The Prevention of Sudden Cardiac Arrest in High-Risk Populations Bobby V. Khan, M.D., Ph.D. Sudden Cardiac Arrest FoundationDirector, Atlanta Vascular Research FoundationSaint Joseph’s Translational Research Institute Atlanta, Georgia December 9, 2010 Financial Disclosures: None
Sudden Cardiac Death (to paraphrase George Orwell…)Everyone is at risk but some people are at more risk than othersCardiovascular disease is the leading cause of death for men and women in all racial and ethnic groups
The Impact of the Problem• Every 29 seconds someone suffers a coronary event in the United States• Every 60 seconds someone dies from such an event• Every 45 seconds someone suffers a new or recurrent stroke• Every 3.1 minutes someone will die of a strokeSudden cardiac death has increased dramatically among people younger than 35
Magnitude of SCA in the U.S. 167,366 Stroke3 SCA claims more lives each year 450,000 SCA4 than these other Lung Cancer2 diseases combined 157,400 Breast Cancer2 40,600 AIDS1 42,1561 U.S. Census Bureau, Statistical Abstract of the United States: 2001.2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.3 2002 Heart and Stroke Statistical Update, American Heart Association.4 Zheng Z. Circulation. 2001;104:2158-2163.
The U.S. Population is Becoming Increasingly DiverseChanging Trends 120Hispanics are the fastest- 100growing segment of thepopulation, and now account 80for 13% U.S., as do African 60Americans. 40The U.S. Asian populationcurrently consists of 10.6 20million people, and represents4% U.S.,; however, this 0population group is expected 2000 2010 2020 2030 2040 2050to triple in size by 2050. White African American Hispanic (any race) Asian Adapted from U.S. Census Bureau, 2004. Table 1a. Accessed Dec. 1, 2006.
SCD Rates for Males and Females Per 100,000 Standard US Population 600 White Black 502.7 American Indian/Alaska Native 500 Asian/Pacific Islander 407.1 400 336.1 300 258.8 270.5 212.6 200 130.0 100 153.4 0 Males FemalesZheng Z. Circulation. 2006;104(18):2158-2163.
Age-Adjusted Prevalence of Diabetes* by Race/Ethnicity in the US American Ind ians/ 19% Ala ska NativesNon -Hispanic Blacks 15% Hispanic/L atino 14% Am ericansNon-Hispan ic Whites 7% 0 5 10 15 20 25 *In people 20+ years old PercentSources: 1997-1999 National Health Interview Survey and 1988-1994 National Health and NutritionExamination Survey (NHANES) estimates projected to year 2000. 1998 outpatient database of the IndianHealth Service CDC. National Diabetes Fact Sheet. 2002.
SCA and Coronary Heart Disease Coronary heart disease and its consequences account for the majority of sudden cardiac deaths in Western cultures. 5% Other* 15% 80% Nonischemic Coronary Heart Cardiomyopathy DiseaseHuikuri HV. N Engl J Med. 2001;345:1473-1482. *ion-channelMyerburg RJ. Heart Disease, A Textbook of Cardiovascular abnormalities, valvularMedicine. 6th ed. W.B. Saunders, Co. 2001. or congenital heart disease, other causes
Incidence of SCD in Specific Populations and Annual SCD Numbers GROUP General population Patients with high coronary-risk profile Patients with previous coronary event Patients with ejection fraction < 35%, congestive heart failure Patients with previous out-of-hospital cardiac arrest Patients with previous myocardial infarction, low ejection fraction, and ventricular tachycardia0 5 10 15 20 25 30 0 100,000 200,000 300,000 Incidence of Sudden Death No. of Sudden Deaths (% of group) Per YearMyerburg RJ. Circulation.1998;97:1514-1521.
Risk-Factor Clustering by Race and Sex 70 60 50 Percentage 40 30 20 10 0 0 1 ≥2 ≥3 White women African-American women White men African-American menStone et al JAMA. 1996;275:1104-1112.
