Prediction and Prevention of Sudden Cardiac Death

1. Prediction and Prevention of Sudden Cardiac Death Slides courtesy of Mark Estes, MD

2. Sudden Cardiac Death • Sudden death Definition • Instantaneous death, unwitnessed death, or death occurring within one hour of the onset of symptoms

3. Deaths/year in the US

4. ICD Clinical Trials : Overview 1o 2o

5. Noninvasive Testing Ischemic Heart Disease

6. ICD Trials for Prevention of Sudden Cardiac Death * Hazard ratios for death from any cause in the ICD group compared with the non-ICD group. Includes only ICD and amiodarone patients from CASH. ‡CI Upper Bound 1.112 CI indicates Confidence Interval, NS = Not statistically significant, NSVT = nonsustained ventricular tachycardia, SAECG = signal-averaged electrocardiogram. Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Table 5.

7. SCD Prevention Trials ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death Circulation. 2006;114:e385-e484

8. Applying Classification of Recommendations and Level of Evidence Level of Evidence

9. Implantable Cardioverter Defibrillators – Class I, Level of Evidence: A I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III A All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

10. Implantable Cardioverter Defibrillators – Class I, Level of Evidence: B I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III B All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

11. Implantable Cardioverter Defibrillators – Class IIa, Level of Evidence: B I IIa IIb III B All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

12. Implantable Cardioverter Defibrillators – Class IIa, Level of Evidence: C I IIa IIb III All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year. †See section 3.2.4; “Hypertrophic Cardiomyopathy,” in the full-text guidelines for definition of major risk factors.

13. Implantable Cardioverter Defibrillators – Class IIa, Level of Evidence: C I IIa IIb III All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

14. Implantable Cardioverter Defibrillators – Class IIa, Level of Evidence: C I IIa IIb III All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

15. Implantable Cardioverter Defibrillators – Class III, Level of Evidence: B I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III B All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

16. Implantable Cardioverter Defibrillators – Class III, Level of Evidence: C I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III C All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

17. Implantable Cardioverter Defibrillators – Class III, Level of Evidence:C I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III C All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

18. ICDs in Pediatric Patients and Patients With Congenital Heart Disease I I I I I I IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III I I I I I I IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III I I I I I I IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III C B All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

19. ICDs in Pediatric Patients and Patients With Congenital Heart Disease I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III C C B All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

20. Notable Changes in 2008 ACC/AHA/HRS Guidelines • ICD recommendations are combined into a single list because of overlap between primary and secondary indications. • Primary prevention ICD indications in nonischemic cardiomyopathy are clarified using data from SCD-HeFT (i.e., ischemic and nonischemic cardiomyopathies and LVEF ≤35%, NYHA II-III) for support. • Indications for ICD therapy in inherited arrhythmia syndromes and selected nonischemic cardiomyopathies are listed. • MADIT II indication (i.e., ischemic cardiomypathy and LVEF ≤30%, NYHA I) is now Class I, elevated from Class IIa. • EF criteria for primary prevention ICD indications are based on entry criteria for trials on which the recommendations are based.

21. Notable Changes in 2008 ACC/AHA/HRS Guidelines • The need for optimization of medical therapy before CRT implantation is emphasized. • 7. Independent risk assessment preceding ICD implantation is emphasized, including consideration of patient preference. • 8. Optimization of pacemaker programming to minimize unneeded RV pacing is encouraged. • 9. Pacemaker insertion is discouraged for asymptomatic bradycardia, particularly at night. • 10. A section has been added that addresses ICD and pacemaker programming at end of life. • 11. Emphasized primary SCD prevention ICD recommendations apply only to patients receiving optimal medical therapy and reasonable expectation of survival with good functional capacity for >1 year.

22. Evidence Based Medicine AEDs *# of Survivors **total mortality