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=== Other Diagnostic Studies ===
=== Other Diagnostic Studies ===
*In survivors of [[sudden cardiac death]] due to lethal [[arrhythmia]] from [[ischemic heart disease]], [[coronary angiography]] and probable [[revascularization]] is recommended.
*In survivors of [[sudden cardiac death]] due to lethal [[arrhythmia]] from [[ischemic heart disease]], [[coronary angiography]] and probable [[revascularization]] is recommended.<ref name="LemkesJanssens2020">{{cite journal|last1=Lemkes|first1=Jorrit S.|last2=Janssens|first2=Gladys N.|last3=van der Hoeven|first3=Nina W.|last4=Jewbali|first4=Lucia S. D.|last5=Dubois|first5=Eric A.|last6=Meuwissen|first6=Martijn M.|last7=Rijpstra|first7=Topm A.|last8=Bosker|first8=Hans A.|last9=Blans|first9=Michiel J.|last10=Bleeker|first10=Gabe B.|last11=Baak|first11=Remon R.|last12=Vlachojannis|first12=George J.|last13=Eikemans|first13=Bob J. W.|last14=van der Harst|first14=Pim|last15=van der Horst|first15=Iwan C. C.|last16=Voskuil|first16=Michiel|last17=van der Heijden|first17=Joris J.|last18=Beishuizen|first18=Albertus|last19=Stoel|first19=Martin|last20=Camaro|first20=Cyril|last21=van der Hoeven|first21=Hans|last22=Henriques|first22=Jose P.|last23=Vlaar|first23=Alexander P. J.|last24=Vink|first24=Maarten A.|last25=van den Bogaard|first25=Bas|last26=Heestermans|first26=Ton A. C. M.|last27=de Ruijter|first27=Wouter|last28=Delnoij|first28=Thijs S. R.|last29=Crijns|first29=Harry J. G. M.|last30=Jessurun|first30=Gillian A. J.|last31=Oemrawsingh|first31=Pranobe V.|last32=Gosselink|first32=Marcel T. M.|last33=Plomp|first33=Koos|last34=Magro|first34=Michael|last35=Elbers|first35=Paul W. G.|last36=Spoormans|first36=Eva M.|last37=van de Ven|first37=Peter M.|last38=Oudemans-van Straaten|first38=Heleen M.|last39=van Royen|first39=Niels|title=Coronary Angiography After Cardiac Arrest Without ST Segment Elevation|journal=JAMA Cardiology|volume=5|issue=12|year=2020|pages=1358|issn=2380-6583|doi=10.1001/jamacardio.2020.3670}}</ref>
 
*[[Electrophysiology study]] is recommended for induction of [[bradyarrhythmia]] ,[[ventricular tachyarrhythmia]], determination the indication for [[ICD]] implantation  in [[dilated cardiomyopathy]],[[ARVC]], [[HCM]].
*[[Electrophysiology study]] is recommended for induction of [[bradyarrhythmia]] ,[[ventricular tachyarrhythmia]], determination the indication for [[ICD]] implantation  in [[dilated cardiomyopathy]],[[ARVC]], [[HCM]].
*[[Electrophysiology study]] is not recommended in [[long QT syndrome]] ([[LQTS]]), [[cathecolaminergic polymorphic ventricular tachycardia]] ([[CPVT]]), [[short QTsyndrome]] ([[SQTS]])..<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Electrophysiology study]] is not recommended in [[long QT syndrome]] ([[LQTS]]), [[cathecolaminergic polymorphic ventricular tachycardia]] ([[CPVT]]), [[short QTsyndrome]] ([[SQTS]])..<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>

Revision as of 13:23, 16 January 2021

Sudden cardiac death Microchapters

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Sudden Cardiac versus Non-Cardiac Death

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Definitions and Diagnosis

Epidemiology and Demographics

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Natural History, Complications and Prognosis

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Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Sudden cardiac arrest is defined as the unexpected cessation of pumping blood into vital organs due to electrical disturbance in the pathway of SA node, AV node, Hiss Purkinje fibers or pumping failure due to cardiogenic shock, massive pulmonary thromboembolism, aorta dissection. ruptured left ventricular free wall. Without any intervention for immediate restoration of the circulation, biologic death or sudden cardiac death will happen minutes to weeks after cardiac arrest. Sudden death may be due to cardiac or noncardiac causes. Sudden cardiac death is responsible for 50% of cardiac death annually in the united state. In hospital cardiac arrest happens in 290,000 adults in the united states every year. The most common cause of sudden cardiac death is coronary artery disease and atherosclerosis process. The presence of underlying disorders such as malignancy or liver disease at the time of cardiac arrest makes the condition worst. Patients with acute myocardial infarction and in-hospital cardiac arrest with shockable rhythm have a better prognosis. Post CPR state management should be focused on neurologic complications, hemodynamic stability, and respiratory support.

