Cardiac Arrest

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Contents 1 More Specific Terms 2 Etiology 3 Epidemiology 4 Pathology 5 Clinical-manifestations 6 Laboratory 7 Diagnostic-procedures 8 Complications 9 Differential-diagnosis 10 Management 11 More General Terms 12 Additional Terms 13 References

More Specific Terms

• sudden death in competitive sports

Etiology

• ventricular fibrillation, primary or secondary to disorders below
• coronary artery disease ( CAD)

• most common cause of cardiac arrest
• cardiac arrest is the initial manifestation in 20-25% of patients with CAD
• chronic ischemia with or without underlying myocardial scarring
• myocardial infarction:

• 20% of out-of- hospital cardiac arrests are associated with myocardial infarction ( MI)
• attribute cardiac arrest to MI only if large, trans- mural or Q-wave infarction

• within 48 hours of acute Q-wave MI

• left ventricular hypertrophy
• obstructive hypertrophic cardiomyopathy
• congestive heart failure
• prolonged QT interval

• congenital ( long QT syndrome)
• drug-induced

• antiarrhythmics
• psychotropics

• Wolf-Parkinson-White syndrome
• Brugada syndrome
• commotio cordis
• toxic, metabolic or electrolyte disturbances

• alcohol
• illicit drugs

• proarrhythmic agents

• ecainide
• flecainide

• pulmonary embolism
• vigorous exercise heightens risk of cardiac arrest [2,5] (see sudden death in competitive sports)

Epidemiology

• 300,000/year in the US
• 1/3 of survivors die within 1 year

Pathology

• cardiac ischemia
• reperfusion injury
• heart failure
• metabolic abnormalities
• cardiogenic shock

Clinical-manifestations

• prodomal symptoms may occur months prior to cardiac arrest

• chest pain
• palpitations
• dyspnea
• fatigue
• lightheadedness

• signs of cardiac arrest

• unresponsiveness
• no pulse
• apnea or agonal respirations
• pallor or cyanosis

Laboratory

• arterial blood gas ( ABG)

• hypoxia
• acidosis

• electrolytes

• hypokalemia or hyperkalemia
• hypomagnesemia

• drug levels

Diagnostic-procedures

• electrocardiogram

• ventricular tachycardia ( VT) or ventricular fibrillation ( VF)
• pulseless electrical activity ( PEA)
• asystole

• echocardiogram

• structural heart disease
• LV dysfunction
• cardiomyopathy

• electrophysiology study

• indications

• survivors of sudden cardiac death
• suspected ventricular arrhythmias
• syncope
• structural heart disease

• see management (follow-up)

Complications

• neurologic impairment in survivors of cardiac arrest generally does not affect ability to live independently [8]

Differential-diagnosis

• aspiration of a foreign body 'cafe coronary'
• vasovagal syncope
• seizure

Management

• basic life support
• advanced cardiac life support
• mild induced hypothermia may improves outcomes [2,6]

• 32.0-34.0 C (89.6-93.2 F) for at least 12 hours in patients who remain unconcious after out-of- hospital cardiac arrest from ventricular arrhythmia
• may improve neurologic outcomes, survival

• follow-up

• stabilization of cardiac rhythm & hemodynamics
• diagnose & treat underlying etiology
• within 48 hours of acute Q-wave MI

• prognosis is good
• standard post- MI management

• cardiac arrest not associated with acute MI

• coronary angiography
• echocardiography

• electrophysiologic testing

• inducible VT or VF

• antiarrhythmics if suppress VT/ VF
• automatic implantable cardioverter defibrillator ( AICD)*
• empiric amiodarone

• 600 mg TID for 9 days, then
• 400 mg QD

• sotalol 160 mg BID

• non-inducible VT or VF

• AICD if left ventricular dysfunction ( LVEF < 40%)
• patient may only need treatment of reversible causes of cardiac arrest

• electrophysiologic testing generally not required for reversible causes of cardiac arrest

• 50% recurrence of ventricular tachycardia within 2 years
• indications for AICD*

• hemodynamically significant, inducible, sustained VT/ VF
• MI with LVEF < 40% & inducible VT/ VF
• non- sustained VT, cardiomyopathy, LVEF 35%
• high-risk hypertrophic cardiomyopathy

• prevention [7]

• do not smoke
• maintain BMI > 25 kg/m2
• exercise at least 30 minutes/day
• adhere to Mediterranean diet

• * treatment of choice

More General Terms

• heart disease; cardiac disease

Additional Terms

• advanced cardiac life support (ACLS)
• basic life support (BLS)

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 235-37
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
3. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 223
4. Journal Watch 20(24):192, 2000 Albert CM et al, Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med 343:1355, 2000 PMID: [1]
5. Journal Watch 25(3):23, 2005 Eckart RE, Scoville SL, Campbell CL, Shry EA, Stajduhar KC, Potter RN, Pearse LA, Virmani R. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004 Dec 7;141(11):829-34. Summary for patients in: Ann Intern Med. 2004 Dec 7;141(11):I26. PMID: [2]
6. Cheung KW et al, Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post-cardiac arrest patients. Can J Emerg Med 2006, 8:329
7. Chiuve SE et al. Adherence to a low-risk, healthy lifestyle and risk of sudden cardiac death among women. JAMA 2011 Jul 6; 306:62. PMID: [3]
8. Mateen FJ et al. Long-term cognitive outcomes following out-of-hospital cardiac arrest: A population-based study. Neurology 2011 Oct 11; 77:1438. PMID: [4]
9. National Guideline Clearinghouse Task Force on Sudden Cardiac Death of the European Society of Cardiology. ngc-guideline: [5]

cardiac arrest (sudden death)