Chapter 3 / Prevention of Sudden Cardiac Death



Prevention of Sudden Cardiac Death
Joseph E. Marine, MD

Since the 1960s, important advances have been made in resuscitation of patients from
sudden cardiac death (SCD). Despite these advances, rates of survival to hospital discharge range from only 2 to 30% (generally 5–10%); rates of survival with intact neurological status are even lower (1). Approximately 400,000 out-of-hospital sudden deaths
occur in the United States each year (2). These grim statistics point to the importance of
prevention in approaching the problem of SCD from a public health standpoint.
It has been estimated that one-half to two-thirds of out-of-hospital sudden death is
caused by ventricular arrhythmias (VA) (ventricular tachycardia [VT] and ventricular
fibrillation [VF]) (3). Bradyarrhythmias, such as complete atrioventricular block and
asystole, are a less frequent cause of arrhythmic sudden death. A substantial minority of
cases of apparent SCD may be because of nonarrhythmic causes, such as massive pulmonary embolus, ruptured aortic aneurysm or dissection, or stroke (4). Because most research
into prevention of SCD has focused on VA, this subject will form the basis for this chapter.
Preventive strategies will be considered according to the etiology of cardiac disease.

Coronary artery disease (CAD) is the leading cause of death in Western countries and
the most common cardiac substrate for SCD. It is now recognized that CAD is a systemic
disease of the cardiovascular system that is often far advanced by the time it is clinically
manifest. The first signs of atheroma formation may begin in adolescence. As CAD
progresses, atheromas may encroach on the coronary artery lumen, causing flow-limiting
stenosis. At this stage, patients may develop ischemia in the absence of infarction, often
with exertion or stress. Ischemia in turn may lead to arrhythmias, particularly polymorphic VT and VF. Ischemic VA may also occur in the absence of significant atherosclerosis, usually associated with coronary artery spasm or congenital coronary anomalies.
From: Contemporary Cardiology: Cardiopulmonary Resuscitation
Edited by: J. P. Ornato and M. A. Peberdy © Humana Press Inc., Totowa, NJ


atherogenic diet. Hopefully. encainide. by reducing infarct size. and they account for a substantial proportion of deaths from AMI. the infarct zone undergoes cellular and tissue remodeling with the laying of collagen scar and ventricular dilatation. Primary Prevention of CAD Approximately 12. These agents block the `-1 adrenergic receptor in the heart. There is evidence that improvements in treatment of AMI are also reducing rates of SCD. Modification of the arrhythmic substrate may also account for some of the mortality benefit of angiotensin-converting enzyme (ACE) inhibitors in treatment of AMI. or . Prospective observational studies published in the early 1980s established that frequent isolated ventricular premature contractions and nonsustained VT are markers of increased mortality risk after MI. Moreover. particularly in patients with left ventricular (LV) systolic dysfunction (12). may also reduce the incidence of coronary disease and related SCD. improved public education regarding primary prevention of CAD will ultimately translate into reduction of SCD rates as well as CAD incidence. Further analysis of this trial has shown reduction in SCD in high-risk patients who underwent surgery (6). particularly in the prehospital setting. dyslipidemia. The antiarrhythmic action of `-blockers was also demonstrated in a recent small trial. such as systemic hypertension and diabetes mellitus. and reducing myocardial oxygen consumption and ischemia. triggering platelet adhesion. acute revascularization in AMI likely reduces late risk of SCD by modifying the substrate for arrhythmogenesis. especially VFs. Particularly important is changing modifiable risk factors. leading to the organization of the Cardiac Arrhythmia Suppression Trial (CAST). thrombus formation. `-blockers have been shown in several trials to reduce all-cause mortality as well as life-threatening VAs (7–10). particular sustained monomorphic VT. are common in this setting. Serious VAs. blunting the pro-arrhythmic effects of the sympathetic nervous system and circulating cathecholamines. Both fibrinolytic therapy and primary percutaneous coronary intervention reduce all-cause mortality as well as SCD.22 Cardiopulmonary Resuscitation Coronary atherosclerotic plaques of any size may rupture. Medical Therapy for Prevention of SCD After Myocardial Infarction Table 1 summarizes the outcomes of nine large trials of antiarrhythmic therapy after AMI. especially cigarette smoking. Publication of the results of this trial. which showed a doubling of mortality rates in patients receiving flecainide. Later in the course of infarction. Optimal control of predisposing medical conditions. Given the scope of the problem. Further studies showed that type I antiarrhythmic drugs effectively suppressed these VAs in this setting. which showed that sympathetic blockade was superior to standard antiarrhythmic drugs for treatment of recurrent VF in AMI (11). and acute myocardial infarction (AMI). Probably the most important aspect of medical treatment of AMI survivors for prevention of SCD is `-blocker therapy. effective primary prevention of CAD could have a substantial impact on prevention of SCD. In addition to reducing incidence of late coronary events. This process creates the anatomic substrate for future VAs. and physical inactivity (5).6 million people in the United States have CAD and about 1 million suffer AMIs annually (2). The Coronary Artery Surgery Study showed that coronary artery bypass grafting (CABG) leads to improved survival in selected high-risk patients with CAD. obesity.

