mass Index (kg/m2)

P<0.001 for trendManson JR, et al. N Engl J Med. 1995;333:677-685.

Who to TreatPractice Prevention

Low Risk Women <10%:

Intervention is useful and effective:

Lifestyle InterventionsSmoking CessationPhysical ActivityHeart Healthy Diet

Weight ReductionTreat Individual CVD risk factors

Practice Prevention

Intermediate Risk Women (10-20%): Smoking Cessation

Physical Activity

Heart Healthy Diet

Weight ReductionControl BP and Lipids

Class Ila- most scientific evidence favors this type of therapy:

ASA Rx- as long as BP is controlled (hemorrhagic stroke) and low risk of GI bleed

Practice Prevention

High Risk Women (>20%): Class ISmoking CessationPhysical Activity/cardiac rehabHeart Healthy Diet- DASH DietWeight ReductionControl BP and Lipids- StatinASA therapyGlycemic control in DM

Croi My Action – 1 year results

Croi My Action – 1 year results

SUDDEN CARDIAC DEATH

IN WOMEN

WELL VISITS

SPORTSCLEARANCE

PALPITATIONS

SYNCOPEFAMILY

SCREENING

CHEST PAIN

Chest Pain Algorithm

Not so straightforwardChest pain is the presenting symptom in <50% of womenAlmost half of MIs in women present with SOB, nausea,

indigestion, fatigue and shoulder painAtypical symptoms contribute to later presentation and higher

rates of misdiagnosis.Women presenting with MI and CAD are more likely to be

older, have a history of DM, HTN, Hyperlipids, CHF, and unstable angina than male counterparts.

Women were less likely have an ECG, antianginal therapy or invasive mangaement.

Women were less likely to enroll in cardiac rehabilitation after an MI or bypass surgery.

CHD Mortality in Younger Women

2.94.1

5.7

8.2

10.7

14.4

18.4

21.8

25.3

6.17.4

9.5

11.1

13.4

16.6

19.1

21.5

24.2

0

5

10

15

20

25

30

< 50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89

Dea

th d

urin

g H

ospi

taliz

atio

n (%

) Men

Women

Figure 1. Rates of death during hospitalization for Myocardial Infarction among w omen and men, according to age. The interaction betw een sex and age w as signif icant (P<0.001).

Women under 65 suffer the highest relative CHD mortality

SUDDEN CARDIAC DEATH

IN WOMEN

WELL VISITS

SPORTSCLEARANCE

PALPITATIONS

SYNCOPEFAMILY

SCREENING

CHEST PAIN

Palpitations AlgorithmHistory, Physical, ECG

Structural Heart Disease Unlikely Structural Heart Disease Suspected

ECHO, Holter, Cardiac ReviewLabs including TFTs, Drug Screen

Daily Symptoms?

24 or 48 hour Holter Event Monitor / LoopYes No

Palpitations During NSRReassurance

Consider alternatives

NonVentricular ArrhythmiaTreat Cause

Routine cardiac evaluation

Ventricular ArrhythmiaUrgent Cardiac ReviewAngio, MRI, EP study

SUDDEN CARDIAC DEATH

IN WOMEN

WELL VISITS

SPORTSCLEARANCE

PALPITATIONS

SYNCOPEFAMILY

SCREENING

CHEST PAIN

.Eur Heart J 2009;30:2631-2671

Cardiac Syncope

Bradycardia

SA Node Dysfunction

AV Conduction Defect

Medication Related

Tachycardia

Supraventricular

Ventricular- Preserved LV- Reduced LV

Hypotension

Hypoperfusion

Reflec Mediated

Medication Related

SUDDEN CARDIAC DEATH

IN WOMEN

WELL VISITS

SPORTSCLEARANCE

PALPITATIONS

SYNCOPEFAMILY

SCREENING

CHEST PAIN

Causes of SCD• Over 35 yrs of age

– Coronary Heart Disease

• Under 35 yrs – Cardiomyopathies – Congenital Heart Disease – ‘Structurally Normal Heart’ (ion channel

disorders, conduction disease) = SADS– Anomalous coronaries – Myocarditis

Hypertrophic cardiomyopathy (HOCM)

Increased thickness of heart muscleMost common inherited cardiac diseasePrevalence

> 1 in 500 people carry gene>11000 in 32 counties90% of cases thought to be inherited (runs in family)10% ‘sporadic’ – pass on to their children?Approx 50% who inherit genetic change develop full-

blown condition (‘incomplete penetrance’)

Inheritance pattern Autosomal Dominant= 50% risk of inheriting gene if parent affected

HOCM

• Symptoms include :– Shortness of breath with exercise– chest pain (usually with exercise) – Diziness (at rest or with exercise) – blackouts – Palpitations– No symptoms

