Unexpected High Prevalence of Cardiovascular Disease Risk Factors and Psychiatric Disease Among Young People With Sudden Cardiac Arrest

Accuracy of etiological classification of out-of-hospital cardiac arrest: A scoping review

INTRODUCTION

The Utstein reporting template classifies the etiology of OHCA into "presumed cardiac" and "obvious non-cardiac" or "medical" and "non-medical" categories; however, the accuracy of these classifications is unclear. Ascertaining more accurately the etiology of OHCA is important to tailor advanced life support and identify etiologically consistent patient cohorts for reporting incidence and outcome and enrollment in clinical trials. This scoping review was proposed to identify the state of agreement on etiological classification based on emergency medical service (EMS) data using the Utstein format against other sources.

METHOD

We searched Medline, EBM-Cochrane, and Embase databases from 1946-2023 to identify studies that reported initial and confirmed etiologies of OHCA. A descriptive review of the included studies was conducted.

RESULT

The search yielded 22,994 citations. After excluding duplicates, 16,932 citations were reviewed for titles and abstracts. Twelve studies met the inclusion criteria of this review. The frequency of presumed cardiac etiologies based on EMS data was higher than confirmed cardiac etiologies (88% vs 33%) with 83-94% sensitivity and 73-76% specificity. In contrast, the frequency of presumed non-cardiac etiologies was lower than confirmed non-cardiac etiologies (3% vs 27%) with 52-74% sensitivity and 90-97.7% specificity estimated for respiratory disease.

CONCLUSION

Major disparities exist between current etiological classifications based on the Utstein reporting template and robust sources such as autopsy and medical records. Data linkage and validation are necessary to confirm the etiology of OHCA. Further research is needed on how this misclassification affects reported incidence and outcomes, and how contributing factors may improve etiological classifications.

Characteristics, survival and neurological outcome in out-of-hospital cardiac arrest in young adults in Sweden: A nationwide study

Aim

The aim of this study was to present a comprehensive overview of out-of-hospital cardiac arrests (OHCA) in young adults.

Methods

The data set analyzed included all cases of OHCA from 1990 to 2020 in the age-range 16-49 years in the Swedish Registry of Cardiopulmonary Resuscitation (SRCR). OHCA between 2010 and 2020 were analyzed in more detail. Clinical characteristics, survival, neurological outcomes, and long-time trends in survival were studied. Logistic regression was used to study 30-days survival, neurological outcomes and Utstein determinants of survival.

Results

Trends were assessed in 11,180 cases. The annual increase in 30-days survival during 1990-2020 was 5.9% with no decline in neurological function among survivors. Odds ratio (OR) for heart disease as the cause was 0.55 (95% CI 0.44 to 0.67) in 2017-2020 compared to 1990-1993. Corresponding ORs for overdoses and suicide attempts were 1.61 (95% CI 1.23-2.13) and 2.06 (95% CI 1.48-2.94), respectively. Exercise related OHCA was noted in roughly 5%. OR for bystander CPR in 2017-2020 vs 1990-1993 was 3.11 (95% CI 2.57 to 3.78); in 2020 88 % received bystander CPR. EMS response time increased from 6 to 10 minutes.

Conclusion

Survival has increased 6% annually, resulting in a three-fold increase over 30 years, with stable neurological outcome. EMS response time increased with 66% but the majority now receive bystander CPR. Cardiac arrest due to overdoses and suicide attempts are increasing.

Artificial Intelligence and Machine Learning Applications in Sudden Cardiac Arrest Prediction and Management: A Comprehensive Review

PURPOSE OF REVIEW

This literature review aims to provide a comprehensive overview of the recent advances in prediction models and the deployment of AI and ML in the prediction of cardiopulmonary resuscitation (CPR) success. The objectives are to understand the role of AI and ML in healthcare, specifically in medical diagnosis, statistics, and precision medicine, and to explore their applications in predicting and managing sudden cardiac arrest outcomes, especially in the context of prehospital emergency care.