61). p = 0.14). After a median follow-up period of 21 months. p = 0. Randomized Trials of Anti-Arrhythmic Medications After MI Trial BHAT (7) ISIS-1 (8) CAPRICORN (9) CAST-I (13) CAST-II (14) SWORD (15) DIAMOND (16) EMIAT (19) CAMIAT (20) Year of publication 1981 1986 2001 1989. There is now general agreement that type I antiarrhythmic drugs. respectively.96). LV systolic dysfunction was not required for entry into the trial (20). p = 0. Patients were randomly assigned to long-term treatment with D -sotalol (a pure type III anti-arrhythmic agent with no `-blocking activity) or matching placebo. overall mortality was identical in the two groups (14% in each. Amiodarone. who had frequent ventricular premature contractions or nonsustained VT.Chapter 3 / Prevention of Sudden Cardiac Death 23 Table 1.4% in the amiodarone group vs 11. a large trial of dofetilide.4% in the placebo group. . In contrast. was originally developed as an anti-anginal medication. Patients were treated with amiodarone (200 mg per day after loading) or placebo. two large trials were organized to test its efficacy in high-risk survivors of AMI (17. particularly type Ic agents. p = 0.18). should be avoided in patients with CAD because of the pro-arrhythmic effects demonstrated in CAST. mortality was nearly identical in the two groups (31 vs 32%. The Canadian Amiodarone Myocardial Infarction Arrhythmia Trial (CAMIAT) studied 1202 patients enrolled 6–42 days after AMI. 1991 1992 1996 2000 1997 1997 Result Improved survival with propranolol Improved survival with atenolol Improved survival with carvedilol Increased mortality with flecainide or encainide Increased mortality with moricizine Increased mortality with D-sotalol No effect of dofetilide on mortality No effect of amiodarone on mortality No effect of amiodarone on mortality moricizine.35 or less to treatment with dofetilide (dose based on creatinine clearance) or matching placebo. On the basis of its efficacy in the treatment of recurrent VA and its safety compared with other antiarrhythmic drugs in survivors of cardiac arrest (CA). No significant difference in overall mortality was found (9.1% in placebo group.006).129). the trial was stopped early because of a 65% increased relative risk of mortality in the D -sotalol treatment arm (5 vs 3. The Survival With Oral D-Sotalol trial recruited 3121 patients with LV ejection fraction (EF) of 0.40 or less (19). Patients were treated with amiodarone (200 mg per day after loading) or placebo and followed for a mean of 1. After a median follow-up of 456 days. led to a re-examination of the use of these agents in patients with CAD and other forms of structural heart disease (13. found no increase in mortality on survivors of MI (16). The European Myocardial Infarction Amiodarone Trial (EMIAT) enrolled 1486 patients 5 or more days after MI only on the basis of depressed LVEF of 0.8 years.40 or less and prior MI. a unique antiarrhythmic drug that exhibits actions of all four VaughnWilliams drug classes. The excess mortality was felt to be because of an increase in arrhythmic deaths. The Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND) Study Group randomized 1510 patients with recent MI and LVEF of 0. another pure class III antiarrhythmic drug. A similar increased risk of death was seen in a trial of the class III antiarrhythmic D-sotalol in postinfarction patients (15). After a mean follow-up period of 150 days and halfway into recruitment.

usually 8–12 beats. This process continues until the arrhythmia is terminated or all programmed therapies (usually a maximum of six to eight) are exhausted. As the design of ICDs improved over the . Finally. They are also capable of detecting arrhythmias in several different programmable rate zones and delivering a different series of programmable therapies for each zone (Fig. ATP is not useful for treating VF or polymorphic VT. This generally takes between 1 and 5 seconds. but the significance of this finding in the absence of overall mortality benefit has been questioned. Amiodarone and dofetilide had a neutral effect on all-cause mortality and are relatively safe to use for treatment of symptomatic arrhythmias in patients with CAD. They have capacity to store large amounts of information regarding each arrhythmia episode for later analysis. ICDs detect VAs from the tip electrode of the lead. When a ventricular rate is detected that exceeds the programmed detection rate (usually 150–200 beats per minute [bpm]) for the programmed number of beats (usually 10–20). Current ICD systems can be implanted transvenously via subclavian or cephalic vein access. they incorporate increasingly sophisticated algorithms for distinguishing supraventricular from VAs. the ICD begins charging the capacitors. Pacing function and programmability were extremely limited. Implantation initially required thoracotomy to place epicardial patches and rate-sensing electrodes. Potential disadvantages of ATP include possibility of accelerating the tachycardia to a more unstable type and delaying delivery of shock therapy if ATP is unsuccessful. with addition of one or more leads. 1). Conceived by Morton Mower and Michel Mirowski and introduced after a decade of preclinical development. Role of the Implantable Cardioverter Defibrillator in CAD The implantable cardioverter defibrillator (ICD) has had a major impact on clinical approach to prevention of SCD. 2B). the ICD proceeds to deliver the next therapy. using a single 8–10 French lead and a pectorally implanted generator as small as 75 g. This therapy has the advantage of being delivered more rapidly and being entirely painless. A posthoc analysis of both trials suggested a possible synergistic benefit of amiodarone and `-blockers. ICDs were targeted toward patients who had survived multiple CAs with recurrent VAs that were refractory to conventional anti-arrhythmic drug treatment. but this remains to be demonstrated prospectively. proven medical therapy for primary prevention of sudden death in patients with CAD is limited to `-blocker use. including. Type I antiarrhythmic drugs and D-sotalol have been shown to be harmful in this population. to terminate sustained monomorphic (regular) VT (Fig. ICDs may be programmed to deliver sequences of antitachycardia pacing (ATP). If the rate has not fallen below the arrhythmia detection limit. In addition to delivering shock therapies. When first released for clinical use in the early 1980s. 2A). usually implanted at the right ventricular apex. They are capable of all bradycardia-pacing functions. Rapid evolution of the ICD ensued. after which the device confirms continuation of tachycardia before delivering the programmed energy (anywhere from 1–40 J) between the metal shell of the generator and one or more coils on the ICD lead (Fig. In summary. similar to pacemakers. leading to a succession of improved lead systems and smaller generators with greater functionality (22). the ICD was first used in humans in the late 1970s (21). First generations of pulse generators were large (>250 g) and required implantation in an abdominal pocket. dual-chamber and biventricular pacing. The ICD then re-analyzes the ventricular rate to determine if therapy was successful.24 Cardiopulmonary Resuscitation Both EMIAT and CAMIAT did find a reduction in death ascribed to arrhythmia.

