Eric Prystowsky MD Director Clinical Electrophysiology Laboratory

1. The EP show: sudden death, part 2 • Eric Prystowsky MD • Director • Clinical Electrophysiology Laboratory • St Vincent Hospital, Indianapolis, IN • Douglas P Zipes MD • Director, Division of Cardiology and • Krannert Institute of Cardiology • Indiana University School of Medicine • Indianapolis, IN • Robert J Myerburg MD • Professor of Medicine and Physiology • Director, Division of Cardiology • University of Miami School of Medicine • Miami, FL

2. The low-risk patient • Patients presenting with sudden death at low risk of recurrence are those having clear-cut evidence for an acute transmural MI who do not also have a low ejection fraction. • Symptoms, enzymes and ECG findings are all used to support this diagnosis. • Patients who do not meet these criteria must be profiled individually for future recurrence risk.

3. Acute MI and low EF • The patient who has an inferior wall MI with a post-event EF of 45% and no arrhythmias (except for VF within the first 48 hours) is a low-risk patient. • The patient who has VF during the acute phase of a large anterior infarct, and who is left with an EF of 30% and non-sustained VT is a high-risk patient (fulfilling criteria for the Multicenter Automatic Defibrillator Trial or MADIT study).

4. Public use of automatic external defibrillators (AEDs) • Deployment of AEDs in emergency vehicles • Advantage a trained group of people responding objectively and repetitively to emergencies • Disadvantage some arrival delays exist, although police may reach victims faster than fire/rescue

5. Public use of automatic external defibrillators (AEDs) • Deployment of AEDs in public access sites • Data from American Airlines, the Chicago airport and Las Vegas casinos confirm that the presence of AEDs shortens response times and improves survival rates. • The year 2000 is the first year that definitive conclusions can be made regarding the data of AED’s in these venues.

6. Public use of automatic external defibrillators (AEDs) • Deployment of AEDs in multifamily dwellings Data are not yet available on the use of AEDs by trained personnel in condominiums and other dwellings. Deployment of AEDs in shopping malls The NIH is funding studies to look at the merits of AEDs in public access sites other than strictly defined areas such as stadiums, airports, etc.

7. AEDs and education • Deployment of AEDs will not be effective without educational strategies geared toward the users. • Systems such as “train the trainers” have health professionals train interested police officers, for example, who then train their colleagues. • Devices may be assigned to individuals in the police force, rather than to a police car, so that when an individual is off duty, he or she actually takes the AED home.

8. The cost of public AEDs • AEDs have become relatively inexpensive, and in the foreseeable future, these devices may become as “standard” to the home as a fire extinguisher is today. • Ultimately, funding for public access AEDs will become an issue of tax spending allocation and public responsibility.

9. Screening athletes at risk for sudden death • Intervention • Screening questionnaire • One approach to screening athletes at high risk of sudden death is to disseminate an extensive questionnaire to the parents of every child who plays sports. • Positive responses on this questionnaire would signal the need for additional screening tests such as ECG’s and echocardiograms. • This idea is in defense of the notion that screening ECG’s for every athlete in the country would be impractical and too expensive.

10. Screening athletes at risk for sudden death • Intervention • Screening questionnaire • The disadvantages to such a questionnaire include the lack of uniform literacy rates among respondents and false negative answers given by athletes who wish to hide their symptoms. • The infrequency with which sudden death occurs in young athletes brings in question the value of widely disseminated screening interventions.

11. Screening athletes at risk for sudden death • Intervention • Screening ECGs • A second approach to screening is that all adolescents should have an ECG. In all adolescent sudden deaths, the incidence in non-athletes exceeds the incidence in athletes. • Regarding the cost of this approach, one study determined a cost-efficiency of $44 000 per life saved which falls within the range of established cost efficacy.

12. Screening athletes at risk for sudden death • Intervention • Screening ECGs • One disadvantage to screening the adolescent population with ECGs is that interpretation of ECG results in this population may not be clear cut, unless grossly abnormal. • How to deal with the medically uninsured population of adolescents is also a major issue.

13. Inheritable syndromes of sudden death • A patient is thought of as high-risk if there is a family history of fatal events or potentially fatal arrhythmias, regardless of symptoms. • For long QT syndromes, beta-blockers are often used as first line in patients who are asymptomatic. If symptoms are present, an ICD is warranted. • The FDA has changed its guidelines so that implantation of an ICD in orphan situations is acceptable (ie, as first line therapy in these situations).

14. The treatment of families with inheritable syndromes • The family should be engaged in the decision-making process regarding treatment options. • The definitive treatment for each of the various long QT syndromes has yet to be determined. • The use of an ICD is an acceptable practice.

15. The young patient with an inheritable syndrome • Compliance is an issue in young patients taking beta-blockers for inheritable syndromes. • On the flipside, an implanted ICD clearly brings home the realization that the patient is “different from everybody else”.