Practice Update: Cardiology

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EMCN121601
PracticeUpdate Cardiology Editor-in-Chief,
Douglas Zipes MD, and Associate Editor,
Joerg Herrmann MD, discuss their top stories in
cardiology for 2016.
Predictionmodel for SCA
By Douglas Zipes MD
Dr Zipes is Distinguished
Professor, Professor
Emeritus of Medicine,
Pharmacology and
Toxicology, and Emeritus
Director of the Division of
Cardiology and Krannert
Institute of Cardiology at
Indiana University School
of Medicine.
Clinical cardiac electrophysiology has come a long way since
the early days of “His bundle studies.” With accurate mapping
and catheter ablation, we’ve been able to eliminate morbidity
and mortality associated with many arrhythmias. Maturation of
pacemakers and implantable cardiac defibrillators (ICDs) has
benefited countless patients. The arrhythmic challenges that remain
include atrial fibrillation (AF) and sudden cardiac arrest (SCA).
Ablation has helped many patients with AF, while ICDs have saved
the lives of many thousands of patients resuscitated from SCA.
Despite these advances, both arrhythmias continue to exert a major
impact on the general population.
An ejection fraction (EF) ≤35% helps identify those at risk for SCA.
However, SCA remains a major clinical problem because a reduced
EF is a better predictor of total mortality than of arrhythmic mortality.
In fact, most SCAs occur in the general population among individuals
with no past history of cardiac disease in whom the EF is not reduced.
The SCA event is often the first manifestation of the presence of
underlying heart disease. Therefore, predicting those at risk for SCA in
the general population has been a major challenge. Yet, they represent
the vast majority of the annual 350,000 sudden cardiac death (SCD)
population in the US.
That is why I have picked “Development and validation of a sudden
cardiac death prediction model for the general population” by Deo
et al (Circulation 2016;134:806–816) as a top story for 2016.
In this article, the authors analysed the records of 13,677 individuals
in the Atherosclerosis Risk in Communities study (ARIC) and 4207
participants in the Cardiovascular Health Study (CHS) free of
cardiovascular disease at baseline to derive a prediction model of
SCD for the general population. There were 345 adjudicated SCD
events in the analysis, which found 12 independent risk factors
for SCD, including age, male sex, African American race, current
smoking, systolic blood pressure, use of antihypertensive medication,
diabetes, serum potassium, serum albumin, HDL, estimated GFR,
and QTc interval. Strikingly, a reduced EF was found in only 1% of
participants in an echocardiographic substudy and did not enhance
risk prediction. This risk model outperformed the 2013 ACC/AHA
CVD Pooled Cohort risk equations.
These findings provide the first generalisable risk score to help
identify people in the general population at risk for SCD. In the
future, this risk score might be used to identify those in the highest-
risk subgroups of the general population, who had a 5% risk of SCD
over 10 years, so that therapy can be focused on this group to help
prevent SCD.
Clinicians need to follow future information from this study, which,
hopefully, will translate into reducing SCD risk for their patients.
2016 Top stories in Cardiology
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