RECENT FINDINGS

The role of AI and ML in healthcare is expanding, with applications evident in medical diagnosis, statistics, and precision medicine. Deep learning is gaining prominence in radiomics and population health for disease risk prediction. There's a significant focus on the integration of AI and ML in prehospital emergency care, particularly in using ML algorithms for predicting outcomes in COVID-19 patients and enhancing the recognition of out-of-hospital cardiac arrest (OHCA). Furthermore, the combination of AI with automated external defibrillators (AEDs) shows potential in better detecting shockable rhythms during cardiac arrest incidents. AI and ML hold immense promise in revolutionizing the prediction and management of sudden cardiac arrest, hinting at improved survival rates and more efficient healthcare interventions in the future. Sudden cardiac arrest (SCA) continues to be a major global cause of death, with survival rates remaining low despite advanced first responder systems. The ongoing challenge is the prediction and prevention of SCA. However, with the rise in the adoption of AI and ML tools in clinical electrophysiology in recent times, there is optimism about addressing these challenges more effectively.

Increasing Utilization of the Preparticipation Physical Evaluation

OBJECTIVE

The American Heart Association and American Academy of Pediatrics endorse the preparticipation physical evaluation (PPE) to screen student athletes for the risk of sudden cardiac arrest. We sought to identify barriers precluding its use and improve utilization.

METHODS

We analyzed documentation of PPE elements during well-care visits of patients aged 12 to 18 years from 5 primary care practices. Employing quality improvement (QI) methodology, we focused on improving PPE utilization in 1 practice by assessing the number of PPE elements addressed per chart. We expanded our QI project to 4 additional practices by using the same interventions but assessing the percentage of charts that had a complete PPE documented.

RESULTS

A baseline analysis of 5 targeted practices revealed an average of 3.5 of 14 PPE elements documented. Using plan-do-study-act cycles, PPE elements addressed increased from 2.5 to 14 over an 18-month period in the initial practice. By spreading successful interventions to 4 other practices, complete PPE utilization increased from a median baseline of 10.0% to a median of 70.0% over a 12-month period. Postintervention, 12 of 16 patients (75%) required additional follow-up with pediatric cardiology beyond the initial consultation, as compared with 2 of 14 patients (14%) preintervention.

CONCLUSION

The PPE is an underutilized but effective tool in screening student athletes for sudden cardiac arrest. QI methodology was helpful in increasing the use of PPE in the primary care setting.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A systematic review of global autopsy rates in all-cause mortality and young sudden death

Autopsy is the gold standard method for determining cause of death. Young sudden death (SD) is a prototype condition in which autopsy is universally recommended. The aim of this review was to quantify real-world global rates of autopsy in either all-cause death or young SD. A systematic review was conducted. Rates of autopsy in all-cause death and in young SD were determined in each country using scientific and commercial search engines. In total, 59 of 195 countries (30.3%) reported autopsy rates in all-cause death, with rates varying from 0.01%-83.9%. Almost all of these figures derived from academic publications rather than governmental statistics. Only 16 of 195 countries (8.2%) reported autopsy rates in the context of young SD, with reported rates ranging from 5%-100%. The definition of "young" was heterogeneous. No governmental statistics reported autopsy rates in young SD. Risks of bias included inability to verify reported figures, heterogeneity in reporting of clinical vs medicolegal autopsies, and the small number of studies identified overall, resulting in the consistent exclusion of low- and middle-income countries. In conclusion, most countries globally do not report autopsy rates in either all-cause death (69.7%) or in SD (92.8%). Without transparent reporting of autopsy rates, global burdens of disease and rates of sudden cardiac death cannot be reliably calculated.

Causes, circumstances, and potential preventability of cardiac arrest in the young: insights from a state-wide clinical and forensic registry

AIMS

The causes, circumstances, and preventability of young sudden cardiac arrest remain uncertain.

METHODS AND RESULTS

A prospective state-wide multi-source registry identified all out-of-hospital cardiac arrests (OHCAs) in 1-50 year olds in Victoria, Australia, from 2019 to 2021. Cases were adjudicated using hospital and forensic records, clinic assessments and interviews of survivors and family members. For confirmed cardiac causes of OHCA, circumstances and cardiac history were collected. National time-use data was used to contextualize circumstances. 1319 OHCAs were included. 725 (55.0%) cases had a cardiac aetiology of OHCA, with coronary disease (n = 314, 23.8%) the most common pathology. Drug toxicity (n = 226, 17.1%) was the most common non-cardiac cause of OHCA and the second-most common cause overall. OHCAs were most likely to occur in sleep (n = 233, 41.2%). However, when compared to the typical Australian day, OHCAs occurred disproportionately more commonly during exercise (9% of patients vs. 1.3% of typical day, P = 0.018) and less commonly while sedentary (39.6 vs. 54.6%, P = 0.047). 38.2% of patients had known standard modifiable cardiovascular risk factors. 77% of patients with a cardiac cause of OHCA had not reported cardiac symptoms nor been evaluated by a cardiologist prior to their OHCA.

