Sudden Cardiac Death

Sudden Cardiac Death
Sudhir Chandra Sinha

MD DM FACC FSCAI
Member, European Heart Rhythm Association
Consultant Interventional Cardiologist
INDUS Hospitals, Visakhapatnam
Case#1: 48 year male with syncope
• Sudden onset palpitations

• BP-90/60, No SOB/Chest Pain
• ECG- monomorphic VT
• Cardioverted with 200 Jx1
• Echo- Non obstructive HCM
Risk factors for sudden death in
Hypertrophic cardiomyopathy
• Syncope especially recurrent
• Family H/O sudden death and
hypertrophic cardiomyopathy
• Ventricular tachycardia
• Subnormal(<20mmHg) increas in systolic
blood pressure on maximal exercise
testing
• Marked (especially if >30mm) left
ventricular hypertrophy
Case #2: 72 y male
• Sudden onset of chest pain

• Cardiac arrest while being transported to
hospital
• CPR started
• Shifted to cath lab
Case #3: 12 y male child
• h/o collapse when he goes for cycling

• No other relevent history
• Seen by neurologist and cardiologist
Case #4: 40y male
• Admitted with h/o acute onset chest pain

and pulmonary edema
• ECG- STE ASMI
• ECHO- RWMA in LAD territory
• Treated as STEASMI medically
• Coronary angiogram-predischarge
After 4 month
• Routine follow up
• Sudden collapse in OPD outside chamber
• CPR-Defibrillation
• ICD
Case #5
• 4 y child
• Congenital deafness
• Develops seizures whenever cries
• No symptoms otherwise
QTc distribution curves in normal males and females and in a cohort of patients with
congenital LQTS
Drew, B. J. et al. J Am Coll Cardiol 2010;55:934-947
Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.

Case #6
• 64y/F
• Admitted with sepsis and MOD
• Developed cardiac arrest
• Cardiology consultation sought
Case #7
• 52y/F
• Presented with h/o one vomiting and
weakness, fits like episodes
• Had recurrent fits while being transported
from Orissa
• O/E patient has flaccid paralysis of all four
limbs
• K-not recordable
Case # 8
• 82y/M
• No h/o HT/DM
• H/o loose motion and collapse
• ECG
• Had cardiac arrest
Case #9
• 20 y/M
• Daily vendor
• Has sudden episode of seizure despite
treatment
• Seen by an anaesthetist and brought to
hospital
Case# 10
Onset of TdP during the recording of a standard 12-lead ECG in a young male with a
history of drug addiction treated with chronic methadone therapy who presented to a
hospital emergency department after ingesting an overdose of prescription and over-the-
counter drugs from his parent's drug cabinet

CASE #11
Top rhythm strip, TdP degenerating into ventricular fibrillation in an 83-year-old female
hospitalized in the intensive care unit for pneumonia

Case #12
• 40y/F
• Admitted with CCF—DCM, NYHA IV
• Developed syncope
• Monitor - VF
•DEFINITION OF SCD
Any modification on the slide of the presentation are under the sole responsibility of his author
What is SCD ?
 Death by malfunctions in the electrical
system of the heart
 SCD is often caused by a rhythm dysfunction

called ventricular fibrillation (VF)
 The ventricular muscle twitches randomly

and the ventricles fail to pump blood into the
arteries and into systemic circulation
 Consequence : lack of oxygen in the body

and finally death
SCD is not a Heart Attack
Sudden Myocardial
cardiac death infarction
Rhythm dysfunction Obstruction

problem
Prevents heart from

Interruption in the
delivering blood into
supply of blood to
the arteries and
the heart
systemic circulation
Heart muscle
Death dies
SCD causes
Albert CM. Circulation. 2003;107:2096-2101.

SCD arrhythmic causes
Most SCD are due to ventricular tachy-arrhythmias
Huikur H. N Engl J Med 2001; 345(20): 1473-82

Tachy-arrhythmias
Atrial Flutter Ventricular Tachycardia
One extra Focus LA

LA
RA
RA
LV RV LV
RV
Atrial Fibrillation Ventricular Fibrillation
LA Multiple Extra Foci LA

RA RA
RV LV LV
RV
Fundamental difference
Atrial Flutter Not directly
Atrial Fibrillation Life threatening
Ventricular Tachycardia Directly

Ventricular Fibrillation Life threatening
Ventricular Arrhythmias
Ventricular Arrhythmias start without warning !
Fast Ventricular
Tachycardia
Sinus Rhythm
Ventricular Arrhythmias
…Degenerate to a lethal rhythm...
Ventricular fibrillation
unless a shock is delivered to restore sinus rhythm
Sinus rhythm
Typical Sequence of SCD
 Has electrical foci so rapid that the heart turns into a twitching
muscle with effectively no cardiac output
 Within seconds the patient becomes unconscious; within
minutes the patient dies
Patient profile courtesy of M. Akhtar, M.D., Sinal-Samaritan Medical Center, Milwaukee, WL.
SCD survival depends on early
defibrillation
 An electrical shock may be delivered by:
an Automated External Defibrillator