Historical Perspective

There is no historical perspective available about sudden cardiac death.

Classification

There are some definitions related to cardiac arrest including:[1]

Classification Definition
Sudden cardiac death Sudden and unexpected death within one hour of being symptomatic or whitin 24 hours in asymptomatic patient due to arrhythmia or hemodynamic instability
Sudden cardiac arrest Suddenly cessation of cardiac activity,unresponsive patient with gasping respiration or no respiratory movement and unpalpable pulses due to cardiac etiology such as arrhythmia, pump failure or non cardiac etiology such as trauma, respiratory failure, electrolytes disturbance, drug overdose, drowning, asphexia
Aborted cardiac arrest Unexpected circulatory collapse within one hour of being symptomatic, which is turned back after successful cardiopulmonary resuscitation
SIDS (sudden infant death syndrome),SADS (sudden arrhythmic death syndrome) Structurally normal heart without any specific findings in autopsy or toxicology
SUDI (sudden unexplained death in infancy), SUDS (sudden

unexplained death syndrome)

Sudden death without any specific findings in autopsy in adult (SUDS) or infants less than 1 year (SUDI)

Pathophysiology



|
 
 
 
Structural and functional causes of sudden cardiac death
 
Trigger
  • Myocardial infarction
  • Myocardial ischemia/reperfusion
  • Emotional, physical stress
  • Hemodynamic decompensation
  • Electrolyte imbalance
  • Hypoxemia,acidosis
  • Neurophysiological interactions
  • Drugs
  •  
    Arrhythmia mechanism
  • Re-entry
  • Automaticity
  • Triggered activity
  • Conduction block
  •  
    Fatal arrhythmia
  • Monomorphic ventricular tachycardia
  • Polymorphic ventricular tachycardia
  • Ventricular fibrillation
  • Profound bradycardia
  • Asystole
  • Pulseless electrical activity
  •  
     
     
     

    Causes

    Sudden cardiac arrest may be caused by :

    Differentiating sudden cardiac death from non-cardiac causes

    Cardiac causes of sudden death

    Non cardiac causes of sudden death:

    Epidemiology and Demographics

    • The prevalence of sudden cardiac death is approximately 1.40 per 100,000 individuals in women to 6.68 per 100.000 individuals in men worldwide.[1]
    • In 2015, the incidence of adult in-hospital cardiac arrests was estimated to be 970 cases per 100,000 individuals in the united states.[7]


    Age

    Gender

    Race

    Risk Factors

    Natural History, Complications and Prognosis

    Sudden cardiac arrest occurs due to sudden disturbance in cardiac electrical propagation or failure of the heart to pumping the blood into vital organs.

    • Factors associated better prognosis after in-hospital cardiac arrest include:
    • Prognosis of in-hospital cardiac arrest is generally better than out of hospital cardiac arrest and the 1-year survival rate of patients who survived to hospital discharge was approximately 25% in the GWTG-R registry.[16]

    Diagnosis

    Diagnostic Criteria

    • The diagnosis of sudden cardiac arrest is made when the following diagnostic criteria are met:
    Components Assessment and findings
    Symptoms
    Palpitations, lightheadedness, syncope, dyspnea, chest pain, cardiac arrest
    Past medical history
    Medications
    Family history

    Symptoms

    Physical Examination

    Laboratory Findings

    Electrocardiogram

    An ECG may be helpful in the diagnosis of Sudden cardiac death. Findings on ECG associated with sudden cardiac arrest include:[22]


    Class I (Level of Evidence: B)


    Class of recommendation Level of evidence Recommendation for ECG and exercise tredmile test
    1 B In patients with wide complex tachycardia and hemodynamically stable, 12 leads ECG should be obtained
    1 B Exercise stress test should be obtained in patients suspected arrhythmia-related exercise such as ischemic heart disease or cathecolaminergic polymorphic ventricular tachycardia
    1 B In patients with documented ventricular arrhythmia, 12 leads ECG should be obtained during sinus rhythm for evaluation of underlying heart disease

    X-ray

    A chest x-ray may be helpful in the diagnosis of the underlying cause of cardiac arrest such as cardiomegally, pulmonary congestion, massive pericardial effusion, widening aorta silhouette.

    Echocardiography or Ultrasound

    Echocardiography may be helpful in the diagnosis the cause of lethal arrhythmia and sudden cardiac arrest by assessment of the following:

    Class I (Level of Evidence: B)

    CT scan

    Cardiac CT scan may be helpful in the diagnosis of the causes of cardiac arrest by evaluation of the following:[23]

    Class I (Level of Evidence: C)

    MRI

    Cardiac MRI is an accurate modality for diagnosis of structural and functional causes of cardiac arrest by the evaluation of the following:[24]


    Class IIa (Level of Evidence: C)

    Other Imaging Findings

    There are no other imaging findings associated with sudden cardiac death.

