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

23
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

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

Page 1: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 2: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 3: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 4: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 5: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

Sudden Death Is Frequently Due To Ventricular

Tachycardia Degenerating To Ventricular Fibrillation

The rhythm recorded depends on the timing of the recording

Page 6: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

24 hr Holter on during CHF Event /

Respiratory Arrest

Just because asystole occurred doesn’t

mean that is what they died from!

Page 7: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

III

V1

AVB – An uncommon cause of SCD

Torsades with High Grade AVB

Infranodal CHB

Page 8: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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, Brugada’s, HCM, ARVD

Page 9: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 10: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 11: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Rx’d with Sotolol 120mg Bid

Iatrogenic SCD!

No mortality benefit with any antiarrhythmic

in any patient group

Page 12: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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)

Page 13: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 14: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

ICD components

Lead + Device Transvenous SICD

ICD shock

Page 15: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 16: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

Recorded 3 weeks after DC home

65 yo M with VF / Aborted SCD

Acute LAD Total Occlusion Rx’d with PTCA

EF = 25% post MI, NSVT x 25 beats

Page 17: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 18: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 19: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

25 yo M had SCD event during

basketball game

Late gadolinium

enhancement

LV

RV

CMR

HCM with septum 3cm

and LGE

Page 20: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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%

Page 21: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

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

Page 22: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

The Evolution of SCD therapy Drug vs Device

Page 23: Sudden Cardiac Death - ccme.osu.edu - Sudden... · Sudden Cardiac Death ... Severity of Heart Failure Modes of Death LANCET. 1999;353:2001-07. 12% 24% ... Just because asystole occurred

Major ICD Trials

Recent CABG

< 40 days from MI

*

*

*

= secondary prevention *