(AED)
an Implantable Cardioverter Defibrillator

(ICD)
 Time is crucial :
Each minute of delay reduces survival rates by about 10%
•EPIDEMIOLOGY
•OF SCD
Incidence of SCD
SCD across Europe
SCD is a worldwide epidemic:
USA 300/400.000 death/year

Europe 350.000 death/year

1st cause of death across

developed countries
Myerburg RJ, et al. Heart disease : a text book of Cardiovascular Medecine, 6th edition; 2001 : 890-931
Size of the problem
1NASPE, May 2000 4National Transportation Safety Board 2000

2American Heart Association 2000 5Center for Disease Control 2001
3National Cancer Institute 2001 6NFPA, US Facts & Figures 2000
Incidence of SCD in specific
populations
Myerburg RJ, et al. Circulation. 1998. 97:1514-1521.

Survival rate after an Sudden
Cardiac Arrest
Only 1 person in 20 usually survives an episode of SCD

The other 19 people die before reaching the hospital
American Heart Association. Heart Disease and Stroke Statistics. 2003 Update. Dallas, Texas: American Heart Association; 2002:3.
Two major risk factors for SCD
Underlying causes of fatal arrhymthmias
Huikur H. N Engl J Med 2001; 345(20): 1473-82

Who is at Risk of SCD?
 People with a prior SCD

 People with a family history of SCD
 People with history of renal dysfunction
 People who have had a Myocardial Infarction (MI)
 People with Congestive Heart Failure (CHF)
 People with a Left Ventricular Ejection Fraction (LVEF) less than or equal to 35%
SCD and post-MI
• People who have had a heart

attack, have a sudden cardiac
death rate that is 4-6 times that
of the general population.
American Heart Association. Heart and Stroke Statistical – 2003 Update. Dallas, Tex.. American Heart Association. 2002
Risk of SCD in post-MI patients
Mortality risk in contemporary post-MI patients with EF ≤ 30%
tends to increase as a function of time from last MI
Wilber D et al. Circulation 2004;109:1082-84

SCD and HF
• In people diagnosed with heart

failure, sudden cardiac death
occurs at 6-9 times the rate of the
general population.
American Heart Association. Heart and Stroke Statistical – 2003 Update. Dallas, Tex.. American Heart Association. 2002
Risk of SCD: many HF patients
concerned
SCD is More Prevalent in NYHA class II/III
The international steering committee. Rational, design, and organization of the Metoprolol CR/XL randomized intervention trail in heart
failure(Merit-HF). Am J Cardiol 1997;80:54J-58J.
Reduced LVEF : an important
risk factor
*
Maggioni AP. Circulation. 1993;87:312-322. *premature ventricular beat

LVEF related to SCD
8 7.5%
7
% of SCD victims
6 5.1%
5
4
2.8%
3
1.4%
2
1
0
0-30% 31-40% 41-50% >50%
LVEF
Gorgels PMA. European Heart Journal. 2003;24:1204-1209.
Emergency management of SCD
• Cardio Pulmonary Resuscitation (CPR)

Hands-Only CPR - No More Mouth-to-Mouth?
Medical Author: Melissa Conrad Stöppler, MD
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR
In April, 2008, the American Heart Association (AHA) took steps to

simplify the process of helping victims of cardiac arrest by introducing "hands-
only" CPR.
It is estimated that each year, around 310,000 Americans die of cardiac arrest that
occurs at home or in a public place.
The Importance of CPR
Heart disease is the number 1 killer in the United States. Each year, almost 330,000
Americans die from heart disease. Half of these will die suddenly, outside of the hospital,
because their heart stops beating.
The most common cause of death from a heart attack in adults is a disturbance in
the electrical rhythm of the heart called ventricular fibrillation.
Ventricular fibrillation can be treated, but it requires applying an electrical

shock to the chest called defibrillation.
If a defibrillator is not readily available, brain death will occur in less than 10
minutes.
One way of buying time until a defibrillator becomes available is to provide artificial
breathing and circulation by performing cardiopulmonary resuscitation, or CPR.
The earlier you give CPR to a person in cardiopulmonary arrest (no breathing,
no heartbeat), the greater the chance of a successful resuscitation.
By performing CPR, you keep oxygenated blood flowing to the heart and brain
until a defibrillator becomes available
Because up to 80% of all cardiac arrests occur in the home, you are most likely to
perform CPR on a family member or loved one.
CPR is one link in what the American Heart Association calls the "chain of
survival." The chain of survival is a series of actions that, when performed in
sequence, will give a person having a heart attack the greatest chance of survival
Chain of Survival
Timing is Everything
Time After the Survival Chances
Onset of Attack
With every minute Chances are reduced by 7-10%
Within 4-6 minutes Brain damage and permanent death start to occur
After 10 minutes Few attempts at resuscitation succeed
Early Access to Emergency Care must be provided by calling emergency

