Transcript Addressing the Risk for Sudden Cardiac Death in Heart

Addressing the Risk for Sudden Cardiac
Death in Heart Failure
Moderator
Panelists
Scott D. Solomon, MD
Philip B. Adamson, MD
Professor of Medicine
Director, Heart Failure Institute
Harvard Medical School
Oklahoma Heart Hospital
Director, Noninvasive Cardiology
Director, Oklahoma Foundation for
Director, Cardiac Imaging Core Laboratory
Cardiovascular Research
and Clinical Trials Endpoints Center
Adjunct Associate Professor of Physiology
Brigham and Women’s Hospital
University of Oklahoma Health Sciences Center
Boston, Massachusetts
Oklahoma City, Oklahoma
Paul Hauptman, MD
Professor of Internal Medicine
Division of Cardiology
Assistant Dean, Clinical and Translational
Research
Saint Louis University School of Medicine
St. Louis, Missouri
Learning Objectives
• Identify persistent treatment gaps for people
with HF
• Evaluate potential mechanisms underlying the
risk for SCD and HF
• Assess the role of ICDs and WCDs to address
the risk of SCD in patients with ischemic and
nonischemic HF
Who Is at Risk of SCD?
• Patients with low EF
• Family history
• Risk stratification can help delineate high,
moderate, and low risk
• Patients with preserved left ventricular
function may have lower risk of SCD but still
have high mortality risk
– Hypokalemia and metabolic abnormalities
– Symptomatology often has inverse relation to SCD
VALIANT: Patients With a First or Subsequent
Acute MI Complicated by HF, Left Ventricular
Systolic Dysfunction, or Both
• n = 14,609
• 1067 had an event
(median, 180 days
after MI)
• 903 died suddenly
• 164 were resuscitated
after cardiac arrest
• The risk was highest
in the first 30 days
after MI
Solomon SD, et al.[1]
Causes of Sudden Death in HF
•
•
•
•
•
Lethal arrhythmias
Cerebrovascular accidents
Pulmonary embolism
Myocardial rupture
Aneurysms
Breakdown of “Sudden Unexpected
Death” by Autopsy Results in VALIANT
N = 105
Pump failure
4%
Other CV death
2%
Non-CV death
3%
Myocardial ruptures
12%
Presumed arrhythmic
death (n = 52)
49%
Myocardial infarction
30%
• 3% of index MI
• 27% of recurrent MI
Pouleur AC, et al.[2]
Cause of Death
Type of Death
DINAMIT (n = 342)
Sudden, presumed
arrhythmic
29 (54%)
Cardiac, nonarrhythmic
17 (31%)
Noncardiac
8 (15%)
Total
54 (16%)
Dorian D, et al.[3]
Implications of β-Blocker Use Prior to
Device Implantation
1. β-Blockers decrease risk of SCD
– This is relevant to time prior to and after device
implant
2. β-Blockers may increase ejection fraction
– Patient may no longer be a candidate for primary
prevention according to the guidelines
3. Underuse of β-Blockers may reflect poor
adherence, a key factor in the successful
application of device therapy
Types of Arrhythmias
• 2% to 5% are probably unrecoverable
• 85% to 90% are tachyarrhythmias
• Electromechanical disassociation PEAtype
• Sustained bradyarrhythmias account for
maybe 10%
CMS, the National Coverage
Determination
• Waiting period before ICD implantation in
patients with cardiomyopathy is 9 months
after first diagnosis of nonischemic
cardiomyopathy
• However, there are 2 types of patients who
present de novo
– Those who have truly de novo cardiomyopathy and
HF
– Those who have established cardiomyopathy but a
de novo presentation of HF
Decision-Making Process for the Patient
at Risk for SCD
• ACC/AHA guidelines
• ACC appropriateness paper across 369
different indications
• CMS, national coverage determination
• Clinical judgment
• Patient preference
• Risk management
Centers for Medicare and Medicaid Services.[9]
Russo AM, et al.[10]
Zipes DP, et al.[11]
HAT- Home Use of Automated External
Defibrillators for Sudden Cardiac Arrest
Overall, 450 patients died
• 228 of 3506 patients (6.5%) in the control group
• 222 of 3495 patients (6.4%) in the AED group
160 deaths (35.6%) were considered to be
sudden cardiac arrest from tachyarrhythmia
• 117 occurred at home
• 58 at-home events were witnessed
AEDs were used in 32 patients
• 14 received an appropriate shock
• 4 survived to hospital discharge
Bardy GH, et al.[12]
Length of Time Patients Wore the WCD
Chung MK, et al.[14]
Thank you for participating
in this activity.
To proceed to the CME/CE posttest,
click the Earn CME Credit link on this
page.