    Other Diagnostic Studies


    Class I, Level of evidence:B
    In patients who recovered from SCA due to ventricular arrhythmia suspected ischemic heart disease, coronary angiography and probabley revascularization is recommmended
    Class I, Level of evidence:C
    In patients with anomalous origin of a coronary artery leading ventricular arrhythmia or SCA, repair or revascularization is recommended
    Class IIa, Level of evidence:B
    In patients with ischemic or nonischemic cardiomyopathy or congenital heart disease presented with syncope arrhythmia and do not meet criteria for primary prevention ICD, an electrophysiological study is recommended for assessing the risk of sustained VT
    Class III, Level of evidence:B
    In patients who meet criteria for ICD implantation, an electrophysiological study is not recommended for only inducing ventricular arrhythmia
    Class III, Level of evidence:B
    An electrophysiological study is not recommended for risk stratification for ventricular arrhythmia in patients with Long QT syndrome, short QT syndrome, cathecolaminergic polymorphic ventricular arrhythmia




    Class I (Level of Evidence: C)
    • In patients with SCA or SCD in their family member, genetic tests and genetic counselling is recommended

    Treatment

    Medical Therapy

    • Management of patients in post-cardiac arrest status include:
    • Treatment of the underlying disorder
    • Hemodynamic stability and
    • Respiratory support
    • Controlling the neurologic complications


    Recommendations for management of cardiac arrest
    CPR (Class I, Level of Evidence A):

    CPR should be done according to basic and advanced cardiovascular life support algorithms

    Amiodarone (Class I, Level of Evidence A) :

    ❑ In the recurrence of ventricular arrhythmia after maximum energy shock delivery and unstable hemodynamic, amiodarone should de infused

    Direct current cardioversion : (Class I, Level of Evidence A)

    ❑ In ventricular arrhythmia and unstable hemodynamic, direct current cardioversion should be delivered

    Revascularization:(Class I, Level of Evidence B)

    ❑ In patients with polymorphic VT and VF and evidence of acute STEMI in ECG, coronary angiography and emergency revascularization is advised

    Wide QRS tachycardia: (Class I, Level of Evidence C)

    Wide QRS tachycardia should be considered as VT if the diagnosis is unclear

    Intravenous procainamide (Class 2a, Level of Evidence A):

    ❑ In hemodynamically stable VT, intravenous procainamide is recommended

    Intravenous lidocaine : (Class 2a, Level of Evidence B)

    Lidocaine is recommended in witness cardiac arrest due to polymorphic VT, VF unresponsed to CPR, defibrillation or vasopressor therapy

    Intravenous betablocker : (Class 2a, Level of Evidence B)

    ❑ In polymorphic VT due to myocardial ischemia, intravenous betablocker maybe helpful

    Intravenous Epinephrine : (Class 2b, Level of Evidence A)

    ❑ In cardiac arrest administration of 1 mg epinephrine every 3-5 minutes during CPR is recommended

    Intravenous amiodarone : (Class 2b, Level of Evidence B)

    ❑ In hemodynamic stable VT, infusion amiodarone or sotalole maybe considered

    High dose of intravenous epinephrine : (Class III , Level of Evidence A)

    ❑ In cardiac arrest, administration of high dose epinephrine>1 mg bolouses is not beneficial
    ❑ In refractory VF not related to torsades de pointes, administration of intravenous magnesium is not beneficial

    Intravenous amiodarone : (Class III , Level of Evidence B)

    ❑In acute myocardial infarction, prophylactic administration of lidocaine or amiodarone for prevention of VT is harmful

    Intravenous verapamil, diltiazem : (Class III , Level of Evidence C)

    ❑ In a wide QRS tachycardia with unknown origin, administration of verapamil and diltiazem is harmful


     
     
     
     
     
     
     
     
     
     
    Sustained monomorphic VT
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Hemodynamic stability
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Stable
     
     
     
     
     
     
     
     
     
     
     
    Unstable
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    12-Lead ECG, history, physical exam
     
     
     
     
     
     
     
     
     
     
     
    Dirrect current cardioversion,ACLS
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Notifying disease causing VT
     
     
     
    Cardioversion(class1)
     
     
     
     
     
     
     
    VT termination
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Structural heart disease
     
     
     
    Intravenous procainamide (class2a)
     
     
     
     
     
    Yes, therapy of underlying heart disease
     
    NO, cardioversion (class1)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO, Ideopathic VT
     
     
     
    Intravenous amiodarone or sotalole (class2b)
     
     
     
     
     
     
     
     
    VT termination
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Verapamil sensitive VT: Verapamil outflow tract VT: betablocker (class2a)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Effective
     
    Non effective: cardioversion
     
     
     
     
     
     
     