Early CPR should be started and maintained until emergency medical services arrive.
Early Defibrillation is the only one that can re-start the heart function of a person with
ventricular fibrillation (VF).
Early Advanced Care, the final link, can then be administered as needed by EMS
personnel.
Type of Care for SCA Victims after Collapse Chance of
Survival
No care after collapse 0%
No CPR and delayed defibrillation (after 10 minutes) 0-2%
CPR from a non-medical person (such as a bystander or 2-8%

family member) begun within 2 minutes, but delayed
defibrillation
CPR and defibrillation within 8 minutes 20%
CPR and defibrillation within 4 minutes; paramedic help 43%

within 8 minutes
more than 70% of SCA cases occur at home, and another 10% to 15% occur at work
where the Chain is strong and when defibrillation occurs within the first few minutes of
cardiac arrest, survival rates can approach 80% to 100%
People who survive sudden cardiac arrest have an
excellent prognosis: 83% survive for at least one
year, and 57% survive for five years or longer. In
fact, when analyzed by age group, survival rates for
SCA survivors are comparable to survival rates of
people who have never had an event. Clearly, early
intervention can offer years of productivity and
fulfillment to victims of SCA
Early Access
Could you recognize the symptoms of SCA?
Unresponsiveness
Loss of consciousness
Lack of pulse
Cessation of breathing
SCA is not the same as a heart attack

Early CPR
Cardiopulmonary resuscitation (CPR) is the second

link in the Chain of Survival; it is the link that can buy
life-saving time between the first link (Early Access to
Emergency Care) and the third link (Early
Defibrillation
Please Note
INTUBATION and VENTILATION

are not necessary during CPR-
DoNOT waste initial few minutes
in trying to intubate patient or
calling an anaesthetist
Early Defibrillation
Although it is an important link in the Chain of Survival, CPR alone cannot fully
resuscitate a person in SCA. Early defibrillation is the third and perhaps most
significant link. Most SCA victims are in ventricular fibrillation (VF), an
electrical malfunction of the heart that causes the heart to twitch irregularly.
Defibrillation, the delivery of an electrical shock to the heart muscle, can
restore normal heart function if it occurs within minutes of SCA onset.
When CPR and defibrillation are provided within eight minutes of an episode, a
person's chance of survival increases to 20%. 1 When these steps are provided
within four minutes and a paramedic arrives within eight minutes, the
likelihood of survival increases to over 40%.
Early Advanced Care
The fourth link in the Chain of Survival is advanced care. Paramedics and other
highly trained EMS personnel provide this care, which can include basic life
support, defibrillation, administration of cardiac drugs, and the insertion of
endotracheal breathing tubes. This type of advanced care can help the heart in
VF respond to defibrillation and maintain a normal rhythm after successful
defibrillation.
•REVIEW OF DRUG
AND ICD TRIALS
Long Term Management of SCD
Major VT/SCD Drug Trials to
Date
 CAST-I (1991)
 CHF-STAT (1992)
 ESVEM (1993)
 GESICA (1994)
 SWORD (1996)
 EMIAT (1997)
 CAMIAT (1997)
Summary of Drug Trials
Trial Patients Trial Design Result
CAST-I1 1498 Encainide, Flecainide / Terminated due to
Placebo excessive death in
treatment arm
CHF-STAT2 674 Amiodarone / Placebo No change in overall
mortality
SWORD3 546 d-Sotalol / Placebo Terminated due to

excessive death in
treatment arm
ESVEM4 486 EPS-guided / Holter- Mortality high in both arms
guided
EMIAT5 1500 Amiodarone / Placebo No change in overall

mortality
CAMIAT6 1200 Amiodarone / Placebo No change in overall

mortality
4 Mason J.W. N Engl J Med. 1993;329(7):452–8. (Supported by Bristol-
Myers Squibb, Knoll Pharmaceutical, Boehringer-Ingelheim, Parke-Davis,
1 Echt, et al. N Engl J Med. 1991;324:781–8. and Ciba-Geigy).
2 Singh, et al. N Engl J Med. 1995;333:77–82 (supported by Sanofi & Wyeth). 5 Julian D.G. The Lancet. 1997;349:667–74.(Supported by Sanofi)
3 Waldo A.L. The Lancet; 1996;348:7–12. (supported by Bristol-Myers Squibb). 6 Cairns J.A. The Lancet. 1997;349:675–82.
Summary of Drug Trials
 Most anti-arrhythmic drugs worsen mortality
 Amiodarone is not effective in improving SCD mortality and carries
significant toxicity
 In prior and post MI patients with LVD, anti-arrhythmic drugs do not
effectively reduce mortality and they can actually decrease survival
1 Echt, et al. N Engl J Med. 1991;324:781–8. 4 Mason J.W. N Engl J Med. 1993;329(7):452–8.
2 Singh, et al. N Engl J Med. 1995;333:77–82. 5 Julian D.G. The Lancet. 1997;349:667–74.
3 Waldo A.L. The Lancet; 1996;348:7–12. 6 Cairns J.A. The Lancet. 1997;349:675–82.
Secondary Prevention
An event has already occurred:
 Survivors of ventricular fibrillation or

Sustained ventricular tachycardia

USA 300/400.000 death/y.