Mortality From High Blood Pressure Is Higher in African AmericansOverall Mortality Rates From Causes Related to Hypertension, 2003* 60 49.7 50 40.8 Mortality Rate, % 40 30 20 14.9 14.5 10 0 Male Female Male Female African American White In hypertensive African Americans, ≈30% and ≈20% of all deaths in men and women, respectively, may be due to high blood pressure.*High blood pressure listed as a primary or contributing cause of death.Adapted from Thom T et al. Circulation. 2006;113:e85–e151. 2006;113:e85–
Years of Potential Life Lost to Total Heart Disease Before Age 75 by Race and Gender 4000 3000 Years 2000 1000 0 1980 1985 1990 1995 White women African-American women White men African-American menClark et al Heart Dis. 2001;3:97-108; National Vital Statistics System, Health, United States, 1996–97. 1996–
The South Has the Highest Concentration of African-Americans 25.0 to 60.0 12.3 to 24.9 5.0 to 12.2 People indicating exactly one race, Black or African 0.3 to 4.9 American, as a percent of total population by stateAdapted from U.S. Census Bureau, 2002 Redistricting Data (PL 94-171) Summary File
Models to Explain Health Disparities▶Racial Genetic Model Cause of HD: Population differences in the distribution of genetic variants▶Health-behavior Model Cause of HD: Differences between R/E groups in the distribution of individual behaviors related to health such as diet, exercise, and tobacco use▶SES Model Cause of HD: Over-representation of some R/E groups within lower SES▶Psychosocial Stress Model Cause of HD: Stresses associated with minority group status, especially the experience of racism and discrimination
Perceptions of Managing SCA by Race• No clear differences but blacks and Hispanics may shy away from withdrawal of care more oftenPossible Reasons:• Less access to medical care• Some distrust of the medical profession• Religious beliefs
Era of Genomic Ancestry and Challenges Related to Health1. Group definition and membership.2. Can we accurately assess genomic ancestry?3. How does genomic ancestry relate to skin color and possibly socioeconomic status?4. How useful is genomic ancestry for informing us about disease risk?5. Health Disparities: are they due to biological differences?6. How do we prevent repeating the negative past abuses of “race”?
Genetic Disorders—Hypertrophic Cardiomyopathy (HCM) • HCM is the most common cause of death in young people • The magnitude of left ventricular hypertrophy is directly correlated to the risk of SCD. Young patients with extreme hypertrophy and few or no symptoms are at substantial long-term risk of SCD • There is a higher prevalence of HCM in the African- American populationMoss AJ. JAMA. 2003;289:2041-2044.Priori SG. N Engl J Med. 2003;348:1866-1874.Spirito P. N Engl J Med. 1997;336:775-785.Maron BJ. N Engl J Med. 2000;342:365-373.
Wall Thickness and Sudden Death in Hypertrophic Cardiomyopathy 20 18.2 Incidence of Sudden Death 18 (per 1,000 person/yr) 16 14 12 11.0 10 8 7.4 6 4 2.6 2 0 0 < 15 16-19 20-24 25-29 > 30 Maximum Left-Ventricular-Wall Thickness (mm)Spirito P. N Engl J Med. 2000;342:1778-1785.
SCD in Heart Failure Despite improvements in medical therapy, symptomatic HF still confers a 20-25% risk of premature death in the first 2.5 years after diagnosis.1,2 ≈ 50% of these premature deaths are SCD1 Bardy G. The Sudden Cardiac Death-Heart Failure Trial (SCD-HeFT) in Woosley RL, Singh S, Arrhythmia Treatment and Therapy, Copyright 2000 by Marcel Dekker, Inc. 323-342.2 Sweeney MO. PACE. 2001;24:871-888.
Heart Failure & Sudden Cardiac Death Age-adjusted Annual Rate/1000 160 No HF Overall 140 HF History Mortality 120 100 Sudden 80 Death 60 40 20 0 Women Men Women Men Heart Failure predicts increased sudden death and overall mortality during a 38- year follow-up of subjects in the Framingham Heart Study.Domanski MJ. J Am Coll Cardiol. 1999;34:1090-1095.
