Eric C. Stecker

Public Health Burden of Sudden Cardiac Death in the United States

Background—Sudden cardiac death (SCD) is a leading cause of death in the United States, but the relative public health burden is unknown. We estimated the burden of premature death from SCD and compared it with other diseases. Methods and Results—Analyses were based on the following data sources (using most recent sources that provided appropriately stratified data): (1) leading causes of death among men and women from 2009 US death certificate reporting; (2) individual cancer mortality rates from 2008 death certificate reporting from the Centers for Disease Control and Prevention’s National Program of Cancer Registries; (3) county, state, and national population data for 2009 from the US Census Bureau; and (4) SCD rates from the Oregon Sudden Unexpected Death Study (SUDS) population-based surveillance study of SCD between 2002 and 2004. Cases were identified from multiple sources in a prospectively designed surveillance program. Incidence, counts, and years of potential life lost for SCD and other major diseases were compared. The age-adjusted national incidence of SCD was 60 per 100 000 population (95% confidence interval, 54–66 per 100 000). The burden of premature death for men (2.04 million years of potential life lost; 95% uncertainty interval, 1.86–2.23 million) and women (1.29 million years of potential life lost; 95% uncertainty interval, 1.13–1.45 million) was greater for SCD than for all individual cancers and most other leading causes of death. Conclusions—The societal burden of SCD is high relative to other major causes of death. Accordingly, improved national surveillance with the goal of optimizing and monitoring SCD prevention and treatment should be a high priority.

Ventricular Arrhythmias After Left Ventricular Assist Device

Despite advances in medical therapy, heart failure remains one of the major causes of hospitalizations and deaths in the United States. Approximately 5.7 million patients have heart failure, and it is the direct cause of death for 57 000 individuals annually.1 Although the combination of optimal medical therapy, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy has reduced mortality rates, an estimated 50% of patients with heart failure still die within 5 years of diagnosis.1 Heart transplant is often the best therapeutic option for patients with end-stage heart failure; however, there has been a stable plateau of ≈2200 transplants/y in the United States due largely to limitations in organ availability.1 For patients who are facing unfavorably long wait times for heart transplantation, left ventricular assist devices (LVAD) have become a lifesaving option as a bridge to transplant. Currently, one quarter to one third of all heart transplant recipients are bridged with mechanical circulatory support before transplantation.2 Much of this support is in the form of permanent LVADs—surgically implanted mechanical assist devices that unload the left ventricle and can function in ambulatory patients (Figure 1). The use of permanent LVADs as destination therapy has increased dramatically, with evidence that they benefit patients with end-stage heart failure, despite noncandidacy for heart transplantation. Since the seminal Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure destination therapy trial in 2001, ≈1578 destination therapy LVADs have been implanted, with implant rates increasing rapidly.3,4 Figure 1. Examples of implantable cardioverter-defibrillators (ICDs) with 2 different types of left ventricular assist devices (LVADs). Posterior-anterior chest x-ray projections of biventricular ICDs in the presence of HVAD ( A ) and Heartmate II ( B ) models of LVAD. Development of LVADs dates to 1969 when the world’s first total artificial heart was implanted by Dr …

Arrhythmias After Heart Transplantation: Mechanisms and Management

Heart transplantation (HT) has significantly altered the treatment paradigm for end-stage heart disease. With current surgical techniques and postoperative immunosuppression, 1-year survival after HT is ≈90%, 5-year survival is ≈70%, and median survival exceeds 10 years.[1][1]–[3][2] These

Patients with Pacemaker or Implantable Cardioverter- Defibrillator

The preparation of patients with a cardiac implantable electronic device (CIED) for the perioperative period necessitates familiarity with recommendations from the American Society of Anesthesiologists and Heart Rhythm Society. Even clinicians who are not CIED experts should understand the indications for implantation, as well as the basic functions, operations, and limitations of these devices. Before any scheduled procedure, proper CIED function should be verified and a specific CIED prescription obtained. Acquiring the requisite knowledge base and developing the systems to competently manage the CIED patient ensures safe and efficient perioperative care.

Relationship Between Seizure Episode and Sudden Cardiac Arrest in Patients With Epilepsy A Community-Based Study

Background— Among patients with epilepsy, sudden cardiac arrest (SCA) is a major cause of death. It is commonly thought that SCA in epilepsy occurs after a seizure, though the strength of evidence supporting this is limited. We sought to evaluate the relationship between seizures and SCA in patients with epilepsy. Methods and Results— From the ongoing Oregon Sudden Unexpected Death Study, cases of SCA identified using prospective, multisource ascertainment (Portland metropolitan area, Oregon; population ≈1 million; February 1, 2002, to March 1, 2012) were evaluated for history of epilepsy. In the subset with witnessed SCA, clinical presentations were analyzed for evidence of seizure activity immediately before the event as well as lifetime clinical history, including nature of seizures before SCA. Only 34% of patients with history of epilepsy and a witnessed arrest had evidence of seizure activity before the arrest. Rates of survival to hospital discharge after attempted resuscitation were 2.7% in patients with history of epilepsy versus 11.9% for patients without epilepsy (P=0.014). Patients with epilepsy had a significantly lower rate of presentation with ventricular tachycardia/ventricular fibrillation as opposed to pulseless electrical activity/asystole (epilepsy, 26%; no epilepsy, 44%; P=0.002), despite nearly identical response times. Conclusions— In the majority (66%) of epilepsy patients, there was no relationship between seizure and SCA, implying that SCA in epilepsy patients often may not involve seizure as a trigger. The significantly worse rate of survival from SCA in epilepsy patients warrants urgent investigation.