Only 10% - 20% survive
Europe 350.000 death/y.
 Those patients already have demonstrated that

they are at risk
Connolly SH et al: Eur Heart J. 2000 Dec;21(24):2071-8.

ICD Trials : Secondary
Prevention
 CASH: 1986 – 1997 (1)
• 8 centers / 191 patients, Follow-up 4.48 years
 CIDS: 1990 – 1997 (2)
 AVID: 1993 – 1997 (3)
• Decreasing total study duration also reflects therapy
acceptance.
 Transvenous systems only became available in the early
nineties.
.
1- Kuck K. Circulation. 2000;102:748-754 Supported by Guidant, Astra
2- Connolly SJ. Circulation. 2000;101:1297-1302. Supported by MRC Canada, Wyeth-Ayerst
3- The AVID Investigators. N Engl J Med. 1997;337(22):1576-1583. Supported by NHLBI
CASH
 Objective :
 Evaluate the effectiveness of ICD therapy (n = 99)
versus Metoprolol (n = 97), Amiodarone (n = 92), and
Propafenone (n = 58) in SCA survivors.
 Inclusion Criteria :
 Cardiac arrest survivor with documented VT
Kuck K. Circulation. 2000;102:748-754.

CASH
24% Mortality reduction with ICD
Circulation. 2000;102:748-754
CIDS
 Objective:
 Evaluate the effectiveness of ICD therapy (n = 328)
versus amiodarone (n = 331) in patients with life-
threatening ventricular tachyarrhythmias
 Inclusion Criteria:
 Documented VF
 Cardiac arrest
 Sustained VT with hemodynamic compromise
Connolly SJ. Circulation. 2000;101:1297-1302.
CIDS
20% Mortality reduction with ICD
Circulation. 2000;101:1297-1302
AVID
 Objective:
 To evaluate the effectiveness of ICD therapy (n = 507) in
reduction of total mortality, when compared with
amiodarone (n = 435) or sotalol (n = 74) in patients
resuscitated from SCD who are at very high risk of
mortality from arrhythmic causes
 Inclusion Criteria:
 Primary VF, or
 Sustained VT with syncope, or
 Sustained VT and LVEF < 40% with hypotension/chest
pain or presyncope
The AVID Investigators. N Engl J Med. 1997;337(22):1576-1583.
AVID
Mortality reduction ICD vs antiarrhythmic
drug
Mortality reduction
with ICD
1 year: 39%
2 years: 27%
3 years: 31%
NEJM 1997; 337:1576-1583

Secondary Prevention Trials
outcomes
Reduction in Mortality with ICD Therapy
80
Overall Death
% Mortality Reduction w/ ICD Rx
Arrhythmic Death
58%
60 56%
40 33%
31%
23%* 20%*
20
0 1 2 3
AVID
3 Years 4.75 CASH
Years CIDS
3 Years
* Non-significant results.
1 The AVID Investigators. N Engl J Med. 1997;337:1576-1583.
2 Kuck K. Circulation. 2000;102:748-754.
3 Connolly S. Circulation. 2000;101:1297-1302.
Secondary Prevention Trials
Conclusions
 In resuscitated VT/VF patients :
 no benefit in survival with amiodarone.
 other antiarrhythmic drugs are ineffective
or potentially harmful
 CASH / CIDS / AVID have shown that ICD therapy is

effective in reducing overall mortality and
arrhythmic death in resuscitated VT/VF patients.
ICD Trials : Primary prevention
 MADIT (1)
 CABG-Patch (2)
 CAT (1)
 MUSTT (3)
 AMIOVIRT (1)
 MADIT II (1)
 SCD-HeFT (4)
 DINAMIT (5)
 DEFINITE (5)
1- supported by Guidant
2- supported by Guidant & NHLBI
3- supported by Guidant, Medtronic, StJude/Ventritex et al.
4- Supported by NIH, Medtronic, Wyeth-Ayerst et al.
5- Supported by St Jude
MADIT
 MADIT: 1990 – 1995
 Multicenter RCT* of ICD vs. Antiarrhythmic drugs as
conventional therapy
 32 centers/196 patients, Follow-up 27 months
 Inclusion criteria: MI ≥ 3 weeks before entry, EF ≤ 35 %
 Additional risk factors: asymptomatic NSVT unrelated to
an acute MI with inducible VT not suppressed after
procainamide
Outcomes:
16% mortality in ICD vs. 39% in conventional therapy.
Absolute risk reduction 23%.
Moss AJ et al. NEJM 1996;335:1933-40 *Randomized Clinical Trial

CABG
 CABG: 1990 – 1995
 Multicenter RCT of ICD vs. Antiarrhythmic drugs as
 Inclusion criteria: CABG, EF ≤ 35 %
 Additional risk factors: Abnormal SAECG (signal averaged
ECG)
 Outcomes:
23% mortality in ICD vs. 21% in control patients. No difference
in all cause mortality.
 Issues: Epicardial leads. CABG surgery has a strong effect on
mortality, that could have confounded the overall results.
Bigger et al. NEJM 1997;337:1569-75

CAT
 CAT: 1991 – 1997

 Inclusion criteria: Symptomatic recent onset DCM, LVEF ≤ 30
%, NYHA II or III
 Additional risk factors: Not specified
 Outcomes:
Mortality 8% in ICD vs. 7% in control (not significant! P = 0.54)
 Issues: Low baseline risk for death due to improved therapy
options. Early termination after 1 year
Bansch, Kuck et al. Circulation 2002;105:1453-901458.