several clinical trials were organized to test the efficacy of the ICD in secondary prevention (for patients who had survived a sustained life-threatening VA) and primary prevention (for high-risk patients without history of sustained arrhythmia) of SCD (Tables 2 and 3).32. 1. A low-energy cardioversion (CV 1) results in a different morphology of monomorphic VT (VT 2). the ICD gained increasing favor for treatment of CA survivors. 122 of 509 patients (24%) in the antiarrhythmic drug therapy group died vs only 80 of 507 patients (16%) assigned to receive an ICD. this treatment effect was demonstrated despite a significant crossover to ICD therapy in the drug therapy arm. Tiered therapy of VAs by the ICD. reaching 25% at 3 years. After the first high-energy defibrillation (DF 1). The mean age of enrolled patients was 65 years and the mean LVEF was 0.02). Four cycles of antitachycardia pacing (ATP 1-4) fail to terminate the arrhythmia. results in restoration of sinus rhythm. Patients were randomly assigned to receive an ICD or to treatment with anti-arrhythmic drug therapy. A ventricular premature beat initiates sustained monomorphic ventricular tachycardia (VT 1). This National Institutes of Health (NIH)-sponsored multicenter study enrolled 1016 patients in 56 North American centers who were resuscitated from VF or sustained VT between 1993 and 1997. Of note.Chapter 3 / Prevention of Sudden Cardiac Death 25 Fig. In this setting. Eighty-one percent of patients had CAD and 67% had a history of MI. This difference corresponds to a 33% relative risk reduction and an 8% absolute risk reduction in total mortality in favor of the ICD (p < 0. Over a mean follow-up period of 18 months. the rhythm degenerates into ventricular fibrillation (VF). and the limitations of anti-arrhythmic drugs were exposed through randomized clinical trials. A second low-energy cardioversion (CV 2) results in polymorphic VT (PVT). The figure shows stored single-channel telemetry strip during an episode of ventricular tachyarrhythmia in a patient with an implantable cardioverter defibrillator who was hospitalized. A second high-energy defibrillation (DF 2). . next decade. ICD FOR SECONDARY PREVENTION IN CAD The first published trial comparing the ICD and conventional medical therapy for secondary prevention of SCD was the Anti-arrhythmics Versus Implantable Defibrillator (AVID) trial (23). predominantly amiodarone (96% of assigned patients).

it is difficult to draw conclusions about benefit of ICD in other subgroups.5 years. mean LVEF of 0. The first event shown in A is an episode of ventricular fibrillation that was successfully treated with a single 20-J internal defibrillation by the ICD. and the United States between 1990 and 1997 (24). enrolled 659 patients with an episode of unstable sustained VA in 24 centers in Canada. No placebo group was used. NIH sponsorship. and an 82% prevalence of CAD. have demonstrated the safety of amiodarone in patients with structural heart disease. `-blocker use was much greater in the ICD arm (about 40%) compared to the drug therapy arm (10– 15%). the Canadian Implantable Defibrillator Study (CIDS). with a mean age of 63. The figure shows stored internal electrograms and marker channels of two episodes of sustained monomorphic ventricular arrhythmia in a 38-year-old man with cardiac sarcoidosis. After a mean follow- . Two smaller trials of ICD therapy in secondary prevention of SCD have been reported since the AVID trial was published. Treatment of different ventricular arrhythmias in the same patients with an implantable cardioverter defibrillator (ICD). raising the question of whether the some of the apparent benefit of the ICD was because of a detrimental effect of amiodarone.34. probably because of the bradycardic effects of amiodarone. and its use of total mortality as an unambiguous and unquestionably important primary endpoint. this discrepancy might account for some of the apparent benefit of the ICD.26 Cardiopulmonary Resuscitation Fig. restoring the patient to sinus rhythm. the AVID trial has led to the ICD becoming the treatment of choice for survivors of CA without contraindications to its use. The second event shown in B is an episode of sustained monomorphic ventricular tachycardia with a rate of 200 bpm successfully treated with a single sequence of 8 beats of antitachycardia pacing. however. Australia. The first. 2. Because the trial included only a small proportion of patients without CAD. Despite these criticisms. Baseline patient characteristics were similar to those of the AVID population. other trials. Strengths of the AVID trial include its relatively large size. Finally.

