Epidemiologic Methods in the Study of Sudden Cardiac Death

Transcription

1 Epidemiologic Methods in the Study of Sudden Cardiac Death Clinical Epidemiology and Biostatistics Mahidol University Bangkok Ross J. Simpson Jr, MD, PhD Division of Cardiology University of North Carolina at Chapel Hill Charles Stewart Roberts. Herrick and Heart Disease Charles Stewart Roberts.

2 "Clinical Features of Sudden Obstruction of the Coronary Arteries, 1912 clinical manifestations of coronary obstruction events: (1) instantaneous, perhaps painless, death (2) severe angina followed minutes later by shock and death (3) mild, nonfatal angina (4) severe angina that is usually eventually fatal, but not immediately Roberts CS STUDY DESIGNS of SUDDEN DEATH OBSERVATIONAL: CROSS SECTIONAL, PERSPECTIVE OR RETROSPECTIVE Case series/ Case control COHORT: Framingham, ARIC REGISTRY: Oregon Sudden Unexpected Death SURVEILANCE: SUDDEN

3 5 Sudden Cardiac Death Douglas P. Zipes, Hein J. J. Wellens Circ 1998

4 Sudden Cardiac Death Douglas P. Zipes, Hein J. J. Wellens Circ 1998 Sudden Cardiac Death - Incidence by risk group: % Risk SCD / Year Number SCD / Year Adult Population High CAD Risk Hx CAD Event EF < 30% CHF Arrest Survivors High risk post MI (%) (x 1000) Myerburg RJ. Circulation. 1992;85(suppl I):I-2 I-10.

5 Atherosclerotic Risk in Communities (ARIC) Cohort Approximately 4,000 adults from each of 4 US communities (Forsyth County, NC; Jackson, MS; Minneapolis, MN; Washington County MD) Study designed to investigate etiology of atherosclerosis and relations to race, gender, risk factors and medical care Participants aged years of age Probability sample from each community except Jackson where only African-Americans selected Baseline examination conducted from Cardiovascular risk factors, SES, ECGs, family and medical history, blood chemistries and medication use

6 Validation of a short rhythm strip compared to ambulatory ECG monitoring for ventricular ectopy Kelly R. Evenson Journal of Clinical Epidemiology 53 (2000)

7 Characteristics of participants with and without PVCs at baseline MW Massing Am J Cardiol 2006 Association of PVCs With ECG Estimated Left Ventricular Mass: the ARIC Study Ross J. Simpson, Jr., MD, PhD Am J Cardiol 2001

8 Association of PVCs With ECG Estimated Left Ventricular Mass: the ARIC Study Ross J. Simpson, Jr., MD, PhD Am J Cardiol 2001 Over 6% of free living, middle aged, adults have at least a single PVCs on a standard 2 min ECG Increasing age, prevalent CHD, faster sinus rates, African-American ethnicity, male gender, lower educational attainment, and lower K+ or Mg++ are directly related to prevalence Hypertension and LV mass are strong associates of PVCs

9 Usefulness of Ventricular Premature Complexes to Predict Coronary Heart Disease Events and Mortality Variables MW Massing Am J Cardiol 2006 Predictor: resting 2 minute ECG classified 3 times by trained coders for single PVCs, runs and multiform patterns Outcome: any death, CHD related death and CHD events Follow-up through By annual phone interviews, review of hospital and vital records Fatal CHD included hospitalized and non-hospitalized deaths CHD event defined as definite or probable MI, fatal CHD, cardiac procedure or serial ECG changes across cohort examinations Covariates: variables associated with VPC mortality and CHD events Prevalent CHD at baseline Diabetes, hypertension, age, education, smoking status, lipids, medications, heart rate and electrolytes Usefulness of PVCs to Predict Coronary Heart Disease Events and Mortality MW Massing Am J Cardiol 2006

10 Usefulness of PVCs to Predict Coronary Heart Disease Events and Mortality MW Massing Am J Cardiol 2006 CHD mortality was over 3 times greater (7.8%) in subjects with than without PVCs (2.1%) Increased risk of CHD and death associated with PVCs persisted after controlling for CVD risk factors After adjustment, participants with PVCs were twice as likely to have CHD death compared to those without PVCs This risk occurred in participants with and without CHD at baseline PVCs and the Risk of Sudden and Non-sudden Cardiac Death: The Atherosclerosis Risk In Communities (ARIC) Study Sunil K. Agarwal

11 PVCs: Are they really benign? PVCs are present in about 6% of adults, and are associated with older age, faster heart rates, male gender, lower educational attainment, hypertension, LV mass, low K+/Mg++ and prevalent CHD Independently of these and other predictors of adverse outcomes, PVCs approximately double the risk of myocardial infarction, stroke and CHF sudden cardiac death Complex PVCs may be more ominous Defining Sudden Death 1. Disease specific? Restricting the study population to cardiac related deaths ignores other potentially preventable events, such as pulmonary embolism or stroke. 2. Timing specific? The pathophysiological process not likely to be related to when a victim that was last seen alive less than OR greater than 24 hours prior to onset of symptoms. 3. A rare or common syndrome?