Distinctive Clinical Profile of Blacks Versus Whites Presenting With Sudden Cardiac Arrest

Background— Sudden cardiac arrest (SCA) is a major contributor to mortality, but data are limited among nonwhites. Identification of differences in clinical profile based on race may provide opportunities for improved SCA prevention. Methods and Results— In the ongoing Oregon Sudden Unexpected Death Study (SUDS), individuals experiencing SCA in the Portland, OR, metropolitan area were identified prospectively. Patient demographics, arrest circumstances, and pre-SCA clinical profile were compared by race among cases from 2002 to 2012 (for clinical history, n=126 blacks, n=1262 whites). Incidence rates were calculated for cases from the burden assessment phase (2002–2005; n=1077). Age-adjusted rates were 2-fold higher among black men and women (175 and 90 per 100 000, respectively) compared with white men and women (84 and 40 per 100 000, respectively). Compared with whites, blacks were >6 years younger at the time of SCA and had a higher prearrest prevalence of diabetes mellitus (52% versus 33%; P<0.0001), hypertension (77% versus 65%; P=0.006), and chronic renal insufficiency (34% versus 19%; P<0.0001). There were no racial differences in previously documented coronary artery disease or left ventricular dysfunction, but blacks had more prevalent congestive heart failure (43% versus 34%; P=0.04) and left ventricular hypertrophy (77% versus 58%; P=0.02) and a longer QTc interval (466±36 versus 453±41 milliseconds; P=0.03). Conclusions— In this US community, the burden of SCA was significantly higher in blacks compared with whites. Blacks with SCA had a higher prearrest prevalence of risk factors beyond established coronary artery disease, providing potential targets for race-specific prevention.

Prediction of sudden cardiac death: Next steps in pursuit of effective methodology

The recognition that severe left ventricular dysfunction is a predictor of sudden cardiac death (SCD) risk enabled widespread utilization of the implantable cardioverter defibrillator (ICD) for SCD prevention. Use of the ICD prior to any signs or symptoms of ventricular arrhythmias (“primary prevention”) is particularly important for SCD because case fatality for patients with sustained ventricular tachyarrhythmias is among the highest of any disease process. At the same time, primary prevention of SCD presents a unique epidemiologic challenge for many reasons [1, 2]: (1) high-risk subgroups constitute only a small proportion of all patients at risk for SCD, (2) the pathophysiologic etiologies of SCD are complex and infrequently recognized prior to arrest, (3) ventricular arrhythmia substrate often evolves over time and may require repeated risk stratification, (4) classification of arrhythmic death is particularly imprecise, (5) triggers for SCD may be transient, and (6) patients at high risk for SCD have many competing risks that are not ameliorated by ICDs. This review will address the limitations of risk stratification based on left ventricular ejection fraction (LVEF), summarize new developments in the field that extend beyond LVEF, and suggest new investigative approaches for refinement of SCD risk assessment.

Improving early identification of the high-risk elderly trauma patient by emergency medical services

STUDY OBJECTIVE We sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients. METHODS This was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score≥16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns. RESULTS 33,298 injured elderly patients were transported by EMS, including 4.5% with ISS≥16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7-20.7) for ISS≥16 to 2.9% (95% CI 2.6-3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS≤14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS≥16: sensitivity (92.1% [95% CI 89.6-94.1%] vs. 75.9% [95% CI 72.3-79.2%]), specificity (41.5% [95% CI 40.6-42.4%] vs. 77.8% [95% CI 77.1-78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices. CONCLUSIONS High-risk elderly trauma patients can be defined by ISS≥16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.

Ischemic Heart Disease Diagnosed Before Sudden Cardiac Arrest Is Independently Associated With Improved Survival

Background Sudden cardiac arrest (SCA) is a significant public health problem, and rates of survival after resuscitation remain well below 10%. While several resuscitation‐related factors are consistently associated with survival from SCA, the impact of specific comorbid conditions has not been assessed. Methods and Results The Oregon Sudden Unexpected Study is an ongoing, multisource, community‐based study in Portland, Oregon. Patients with SCA who underwent attempted resuscitation between 2002 and 2012 were included in this analysis if there were both arrest and prearrest medical records available. Information from the emergency medical services system, medical examiner, public health division, hospitals, and clinics was used to adjudicate SCA, evaluate comorbidities, and identify medical treatments. Univariate and multivariate analyses were performed to investigate the influence of prearrest comorbidities on survival to hospital discharge. Among 1466 included patients, established resuscitation‐related predictors (Utstein factors) were associated with survival, consistent with prior reports. When a panel of prearrest comorbidities was evaluated along with Utstein factors, recognized coronary artery disease was significantly associated and predicted higher odds of survival (unadjusted odds ratio 1.5, P<0.001; adjusted odds ratio 1.5, P=0.02). In multivariable logistic models, prearrest coronary artery disease modified the survival effects of bystander cardiopulmonary resuscitation, but did not modify other Utstein factors. Conclusions An established diagnosis of coronary artery disease was associated with 50% higher odds of survival from resuscitated SCA after adjustment for all arrest‐related predictors. These findings raise novel potential mechanistic insights into survival after SCA, while highlighting the importance of early recognition and treatment of coronary artery disease.

Clinical ResearchHealth Services Research: Editorial CommentValue-Based Insurance Design in Cardiology: Using “Clinical Nuance” to Improve Quality of Care and Contain Costs⁎

The past several decades have produced remarkable technological and therapeutic innovations in the prevention and treatment of cardiovascular disease, resulting in impressive reductions in cardiovascular-related morbidity and mortality ([1,2][1]). These enhanced clinical outcomes coincide with a