CONCLUSION

Approximately half of OHCAs in the young have a cardiac cause, with coronary disease and drug toxicity dominant aetiologies. OHCAs disproportionately occur during exercise. Of patients with cardiac cause of OHCA, almost two-thirds have no standard modifiable cardiovascular risk factors, and more than three-quarters had no prior warning symptoms or interaction with a cardiologist.

Cardiac disease and prognosis associated with ventricular tachyarrhythmias in young adults and adults

Background

This study evaluates cardiac diseases and prognosis in young adults and adults presenting with ventricular tachyarrhythmias (VTA).

Methods

The present longitudinal, observational, registry-based, monocentric cohort study includes all consecutive patients 45 years old or younger presenting with VTA at admission from 2002 to 2016. Rates of coronary angiography, coronary artery disease (CAD) and need for percutaneous coronary intervention (PCI), cardiac diseases associated with VTA, and differences in long-term prognostic endpoints for young adults (20–34 years old) were analyzed and compared to those of adults (35–45 years old), for whom multivariable risk prediction models were developed. Kaplan–Meier analyses were performed according to age and type of VTA.

Results

A total of 259 consecutive patients were included in the study (36% young adults and 64% adults). At admission, 38% of young adults had VTA due to CAD that required PCI. Furthermore, VTA in young adults was commonly idiopathic (27%), or had underlying channelopathies (18%), primary cardiomyopathies (13%) or acute myocardial infarction (AMI, 11%). In adults, VTA was mostly associated with AMI (28%), though the rate of idiopathy was still high (20%). A total 41% of all patients received cardiopulmonary resuscitation (CPR), for whom AMI (STEMI 17%, NSTEMI 24%) was most frequently observed. Irrespective of the type of VTA, all-cause mortality was similar for young adults and adults. In young adults, left ventricular ejection fraction (LVEF) < 35% (HR = 33.590) was associated with increased long-term all-cause mortality.

Conclusion

Despite high rates of idiopathic ventricular tachyarrhythmias, CAD and AMI are common causes of VTA and CPR in adults 45 years old and younger. Young adults and adults had comparable survival at index hospitalization and after 2.5 years irrespective of the type of VTA.

Clinical trial registration clinicaltrials.gov identifier: NCT02982473.

Incidence, characteristics and outcomes of out-of-hospital cardiac arrests in patients with psychiatric illness: A systematic review

Aim

To conduct a systematic literature review of the existing evidence on incidence, characteristics and outcomes after out-of-hospital cardiac arrest (OHCA) in patients with psychiatric illness.

Methods

We searched Embase, Medline, PsycINFO and Web of Science using a comprehensive electronic search strategy to identify observational studies reporting on OHCA incidence, characteristics or outcomes by psychiatric illness status. One reviewer screened all titles and abstracts, and a second reviewer screened a random 10%. Two reviewers independently performed data extraction and quality assessment.

Results

Our search retrieved 11,380 studies, 10 of which met our inclusion criteria (8 retrospective cohort studies and two nested case-control studies). Three studies focused on depression, whilst seven included various psychiatric conditions. Among patients with an OHCA, those with psychiatric illness (compared to those without) were more likely to have: an arrest in a private location; an unwitnessed arrest; more comorbidities; less bystander cardiopulmonary resuscitation; and an initial non-shockable rhythm. Two studies reported on OHCA incidence proportion and two reported on survival, showing higher risk, but lower survival, in patients with psychiatric illness.

Conclusion

Psychiatric illness in relation to OHCA incidence and outcomes has rarely been studied and only a handful of studies have reported on OHCA characteristics, highlighting the need for further research in this area. The scant existing literature suggests that psychiatric illness may be associated with higher risks of OHCA, unfavourable characteristics and poorer survival. Future studies should further investigate these links and the role of potential contributory factors such as socioeconomic status and comorbidities.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A review of the causes and risk factors for sudden unexpected death in the young

