DEMYSTIFYING SUDDEN DEATH IN NIGERIA- DEVELOPING LEGISLATION FOR REGULAR HEALTH CHECKUP

1. DEMYSTIFYING SUDDEN DEATH IN NIGERIA- DEVELOPING LEGISLATION FOR REGULAR HEALTH CHECKUP Dr Abiodun M Adeoye MB.BS, FWACP, Cert. Cardiology

2. Introduction Burden of sudden cardiac death Risk factors Prevention Legislation conclusion OUTLINE

3. INTRODUCTION • Death is certain and inevitable but in the plan of God for man, untimely or premature death was not there at creation • World Heart Federation has released a global plan to reduce cardiovascular morbidity and mortality by 25% come 2025 • Sudden cardiac death (SCD) is an unexpected death due to cardiac causes occurring in a short time period (generally within 1 hour of symptom onset) in a person with known or unknown cardiac disease • Worse prognosis in people with no background heart diseases • sudden death occurs when the heart stops beating and breathing ceases abruptly or unexpectedly.

4. INTRODUCTION • Death is defined as irreversible cessation of all biological functions in the body.  • Sudden Cardiac Arrest (SCA) isan abrupt cessation of cardiac pump function, which may be reversible but will lead to death in the absence of prompt intervention.  It is very rare for it to reverse spontaneously • Heart Attack/ Acute Myocardial Infarction.  Heart attacks occur when there is a blockage in one or more of the arteries to the heart, preventing the heart from receiving enough oxygen-rich blood.

5. The four temporal elements considered in the definition include prodromes, acute cardiovascular collapse, cardiac arrest and biological death • The prodromes- warning symptoms such as dyspnea,palpitation and chest pain • Acute cardiovascular collapse is a terminal event that precedes cardiac arrest (reversible in the presence of appropriate interventions) • biological death (irreversible no matter the intervention or technology).

6. BURDEN OF SUDDEN CARDIAC DEATH • SCD is estimated to claim more than 7 million lives per year worldwide • the united state of America, with high incidence of CHD, the rate of SCD is estimated at between 300,000 to 350,000 annually. • > 50% of patient with CHD present with sudden cardiac death • In 20%-25% of the SCD victims, the cardiac arrest is the first clinical manifestation of previously silent or unrecognized heart disease • Incidence in Nigeria largely unknown

7. AETIOLOGY AND RISK FACTORS • Varies with age, sex and race(geographical location) • common causes of sudden cardiac death • Hypertensive heart diseases • Coronary artery diseases • Left ventricular hypertrophy • Cardiomyopathies • Myocarditis • Congenital heart diseases • Valvular heart diseases • Aortic dissection

8. AETIOLOGY • Primary electrophysiological abnormalities • Atrioventricular blocks • Sinus node dysfunction • Pre-excitation syndromes e. g Wolff-Parkinson-White syndrome • Brugada syndrome • Long QT syndromes • Short QT syndrome • Idiopathic ventricular tachycardia • Catecholaminergic polymorphic ventricular tachycardia • Idiopathic ventricular fibrillation

9. Hypertensive heart disease

10. PREVENTABLE CAUSES OF DEATH

11. DATA FROM NIGERIA • Rotimi et.al - autopsy study of 50 cases between 28 and 80 years who died suddenly • hypertensive heart disease was the cause of death in 82% of the cases and only 18% were previously diagnosed Only 4% of the cases died of acute myocardial infarction. • In a review of 2529 medico-legal autopsies over a 10 year period (1987-1997) 79 were found to be cases of SCDs and hypertensive heart disease was the most common cause of death. In a prospective study • Aligbe et al(2002) in Benin City, Nigeria over a two year period (1997-1998), -complication of hypertension • Mandong et al(2006) autopsy report of 279 medico-legal cases over a period of8 years in North Central Nigeria-hypertensive heart failure

12. SCD exhibits diurnal variation in the general population. Occurrence of SCD increases sharply within few hours of rising in the morning, and a second peak is evident in the evening hours • Early morning blood pressure rise- use anti- hypertensive with 24 hour coverage

13. Acute coronary syndrome

14. Overview • CAD/ACS/MI account for most deaths • >50% death occur within one hour/pre- hospital • In 17% of patients it is their first, last and only symptom • Early diagnosis and treatment of AMI significantly reduces mortality, improves local and overall left ventricular function, and decreases incidence of heart failure • Interventions must be administered within the first few hours of symptom onset • Early intervention – PCI/fibrinolytic agents

