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Out of Hospital SuddenOut of Hospital Sudden
Cardiac Death (SCD):Cardiac Death (SCD):
Declining or Escalating?Declining or...
 Every 29 seconds, one American suffersEvery 29 seconds, one American suffers
from an unexpected heart attack. Sadly,from...
 The single most important cause of death in theThe single most important cause of death in the
adult population of the i...
 50% of victims of sudden out-of-hospital50% of victims of sudden out-of-hospital
cardiac death have no prior diagnosis o...
 The number of adolescents and youngThe number of adolescents and young
adults dying each year from suddenadults dying ea...
Age-adjusted death rates (per 100
000 US population) for sudden
cardiac death among men aged 35
years and older by race in...
Age-adjusted death rates (per 100 000
US population) for sudden cardiac
death among women aged 35 years
and older by race ...
 400,000 to 450,000 SCD per year from400,000 to 450,000 SCD per year from
1989 to 1998 occurred out of hospital, in1989 t...
Survival to 1 month relative to delay time from cardiac arrest toSurvival to 1 month relative to delay time from cardiac a...
 There is evidence of a slight decline inThere is evidence of a slight decline in
average delay times in patientsaverage ...
 Delay times are shorter in patients withDelay times are shorter in patients with
cardiogenic shock than less severely il...
 Poor knowledge of warning symptoms ofPoor knowledge of warning symptoms of
heart attack and lack of a convenientheart at...
ConclusionConclusion
“Epidemiology”“Epidemiology”
I.I. Women increasingly die with SCD out-Women increasingly die with SCD...
ConclusionConclusion
“Pathology”“Pathology”
I.I. Coronary thrombosisCoronary thrombosis (a product of(a product of
vulnera...
ConclusionConclusion
“Public Health”“Public Health”
I.I. Pre-hospital delay in the US has notPre-hospital delay in the US ...
ConclusionConclusion
“Public Health”“Public Health”
II.II. The encouraging declines in the proportionThe encouraging decli...
 For saving more lives from SCD which oneFor saving more lives from SCD which one
of the following should be our firstof ...
ReferencesReferences
1- Priori SG, Wellens JJ, Zipes DP, et al.; Task Force on Sudden Cardiac Death of the1- Priori SG, We...
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Out of hospital sudden cardiac death (scd) declining or escalating

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Out of hospital sudden cardiac death (scd) declining or escalating

  1. 1. Out of Hospital SuddenOut of Hospital Sudden Cardiac Death (SCD):Cardiac Death (SCD): Declining or Escalating?Declining or Escalating? Alireza Zarrabi, M.D.Alireza Zarrabi, M.D. Morteza Naghavi, M.D.Morteza Naghavi, M.D. Center for Vulnerable Plaque ResearchCenter for Vulnerable Plaque Research The University of Texas Health Science Center at HoustonThe University of Texas Health Science Center at Houston and, Texas Heart Institute, U.S.A.and, Texas Heart Institute, U.S.A. March 2002March 2002
  2. 2.  Every 29 seconds, one American suffersEvery 29 seconds, one American suffers from an unexpected heart attack. Sadly,from an unexpected heart attack. Sadly, one will die nearly every minute.one will die nearly every minute.  Every year 225,000 people die of heartEvery year 225,000 people die of heart attack before reaching the hospital.attack before reaching the hospital.
  3. 3.  The single most important cause of death in theThe single most important cause of death in the adult population of the industialized world isadult population of the industialized world is sudden cardiac death (SCD) due to coronarysudden cardiac death (SCD) due to coronary disease.disease. 11  SCD is defined as follows: " Natural death due toSCD is defined as follows: " Natural death due to cardiac causes, heralded by abrupt loss ofcardiac causes, heralded by abrupt loss of consciousness within one hour of the onset ofconsciousness within one hour of the onset of acute symptoms; preexisting heart disease mayacute symptoms; preexisting heart disease may have been known to be present, but the time andhave been known to be present, but the time and mode of death are unexpected.mode of death are unexpected. 22
  4. 4.  50% of victims of sudden out-of-hospital50% of victims of sudden out-of-hospital cardiac death have no prior diagnosis ofcardiac death have no prior diagnosis of heart disease (asymptomatic).heart disease (asymptomatic). 33  More than 60% of cardiac death continuesMore than 60% of cardiac death continues to remain sudden. In 1998, there wereto remain sudden. In 1998, there were 719 456 cardiac disease deaths among US719 456 cardiac disease deaths among US residents aged >=35 years, of whichresidents aged >=35 years, of which 456,076 (63.3%) were defined as SCD.456,076 (63.3%) were defined as SCD. 44