which was discontinued in 1992 because of the 61% higher all-cause mortality in that group. amiodarone therapy.9% per year in favor of the ICD arm. Although neither CIDS nor CASH reached statistical significance.005). 98 of 331 patients (29.3% 8% 23% 31% –1.7% 5.001 p = NS p = 0.02 p = 0. On an annualized basis.3%).4% in the ICD arm and 44. or metoprolol treatment in a 1:1:1 fashion (25).4% in the two drug treatment arms. The relative risk reduction was 42% at 1 year and 28% at 3 years. there was a trend toward increased efficacy of the ICD in higher risk subgroups with lower LVEF and higher New York Heart Association (NYHA) heart failure class. The trial had originally included a propafenone treatment arm.142).081).08 p = 0.6%) assigned to amiodarone had died vs 83 of 328 patients assigned to ICD therapy (25.016 Table 3 Nonischemic Cardiomyopathies Associated With Sudden CA Dilated cardiomyopathies Idiopathic Postviral Alcohol-related Valvular heart disease Postpartum Familial Chagas’ disease Hypertrophic cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy Cardiac sarcoidosis Cardiac amyloidosis up period of 3 years. with a relative risk reduction of 19. the absolute risk reduction for death was 1.14 p = 0.Chapter 3 / Prevention of Sudden Cardiac Death 27 Table 2 ICD Trials for Primary and Secondary Prevention of SCD Trial Primary or Year secondary of prevention publication AVID (23) CIDS (24) CASH (25) MADIT (26) MUSST (27) CABG-Patch (28) MADIT-II (29) Secondary Secondary Secondary Primary Primary Primary Primary 1997 2000 2000 1996 1999 1997 2002 Number of patients Mean follow-up (months) Relative risk reduction Absolute risk reduction 1016 659 288 196 704 900 1232 18 36 57 27 39 32 20 33% 28% 18% 59% 60% –8% 28% 8% 4. the degree of treatment effect was similar to that seen in AVID and these trials are generally viewed a supportive for ICD treatment in secondary prevention of SCD.009 p < 0. Secondary analysis showed that this nonsignificant reduction in total mortality appeared to be due entirely to a significant reduction in sudden death (p = 0.6% p-value p < 0. As in CIDS.7% (p = 0. . Over a mean follow-up period of 57 months. The Cardiac Arrest Study Hamburg (CASH) enrolled 288 CA survivors (84% with VF) in eight centers in northern Germany between 1987 and 1996 and randomly assigned them to ICD implantation. the crude death rates were 36. an absolute reduction of 8% and a relative risk reduction of 18% (p = 0.

The mean age of randomized patients was 64 years. were eligible for randomization to either electrophysiologically guided anti-arrhythmic therapy or to no anti-arrhythmic therapy. 202 in this arm (58%) ultimately received an ICD. p = 0. Similar to MADIT. eligible patients had CAD with depressed LVEF (0. with additional grant support from several drug and ICD manufacturers.30. the 2. Despite the results. Potential patients underwent invasive electrophysiologic (EP) study and. an ICD was implanted. The relative hazard for overall mortality was 0. Eligible patients then underwent invasive electro-physiologic study. then the patient became eligible for randomization. ICD industry-sponsorship. This device industry-sponsored study enrolled 196 high-risk CAD patients in 32 US and European centers from 1990 to 1996 and randomly assigned them to implantation of ICD or to conventional therapy (determined by treating physician. after one to three failed drug trials. and a qualifying episode of nonsustained VT of three or more beats at least 96 hours after a MI or revascularization procedure. at investigator discretion.40 or less). After a median follow-up period of 39 months. This study involved 704 patients with CAD enrolled at 85 centers in the United States and Canada between 1990 and 1996. Over the follow-up period.and 5-year rates of overall mortality were 28% and 48% in the group assigned to no anti-arrhythmic therapy and 22% and 42% in the EP-guided therapy arm (relative risk 0. Patients with NYHA class IV symptoms were excluded because of a known high mortality from pump failure. and low use of `-blockers (5–8%) in the conventional therapy arm. MADIT initially met with skepticism owing to its small sample size. with delivery of one.46 in the ICD arm (p = 0. Several trials were designed to test this hypothesis.06).009). the mean LVEF was 0. the overall mortality rate at 5 years was 24% in patients . Out of 351 patients. If sustained VT or VF was induced. the trial was stopped early because of a marked treatment effect in favor of the ICD. 39 of 101 patients (39%) in conventional treatment group died vs only 15 of 95 patients (16%) assigned to ICD.28 Cardiopulmonary Resuscitation ICD FOR PRIMARY PREVENTION IN CAD With the rapid evolution of the ICD and its clear effectiveness in treating VAs. and three-paced ventricular premature beats at increasingly close coupling intervals. `-Blocker and ACE inhibitor treatment was encouraged in all patients. Eligible patients had a documented MI greater than 3 weeks prior to enrollment and an episode of asymptomatic nonsustained VT of 3 to 30 beats with a rate of at least 120 bpm. Patients in the therapy arm were then randomly assigned to a Food and Drug Administration-approved class I or class III antiarrhythmic drug followed by repeat EP testing.80 at 5 years. and 65% had NYHA class II or III symptoms. If the arrhythmia remained inducible. and 40% of all patients were receiving `-blockers at hospital discharge. After a mean follow-up of 27 months. If no effective anti-arrhythmic drug was found. ICD therapy was permitted. These criticisms were largely answered with the publication of the Multicenter Unsustained Tachycardia Trial (MUSTT) 3 years later (27). with amiodarone in 74%). Subsequent analysis of the data showed that this treatment effect was entirely attributable to treatment with the ICD. if inducible for sustained VA. The median age of enrolled patients was 66 years and the median LVEF was 0. stimulation was repeated after giving intravenous procainamide. an absolute risk reduction of 23% and a relative risk reduction of 59%. it was reasonable to presume that the ICD might be effective in primary prevention of SCD in high-risk patients. two. and was sponsored by the NIH. The first to be published was the Multicenter Automatic Defibrillator Implantation Trial (MADIT) (26).26.