     
    Yes,therapy of underlying heart disease
     
    NO, Sedation ,anesthesia, reassess antiarrhythmic therapy, repeating cardioversion
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Therapy to prevent recurrence of VT
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    No VT termination
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Catheter ablation (class1)
     
     
    Catheter ablation (class1)
     
    Verapamil , betablocker (class2a)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

    Intervention

    Catheter ablation can only be performed for patients with sustained monomorphic ventricular tachycardia based on these characteristics:

    Prevention

    Abbreviations: MI: Myocardial infarction; VT: Ventricular tachycardia; VF: Ventricular fibrillation; LVEF: Left ventricular ejection fraction; ICD: Intracardiac defibrillation; 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
    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







    Abbreviations: IHD: Ischemic heart disease; VT: Ventricular tachycardia; SCD: Sudden cardiac death; SCA: Sudden cardiac arrest; ICD: Intracardiac defibrillation; EPS: Electrophysiologic study

     
     
     
     
     
     
    Secondary prevention in patients with IHD
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    SCA survivor or sustained monomorph VT
     
     
     
    Cardiac syncope
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Ischemia
     
     
     
    LVEF≤35%
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    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
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

    References

    1. 1.0 1.1 Priori, Silvia G.; Blomström-Lundqvist, Carina; Mazzanti, Andrea; Blom, Nico; Borggrefe, Martin; Camm, John; Elliott, Perry Mark; Fitzsimons, Donna; Hatala, Robert; Hindricks, Gerhard; Kirchhof, Paulus; Kjeldsen, Keld; Kuck, Karl-Heinz; Hernandez-Madrid, Antonio; Nikolaou, Nikolaos; Norekvål, Tone M.; Spaulding, Christian; Van Veldhuisen, Dirk J. (2015). "2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". European Heart Journal. 36 (41): 2793–2867. doi:10.1093/eurheartj/ehv316. ISSN 0195-668X.
    2. Osman, Junaida; Tan, Shing Cheng; Lee, Pey Yee; Low, Teck Yew; Jamal, Rahman (2019). "Sudden Cardiac Death (SCD) – risk stratification and prediction with molecular biomarkers". Journal of Biomedical Science. 26 (1). doi:10.1186/s12929-019-0535-8. ISSN 1423-0127.
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    4. Akhtar, Masood (1991). "Sudden Cardiac Death: Management of High-Risk Patients". Annals of Internal Medicine. 114 (6): 499. doi:10.7326/0003-4819-114-6-499. ISSN 0003-4819.
    5. 5.0 5.1 5.2 Basso, Cristina; Perazzolo Marra, Martina; Rizzo, Stefania; De Lazzari, Manuel; Giorgi, Benedetta; Cipriani, Alberto; Frigo, Anna Chiara; Rigato, Ilaria; Migliore, Federico; Pilichou, Kalliopi; Bertaglia, Emanuele; Cacciavillani, Luisa; Bauce, Barbara; Corrado, Domenico; Thiene, Gaetano; Iliceto, Sabino (2015). "Arrhythmic Mitral Valve Prolapse and Sudden Cardiac Death". Circulation. 132 (7): 556–566. doi:10.1161/CIRCULATIONAHA.115.016291. ISSN 0009-7322.
    6. Yap, Sing-Chien; Harris, Louise (2014). "Sudden cardiac death in adults with congenital heart disease". Expert Review of Cardiovascular Therapy. 7 (12): 1605–1620. doi:10.1586/erc.09.153. ISSN 1477-9072.
    7. Holmberg, Mathias J.; Ross, Catherine E.; Fitzmaurice, Garrett M.; Chan, Paul S.; Duval-Arnould, Jordan; Grossestreuer, Anne V.; Yankama, Tuyen; Donnino, Michael W.; Andersen, Lars W.; Chan, Paul; Grossestreuer, Anne V.; Moskowitz, Ari; Edelson, Dana; Ornato, Joseph; Berg, Katherine; Peberdy, Mary Ann; Churpek, Matthew; Kurz, Michael; Starks, Monique Anderson; Girotra, Saket; Perman, Sarah; Goldberger, Zachary; Guerguerian, Anne-Marie; Atkins, Dianne; Foglia, Elizabeth; Fink, Ericka; Lasa, Javier J.; Roberts, Joan; Bembea, Melanie; Gaies, Michael; Kleinman, Monica; Gupta, Punkaj; Sutton, Robert; Sawyer, Taylor (2019). "Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States". Circulation: Cardiovascular Quality and Outcomes. 12 (7). doi:10.1161/CIRCOUTCOMES.119.005580. ISSN 1941-7713.
    8. Becker, Lance B.; Han, Ben H.; Meyer, Peter M.; Wright, Fred A.; Rhodes, Karin V.; Smith, David W.; Barrett, John (1993). "Racial Differences in the Incidence of Cardiac Arrest and Subsequent Survival". New England Journal of Medicine. 329 (9): 600–606. doi:10.1056/NEJM199308263290902. ISSN 0028-4793.
    9. Adabag AS, Luepker RV, Roger VL, Gersh BJ (April 2010). "Sudden cardiac death: epidemiology and risk factors". Nat Rev Cardiol. 7 (4): 216–25. doi:10.1038/nrcardio.2010.3. PMC 5014372. PMID 20142817.
    10. Naruse, Yoshihisa; Tada, Hiroshi; Harimura, Yoshie; Hayashi, Mayu; Noguchi, Yuichi; Sato, Akira; Yoshida, Kentaro; Sekiguchi, Yukio; Aonuma, Kazutaka (2012). "Early Repolarization Is an Independent Predictor of Occurrences of Ventricular Fibrillation in the Very Early Phase of Acute Myocardial Infarction". Circulation: Arrhythmia and Electrophysiology. 5 (3): 506–513. doi:10.1161/CIRCEP.111.966952. ISSN 1941-3149.
