Sudden Cardiac Death Treatment & Management
- Author: Ali A Sovari, MD, FACP; Chief Editor: Jeffrey N Rottman, MD more...
Advanced cardiac life support (ACLS): In the event of cardiac arrest, the immediate implementation of ACLS guidelines is indicated. Widespread interest in improving rates of public ACLS training with a special emphasis on use of early defibrillation by public service personnel (eg, police, fire, airline attendants) exists. Through these measures, the greatest public health benefits can be achieved in the fight against sudden death. In 2010, the American Heart Association (AHA) published new Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science.
The 2009 American Heart Association Cardiac Arrest Survival Summit released consensus recommendations for implementation strategies to optimize the care of patients with out-of-hospital sudden cardiac arrest (OHCA). These recommendations included collection of national data on OHCA and local culture changes because incomplete implementation of existing standards was seen as the limiting problem.
In general, ACLS guidelines should be followed in all cases of SCA; however, depending on the presented rhythm, the following should be considered in acute therapy of SCA:
The best techniques for bystander CPR continue to evolve based on rigorous scientific evaluation and considerations of practical applicability. Recent data suggest, for example, that compression-only CPR may be of equal or greater effectiveness than traditional compression plus ventilation techniques.
Adielsson et al suggest that the long-term perspective data among patients in VF or pulseless VT who were given bystander CPR revealed that survival to 1 month after VF almost doubled.
Berdowski and colleagues in a recent cohort study demonstrated that the bystander use of automated external defibrillators can reduce the time to defibrillation from 11 minutes to 4.1 minutes and improves neurologically intact survival to discharge from 14.3% to 49.6%. That observation is consistent with already known facts that the main initiating mechanisms of sudden cardiac death are ventricular tachycardia and ventricular fibrillation, and that time to defibrillation is a critical factor in restoring the rhythm.
The conclusion that may be drawn from the above studies is that immediate chest compression and defibrillation are the most important interventions to improve the outcome in sudden cardiac arrest, whereas ventilation does not play as important a role.
Ventricular arrhythmia (VF and VT)
Defibrillation is the mainstay of the acute therapy of SCA due to VF or VT. Epinephrine (1 mg q3-5min) or vasopressin (40 U single dose) are given. Amiodarone (300 mg IV push and 150 mg repeat IV push if needed) and lidocaine (1 mg/kg IV push q3-5min up to 3 doses) can be used as antiarrhythmic drugs if defibrillation does not control the VF/VT. In case of polymorphic VT or suspected hypomagnesemia, 1-2 g IV push of magnesium is recommended.
Pulseless electrical activity (PEA)
Epinephrine (1 mg q3-5min) can be used as there is no evidence supporting the use of vasopressin in PEA. Atropine (1 mg q3-5min) should be used in case of bradycardia. Sodium bicarbonate (1 meq/kg) should be given if there is associated hyperkalemia and its use may be considered in long arrest intervals and suspected metabolic acidosis.
One study suggested that vasopressin is more effective in acute therapy of asystole than epinephrine. Atropine and sodium bicarbonate are used with similar indications in PEA.
Careful postresuscitative care is essential to survival because studies have shown a 50% repeat inhospital arrest rate for people admitted after an SCD event. Treatment of myocardial ischemia, heart failure, and electrolyte disturbances are all justified by the results of multiple acute MI and congestive heart failure randomized trials. Empiric beta-blockers are reasonable in many circumstances because of favorable properties discussed in Causes. Empiric antiarrhythmics, including amiodarone, should not supersede ICD implantation unless control of recurrent VT is needed while the patient is in the hospital.
This intervention limits neurologic injury associated with brain ischemia during a cardiac arrest and reperfusion injury associated with resuscitation.
There are several plausible ways that therapeutic hypothermia may prevent neurologic injury, including reduction in metabolism and oxygen consumption of the brain, inhibition of glutamate and dopamine release, and prevention of oxidative stress and apoptosis. Therefore, therapeutic hypothermia should be considered for patients who have been successfully resuscitated from SCA and who are comatose.
In a prospective study of 1145 consecutive patients with out-of-hospital cardiac arrest who had successful resuscitation, therapeutic hypothermia was associated with increased odds of good neurological outcome (odds ratio, 1.9; 95% confidence interval, 1.18-3.06) in patients with VT or VF.
Therapeutic hypothermia is more effective in patients with initial rhythm of VF/VT but is also recommended for patients presenting with asystole and PEA.
Patients who should not receive this therapy include (1) those with tympanic membrane temperature of below 30ºC at the time of presentation, (2) those who were comatose before SCA, (3) those who are pregnant, (4) those who have inherited coagulation disorders, and (5) those who are terminally ill. Two main techniques for induction of therapeutic hypothermia are surface cooling methods with the use of precooled surface cooling pads and core cooling methods with the use of cold intravenous fluids.
Primary prevention of SCD
Several studies have evaluated the use of prophylactic ICDs in patients who have not yet experienced SCD but are at high risk for future SCD. The first of these trials, Multicenter Automatic Defibrillator Implantation Trail (MADIT) demonstrated that patients with ischemic cardiomyopathy (LVEF ≤35%) and inducible but nonsuppressible VT on EPS had a survival advantage by implanting an ICD.
This study was followed by MADIT-2, demonstrating that post-MI patients with an LVEF ≤30% have a survival benefit with ICD implantation. The Defibrillators in Nonischemic Cardiomyopathy Treatment Evaluation (DEFINITE) study showed that implantation of an ICD reduced the risk of sudden cardiac death in a patient population of nonischemic cardiomyopathy (LVEF < 36%) who also had PVCs or nonsustained VT.
Finally, the Sudden Cardiac Death in Heart Failure Trial (SCD-Heft) demonstrated that patients with either ischemic or nonischemic cardiomyopathy on optimal medical therapy, LVEF ≤35%, and NYHA II or III treated with an ICD demonstrate greater survival as compared with either amiodarone or placebo.
The recent Home Automated Defibrillator Trial (HAT) demonstrated no survival benefit for the use of a home AED in patients surviving a recent anterior MI who were not candidates for an ICD. However, the overall mortality and incidence of SCD was much lower than predicted from previous data and the noncardiac mortality was as high as cardiac mortality in the population of this study. These factors led to much less power than initially projected in this trial to detect a significant difference in the mortality rate between the arms.
The use of microvolt T wave alternans (MTWA) to determine which patients with depressed LV systolic function would best benefit from prophylactic ICD placement has been the subject of several recent clinical trials. To date, the results of these clinical trials has not been conclusive.
Temporary cardiac pacing
Transcutaneous of transvenous cardiac pacing may be considered in the patients with bradycardia and asystole.
Radiofrequency ablation, now routinely available, may be indicated for patients with accessory pathways, bundle-branch block VT, RVOT VT, idiopathic LV tachycardia, and more rare forms of automatic focus VT. Unfortunately, most cases of SCD are not amenable to radiofrequency ablation and require ICD implantation. Radiofrequency ablation may be useful in the treatment of patients with SCD who experience frequent recurrent VT/VF after ICD placement, especially those who require frequent defibrillation.
Cardioverter defibrillator therapy
Several multicenter trials examining the prophylactic use of cardioverter defibrillator therapy in patients at high risk for SCD have been performed.
The annual SCD rate in patients with these devices has been reduced from 25% to 1-2%. Studies have shown that in patients at high risk in whom electrophysiologic-guided therapy with antiarrhythmics has failed, ICD placement is beneficial. In several studies comparing ICD placement to antiarrhythmic therapy in patients with VT and/or prior cardiac arrest, ICD placement has been shown to be associated with decreased mortality.
The use of ICDs for primary prevention of SCD is now standard care for most patients with LVEF ≤35%. Newer ICDs with pacing capabilities have addressed bradyarrhythmias either causing or complicating VT or VF.
Cardiac surgery can be a primary treatment for SCD via a variety of strategies.
Surgical treatment in patients with ventricular arrhythmias and ischemic heart disease includes coronary artery bypass grafting (CABG). The CASS study illustrated that patients with significant CAD and operable vessels who underwent CABG had a decrease in the incidence of sudden death when compared to patients on conventional medical treatment. The reduction was most evident in patients who had 3-vessel disease and CHF.
Surgical treatment of ventricular arrhythmias in patients with nonischemic heart disease includes excision of VT foci after endocardial mapping and excision of LV aneurysms. This is performed with decreasing frequency, because of perioperative mortality and the alternative, transvenous ICD implantation.
Aortic valve replacement is associated with improved outcome in patients with hemodynamically significant valvular stenosis and well-preserved ventricular function. In patients with MVP associated with significant valvular regurgitation and LV dysfunction, malignant tachyarrhythmias and SCD have been reported. These patients are candidates for mitral valve repair or replacement.
Orthotopic heart transplantation is indicated in cases of SCD and refractory heart failure in which significant improvement in actuarial survival is expected. Given a limited donor service, this form of treatment is expected to be beneficial for very few people who survive SCD.
Patients with long QT syndrome who do not respond to beta-blockers are candidates for ICD implantation or high thoracic left sympathectomy.
A cardiologist always should be participating in the care of these patients. Cardiac electrophysiologists should be involved in the care of these patients, which generally involves ICD implantation.
Other consultations for expertise include an interventional cardiologist and cardiac surgeon and are made on an individual basis.
Patients with coronary artery disease are advised to follow a diet low in fat and cholesterol. Patients with severe heart failure should monitor their fluid and sodium intake.
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