Sudden unexpected death in the young (SUDY) is a tragic event resulting in the fatality of seemingly healthy individuals between the ages of one and 40 years. Whilst studies have been performed on sudden unexpected death in infants, children, and adults respectively, little is known about trends in risk factors and causes of death of SUDY cases. Understanding the factors surrounding these deaths could lead to targeted interventions for at-risk individuals. Hence, a systematic approach to investigate the reported possible causes of SUDY was employed using three major databases and Primo, wherein 67 relevant articles were identified and 2 additional guidelines were read. Sudden unexpected death in epilepsy and sudden cardiac events were well-established causes of death with risk factors such as male predominance, substance use and a familial history identified. It was acknowledged that while the cause of death is established following post-mortem examination in many cases, some remain non-specific or undetermined. Considering the genetic etiology, these cases would be ideal candidates for molecular autopsies in the future. Thus, this review emphasized the significance of acquiring the relevant information to aid in resolving cause of death of these SUDY cases and subsequently highlighted the potential for further studies on risk factors and the value of molecular autopsies.

Prediction of sudden cardiac arrest in the general population: Review of traditional and emerging risk factors

Sudden cardiac death (SCD) is the most common and devastating outcome of sudden cardiac arrest (SCA), defined as an abrupt and unexpected cessation of cardiovascular function leading to circulatory collapse. The incidence of SCD is relatively infrequent for individuals in the general population, in the range of 0.03-0.10% per year. Yet, the absolute number of cases around the world is high due to the sheer size of the population at risk, making SCA/SCD a major global health issue. Based on conservative estimates, there are at least 2 million cases of SCA occurring worldwide on a yearly basis. As such, identification of risk factors associated with SCA in the general population is an important objective from a clinical and public health standpoint. This review will provide an in-depth discussion of established and emerging factors predictive of SCA/SCD in the general population beyond coronary artery disease and impaired left ventricular ejection fraction. Contemporary studies evaluating the association between age, sex, race, socioeconomic status and the emerging contribution of diabetes and obesity to SCD risk beyond their role as atherosclerotic risk factors will be reviewed. In addition, the role of biomarkers, particularly electrocardiographic ones, on SCA/SCD risk prediction in the general population will be discussed. Finally, the use of machine learning as a tool to facilitate SCA/SCD risk prediction will be examined.

Human Immunodeficiency Virus Infection and Out-of-Hospital Cardiac Arrest

Patients with human immunodeficiency virus (HIV) infection are at increased risk of cardiovascular disease, but studies on HIV as a risk factor for cardiac arrest in the general population are lacking. We aimed to examine the association of HIV infection with out-of-hospital cardiac arrests (OHCAs). We used the Office of Statewide Health Planning and Development data to evaluate HIV infection as a predictor of OHCA in all California emergency department encounters from 2005 to 2015, adjusting for age, gender, race, income, obesity, smoking, alcohol, substance abuse, hypertension (HTN), diabetes, coronary artery disease, congestive heart failure (CHF), atrial fibrillation, and chronic kidney disease (CKD). We also determined patient characteristics modifying these associations by including interaction terms in multivariable-adjusted models. In 18,542,761 patients (mean age 47 ± 20 years, 53% women, 43,849 with HIV) followed for a median 6.8 years, 133,983 new OHCA events occurred. Incidence rates in patients with HIV were higher than in patients without HIV (1.99 vs 1.16 OHCA events per 1,000-person-years follow-up). After multivariable adjustment, HIV was associated with a 2.5-fold higher risk of OHCA (hazard ratio 2.47, 95% confidence interval 2.29 to 2.66, p <0.001). The risk of OHCA with HIV was disproportionately stronger in younger patients, women, and in those with HTN, CHF, and CKD. In this large prospective study, HIV was associated with a 2.5-fold increased risk of OHCA, with a greater vulnerability to this outcome in patients with HIV who were female or had HTN, CHF, or CKD.

2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families

This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Risk of out-of-hospital cardiac arrest in patients with bipolar disorder or schizophrenia

OBJECTIVE

Patients with bipolar disorder and schizophrenia are at high cardiovascular risk; yet, the risk of out-of-hospital cardiac arrest (OHCA) compared with the general population remains scarcely investigated.

METHODS

We conducted a nested case-control study using Cox regression to assess the association of bipolar disorder and schizophrenia with the HRs of OHCA of presumed cardiac cause (2001-2015). Reported are the HRs with 95% CIs overall and in subgroups defined by established cardiac disease, cardiovascular risk factors and psychotropic drugs.

