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Key Features

Essentials of Diagnosis

  • Most patients with sudden cardiac death have underlying coronary heart disease

  • In the absence of reversible cause, implantable cardioverter defibrillator (ICD) is recommended

General Considerations

  • Sudden cardiac arrest: defined as the successful resuscitation of ventricular fibrillation, either spontaneously or via intervention (defibrillation)

  • Sudden cardiac death: 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

  • A disproportionate number of sudden deaths occur in the early morning hours; this suggests that there is a strong interplay with the autonomic nervous system

  • Prompt evaluation to exclude reversible causes of sudden cardiac arrest should begin immediately following resuscitation

Clinical Findings

  • Underlying coronary heart disease

    • Cause of sudden cardiac death in approximately 70% of cases

    • May be the initial manifestation of sudden cardiac death in up to 20% of patients

  • Initiating arrhythmia in most patients is unknown, but is presumed to be

    • Sustained monomorphic ventricular tachycardia

    • Polymorphic ventricular tachycardia

    • Primary ventricular fibrillation (especially in the setting of acute ischemia)

  • Complete heart block and sinus node arrest may also cause sudden death

  • Other forms of structural heart disease can predispose to sudden cardiac death including

    • Idiopathic cardiomyopathy

    • Hypertrophic cardiomyopathy

    • Valvular heart disease (aortic stenosis, pulmonic stenosis)

    • Congenital heart disease

    • Arrhythmogenic right ventricular cardiomyopathy

    • Myocarditis

  • Five to ten percent of cases of sudden cardiac death are primarily arrhythmic and occur in the absence of structural heart disease; etiologies include

    • Long QT syndrome

    • Brugada syndrome

    • Catecholaminergic polymorphic ventricular tachycardia

    • Wolff-Parkinson-White syndrome

Diagnosis

  • Laboratory testing

    • Should be performed to exclude severe electrolyte abnormalities (particularly hypokalemia and hypomagnesemia), acidosis, and to evaluate cardiac biomarkers

    • Abnormalities may be secondary to resuscitation and not causative of the event; use caution in attributing cardiac arrest solely to an electrolyte disturbance

  • A 12-lead ECG should be performed to evaluate for ongoing ischemia or conduction system disease

  • Echocardiography should be done to evaluate ventricular function

  • Coronary arteriography should be performed to exclude coronary disease as the underlying cause, since revascularization may prevent recurrence

Treatment

  • Intervention is required unless ventricular fibrillation

    • Occurs shortly after myocardial infarction

    • Is associated with ischemia

    • Is seen with a correctable process (eg, electrolyte abnormality or medication toxicity)

  • Hypothermia protocol should be initiated rapidly and continued for 24–36 hours after cardiac arrest

  • ICD is generally indicated in patients who survive sudden cardiac arrest

  • Sudden cardiac arrest in the setting of acute ischemia or infarct should be managed with prompt coronary revascularization

  • Wearable defibrillator vest

    • Alternative to implantation of a prophylactic ICD in patients early after myocardial infarction

    • May be used until recovery of ventricular function can be assessed by echocardiogram 6–12 weeks following myocardial infarction or coronary intervention

Outcome

Prognosis

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