    11. Bjork, Randall J. (1982). "Medical Complications of Cardiopulmonary Arrest". Archives of Internal Medicine. 142 (3): 500. doi:10.1001/archinte.1982.00340160080018. ISSN 0003-9926.
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    13. Chan, Paul S. (2012). "A Validated Prediction Tool for Initial Survivors of In-Hospital Cardiac Arrest". Archives of Internal Medicine. 172 (12): 947. doi:10.1001/archinternmed.2012.2050. ISSN 0003-9926.
    14. Ebell MH, Afonso AM (October 2011). "Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta-analysis". Fam Pract. 28 (5): 505–15. doi:10.1093/fampra/cmr023. PMID 21596693.
    15. Topjian AA, Localio AR, Berg RA, Alessandrini EA, Meaney PA, Pepe PE, Larkin GL, Peberdy MA, Becker LB, Nadkarni VM (May 2010). "Women of child-bearing age have better inhospital cardiac arrest survival outcomes than do equal-aged men". Crit Care Med. 38 (5): 1254–60. doi:10.1097/CCM.0b013e3181d8ca43. PMC 3934212. PMID 20228684.
    16. Virani, Salim S.; Alonso, Alvaro; Benjamin, Emelia J.; Bittencourt, Marcio S.; Callaway, Clifton W.; Carson, April P.; Chamberlain, Alanna M.; Chang, Alexander R.; Cheng, Susan; Delling, Francesca N.; Djousse, Luc; Elkind, Mitchell S.V.; Ferguson, Jane F.; Fornage, Myriam; Khan, Sadiya S.; Kissela, Brett M.; Knutson, Kristen L.; Kwan, Tak W.; Lackland, Daniel T.; Lewis, Tené T.; Lichtman, Judith H.; Longenecker, Chris T.; Loop, Matthew Shane; Lutsey, Pamela L.; Martin, Seth S.; Matsushita, Kunihiro; Moran, Andrew E.; Mussolino, Michael E.; Perak, Amanda Marma; Rosamond, Wayne D.; Roth, Gregory A.; Sampson, Uchechukwu K.A.; Satou, Gary M.; Schroeder, Emily B.; Shah, Svati H.; Shay, Christina M.; Spartano, Nicole L.; Stokes, Andrew; Tirschwell, David L.; VanWagner, Lisa B.; Tsao, Connie W. (2020). "Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association". Circulation. 141 (9). doi:10.1161/CIR.0000000000000757. ISSN 0009-7322.
    17. Harrison's Principles of Internal Medicine 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7
    18. Zimetbaum, Peter; Josephson, Mark E. (1998). "Evaluation of Patients with Palpitations". New England Journal of Medicine. 338 (19): 1369–1373. doi:10.1056/NEJM199805073381907. ISSN 0028-4793.
    19. Noda, Takashi; Shimizu, Wataru; Taguchi, Atsushi; Aiba, Takeshi; Satomi, Kazuhiro; Suyama, Kazuhiro; Kurita, Takashi; Aihara, Naohiko; Kamakura, Shiro (2005). "Malignant Entity of Idiopathic Ventricular Fibrillation and Polymorphic Ventricular Tachycardia Initiated by Premature Extrasystoles Originating From the Right Ventricular Outflow Tract". Journal of the American College of Cardiology. 46 (7): 1288–1294. doi:10.1016/j.jacc.2005.05.077. ISSN 0735-1097.
    20. Marijon E, Uy-Evanado A, Dumas F, Karam N, Reinier K, Teodorescu C, Narayanan K, Gunson K, Jui J, Jouven X, Chugh SS (January 2016). "Warning Symptoms Are Associated With Survival From Sudden Cardiac Arrest". Ann Intern Med. 164 (1): 23–9. doi:10.7326/M14-2342. PMC 5624713. PMID 26720493.
    21. Scott, Paul A.; Barry, James; Roberts, Paul R.; Morgan, John M. (2009). "Brain natriuretic peptide for the prediction of sudden cardiac death and ventricular arrhythmias: a meta-analysis". European Journal of Heart Failure. 11 (10): 958–966. doi:10.1093/eurjhf/hfp123. ISSN 1388-9842.
    22. Jayaraman, Reshmy; Reinier, Kyndaron; Nair, Sandeep; Aro, Aapo L.; Uy-Evanado, Audrey; Rusinaru, Carmen; Stecker, Eric C.; Gunson, Karen; Jui, Jonathan; Chugh, Sumeet S. (2018). "Risk Factors of Sudden Cardiac Death in the Young". Circulation. 137 (15): 1561–1570. doi:10.1161/CIRCULATIONAHA.117.031262. ISSN 0009-7322.
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    24. Zareba, Wojciech; Zareba, Karolina M. (2017). "Cardiac Magnetic Resonance in Sudden Cardiac Arrest Survivors". Circulation: Cardiovascular Imaging. 10 (12). doi:10.1161/CIRCIMAGING.117.007290. ISSN 1941-9651.
    25. Lemkes, Jorrit S.; Janssens, Gladys N.; van der Hoeven, Nina W.; Jewbali, Lucia S. D.; Dubois, Eric A.; Meuwissen, Martijn M.; Rijpstra, Topm A.; Bosker, Hans A.; Blans, Michiel J.; Bleeker, Gabe B.; Baak, Remon R.; Vlachojannis, George J.; Eikemans, Bob J. W.; van der Harst, Pim; van der Horst, Iwan C. C.; Voskuil, Michiel; van der Heijden, Joris J.; Beishuizen, Albertus; Stoel, Martin; Camaro, Cyril; van der Hoeven, Hans; Henriques, Jose P.; Vlaar, Alexander P. J.; Vink, Maarten A.; van den Bogaard, Bas; Heestermans, Ton A. C. M.; de Ruijter, Wouter; Delnoij, Thijs S. R.; Crijns, Harry J. G. M.; Jessurun, Gillian A. J.; Oemrawsingh, Pranobe V.; Gosselink, Marcel T. M.; Plomp, Koos; Magro, Michael; Elbers, Paul W. G.; Spoormans, Eva M.; van de Ven, Peter M.; Oudemans-van Straaten, Heleen M.; van Royen, Niels (2020). "Coronary Angiography After Cardiac Arrest Without ST Segment Elevation". JAMA Cardiology. 5 (12): 1358. doi:10.1001/jamacardio.2020.3670. ISSN 2380-6583.
    26. 26.0 26.1 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.