RESULTS

We included 35 017 OHCA cases and 175 085 age-matched and sex-matched controls (median age 72 years and 66.9% male). Patients with bipolar disorder or schizophrenia had overall higher rates of OHCA compared with the general population: HR 2.74 (95% CI 2.41 to 3.13) and 4.49 (95% CI 4.00 to 5.10), respectively. The association persisted in patients with both cardiac disease and cardiovascular risk factors at baseline (bipolar disorder HR 2.14 (95% CI 1.72 to 2.66), schizophrenia 2.84 (95% CI 2.20 to 3.67)) and among patients without known risk factors (bipolar disorder HR 2.14 (95% CI 1.09 to 4.21), schizophrenia HR 5.16 (95% CI 3.17 to 8.39)). The results were confirmed in subanalyses only including OHCAs presenting with shockable rhythm or receiving an autopsy. Antipsychotics-but not antidepressants, lithium or antiepileptics (the last two only tested in bipolar disorder)-increased OHCA hazard compared with no use in both disorders.

CONCLUSIONS

Patients with bipolar disorder or schizophrenia have a higher rate of OHCA compared with the general population. Cardiac disease, cardiovascular risk factors and antipsychotics represent important underlying mechanisms.

2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families

This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.

Sudden cardiac death in children with congenital heart disease: a critical review of the literature

Sudden cardiac death is an uncommon but yet catastrophic event, which can occur in neonates and young children. Although extensive research has been carried out assessing the underlying causes, there still remains a degree of uncertainty around this area. Congenital heart disease (CHD) is one known cause of sudden cardiac death in children, the aetiology of which embraces virally induced mechanisms, genetic susceptibility, drug-induced, and maternal factors. Screening tools and investigations including electrocardiograms and echocardiograms alongside a concise history taking and physical examination can be used to identify the potential cardiovascular risk factors of sudden death. This review has comprehensively studied the causes and risk factors for sudden cardiac death in children with CHD and provides a collation and summary of the evidence available so far underpinning the complex link between the two. Moreover, current screening and prevention methods are discussed in detail in order to increase awareness and understanding of how we can improve patient outcomes.

Toward acellular xenogeneic heart valve prostheses: Histological and biomechanical characterization of decellularized and enzymatically deglycosylated porcine pulmonary heart valve matrices

The use of decellularized xenogeneic heart valves might offer a solution to overcome the issue of human valve shortage. The aim of this study was to revise decellularization protocols in combination with enzymatic deglycosylation, in order to reduce the immunogenicity of porcine pulmonary heart valves, in means of cells, carbohydrates, and, primarily, Galα1-3Gal (α-Gal) epitope removal. In particular, the valves were decellularized with sodium dodecylsulfate/sodium deoxycholate (SDS/SD), Triton X-100 + SDS (Tx + SDS), or Trypsin + Triton X-100 (Tryp + Tx) followed by enzymatic digestion with PNGaseF, Endoglycosidase H, or O-glycosidase combined with Neuraminidase. Results showed that decellularization alone reduced carbohydrate structures only to a limited extent, and it did not result in an α-Gal free scaffold. Nevertheless, decellularization with Tryp + Tx represented the most effective decellularization protocol in means of carbohydrates reduction. Overall, carbohydrates and α-Gal removal could strongly be improved by applying PNGaseF, in particular in combination with Tryp + Tx treatment, contrary to Endoglycosidase H and O-glycosidase treatments. Furthermore, decellularization with PNGaseF did not affect biomechanical stability, in comparison with decellularization alone, as shown by burst pressure and uniaxial tensile tests. In conclusion, valves decellularized with Tryp + Tx and PNGaseF resulted in prostheses with potentially reduced immunogenicity and maintained mechanical stability.

Association of prescription opioids and incident cardiovascular risk factors among post-9/11 Veterans

