Dr. Hein Jj Wellens
Thanks to our efforts, death from heart disease has continued to diminish for the last two decades. Still, half of those deaths are sudden, often occurring unexpectedly outside hospital. This problem continues to haunt us, claiming at least 250.000 lives in Europe each year. What can we do to prevent this from happening and when it occurs how can we successfully resuscitate the victim?
As stressed by Dr Xavier Jouven from Paris, while the incidence of cardiac death is decreasing, less of a change is seen in the number of sudden deaths. Identification of the sudden death candidate remains difficult, only a small percentage ( 10-15%) of the sudden death group falling in the high risk category. Primary prevention by ICD implant reduces the number of victims but our current selection criteria should be criticized and adapted because of the low number of patients requiring shocks, high costs and side effects such as infection, inappropriate shocks and mechanical device problems.
Dr Peter Schwartz from Pavia presented the role of the autonomic system in dying suddenly. Both animal studies and investigations in humans, as in the Atrami study, show that measuring baroreflex sensitivity (a marker of reflex vagal activity) is of value in risk stratification. The same holds for other tests such as the heart rate behaviour during exercise and mental stress. He believes that devices able to stimulate the vagus nerve could be useful in preventing ventricular fibrillation.
The role of genetic testing was discussed by Dr Stefan Kaab from Munich. He indicated that in long QT, Cathecholaminergic polimorphic VT, Arrhythmogenic right ventricular dysplasia and Hypertrophic cardiomyopathy, the clinical diagnosis can be substantiated with a molecular diagnosis. Also family members can be identified who carry the mutation with possible impact on lifestyle changes, monitoring and therapy. Of interest is the recent HRS/EHRA expert consensus statement ( published in EUROPACE and Heart Rhythm) in which the current state of genetic testing for identifying those at high risk for life threatening arrhythmias in the different channelopathies and cardiomyopathies is reviewed.
When an arrhythmic sudden death occurs outside hospital, the only chance for survival is recognition of the situation by a witness, the start of cardiac massage and a call to bring a defibrillator and experienced people to the scene as soon as possible. Increasing the number of people trained in resuscitation and also the density of the automatic external defibrillator ( AED) in the community are essential factors for success.
Dr Hans-Jochem Trappe from Herne, Germany discussed how this is attempted in different European countries. He raised the important question of where, in relation to efficacy and cost, those defibrillators should be placed. He mentioned that even in public places where a lot of people pass during the 24 hours, use of the AED might be surprisingly small. As an example he mentioned a survey in the Frankfurt airport where in a period of 8 years with 400 million people visiting the airport the AED was used only 21 times. So where to place the AED’s is still an open question. Currently, financing of the devices and their maintenance mostly come from private sources.
It is obvious that we as cardiologists still have a lot of work to do before we obtain a real reduction in sudden death, both as far as prevention and management is concerned.
Preventing sudden death
Our mission: To reduce the burden of cardiovascular disease
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