MUSTT
 MUSTT: 1989 – 1998
 Multicenter ICD VS. Anitiarrythmic Drug Treatment in Post-MI Patients
 Inclusion criteria: Coronary artery disease (CAD), Asymptomatic,
unsustained VT, LVEF ≤ 40%, inducible VT on EP testing, history of MI
in 95%
Outcomes:
For post-MI patients with EF < 40%, and asymptomatic
NSVT:
• 44% death rate in Registry Patients (non-inducible VT)
• ICD therapy significantly reduced the incidence of death in the
patients with inducible VT:
Arrhythmic death or cardiac arrest (73% - 76% reduction)
Overall mortality (55% - 60% reduction)
• EP-guided pharmacologic antiarrhythmic therapy provides no
survival benefit
Buxton AE et al. NEJM 1999;331:1882-90.
AMIOVIRT
 AMIOVIRT: 1996 – 2000
 Inclusion criteria: NIDCM, EF ≤ 35%, asymptomatic
NSVT, NYHA class I to III
 Additional risk factors: NSVT
Outcomes:
Survival 88% in ICD vs. 87% with Amiodarone.
 Issues: Low baseline risk for death due to
improved therapy. Early termination after 3 years
due to low 3 year mortality in both arms.
MADIT II
 MADIT II: 1997 – 2001

 Multicenter RCT of ICD vs. optimized medical therapy
 Inclusion criteria: Prior MI, EF ≤ 30%
 Outcomes:
14.2% in ICD vs. 19.8 in optimized group. Absolute risk reduction 5.6%. p=0.007
Moss JA et al. NEJM 2002;346:887-83

SCD-HeFT
 SCD-HeFT: 1997 – 2001
 Multicenter RCT of ICD vs. optimized medical therapy vs
optimzed medical therapy with amiodarone
 Inclusion criteria: Ischemic and non ischemic
cardiomyopathy, EF ≤ 35 %
 Outcomes:
22% mortality in ICD group, 28% in amiodarone, 29% in
control. 7% of absolute risk reduction ICD vs control. p=0.007
Bardy GH et al. NEJM 2002;346:877-83

DINAMIT
 DINAMIT: 1998 – 2002

 Inclusion criteria: 6 to 40 days after MI, LVEF ≤ 35%
 Additional risk factors: depressed HRV or elevated average heart
rate on 24 hour holter
 Outcomes:
7.5% mortality in ICD vs. 6.9% in non ICD group, not significant.
 Issues: Therapy with strong effects on mortality, that could have
confounded the overall results.
Hohnloser Kuck, Connolly et al. NEJM 2004;351:2481-88

DEFINITE
 DEFINITE: 1998 – 2002
 Inclusion criteria: NIDCM, EF < 36 %
 Additional risk factors: NSVT or frequent premature
complexes
 Outcomes:
8.1% overall mortality in ICD vs. 13.8% in optimized therapy.
Absolute risk reduction 5.7%, but not significant (p=0.6). The
risk for sudden death from arrhythmia was significantly
reduced (p=0.006).
Kadish, Levine et al. NEJM 2004;350:2151-58

Indications for ICD Therapy
Implantable Cardioverter-
Defibrillators
I IIa IIb
IIbIII
III ICD therapy is indicated in patients who are survivors of cardiac
arrest due to ventricular fibrillation or hemodynamically unstable
sustained VT after evaluation to define the cause of the event
and to exclude any completely reversible causes.
ICD therapy is indicated in patients with structural heart disease

I IIa IIb III
and spontaneous sustained VT, whether hemodynamically
stable or unstable.
ICD therapy is indicated in patients with syncope of

I IIa IIb III undetermined origin with clinically relevant, hemodynamically
significant sustained VT or VF induced at electrophysiological
study.
All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of
survival with good functional capacity for more than 1 year.
I IIa IIb
IIbIII
III Defibrillators
ICD therapy is indicated in patients with LVEF less than or
equal to 35% due to prior MI who are at least 40 days post-MI
and are in NYHA functional Class II or III.
I IIa IIb III ICD therapy is indicated in patients with nonischemic DCM
who have an LVEF less than or equal to 35% and who are in
NYHA functional Class II or III.
ICD therapy is indicated in patients with LV dysfunction due to

