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Sudden Cardiac Deathmanagement challenges of a global problem
Zayd A. Eldadah, MD, PhD
Co-Director, Cardiac Electrophysiology, Washington Hospital Center
Director, Cardiac Electrophysiology, Georgetown University Hospital
Washington DC
NAAMA International Medical Convention ● Beirut ● 26 June 2010
I have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. I will inform the audience of any off-label uses discussed.
Name of Presenter: Zayd A. Eldadah, MD, PhD
Affiliation/Financial Interest Organization Grant/Research Support Medtronic, St. Jude Medical,
Boston Scientific
Consultant Boston Scientific
NAAMA’s 24th International Medical ConventionMedicine in the Next Decade: Challenges and Opportunities
Beirut, LebanonJune 26 – July 2, 2010
Objectives
Recognize the public health
significance of sudden cardiac death
Review the preventive role of ICD
therapy
Recognize challenges to global
prevention of sudden cardiac death,
particularly in the developing world
Case Presentation
69 year-old academic cardiologist with no
documented cardiac history
– Non-smoker, non-diabetic, mild hypertension
– An avid bicyclist
– Exercised regularly, robust & active life
– Particular fondness for Lebanese cuisine and
Arab history
Case Presentation
69 year-old academic cardiologist with no
documented cardiac history
– Found dead on his favorite bicycling route
(with his feet still clipped in the bicycle
pedals)
– Autopsy showed enlarged heart, coronary
atherosclerosis, but no infarct
– Office desk drawers later found to be filled
with antacids
Sudden Cardiac Death
Unexpected death due to cardiac cause
Abrupt loss of consciousness within one
hour of the onset of acute symptoms
If unwitnessed, death within 24 hours of
being last known alive & asymptomatic
Sudden Cardiac Death
Traditional estimate: ~1 SCD per 1,000
population per year in the U.S. and Western
Europe
Japanese data: ~1-2 SCDs per 1,000
population per year
Single-county prospective study in Oregon:
0.53 SCDs per 1,000 population
Smith and Cain. J Interv Card Electrophysiol. 2006.
Chugh, et al. J Am Coll Cardiol. 2004
Global All-Cause Death
58 million deaths worldwide (2005)
– ~1% of human population
Non-communicable diseases (cardiac,
cancer, etc.): 60% of all deaths
Cardiovascular disease is the leading
cause of non-communicable human
mortality
– 17 million (30% of all global deaths)World Health Organization. 2005
The leading cause of death in developed countries:
1. Myerberg RJ, Catellanos A. Cardiac Arrest and Sudden Cardiac Death. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th Ed. New York: WB Saunders. 1997: 742-779.
2. Circulation. 2001; 104: 2158-2163.
3. Vreede-Swagemakers JJ et al. J Am Coll Cardiol 1997; 30: 1500-1505.
4. MMWR Vol. 51 Feb 15, 2002.
Sudden Cardiac Death
An increasing cause of death in developing countries
High recurrence rate
Vast majority (>75%) due to VT / VF
<5%~400,0003W. Europe
5%~300,0002U.S.
<1%3.5m – 7.0m1Worldwide
SurvivalIncidence(cases/year)
1. U.S. Census Bureau, Statistical Abstract of the United States: 2001.
2. American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.
3. 2002 Heart and Stroke Statistical Update, American Heart Association.
4. Circulation. 2001;104:2158-2163.
SCD in the U.S.impact relative to other major killers
1 2 2 3 4
0
100,000
200,000
300,000
400,000
500,000
AIDS Breast
Cancer
Lung
Cancer
Stroke SCD
# d
ea
ths
/ye
ar
ICD therapy for SCD
Highly effective secondary prevention
– AVID
Eight clinical trials assessed efficacy of ICD
as primary prevention:
MADIT-I, MADIT-II, SCD-HeFT, DEFINITE,
DINAMIT, COMPANION, CABG-Patch,
MUSTT
Meta-analysis: primary-prevention ICDs
reduce mortality by 28% at two years vs.
conventional therapyAVID Investigators. N Engl J Med. 1997.
Moss. Circulation. 2005.