  5. 5.  The number of adolescents and youngThe number of adolescents and young adults dying each year from suddenadults dying each year from sudden cardiac arrest rose by about 10% betweencardiac arrest rose by about 10% between 1989 and 1996, the first study of1989 and 1996, the first study of nationwide trends in the United States hasnationwide trends in the United States has shown.shown. 77  The number of sudden cardiac deaths inThe number of sudden cardiac deaths in the 15-34 age group went up from 2,724the 15-34 age group went up from 2,724 in 1989 to 3,000 in 1996, an increase ofin 1989 to 3,000 in 1996, an increase of 10%. Of all the young people who died10%. Of all the young people who died over the eight year period, 71% were menover the eight year period, 71% were men and 29% women.and 29% women. 77
  6. 6. Age-adjusted death rates (per 100 000 US population) for sudden cardiac death among men aged 35 years and older by race in the US from 1989 to 1990. Adapted from:Adapted from: Zhi-Jie Zheng, George A. Mensah, et al.; Sudden Cardiac Death in the UnitedZhi-Jie Zheng, George A. Mensah, et al.; Sudden Cardiac Death in the United States, 1989 to 1998 .Circulation. 2001;104:2158States, 1989 to 1998 .Circulation. 2001;104:2158
  7. 7. Age-adjusted death rates (per 100 000 US population) for sudden cardiac death among women aged 35 years and older by race in the US from 1989 to 1990. Adapted from:Adapted from: Zhi-Jie Zheng, George A. Mensah, et al.; Sudden Cardiac Death in the UnitedZhi-Jie Zheng, George A. Mensah, et al.; Sudden Cardiac Death in the United States, 1989 to 1998 .Circulation. 2001;104:2158States, 1989 to 1998 .Circulation. 2001;104:2158
  8. 8.  400,000 to 450,000 SCD per year from400,000 to 450,000 SCD per year from 1989 to 1998 occurred out of hospital, in1989 to 1998 occurred out of hospital, in the emergency room, or as "dead onthe emergency room, or as "dead on arrival."arrival." 66  The automated external defibrillatorsThe automated external defibrillators (AEDs) represents an efficient method of(AEDs) represents an efficient method of delivering defibrillation to personsdelivering defibrillation to persons experiencing out-of-hospital cardiac arrestexperiencing out-of-hospital cardiac arrest and its use appears to be safe andand its use appears to be safe and effective.effective. 88
  9. 9. Survival to 1 month relative to delay time from cardiac arrest toSurvival to 1 month relative to delay time from cardiac arrest to first defibrillation for bystander-witnessed patients withfirst defibrillation for bystander-witnessed patients with ventricular tachycardia/ventricular fibrillation on firstventricular tachycardia/ventricular fibrillation on first electrocardiogram (n = 2,748).electrocardiogram (n = 2,748). ArrowArrow indicates median delayindicates median delay time (13 minutes).time (13 minutes). Adapted from: Holmberg M, Holmberg S, Herlitz J.; The problem of out-of-hospital cardiac-arrest prevalence of sudden death in Europe today. Am J Cardiol. 1999 Mar 11;83(5B):88D-90D. (Minutes)
  10. 10.  There is evidence of a slight decline inThere is evidence of a slight decline in average delay times in patientsaverage delay times in patients hospitalized in 1997 (5.5 hours) comparedhospitalized in 1997 (5.5 hours) compared with those hospitalized in 1994 (5.7with those hospitalized in 1994 (5.7 hours).hours).  Approximately 20% of patients presentedApproximately 20% of patients presented to the hospital within 1 hour of acuteto the hospital within 1 hour of acute symptom onset, and slightly more thansymptom onset, and slightly more than two thirds presented within 4 hours.two thirds presented within 4 hours.
  11. 11.  Delay times are shorter in patients withDelay times are shorter in patients with cardiogenic shock than less severely illcardiogenic shock than less severely ill patients.patients.  Patients with previous acute MI or thosePatients with previous acute MI or those with history of coronary angioplastywith history of coronary angioplasty presented to hospital with shorter delaypresented to hospital with shorter delay times.times.
  12. 12.  Poor knowledge of warning symptoms ofPoor knowledge of warning symptoms of heart attack and lack of a convenientheart attack and lack of a convenient method for out-of-hospital screening ofmethod for out-of-hospital screening of patients with chest discomfort are amongpatients with chest discomfort are among major factors contributing to themajor factors contributing to the overwhelming burden of out-of-hospitaloverwhelming burden of out-of-hospital SCD.SCD.
  13. 13. ConclusionConclusion “Epidemiology”“Epidemiology” I.I. Women increasingly die with SCD out-Women increasingly die with SCD out- of-hospital.of-hospital. II.II. The increased death rates for SCDThe increased death rates for SCD among younger women warrantsamong younger women warrants additional investigation of their potentialadditional investigation of their potential risk factors.risk factors.
