Sudden cardiac death post arrest care and prevention
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Editor-In-Chief: C. Michael Gibson, M.S., M.D.  Associate Editor(s)-in-Chief: Sara Zand, M.D.
See also Post cardiac arrest syndrome care pathway
Effective measures for the primary prevention of sudden cardiac death in individuals who are at risk of SCD but have not yet experienced an aborted cardiac arrest or life-threatening arrhythmias include ICD implantation based on the guideline. Secondary prevention strategy following aborted sudden cardiac death include revascularization in patients with ischemic heart disease and ICD implantation in patients with reduced left ventricular ejection fraction who had an experience of lethal arrhythmia. The optimal approach to prevention of SCD following ST-elevation MI (STEMI) has been evaluated in multiple randomized trials. In general, post-STEMI patients should be treated with evidence-based therapies that have been associated with a reduction in SCD including beta-blockers, ACE-inhibitors (or ARBs in patients who are ACEI intolerant) and statins. In patients who have symptomatic congestive heart failure (CHF), an aldosterone antagonist may be a reasonable additional therapy. Despite the intuitive benefits of antiarrhythmic, amiodarone and sotalol have not been shown to reduce all-cause mortality following STEMI, although amiodarone may be useful in reducing the frequency of shocks in patients with ICDs who have unacceptably high rates of shock. In general terms, ICD placement is indicated in those patients with a reduced left ventricular ejection fraction at 40 days post-MI and/or 3 months following revascularization (PCI or CABG) for STEMI given the survival benefits in this population.
Post cardiac arrest survivors
CIEDs: Cardiac insertable electronic devices;
CMR: Cardiac magnetic resonance;
CT: Computed tomography;
LGE: Late gadolinium enhancemen;
SCA: Sudden cardiac arrest
|Recommendations for evaluation of sudden cardiac arrest survivors|
|Extra cardiac cause (Class I, Level of Evidence B):|
❑ The investigation of a SCA survivor without obvious extra-cardiac cause is recommended by a multidisciplinary team
|Coronary angiogram (Class I, Level of Evidence C) :|
❑ In electrically unstable patients after SCA, with suspicion of ongoing myocardial ischemia, a coronary angiogram is indicated
|Brain and chect CT scan (Class I, Level of Evidence C)|
❑In SCA survivors, brain/chest CT scan should be considered when patient characteristics, ECG, and echocardiography are not consistent with a cardiac cause
|Blood sample, ECG, Cardiac imaging (Class I, Level of Evidence B)|
❑In SCA survivors, collection of blood samples at presentation is recommended for potential toxicology and genetic testing
|Echocardiography (Class IC, Level of Evidence B)|
❑Echocardiography is recommended to evaluate cardiac structure and function in all SCA survivors
|Coronary vasospasm (Class IIb, Level of Evidence B)|
❑In SCA survivors, ergonovine, acetylcholine, or hyperventilation testing may be considered for the diagnosis of coronary vasospasm
|The above table adopted from 2022 ESC Guideline|
Sudden cardiac death victim
|Recommendations for evaluation of sudden cardiac arrest victims|
|Medical history, Autopsy, Toxicology, Genetic testing (Class I, Level of Evidence B):|
❑ Investigation of unexpected sudden death, especially in case of suspicion of inherited disease, should be made a public health priority
|(Class IIb, Level of Evidence C) :|
❑Following sudden arrhythmic death syndrome, post-mortem genetic testing in the decedent for additional genes may be considered
|(Class III, Level of Evidence B)|
❑Following sudden arrhythmia death syndrome, hypothesis-free post-mortem genetic testing using exome or genome sequencing is not recommended
|The above table adopted from 2022 ESC Guideline|
- Effective measures for the primary prevention of sudden cardiac death in individuals who are at risk of SCD but have not yet experienced an aborted cardiac arrest or life-threatening arrhythmias include ICD implantation based on the guideline.
