eccu survivor workshop: khan
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Sudden Cardiac Arrest: The Diversitiesand the Similarities
Bobby V. Khan, M.D., Ph.D.Sudden Cardiac Arrest Foundation
Director, Atlanta Vascular Research FoundationSaint Joseph’s Translational Research Institute
Atlanta, GeorgiaDecember 8, 2010
Financial Disclosures: None
Sudden Cardiac Death (toSudden Cardiac Death (toparaphrase George Orwellparaphrase George Orwell……))
Everyone is at risk but some people are at morerisk than others
Cardiovascular disease is the leading cause ofdeath for men and women in all racial andethnic groups
Magnitude of SCA in the U.S.Magnitude of SCA in the U.S.
1 U.S. Census Bureau, Statistical Abstract of the United States: 2001.2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.3 2002 Heart and Stroke Statistical Update, American Heart Association.4 Zheng Z. Circulation. 2001;104:2158-2163.
AIDS1
Breast Cancer2
Lung Cancer2
Stroke3
SCA4SCA claims morelives each yearthan these otherdiseases combined
450,000
167,366
157,400
40,60042,156
0
20
40
60
80
100
120
2000 2010 2020 2030 2040 2050
White African American Hispanic (any race) Asian
Changing TrendsChanging Trends
Hispanics are the fastest-Hispanics are the fastest-growing segment of thegrowing segment of thepopulation, and now accountpopulation, and now accountfor 13% U.S., as do Africanfor 13% U.S., as do AfricanAmericans.Americans.
The U.S. Asian populationThe U.S. Asian populationcurrently consists of 10.6currently consists of 10.6million people, and representsmillion people, and represents4% U.S.,; however, this4% U.S.,; however, thispopulation group is expectedpopulation group is expectedto triple in size by 2050.to triple in size by 2050.
The U.S. Population is BecomingThe U.S. Population is BecomingIncreasingly DiverseIncreasingly Diverse
Adapted from U.S. Census Bureau, 2004. Table 1a. Accessed Dec. 1, 2006. Adapted from U.S. Census Bureau, 2004. Table 1a. Accessed Dec. 1, 2006.
SCD Rates for Males and FemalesSCD Rates for Males and Females
0
100
200
300
400
500
600
Males Females
WhiteBlackAmerican Indian/Alaska NativeAsian/Pacific Islander
407.1
502.7
270.5336.1
Per 1
00,0
00 S
tand
ard
US
Popu
latio
n
258.8212.6
153.4
130.0
Zheng Z. Circulation. 2006;104(18):2158-2163.
0 5 10 15 20 25
American Indians/American Indians/Alaska NativesAlaska Natives
Age-Adjusted Prevalence of Diabetes*Age-Adjusted Prevalence of Diabetes*by Race/Ethnicity in the USby Race/Ethnicity in the US
PercentPercent
Hispanic/LatinoHispanic/LatinoAmericansAmericans
Non-Hispanic BlacksNon-Hispanic Blacks
Non-Hispanic WhitesNon-Hispanic Whites
*In people 20+ years old*In people 20+ years old
CDC. National Diabetes Fact Sheet. 2002.CDC. National Diabetes Fact Sheet. 2002.
Sources: 1997-1999 National Health Interview Survey and 1988-1994 National Health and NutritionSources: 1997-1999 National Health Interview Survey and 1988-1994 National Health and NutritionExamination Survey (NHANES) estimates projected to year 2000. 1998 outpatient database of the IndianExamination Survey (NHANES) estimates projected to year 2000. 1998 outpatient database of the IndianHealth ServiceHealth Service
19%19%
15%15%
14%14%
7%7%
The The ““ProblemProblem””
SCA and Coronary Heart DiseaseSCA and Coronary Heart Disease Coronary heart disease and its consequencesaccount for the majority of sudden cardiac deaths in
Western cultures.
Huikuri HV. N Engl J Med. 2001;345:1473-1482.Myerburg RJ. Heart Disease, A Textbook of CardiovascularMedicine. 6th ed. W.B. Saunders, Co. 2001.
*ion-channelabnormalities, valvularor congenital heartdisease, other causes
80%Coronary Heart
Disease
15%Nonischemic
Cardiomyopathy
5% Other*
Incidence of SCD in Specific PopulationsIncidence of SCD in Specific Populationsand Annual SCD Numbersand Annual SCD Numbers
Myerburg RJ. Circulation.1998;97:1514-1521.
