Sudden death prevention Top 5 new things clinicians should know

Dan Musat, MDArrhythmia Institute of the

Valley Health System02/08/2019

Disclosures

• None

Definitions

• CARDIAC ARREST is the cessation of cardiac mechanical activity, as confirmed by the absence of signs of circulation.

• SUDDEN CARDIAC ARREST - unexpected cardiac arrest with attempts to restore circulation.

• If attempts are unsuccessful, this situation is referred to as SUDDEN CARDIAC DEATH

• We wish it would be so easy!

The New Things…

• 1. Did SCD occurrence changed over years?• 2. Are all the cardiomyopathies the same?• 3. Does LifeVest save lives?• 4. New CMS requirements for ICD implantation• 5. Current new and future developments in risk

stratification of sudden cardiac death

SCD Statistics

Sudden cardiac death is the largest cause of natural death in the United States

110.8 individuals per 100,000 population

Lifetime risk of SCD – 1 in 7.5 people

366,494 persons

Risk factors- CAD and structural heart disease- Young males- Low socioeconomic status- Smoking- Exercise- Diet- Weight- Depression

SCD – Age and Over the years

Age-specific death rates for any mention of sudden cardiac death by age, 2016

Age-adjusted death rates for any mention of sudden cardiac death, 1999 to 2016

Benjamin, Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:00–00. DOI: 10.1161

Why did it improve?

• CAD and structural heart disease – major risk factors• Better prevention

– Smoking cessation

– Treatment of risk factors – hypertension, diabetes, hyperlipidemia

• Better treatment– STEMI/NSTEMI

– Cardiomyopathies – beta-blockers, ACEI/ARB, Aldosterone inhibitors

• Needs improvement– Obesity

– Fitness

2. Cardiomyopathies Are all the same?

Ischemic Dilated Other

HCM

Is this patient with MI at risk for SCD?

• 72-year-old man with hypertension, smoker and COPD suffered an antero-lateral STEMI for which he underwent PCI with 2 stents to proximal LAD and D1. LVEF 25% with evidence of antero-lateral scar, class I heart failure symptoms.

• During hospitalization he has episodes of non-sustained ventricular tachycardia up to 20 beats, asymptomatic, > 48 hours post intervention.

What should be the next step?

• 1. Insert ICD at this time• 2. Treat medically for 3 months and ICD

implantation if LVEF still < 30%• 3. Wearable defibrillator (LifeVest) until ICD is

implanted in 3 months• 4. EP study and if VT inducible ICD

implantation now

Risk of SCD after MI

Solomon S N Engl J Med 2005;352:2581-8

ICD immediate after AMI

DINAMIT IRIS

3. Does Life Vest Saves Lives?

VEST 1524 randomly assigned to vest778 randomly assigned to control

Primary outcome:SCD from VT at 90 days

VEST on treatment analysis

Dilated Cardiomyopathy

Kadish A N Engl J Med 2004;350:2151-8

Bady N Engl J Med 2005; 352:225-237

DEFINITE SCD-HEFT

Dilated Cardiomyopathy

Kobec N Engl J Med 2016;375:1221-30

DANISH

Goldberger J Am Coll Cardiol 2014;63:1879–89

Annual Rate of the Arrhythmic Endpoint Based on LGE

Di Marco et al. J Am Coll Cardiol HF 2017;5:28–38

Risk of SCD based on LGE

Di Marco et al. J Am Coll Cardiol HF 2017;5:28–38

4. New CMS requirements for ICD implantation

5. Current and future developments in risk stratification of sudden cardiac death

HCM – LGE on CMR MARVEN Study

1) Validate the MADIT-CRT-derived model predicting fast VT/VF in nonischemiccardiomyopathy patients with QRS≥120 ms.

2) Determine whether CMR added to the risk model validated in specific aim 1 will further improve risk stratification for predicting fast VT/VF in nonischemiccardiomyopathy patients with QRS≥120ms.

Genetics in evaluating the future risk for SCD

• Myocardial fibrosis is a common postmortem finding among young individuals with sudden cardiac death

• 4031 consecutive individuals with sudden cardiac death in Northern Finland, among whom PMF was the only structural finding in 145 subjects with sudden cardiac death

• 96 specimens with DNA - genetic tests identified 24 variants of known or uncertain significance in 26 subjects (27%). – 10 were pathogenic/likely pathogenic variants in 10 subjects (10%)

• 5 – ARVC (ACM)• 6 – HCM• 11 - DCM

– 14 were variants of uncertain significance in 11 genes among 16 subjects (17%)