p < 0. Ninety-one percent of patients had two. An unexplained trend toward higher rates of hospitalization for heart failure was also present in the ICD arm. These include relatively low mortality rate in the control arm. Patients were screened with signal-averaged electrocardiography (SAECG). which was not primarily intended to test the efficacy of the ICD. The Multicenter Automatic Defibrillator Implantation Trial II (MADIT-II) was recently published and may significantly expand the population eligible for primary prophylaxis of SCD with the ICD (29).(36%) or three. After an average follow-up of 32 months. No subgroups were identified that appeared to benefit from the ICD. possibly because of a high use of type I anti-arrhythmic agents in the drug-therapy group (26% at initial hospital discharge). but patients with lower LVEFs and those with wider QRS duration showed trend toward greater benefit from the ICD. In contrast to MADIT and MUSST. This industry-sponsored trial randomized 1232 patients in 76 US and European centers with prior MI (1 month or more before entry) and LVEF of 0. indicating a hazard ratio of 0. Neither nonsustained VT nor invasive EP study was required for study entry. although MUSTT had a complex design. After screening.001). In contrast to MADIT. There are several possible explanations for the difference in outcome between the CABG-Patch Trial and other trials.69 in favor of the ICD arm. which demonstrate efficacy of the ICD for primary prophylaxis. A pilot study had shown that patients with abnormal SAECG had a mortality rate in the 2 years after CABG surgery twice as high as patients with normal SAECG. After a mean follow-up of 20 months. 19.2% of patients in the ICD arm (p = 0.35 or less who were scheduled for CABG surgery at 37 centers in the United States and Germany between 1990 and 1996. In fact. use of epicardial devices.30 or less to receive a transvenous ICD or usual medical therapy.Chapter 3 / Prevention of Sudden Cardiac Death 29 receiving an ICD and 55% in those who did not (adjusted relative risk of overall mortality 0. There were no statistically significant interactions with baseline characteristics.23. mean LVEF of 0. Enrolled patients had a mean age of 64 years and a mean LVEF of 0. which is in line with previous studies of this technique. its results supported the apparent benefit of the ICD for primary prophylaxis demonstrated in MADIT and led to widespread use of the ICD in high-risk coronary patients for this indication. patients treated with anti-arrhythmic drugs without an ICD had a trend toward higher mortality than the control arm of the study. a variation of the standard surface ECG used to analyze QRS complexes for prolongation or the presence of late potentials. Thus.(55%) vessel CAD. an independent anti-arrhythmic effect of complete revascularization. 900 patients were assigned randomly to receive an epicardial ICD system at the time of CABG surgery (446 patients) or to CABG surgery alone (454 patients). the Coronary Artery Bypass Graft (CABG) Patch trial used a different test (signal-averaged ECG) to identify high-risk CAD patients and found no benefit to prophylactic epicardial ICD implantation in the population studied (28). `-blocker use was high (70% in each arm).9%) patients in the control arm. with a mean age of 64 years. This NIH-sponsored study screened patients less than 80 years old with LVEF of 0. the trial was terminated because of a lack of efficacy. and potential harmful effect of prolonging operative time with ICD implant and testing.6%.6%) patients in the ICD arm had died vs 95 of 454 (20. and 14.40. which reflect myocardial scarring and substrate for VAs. Baseline characteristics were similar to MADIT patients. and 73% with NYHA class II or III heart failure symptoms. at which point 101 of 446 (22. and an absolute risk reduction of 5. .8% of patients in the usual therapy group had died. Patients were not required to have any spontaneous or induced arrhythmias for entry.27.016).

based on a survival advantage of 0.000 in the control group. the cost-effectiveness ratio was higher—about $67. showed a cost-effectiveness ratio of $27. These costeffectiveness ratios.000. are comparable to other accepted health care interventions.000 new patients annually (29).000 per ICD implant. the proportion of deaths classified as because of SCD is lower than in those with lower heart failure class. and in other lower risk populations with CAD. although high. Other ongoing trials are testing the ability of the ICD to reduce SCD mortality in other populations. for the first time. demonstrated efficacy of the ICD in reducing all-cause mortality in a population defined solely by cardiac substrate (prior MI and reduced LVEF) and not by presence of any arrhythmia. The MADIT-II authors estimated that up to 4 million patients in the United States might qualify for ICD therapy under the new indication. with addition of up to 400. Patients in the ICD arm had higher initial costs. because of a smaller absolute survival advantage. the absolute cost of expanding ICD indications will have to be considered by health care payers. and that degree of risk correlates with heart failure class (33).21 years advantage for ICD). The health care cost implications of such expansion of ICD indications are substantial. and lower costs for anti-arrhythmic drugs in the control arm. which had initial ICD implantation cost of $18. Regardless of the ratio. generator replacements. including all patients with heart failure and reduced EF from any cause.30 Cardiopulmonary Resuscitation ECONOMIC IMPACT OF ICD USE IN CAD The MADIT-II trial. Total net health care costs over follow-up were about $98.000 in the ICD group and $76. Cost-effectiveness analysis of ICD therapy has been performed based on MADIT and AVID data. Corresponding economic analysis of the AVID study showed estimated 3-year medical costs of $87. and management of late complications and device/lead malfunction. Because the mortality difference was smaller in AVID (about 0. There would be additional costs associated with follow-up. At a conservative estimate of $25.000 per year of life saved. Numerous studies have shown that patients with DCM have significantly elevated risk of all-cause mortality and SCD.000 in the ICD group and $73. Review of currently published data suggests that the cost-effectiveness ratio may be higher than in MADIT. it would cost $100 billion to implant all current MADIT-II eligible patients in the United States. and $10 billion to implant newly eligible cases each year. As in MADIT. Economic analysis of MADIT-II is currently in progress. Analysis of MADIT results. The most prevalent of these is dilated cardiomyopathy (DCM).8 years in the ICD group (30). DILATED CARDIOMYOPATHY Although not as common as CAD.000–$27. the difference was largely because of a longer survival in the ICD group. higher costs for heart failure hospitalizations in the ICD group. the .000 in the anti-arrhythmic drug group (31). although patients with the most severe heart failure symptoms have the highest mortality rates. Some investigators have expressed hope that market competition will reduce costs of ICD therapy and that expanding indications for the ICD will spur manufacturers to design and market a lower cost model for primary prophylaxis in lower risk patients (32). which were later balanced by higher medication costs in the medically treated group after 4 years. Interestingly.000 per year of life saved. several other forms of cardiomyopathy (listed in Table 2) are associated with an elevated risk of SCD. initial hospital costs were higher in the ICD arm and medication costs were higher in the drug arm.

