Survival Death Research Articles

Benefit and risks of long-term amiodarone therapy for sustained ventricular tachycardia/fibrillation: Minimum of three-year follow-up in 145 patients

Our experience with amiodarone therapy in 145 consecutively referred patients with medically refractory sustained ventricular tachycardia and/or fibrillation treated for at least 3 years was reviewed. Ninety-seven had sustained ventricular tachycardia; the remaining 48 patients were survivors of sudden cardiac death. The patients had a mean of 3.7 +/- 1.4 unsuccessful anti-arrhythmic drug trials before initiation of amiodarone. The initial doses of amiodarone averaged 845 +/- 258 mg for the first 2 weeks and 56% of all patients received a type I antiarrhythmic drug in addition to amiodarone during the initial phase of therapy. The average maintenance dose of amiodarone was 410 +/- 187 mg per day. All patients were followed for a minimum of 3 years or until death or withdrawal from therapy. The maximum follow-up was a period of 8 years. Thus, the average duration of amiodarone therapy was 39 +/- 26 months, representing 472 patient years of therapeutic time on amiodarone. The incidence of deaths either caused by a documented ventricular tachyarrhythmia or presumed to result from an arrhythmic cause was 5.5% in the first year and 3.4% in each of the second and third years of follow-up. During the entire period of follow-up, 56 patients died of all causes (38.6% of the study population). Survival over the follow-up period was influenced significantly by left ventricular function, as judged by either New York Heart Association Functional Class or objective assessment of left ventricular ejection fraction, which was available in 102 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial infarction and sudden death after sport: Acute coronary angiographic findings

Thirteen patients, seven with acute myocardial infarction and six survivors of sudden death after sport, underwent coronary angiography within a mean of 104 min after the onset of symptoms. The admission electrocardiogram showed transmural myocardial ischemia in all patients. The ischemia-related vessel was occluded in all cases of sudden death and in three cases of acute myocardial infarction. Reperfusion was achieved in eight vessels: after intracoronary streptokinase in three, after intracoronary nitroglycerin in three, and mechanically in two. Coronary spasm was demonstrated in three vessels, and coronary thrombi, in four. The coronary lesion was described as either concentric in two or eccentric with irregular borders in eight. There was a high incidence of eccentric lesions consistent with ruptured plaques. The acute coronary angiographic findings of acute myocardial infarction and sudden death after sport are similar. Physical exercise can provoke myocardial infarction and sudden death probably by inducing plaque rupture that can evoke coronary spasm, thrombosis, or both.

Development of the Grief Experience Questionnaire.

The development of the Grief Experience Questionnaire (GEQ) is reported. This questionnaire is an instrument for measuring various components of grief, including somatic reactions, general grief reactions, search for explanation, loss of social support, stigmatization, guilt, responsibility, shame, rejection, self-destructive behavior, and reactions to a unique form of death. Initial results with the GEQ suggest its potential to differentiate grief reactions experienced by suicide survivors from those experienced by survivors of accidental death, unexpected natural death, and expected natural death. Conclusions support its use in redressing common methodological criticisms of suicide survivor research. Six additional benefits derived from use of this instrument are discussed.

Early experience with the automatic implantable cardioverter defibrillator in sudden death survivors

Medical management of life-threatening ventricular arrhythmias is difficult because of the toxicity and limited efficacy of antiarrhythmic drugs. The automatic implantable cardioverter defibrillator (AICD) offers protection against malignant ventricular arrhythmias and allows some patients to be managed without antiarrhythmic drugs. We reviewed our experience with the AICD to determine its safety and efficacy. Since June 1987, 24 patients (mean age 63 years) who survived out-of-hospital ventricular fibrillation or hemodynamically unstable ventricular tachycardia not associated with acute myocardial infarction had implantation of an AICD. None had inducible monomorphic ventricular tachycardia associated with ventricular aneurysm. Twenty-three had abnormal left ventricular function (mean ejection fraction 0.32). There were no operative deaths and three complications. At last follow-up (mean 8.9 months) 23 patients were alive. Eight patients had one or more AICD discharges associated with symptomatic or monitored cardiac arrest. AICD implantation can be performed with low risk and appears to be an effective alternative to antiarrhythmic therapy with toxic drugs.

Long-segment coronary ulcerations in survivors of sudden cardiac death

Angiographically irregular coronary stenoses usually represent plaque rupture with or without superimposed thrombi. Long-segment coronary stenoses with diffuse irregularities (type IIB morphology) have been shown to be more prevalent than focal irregular lesions (type IIA morphology) in survivors of cardiac arrest without acute myocardial infarction. To further understand the pathogenetic importance of type IIB morphology, the clinical and angiographic characteristics in 59 such patients were analyzed. Type IIB lesions accounted for 63% of all type II lesions. Type IIB patients were older than type IIA patients ( p < 0.05). There was a tendency for type IIB morphology to be associated with more extensive disease than other types of lesion morphology ( p < 0.10). Type IIB morphology probably reflects more advanced atherosclerosis. Platelet microemboli may precipitate spasm and/or acute ischemic ventricular tachyarrhythmias. It is possible that long-segment coronary ulcerations are associated with a higher risk for local coronary thromboembolism, and hence with sudden death, than focal lesions.

