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