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1 American Heart Association. Heart and Stroke Statistical

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1 American Heart Association. Heart and Stroke Statistical 2003 Update. Dallas, Tex. ... 1988) in Atlas of Heart Diseases. 4 American Heart Association. ... – PowerPoint PPT presentation

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Title: 1 American Heart Association. Heart and Stroke Statistical


1
Sudden Cardiac Arrest
  • Prepared for Referring MD Group
  • Insert Presentation Date

2
Sudden Cardiac Arrest (SCA)
  • SCA claims an estimated 325,000 lives each year
  • 1,000 lives every day, one life every two minutes
  • SCA accounts for half of all cardiac-related
    deaths
  • Over half of SCA victims have no prior symptoms
  • Survival requires emergency medical intervention
    and defibrillation within the first minutes
    following arrest
  • The survival rate is as high as 90 percent if
    treatment is initiated within the first minutes
    following arrest
  • An estimated 95 percent of SCA victims die before
    they reach a hospital or other source of
    emergency help

3
Sudden Cardiac Arrest (SCA)
  • 85-90 percent of SCAs are actually the first
    arrhythmic event a patient experiences
  • Death from SCA can frequently be predicted and
    prevented by identifying individuals at high risk
    and intervening

4
What Causes SCA?
  • Ventricular tachycardia
  • Ventricular fibrillation
  • Hypertrophic cardiomyopathy
  • Inherited and acquired electrical diseases, e.g.
    Long QT syndromes
  • Congenital anomalous coronary artery
  • Reduced Ejection Fraction

5
Sudden Cardiac Arrest
6
Impact of Sudden Cardiac Arrest
  • More people die from Sudden Cardiac Arrest than
    from AIDS, Breast Cancer and Lung Cancer combined

Heart Rhythm Society 2005 American Cancer
Society 2005, CDC 2003 Est.
7
Urgency of Sudden Cardiac Arrest
  • Resuscitation Success vs. Time

Chance of success reduced 7-10 each minute


Success
Success
Non
Non
-
-
linear
linear
Adapted from text Cummins RO, Annals Emerg Med.
1989, 181269-1275.
8
Risk Factors
  • High-risk patient populations have been
    identified
  • Prior Sudden Cardiac Arrest
  • Prior Myocardial Infarction
  • Heart Failure (Class II to IV)
  • Ejection Fraction less than 40
  • Family History of Sudden Cardiac Arrest

9
Risk Factors
  • Additional risk factors include
  • Recurrent unexplained syncope
  • Idiopathic cardiomyopathy with syncope or VT
  • Hypertrophic cardiomyopathy with syncope or VT
  • Right ventricular dysplasia
  • Long-QT syndrome

10
SCA and Coronary Heart Disease
  • An estimated 13 million people had CHD in the
    U.S. in 20021
  • Sudden death was the first manifestation of
    coronary heart disease in 50 of men and 63 of
    women1
  • CHD accounts for at least 80 of sudden cardiac
    deaths in Western cultures3

Etiology of Sudden Cardiac Death2,3
ion-channel abnormalities, valvular or
congenital heart disease, other causes
1 American Heart Association. Heart Disease and
Stroke Statistics2003 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.
11
SCA and Heart Failure
  • In people diagnosed with CHF, sudden cardiac
    death occurs at 6-9 times the rate of the general
    population1
  • CHF significantly increased sudden death and
    overall mortality in both men and women2

1 American Heart Association. Heart and Stroke
Statistical 2003 Update. Dallas, Tex.
American Heart Association 2002. 2 Redrawn from
Kannel WB, Wilson PWF, D'Agostino RB, Cobb J.
Sudden coronary death in women. Am Heart J 1998
Aug 136 205-212 3 Framingham Heart Study (1948
1988) in Atlas of Heart Diseases. 4 American
Heart Association. Heart Disease and Stroke
Statistics2003 Update
12
SCA and Myocardial Infarction
  • The prevalence of Myocardial Infarction (MI) in
    the U.S. in 2002 was 7.6 million1
  • MIs are identified in as many as 50-75 of sudden
    cardiac arrest victims2,3,4
  • Within 6 years of a recognized MI, 7 of men and
    6 of women will experience sudden death1
  • Individuals with a prior MI have a sudden death
    rate 4-6 times that of the general population1

