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Inhospital SCD

Inhospital SCD. Doc.Dr Emir Fazlibegović,ESC,FESC Prof.Dr Mustafa Hadžiomerović, ESC,FESC 5th International Congress of cardiologysts and angyologysts of Bosnia and Herzegovina,Sarajevo 2010. Time references in SCD. Biological Model of SCD. Magnitude of SCA in the U.S. 167,366. Stroke 3.

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Inhospital SCD

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  1. Inhospital SCD Doc.Dr Emir Fazlibegović,ESC,FESC Prof.Dr Mustafa Hadžiomerović, ESC,FESC 5th International Congress of cardiologysts and angyologysts of Bosnia and Herzegovina,Sarajevo 2010.

  2. Time references in SCD

  3. Biological Model of SCD

  4. Magnitude of SCA in the U.S. 167,366 Stroke3 450,000 SCA claims more lives each year than these other diseases combined SCA4 Lung Cancer2 157,400 #1 Killer in the U.S. 40,600 Breast Cancer2 42,156 AIDS1 1 U.S. Census Bureau, Statistical Abstract of the United States: 2001. 2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures2001. 3 2002Heart and Stroke Statistical Update, American Heart Association. 4 Zheng Z. Circulation. 2001;104:2158-2163.

  5. Magnitude of SCA in the U.S. • ~450,000 per year1 • 1,200 per day • 1 every 80 seconds • Although SCA is the first presentation of cardiac disease in 20-25% of patients, most cases occur in patients with clinically recognized heart disease.2 1 Zheng Z. Circulation. 2001;104::2158-2163. 2 Myerburg RJ, Heart Disease, A textbook of Cardiovascular Medicine. 6th ed. 2001. W.B. Saunders, Co.

  6. SCA Different from MI SCA Caused by heart electrical system problem. MI Occurs when one or more of thearteries that supply blood to theheart muscle becomes blocked.The affected area loses blood supply (ischemia)and results in damage to the heart tissue.

  7. SCA Symptoms: Collapse and loss of consciousness Cessation of normal breathing Loss of pulse and blood pressure MI Symptoms: Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest lasting more than few minutes Pain spreading to the shoulders, neck, or arms Chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath Atypical chest pain, stomach or abdominal painNausea ordizziness Shortness of breath and difficulty breathing Unexplained anxiety, weakness, or fatigue Palpitations, cold sweat, or paleness SCA and MI Symptoms SCA has few to no premonitory signs and death is usually rapid--within one hour. An impending MI typically has many premonitory signs that may develop over the course of hours or days. www.americanheart.org

  8. 5% Other* 15%Cardiomyopathy 80%Coronary Heart Disease Etiology of SCD -An estimated 13 million people had coronary heart disease (CHD) in the U.S. in 2002. 1 -Sudden death was the first manifestation of CHD in 50% of men and 63% of women. 1 -CHD accounts for at least 80% of sudden cardiac deaths in Western cultures.3 Etiology of Sudden Cardiac Death2,3 * ion-channel abnormalities, valvular or congenital heart disease, other causes 1 American Heart Association. Heart Disease and Stroke Statistics—2003 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.

  9. Causes of in-hospital mortality • The cause of death in hospital is most often noncardiac, usually being due to anoxic encephalopathy or to respiratory complications from long-term respirator dependence • Only about 10 percent of patients die from recurrent arrhythmia, while approximately 30 percent die from a low cardiac output or cardiogenic shock

  10. PROVOKING FACTORS • Electrolyte disturbances • Any reversible metabolic abnormalities should be identified and corrected, particularly hypokalemia and hypomagnesemia which may predispose to ventricular tachyarrhythmias • Antiarrhythmic drugs • Whenever possible, antiarrhythmic drugs should be discontinued prior to any diagnostic studies

  11. PROVOKING FACTORS • Use of an illicit drug such as cocaine can directly cause arrhythmia or produce coronary artery vasospasm and ischemia • A prolonged QT interval which may be acquired (due, for example, to a drug or electrolyte disturbance) or inherited

  12. Arrhythmic Cause of SCD 12%Other CardiacCause 88%ArrhythmicCause Albert CM. Circulation. 2003;107:2096-2101.

  13. Underlying Arrhythmias of Sudden Cardiac Arrest Torsades de Pointes13% Bradycardia17% VT62% Primary VF8% Bayés de Luna A. Am Heart J. 1989;117:151-159.

  14. SCD Rates for Males and Females 502.7 407.1 336.1 Per 100,000 Standard US Population 270.5 258.8 212.6 130.0 153.4 Zheng Z. Circulation. 2001;104(18):2158-2163.