ICD Implant Criteria ACC/AHA Guidelines
Resuscitated VF / hemodynamically
unstable VT (Class I)
Ischemic or non-ischemic cardiomyopathy,
LVEF ≤35%, NYHA Class II-III (Class I)
Ischemic or non-ischemic cardiomyopathy,
LVEF ≤35%, NYHA Class I
– Class IIa evidence for ischemic cardiomyopathy
– Class IIb evidence for non-ischemic
cardiomyopathy
Sudden Cardiac Death Incidence and LVEF
0
1
2
3
4
5
6
7
8
0-30% 31-40% 41-50% >50%
Vreede-Swagemakers JJ. J Am Coll Cardiol. 1997;30:1500-1505.LVEF
% S
CD
Vic
tim
s
7.5%
5.1%
2.8%
1.4%
For post-infarct
patients, mean
interval between
MI and SCD: 6.5
years
Sudden Cardiac Death in the general population
adapted from Myerburg et al, Circulation 1998; 97:1514
00 100100 200200 300300
x1,000x1,000
Incidence (%/Year)Incidence (%/Year) Total Events (No./Year)Total Events (No./Year)
General adultGeneral adult
populationpopulation
MultiriskMultirisk
subgroupsubgroup
Any previousAny previous
coronary eventcoronary event
EF <35% orEF <35% or
heart failureheart failure
Cardiac arrest,Cardiac arrest,
VF/VT survivorsVF/VT survivors
00
High-risk post-MIHigh-risk post-MI
subgroupssubgroups
11 22 55 1010 2020 40403030 00 100100 200200 300300
x1,000x1,000
Incidence (%/Year)Incidence (%/Year)
General adultGeneral adult
populationpopulation
MultiriskMultirisk
subgroupsubgroup
Any previousAny previous
coronary eventcoronary event
EF <35% orEF <35% or
heart failureheart failure
Cardiac arrest,Cardiac arrest,
VF/VT survivorsVF/VT survivors
00
High-risk post-MIHigh-risk post-MI
subgroupssubgroups
11 22 55 1010 2020 40403030
~450,000
00 100100 200200 300300
x1,000x1,000
Incidence (%/Year)Incidence (%/Year)
General adultGeneral adult
populationpopulation
MultiriskMultirisk
subgroupsubgroup
Any previousAny previous
coronary eventcoronary event
EF <35% orEF <35% or
Cardiac arrest,Cardiac arrest,
VF/VT survivorsVF/VT survivors
00
High-risk post-MIHigh-risk post-MI
subgroupssubgroups
11 22 55 1010 2020 40403030
MADIT-II, SCD-HeFT,COMPANION
CARE-HF
ICD ChallengesPicking the Population to Treat
LVEF as a risk marker
– a crude criterion alone
– will not capture the majority of SCDs
Risk-stratification and cost-effectiveness
strategies are direly needed, particularly
in developing countries.
ICD ChallengesUnder-Use of Therapy in U.S.
In 49,517 SCD survivors, only 31%
received an ICD before discharge
U.S. CMS & Managed Care data:
– 1,226 per million population found to be
ICD candidates (ventricular arrhythmia or
SCD)
– Yet actual ICD use rate is 416 per million
In 20,511 potentially eligible HF patients,
only 33% received ICD before dischargeVoigt, et al. J Am Coll Cardiol. 2004.
Ruskin, et al. J Cardiovasc Electrophysiol. 2002.
Hernandez et al. JAMA. 2007.
ICD Challenges Gender, Race, Ethnicity Disparities in ICD Therapy
Hernandez, et al. JAMA. 2007
-27%
Compared to ICD Usage Rates in White Men:
African-American Men
-38%
-48%
White Women
African-American Women
Global ICD Usage
2005 World Survey of Cardiac Pacing and ICDs. Mond et al. PACE. 2008
New New Implants
Americas Implants per million population
Argentina 672 18
Brazil 1,413 8
Canada 3,000 91
USA 119,121 401
Global ICD Usage
World Survey of Cardiac Pacing and ICDs. Mond et al. PACE. 2008
New New Implants
Europe Implants per million population
Belgium 846 82
Denmark 540 105
Greece 345 31
Italy 7,439 129
Russia 151 2
Spain 1,400 32
Sweden 412 46
Switzerland 627 84
United Kingdom 2,835 47
Global ICD Usage
World Survey of Cardiac Pacing and ICDs. Mond et al. PACE. 2008
New New Implants
Asia Implants per million population
Australia 2,864 142
China 186 <<1
Hong Kong 211 28
India 415 <<1
Japan 2,360 19
South Korea 148 3
Global ICD Usage
World Survey of Cardiac Pacing and ICDs. Mond et al. PACE. 2008
New New Implants
Middle East / Africa Implants per million population
UAE 13 4
Iran 314 5
Israel 683 98
South Africa 105 2
~80% of the global mortality of SCD
is in middle- to low-income countries
ICD Challengeseconomics
Individual ‘cost’ of SCD incalcuable
Population cost can be measured as Quality-
Adjusted Life Years (QALY) gained
Six-trial analysis (MADIT-1, MADIT-2, MUSTT, SCD-
HeFT, DEFINITE, COMPANION)
– ICDs added 1.01-2.99 QALYs
– Costs ranged from $34,000 - $70,200 per QALY
gained
– Viable in developed economies, but not elsewhereSanders, et al. N Engl J Med. 2005
Challenges to Global SCD Therapy
Overcoming barriers to ICD therapy
– Education (patients, caregivers, broader
population)
– Enhancing safety of implants
– Employing strategies to minimize
inappropriate shocks
Strategies for resource-limited populations:
– Primary prevention with risk-factor modification (e.g., diet and anti-smoking campaigns)
– Genomic-based risk stratification
– Improving EMS, medical, and transportation infrastructure
– Home-based automatic external defibrillators (AEDs) for high-risk patients
– Reducing therapy costs (e.g., simpler devices, reused devices)
Challenges to Global SCD Therapy
Summary
Sudden cardiac death is a major global public
health problem
Weakened hearts predispose to sudden death.
(Ejection Fraction ≤ 35%)
When added to optimal medical therapy, ICDs
reduce mortality in at-risk patients.
ICD therapy remains under-utilized
Effective strategies to address SCD will require
more education, better risk-stratification, and
creative focus on this worldwide killer
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