Sudden Cardiac Arrest: The Diversities and the Similarities

1. Sudden Cardiac Arrest: The Diversities
and the Similarities
Bobby V. Khan, M.D., Ph.D.
Sudden Cardiac Arrest Foundation
Director, Atlanta Vascular Research Foundation
Saint Joseph’s Translational Research Institute
Atlanta, Georgia
December 8, 2010
Financial Disclosures: None

2. Sudden Cardiac Death (to
paraphrase George Orwell…)
Everyone is at risk but some people are at more
risk than others
Cardiovascular disease is the leading cause of
death for men and women in all racial and
ethnic groups

3. Magnitude of SCA in the U.S.
167,366
Stroke3
SCA claims more
lives each year 450,000
SCA4
than these other
Lung Cancer2 diseases combined
157,400
Breast Cancer2 40,600
AIDS1 42,156
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.

4. The U.S. Population is Becoming
Increasingly Diverse
Changing Trends 120
Hispanics are the fastest- 100
growing segment of the
population, and now account 80
for 13% U.S., as do African
60
Americans.
40
The U.S. Asian population
currently consists of 10.6
20
million people, and represents
4% U.S.,; however, this
0
population group is expected
2000 2010 2020 2030 2040 2050
to triple in size by 2050.
White African American Hispanic (any race) Asian
Adapted from U.S. Census Bureau, 2004. Table 1a. Accessed Dec. 1, 2006.

5. SCD Rates for Males and Females
Per 100,000 Standard US Population
600 White
Black
502.7 American Indian/Alaska Native
500
Asian/Pacific Islander
407.1
400
336.1
300 258.8 270.5
212.6
200
130.0
100
153.4
0
Males Females
Zheng Z. Circulation. 2006;104(18):2158-2163.

6. Age-Adjusted Prevalence of Diabetes*
by Race/Ethnicity in the US
American Ind ians/
19%
Ala ska Natives
Non -Hispanic Blacks 15%
Hispanic/L atino
14%
Am ericans
Non-Hispan ic Whites 7%
0 5 10 15 20 25
*In people 20+ years old Percent
Sources: 1997-1999 National Health Interview Survey and 1988-1994 National Health and Nutrition
Examination Survey (NHANES) estimates projected to year 2000. 1998 outpatient database of the Indian
Health Service CDC. National Diabetes Fact Sheet. 2002.

7. The “Problem”

8. SCA and Coronary Heart Disease
Coronary heart disease and its consequences
account for the majority of sudden cardiac deaths in
Western cultures.
5% Other*
15%
80%
Nonischemic Coronary Heart
Cardiomyopathy
Disease
Huikuri HV. N Engl J Med. 2001;345:1473-1482. *ion-channel
Myerburg RJ. Heart Disease, A Textbook of Cardiovascular abnormalities, valvular
Medicine. 6th ed. W.B. Saunders, Co. 2001. or congenital heart
disease, other causes

9. Incidence of SCD in Specific Populations
and Annual SCD Numbers
GROUP
General population
Patients with high
coronary-risk
profile
Patients with previous
coronary event
Patients with ejection
fraction < 35%,
congestive heart failure
Patients with previous
out-of-hospital cardiac
arrest
Patients with previous
myocardial infarction,
low ejection fraction,
and
ventricular tachycardia0 5 10 15 20 25 30 0 100,000 200,000 300,000
Incidence of Sudden Death No. of Sudden Deaths
(% of group) Per Year
Myerburg RJ. Circulation.1998;97:1514-1521.

10. Models to Explain Health Disparities
▶Racial Genetic Model
Cause of HD: Population differences in the distribution
of genetic variants
▶Health-behavior Model
Cause of HD: Differences between R/E groups in the
distribution of individual behaviors related to health
such as diet, exercise, and tobacco use
▶SES Model
Cause of HD: Over-representation of some R/E groups
within lower SES
▶Psychosocial Stress Model
Cause of HD: Stresses associated with minority group
status, especially the experience of racism and
discrimination

11. Critical Relationships
Lifestyle
(Social/
Economic)
Disease
Ancestry
(Genetic)

12. SCD in Heart Failure
Despite improvements in medical
therapy, symptomatic HF still confers a
20-25% risk of premature death in the
first 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.

13. Heart Failure & Sudden Cardiac Death
Age-adjusted Annual Rate/1000
160 No HF Overall
140 HF History Mortality
120
100 Sudden
80 Death
60
40
20
0
Women Men Women Men
Heart Failure predicts increased sudden death and overall mortality during a 38-
year
follow-up of subjects in the Framingham Heart Study.
Domanski MJ. J Am Coll Cardiol. 1999;34:1090-1095.

14. An example to follow?
The South Carolina Department of
Health and Environmental Control-
the Heart Disease and Stroke
Prevention (HDSP) Program
One of 13 states funded at the implementation level
1. Increase control of cardiovascular risk factors
(mostly HTN)--primarily in adults & older adults
2. Increase knowledge of signs & symptoms for heart
attack and stroke and the importance of calling 9-1-1
3. Improve emergency response
4. Improve quality of heart disease and stroke care
5. Eliminate health disparities in term of race, ethnicity,
gender, geography, & socio-economic status

15. Cardiovascular Disease Risk Factors
100%
83.0%
90%
80%
70% 61.3%
54.0%
60%
50% 33.4%
40%
28.8% 24.3%
30%
20%
10%
0%
Co-Morbid Hypertension Sedentary High Obesity Current Smoker
Lifestyle Cholesterol
Source: SC Behavioral Risk Factor Surveillance System
2006

16. DHEC Strategic Plan and the Heart Disease and
Stroke Prevention Division
Primary Goal and Objectives Addressed:
Eliminate health disparities
Reduce disparities in illness, disability and premature
deaths from chronic diseases
Increase the number of minorities at risk for heart attacks and
stroke who are receiving education interventions
Develop and implement community and faith-based initiatives
to address health disparities

17. Collaboration
Partnering is key to our state efforts
Public Health Regions
American Heart/ Tri-State Stroke Network
Stroke Assn.
Primary Care Providers
Hospitals
Academia
Hospitals
Emergency
Primary Medical
Healthcare Faith Based Services
Assn. Community Based Organizations
Organizations

18. Community / Organizational
policies, 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)

19. Stroke Death Rates, 1979-2004
120
South Carolina United States
Age-Adjusted Death Rate
100
80
64.8
64.7
60
40
20
0
'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
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.

20. Summary
• 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 will
come a long way in reducing the disparities and the
overall disease burden.