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| {{SI}} | | __NOTOC__ |
| | {{Sudden cardiac death}} |
| | {{CMG}} {{AE}} {{Sara.Zand}} {{EdzelCo}} |
| | ==Overview== |
| | Common [[risk factors]] related to underlying [[coronary artery disease]] ([[CAD]]) and [[inherited]] causes in the development of [[ sudden cardiac arrest]] ([[SCA]]) are [[hypertension]], [[male]] [[gender]] |
| | ,[[diabetes mellitus]], [[hyperlipidemia]], [[obesity]], [[smoking]], [[older age]], [[obstructive sleep apnea]] ([[OSA]]) due to [[hypoxia]], early [[ventricular fibrillation]] ([[VF]]) (within 48 hours of [[ACS]] increasing in-hospital mortality five times), [[early repolarization]] patten in early phase of [[myocardial infarction]] ([[MI]]), and [[family history]] of [[sudden death]]. |
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| {{CMG}}
| | ==Risk Factors== |
| | | *Common [[risk factors]] related to underlying [[coronary artery disease]] and inherited causes in the development of [[SCA]] are:<ref name="pmid20142817">{{cite journal |vauthors=Adabag AS, Luepker RV, Roger VL, Gersh BJ |title=Sudden cardiac death: epidemiology and risk factors |journal=Nat Rev Cardiol |volume=7 |issue=4 |pages=216–25 |date=April 2010 |pmid=20142817 |pmc=5014372 |doi=10.1038/nrcardio.2010.3 |url=}}</ref> |
| | | :*[[Hypertension]] |
| | | :*[[Male gender]] |
| ==Cardiac Arrest or VT/VF Occurring As A Complication of STEMI== | | :*[[Diabetes mellitus]] |
| | | :*[[Hyperlipidemia]] |
| VT/VF and/or sudden death may occur early after the presentation of STEMI symptoms (<48 hours) and late after presentation (>48 hours)<ref name="pmid1951071">{{cite journal |author=Zehender M, Utzolino S, Furtwängler A, Kasper W, Meinertz T, Just H |title=Time course and interrelation of reperfusion-induced ST changes and ventricular arrhythmias in acute myocardial infarction |journal=Am. J. Cardiol. |volume=68 |issue=11 |pages=1138–42 |year=1991 |month=November |pmid=1951071 |doi= |url=}}</ref> <ref name="pmid1731450">{{cite journal |author=Gressin V, Louvard Y, Pezzano M, Lardoux H |title=Holter recording of ventricular arrhythmias during intravenous thrombolysis for acute myocardial infarction |journal=Am. J. Cardiol. |volume=69 |issue=3 |pages=152–9 |year=1992 |month=January |pmid=1731450 |doi= |url=}}</ref><ref name="pmid1883665">{{cite journal |author=Six AJ, Louwerenburg JH, Kingma JH, Robles de Medina EO, van Hemel NM |title=Predictive value of ventricular arrhythmias for patency of the infarct-related coronary artery after thrombolytic therapy |journal=Br Heart J |volume=66 |issue=2 |pages=143–6 |year=1991 |month=August |pmid=1883665 |pmc=1024606 |doi= |url=}}</ref><ref name="pmid3743145">{{cite journal |author=Buckingham TA, Devine JE, Redd RM, Kennedy HL |title=Reperfusion arrhythmias during coronary reperfusion therapy in man. Clinical and angiographic correlations |journal=Chest |volume=90 |issue=3 |pages=346–51 |year=1986 |month=September |pmid=3743145 |doi= |url=}}</ref><ref name="pmid8245327">{{cite journal |author=Berger PB, Ruocco NA, Ryan TJ, Frederick MM, Podrid PJ |title=Incidence and significance of ventricular tachycardia and fibrillation in the absence of hypotension or heart failure in acute myocardial infarction treated with recombinant tissue-type plasminogen activator: results from the Thrombolysis in Myocardial Infarction (TIMI) Phase II trial |journal=J. Am. Coll. Cardiol. |volume=22 |issue=7 |pages=1773–9 |year=1993 |month=December |pmid=8245327 |doi= |url=}}</ref><ref name="pmid9843464">{{cite journal |author=Newby KH, Thompson T, Stebbins A, Topol EJ, Califf RM, Natale A |title=Sustained ventricular arrhythmias in patients receiving thrombolytic therapy: incidence and outcomes. The GUSTO Investigators |journal=Circulation |volume=98 |issue=23 |pages=2567–73 |year=1998 |month=December |pmid=9843464 |doi= |url=}}</ref>. The occurrence of both early and late VT/VF is associated with higher mortality. In a large contemporary analysis which included 5,745 high risk patients undergoing primary PCI in the APEX AMI trial, about 6% of patients developed VT/VF. the majority of the cases (64%) occurred during cardiac catheterization, and 90% of cases occurred withing 48 hours of presentation of STEMI symptoms. 