Addressing the Risk for Sudden

Cardiac Death in Heart Failure

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

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

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

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

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]

Causes of Sudden Death in HF

Lethal arrhythmias
Cerebrovascular accidents
Pulmonary embolism
Myocardial rupture
Aneurysms

Breakdown of Sudden
Unexpected Death by
Other CV death
N=
Autopsy
Results
VALIANT
2% in
Non-CV
death
105
Pump failure
4%

3%

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]

Cause of Death

Type of Death

DINAMIT (n = 342)

Sudden, presumed
arrhythmic

29 (54%)

Cardiac, nonarrhythmic

17 (31%)

Noncardiac

8 (15%)

Total

54 (16%)

Dorian D, et al.[3]

Implications of -Blocker Use

Prior to Device Implantation
1. -Blockers decrease risk of SCD
This is relevant to time prior to and after
device implant

2. -Blockers may increase ejection

fraction
Patient may no longer be a candidate for
primary prevention according to the
guidelines

3. Underuse of -Blockers may

reflect poor adherence, a key
factor in the successful
application of device therapy

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

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]

HAT- Home Use of Automated

External
Defibrillators
for died
Sudden
Overall, 450 patients
228 of 3506
patients (6.5%) in the control group
Cardiac
Arrest
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]

Length of Time Patients Wore

the WCD

Chung MK, et al.[14]

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