Sudden

Cardiac
Death:
What We Have to
Know

Dr. Ardian Rizal, SpJP

Arrhythmia and Electrophysiology Division
Cardiology and Vascular Medicine
Faculty of Medicine, Brawijaya University
Introduction
 Size of The Problem

1 – 3
Per 100.000
10-75
Per 100.000 in 3M < 1 %
In those 1 – 35 those 35 – 64 Cases worldwide Survival rate
y.o. y.o. annually

European Heart Journal doi:10.1093/eurheartj/ehv316

Sudden Cardiac Death
Etiology

Circ Res. 2015;116:1887-1906

Different Age
Etiology

• Over 35 yrs of age

• Coronary Heart Disease
• Under 35 yrs
• Cardiomyopathies
• Channelopathies
• Congenital Heart Disease
• Myocarditis
Circ Res. 2015;116:1887-1906
 SCD
in Coronary Heart
Disease
Coronary Artery Disease
Clinical Manifestation

• Asymptomatic
• Stable angina
• Acute coronary syndrome
• Heart failure
• Sudden cardiac death
 Ventricular Arrhythmia
Mechanism

• Automaticity
• Re – entry
• Triggered activity
Ventricular arrhythmias
Associated with ACS
• A significant number of SCD
events occur in the pre-hospital
phase of ACS
• The incidence in the hospital
phase has declined in recent
decades, mainly due to early
revascularization strategies and
the early introduction of
adequate pharmacological
treatment.
ESC Guidelines Class LOE
Beta-blocker treatment is recommended for I B
recurrent polymorphic VT.
Intravenous amiodarone is recommended for I C
the treatment of polymorphic VT.
Correction of electrolyte imbalances is I C
recommended in patients with recurrent VT or
VF.
Intravenous lidocaine may be considered IIb C
Prophylactic treatment with anti-arrhythmic III B
drugs (other than beta-blockers) is not
recommended.
ICD implantation for the primary prevention of III A
SCD is generally not indicated ,40 days after
myocardial infarction.
Beta Blocker
Trend in Heart Failure

CIBIS III
SENIORS
COMET
Recognition of
MERIT-HF
neurohormonal
CIBIS II
activation
Swedberget al, 1973 USCP
Waagstein et al, 1973 CIBIS
MDC

Contraindicated Indicated
Early after MI
Death due to MI

SCD is an important cause of

death after acute myocardial
infarction à even after BB era

Prior SG, et al. Eur Heart J. 2001;22:1374-1450.

MERIT-HF Study Group. Lancet. 1999;353:2001-2007.Sweeney MO, PACE. 2001;24:871-888.
 Case Ilutration
Patient 1

History
• 54 y.o. Javanesse female
• Ischemic cardiomyopathy
• NYHA Class I
• LVEF 45% per echo at your institution
• Compliant and stable on optimal medical therapy
• Syncopal episodes; with documented episodes
of VT
 Arrhythmic Death in VT/VF Patients
AVID Results in Non-ICD Arm

20 18%
18
16

% Arrhythmic Death
14
12 11%
10
8%
8
6
4
2
0
1 Year 2 Years 3 Years

Pratt CM. Circulation. 1998;98(suppl I):1494-1495.

It can be anywhere …..
SCA Resuscitation
Success versus Time*
100

90 Chance of success reduced

7-10% each minute
80

70

60
%
Success 50

40
*Non-linear
30

20

10

0 1 2 3 4 5 6 7 8 9
Time (minutes)
Cummins RO. Annals Emerg Med. 1989;18:1269-1275.
Implantable Cardioverter Defibrillator
 Clinical CAD

Primary Prevention

Sudden Cardiac
Arrest

Secondary Prevention

Survivor
Grundy SM, et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations. Circulation. 1999;100:1481–92.
 Secondary Prevention Trials:
Reduction in Mortality with ICD Therapy

80
Overall Death

% Mortality Reduction w/ ICD Rx

Arrhythmic Death
58%
60 56%

40
31% 33%
23%* 20%*
20

0
AVID1 CASH 2 CIDS 3

•Non-significant results.
1 The AVID Investigators. N Engl J Med. 1997;337:1576-1583.

2 Kuck Kh, et al. Circulation. 2000;102:748-754.

3 Connolly SJ, et al. Circulation. 2000;101:1297-1302.
 2008 ACC/AHA/HRS Class I ICD
Secondary Prevention Guidelines for the Management of
Ventricular Arrhythmias

1. History of SCA, VF, hemodynamically unstable sustained VT

(exclude reversible causes)
2. Structural heart disease and spontaneous sustained VT,
whether hemodynamically stable or unstable

3. Syncope of undetermined origin with clinically relevant,

hemodynamically significant sustained VT or VF induced at
EP study

4. Non-sustained VT due to prior MI, LVEF < 40% and inducible

VT at EP study

Epstein AE, et al. Circulation 2008;117:e350-408.