1 American Heart Association. Heart Disease and
Stroke Statistics2003 Update. Dallas, Tex.
American Heart Association 2002. 2 Myerberg RJ.
Heart Disease, A Textbook of Cardiovascular
Medicine. 6th ed. Philadelphia WB Saunders Co
1997chapter 24. 3 Lombardi G. JAMA.
1994271678-683. 4 Bigger JT. Circulation.
198469250-258.
13
Ejection Fraction
  • Reduced left ventricular ejection fraction (LVEF)
    remains the single most important risk factor for
    overall mortality and sudden cardiac death1
  • Post-MI patients with LV dysfunction (lt 40) have
    a sudden death rate thats similar to a CHF
    population

LVEF and SCA Incidence2
1 Prior SG, Aliot E, Blonstrom-Lundqvist C, et
al. Task Force on Sudden Cardiac Death of the
European Society of Cardiology. Eur Heart J,
Vol. 22 16 August 2001. 2 Vreede-Swagemakers
JJ. J Am Coll Cardiol. 1997301500-1505.
14
Treatment
  • Risk Factor Modification
  • Healthy diet
  • Regular exercise
  • Weight loss
  • Smoking cessation
  • Medical Therapy
  • Beta blockers
  • ACE inhibitors
  • Lipid therapy
  • Interventional Procedures
  • Implantable cardioverter defibrillator (ICD)
  • Revascularization

15
Medical Therapy
  • General Measures
  • RBP lt130 systolic, lt80 diastolic
  • Glycemic control
  • Prevent Ischemia
  • Revascularization
  • Beta-blockers
  • Nitrates
  • Calcium channel blockers
  • ACE Inhibitors
  • Statins
  • Stabilize Plaque
  • Lipid therapy
  • ACE inhibitors
  • Improve Pump Function
  • ACE inhibitors
  • Beta-blockers
  • Aldosterone antagonists
  • Prevent Arrhythmias
  • Beta-blocker
  • ACE inhibitors
  • Aldosterone antagonists
  • Terminate Arrhythmias
  • ICDs
  • AEDs

Adapted from Zipes DP. Circulation.
1998982334-2351. Pitt B. N Engl J Med.
20033481309-1321.
16
ACE Inhibitors
  • Patients with a history of coronary artery
    disease, stroke, or peripheral vascular disease,
    or diabetes plus one other cardiovascular risk
    factor
  • Patients at high risk for heart attack or stroke
    can reduce the risk of sudden cardiac arrest by
    21 by taking ACE inhibitors

Heart Outcomes Prevention Evaluation Study
Investigators N Engl J Med. 2000 Jan
20342(3)145-53.
17
Beta Blockers
  • Beta blockers can reduce the risk of sudden
    cardiac arrest by up to 50 and overall risk of
    death by 25-40

CIBIS-II Investigators, Lancet, 353 9, 1999
18
Effect of Spironolactone on Morbidity and
Mortality
Pitt et al, N Engl J Med, 341 709, 1999
19
Lipid Lowering Therapies
  • Statins have consistently shown the greatest
    benefits in patients with low HDL-C and average
    LDL (CARE, LIPID,AFCAPS/TexCAPS) or high LDL-C
    94S, WOSCOPS)
  • Fibrates have shown benefits in patients with
  • - High triglycerides and low HDL-C (Helsinki)
  • - Normal LDL-C and low HDL-C (VA-HIT)

20
ICD Therapy
  • First-line therapy for ventricular tachycardia
    (VT)/ ventricular fibrillation (VF) patients
  • Transvenous, single incision
  • Local anesthesia conscious sedation
  • Short hospital stay
  • Perioperative mortality lt 1
  • Programmable therapy options
  • Single- or dual-chamber therapy
  • Battery longevity up to 7 years
  • More than 100,000 implants/year