- Secondary prevention strategy following aborted sudden cardiac death include revascularization, ICD implantation.
Abbreviations: ICD: Implantable cardioverter defibrillator; PVC: Premature ventricular complex; VF: Ventricular fibrillation; VT: Ventricular fibrillation;
|Recommendations for secondary prevention of sudden cardiac death|
|ICD implantation (Class I, Level of Evidence A):|
❑ ICD implantation is recommended in patients with documented VF or hemodynamically not-tolerated VT in the absence of reversible causes
|Amiodarone, Catheter ablation (Class IIb, Level of Evidence C) :|
❑In patients with VT/VF, an indication for ICD, and no contraindication for amiodarone, amiodarone may be considered when an ICD is not available,
contraindicated for concurrent medical reasons, or declined by the patient
|The above table adopted from 2022 ESC Guideline|
2017AHA/ACC/HRS Guideline for management of sudden cardiac arrest and ventricular arrhythmia
MI: Myocardial infarction;
VT: Ventricular tachycardia;
VF: Ventricular fibrillation;
LVEF: Left ventricular ejection fraction;
ICD: Implantable cardioverter defibrillator;
NYHA: New York Heart Association functional classification;
LVAD: Left ventricular assist device;
EPS: Electrophysiology study
|Recommendations for primary prevention of sudden cardiac death in ischemic heart disease|
|ICD implantation (Class I, Level of Evidence A):|
❑ In patients with LVEF≤ 35% and NYHA class 2,3 heart failure despite medical therapy, at least 40 days post MI or 90 days post revascularization with life expectancy > 1 year
|ICD implantation (Class I, Level of Evidence B) :|
❑ In patients with LVEF ≤ 40% and nonsustained VT due to prior MI or VT ,VF inducible in EPS with life expectancy >1 year
|ICD implantation : (Class IIa, Level of Evidence B)|
❑ In patients with NYHA class 4 who are candidates for cardiac transplantation or LVAD with life expectancy > 1 year
|(Class III, Level of Evidence C)|
❑ ICD is not beneficial in patients with NYHA class 4 despite optimal medical therapy who are not candidates for cardiac transplantation or LVAD
IHD: Ischemic heart disease;
VT: Ventricular tachycardia;
SCD: Sudden cardiac death;
SCA: Sudden cardiac arrest;
ICD: [Implantable cardioverter defibrillator];
EPS: Electrophysiologic study
|Secondary prevention in patients with IHD|
|SCA survivor or sustained monomorph VT||Cardiac syncope|
|Yes: revascularization, reassessment about SCD risk (class1)||NO:ICD candidate|
|Yes:ICD (class1)||NO: medical therapy (class1)||Yes:ICD (CLASS1)||NO:EP study (class 2a)|
|Ventriculat arrhythmia induction|
|Yes: ICD (class1)||NO: monitoring|
Timing of Sudden Cardiac Death Following ST-elevation MI
Patients with STEMI are at risk of sudden cardiac death. The timing of sudden cardiac death following STEMI is as follows:
- In the first 3 months after STEMI, one-quarter of sudden cardiac deaths occur. This statistic is critical in so far as implantable cardiac defibrillators are often not implanted in the first three months. It is for this reason that wearable defibrillators are sometimes used in patients with a large MI and reduced ejection fraction.
- In the first year following STEMI, one-half of the sudden cardiac deaths occur.
- Beyond one year, there is still an increased risk of sudden cardiac death for a prolonged period of time.
Medical Therapy to Prevent Sudden Death Following STEMI
- Therapies aimed to reduce disease progression, stabilize plaque, improve left ventricular function, and reduce ischemia may minimize the risk of sudden cardiac death. These therapies include beta blockade, ACE inhibition, and statins.
- Beta blocker administration has been associated with a reduction in sudden cardiac death. . The reduction in SCD was greatest among patients with congestive heart failure.
