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Definition
Sudden cardiac death natural death from cardiac causes, heralded by
abrupt loss of consciousness within 1 hour of the onset of an acute
change in cardiovascular status

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac death

TermsRelatedtoSuddenCardiacDeath

TERM

DEFINITION

QUALIFIERS

Sudden cardiac death

Sudden, irreversible
cessation of all biologic None
functions

Cardiac arrest

Abrupt cessation of
cardiac mechanical
function, which may be
reversible by a prompt
intervention but will
lead to death in its
absence

Sudden loss of effective

blood flow due to
cardiac and/or
peripheral vascular
factors that may
Cardiovascular collapse reverse spontaneously
(e.g., neurocardiogenic
syncope; vasovagal
syncope) or require
interventions (e.g.,
cardiac arrest)

MECHANISMS

Rare spontaneous
Ventricular fibrillation,
reversions; likelihood of
ventricular tachycardia,
successful intervention
asystole, bradycardia,
relates to mechanism of
pulseless electrical
arrest, clinical setting,
activity, mechanical
and prompt return of
factors
circulation

Nonspecific term;
includes cardiac arrest
and its consequences
and transient nonlifethreatening conditions
that usually revert
spontaneously

Same as cardiac arrest,

plus vasodepressor
syncope or other causes
of transient loss of
blood flow

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Four temporal perspectives of sudden

cardiac death

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Epidemiology

Fewer than 250,000SCDs annually when the etiologic definition is

limited to coronary heart disease

More than 460,000SCDs per year when all causes are included.

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Braunwalds hearts disease 9th e,

part 41 Cardiac arrest and sudden
cardiac death

Braunwalds hearts disease 9th e,

part 41 Cardiac arrest and sudden
cardiac death

Causes and contributing factors in

sudden cardiac death

Coronary artery abnormalities

Hypertrophy of ventricular myocardium

Myocardial diseases and heart failure

Inflammatory, infiltrative, neoplastic, and degenerative processes

Diseases of the cardiac valves

Congenital heart disease

Electrophysiologic abnormalities

Electrical instability related to neurohumoral and central nervous system influences

Sudden infant death syndrome and sudden death in children

Miscellaneous
Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Pathology dan Pathophysiology

Pathologic studies in SCD victims reflect the epidemiologic and

clinical observations that coronary atherosclerosis is the major
predisposing cause

CORONARY ARTERIES

Extensive atherosclerosis has long been recognized as the most

common pathologic finding in the coronary arteries of victims of SCD

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

The role of active coronary artery lesions, characterized by plaque

fissuring, plaque erosion or rupture, platelet aggregation, and
thrombosis, as a major pathophysiologic mechanism of the onset of
cardiac arrest has become clarified

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Coronary artery spasm, an established cause of acute ischemia and SCD is commonly
associated with nonobstructive plaques, and spasm itself has been recognized at
postmortem examination in rare cases

MYOCARDIUM
Healed myocardial infarction is a common finding in SCD victims, with most investigators
reporting frequencies ranging from 40% to more than 70%.

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac death

VENTRICULAR HYPERTROPHY
heart

weights are higher in SCD victims than in those whose death is not sudden,

despite similar prevalences of history of hypertension before death

SPECIALIZED CONDUCTING SYSTEM IN SUDDEN CARDIAC DEATH
Fibrosis

of the specialized conducting system may be observed in SCD victims

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

CARRDIAC NERVES AND SUDDEN CARDIAC DEATH

Diseases

of cardiac nerves have been postulated to have a role in SCD

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Mechanism of Sudden Cardiac Death

Triggering factors ischemia, hemodynamic changes, fluctuations in

the autonomic nervous system, electrolyte abnormalities,
proarrythmic effect of drugs

TACHYARRYHTMIAS IN SCD

VF first recorded rhythm in approximately 75% SCD

VT degenerating into VF
Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

BRADYARRHYTHMIAS IN SCD
Bradyarrhytmias
The

were documented infrequently

basic electrophysiologic mechanism in this form of arrest is failure

of normal subordinate automatic activity to assume the pacemaking

function of the heart in the absence of normal function of the sinus
node, AV junction, or both
Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac death