this trial showed no significant difference in outcome between the two groups. III.35 or less (mean = 0. In contrast to GESICA. hydralazine-isosorbide. After a mean 13 months of follow-up. Frequency of nonsustained VT has also been shown to increase risk of mortality in one study (34). including enoximone. have been shown to increase mortality in heart failure patients. especially with left bundle branch block. In contrast. and IV congestive heart failure on appropriate medical treatment with LVEF of 0. was shown in one study to increase risk of mortality nearly fourfold (36). On the basis of these trials. or IV congestive heart failure symptoms. Digoxin use. impairment of LV systolic function.39). Sodium-channel blocking drugs have both negative-inotropic and proarrhythmic side effects in this population. Several studies of type I (sodium-channel blocking) anti-arrhythmic drugs have shown that these agents are associated with excess mortality in patients with heart failure and structural heart disease (13.4%). Forty percent of patients had prior MI and 10% had Chagas’ disease. possibly through ventricular proarrhythmic effects. Other important risk factors for arrhythmic mortality in DCM include degree of LV dilatation. mean age 59 years) with stable chronic class II. The explanation for the discrepancy between the two trials has been attributed to the difference in populations studied. Patients were randomized to amiodarone (300 mg per day) or placebo and were followed for a mean of 4 years.9% (p = 0. metoprolol. The GESICA trial was conducted in 26 hospitals in Argentina between 1989 and 1993.14. Although recognized as an insensitive marker. several positive inotropic drugs. These medications include ACE inhibitors. class II. Subsequent substudies of GESICA showed particular benefit in patients with baseline heart rate above 90 bpm.5%) treated with amiodarone died vs 106 of 256 control patients (41. there was also a trend toward improved survival with amiodarone in the smaller subgroup without CAD. regardless of etiology. Additionally. and 10 or more ventricular premature contractions per hour on Holter monitor (41). suggesting that amiodarone may only benefit . mortality in the placebo group at 2 years was higher in GESICA (50%) than in CHF-STAT (30%). III. Medical Therapy of DCM Several medications without anti-arrhythmic action have been shown to improve allcause mortality in DCM. and spironolactone. either in total mortality or in sudden death. a relative risk reduction of 28% and an absolute risk reduction of 7. AMIODARONE FOR DCM There have been two large trials of amiodarone for primary prophylaxis of SCD in heart failure patients. and high-dose vesnarinone.20) were randomized to receive amiodarone (300 mg/day chronically) or usual treatment (40). amrinone. including Chagas’ disease in 10%. carvedilol. 87 of 260 patients (33.Chapter 3 / Prevention of Sudden Cardiac Death 31 proportion of deaths because of pump failure rises accordingly. Patients (N = 516. and also may reduce SCD because of a modification of the underlying arrhythmic substrate. In CHF-STAT. GESICA included a higher proportion of patients with nonischemic cardiomyopathy. inducibility of sustained VAs at invasive EP study also seems to confer elevated risk of death (37).40 or less. does not appear to significantly affect survival (38). but another failed to show this association (35). and increased QRS duration. Syncope. these drugs should generally be avoided in patients with DCM. The STAT-CHF trial was a US-based trial conducted in Veteran’s Affairs medical centers enrolling 674 patients (99% men) with LVEF of 0.024). even though improving heart failure symptoms and modestly reducing hospitalization.