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    Overview

    The term sudden cardiac death refers to natural death from cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of acute symptoms.[1] Other forms of sudden death may be noncardiac in origin and are therefore termed sudden death rather than sudden cardiac death. Examples of this include respiratory arrest (such as due to airway obstruction, which may be seen in cases of choking or asphyxiation), toxicity or poisoning, anaphylaxis, or trauma.[2]

    It is important to make a distinction between this term and the related term cardiac arrest, which refers to cessation of cardiac pump function which may be reversible (i.e., may not be fatal). The phrase Sudden Cardiac Death is a public health concept incorporating the features of natural, rapid, and unexpected. It does not specifically refer to the mechanism or cause of death. Although the most frequent underlying cause of Sudden Cardiac Death is Coronary Artery Disease, other categories of causes are listed below.

    Cardiac Arrest as a Subtype of Sudden Death

    A cardiac arrest, also known as cardiorespiratory arrest, cardiopulmonary arrest or circulatory arrest, is the abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole.[3]

    "Arrested" blood circulation prevents delivery of oxygen to all parts of the body. Cerebral hypoxia, or lack of oxygen supply to the brain, causes victims to lose consciousness and to stop normal breathing. Brain injury is likely if cardiac arrest is untreated for more than 5 minutes,[4] To improve survival and neurological recovery immediate response is paramount.[5]

    Cardiac arrest is a medical emergency that, in certain groups of patients, is potentially reversible if treated early enough (See Reversible Causes, below). When unexpected cardiac arrest leads to death this is called sudden cardiac death (SCD)[3]. The primary first-aid treatment for cardiac arrest is cardiopulmonary resuscitation (commonly known as CPR) to provide circulatory support until availability of definitive medical treatment, which will vary dependant on the rhythm the heart is exhibiting, but often requires defibrillation.

