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Sudden Cardiac Death in Women

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Title: Sudden Cardiac Death in Women


1
Sudden Cardiac Deathin Women
  • Briain MacNeill
  • Galway University Hospital
  • Oct 6th, 2012

2
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.

3
Women and Heart DiseaseMyths and Truths
  • MYTH Heart disease is a mans 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.

4
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.

5
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

6
WELL VISITS
CHEST PAIN
SUDDEN CARDIAC DEATH IN WOMEN
SPORTS CLEARANCE
PALPITATIONS
SYNCOPE
FAMILY SCREENING
7
WELL VISITS
CHEST PAIN
SUDDEN CARDIAC DEATH IN WOMEN
SPORTS CLEARANCE
PALPITATIONS
SYNCOPE
FAMILY SCREENING
8
Well Visit
Personal History Heart murmur Systemic
hypertension Fatigability Syncope Exertional
dyspnoea Exertional chest pain Family
History Premature sudden death Heart disease
in relatives
Cardiac Risk Profile Exercise Capacity Cardiac
Symptoms Lipid Levels
  • Physical examination
  • BMI, Pulse and Blood pressure measurement
  • Heart murmur (supine / sitting / standing)
  • Peripheral Pulses
  • Stigmata of Marfans Syndrome

9
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 4-6xs more likely to suffer a heart
    attack
  • Women who smoke and take OCPs increase their
    risk of heart disease 30x
  • Smoking cessation was associated with a 36
    reduction in mortality among patients with CHD

10
Obesity and Coronary Heart Disease Mortality
Nurses Health Study Women who never smoked
Relative Risk of Coronary Heart
Disease mortality
Body Mass Index (kg/m2)
Plt0.001 for trend
Manson JR, et al. N Engl J Med. 1995333677-685.
11
Who to TreatPractice Prevention
  • Low Risk Women lt10
  • Intervention is useful and effective
  • Lifestyle Interventions Smoking
    Cessation Physical Activity Heart Healthy
    Diet
  • Weight Reduction Treat Individual CVD risk
    factors

12
Practice Prevention
  • Intermediate Risk Women (10-20) Smoking
    Cessation
  • Physical Activity
  • Heart Healthy Diet
  • Weight Reduction Control 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

13
Practice Prevention
  • High Risk Women (gt20) Class I Smoking
    Cessation Physical Activity/cardiac
    rehab Heart Healthy Diet- DASH Diet Weight
    Reduction Control BP and Lipids- Statin ASA
    therapy Glycemic control in DM

14
Croi My Action 1 year results
15
Croi My Action 1 year results
16
WELL VISITS
CHEST PAIN
SUDDEN CARDIAC DEATH IN WOMEN
SPORTS CLEARANCE
PALPITATIONS
SYNCOPE
FAMILY SCREENING
17
Chest Pain Algorithm
18
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19
Not so straightforward
  • Chest pain is the presenting symptom in lt50 of
    women
  • Almost half of MIs in women present with SOB,
    nausea, indigestion, fatigue and shoulder pain
  • Atypical 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.

20
CHD Mortality in Younger Women
Women under 65 suffer the highest relative CHD
mortality
21
WELL VISITS
CHEST PAIN
SUDDEN CARDIAC DEATH IN WOMEN
SPORTS CLEARANCE
PALPITATIONS
SYNCOPE
FAMILY SCREENING
22
Palpitations Algorithm
23
WELL VISITS
CHEST PAIN
SUDDEN CARDIAC DEATH IN WOMEN
SPORTS CLEARANCE
PALPITATIONS
SYNCOPE
FAMILY SCREENING
24
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25
.Eur Heart J 2009302631-2671
26
Cardiac Syncope
Hypotension
Bradycardia
Tachycardia
SA Node Dysfunction AV Conduction
Defect Medication Related
  • Supraventricular
  • Ventricular
  • - Preserved LV
  • - Reduced LV

Hypoperfusion Reflec Mediated Medication
Related
27
WELL VISITS
CHEST PAIN
SUDDEN CARDIAC DEATH IN WOMEN
SPORTS CLEARANCE
PALPITATIONS
SYNCOPE
FAMILY SCREENING
28
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

29
Hypertrophic cardiomyopathy (HOCM)
  • Increased thickness of heart muscle
  • Most common inherited cardiac disease
  • Prevalence
  • gt 1 in 500 people carry gene
  • gt11000 in 32 counties
  • 90 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

30
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

31
Other Cardiomyopathies- Dilated
  • May 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

32
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

33
Other inherited conditions
  • Marfans 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
  • lt 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

34
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 dont 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

35
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 done
  • Structural cause of death may be missed
  • Minor abnormalities may be incorrectly recorded
    as cause of sudden death
  • True number of SCD which are actually due to SADS
    probably under-estimated

36
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)

37
WELL VISITS
CHEST PAIN
SUDDEN CARDIAC DEATH IN WOMEN
SPORTS CLEARANCE
PALPITATIONS
SYNCOPE
FAMILY SCREENING
38
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39
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40
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
  • Ebsteins anomaly
  • Marfans Syndrome
  • Wolff-Parkinson White Syndrome WPW
  • Ruptured AVM
  • SAH

41
Sports Screening Italian Protocol
42
Results of Screening in Veneto Italy
43
Conditions Screened
44
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45
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
46
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47
Sudden Cardiac Deathin Women
  • Briain MacNeill
  • Galway University Hospital
  • Oct 6th, 2012
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