Electrophysiologic Effects of Ischemia

Acute myocardial ischemia intracellular and extracellular acidosis

and loss of myocellular membrane integrity with efflux of potassium
and influx of calcium decrease in the amplitude and upstroke
velocity of the cardiac action potential, inhomogeneous
depolarization of the resting membrane potential, and shortening of
action potential duration.
Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

Fast sodium and slow calcium channels in partially depolarized fibers

may remain inactiveprolonging refractoriness electrical
inhomogeneities within and around the ischemic zoneconduction
delays, unidirectional block, and reentrant arrhythmias

Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

Mechanoelectrical Feedback

acute changes in the mechanical state of the heart related to altered

preload and contractility can have direct electrophysiologic effects
that may precipitate arrhythmias; this relationship is referred to as
mechanoelectrical feedback.

Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

Cardiac disease associated with sudden

death
1. ISCHEMIC HEART DISEASE

Coronary atherosclerosis

2. NONISCHEMIC HEART DISEASE

Cardiomyopathies

Idiopathic Dilated Cardiomyopathy

Hypertropic Cardiomyopathy

Hypertensive Cardiomyopathy

Arrhythmogenic Right Ventricular Dysplasia

Valvular

Heart Disease

Mitral Valve Prolaps

Infammatory

and Infiltrative Myocardial Disease

Congenital

Heart Disease

Electrolyte

abnormalities

Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

Primary Electrical Abnormality

WPW Syndrome
Idiopathic Ventricular Tachycardia
Idiopathic Ventricular Fibrillation
Brugada Syndrome
Drug and Other Toxic Agents
Pro-arrhythmia
Coccain
Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

Clinical Features

Prodromal Symptoms patients at risk for SCD can have prodromes

such as chest pain, dyspnea, weakness or fatigue, palpitations,
syncope, and a number of nonspecific complaints.

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Onset of the Terminal Event the period of 1 hour or less between

acute changes in cardiovascular status and the cardiac arrest itself is
defined as the onset of the terminal event.

Cardiac arrest characterized by abrupt loss of consciousness

caused by lack of adequate cerebral blood flow due to failure of
cardiac pump function.

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Progression to Biologic Death The time course for progression from

cardiac arrest to biologic death is related to the mechanism of the
cardiac arrest, the nature of the underlying disease process, and the
delay between onset and resuscitative efforts

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death

Survivors of Cardiac Arrest

Cardiac arrests during the acute phase of myocardial infarction are

classified as :
- primary (electrical event not associated with hemodynamic
dysfunction). Patients who are resuscitated immediately from primary
VF associated with acute coronary syndromes usually stabilize
promptly
- secondary (electrical event linked to hemodynamic dysfunction).

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Risk Stratification for SCD

Clinical history

Left ventricular function

Electrocardiographic abnormalities

Autonomic markers

Signal-averaged electrocardiography

T-wave alternans

Electrophysiologic studies
Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

Treatment options for patients at risk of

SCD

-blockers

ACE-I

HMG Co-A reductase inhibitor

Dofetilide

Amiodarone

Device therapy ICD

Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

ROLE OF SURGERY
Revascularization
Antiarrythmia
Catheter

surgery

ablation therapy

Hursts The Heart 12th edition, Chapter 49 Sudden cardiac death

Management of cardiac arrest

Basic life support

- Chest tump
- Airway This process includes tilting the head backward and
lifting the chin, in addition to exploring the airway for foreign
bodies, including dentures, and removing them
- Breathing With the head properly placed and the
clear, mouth-to-mouth resuscitation can be initiated
rescue equipment is available

oropharynx
if no specific

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

- Circulation The palm of one hand is placed over the lower

sternum and the heel of the other rests on the dorsum of the lower
hand. The sternum is then depressed, with the resuscitator's arms
straight at the elbows to provide a less tiring and more forceful fulcrum
at the junction of the shoulders and back. By use of this technique,
sufficient force is applied to depress the sternum about 4 to 5cm, with
abrupt relaxation, and the cycle is carried out at a rate of about 100
compressions/min.

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

Braunwalds hearts disease 9th e, part 41 Cardiac arrest and sudden cardiac
death

ACLS AHA 2010

ACLS AHA 2010

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