Secondary prevention of sudden cardiac death in heart failure and cardiomyopathy
- Joseph E Marine, MD, FACC, FHRS
Joseph E Marine, MD, FACC, FHRS
- Associate Professor of Medicine
- Associate Director of Electrophysiology
- Johns Hopkins University School of Medicine
- Andrea M Russo, MD, FACC, FHRS
Andrea M Russo, MD, FACC, FHRS
- Professor of Medicine
- Cooper Medical School of Rowan University
- Section Editors
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
- Samuel Lévy, MD
Samuel Lévy, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Cardiology
- University of Marseille, France
Life-threatening ventricular arrhythmias, including sustained ventricular tachycardia (VT) and ventricular fibrillation (VF), are common in patients with heart failure (HF) and cardiomyopathy and may lead to sudden cardiac death (SCD). Secondary prevention of SCD refers to medical or interventional therapy undertaken to prevent SCD in patients who have experienced symptomatic life-threatening sustained VT/VF or have been successfully resuscitated from sudden cardiac arrest (SCA). The secondary prevention of SCD in patients with heart failure and cardiomyopathy will be reviewed here, with emphasis on the role of implantable cardioverter-defibrillators (ICDs). The different types of ventricular arrhythmias, the effects of HF therapy on ventricular arrhythmias, and the role of electrophysiologic testing are discussed separately. (See "Ventricular arrhythmias in heart failure and cardiomyopathy".)
The approaches to the treatment of ventricular arrhythmias related to specific heart muscle diseases, such as hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and isolated left ventricular noncompaction, are discussed elsewhere. (See "Hypertrophic cardiomyopathy: Assessment and management of ventricular arrhythmias and sudden cardiac death risk" and "Arrhythmogenic right ventricular cardiomyopathy: Treatment and prognosis" and "Isolated left ventricular noncompaction".)
CAUSES OF DEATH IN HEART FAILURE
While the exact percentages and mode of death in patients with heart failure vary with heart failure class and type of cardiomyopathy, progressive pump failure, unexpected sudden cardiac death (SCD), and SCD during episodes of clinical worsening of HF each account for approximately one-third of deaths in HF patients . VT and VF are the most common arrhythmic causes of SCD, although bradyarrhythmias and pulseless electrical activity (PEA) are responsible in 5 to 33 percent of cases [2,3].
More severe HF is associated with a higher overall mortality rate and a higher absolute rate of SCD, but a decreasing proportion of SCD to total deaths. This trend was illustrated in the MERIT-HF (Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure) trial in which patients with increasing HF class (NYHA class II, III and IV) had increasing rates of SCD at one year (6.3, 10.5, and 18.6 percent, respectively), but a decreasing percentage of deaths that were classified as SCD (64, 59, and 33 percent, respectively) .
Patients who have received an implantable cardioverter defibrillator (ICD) for secondary prevention have significantly higher rates of recurrent ventricular arrhythmias triggering appropriate ICD intervention than recipients of primary prevention ICDs, approximately threefold higher in one national registry from Israel . Although ICD therapy improves survival of patients who suffered prior SCA, mortality remains high. The mechanisms of death in such patients were illustrated in analyses from several secondary prevention ICD studies [6-8]:
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- CAUSES OF DEATH IN HEART FAILURE
- SECONDARY PREVENTION OF SCD
- Reversible causes of SCA or sustained VT
- Use of an ICD
- - AVID trial
- - CASH trial
- - CIDS trial
- - Meta-analysis
- - Generalizability of ICD clinical trial results
- - Effect in elderly patients
- - Effect in heart failure
- - Patients with syncope
- - Patients with transient or reversible disorders
- - SCD despite ICD implantation
- Other treatment options
- - Antiarrhythmic drugs
- - Other medical therapies
- Beta blockers
- Lipid-lowering therapy
- - Radiofrequency ablation
- - Arrhythmia surgery
- Ischemic cardiomyopathy
- Nonischemic cardiomyopathy
- - Cardiac transplantation
- OUR APPROACH
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS