Prevention of Sudden Cardiac Death. Mark Greenberg, MD. Magnitude of Sudden Cardiac Arrest in the U.S. 167,366. Stroke 3. 450,000. Sudden cardiac arrest claims more lives each year than these other diseases combined. Sudden Cardiac Arrests 4. Lung Cancer 2. 157,400. #1 Killer in the U.S.
Mark Greenberg, MD
Sudden cardiac arrest claims more lives each year than these other diseases combined
Sudden Cardiac Arrests4
#1 Killer in the U.S.
1 U.S. Census Bureau, Statistical Abstract of the United States: 2001.
2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures2001.
3 2002Heart and Stroke Statistical Update, American Heart Association.
4 Zheng Z. Circulation. 2001;104:2158-2163.
Preventing Plaque Rupture
Stabilizing Autonomic Balance
Improving Pump Function
Prevention of Arrhythmias
Prevent Ventricular Remodeling and Collagen Formation
Aldosterone receptor blockadeTreatments to Reduce Sudden Cardiac Death
Zipes DP. Circulation. 1998;98:2334-2351.
Pitt B. N Engl J Med. 2003;348:1309-1321.
Number of Worldwide ICD Implants Per Year* Under clinical investigation in the USEvolution of ICD Therapy: 1980 to Present
First-line therapy for patients at risk for VT/VF
1Morgan Stanley Dean Witter. Investors Guide to ICDs. 2000.
“Reduced left ventricular ejection fraction (LVEF) remains the single most important risk factorfor overall mortality and sudden cardiac death.”1
1Prior SG, Aliot E, Blonstrom-Lundqvist C, et al. Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J, Vol. 22; 16; August 2001.
MULTICENTER AUTOMATIC DEFIBRILLATOR IMPLANTATION TRIAL-II (MADIT-II) 1997-2001A trial designed to evaluate the effect of prophylactic ICD therapy on survival in patients with prior MI and LV dysfunction. Supported by a research grant from Guidant Corp.
*No significant differences between CONV and DEFIB groups.
EF < .402
1 Mushlin A. Circulation. 1998;97:2129-35.
2 Kupersmith J. Progress in Cardiovascular Diseases. 1995;37:307-46.
3 Kupperman M. Circulation. 1990;81:91-100.
MADIT II52 yearsICD Trials Summary
1 The AVID Investigators. N Engl J Med. 1997;337:1576-1583.
2 Connolly SJ. Circulation. 2000; 101; 1297-1302.
3 Moss AJ. N Engl J Med. 1996;335;1933-1940.
4 Buxton AE. N Engl J Med. 1999; 341:1882-90.
5 Moss AJ. N Engl J Med. 2002;346:877-83.
ACC/AHA/NASPE Guidelines updated
BCBS, Aetna, Kaiser recommend coverage
Modified CMS approval
“You need an ICD, but it may not be reimbursed.”
In patients with moderately symptomatic CHF and LVEF <=35%, amiodarone and/or ICD added to standard medical Rx will be associated with reduced mortality compared with standard medical Rx alone.
Long APD Region
Short APD Region
Long APD Short APD Long APD Short APD
Spatially Discordant Alternans Leads to
Dispersion of Recovery,
Wave Front Fractionation, and Reentry
Action Potential Alternans Leads
to T-Wave Alternans
“Ultimately, risk stratification will be important only if it can be coupled with a therapeutic intervention that reduces the risk of dying.”
Zipes and Wellens. Sudden Cardiac Death. Circulation. 1998;98:2334-51.