    FDA Guidance re Classification and Types of Cardiovascular and Non-Cardiovascular Death

    Definition of Cardiovascular Death [6]

    The determination of the specific cause of cardiovascular death is complicated by the fact that we are particularly interested in one underlying cause of death (acute myocardial infarction (AMI)) and several modes of death (arrhythmia and heart failure/low output). It is noted that heart attack-related deaths are manifested as sudden death or heart failure, so these events need to be carefully defined. Cardiovascular death includes death resulting from an acute myocardial infarction, sudden cardiac death, death due to heart failure, death due to stroke, and death due to other cardiovascular causes, as follows:

    1.Death due to Acute Myocardial Infarction

    This refers to a death by any mechanism (arrhythmia, heart failure, low output) within 30 days after a myocardial infarction (MI) related to the immediate consequences of the myocardial infarction, such as progressive congestive heart failure (CHF), inadequate cardiac output, or recalcitrant arrhythmia. If these events occur after a “break” (e.g., a CHF and arrhythmia free period of at least a week), they should be designated by the immediate cause, even though the MI may have increased the risk of that event (e.g., late arrhythmic death becomes more likely after an acute myocardial infarction (AMI)). The acute myocardial infarction should be verified to the extent possible by the diagnostic criteria outlined for acute myocardial infarction or by autopsy findings showing recent myocardial infarction or recent coronary thrombus. Sudden cardiac death, if accompanied by symptoms suggestive of myocardial ischemia, new ST elevation, new LBBB, or evidence of fresh thrombus by coronary angiography and/or at autopsy should be considered death resulting from an acute myocardial infarction, even if death occurs before blood samples or 12-lead electrocardiogram (ECG) could be obtained, or at a time before the appearance of cardiac biomarkers in the blood.

    Death resulting from a procedure to treat a myocardial infarction (percutaneous coronary intervention (PCI), coronary artery bypass graft surgery (CABG), or to treat a complication resulting from myocardial infarction, should also be considered death due to acute MI.

    Death resulting from a procedure to treat myocardial ischemia (angina) or death due to a myocardial infarction that occurs as a direct consequence of a cardiovascular investigation/procedure/operation should be considered as a death due to other cardiovascular causes.

    2.Sudden Cardiac Death

    This refers to a death that occurs unexpectedly, not following an acute AMI, and includes the following deaths:

    a. Death witnessed and instantaneous without new or worsening symptoms
    b. Death witnessed within 60 minutes of the onset of new or worsening cardiac symptoms, unless the symptoms suggest AMI
    c. Death witnessed and attributed to an identified arrhythmia (e.g., captured on an electrocardiographic (ECG) recording, witnessed on a monitor, or unwitnessed but found on implantable cardioverter-defibrillator review)
    d. Death after unsuccessful resuscitation from cardiac arrest
    e. Death after successful resuscitation from cardiac arrest and without identification of a non-cardiac etiology (Post-Cardiac Arrest Syndrome)
    f. Unwitnessed death without other cause of death (information regarding the patient’s clinical status preceding death should be provided, if available)
    General Considerations
    • A subject seen alive and clinically stable 12-24 hours prior to being found dead without any evidence or information of a specific cause of death should be classified as :sudden cardiac death.”. Typical scenarios include
    • Subject well the previous day but found dead in bed the next day
    • Subject found dead at home on the couch with the television on
    • Deaths for which there is no information beyond “Patient found dead at home” may be classified as “death due to other cardiovascular causes” or in some trials, “undetermined cause of death.” Please see Definition of Undetermined Cause of Death, below, for full details.

    3. Death due to Heart Failure or Cardiogenic Shock

    This refers to a death occurring in the context of clinically worsening symptoms and/or signs of heart failure (see Chapter 7) without evidence of another cause of death and not following an AMI. Note that deaths due to heart failure can have various etiologies, including one or more AMIs (late effect), ischemic or non-ischemic cardiomyopathy, or valve disease.

    Death due to Heart Failure or Cardiogenic shock should include sudden death occurring during an admission for worsening heart failure as well as death from progressive heart failure or cardiogenic shock following implantation of a mechanical assist device.

    New or worsening signs and/or symptoms of congestive heart failure (CHF) include any of the following:

    a. New or increasing symptoms and/or signs of heart failure requiring the initiation of, or an increase in, treatment directed at heart failure or occurring in a patient already receiving maximal therapy for heart failure
    b. Heart failure symptoms or signs requiring continuous intravenous therapy or chronic oxygen administration for hypoxia due to pulmonary edema
    c. Confinement to bed predominantly due to heart failure symptoms
    d. Pulmonary edema sufficient to cause tachypnea and distress not occurring in the context of an acute myocardial infarction, worsening renal function, or as the consequence of an arrhythmia occurring in the absence of worsening heart failure
    e. Cardiogenic shock not occurring in the context of an acute myocardial infarction or as the consequence of an arrhythmia occurring in the absence of worsening heart failure

    Cardiogenic shock is defined as systolic blood pressure (SBP) < 90 mm Hg for greater than 1 hour, not responsive to fluid resuscitation and/or heart rate correction, and felt to be secondary to cardiac dysfunction and associated with at least one of the following signs of hypoperfusion:

    • Cool, clammy skin or
    • Oliguria (urine output < 30 mL/hour) or
    • Altered sensorium or
    • Cardiac index < 2.2 L/min/m2

    Cardiogenic shock can also be defined if SBP < 90 mm Hg and increases to ≥ 90 mm Hg in less than 1 hour with positive inotropic or vasopressor agents alone and/or with mechanical support.

