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Heart Failure Burden by Autopsy, Guideline-Directed Medical Therapy, and ICD Utilization Among Sudden Deaths
Satvik Ramakrishna1, James W Salazar2, Jeffrey E Olgin2
1Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
JACC. Clinical Electrophysiology
|February 8, 2023
Summary
Nearly 20% of sudden cardiac deaths involve heart failure (HF). Most HF-related sudden deaths are arrhythmic, yet guideline-directed medical therapy (GDMT) and implantable cardioverter-defibrillator (ICD) use remain low, highlighting key prevention targets.
Area of Science:
- Cardiology
- Forensic Pathology
- Public Health
Background:
- Sudden cardiac death (SCD) is a significant concern in heart failure (HF), particularly in heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).
- However, the underlying causes of SCD in HF patients within the community, as well as the utilization of guideline-directed medical therapy (GDMT) and implantable cardioverter-defibrillators (ICDs), remain largely uncharacterized.
Purpose of the Study:
- To investigate the prevalence of HF in autopsied SCD cases.
- To determine the proportion of sudden arrhythmic deaths (SADs) in HF patients.
- To assess the use of GDMT and ICDs in HF patients who experienced SCD.
Main Methods:
- A countywide postmortem study (POST SCD) examined all presumed SCDs in San Francisco County from 2011-2014.
- Autopsies were performed on individuals aged 18-90 years with incident WHO-defined presumed SCDs.
- Sudden arrhythmic deaths (SADs) were defined as those without an identifiable nonarrhythmic cause, suggesting potential benefit from ICD therapy.
Main Results:
- Heart failure was present in 19% (100 of 525) of presumed SCDs, including 85 patients with known HF and 15 with subclinical HF.
- Sudden arrhythmic deaths (SADs) accounted for 69% of HF-related SCDs, with similar rates in HFrEF (74%) and HFpEF (61%).
- Only 4% of SAD patients had an ICD, and complete GDMT use in HFrEF was only 6%.
Conclusions:
- Heart failure is a significant contributor to community sudden cardiac deaths, with a majority of these being potentially preventable arrhythmic events.
- Current utilization of ICDs and GDMT in HF patients experiencing SCD is critically low, indicating substantial room for improvement in sudden death prevention strategies.
- There is a need to optimize the identification and treatment of HF patients at risk for SCD to reduce mortality from these events.
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