I IIa IIb
IIbIII
III prior MI who are at least 40 days post-MI, have an LVEF less
than or equal to 30%, and are in NYHA functional Class I.
ICD therapy is indicated in patients with nonsustained VT due

to prior MI, LVEF less than or equal to 40%, and inducible VF
I IIa IIb III
or sustained VT at electrophysiological study.
I IIaIIbIII Defibrillators
ICD implantation is reasonable for patients with unexplained
syncope, significant LV dysfunction, and nonischemic DCM.
I IIaIIbIII ICD implantation is reasonable for patients with sustained VT and
normal or near-normal ventricular function.
I IIaIIbIII ICD implantation is reasonable for patients with HCM who have 1 or
more major† risk factors for SCD.
ICD implantation is reasonable for the prevention of SCD in patients

I IIaIIbIII with arrhythmogenic right ventricular dysplasia/cardiomyopathy
(ARVD/C) who have 1 or more risk factors for SCD.
ICD implantation is reasonable to reduce SCD in patients with long-

I IIaIIbIII QT syndrome who are experiencing syncope and/or VT while
receiving beta blockers.
† See Section 3.2.4, “Hypertrophic Cardiomyopathy,” in the full-text guidelines for definition of major risk factors.
Defibrillators
I IIaIIbIII ICD implantation is reasonable for nonhospitalized patients
awaiting transplantation.
I IIaIIbIII ICD implantation is reasonable for patients with Brugada

syndrome who have had syncope.
I IIaIIbIII ICD implantation is reasonable for patients with Brugada

syndrome who have documented VT that has not resulted in
cardiac arrest.
ICD implantation is reasonable for patients with

I IIaIIbIII catecholaminergic polymorphic VT who have syncope and/or
documented sustained VT while receiving beta blockers.
ICD implantation is reasonable for patients with cardiac

I IIaIIbIII sarcoidosis, giant cell myocarditis, or Chagas disease.
Defibrillators
I IIaIIbIII ICD therapy may be considered in patients with nonischemic heart
disease who have an LVEF of less than or equal to 35% and who
are in NYHA functional Class I.
I IIaIIb
IIbIII
III ICD therapy may be considered for patients with long-QT syndrome
and risk factors for SCD.
ICD therapy may be considered in patients with syncope and

I IIaIIbIII advanced structural heart disease in whom thorough invasive and
noninvasive investigations have failed to define a cause.
ICD therapy may be considered in patients with a familial

cardiomyopathy associated with sudden death.
I IIaIIbIII
ICD therapy may be considered in patients with LV noncompaction.
I IIaIIbIII
I IIa IIb III
Defibrillators
ICD therapy is not indicated for patients who do not have a
reasonable expectation of survival with an acceptable
functional status for at least 1 year, even if they meet ICD
implantation criteria specified in the Class I, IIa, and IIb
recommendations above.
I IIa IIb III
ICD therapy is not indicated for patients with incessant VT or
VF.
ICD therapy is not indicated in patients with significant
I IIa IIb III
psychiatric illnesses that may be aggravated by device
implantation or that may preclude systematic follow-up.
ICD therapy is not indicated for NYHA Class IV patients with
I IIa IIb III drug-refractory congestive heart failure who are not candidates
for cardiac transplantation or cardiac resynchronization
therapy defibrillators (CRT-D).
Defibrillators
I IIa IIb III ICD therapy is not indicated for syncope of undetermined
cause in a patient without inducible ventricular
tachyarrhythmias and without structural heart disease.
ICD therapy is not indicated when VF or VT is amenable
I IIa IIb III
to surgical or catheter ablation (e.g., atrial arrhythmias
associated with the Wolff-Parkinson-White syndrome, RV
or LV outflow tract VT, idiopathic VT, or fascicular VT in
the absence of structural heart disease).
I IIa IIb III ICD therapy is not indicated for patients with ventricular
tachyarrhythmias due to a completely reversible disorder
in the absence of structural heart disease (e.g.,
electrolyte imbalance, drugs, or trauma).
ICDs in Pediatric Patients and Patients
With Congenital Heart Disease
I IIa IIb III ICD implantation is indicated in the survivor of
cardiac arrest after evaluation to define the cause of
the event and exclusion of any reversible causes.
I IIa IIb III
ICD implantation is indicated for patients with
symptomatic sustained VT in association with
congenital heart disease who have undergone
hemodynamic and electrophysiological evaluation.
Catheter ablation or surgical repair may offer
possible alternatives in carefully selected patients.
ICDs in Pediatric Patients and Patients
With Congenital Heart Disease
I IIa IIb
IIbIII
III ICD implantation is reasonable for patients with congenital
heart disease with recurrent syncope of undetermined origin
in the presence of either ventricular dysfunction or inducible
ventricular arrhythmias at electrophysiological study.
I IIa IIb III ICD implantation may be considered for patients with
recurrent syncope associated with complex congenital heart
disease and advanced systemic ventricular dysfunction when
thorough invasive and noninvasive investigations have failed
to define a cause.
I IIa IIb III All Class III recommendations found in Section 3 of the full-
text guidelines, “Indications for Implantable Cardioverter-
Defibrillator Therapy,” apply to pediatric patients and patients
with congenital heart disease, and ICD implantation is not
indicated in these patient populations.
Major Implantable Cardioverter-
Defibrillator Trials for Prevention of
Sudden Cardiac Death
Trial Year Patients LVEF Additional Study Hazard 95% CI p
(n) Features Ratio*
MADIT I 1996 196 < 35% NSVT and EP+ 0.46 (0.26-0.82) p=0.009
MADIT II 2002 1232 < 30% Prior MI 0.69 (0.51-0.93) p=0.016
CABG-Patch 1997 900 < 36% +SAECG and CABG 1.07 (0.81-1.42) p=0.63
DEFINITE 2004 485 < 35% NICM, PVCs or NSVT 0.65 (0.40-1.06) p=0.08
DINAMIT 2004 674 < 35% 6-40 days post-MI 1.08 (0.76-1.55) p=0.66
and Impaired HRV
SCD-HeFT 2006 1676 < 35% Prior MI of NICM 0.77 (0.62-0.96) p=0.007
AVID 1997 1016 Prior cardiac NA 0.62 (0.43-0.82) NS

