The Primary Prevention of Sudden Death in Patients with Coronary Artery Disease

About 300 000 people suffer sudden cardiac arrest in the United States each year [1]. In those who recover, the risk for recurrent cardiac arrest approaches 30% during the next 2 years when the initial arrest was not associated with acute myocardial infarction [2, 3]. This risk has increased interest in secondary prevention, that is, in preventing subsequent cardiac arrest. Unfortunately, only a few persons who have an out-of-hospital cardiac arrest survive to hospital discharge [3, 4]. Focused attempts at resuscitation by community-based emergency teams result in survival rates of 14% to 16% of cardiac arrests [3, 4]. Because of the continuing dismal prognosis, the effect of secondary prevention, no matter how effective, is limited. Attention is now focused on primary prevention (preventing an initial episode of cardiac arrest). For this maneuver to substantially reduce mortality, however, those persons in the population who are at high risk for cardiac arrest must be identifiable, and effective interventions to prevent cardiac arrest must be available.

In this issue of Annals, Myerburg and colleagues [5] address the problem of identifying those persons in the total population who are at increased risk for cardiac arrest. Because the 300 000 deaths that occur each year in the United States occur in a population of more than 250 million, the incidence of cardiac arrest in the total population is low. Applying any active intervention to the entire population is impractical; therefore, those groups at high risk must be identified. In the article by Myerburg and colleagues, Figure 1 illustrates the inverse relation between incidence of cardiac arrest in a subgroup and the percentage of the total population that the subgroup represents. Currently, research on primary prevention should involve groups that strike a reasonable compromise between having relatively high risk and representing a …