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Sudden cardiac death is defined as unexpected nontraumatic death in clinically well or stable patients who die within 1 hour after onset of symptoms The causative rhythm in most cases is ventricular fibrillation, which is usually preceded by ventricular tachycardia except in the setting of acute ischemia or infarction Complete heart block and sinus node arrest may also cause sudden death A disproportionate number of sudden deaths occur in the early morning hours Over 75% of victims of sudden cardiac death have severe CAD Many have old infarctions Sudden death may be the initial manifestation of coronary disease in up to 20% of patients and accounts for approximately 50% of deaths from coronary disease Other conditions that predispose to sudden death include severe LVH, hypertrophic cardiomyopathy, congestive cardiomyopathy, aortic stenosis, pulmonary stenosis, primary pulmonary hypertension, cyanotic congenital heart disease, atrial myxoma, mitral valve prolapse, hypoxia, electrolyte abnormalities, prolonged QT interval syndrome, the Brugada syndrome and conduction system disease Late potentials (after the QRS complex) on a signal-averaged surface ECG in patients with prior myocardial infarction may identify a group of patients at risk for ventricular arrhythmias and sudden death

Unless ventricular fibrillation occurred shortly after myocardial infarction, is associated with ischemia, or is seen with an unusual correctable process (such as an electrolyte abnormality, drug toxicity, or aortic stenosis), surviving patients require evaluation and intervention since recurrences are frequent Exercise testing or coronary arteriography should be performed to exclude coronary disease as the underlying cause, since revascularization may prevent recurrence When ventricular fibrillation occurs in the initial 24 hours after infarction, long-term management is

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less than that of ventricular tachycardia with a rapid rate, and treatment is not indicated unless there is hemodynamic compromise or more serious arrhythmias This rhythm also is common in digitalis toxicity Accelerated idioventricular rhythm must be distinguished from the idioventricular or junctional rhythm with rates less than 40 45 beats/min that occurs in the presence of complete AV block AV dissociation where ventricular rate exceeds sinus but not AV block occurs in most cases of accelerated idioventricular rhythm

no different from that of other patients with acute infarction Conduction disturbances should be managed as described in the next section If prodromal supraventricular arrhythmias or ventricular arrhythmias, such as sustained or nonsustained ventricular tachycardia, are found by ambulatory ECG monitoring, their elimination by pharmacologic therapy or ablation may prevent further episodes There is growing consensus that if myocardial infarction or ischemia, other precipitating causes of ventricular fibrillation, or bradyarrhythmias and conduction disturbances are not found to be the cause of the sudden death episode, an implantable defibrillator is the treatment of choice for appropriate patients In addition, evidence from the MADIT II study and Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) suggest that patients with severe LV dysfunction whether due to an ischemic cause such as a remote myocardial infarction or a nonischemic cause of advanced heart failure have a reduced risk of death with the prophylactic implantation of a implantable cardioverter-defibrillator However, there is also evidence that implanting prophylactic ICDs in patients early after myocardial infarction is associated with a trend toward worse outcomes

Bokhari F et al Long-term comparison of the implantable cardioverter defibrillator versus amiodarone: eleven-year follow-up of a subset of patients in the Canadian Implantable Defibrillator Study (CIDS) Circulation 2004 Jul 13;110(2): 112 6 [PMID: 15238454] Brodine WN et al; MADIT-II Research Group Effects of betablockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation TrialII) Am J Cardiol 2005 Sep 1;96(5):691 5 [PMID: 16125497] Eckardt L et al Long-term prognosis of individuals with right precordial ST-segment-elevation Brugada syndrome Circulation 2005 Jan 25;111(3):257 63 [PMID: 15642768] Hohnloser SH et al; DINAMIT Investigators Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction N Engl J Med 2004 Dec 9;351(24): 2481 8 [PMID: 15590950] Kadish A et al; Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy N Engl J Med 2004 May 20;350(21): 2151 8 [PMID: 15152060] Sanders GD et al Cost-effectiveness of implantable cardioverter-defibrillators N Engl J Med 2005 Oct 6;353(14):1471 80 [PMID: 16207849]

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FIGURE 3-26

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