This document discusses sudden cardiac arrest (SCA) and strategies for preventing SCA in high-risk populations. It notes that cardiovascular disease is a leading cause of death and that SCA claims more lives each year than lung cancer, breast cancer, and AIDS combined. It reviews data showing higher rates of SCA and associated risk factors like diabetes and hypertension in certain racial/ethnic groups. The document proposes models to explain health disparities and discusses the role of genetics, behaviors, socioeconomic status, and stress in influencing cardiovascular disease risk. It advocates for identifying at-risk populations and implementing community-based prevention programs, education, and healthcare system improvements to reduce SCA.

1. The Prevention of Sudden Cardiac
Arrest in High-Risk Populations
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 9, 2010
Financial Disclosures: None

2. Sudden Cardiac Death (to
paraphrase George Orwell…)
Everyone is at risk but some people are at more
risk than others
Cardiovascular disease is the leading cause of
death for men and women in all racial and
ethnic groups

3. 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 stroke
Sudden cardiac death has increased dramatically
among people younger than 35

4. 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 42,156
1 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.

5. The U.S. Population is Becoming
Increasingly Diverse
Changing Trends 120
Hispanics are the fastest- 100
growing segment of the
population, and now account 80
for 13% U.S., as do African
60
Americans.
40
The U.S. Asian population
currently consists of 10.6
20
million people, and represents
4% U.S.,; however, this
0
population group is expected
2000 2010 2020 2030 2040 2050
to 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.

6. 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 Females
Zheng Z. Circulation. 2006;104(18):2158-2163.

7. Age-Adjusted Prevalence of Diabetes*
by Race/Ethnicity in the US
American Ind ians/
19%
Ala ska Natives
Non -Hispanic Blacks 15%
Hispanic/L atino
14%
Am ericans
Non-Hispan ic Whites 7%
0 5 10 15 20 25
*In people 20+ years old Percent
Sources: 1997-1999 National Health Interview Survey and 1988-1994 National Health and Nutrition
Examination Survey (NHANES) estimates projected to year 2000. 1998 outpatient database of the Indian
Health Service CDC. National Diabetes Fact Sheet. 2002.

8. The “Problem”

9. 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
Disease
Huikuri HV. N Engl J Med. 2001;345:1473-1482. *ion-channel
Myerburg RJ. Heart Disease, A Textbook of Cardiovascular abnormalities, valvular
Medicine. 6th ed. W.B. Saunders, Co. 2001. or congenital heart
disease, other causes

10. 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 Year
Myerburg RJ. Circulation.1998;97:1514-1521.

11. 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 men
Stone et al JAMA. 1996;275:1104-1112.

12. Mortality From High Blood Pressure
Is Higher in African Americans
Overall 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–

13. 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 men
Clark et al Heart Dis. 2001;3:97-108; National Vital Statistics System, Health, United States, 1996–97.
1996–

14. 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 state
Adapted from U.S. Census Bureau, 2002 Redistricting Data (PL 94-171) Summary File

15. 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

16. Perceptions of Managing SCA by
Race
• No clear differences but blacks and
Hispanics may shy away from
withdrawal of care more often
Possible Reasons:
• Less access to medical care
• Some distrust of the medical profession
• Religious beliefs

17. The “Problem”

18. Does Being African American
Aggravate the “Problem”?

19. Critical Relationships
Lifestyle
(Social/
Economic)
Disease
Ancestry
(Genetic)

20. Era of Genomic Ancestry and
Challenges Related to Health
1. 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”?

21. 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 population
Moss 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.

22. 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.

23. 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 SCD
1 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.

24. 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.

25. Evidence for Health
Benefits 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

26. 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

27. 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)

28. Study Design
44 HF patients
• NYHA Class I-III • Patients underwernt
• Hospitalization >30 days Hatha yoga class twice/wk
• Patients on appropriate for 8 weeks
standard of care therapy • Daily yoga breathing in
interim
• QOL parameters and
Surrogate biomarkers of
HF

29. Yoga therapy improves general
quality of life (QoL) markers-
New Longitudinal Criteria
General Incidences Ability to Ability to
Well-Being of concentrate handle
fatigue stress
Improved 70.4 64.8 58.2 72.8
Worsened 2.3 2.3 4.7 0.0
No change 27.3 32.9 37.1 27.2
Med Sci Sports Exercise (available online November 27, 2009)

30. An example to follow?
The South Carolina Department of
Health and Environmental Control-
the Heart Disease and Stroke
Prevention (HDSP) Program
One of 13 states funded at the implementation level
1. Increase control of cardiovascular risk factors
(mostly HTN)--primarily in adults & older adults
2. Increase knowledge of signs & symptoms for heart
attack and stroke and the importance of calling 9-1-1
3. Improve emergency response
4. Improve quality of heart disease and stroke care
5. Eliminate health disparities in term of race, ethnicity,
gender, geography, & socio-economic status

31. Cardiovascular Disease Risk Factors
100%
83.0%
90%
80%
70% 61.3%
54.0%
60%
50%
33.4%
40% 28.8% 24.3%
30%
20%
10%
0%
Co-Morbid Hypertension Sedentary High Obesity Current Smoker
Lifestyle Cholesterol
Source: SC Behavioral Risk Factor Surveillance System
2006

32. 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

33. Collaboration
Partnering is key to our state efforts
Public Health Regions
American Heart/ Tri-State Stroke Network
Stroke Assn.
Primary Care Providers
Hospitals
Academia
Hospitals
Emergency
Primary Medical
Healthcare Faith Based Services
Assn. Community Based Organizations
Organizations

34. Secondary Prevention & Systems Change
Strengthening the Chain of Survival for
Sudden Cardiac Arrest
Primary Care Provider
Individual EMS Hospital Rehab
Community

35. Individual / Interpersonal
knowledge, attitudes, skills, support
Media & Marketing Campaign to increase public
awareness: press releases, PSAs, and paid advertising
in 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

36. 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)

37. Secondary Prevention & Systems Change
Strengthening Health Care Systems
training, quality assurance & improvement initiatives
• Primary Care Settings
• Pre-Hospital EMS
• Hospital – Acute & Sub-Acute

38. 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

39. Stroke Death Rates, 1979-2004
120
South Carolina United States
Age-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.

40. Pre-Hospital EMS
• Advanced Stroke Life Support courses
• ASLS Pre – Hospital/Hospital Courses
• State EMS Pre-hospital Data Committee
(NEMSIS Statewide Electronic Reporting
System)

41. 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

42. 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.

43. Bobby V. Khan, M.D., Ph.D.
Sudden Cardiac Arrest Foundation
Atlanta Vascular Research Foundation
Saint Joseph’s Translational Research Institute
bobby.khan@atlantaclinicalresearch.com
(770) 621-9656
Thank you!