Sudden Cardiac Death. An Essay for 2008

Prologue

Sudden cardiac death (SCD) has been an acquaintance, but not quite a friend, for nearly my entire professional life. Early in my career, in 1980, with my colleague and chief, Dr. Edward M. Dwyer, Jr., I planned a conference on Sudden Coronary Death sponsored by the New York Academy of Sciences. The conference was held in 1981 and published in 1982.¹ Now, 25 years later, if not at the end, certainly late in my career, I am again participating in the planning of a symposium on Sudden Cardiac

The Stage

From a clinician's vantage point, sudden cardiac death can be trifurcated into distinct categories each of which requires unique insights into management and prevention.

The first category is that of the desperately sick heart. Initially the focus was limited to the coronary patient, defining high risk as prior aborted sudden death or easily induced malignant arrhythmia, but ultimately patients with an EF <30% due to myocardial infarction dominated the systematic enrollment into clinical trials.⁴

The Current Players

The bottom three steps of Myerburg's ziggurat embrace patients easiest to identify as SCD candidates, those with very sick hearts. Step 6, patients with an EF <30% and a prior myocardial infarction, are MADIT II patients⁴; step 4 patients, those with congestive heart failure and an EF <35%, are the population for SCD-Heft⁵ and for those patients with a prolonged QRS duration, the currently enrolling MADIT CRT.¹⁶ Patients in Step 5, those with prior out-of-hospital aborted sudden death or some

The Next Act

In the 1980's categories of risk were beginning to be defined and mechanisms were tentatively proposed. The search for mechanisms of SCD genesis and mechanisms of intervention was the dominant theme of the 1981 conference. Much of the focus was on electrical instability, but coronary spasm, platelet function, and autonomic nervous system dysfunction were all considered fruitful areas of inquiry. The intervention spotlight focused on drugs, although the ICD had begun to creep on to the stage.