21
ICD Therapy
22
ICD Trials MADIT I
  • Nearly 200 patients randomized to ICD or
    conventional medical therapy over 63 months
  • Prior MI
  • LVEF ? 35
  • Inducible/nonsuppressible sustained VT and
  • Asymptomatic NSVT (330 beats)
  • ICD therapy reduced total mortality by 54
  • ICD therapy reduced arrhythmic mortality by 74
  • Trial stopped early due to significantly superior
    survival for ICD patients

23
ICD Trials MADIT II
  • Over 1,200 patients randomized to ICD or
    conventional medical therapy
  • Coronary artery disease
  • MI ? 30 days prior
  • LVEF ? 30
  • EP studies results considered
  • ICD therapy reduced total mortality by 31
  • Subsequent analysis shows risk of SCA in this
    population does not decrease over time

24
ICD Trials MADIT II
Moss et al. New Engl J Med. 2002 346 (12) 877
25
ICD Trials MUSTT
  • Over 1,250 registry patients followed over 60
    months to evaluate the efficacy of
    anti-arrhythmic therapy guided by
    electrophysiology (EP) studies
  • Coronary artery disease
  • Asymptomatic or minimally symptomatic NSVT
  • LVEF ? 40
  • ICD therapy reduced overall mortality by 55-60
  • EP-guided therapy provided no survival benefit

26
ICD Trials MUSTT
Buxton, et al. New Engl J Med. 1999 341 1882-90.
27
ICD Trials SCD-HeFT
  • Largest ICD trial to date following 2,500
    patients in 150 center with 2 ½ year follow-up
  • Symptomatic CHF (NYHA class II and III) due to
    ischemic or nonischemic dilated cardiomyopathy
  • CHF ? 3 months
  • LVEF ? 35
  • ACE I and Beta Blocker therapy if tolerated
  • ICD therapy reduced overall mortality by 23 in
    patients with moderate heart failure

28
ICD Trials SCD-HeFT
Bardy et al. , et al. New Engl J Med. 352 (3)
225, Figure 1  
29
ICD Trials DEFINITE
  • First trial to study ICD therapy as primary
    prevention in non-ischemic patients
  • Mild to moderate heart failure
  • LVEF lt 35
  • 450 patients randomized to conventional medical
    therapy (CMT) or CMT plus ICD
  • At two years, ICD group showed mortality of 8
    compared with mortality of nearly 14 in the CMT
    group

30
ICD Trials COMPANION
  • Largest heart failure trial to date following
    over 1,500 chronic CHF patients at 128 centers
  • CHF (NYHA class III or IV)
  • CHF-related hospitalization within 12 months
  • QRS width of 120 ms due to ischemic or
    nonischemic cardiomyopathy
  • Patients were randomized to
  • 20 received OPT (optimal pharmacologic therapy)
    alone
  • 40 received OPT plus CRT-P (device with pacing
    stimulation)
  • 40 received OPT plus CRT-D (device with
    defibrillation)
  • OPT plus CRT-D reduced overall mortality by 36

31
Trial Implications
  • Recent clinical trials have shown ICDs to be
    effective in a variety of patient populations
  • Medicare has recently expanded coverage of ICD
    placement for up to 500,000 individuals
  • Criteria for coverage include specific history
    of
  • Cardiomyopathy
  • Previous heart attack
  • Heart failure
  • Low Ejection Fraction (lt 35)
  • Medicare coverage for an ICD is approximately
    30,000

32
Summary
  • SCA is leading cause of death and can frequently
    be predicted and prevented
  • Individuals with a prior SCA event, prior MI or
    heart failure are at risk for SCA
  • Ejection Fraction is a key indicator of risk
    level for SCA. EF less than 40 warrants further
    cardiac evaluation
  • Medical therapies (Beta Blockers, ACE Inhibitors
    and Lipid therapy) have been effective in
    reducing the risk of SCA
  • A series of clinical trials have demonstrated the
    effectiveness of ICD therapy in a variety of
    patient populations
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