Transcript Sudden Cardiac Death in Women

Sudden Cardiac Death
in Women
Briain MacNeill
Galway University Hospital
Oct 6th, 2012
Women and Heart Disease
Myths 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.
Women and Heart Disease
Myths and Truths
• MYTH: Heart disease is a man’s 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.
Women and Heart Disease
Myths 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.
Women and Heart Disease
Myths 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
WELL VISITS
SPORTS
CLEARANCE
CHEST PAIN
SUDDEN
CARDIAC DEATH
IN WOMEN
FAMILY
SCREENING
PALPITATIONS
SYNCOPE
WELL VISITS
SPORTS
CLEARANCE
CHEST PAIN
SUDDEN
CARDIAC DEATH
IN WOMEN
FAMILY
SCREENING
PALPITATIONS
SYNCOPE
Well Visit
Cardiac Risk Profile
Exercise Capacity
Cardiac Symptoms
Lipid Levels
Personal History:
Heart murmur
Systemic hypertension
Fatigability
Syncope
Exertional dyspnoea
Exertional chest pain
Family History:
Premature sudden death
Heart disease in relatives
Physical examination:
BMI, Pulse and Blood pressure measurement
Heart murmur (supine / sitting / standing)
Peripheral Pulses
Stigmata of Marfans Syndrome
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 4-6x’s more likely to suffer a
heart attack
• Women who smoke and take OCP’s
increase their risk of heart disease 30x
• Smoking cessation was associated with a
36% reduction in mortality among patients
with CHD
Obesity and Coronary Heart Disease
Mortality
Nurses’ Health Study: Women who never smoked
6
5
Relative
Risk of
Coronary
Heart
Disease
mortality
4
3
2
1
0
<19
P<0.001 for trend
19.0- 22.0- 25.0- 27.0- 29.021.9
24.9
26.9
28.9
31.9
Body Mass Index (kg/m2)
>32.0
Manson JR, et al. N Engl J Med. 1995;333:677-685.
Who to Treat
Practice Prevention
Low Risk Women <10%:
Intervention is useful and effective:
Lifestyle Interventions
Smoking Cessation
Physical Activity
Heart Healthy Diet
Weight Reduction
Treat Individual CVD risk factors
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
Practice Prevention
High Risk Women (>20%): 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
Croi My Action – 1 year results
Croi My Action – 1 year results
WELL VISITS
SPORTS
CLEARANCE
CHEST PAIN
SUDDEN
CARDIAC DEATH
IN WOMEN
FAMILY
SCREENING
PALPITATIONS
SYNCOPE
Chest Pain Algorithm
Not so straightforward
Chest pain is the presenting symptom in <50% 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.
CHD Mortality in Younger Women
Women
under 65 suffer the highest relative CHD mortality
30
Death during Hospitalization (%)
25.3
24.2
25
Men
20
21.8
Women
18.4
21.5
19.1
16.6
15
13.4
11.1
10.7
9.5
10
8.2
7.4
6.1
5
14.4
5.7
4.1
2.9
0
< 50
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
Figure 1. Rates of death during hospitalization for Myocardial Infarction among w omen and men, according to age. The interaction betw een sex
and age w as significant (P<0.001).
WELL VISITS
SPORTS
CLEARANCE
CHEST PAIN
SUDDEN
CARDIAC DEATH
IN WOMEN
FAMILY
SCREENING
PALPITATIONS
SYNCOPE
Palpitations Algorithm
History, Physical, ECG
Structural Heart Disease Unlikely
Structural Heart Disease Suspected
Labs including TFTs, Drug Screen
ECHO, Holter, Cardiac Review
Daily Symptoms?
No
Event Monitor / Loop
Palpitations During NSR NonVentricular Arrhythmia
Reassurance
Treat Cause
Consider alternatives
Routine cardiac evaluation
Ventricular Arrhythmia
Urgent Cardiac Review
Angio, MRI, EP study
24 or 48 hour Holter
Yes
WELL VISITS
SPORTS
CLEARANCE
CHEST PAIN
SUDDEN
CARDIAC DEATH
IN WOMEN
FAMILY
SCREENING
PALPITATIONS
SYNCOPE
.Eur Heart J 2009;30:2631-2671
Cardiac Syncope
Bradycardia
Tachycardia
Hypotension
SA Node Dysfunction
Supraventricular
Hypoperfusion
AV Conduction Defect
Ventricular
- Preserved LV
- Reduced LV
Reflec Mediated
Medication Related
Medication Related
WELL VISITS
SPORTS
CLEARANCE
CHEST PAIN
SUDDEN
CARDIAC DEATH
IN WOMEN
FAMILY
SCREENING
PALPITATIONS
SYNCOPE
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
Hypertrophic cardiomyopathy
(HOCM)
Increased thickness of heart muscle
Most common inherited cardiac disease
Prevalence
> 1 in 500 people carry gene
>11000 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 fullblown condition (‘incomplete penetrance’)
Inheritance pattern Autosomal Dominant
= 50% risk of inheriting gene if parent affected
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
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
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
Other inherited conditions
• Marfan’s 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
– < 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
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 don’t 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
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
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)
WELL VISITS
SPORTS
CLEARANCE
CHEST PAIN
SUDDEN
CARDIAC DEATH
IN WOMEN
FAMILY
SCREENING
PALPITATIONS
SYNCOPE
Piermario Morosini
Fabrice Muamba
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
•Ebstein’s anomaly
•Marfan’s Syndrome
•Wolff-Parkinson White Syndrome
– WPW
•Ruptured AVM
•SAH
Sports Screening – Italian Protocol
Results of Screening in Veneto Italy
Conditions Screened
Piermario Morosini
Fabrice Muamba
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
Sudden Cardiac Death
in Women
Briain MacNeill
Galway University Hospital
Oct 6th, 2012