90 day mortality was higher in those patients who sustained VT/VF (23.2% vs 3.6%, a multivariate hazard ratio of 3.63)<ref name="pmid19417195">{{cite journal |author=Mehta RH, Starr AZ, Lopes RD, Hochman JS, Widimsky P, Pieper KS, Armstrong PW, Granger CB |title=Incidence of and outcomes associated with ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention |journal=[[JAMA : the Journal of the American Medical Association]] |volume=301 |issue=17 |pages=1779–89 |year=2009 |month=May |pmid=19417195 |doi=10.1001/jama.2009.600 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=19417195 |issn=}}</ref>. Mortality was higher among those patients with late VT/VF (33.3%) vs early VT/VF (17.2%). It should also be noted that while many of the subsequent deaths in patients with VT/VF were due to sudden cardiac death, sudden cardiac death accounted for less than 50% of the mortality in VT/VF patients. Although VT/VF was not associated with one year mortality in the Primary Angioplasty and Myocardial Infarction (PAMI) trials <ref>Mehta RH, Harjai KJ, Grines L, et al; Primary Angioplasty in Myocardial Infarction (PAMI) Investigators. Sustained ventricular tachycardia or fibrillation in the cardiac catheterization laboratory among patients receiving primary percutaneous coronary intervention: incidence, predictors, and outcomes. JAmColl Cardiol. 2004;43(10):1765-1772.</ref>, this is likely due to the fact that the PAMI population was of lower risk and had a lower one year mortality (4.5% in PAMI vs 23.2% reported in the present study).
| | :*[[Obesity]] |
| | | :*[[Smoking]] |
| ===Multivariate Predictors of Early VT/VF in the Setting of STEMI===
| | :*[[Older age]] |
| #Pre-PCI thrombolysis in MI (TIMI) flow grade 0 (HR, 2.94; 95% CI, 1.93-4.47)
| | :*[[Obstructive sleep apnea]] due to [[hypoxia]] |
| #Inferior infarction (HR, 2.16;95%CI, 1.58-2.93)
| | :* Early [[VF]] (within 48 hours of [[ACS]] increasing in-hospital mortality five times) |
| #Total baseline ST deviation (HR, 1.39;95%CI, 1.19-1.63)
| | :*[[Early repolarization]] patten in early phase of [[MI]]<ref name="NaruseTada2012">{{cite journal|last1=Naruse|first1=Yoshihisa|last2=Tada|first2=Hiroshi|last3=Harimura|first3=Yoshie|last4=Hayashi|first4=Mayu|last5=Noguchi|first5=Yuichi|last6=Sato|first6=Akira|last7=Yoshida|first7=Kentaro|last8=Sekiguchi|first8=Yukio|last9=Aonuma|first9=Kazutaka|title=Early Repolarization Is an Independent Predictor of Occurrences of Ventricular Fibrillation in the Very Early Phase of Acute Myocardial Infarction|journal=Circulation: Arrhythmia and Electrophysiology|volume=5|issue=3|year=2012|pages=506–513|issn=1941-3149|doi=10.1161/CIRCEP.111.966952}}</ref> |
| #Creatinine clearance (HR, 0.88; 95% CI, 0.83-0.94)
| | :*Family history of premature death (sudden and unexpected) before age 50 attributed to [[heart]] disease in > 1 relative, presence of [[heart]] disease in close relative less than age 50, presence of ion [[channelopathies]] in family members |
| #Killip class greater than I (HR, 1.88;95%CI, 1.29-2.76)
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| #Baseline systolic blood pressure (HR, 0.92;95%CI, 0.87-0.98)
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| #Body weight (HR, 1.16; 95% CI, 1.04-1.29)
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| #baseline heart rate greater than 70/min (HR,1.10;95%CI, 1.01-1.20)
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| c index for the model = 0.75
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| ===Multivariate Predictors of Late VT/VF in the setting of STEMI===