 Case Ilutration
Patient 2

History
• 52 y.o. woman
• Lives alone in rural community
• NYHA Class III
• PMHX: MI one year ago, echo on discharge
was 35%
• Medications: BB, ACE-I, lipid-lowering agent,
clopidorgrel, omega-3
 ICD
Primary Prevention

Primary Prevention à Risk Stratification is needed to

predict who will get the most benefit of ICD implantation
after MI

Several non invasive risk assessment have been proposed

T wave alternant, Heart Rate turbulent etc

Heart Rhythm, Vol 11, No 10, October 2014

European Heart Journal doi:10.1093/eurheartj/ehv316
Reduced (LVEF) remains the
single most important risk
factor for overall mortality
and SCD

1 Prior SG, et al. Eur

Heart J. 2001;22:1374-1450.
2 MERIT-HF Study Group. Lancet. 1999;353:2001-2007.
3 Sweeney MO, PACE. 2001;24:871-888.
 Randomized Clinical Trials
Supporting Device Therapy
Mortality (%)
ICD and CRT-D for the Primary Prevention of SCA
Trial N Mean Mean Mean Control Therapy Control ICD P
Age (yrs) LVEF Follow-up
(%) (mos)

SCD-HeFT 1,2 2,521 60.1 25 45.5 Optimal Medical 36.1 28.9 .007
Therapy

COMPANION 3 1,520 67 21 12 -16 months Optimal Medical 19 12 .0003

Therapy (CRT-D)

4
MUSTT 704 67 30 39 No EP-guided 48 24 .06
Therapy

5
MADIT II 1,232 64 23 20 Optimal Medical 19.8 14.2 .007
Therapy

1 Bardy GH, et al. N Engl J Med. 2005;352:225-237.

Reduction in Primary Prevention Trials are Equal to
2 Packer DL. Heart Rhythm. 2005;2:S38-S39

3 Bristow MR, et al. N Engl J Med. 2004;350:2140-2150.

or Greater than those in secondary prevention trial 4Buxton AE, et al. N Engl J Med. 1999;341:1882-1890.
5 Moss AJ, et al. N Engl J Med. 2002;346:877-883.
Early after MI
Other Risk Stratification for SCD
 When ?

ICD
 SCD Dilated Cardiomyopathy
in Non Ischemic Hypertrophic Cardiomyopathy
Arrhythmogenic Right Ventricular
Cardiomyopathy Cardiomyopathy
Dilated Cardiomyopathy
• Optimal medical therapy (ACE inhibitors, beta-blockers and
MRA) is recommended to reduce the risk of sudden death
and progressive HF
(Class Recommendation I ; LOE A)

• Secondary Prevention
An ICD is recommended in patients with DCM and
hemodynamically not tolerated VT/VF, who are expected to
survive for 1 year with good functional status
(Class Recommendation I ; LOE A)

• Primary Prevention
An ICD is recommended in patients with DCM, symptomatic HF
(NYHA class II–III) and an ejection fraction ≤35% despite ≥3
months of treatment with optimal pharmacological therapy
who are expected to survive for 1 year with good functional
status
(Class Recommendation I ; LOE B)
SCD
in Hypertrophic Obstructive Cardiomyopathy
• Young adult >>
• Overall annual
cardiovascular mortality is
0.81%.
• Beta-blockers are used to
treat LVOT obstruction,
but there is no evidence
that they reduce the risk
of SCD
Ø 6 %
Ø ICD indication for primary
prevention (Iib)
 SCD
in Channelopathies
“ECG and echocardiographic signs of
inheritable arrhythmogenic diseases a
seems to be an important part of
clinical practice and can contribute to
the early identification of patients at
risk of SCD”

European Heart Journal doi:10.1093/eurheartj/ehv316

Brugada Syndrome
Long QT Syndrome
Short QT Syndrome
Prevalence of Brugada Syndrome
ECG Pathognomonic
in Brugada Syndrome
 Long QT Syndrome
Case Ilustration

• Female 34 y.o.
• Frequent Syncope
• Witnessed VT/VF
• SCA Survivor
Measure QTC 550 ms
• Referred from Jember
Measuring QT and QTC
Frequent VF is detected during
Follow Up
 Approach Management
& Risk Stratification in BrS & LQTS
• Beta-blockers are recommended in patients with a clinical diagnosis of LQTS (I B)

• ICD implantation with the use of beta- blockers is recommended in LQTS patients
with previous cardiac arrest (I B)

• ICD implantation is recommended in patients with a diagnosis of Brugada

syndrome who Are survivors of an aborted cardiac arrest and/or Have
documented spontaneous sustained VT (I C)

• Quinidine or isoproterenol should be considered in patients with Brugada

syndrome to treat electrical storms (Iia C)

European Heart Journal doi:10.1093/eurheartj/ehv316

 Screening the
general population
for the risk of SCD
 Prevention and Screening
of SCD

• Approximately 50% of cardiac arrests occur in

individuals without a known heart disease

• But most suffer from concealed ischemic heart disease

• Screening SCD à screening CAD

Heart Rhythm, Vol 11, No 10, October 2014

European Heart Journal doi:10.1093/eurheartj/ehv316
Screening in General Population
• There are no clear data supporting the benefit of broad screening
programs in the general population

Screening family members of SCD victims

Take Home Messages
• The incidence of SCD not really low

• The leading cause of SCD (in adult) is coronary heart disease

• ICD implantation indication not only for secondary prevention, but in

some cases for primary prevention

• Risk stratification is important, to get the most benefit after the

implantation
Thank You