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Sudden Cardiac Death: Management of High-Risk Patients
- Masood Akhtar, MD;
- Hasan Garan, MD;
- Michael H. Lehmann, MD; and
- Paul J. Troup, MD
Abstract
Sudden cardiac death remains a leading cause of death in the United States, accounting for more than 350 000 deaths each year, and the survival rate of victims remains low. Most survivors face a significant risk for recurrence. The typical substrate is chronic—abnormal myocardium with fibrosis (often from previous myocardial infarction) and left ventricular dysfunction. Acute triggers for sudden cardiac death are primarily electrical, ischemic, metabolic, neurohormonal, and pharmacologic. In most electrocardiographically documented cases of sudden cardiac death, the trigger-substrate interaction appears to result in ventricular tachycardia and fibrillation. After initial resuscitation, survivors need a thorough cardiovascular evaluation, including definition of coronary anatomy, left ventricular function, and wall-motion abnormalities, as well as an electrophysiologic evaluation. An attempt must be made to determine what each survivor's correctable triggers are. Management should address all reversible triggers, such as acute ischemia and electrolyte abnormalities, and should include modifying or correcting the arrhythmogenic substrate. Empiric antiarrhythmic therapy offers no advantage in such modification. Pharmacologic therapy with antiarrhythmic drugs should be guided by an objective therapeutic endpoint, which is best accomplished through the use of programmed ventricular stimulation and serial electrophysiologic studies. Other therapeutic options include surgical suppression of ventricular tachycardia and implantation of a cardioverter defibrillator.
Article and Author Information
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From the Interdepartmental Dean's Conference arranged by the Department of Medicine, University of California, Davis, School of Medicine, Davis, California, and the Medical Service Department of Veterans Affairs Martinez Medical Center, Martinez, California, and held on 6 September 1989. Michael C. Geokas, MD, PhD, is permanent chairman and organizer of these conferences.
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Authors who wish to cite a section of the conference and specifically indicate its author can use this example for the form of reference:
Garan H. Contemporary evaluation of high-risk patients, pp. 502-504. In: Akhtar M. Sudden cardiac death: management of high-risk patients. Ann Intern Med. 1991;114: 499-512.
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Grant Support: In part by a grant-in-aid from Cardiac Pacemakers, Inc.
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Requests for Reprints: Michael C. Geokas, MD, PhD, Department of Veterans Affairs Martinez Medical Center (612/111), 150 Muir Road, Martinez, CA 94553.
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Current Author Addresses: Drs. Akhtar and Troup: Electrophysiology Laboratory, Sinai Samaritan Medical Center, Mount Sinai Campus, 950 North 12th Street, Milwaukee, WI 53233.
Dr. Garan: Cardiac Unit, Massachusetts General Hospital, Boston, MA 02114.
Dr. Lehmann: Division of Cardiology, Harper Hospital, 3990 John R, Detroit, MI 48201.
- © 1991 American College of Physicians