- Among patients with an ICD, beta blocker administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of ICD discharge .
- ACE inhibitor administration has been associated with reduction in the risk of SCD. .
Angiotensin II Receptor Blockers (ARBs)
- If a patient is intolerant to ACE inhibitor, an ARB can be administered.
- Valsartan is non-inferior to captopril in reducing post MI mortality, and may therefore confer similar benefits in SCD .
- Among patients with an ICD implanted, statin administration has been associated with a reduction in documented arrhythmias post-MI. .
- In the EPHESUS trial, among the specific subgroup of post MI patients who have left ventricular dysfunction and / or diabetes, eplerenone administration was associated with reduction in all cause and SCD mortality (4.9% vs 6.1%).
- Despite the intuitive benefits of anti-arrhythmic treatments, antiarrhythmics have not shown a reduction in all-cause mortality in the management of post MI SCD.
- Amiodarone was associated with a reduction in arrhythmic death among patients with an LVEF of <40% following STEMI, but all cause mortality was not improved in the CAMIAT   trial.
- Anti-arrhythmics such as amiodarone may be useful in reducing the frequency of shocks in patients with an ICD who have excessively frequent shocks. Flecainide and *propafenone should not be administered as these Class I C agents are proarrhythmic in patients with coronary artery disease .
Induced Hypothermia to Improve Neurological Outcome
- A systematic review by the Cochrane Collaboration suggests benefit.
- A second systematic review focusing on survivors of non-shockable rhythms suggests benefit.
- Patients surviving cardiac arrest who cannot follow commands or who are comatose may have increased chance of favorable neurological outcome if their body temperature is cooled to 32 to 34 degrees centigrade.  ,
Prevention of Sudden Death and Implantable Cardioverter Defibrillators Following STEMI
- ICD placement is indicated in those patients with a reduced left ventricular ejection fraction at 40 days post-MI and/or 3 months following revascularization (PCI or CABG) for STEMI given the survival benefits in this population.
- Patients should also be treated with beta-blockers, ACE inhibitors, and statins.
- Patients undergoing ICD implantation should not have a limited life expectancy due to non-cardiovascular causes.
Role of Electrophysiology Testing
- Inducibiity and pharmacologic suppression of VT/VF on electrophysiologic studies is no longer deemed to be relevant based upon the MUSTT study  and the MADITT I study .
- Importantly, lack of inducibility on electrophysiological testing should not preclude implantation of an ICD.
The Benefit of ICD Implantation May Be Greater in Patients with a QRS Duration > 120 msec
- In both SCD-HeFT and MADIT II, the reduction in SCD was greater in patients with a QRS duration > 120 msec.
In patients with a large MI with a low EF who are awaiting permanent ICD implantation, the use of a wearable defibrillator is a reasonable strategy.
Cardiac resynchronization therapy (CRT) Combined with ICD Placement
Based upon the results of the COMPANION trial it is reasonable to place a combined ICD / CRT device in patients with the following:
- Symptomatic NYHA Class III or IV congestive heart failure
- A left ventricular ejection fraction < 35%
- Evidence of left ventricular dyssynchrony with a QRS > 120 msec
- Sudden cardiac death
- Sudden cardiac death post arrest care and prevention
- Post cardiac arrest syndrome care pathway
- Therapeutic hypothermia
- ↑ 1.0 1.1 1.2 Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M (August 2022). "2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". Eur Heart J. doi:10.1093/eurheartj/ehac262. PMID 36017572 Check
- ↑ Al-Khatib, Sana M.; Stevenson, William G.; Ackerman, Michael J.; Bryant, William J.; Callans, David J.; Curtis, Anne B.; Deal, Barbara J.; Dickfeld, Timm; Field, Michael E.; Fonarow, Gregg C.; Gillis, Anne M.; Granger, Christopher B.; Hammill, Stephen C.; Hlatky, Mark A.; Joglar, José A.; Kay, G. Neal; Matlock, Daniel D.; Myerburg, Robert J.; Page, Richard L. (2018). "2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death". Circulation. 138 (13). doi:10.1161/CIR.0000000000000549. ISSN 0009-7322.