• Risk of sudden death ~ 1% per year• Intensive exercise can increase risk• Usually identifiable on ECG and Echo

Other Cardiomyopathies- DilatedMay be inherited, much less common

Other causes include viral illness, drugs, alcohol

May cause shortness of breath, palpitations, blackout, sudden death

ECG and echo usually identifies

Other tests may be necessary

Treatment: Medications, pacemakers and/or ICD

Risk of SCD usually highest in those with poorest pump function, who usually have symptoms

Other Cardiomyopathies – Arrhythmogenic (ARVC or ARVD)

• Heart may become enlarged• Scarring develops in heart • Causes palpitations, dizzy spells, blackouts,

shortness of breath, sudden death• Often inherited• May need several tests to diagnose

– ECG, echo, Exercise test, Holter, Cardiac MRI• Milder cases can be missed • Treatment

– Medications– Lifestyle modification– If high risk, recommend ICD

Other inherited conditions• Marfan’s syndrome

– Weakness of walls or large blood vessels– May be associated with tall stature and hyperflexibility, eye

problems– Identified on physical exam, echo and X-ray scans

• Congenital heart disease– Abnormal development of cardiac structure(s) in the womb– Milder forms generally not life-threatening– < 10 % inherited, most occur spontaneously

• Mitral valve prolapse– 1% of population have at least mild case– Severe cases may be associated with sudden death– May be over-estimated as cause of sudden death

Other conditions

• Valve disease– Usually causes a murmur– May cause reduction in exercise tolerance

• Anomalous coronaries– Anatomical variant in placement of blood vessels– Some may reduce blood supply during stress or exercise but

most probably don’t cause problem and may be over-estimated as cause of SCD

• Myocarditis– Inflammation of heart muscle– Usually thought to follow viral infection– 1/8 people with virus + fever have ECG change– Probably should avoid exercise during viral infection– Possible genetic predisposition to being affected by virus

Sudden Arrhythmic (Adult) Death Syndrome (SADS)

‘Diagnosis of exclusion’ - Electrical problem is cause of death, but no electrical activity after death so not detectable at post-mortem

Sudden death occurs, and is consistent with cardiac rhythm disturbance, but post-mortem examination finds no abnormality

If post-mortem not carefully doneStructural cause of death may be missedMinor abnormalities may be incorrectly recorded as

cause of sudden death True number of SCD which are actually due to SADS

probably under-estimated

Electrical problems – ‘Channelopathies’• Electricity in heart is generated by pump channels in walls of each cell in

heart – pump salts (Na, K, Ca) in and out of cell– Pump channel = ion channel

• If pump malfunctions (under or over-active) changes electrical activation of heart which causes electrical instability and increases chance of arrhythmia

• May not cause symptoms unless palpitations, dizzy episodes or blackouts

• Usually detectable on ECG (if looking for it) • Different genes code for different pumps and mutations cause different

conditions : – Long QT syndrome– Brugada Syndrome– Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)

• Not identifiable on PM• Can be identified on ECG (+/- exercise test and rhythm monitor) in living• 40% of families of those who die of SADS have inherited cause identified

(mostly LQT syndrome and Brugada syndrome)

SUDDEN CARDIAC DEATH

IN WOMEN

WELL VISITS

SPORTSCLEARANCE

PALPITATIONS

SYNCOPEFAMILY

SCREENING

CHEST PAIN

Piermario Morosini Fabrice Muamba

Etiology based on largest US data set

1) HCM – 36%2) Coronary Anomalies 17%3) Increased Cardiac Mass

(possible HCM) 10%4) Ruptured Aorta/Dissect 5%5) Tunneled LAD 5%6) Aortic Stenosis 5%7) Myocarditis 3%8) Dilated CM 3%9) Idiopathic Myocdardial

scarring 3%10)Arrhythmogenic RV dysplasia

3%

•OTHERS…•MVP•CAD•ASD•Brugada Syndrome•Commotio Cordis•Complete heart block•QT prolongation syndrome•Ebstein’s anomaly•Marfan’s Syndrome•Wolff-Parkinson White Syndrome – WPW•Ruptured AVM•SAH

Sports Screening – Italian Protocol

Results of Screening in Veneto Italy

Conditions Screened

Piermario Morosini Fabrice Muamba

Will This Work in Ireland

“We're taking this match awful seriously.We're training three times a week now, and some of the boys are off the beer since Tuesday.”Offaly hurler,In the week before a Leinster hurling final vs. Kilkenny.

“The stopwatch has stopped. It's up to God and the referee now. The referee is Pat Horan. God is God.”Micheal O Muircheartaigh

“Sean Og O'Hailpin... his father's from Fermanagh, his mother's from Fiji, neither a hurling stronghold.”Micheal O Muircheartaigh

Sudden Cardiac Deathin Women

Briain MacNeill

Galway University Hospital

Oct 6th, 2012