  14. 14. ConclusionConclusion “Pathology”“Pathology” I.I. Coronary thrombosisCoronary thrombosis (a product of(a product of vulnerable plaque and vulnerable blood)vulnerable plaque and vulnerable blood) does not exist in 43-51% of SCD cases.does not exist in 43-51% of SCD cases. In other words, about half of SCDs areIn other words, about half of SCDs are not caused by plaque rupture ornot caused by plaque rupture or coronary thrombosis.coronary thrombosis. II.II. This reiterates the fact that SCD is aThis reiterates the fact that SCD is a product ofproduct of vulnerable plaque +vulnerable plaque + vulnerable blood + vulnerablevulnerable blood + vulnerable myocardiummyocardium..
  15. 15. ConclusionConclusion “Public Health”“Public Health” I.I. Pre-hospital delay in the US has notPre-hospital delay in the US has not declined in the past few decades anddeclined in the past few decades and holds as a major bottle neck in ourholds as a major bottle neck in our challenge against SCD.challenge against SCD.
  16. 16. ConclusionConclusion “Public Health”“Public Health” II.II. The encouraging declines in the proportionThe encouraging declines in the proportion of cardiac deaths occurring in the hospitalof cardiac deaths occurring in the hospital or the emergency room may reflect theor the emergency room may reflect the improvements in emergency services andimprovements in emergency services and more timely and appropriate treatment inmore timely and appropriate treatment in hospital.hospital. However, the increased trend in SCDHowever, the increased trend in SCD outside of the hospital reiterates the needoutside of the hospital reiterates the need for public health initiatives to improve thefor public health initiatives to improve the early recognition of heart attack symptomsearly recognition of heart attack symptoms and signs with rapid intervention.and signs with rapid intervention.
  17. 17.  For saving more lives from SCD which oneFor saving more lives from SCD which one of the following should be our firstof the following should be our first impression:impression: A.A. Detection and treatment of vulnerableDetection and treatment of vulnerable plaque?plaque? B. Detection and treatment of vulnerable heart?B. Detection and treatment of vulnerable heart? C. Rapid out-of-hospital screening, detection,C. Rapid out-of-hospital screening, detection, and treatment of patients with cardiac chestand treatment of patients with cardiac chest discomfort?discomfort?
  18. 18. ReferencesReferences 1- Priori SG, Wellens JJ, Zipes DP, et al.; Task Force on Sudden Cardiac Death of the1- Priori SG, Wellens JJ, Zipes DP, et al.; Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J. 2001 Aug;22(16):1374-450.European Society of Cardiology. Eur Heart J. 2001 Aug;22(16):1374-450. 2- Braunwald E, Heart disease: a tetbook of cardiovascular medicine. WB Saunders2- Braunwald E, Heart disease: a tetbook of cardiovascular medicine. WB Saunders Publishing Co., 1997:742-79.Publishing Co., 1997:742-79. 3- Wellens JJ; JACC 1997; 30:1500.3- Wellens JJ; JACC 1997; 30:1500. 4- Zhi-Jie Zheng, George A. Mensah, et al.; Sudden Cardiac Death in the United States,4- Zhi-Jie Zheng, George A. Mensah, et al.; Sudden Cardiac Death in the United States, 1989 to 1998 .Circulation. 2001;104:2158.1989 to 1998 .Circulation. 2001;104:2158. 5- Farb A, Virmani R, et al. Sudden coronary death.frequency of active coronary lesions,5- Farb A, Virmani R, et al. Sudden coronary death.frequency of active coronary lesions, and MI. Circulation 1995; 92:1701.and MI. Circulation 1995; 92:1701. 6- Goff DC Jr, Sellers DE, McGovern PG, et al. Knowledge of heart attack symptoms in6- Goff DC Jr, Sellers DE, McGovern PG, et al. Knowledge of heart attack symptoms in aa population survey in the United States: the REACT Trial. Rapid Early Action forpopulation survey in the United States: the REACT Trial. Rapid Early Action for Coronary Treatment. Arch Intern Med. 1998; 158: 2329–2338.Coronary Treatment. Arch Intern Med. 1998; 158: 2329–2338. 7-7- 2002 Heart and Stroke Statistical Update; American Heart Association. 8- Marenco JP, Wang PJ, Link MS, Homoud MK, Estes NA 3rd. ; Improving survival from sudden cardiac arrest: the role of the automated external defibrillator. JAMA. 2001 Mar 7;285(9):1193-200. 9- Goldberg RJ, Gurwitz JH, Gore JM.; Duration of, and temporal trends (1994-1997) in, prehospital delay in patients with acute myocardial infarction: the second National Registry of Myocardial Infarction. Arch Intern Med 1999 Oct 11;159(18):2141-7.

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