- ↑ Nuttall SL, Toescu V, Kendall MJ (2000). "beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction". BMJ (Clinical Research Ed.). 320 (7234): 581. PMC 1117610. PMID 10688573. Retrieved 2011-02-06. Unknown parameter
- ↑ Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP (2005). "Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II)". The American Journal of Cardiology. 96 (5): 691–5. doi:10.1016/j.amjcard.2005.04.046. PMID 16125497. Retrieved 2011-02-06. Unknown parameter
- ↑ Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA (1999). "Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials". Journal of the American College of Cardiology. 33 (3): 598–604. PMID 10080457. Retrieved 2011-02-06. Unknown parameter
- ↑ Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM (2003). "Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both". The New England Journal of Medicine. 349 (20): 1893–906. doi:10.1056/NEJMoa032292. PMID 14610160. Retrieved 2011-02-06. Unknown parameter
- ↑ Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP (2003). "Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial". Journal of the American College of Cardiology. 42 (1): 81–7. PMID 12849664. Retrieved 2011-02-06. Unknown parameter
- ↑ Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH (2007). "Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)". American Heart Journal. 153 (4): 573–8. doi:10.1016/j.ahj.2007.02.002. PMID 17383296. Retrieved 2011-02-06. Unknown parameter
- ↑ Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M (2003). "Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction". The New England Journal of Medicine. 348 (14): 1309–21. doi:10.1056/NEJMoa030207. PMID 12668699. Retrieved 2011-02-06. Unknown parameter
- ↑ Cairns JA, Connolly SJ, Roberts R, Gent M (1997). "Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators". Lancet. 349 (9053): 675–82. PMID 9078198. Retrieved 2011-02-04. Unknown parameter
- ↑ Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J (1999). "Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials". The American Journal of Cardiology. 83 (5B): 55D–63D. PMID 10089841. Unknown parameter
- ↑ Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL (1991). "Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial". The New England Journal of Medicine. 324 (12): 781–8. doi:10.1056/NEJM199103213241201. PMID 1900101. Retrieved 2011-02-07. Unknown parameter
- ↑ ECC Committee, Subcommittees and Task Forces of the American Heart Association (2005). "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 112 (24 Suppl): IV1–203. doi:10.1161/CIRCULATIONAHA.105.166550. PMID 16314375.
- ↑ Arrich J, Holzer M, Havel C, Müllner M, Herkner H (2012). "Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation". Cochrane Database Syst Rev. 9: CD004128. doi:10.1002/14651858.CD004128.pub3. PMID 22972067.
- ↑ Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW (2012). "Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies". Resuscitation. 83 (2): 188–96. doi:10.1016/j.resuscitation.2011.07.031. PMID 21835145.
- ↑ Hypothermia after Cardiac Arrest Study Group (2002). "Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest". N Engl J Med. 346 (8): 549–56. doi:10.1056/NEJMoa012689. PMID 11856793. Review in: ACP J Club. 2002 Sep-Oct;137(2):46 Review in: Evid Based Nurs. 2002 Oct;5(4):111
- ↑ Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G; et al. (2002). "Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia". N Engl J Med. 346 (8): 557–63. doi:10.1056/NEJMoa003289. PMID 11856794.
- ↑ Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G (1999). "A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators". The New England Journal of Medicine. 341 (25): 1882–90. doi:10.1056/NEJM199912163412503. PMID 10601507. Retrieved 2011-02-06. Unknown parameter
- ↑ Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M (1996). "Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators". The New England Journal of Medicine. 335 (26): 1933–40. doi:10.1056/NEJM199612263352601. PMID 8960472. Retrieved 2011-02-06. Unknown parameter