arrest
CASH† 2000 191 Prior cardiac NA 0.766 ‡ 1-sided
arrest p=0.081
CIDS 2000 659 Prior cardiac NA 0.82 (0.60-1.1) NS
arrest, syncope
* Hazard ratios for death from any cause in the ICD group compared with the non-ICD group. Includes only ICD and amiodarone patients from CASH.
‡CI Upper Bound 1.112 CI indicates Confidence Interval, NS = Not statistically significant, NSVT = nonsustained ventricular tachycardia, SAECG = signal-averaged
electrocardiogram.
Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Table 5.
Comparison of Medical Therapy, Pacing,
and Defibrillation in Heart Failure
(COMPANION) Trial
• 1520 patients with NYHA Class III or IV HF, ischemic
cardiomyopathy (ICM) or nonischemic cardiomyopathy
(NICM) and QRS ≥ 120 ms
• Randomized 1:2:2 to optimal pharmacological therapy
(OPT) alone or in combination with cardiac
resynchronization therapy with either a pacemaker (CRT-
P) or pacemaker-defibrillator (CRT-D)
• Both device arms significantly ↓ combined risk of all-cause
hospitalization and all-cause mortality by ~20% compared
with OPT
• CRT-D ↓ mortality by 36% compared with OPT (p=0.003)
• Insufficient evidence to conclude that CRT-P inferior to
CRT-D
Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced
chronic heart failure. N Engl J Med 2004;350:2140-50.
Implantable Cardioverter-Defibrillators and
Prevention of Sudden Cardiac Death in
Hypertrophic Cardiomyopathy
• Multicenter registry study of implanted ICDs in 506
unrelated patients with HCM @ high risk for SCD (family
hx of SCD, [septal thickness ≥ 30 mm], NSVT, syncope)
• Mean patient age 42 years (SD=17) and 87% had no or
only mildly limiting symptoms
• Appropriate ICD discharge rates were 11% per year for
2o prevention and 4% per year for 1o prevention
• For 1o prevention, 35% of patients with appropriate ICD
interventions had undergone implantation for only 1 risk
factor
Maron BJ, Spirito P, Shen WK, et al. Implantable cardioverter-defibrillators and prevention of sudden cardiac death in hypertrophic
cardiomyopathy. JAMA 2007;298:405-12.
Multicenter Automatic Defibrillator
Implantation Trial II (MADIT II)
• 1232 patients ≥ 1 month post-MI and LVEF ≤ 30%
• Randomized to ICD (n=742) or medical therapy (n=490)
• No spontaneous or induced arrhythmia required for
enrollment
• 6% absolute and 31% relative risk ↓ in all-cause mortality
with ICD therapy (p=0.016)
Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced
ejection fraction. N Engl J Med 2002;346:877-83.
Sudden Death in Heart Failure
(SCD-HeFT) Trial
• 2521 patients with NYHA Class II or III HF, ICM, or
NICM and LVEF ≤ 35%
• Randomized to
1) conventional rx for HF + placebo;
2) conventional rx + amiodarone; or
3) conventional rx + conservatively programmed shock-
only single lead ICD
• No survival benefit for amiodarone
• 23% ↓ in overall mortality with ICD therapy
• Absolute ↓ in mortality of 7.2% after 5 y in the overall
population
Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med
2005;352:225-37.
Defibrillator in Acute Myocardial Infarction
(DINAMIT) Trial
• 674 patients 6 to 40 days post-MI with LVEF ≤ 35% and

impaired cardiac autonomic function
• Randomized to ICD therapy (n=332) or no ICD therapy
(n=342)
• Arrhythmic death ↓ in ICD group, but ↑ in nonarrhythmic
death (6.1% per year vs. 3.5% per year, HR 1.75 (95%
CI 1.11 to 2.76; p=0.016)
• No difference in total mortality
Hohnloser SH, Kuck KH, Dorian P, et al. Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction.
N Engl J Med 2004;351:2481-8.
Defibrillators in Nonischemic
Cardiomyopathy Treatment Evaluation
(DEFINITE) Trial
• 458 patients with NYHA Class I to III, NICM, LVEF ≤

