SUDDEN DEATH
BY NAZNEEN NAVEED SAIT
GROUP 7
IVANE JAVAKISVILI TBILISI STATE
UNIVERSITY UNIVERSITY
Sudden cardiac death
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Sudden cardiac death (SCD) is death due
to a cardiovascular cause that
occurs within one hour of the onset of
symptoms. A sudden cardiac arrest occurs
when the heart stops beating or is not
beating sufficiently to maintain perfusion
and life.
ETHIOLOGY
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Coronary artery disease is the most common cause of sudden
cardiac death, accounting for up to 80% of all cases.
Cardiomyopathies and genetic channelopathies account for
the remaining causes. The most common causes of nonischemic sudden cardiac death are cardiomyopathy related to
obesity, alcoholism, and fibrosis.
In patients younger than 35, the most common cause of sudden
cardiac death is a fatal arrhythmia, usually in the context of a
structurally normal heart.
In patients from birth to 13 years, the primary cause is a
congenital abnormality.
In patients aged 14 to 24 years, the cause of sudden cardiac
death is attributed to hypertrophic cardiomyopathy (HCM),
arrhythmogenic right ventricular cardiomyopathy (ARVC),
congenital coronary anomalies, genetic channelopathies,
myocarditis, Wolff-Parkinson-White syndrome, and Marfan
syndrome.
Common causes of sudden cardiac arrest
Ischemic Heart
disease
Cardiomyopathies
Heart Failure
Inherited
Channelopathies
yocardial infarction
omalous coronary origin
ronary spasm
•Long QT syndrome (LQTS)
•Short QT syndrome (SQTS)
•Brugada syndrome
•Early repolarization syndrome
Valve disease
•Catecholaminergic
•Aortic
polymorphic ventricular
stenosis
tachycardia (CPVT)
•Alcoholic
•Hypertrophic
•Idiopathic
•Obesity-related
•Fibrotic
•Arrhythmogenic right
ventricular cardiomyopathy
(ARVC)
•Myocarditis
•Nonpreserved ej
ection fraction
(EF) systolic
heart failure (EF
less than 35%)
Congenital diseases
•Tetraology of Fallot
WARNING SIGNS
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Introduction
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Epidemiology
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Each year, approximately 0.1% of the United States population
experiences a medical services-assessed, out-of-hospital cardiac
arrest. European studies have a similar incidence ranging from 0.04%
to 0.1% of the population. The median age in the US is between age
66 and 68. Males are more likely to suffer from sudden cardiac
arrest.
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While rare, sudden cardiac death is the leading cause of nontraumatic
cause of death among young athletes. In the general population,
sports-related, sudden death from any cause is 0.5 to 2.1 per 100,000
yearly. Sports-related, sudden deaths are higher in elite athletes
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A circadian peak of sudden cardiac death occurs between 6 am and
noon, and a smaller peak occurs in the late afternoon. The overall
incidence of sudden cardiac death is higher on Mondays
Pathophysiology
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After a myocardial infarction, the risk of sudden cardiac death is
highest during the first months due to fatal tachyarrhythmias, reinfarction, or myocardial rupture.
Ventricular fibrillation (VF) and ventricular tachycardia (VT) were
initially thought to be the most common causes of out-of-hospital
cardiac arrest.
More recent studies show pulseless, electrical activity (PEA) and
asystole as more frequent.
Approximately 50% of patients initially have asystole, and 19% to
23% have PEA as the first identifiable rhythm.
Immediately following OHCA the blood flow to the brain slows to
essentially zero and ultimately leading to death.
History and Physical
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Some patients experience palpitations, dizziness, or near syncope prior to sudden cardiac
arrest. Almost half of the patients who have sudden cardiac arrests report no symptoms
prior to collapse.
The American Heart Association recommends cardiovascular screening for high school
and collegiate athletes.
screening should follow the AHA guidelines: EVALUATE:
Personal
History
Family
History
Physical
Examination
Personal history
1.Chest pain/discomfort/tightness/pressure related to exertion
2.Unexplained syncope or near syncope
3.Excessive exertional and unexplained dyspnea/fatigue or palpitations,
associated with exercise
4.Prior recognition of a heart murmur
5.Elevated systemic blood pressure
6.Prior restriction from participation in sports
7.Prior testing for the heart, ordered by a physician
Family History
1.Premature death (sudden and unexpected) before age 50 attributed to
heart disease in > 1 relative
2.Disability from heart disease in close relative less than age 50
3.Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other
ion channelopathies, Marfan syndrome, or clinically significant
arrhythmia specific knowledge of certain cardiac conditions in family
members
Physical Examination
1.Heart murmur should be evaluated with the patient both supine and
standing or with Valsalva
2.Femoral pulses to exclude aortic coarctation
3.Physical stigmata of Marfan syndrome
4.Brachial artery blood pressure (sitting position), prefer both arms
Routine ECG testing is not recommended for student-athletes. Students
found to have an abnormal exam or those with a positive personal or
family history may be referred for cardiac testing including ECG and
echocardiogram.
Sudden cardiac arrest patients may demonstrate brief myoclonic or
seizure-like activity.
Evaluation
Before transportation to a hospital, emergency medical services (EMS) or lay people may utilize
an automated external defibrillator (AED). Once EMS arrives cardiac monitoring via ECG should occur.
Full cardiac assessment is required for cardiac arrest survivors. The following tests should be completed to
establish a cause
•ECG diagnosis of ischemic heart disease, myocardial infarction, and inherited channelopathies.
•Echocardiogram evaluate for evidence of heart failure, cardiomyopathy, valvular heart disease, and
congenital heart disease.
•Coronary angiography further evaluates coronary artery disease, congenital coronary anomalies, and
coronary spasms.
•Exercise test ischemic heart disease, LQTS, and CPVT.
•Electrophysiology testing ischemic heart disease, LQTS, and CPVT.
•Cardiac MRI
•Genetic testing if ARVC, Brugada syndrome, CPVT, or LQTS are found
•Cardiac biopsy may be considered if no other cause is found
Treatment / Management
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Treatment for sudden cardiac arrest should be initiated immediately by lay people and EMS.
includes the use of an automated external defibrillator and cardiopulmonary resuscitation (CPR). CPR
provides enough oxygen to the brain until a stable electrical rhythm can be established.
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After transfer to a hospital, therapeutic hypothermia can be induced to limit neurologic injury and
reperfusion injuries. Therapeutic hypothermia is more effective for the management of ventricular
tachycardia and ventricular fibrillation but can also be used in PEA and asystole.
Limitations to therapeutic hypothermia include a tympanic membrane temperature below 30 degrees at
presentation, being comatose before the sudden cardiac arrest, pregnancy, inherited coagulation disorder,
and the terminally ill patient.
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If a patient survives the out-of-hospital cardiac arrest, long-term treatment is aimed at the underlying cause.
An implantable cardioverter defibrillator (ICD) is used for secondary prevention of sudden cardiac death in
any person who has experienced arrhythmia-related syncope or survived sudden cardiac arrest.
Medication is targeted at the underlying cause of sudden cardiac arrest.
Enhanching Healthcare Team Outcomes
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To reduce the risk of sudden death, healthcare workers should educate
the family members of young sudden cardiac death victims that they
may also be at an increased risk for ischemic heart disease and
ventricular arrhythmias. First-degree relatives, particularly those 63%
younger than 35, should be screened. If cardiomyopathy or a genetic
channelopathy is present, the evaluation of other family members
should also occur. For the most part, the evaluation should be done by a
cardiologist or an internist.
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