Reports indicate that long-term opioid therapy is associated with cardiovascular disease (CVD). Using VA electronic health record data, we measured the impact of opioid use on the incidence of modifiable CVD risk factors. We included Veterans whose encounter was between October 2001 to November 2014. We identified Veterans without CVD risk factors during our baseline period, defined as the date of first primary care visit plus 365 days. The main exposure was opioid prescriptions (yes/no, long-term (i.e. ≥90 days) vs no opioid, and long-term vs short-term (i.e. <90 days)), which was time-updated yearly from the end of the baseline period to February 2015. The main outcome measures were incident CVD risk factors (hypertension, dyslipidemia, diabetes, obesity, and current smoking). After excluding prevalent CVD risk factors, we identified 308,015 Veterans. During the first year of observation, 12,725 (4.1%) Veterans were prescribed opioids, including 2028 (0.6%) with long-term exposure. Compared to patients without opioid use, Veterans with opioid use were more likely to have CVD risk factors. Those with long-term exposure were at higher risk of having hypertension (adjusted average hazards ratio [HR] 1.45, 99% confidence interval [CI] 1.33-1.59), dyslipidemia (HR 1.45, 99% CI 1.35-156), diabetes (HR 1.30, 99% CI 1.07-1.57), current smoking status (HR 1.34, 99% CI 1.24-1.46), and obesity (HR 1.22, 99% CI 1.12-1.32). Compared to short-term exposure, long-term had higher risk of current smoking status (HR 1.12, 99% CI 1.01-1.24). These findings suggest potential benefit to screening and surveillance of CVD risk factors for patients prescribed opioids, especially long-term opioid therapy.

Developing a Pan-Canadian Registry of Sudden Cardiac Arrest: Challenges and Opportunities

Sudden cardiac arrest (SCA) has a devastating impact on both the family of the patient with SCA and his or her community. Because of various methodological differences between studies, reported incidence rates for SCA can vary widely, emphasizing the lack of clarity with respect to the true scope of this phenomenon. In recognition of the importance of accurately ascertaining the incidence and causes of SCA, there have been repeated calls for the development of national, prospective, population-based registries that use uniform definitions and multiple source methods to confirm cases. In this article, we discuss the challenges and opportunities in establishing a pan-Canadian registry and how its development will provide data on the current knowledge and treatment gaps to ultimately help reduce the burden of SCA in Canada.

Unexpected High Prevalence of Cardiovascular Disease Risk Factors and Psychiatric Disease Among Young People With Sudden Cardiac Arrest

Background

It is believed that most sudden cardiac arrests (SCAs) in young people occur in previously healthy people with rare risk factors for sudden death. Few studies have investigated large populations with complete ascertainment. Our objective was to use multisource records to identify and classify all out‐of‐hospital cardiac arrests in the Greater Toronto Area (population 6.6 million) in people aged 2 to 45 years from 2009 to 2012.

Methods and Results

Expert reviewers employed a systematic process, with emergency medical services, in‐hospital and coroner records, to adjudicate the cause of death as SCA from cardiac or noncardiac causes. We report the adjudicated etiologies, circumstances, triggers, and characteristics of the SCA cohort. Of 2937 eligible out‐of‐hospital cardiac arrest cases, 608 (20.7%) SCAs had an adjudicated etiology of cardiac cause (120 survivors and 488 nonsurvivors). Two thirds of these SCA patients had a history of cardiovascular disease, and over 50% had been diagnosed with ≥1 cardiovascular disease risk factor. Moreover, 20.1% of SCAs were diagnosed with psychiatric disease and 30% had central nervous system drugs prescribed. Over 30% of SCA patients had central nervous system active drugs, including drugs of abuse detected postmortem, with opioids and ethanol being detected most frequently. Potentially heritable structural cardiac diseases accounted for only 6.9% of SCA events, with acquired cardiac diseases comprising the rest.

Conclusions

The underlying causes of SCA, in people aged 2 to 45 years, often occur in those with previously diagnosed cardiovascular diseases, and are associated with contributory factors including prescribed medications, recreational drugs, and a concomitant psychiatric history.

See Editorial by Atkins

The central role of CT coronary angiography in postcardiac arrest care in the young adult

A 32-year-old man with no medical history went into ventricular fibrillation while running at the gym. He was transferred to our tertiary centre post successful resuscitation where admission electrocardiography and echocardiography were unremarkable. The initial cause of cardiac arrest was suspected arrhythmogenic and he was admitted for further investigations including exercise testing, ajmaline challenge, CT coronary angiography (CTCA) and cardiovascular MRI, with the likely outcome of cardioverter-defibrillator implantation. CTCA, however, revealed significant stenosis in the proximal left anterior descending artery as the likely cause for his arrest. Invasive coronary angiography confirmed this and facilitated successful stent implantation, avoiding the need for implantable cardioverter-defibrillator implantation. This case highlights the importance of CTCA, a non-invasive and readily-available test in the investigation of young patients postcardiac arrest, who require active exclusion of coronary artery disease and anomalous coronary anatomy, though they represent a low-risk population group.

Sudden Cardiac Arrest in a Young Population: Not So Unpredictable

See Article by Allan et al