35% and premature ventricular contractions (> 10/h) or
NSVT
• Randomized to standard medical rx alone or in
combination with single-chamber ICD
• Strong trend toward ↓ all-cause mortality with ICD
therapy, although not statistically significant (p=0.08)
Kadish A, Dyer A, Daubert JP, et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J
Med 2004;350:2151-8.
Notable Changes in 2008 ACC/AHA/HRS Guidelines
1. ICD recommendations are combined into a single list because of overlap between primary
and secondary indications.
2. Primary prevention ICD indications in nonischemic cardiomyopathy are clarified using data
from SCD-HeFT (i.e., ischemic and nonischemic cardiomyopathies and LVEF ≤35%, NYHA
II-III) for support.
3. Indications for ICD therapy in inherited arrhythmia syndromes and selected nonischemic
cardiomyopathies are listed.
4. MADIT II indication (i.e., ischemic cardiomypathy and LVEF ≤30%, NYHA I) is now Class I,
elevated from Class IIa.
5. EF criteria for primary prevention ICD indications are based on entry criteria for trials on
which the recommendations are based.
6. Emphasized primary SCD prevention ICD recommendations apply only to patients
receiving optimal medical therapy and reasonable expectation of survival with good
functional capacity for >1 year.
7. Independent risk assessment preceding ICD implantation is emphasized, including
consideration of patient preference.
8. Optimization of pacemaker programming to minimize unneeded RV pacing is encouraged.
9. Pacemaker insertion is discouraged for asymptomatic bradycardia, particularly at night.
10. A section has been added that addresses ICD and pacemaker programming at end of life.
Conclusion
• Identifying SCD is prime importance
• Correctible causes like dysselectrolytemia,
proarrythmia to be corrected promptly
• AMI and myocarditis are two leading cause of
SCD
• Knowledge of CPR is must for every medical
professional including skills of Defibillation
• Defibrillators should be made available every
where in hospital including wards
• ICD is advisable in secondary and primary
prevention
Thank you very much

Sudden Cardiac Death

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Sudden Cardiac Death

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Sudden Cardiac Death

Sudhir Chandra Sinha

• Sudden onset palpitations

• Sudden onset of chest pain

• h/o collapse when he goes for cycling

• Admitted with h/o acute onset chest pain

Drew, B. J. et al. J Am Coll Cardiol 2010;55:934-947

Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.

Drew, B. J. et al. J Am Coll Cardiol 2010;55:934-947

Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.

Drew, B. J. et al. J Am Coll Cardiol 2010;55:934-947

Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.

 SCD is often caused by a rhythm dysfunction

 The ventricular muscle twitches randomly

 Consequence : lack of oxygen in the body

Rhythm dysfunction Obstruction

Prevents heart from

Albert CM. Circulation. 2003;107:2096-2101.

Most SCD are due to ventricular tachy-arrhythmias

Huikur H. N Engl J Med 2001; 345(20): 1473-82

One extra Focus LA

Atrial Fibrillation Ventricular Fibrillation

LA Multiple Extra Foci LA

Atrial Flutter Not directly

Atrial Fibrillation Life threatening

Ventricular Tachycardia Directly

Ventricular Arrhythmias start without warning !

unless a shock is delivered to restore sinus rhythm

an Automated External Defibrillator

an Implantable Cardioverter Defibrillator

1st cause of death across

1NASPE, May 2000 4National Transportation Safety Board 2000

Myerburg RJ, et al. Circulation. 1998. 97:1514-1521.

Only 1 person in 20 usually survives an episode of SCD

Huikur H. N Engl J Med 2001; 345(20): 1473-82

 People with a prior SCD

• People who have had a heart

Wilber D et al. Circulation 2004;109:1082-84

• In people diagnosed with heart

Maggioni AP. Circulation. 1993;87:312-322. *premature ventricular beat

• Cardio Pulmonary Resuscitation (CPR)

In April, 2008, the American Heart Association (AHA) took steps to

Ventricular fibrillation can be treated, but it requires applying an electrical

With every minute Chances are reduced by 7-10%

After 10 minutes Few attempts at resuscitation succeed

Early Access to Emergency Care must be provided by calling emergency

No care after collapse 0%

No CPR and delayed defibrillation (after 10 minutes) 0-2%

CPR from a non-medical person (such as a bystander or 2-8%

CPR and defibrillation within 8 minutes 20%

CPR and defibrillation within 4 minutes; paramedic help 43%

Could you recognize the symptoms of SCA?

SCA is not the same as a heart attack

Cardiopulmonary resuscitation (CPR) is the second

INTUBATION and VENTILATION

SWORD3 546 d-Sotalol / Placebo Terminated due to

EMIAT5 1500 Amiodarone / Placebo No change in overall

CAMIAT6 1200 Amiodarone / Placebo No change in overall

USA 300/400.000 death/y.

 Those patients already have demonstrated that

Connolly SH et al: Eur Heart J. 2000 Dec;21(24):2071-8.

Kuck K. Circulation. 2000;102:748-754.

NEJM 1997; 337:1576-1583

 CASH / CIDS / AVID have shown that ICD therapy is