GROUP
300,000
Patients with highcoronary-riskprofilePatients with previouscoronary event
Patients with ejectionfraction < 35%,congestive heart failure
Patients with previousout-of-hospital cardiacarrest
Patients with previousmyocardial infarction,low ejection fraction,andventricular tachycardia
General population
200,000100,0000
No. of Sudden DeathsPer Year
30252015100
Incidence of Sudden Death(% of group)
5
Models to Explain Health DisparitiesModels to Explain Health Disparities▶Racial Genetic Model
Cause of HD: Population differences in the distributionof genetic variants
▶Health-behavior ModelCause of HD: Differences between R/E groups in thedistribution of individual behaviors related to healthsuch as diet, exercise, and tobacco use
▶SES ModelCause of HD: Over-representation of some R/E groupswithin lower SES
▶Psychosocial Stress ModelCause of HD: Stresses associated with minority groupstatus, especially the experience of racism anddiscrimination
LifestyleLifestyle(Social/(Social/Economic)Economic)
AncestryAncestry(Genetic)(Genetic)
Disease Disease
Critical Relationships
SCD in Heart FailureSCD in Heart Failure
Despite improvements in medicaltherapy, symptomatic HF still confers a20-25% risk of premature death in thefirst 2.5 years after diagnosis.1,2
≈ 50% of these premature deaths are SCD
1 Bardy G. The Sudden Cardiac Death-Heart Failure Trial (SCD-HeFT) in Woosley RL, Singh S,Arrhythmia Treatment and Therapy, Copyright 2000 by Marcel Dekker, Inc. 323-342.
2 Sweeney MO. PACE. 2001;24:871-888.
Heart Failure & Sudden Cardiac Death
Domanski MJ. J Am Coll Cardiol. 1999;34:1090-1095.
Heart Failure predicts increased sudden death and overall mortality during a 38-year
follow-up of subjects in the Framingham Heart Study.
0
2040
60
80100
120
140160 No HF
HF History
Age
-adj
uste
d A
nnua
l Rat
e/10
00
Women WomenMen Men
SuddenDeath
OverallMortality
An example to follow?An example to follow?The South Carolina Department ofThe South Carolina Department ofHealth and Environmental Control-Health and Environmental Control-
the Heart Disease and Strokethe Heart Disease and StrokePrevention (HDSP) ProgramPrevention (HDSP) Program
One of 13 states funded at the implementation level1. Increase control of cardiovascular risk factors
(mostly HTN)--primarily in adults & older adults2. Increase knowledge of signs & symptoms for heart
attack and stroke and the importance of calling 9-1-13. Improve emergency response4. Improve quality of heart disease and stroke care5. Eliminate health disparities in term of race, ethnicity,
gender, geography, & socio-economic status
24.3%28.8%33.4%
54.0%61.3%
83.0%
0%10%20%30%40%50%60%70%80%90%
100%
Co-Morbid Hypertension SedentaryLifestyle
HighCholesterol
Obesity Current Smoker
Cardiovascular Disease Risk Factors
Source: SC Behavioral Risk Factor Surveillance System2006
DHEC Strategic Plan and the Heart Disease andDHEC Strategic Plan and the Heart Disease andStroke Prevention DivisionStroke Prevention Division
Primary Goal and Objectives Addressed:
Eliminate health disparities
Reduce disparities in illness, disability and prematuredeaths from chronic diseases
Increase the number of minorities at risk for heart attacks andstroke who are receiving education interventions
Develop and implement community and faith-based initiativesto address health disparities
CollaborationCollaborationPartnering is key to our state efforts
American Heart/Stroke Assn.
Hospitals
Hospitals
PrimaryHealthcare
Assn.
EmergencyMedicalServices
Community BasedOrganizations
Faith BasedOrganizations
Public Health Regions
Primary Care Providers
Tri-State Stroke Network
Academia
Community / OrganizationalCommunity / Organizationalpolicies, practices, environmentspolicies, practices, environments
• Community Faith-Based “Search Your Heart” Initiative –Train-the-Trainer Workshops (Faith-based organizations &Public Health staff)
• Office of Minority Health Faith & Health Initiative• Power to End Stroke DHEC Ambassadors Campaign• Worksite Initiatives – policy & environmental supports,
HD&SP awareness and screening access• CDC Worksite Toolkit implementation (2006)
Stroke Death Rates, 1979-2004Stroke Death Rates, 1979-2004
0
20
40
60
80
100
120
'79 '80 '81 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04
Ag
e-A
dju
ste
d D
ea
th R
ate
South Carolina United States
1999-2002: ICD-10 codes I60-I69; 1979-1998: ICD-9 codes 430-434,436-438 multiplied by comparability ratio of 1.0588.Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population.Data Source: Compressed Mortality File, CDC Wonder.
64.7 64.8
• Prevention is the key!• Education and awareness play a significant role• An understanding of the high-risk population and the
vulnerabilities is essential. Clear identification willcome a long way in reducing the disparities and theoverall disease burden.
SummarySummary
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