  15. Incidence of Sudden Death Increases with Age During a 38 years follow-up of subjects in the Framingham Heart Study, the annual incidence of sudden death increased with age in both men and women.However, at each age, the incidence of sudden death is higher in men than women. (Am Heart J 1998; 136:205)

  16. SCD gender

  17. SCD age

  18. SCD in Clinical Hospital Mostar (10 years)

  19. Clinical Substrates Associated with VF Arrest • Congestive heart failure • The presence of CHF increases overall mortality and the incidence of SCD in both men and women • AIM ,cardiogenic shock , ICV

  20. CHF Predict Increased Sudden Death and Overall Mortality During a 38 years follow-up of subjects in the Framingham Heart Study, the presence of CHF significantly increased sudden death and overall mortality in both men and women. *P <0.001.

  21. SCD in CHF

  22. In people diagnosed with CHF, sudden cardiac death occurs at 6-9 times the rate of the general population.1 1 American Heart Association. Heart and Stroke Statistical –2003 Update. Dallas, Tex.: American Heart Association: 2002.

  23. Clinical Substrates Associated with VF Arrest • Myocardial ischemia and infarction • Acute myocardial infarction is associated with an approximate 15% risk of VF within the first 24 to 48 hours, with the incidence falling to only 3 percent over the next several days • When VF is provoked by an AMI, symptoms of the infarction are present for minutes to hours before sudden death occurs; over 80 percent of VF episodes occur within the first 6 hours

  24. SCD Rates in Post-MI Patients with LV Dysfunction Total Mortality ~20-30%; SCD accounts for ~50% of the total deaths. References in slide notes. * MADIT-II mortality values at 20 months.

  25. SCD in AIM

  26. SCD IN ICV

  27. SCD IN SCHOCK CARDIONGENES

  28. SCD in AHF

  29. SCD in CARDIAC ARREST

  30. SCD on the road to Hospital

  31. 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 SCA Resuscitation Success vs. Time* Chance of success reduced 7 - 10% each minute % Success *Non-linear Time (minutes) Cummins RO. Annals Emerg Med. 1989;18:1269-1275.

  32. SCA Chain of Survival Statistics • 5% estimated SCA out-of-hospital survival2,3 • Even in the best EMS/early defibrillation programs it is difficult to have high survival times due to many SCA events not being witnessed and the difficulty of reaching victims within 6-8 minutes. • 40% SCAs not witnessed or occur in sleep1 • 80% SCAs occur at home1 1 Swagemakers V. J Am Cardiol. 1997;30:1500-1505 2 Ginsburg W. Am J Emer Med. 1998;16:315-319. 3 Cobb LA. Circ. 1992;85:I98-102.

  33. Sudden Cardiac Death • Incidence400,000 - 500,000/year in U.S. • Only 2% - 15% reach the hospital • Half of these die before discharge • High recurrence rate

  34. Risk of Sudden Death: Data from GISSI-2 Trial 1.00 1.00 0.98 0.98 p log-rank 0.002 0.96 0.96 0.94 0.94 Survival Survival 0.92 0.92 p log-rank 0.0001 0.90 0.90 Patients withoutLV Dysfunction 0.88 0.88 A B 0.86 0.86 0 30 60 90 120 150 180 0 30 60 90 120 150 180 Days Days Patients withLV Dysfunction No PVBs1-10 PVBs/h> 10 PVBs/h

  35. People who’ve had a heart attack and have LV dysfunction (less than or equal to 40%) have a sudden death rate that’s similar to a CHF population.

  36. “People who’ve had a heart attack have a sudden death rate that’s 4-6 times that of the general population.”1 1American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex.: American Heart Association; 2002.

  37. Correcting Ischemia Revascularization Beta-blocker Preventing Plaque Rupture Statin ACE inhibitor Aspirin Stabilizing Autonomic Balance Beta-blocker ACE inhibitor Improving Pump Function ACE inhibitor Beta-blocker Prevention of Arrhythmias Beta-blocker Amiodarone Terminating Arrhythmias ICDs AEDs Prevent Ventricular Remodeling and Collagen Formation Aldosterone receptor blockade Treatments to Reduce SCD Zipes DP. Circulation. 1998;98:2334-2351. Pitt B. N Engl J Med. 2003;348:1309-1321.

  38. Symptoms in terminal episodes

  39. Summary 1 Defibrillation is the only effective treatment for SCA. Few SCA victims are treated quickly enough to survive.

  40. Summary 2 High risk SCA patients can be identified: low LVEF, HF, prior MI, and prior SCA or VT/VF event. ICD and CRT-D therapies can prevent SCA. Most eligible patients are not receiving device therapy. Some healthcare organizations have developed care pathways to identify and treat patients at high risk of SCA.

  41. Summary 3 Detailed in ESC and ACC/AHA/HRS Device Guidelines for SCD/SCA and VODIČ ZA SCD ESC UKBIH 2010 Epstein AE, et al. Circulation. 2008;117:e350-408.

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