12 What is Sudden Death? It s not just sudden cardiac death Out of Hospital Sudden Unexpected Death Acute Myocardial Infarction Arrhythmia Intracranial Emergencies Pulmonary Embolism Aortic Catastrophe Slovis, C., et al. Five Common Causes of Sudden Unexpected Death. Patient Care. January 21, 2015 What is Sudden Unexpected Death? It s not just sudden cardiac death Out-of-hospital sudden unexpected death Sudden Cardiac Death WHO defined SCD

13 SUDDEN Case Ascertainment Wake county EMS Referrals 1759 Primary Exclusions Not years old Non natural deaths and non-free living Expected deaths: hospice, end stage disease Survival to hospital Non-resident of NC 192 Secondary Exclusions By adjudication committee using medical and post-mortem records 408 Out-of-Hospital Sudden Unexpected ected Death Victims Comparison of Previous Sudden Death Studies 18 to 65 year population Criteria from previous studies as applied to the SUDDEN population OHSUD per 100, Gillum (1989) Escobedo (1996) Zheng (2001) Cobb (2002) Chugh (2004) SUDDEN SUDDEN

14 Geocoded Resuscitation Attempted in Sudden Death Victims SUDDEN Victim profile 100 % OHSUD Population 25 0

15 SUDDEN Risk factors by age 63% 75% 70% yr yr 47% 55% 51% 51% 51% yr 35% 30% 38% 22% 17% 15% 12% Hypertension Smoking Dyslipidemia Diabetes Mellitus Cardiomyopathy SUDDEN Risk factors by age 80% 70% 60% 50% 51% 52% yr yr yr 40% 30% 20% 35% 32% 27% 28% 28% 28% 25% 10% 0% Obesity Coronary Artery Disease Chronic Respiratory Diseases

16 SUDDEN incidence by gender OHSUD/100, OHSUD incidence/100, Males 100 Females $68,700 $45,300 $69,000 $106,300 Overall Income Tertile 1 Tertile 2 Tertile 3 SUDDEN Medication use 40 % Pts 20 0

17 SUDDEN Medication use by diagnosis % Pts 50 CAD DM HTN 25 0 SUDDEN Health care utilization (HCU) 270/408 victims had health records 50/270 had no HCU in 2 yrs before death HCU increased in the 6 months before death Number of HCU encounters PCP 595 Total Days prior to death

18 SUDDEN mental health disorder and substance use % OHSUD Victims US Population 25 0 SUDDEN Case Ascertainment Statewide Electronic Death Certificate Screening Out of hospital, natural, non cancer deaths, years old Record Procurement EMS Records, Medical Records, Medical Examiner Reports, Physical Death Certificate Data Final Screening Exclude expected deaths, hospice patients and drug overdoses Chart Abstraction Co morbidities, meds, healthcare utilization, others

19 SUDDENRA Project: This project is the collaboration research of Sudden Unexpected Death (SUD) with University of North Carolina, USA. Primary Investigator: Assist. Prof. Smith Srisont, MD., LLB, MSc Co-Investigator: Prof. Ross J. Simpson, Jr., MD., PhD. Team members: Pattara Rattanawong, MD. Prapaipan Putthapiban, MD. Weera Sukhumthammarat, DDS., MD. Wasawat Vutthikraivit, MD. Running Project: Incidence and causes of Sudden Unexpected Death (SUD) in Bangkok, Thailand compared to Wake County, NC, US Abstract Submission: AHA 2017 Conference Causes of Death PRIMARY CAUSE OF DEATH BANGKOK WAKE COUNTY Atherosclerotic vascular disease I. Coronary artery related - MI, rupture MI - Coronary atherosclerosis II. Non-coronary artery related - Aortic dissection / aneurysm - Hemorrhagic stroke -Ischemic stroke Heart diseases - Hypertrophic cardiomyopathy - Restrictive cardiomyopathy - Dilated cardiomyopathy - Myocardial bridging Lung diseases - Asthma / COPD -OSA - Pulmonary embolism Chronic kidney disease Infectious disease -AIDS - Pneumonia - Pulmonary TB - Peritonitis - Myocarditis - Pericarditis Others - Gastric / duodenal ulcer with UGIB - Pancreatitis - Fatty liver - Cirrhosis Autopsy negative Total cases = approximately 300 (1 dx per 1 case) Chronic Disease Infectious Disease Authopsy Negative GI Disease Others Percent

20 Intervention and Prevention Sudden Death Prevention Program Focus Unwitnessed death at home Obstacles Incidence data Location Clinical profile Prevention resources, intervention plan Many potential victims are socially and medicaly isolated

21 Sudden Death Prevention Task Force Model Members County Health Director EMS Physician Director SUDDEN Representative Hospital Case Manager County Medical Examiner County Commissioner Military Service Organization Community Health Worker Rep ED Nurse Manager Mental Health Practitioner Pharmacist Pilot Program Surry County NC Meeting 1 May 2016 Organization, structure and members defined Meeting 2 August 2016 Presentation of SUDDEN victim data Assessment of county resources Referral structure and patient engagement plan Meeting 3 February 2017 First engagement and intervention plan presentation (American Heart Association HEART360 Program)

22 Conclusions Sudden death is common and is under recognized Victims are socioeconomically deprived and have a high incidence of vascular disease and substance abuse Most victims are not candidates for resuscitation Treatment/prevention of common diseases has the potential to reduce incidence Community prevention projects can identify and intervene on potential victims

23 Facilitators and Collaborators Academic Partners International Affiliations The SUDDEN team