Preliminary results of the Sudden Cardiac Death in Heart Rate Failure Trial (SCD-HeFT. compared ICD therapy with amiodarone in 178 patients with nonischemic cardiomyopathy and nonsustained VT (43). Patients with ischemic and nonischemic etiologies of heart failure appeared to benefit equally. cardiac sarcoidosis. No clear consensus exists for utility of amiodarone for primary prevention of SCD in the heart failure population because of the conflicting results of these two trials. To date. Patients were randomly assigned to ICD implantation. The Amiovert trial. After 5 years of follow-up. Other indications for ICD implantation in this group need to be defined. there have been no completed large-scale randomized trials of the ICD for primary prevention of SCD in patients with DCM. The SCD-HeFT is a multicenter study that has enrolled approx 2500 patients with DCM because of any cause with LVEF of 0. ICD FOR DCM Patients with DCM who are resuscitated from sustained VT or VF warrant strong consideration for ICD therapy based on AVID and the other secondary prevention studies discussed above. and was terminated prematurely having shown no significant difference in outcome between the two groups. or placebo in a 1:1:1 fashion. Lack of efficacy of the ICD was ascribed to lowerthan-expected mortality in this group. This trial also appeared to be underpowered to detect a treatment effect of the ICD. Assuming these results are confirmed in the final published report. there was a statistically significant 23% relative reduction in allcause mortality in the patients assigned to ICD therapy. There was no significant mortality difference in patients assigned to amiodarone treatment. Follow-up was completed in 2003 and preliminary results were presented at the annual Scientific Sessions of the American College of Cardiology in March 2004 (available at www. ICDs are also appropriate for patients with symptoms consistent with VA (such as syncope) who have inducible VAs at EP study. To date. SCD-HeFT may result in significant expansion in patients eligible for ICD therapy for primary prevention of SCD. Alternatively.30 or less to ICD or usual therapy (42).org). After a mean follow-up period of 45 months. One small pilot trial conducted in Germany randomized 104 patients with DCM and LV ejection of 0. there was no significant difference in mortality between the two groups. OTHER FORMS OF CARDIOMYOPATHY Several forms of cardiomyopathy expose individuals to elevated risk of SCD in the absence of significant LV systolic dysfunction. unexplained syncope is considered by some to constitute an indication for an ICD in patients with DCM. CHF-STAT included a much longer follow-up period.35 or less and class II or III heart failure symptoms (44). Based on natural history studies. and hence GESICA might have shown less benefit for amiodarone if patients had been followed longer. Hypertrophic Cardiomyopathy HCM is a group of diseases caused by inherited mutations in genes encoding protein components of the cardiac sarcomere (45). arrhythmogenic right ventricular cardiomyopathy. amiodarone therapy.32 Cardiopulmonary Resuscitation those at very high risk. 11 different HCM-associated genes . These less common diseases include hypertrophic cardiomyopathy (HCM). recently reported in abstract form. see below) also suggest that amiodarone does not prolong survival in heart failure patients.sicr. and cardiac amyloidosis.

25 of these patients did not receive an appropriate discharge from the device. . confer increased risk of SCD. These patients generally warrant ICD therapy for secondary prophylaxis. Vigorous physical exertion and participation in competitive sports should be proscribed. Resulting from the relative rarity of the disease and the overall low mortality rate. The disease was first characterized in patients that had disproportionate thickening of the interventricular septum with dynamic LV outflow tract gradient (idiopathic hypertrophic subaortic stenosis [IHSS]). Younger patients appear to be at higher risk. The disease results in myocyte disorganization. This percentage is lower than that seen in primary prophylaxis trials in patients with CAD or DCM. SCD as a result of VAs is believed to be the most common cause of death in HCM. it is difficult to draw conclusions regarding mortality reduction in this study. however. and diastolic dysfunction. A retrospective cohort study of 128 patients with HCM who had ICDs implanted for perceived high risk of SCD was recently reported (48). frequent runs of nonsustained VT on Holter monitoring. The highest risk is present in patients who have survived a CA or episode of sustained VT. Other proposed markers of risk include extreme LVH with wall thickness greater than 30 mm. particularly applied to young people with long life expectancy. 19 of 43 patients (44%) implanted for secondary prophylaxis had appropriate ICD discharges for VT or VF. and 10 of 85 patients (12%) implanted for primary prophylaxis did as well. definitive data to guide patient selection for primary prophylaxis are not currently available. hypotensive response to exercise. Genotyping. This study found that. over a mean follow-up period of 3 years. These data underscore the potential complications of ICD therapy. Amiodarone has been used to treat nonsustained and sustained VAs. Some forms may develop systolic dysfunction late in the course of disease. Moreover. Thirty-two patients (25%) had inappropriate ICD discharges for sinus tachycardia. progressive myocardial wall thickening. 18 of 128 patients (14%) had device-related complications in the 3-year follow-up period. There are no prospectively defined criteria for ICD implantation for primary prophylaxis in this disease. including 12 ICD lead failures. others likely remain to be discovered.Chapter 3 / Prevention of Sudden Cardiac Death 33 have been identified. although a cut-off age indicating low risk has not been defined. atrial fibrillation. but the potential for extracardiac adverse effects with lifelong treatment in relatively young patients is substantial (47). or ICD lead failure. Further studies have demonstrated that neither septal hypertrophy nor outflow tract gradient is a requirement for the disease. There are no controlled trials of ICD use in patients with HCM. Criteria for secondary prevention are applied generally as with other AVID-eligible patients. Because the ICD cannot distinguish between truly life-threatening arrhythmias and VT which would terminate spontaneously without treatment. it has been difficult to define effective therapies for prevention of SCD in HCM. with annual incidence ranging from 1% per year in all patients and up to 5% per year in highrisk subgroups. and numerous different patterns of LV wall thickening have been identified. a retrospective study also suggests effectiveness (46). and malignant family history. history of unexplained syncope. while this study suggests that some HCM patients may benefit from ICD therapy. Increased LV wall thickening develops during childhood and adolescence and is usually present by young adulthood in affected individuals. is not widely available and not currently practical for risk stratification. particular certain mutations in `-myosin heavy chain and cardiac troponin T. Preliminary data suggest that some genotypes. `-Blockers have been used based on their efficacy in other cardiac substrates. Thus.