Evidence for HealthBenefits of Yoga• HTN–creates a relaxation response• Carpal tunnel syndrome• Asthma–creates improved vital capacity• Stress reduction to diminish the many conditions caused or made worse by stress• Improves quality of life in patients with cancer
Yoga • 5000 years old • The word “Yoga” means “yoke” or “unity” of body and mind • The purpose of yoga: Awareness on your physical body through breathing and postures
Managing Heart Failure with Yoga:A series of pilot investigations to determine the effects of yoga on vascular function and quality of life in chronic HF J. Cardiac Failure 14:223-229 (2008) Med. Sci. Sports and Exercise (available online November 27, 2009)
Study Design 44 HF patients• NYHA Class I-III • Patients underwernt• Hospitalization >30 days Hatha yoga class twice/wk• Patients on appropriate for 8 weeksstandard of care therapy • Daily yoga breathing in interim • QOL parameters and Surrogate biomarkers of HF
Yoga therapy improves general quality of life (QoL) markers- New Longitudinal Criteria General Incidences Ability to Ability to Well-Being of concentrate handle fatigue stressImproved 70.4 64.8 58.2 72.8Worsened 2.3 2.3 4.7 0.0No change 27.3 32.9 37.1 27.2 Med Sci Sports Exercise (available online November 27, 2009)
An example to follow? The South Carolina Department of Health and Environmental Control- the Heart Disease and Stroke Prevention (HDSP) ProgramOne of 13 states funded at the implementation level1. Increase control of cardiovascular risk factors (mostly HTN)--primarily in adults & older adults2. Increase knowledge of signs & symptoms for heart attack and stroke and the importance of calling 9-1-13. Improve emergency response4. Improve quality of heart disease and stroke care5. Eliminate health disparities in term of race, ethnicity, gender, geography, & socio-economic status
DHEC Strategic Plan and the Heart Disease and Stroke Prevention Division Primary Goal and Objectives Addressed: Eliminate health disparities Reduce disparities in illness, disability and premature deaths from chronic diseases Increase the number of minorities at risk for heart attacks and stroke who are receiving education interventions Develop and implement community and faith-based initiatives to address health disparities
Collaboration Partnering is key to our state efforts Public Health Regions American Heart/ Tri-State Stroke Network Stroke Assn. Primary Care ProvidersHospitals Academia Hospitals Emergency Primary MedicalHealthcare Faith Based Services Assn. Community Based Organizations Organizations
Secondary Prevention & Systems Change Strengthening the Chain of Survival for Sudden Cardiac Arrest Primary Care Provider Individual EMS Hospital Rehab Community
Individual / Interpersonalknowledge, attitudes, skills, supportMedia & Marketing Campaign to increase publicawareness: press releases, PSAs, and paid advertisingin targeted publications and media outlets• Make healthy choices to reduce risks / prevent CVD• Know your numbers / see your doctor• Signs and symptoms of heart attack and stroke• Fast Reaction 9-1-1 media campaign• Culturally competent educational materials• Enhanced website with downloadable materials and links
Community / Organizational policies, practices, environments• Community Faith-Based “Search Your Heart” Initiative – Train-the-Trainer Workshops (Faith-based organizations & Public Health staff)• Office of Minority Health Faith & Health Initiative• Power to End Stroke DHEC Ambassadors Campaign• Worksite Initiatives – policy & environmental supports, HD&SP awareness and screening access• CDC Worksite Toolkit implementation (2006)
Secondary Prevention & Systems Change Strengthening Health Care Systems training, quality assurance & improvement initiatives• Primary Care Settings• Pre-Hospital EMS• Hospital – Acute & Sub-Acute
Primary Care Settings• ASH Hypertension Expert Trainings *• SC Hypertension Initiative Data Support• COSEHC Centers of Excellence Initiative• BP Measurement in the 21st Century *• Sr. Center Hypertension Lifestyle U - CHA Outreach Initiative• SC Chronic Disease Collaborative• BCBS & NCQA Physician Recognition Program CAD• BCBS ASH, Inc. Hypertension Expert Recognition Program• CVH/Diabetes Annual Winter Evidence Based Symposium• SCPHA Clinical Network Retreat * Funded regions had role in this initiative
Stroke Death Rates, 1979-2004 120 South Carolina United StatesAge-Adjusted Death Rate 100 80 64.8 64.7 60 40 20 0 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 1999-2002: ICD-10 codes I60-I69; 1979-1998: ICD-9 codes 430-434,436-438 multiplied by comparability ratio of 1.0588. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Compressed Mortality File, CDC Wonder.
Pre-Hospital EMS• Advanced Stroke Life Support courses• ASLS Pre – Hospital/Hospital Courses• State EMS Pre-hospital Data Committee (NEMSIS Statewide Electronic Reporting System)
Management in the Hospital – Acute & Sub-Acute Cardiac Events• Get With The Guidelines – Pursuing Excellence Statewide Trainings - CAD & Stroke• Get With The Guidelines PMT License Support• Stroke Systems Assessments – State & Regional• Hospital-Based Regional Heart & Stroke Trainings
Summary• Prevention is the key!• Education and awareness play a significant role• An understanding of the high-risk population and the vulnerabilities is essential. Clear identification will come a long way in reducing the disparities and the overall disease burden.
Bobby V. Khan, M.D., Ph.D. Sudden Cardiac Arrest Foundation Atlanta Vascular Research FoundationSaint Joseph’s Translational Research Institute firstname.lastname@example.org (770) 621-9656 Thank you!