Addressing the Risk for Sudden Cardiac Death in Heart Failure

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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 Womens Hospital Boston,
Massachusetts
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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

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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

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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
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Causes of Sudden Death in HF

• Lethal arrhythmias
• Cerebrovascular accidents
• Pulmonary embolism
• Myocardial rupture
• Aneurysms

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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
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Cause of Death
Type of Death DINAMIT (n 342)
Sudden, presumed arrhythmic 29 (54)
Cardiac, non-arrhythmic 17 (31)
Noncardiac 8 (15)
Total 54 (16)
Dorian D, et al.3
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Implications of ß-Blocker Use Prior to Device
Implantation

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

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Types of Arrhythmias

• 2 to 5 are probably unrecoverable
• 85 to 90 are tachyarrhythmias
• Electromechanical disassociation PEA-type
• Sustained bradyarrhythmias account for maybe 10

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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 are 2 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

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