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| #Systolic blood pressure (HR, 0.83; 95% CI, 0.76-0.91)
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| #ST resolution less than 70% (HR, 3.17; 95% CI,1.60-6.28)
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| #Baseline heart rate greater than 70/min (HR, 1.20; 95% CI, 1.08-1.33)
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| #Total baseline ST deviation (HR, 1.43; 95% CI, 1.14-1.79)
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| #Post-PCI TIMI flow less than grade 3(HR, 2.09;95%CI, 1.24-3.52)
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| #Pre-PCI TIMI flow grade 0(HR, 2.12;95%CI, 1.20-3.75),
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| #Blockers less than 24 hours (HR, 0.52; 95% CI, 0.32-0.85)
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| c index for the model = 0.74
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| Multivariate modeling did demonstrate that about one-fifth of the variability in 90 day mortality was explained by VT/VF. It should be noted that many patients did not undergo left ventriculography in this study. When left ventricular ejection fraction was available and included in the multivariate model, it failed to be statistically significant. This is likely because it was co-linear with other variables such as Killip class, infarct location, TIMI flow and pulse.
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| ===Clinical Implications===
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| Those patients with < TIMI grade 3 flow and < 70% ST resolution following PCI are at higher risk of VT/VF and should be monitored more carefully in an ICU or telemetry setting.
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| ==VT/VF Complicating AMI (both STEMI and NSTEMI taken together)==
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| While the prior information focuses on STEMI, a study by Piccini et al of 9,000 patients focused on both STEMI as well as NSTEMI who underwent PCI within 24 hours of acute MI in the New York State Coronary Angioplasty Reporting System database <ref>Piccini JP, Berger JS, Brown DL. Early sustained ventricular arrhythmias complicating acute myocardial infarction. Am J Med. 2008;121(9):797-804. </ref>. 5.2% of patients sustained VT/VF and mortality was over 4 times higher among patients with VT/VF (16.3% vs 3.7%). Operator reported successful PCI was associated with a lower subsequent mortality associated with VT/VF. The following were identified as independent predictors of early VT/VF:
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| #Cardiogenic shock (OR, 4.10; 95%CI, 3.20-5.58)
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| #Heart failure (OR, 2.86;95% CI, 2.24-3.67)
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| #Chronic kidney disease (OR, 2.58; 95% CI, 1.27-5.23)
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| #Early presentation (6 hours from symptom onset; OR, 1.46; 95% CI, 1.18-1.81)
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| The following variables were found to be independently associated with a lower risk of VT/VF:
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| #History of hypertension (OR, 0.81; 95% CI, 0.65-1.00)
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| #Lleft circumflex as infarct artery (OR, 0.80; 95% CI, 0.65-0.99)
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| #Diabetes mellitus (OR,0.57; 95% CI, 0.42-0.78)
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| #Higher left ventricular ejection fraction (every 5% increment; OR, 0.93; 95% CI, 0.91-0.96)
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| ==References== | | ==References== |
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| | [[Category:Public health]] |
| | [[Category:Electrophysiology]] |
| | [[Category:Emergency medicine]] |
| | [[Category:Needs overview]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |