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Addressing the Risk for Sudden Cardiac Death in Heart Failure

Addressing the Risk for Sudden Cardiac Death in Heart Failure. Panelists Philip B. Adamson, MD Director, Heart Failure Institute Oklahoma Heart Hospital Director, Oklahoma Foundation for Cardiovascular Research Adjunct Associate Professor of Physiology

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Addressing the Risk for Sudden Cardiac Death in Heart Failure

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  1. Addressing the Risk for Sudden Cardiac Death in Heart Failure Panelists Philip B. Adamson, MD Director, Heart Failure Institute Oklahoma Heart Hospital Director, Oklahoma Foundation for Cardiovascular Research Adjunct Associate Professor of Physiology University of Oklahoma Health Sciences Center 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 Moderator Scott D. Solomon, MD Professor of Medicine Harvard Medical School Director, Noninvasive Cardiology Director, Cardiac Imaging Core Laboratory and Clinical Trials Endpoints Center Brigham and Women’s Hospital Boston, Massachusetts

  2. 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

  3. 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

  4. 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]

  5. Causes of Sudden Death in HF • Lethal arrhythmias • Cerebrovascular accidents • Pulmonary embolism • Myocardial rupture • Aneurysms

  6. Breakdown of “Sudden Unexpected Death” by Autopsy Results in VALIANT N = 105 Other CV death 2% Non-CV death 3% Pump failure 4% 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]

  7. Cause of Death Dorian D, et al.[3]

  8. Implications of β-Blocker Use Prior to Device Implantation • β-Blockers decrease risk of SCD • This is relevant to time prior to and after device implant • β-Blockers may increase ejection fraction • Patient may no longer be a candidate for primary prevention according to the guidelines • Underuse of β-Blockers may reflect poor adherence, a key factor in the successful application of device therapy

  9. Types of Arrhythmias • 2% to 5% are probably unrecoverable • 85% to 90% are tachyarrhythmias • Electromechanical disassociation PEA-type • Sustained bradyarrhythmias account for maybe 10%

  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 are2 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

  11. 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]

  12. HAT- Home Use of Automated ExternalDefibrillators 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]

  13. Length of Time Patients Wore the WCD Chung MK, et al.[14]

  14. Thank you for participatingin this activity.To proceed to the CME/CE posttest, click the Earn CME Credit link on this page.

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