15. CORONARY ARTERIES

16. Definition of Terms • Atherosclerosis is a systemic disease- thickening of arterial wall • Coronary artery disease is the presence of atherosclerosis in the coronary arteries • Acute coronary syndromes – spectrum of symptomatic clinical conditions representing acute closure of the coronary arteries with varying degrees of cholesterol plaque, clot and spasm • These syndromes include unstable angina and myocardial infarction

17. Sequence of Atherosclerosis

18. ARTHEROSCLEROSIS PLAQUE OCCLUSION BLOOD DIVERSION HAEMORRHAGE SPASM NEUROGENIC INFLUENCE PLATELET VASOACTIVE SUBSTANCE LEUKOTRIENES BLOOD CLOT

19. SEQUENCE OF ARTHEROSCLEOSIS

20. PATHOPHYSIOLOGY • Problem of demand and supply • Reduced supply- under perfusion of myocytes-ischaemia or infarction in prolong time • Myocardial infarction caused by complete coronary artery occlusion begins to develop after 15-30 minutes of severe ischemia; where a coronary occlusion persists for more than 30 minutes, irreversible damage to the myocardium (or myocardial infarction) begins to occur. • Continuing coronary occlusion results in a progressive increase of the infarct size. • After about 6 hours of continuous occlusion the myocardium supplied by that artery becomes necrotic.

22. “Red Flags” or Warning Signs of Heart Attack • Chest discomfort is the most important signal of a heart attack • Sweating,nausea,vomiting, or shortness of breath • Discomfort may not be severe especially in “silent MI”. Act once is prolonged and not relieved by rest and NTG • The person does not necessarily have to “look bad” • Stabbing, momentary twinges of pain are usually not signals of heart attack. Sharp or stabbing pain that can be localised by a tip of finger is not likely cardiac.

23. PATIENT WITH RECURRENT SYNCOPE

24. CORONARY ANGIOGRAPHY

25. PTCA

26. POST PTCA

27. Prevention of SCD

28. MAJOR RISK FACTORS FOR CARDIOVASCULAR DISEASE MODIFIABLE RISK FACTORS GENDER 50% of patients may not have a recognisable risk factor HYPER TENSION FAMILY HISTORY OF CV DIS CORONARY HEART DISEASE HYPER LIPIDAEMIA PERSONAL HISTORY OF CV DIS OBESITY AGE SMOKING NON-MODIFIABLE RISK FACTORS DIABETES MICRO- ALBU- MINURIA HYPER- HOMO- CYSTEINE INFLAM- MATION DRUG ABUSE

30. Screening of General Population and RiskProfiling • Screening of the general population - discover people with underlying heart diseases in the society • the first manifestation of such a heart disease in the general population may be the SCD • Medical evaluation of athletes before competition offers the potential to identify asymptomatic athletes with potentially lethal cardiovascular abnormalities • 10 year risk estimation for cardiovascular death – stratify patients • Using QRISK2-2011 models, subjects were grouped as low risk (<5%), moderate risk (6-20%), and high risk (>20%)

31. PHYSICIAN HEAL THYSELF • The overall risks among the subjects were low risk (38%), moderate risk (50%), and High risk (12%). • Compared with females, male counterparts had higher prevalence of moderate risk (60% vs 38.6%,p=0.0001) and high risk(16% vs 7.1%, p=0.0001) • Hypertension among health workers – 32.5% had normal blood pressure • Metabolic syndrome - The overall prevalence of metabolic syndrome was 24.2%. • Compared with males, females have higher frequency of metabolic syndrome (34.9% vs 2.4%, p<0.0001) • Nurses were found to have greater frequency of metabolic syndrome when compared with physicians (40.2% vs 4.8%, p<0.0001)

32. PREVENTION • Lifestyle modification • Pharmacological Therapy- beta blockers, antiarrhythmic drugs • Implantable inter cardiac defibrillator • External cardiac defibrillator • Cardiac resynchronization therapy

33. LEGISLATION OF HEALTH CHECKS • Most time obituary reads 'death after a brief illness' How brief was the illness? • Regular health exams and tests can help find problems before they start. • On behalf of the Nigerian Medical Association,  I wish to restate our call on the executive and legislative arms of Government at local, state and federal government levels to create a separate day, at least six-monthly or once a year dedicated to free health check-up by Nigerian citizens under their jurisdiction. This is doable and will surely ensure a healthy polity and a productive workforce in Nigeria.

34. THANK YOU