    General Considerations

    Heart failure may have a number of underlying causes, including acute or chronic ischemia, structural heart disease (e.g. hypertrophic cardiomyopathy), and valvular heart disease. Where treatments are likely to have specific effects, and it is likely to be possible to distinguish between the various causes, then it may be reasonable to separate out the relevant treatment effects. For example, obesity drugs such as fenfluramine (pondimin) and dexfenfluramine (redux) were found to be associated with the development of valvular heart disease and pulmonary hypertension. In other cases, the aggregation implied by the definition above may be more appropriate.

    4.Death due to Stroke

    This refers to death occurring up to 30 days after a stroke that is either due to the stroke or caused by a complication of the stroke.

    5.Death due to Other Cardiovascular Causes

    This refers to a cardiovascular death not included in the above categories (e.g. dysrhythmia unrelated to sudden cardiac death, pulmonary embolism, cardiovascular intervention (other than one related to an AMI), aortic aneurysm rupture, or peripheral arterial disease). Mortal complications of cardiac surgery or non-surgical revascularization should be classified as cardiovascular deaths.

    Definition of Non-Cardiovascular Death

    Non-cardiovascular death is defined as any death that is not thought to be due to a cardiovascular cause. Detailed recommendations on the classification of non-cardiovascular causes of death are beyond the scope of this document. The level of detail required and the optimum classification will depend on the nature of the study population and the anticipated number and type of non-cardiovascular deaths. Any specific anticipated safety concern should be included as a separate cause of death. The following is a suggested list of non-cardiovascular* causes of death:

    Non-Malignant Causes

    • Pulmonary
    • Renal
    • Gastrointestinal
    • Hepatobiliary
    • Pancreatic
    • Infection (includes sepsis)
    • Non-infectious (e.g., systemic inflammatory response syndrome (SIRS))
    • Hemorrhage, not intracranial
    • Non-cardiovascular system organ failure (e.g., hepatic failure)
    • Non-cardiovascular surgery
    • Other non-cardiovascular, specify: ________________
    • Accidental/Trauma
    • Suicide
    • Drug Overdose
    • Death due to a gastrointestinal bleed should not be considered a cardiovascular death.

    Malignant Causes

    Malignancy should be coded as the cause of death if:

    • Death results directly from the cancer; or
    • Death results from a complication of the cancer (e.g. infection, complication of surgery / chemotherapy / radiotherapy); or
    • Death results from withdrawal of other therapies because of concerns relating to the poor prognosis associated with the cancer

    Cancer deaths may arise from cancers that were present prior to randomization or which developed subsequently. It may be helpful to distinguish these two scenarios (i.e. worsening of prior malignancy; new malignancy). Suggested categorization includes common organ systems, hematologic, or unknown.

    Definition of Undetermined Cause of Death

    Undetermined Cause of Death refers to a death not attributable to one of the above categories of cardiovascular death or to a non-cardiovascular cause. Inability to classify the cause of death may be due to lack of information (e.g., the only available information is “patient died”) or when there is insufficient supporting information or detail to assign the cause of death. In general, the use of this category of death should be discouraged and should apply to a minimal number of patients in well-run clinical trials. A common analytic approach for cause of death analyses is to assume that all undetermined cases are included in the cardiovascular category (e.g., presumed cardiovascular death, specifically “death due to other cardiovascular causes”). Nevertheless, the appropriate classification and analysis of undetermined causes of death depends on the population, the intervention under investigation, and the disease process. The approach should be prespecified and described in the protocol and other trial documentation such as the endpoint adjudication procedures and/or the statistical analysis plan.

    References

    1. Myerburg, Robert J. "Cardiac Arrest and Sudden Cardiac Death" in Heart Disease: A Textbook of Cardiovascular Medicine, 7th edition. Philadelphia: WB Saunders, 2005.
    2. Sudden Unexpected Death: Causes and Contributing Factors on poptop.hypermart.net.
    3. 3.0 3.1 Harrison's Principles of Internal Medicine 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7
    4. Safar P (1986). "Cerebral resuscitation after cardiac arrest: a review". Circulation. 74 (6 Pt 2): IV138–53. PMID 3536160. Unknown parameter |month= ignored (help)
    5. Irwin and Rippe's Intensive Care Medicine by Irwin and Rippe, Fifth Edition (2003), Lippincott Williams & Wilkins, ISBN 0-7817-3548-3
    6. FDA guinace issued October 20, 2010

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