Sudden Cardiac Arrest: The Diversities and the Similarities Bobby V. Khan, M.D., Ph.D. Sudden Cardiac Arrest Foundation Director, Atlanta Vascular Research Foundation Saint Joseph’s Translational Research Institute Atlanta, Georgia December 8, 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
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.
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
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.
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
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)
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.
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.