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1、Sudden Cardiac Death: Prevention and Treatment,Lexin Wang, M.D., Ph.D. Professor of Clinical Pharmacology Head, Cardiovascular Research,Incidence of SCD,SCD (caused by sudden cardiac arrest) is the most common cause of death in Western societies Incidence: 300,000 to 400,000 each year (U.S.) only 2%
2、 15% reach the hospital Half of these early survivors die before discharge,Risk Factors of SCD,Left ventricular failure CHD, cardiomyopathy Sudden cardiac death syndromes Long QT syndromes Brugada syndrome Polymorphic catecholaminergic VT Isolated ventricular fibrillation,CAD has become a main cause
3、 of SCD,Huikuri HV. N Engl J Med. 2001;345:1473-1482. Myerburg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. W.B. Saunders, Co. 2001.,*ion-channel abnormalities, valvular or congenital heart disease, other causes,Bays de Luna A. Am Heart J. 1989;117:151-159.,Bradycardia 17%,Monom
4、orphic VT 62%,Primary VF 8%,TdP 13%,Prevalence of arrhythmia at SCD,Heart Failure and SCD,More than one million new heart failure patients every year in the USA 25% mortality in 2.5 years in moderate to severe CHF A total of 15% of CHF patients die of SCD,Gorgels, PMA. Eur Heart J .2003;24:1204-1209
5、.,LVEF,% SCD Victims,7.5%,5.1%,2.8%,1.4%,LVEF and SCD,Causes of deaths in HF: mainly SCD in NYHA II-III, heart failure in NYHA IV,MERIT-HFStudy Group. LANCET. 1999;353:2001-2007.,NYHA Class III n = 103,NYHA Class II n = 103,NYHA Class IV n = 27,64%,12%,24%,11%,56%,33%,59%,15%,26%,Myocardial infarcti
6、on and SCD Acute phase: ischemia-provoked VF; or mechanical dysfunctions (e.g. ventricular or papillary rupture) Chronic phase: structural remodelling of the LV, leading to re-entry or heart failure,Risk stratification of SCD,Risk assessment Clinical data Aetiology; family history; LVEF EPS T wave a
7、lternans QT dispersion Arrhythmia during Holter monitoring or stress test,Ideka T, et al JACC 2006; 48:2268,Predictive values of positive TWA, nonsustained VT and ventricular Late potentials,So what we do?,The most important criterion is reduced left ventricular function LVEF35% and 40 days after MI
8、,Prevention of SCD,Anti-arrhythmic drugs Amiodarone is probably the most effective drug for secondary prevention of VT Marginally reduce SCD and mortality ICD Most effective when LVEF30% Other Surgery Long QT (http:/www.scd-symposium.org) Ventricular aneurysm, heart transplant Catheter ablation,Prev
9、ention of SCD,SecondaryPrevention in those who had a history of SCA Primary Prevention in those with a high risk but no history of SCA,80,85,2000,90,95,AVID,CASH,CIDS,SCD-HeFT,MADIT-II,MUSTT,MADIT,二级,Secondary,Primary,DEFINITE,MUSTT,Multicenter Unsustained Tachycardia Trial (MUSTT), a randomized con
10、trolled trial Can electrophysiologically guided antiarrhythmic therapy reduce the risk of sudden death? Looked at coronary artery disease patients with a left ventricular ejection fraction 4 weeks); left ventricular EF 21 years Patients randomly assigned in a 3:2 ratio to receive ICD or conventional
11、 medical therapy,MADIT-II,Trial started July 8, 1997 Trial stopped prematurely in November 20, 2001 because ICD saved lives 1,232 patients enrolled from 76 centers in U.S. and Europe,MADITT II- Mortality,CONV DEFIB (n=490) (n=742) Deaths 97 19.8% 105 14.2% - Hazard Ratio (ICD:CONV) 0.69 (31% mortali
12、ty) (95% CI) (0.51, 0.93) P-value 0.016,MADIT-II,Moss AJ. N Engl J Med. 2002;346:877-83.,Defibrillator,Conventional,P = 0.007,1.0,0.9,0.8,0.7,0.6,0.0,Probability of Survival,0,1,2,3,4,Year,No. At Risk Defibrillator 742 502 (0.91) 274 (0.94) 110 (0.78) 9 Conventional 490 329 (0.90) 170 (0.78) 65 (0.6
13、9) 3,SCD-HeFT,Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) NYHA class 2-3 HF and LVEF 35% Largest internal-cardioverter-defibrillator (ICD) trial ever conducted ICD vs placebo Median follow-up of 45 months,SCD- HeFT,Bardy et al. N Eng J Med 2005; 352 (3): 225,SCD-HeFT: All-cause mortality,
14、Jared Bunch T, et al. Circulation 2007;115:2451-57,Jared Bunch T, et al. Circulation 2007;115:2451-57,Summary,Most SCD are due to coronary artery disease and heart failure LVEF is the most reliable non-invasive predictor for SCD SCD under 30 years of age is usually due to inherited heart disease,Summary,Anti-arrhythmic drugs to prevent sudden death are not as important as once thought -blockers are more effective than amiodarone or sotalol in pts with CHF or CHD,