the reader is referred to www. LQT5. but LQT3 is caused by mutations in the cardiac sodium channel. Primary prevention with an ICD can be considered for patients with unexplained syncope. Occasion- . For a complete updated list of medications associated with LQTS. AVID-eligible patients with ARVC are generally treated with an ICD. Another study of nine patients implanted for sustained VT also showed high rate of appropriate ICD therapies (52). which may make recognition difficult. Patients with cardiac amyloidosis and VAs generally have a very poor prognosis in the absence of organ transplantation and/or highdose chemotherapy.34 Cardiopulmonary Resuscitation Arrhythmogenic Right Ventricular Cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare entity first described in 1977. and LQT6 are all caused by mutations in different genes encoding for components of cardiac potassium channels. Resulting from the rarity of the disease and its diverse clinical presentation and challenging diagnosis. The congenital form of the disease is associated with mutations in one of at least six identified gene loci (LQT 1–6) (55). and neurological insults. LQT2. The pathologic hallmark of the disease is progressive replacement of the free wall of RV with fibrofatty tissue. CS has a wide clinical spectrum and the natural history regarding risk of SCD is not well-defined. Other causes of acquired LQTS include hypokalemia and hypomagnesemia. The interventricular septum and LV may be involved later in the disease. such as subarachnoid hemorrhage and stroke. All result in prolonged repolarization of the cardiac action potential with resulting prolongation of the QT interval and predisposition to torsades de pointes.torsades. Anti-arrhythmic drug and ICD therapy is generally prescribed as with other forms of cardiomyopathy (53). LQT1. which appears to be more common in Italy (49). Cardiac Sarcoidosis and Amyloidosis Cardiac sarcoidosis (CS) and amyloidosis are infiltrative heart diseases that may cause conduction disturbances. Long QT Syndrome The long QT syndrome (LQTS) is the most common of the cardiac ion channel diseases that cause SCD. One cohort study of 12 patients found that 8 (66%) had appropriate ICD discharges in follow-up (51). One small cohort study of ICD use in this disease found a high mortality rate and low ICD efficacy because of rapid progression of heart failure. including complete AV block. the natural history of ARVC and risk factors for SCD have not been well-defined. pulseless electrical activity. The acquired form is most commonly caused by medications. which prolong cardiac repolarization. a malignant family history. Efficacy data for ICD therapy in this disease are limited. such as during complete AV block. Sotalol was shown in one study to be the most effective drug in suppressing inducibility of VT (50).org. Detection of LQTS is an important reason for careful review of the ECG in any patient presenting with palpitations or syncope. The ECG in LQTS is highly variable in degree of QT prolongation and morphology of the T wave. and VAs in the absence of LV dysfunction. and failure of other organ systems (54). severe bradycardia. or nonsustained VT with inducible VT at invasive EP study. patients typically present with nonsustained or sustained VT with a left bundle branch block pattern originating in the right ventricle and may later develop heart failure symptoms. often with discrete aneurysm formation. Clinically. which may in turn degenerate into VF. Recognition of the ECG pattern in patients presenting with symptoms is an important component of sudden death prevention in this disorder (56).

This medication has been shown to reduce incidence of syncope and sudden death in congenital LQTS patients (57). Preventive efforts have focused on use of softer baseballs and improved chest protection equipment. Commotio Cordis Commotio cordis has received attention as a cause of SCD in children and young adults during sporting activities. Once an affected individual has been identified. FUTURE DIRECTIONS Recent efforts to reduce the public health burden of SCD have focused on expansion of indications for ICD therapy. Although very rare. and health effects of chronic ICD therapy in low-risk populations are not yet well-understood. family members should be screened for the disease. Other treatments that have been shown to reduce symptoms include left cardiac sympathectomy and permanent atrial pacing. Patients with syncope of undetermined etiology and patients with malignant family history are often considered as well. psychological. Brugada Syndrome The Brugada syndrome is a recently described inherited disease consisting of an abnormal ECG pattern (incomplete right bundle branch block with coved ST segment elevation in leads V1–V3) and idiopathic VF (58). and it is unclear to what degree low-risk populations would accept ICD therapy. an agent should have low cost and side-effect profile and negli- . ICD implantation is currently the only effective therapy for symptomatic individuals. One report suggests that VT or VF inducibility at EP study has prognostic value (59). the long-term economic. These trials have clearly shown efficacy of the ICD in the high-risk groups in which it has been studied. Evaluation and treatment of asymptomatic patients and affected family members is controversial. Although further reduction in implant-related complications may make the ICD effective in lower risk patients. The disappointing history of anti-arrhythmic drug trials for prevention of SCD make these agents unattractive for primary prophylaxis of SCD in lower risk groups. the cost-effectiveness ratios associated with this approach would be prohibitively high without a reduction in ICD costs. In some cases. less commonly. Preliminary data suggest that sodium channel blockade may be beneficial in the LQT3 subtype. Criteria for ICD implantation are controversial. It has been noted that the majority of victims of SCD do not have risk factors that would currently make them eligible for an ICD (62). and the decision is difficult in young patients with long life expectancy. The mechanism is believed to be VF induced by a blow to the precordium during the vulnerable period of the cardiac cycle (just prior to the peak of the T-wave). Additionally. the ECG pattern is elicited only after sodium-channel blockade. Patients usually present after resuscitation from CA or. Most affected individuals have structurally normal hearts. with recurrent syncope. Patients resuscitated from CA and those with recurrent syncope because of torsade de pointes despite `-blockade are the most obvious candidates. the syndrome presents as a seizure disorder in young children.Chapter 3 / Prevention of Sudden Cardiac Death 35 ally. particularly baseball and hockey (61). The most important medical component of treatment for congenital LQTS is `-blocker therapy. events have a high mortality rate and wider impact on affected families and communities. To be useful for this purpose. Although another report reached the opposite conclusion (60).

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