Drug Therapy for Survivors of Sudden Cardiac Death

The proliferation of standard as well as novel community based systems for resuscitation of victims of out-of-hospital cardiac arrest has provided a large group of sudden cardiac death survivors who present a therapeutic challenge. The nature and severity of the underlying heart disease must be delineated. Particularly, myocardial ischemia and congestive heart failure must be controlled. Prior to considering device therapy of surgical intervention, pharmacologic therapy should be evaluated. Baseline electrophysiological studies determine the applicability of serial pharmacologic testing. In patients with inducible VT/VF, serial electrophysiological testing can identify drug regimens that prevent the arrhythmia in approximately 40% of patients. In an additional 20% of patients, regimens which slow the ventricular tachycardia and significantly reduce the arrhythmia related mortality can be identified. Three to 5-year follow-up has shown such an approach can reduce the sudden death mortality in these patients to less than 3% per year. It has been suggested that certain medication, most notably amiodarone, electrophysiological testing has not been useful in assessing efficacy. Several recent studies, however, have shown that electrophysiological testing is indeed useful even in evaluating the efficacy of amiodarone. In patients in whom ventricular tachycardia/ventricular fibrillation cannot be prevented or significantly slowed, medical therapy is generally ineffective and the sudden death mortality is 20% to 40% per year. In such patients, other therapeutic modalities should be considered.

Impending Sudden Cardiac Death: Treatment with Myocardial Revascularization and the Automatic Implantable Cardioverter Defibrillator

Myocardial revascularization and implantation of the automatic implantable cardioverter defibrillator (AICD) have individually been shown to improve survival in patients after sudden cardiac death. Their combined role has not been well defined. Twenty-three survivors of sudden death underwent revascularization and AICD implantation at an average age of 59 years. The initial arrest was caused by ventricular fibrillation in 15 and ventricular tachycardia in 8. Exercise stress tests, ambulatory ECGs, and electrophysiological monitoring with programmed electrical stimulation were done preoperatively and postoperatively. Follow-up averaged 24 months with a two-year survival of 91%. Eight patients (35%) required AICD resuscitation an average of 8 months postoperatively, and electrophysiological testing did not accurately predict arrhythmia recurrence. The addition of AICD implantation to revascularization substantially improves survival of patients with sudden cardiac death.

Family survivors of suicide and accidental death: consequences for widows.

The impact of completed suicide on the surviving family was studied. Thirteen widows whose husbands had died through suicide were compared with 13 widows whose husbands had died in accidents. The widows' views of their families' functioning, and the extent of life stress and psychiatric symptoms experienced by the widows, were assessed. Interview data suggested more guilt and blaming in suicide survivor families. However, on standardized questionnaires, suicide survivors showed no more family dysfunction, life stress, or psychiatric symptomatology than accident survivors. Both groups acknowledged clinically significant levels of symptoms. The findings raise questions about the validity of generalizations based on the clinical literature regarding the uniquely pathogenic impact of suicide on family functioning.

An examination of the early impact of bereavement on psychological distress in survivors of suicide.

The impact on mental health of survivors (n = 108) of suicides of older adult spouses (55 years of age and older) in the first 8 weeks of the bereavement process was compared with that of two control groups: older adult survivors of natural deaths (n = 99) and a married non-bereaved group (n = 144). On all measures both survivor groups scored significantly poorer than the non-bereaved controls. Only anxiety was reported significantly more often by suicide survivors than by natural death survivors.

When Disaster Strikes: How Individuals and Communities Cope With Catastrophe

There is a paradox about events of disastrous magnitude. While it is well known that calamities such as hurricanes, earthquakes, and raging fires can wreak immediate havoc, damaging life and property, it is less well recognized that mental trauma surfacing in some individuals after such incidents can have a long-lasting, pervasive effect. Disasters test individuals and communities far beyond their usual capabilities. Most often, rescuers rise to meet the need in valiant fashion, but the emotional aftermath in some individuals seems less heroic; these persons are left to battle it out alone and unnoticed. Minor everyday events can trigger reenactment of a brush with death in survivors, who may remain emotionally disabled long after the danger is past. Such morbidity is not usually calculated when statisticians tabulate the destructive effect of a disastrous event. Additionally, there may be unanticipated victims following a disaster. Behind the primary victims lies a whole

Emergency department experience with sudden death: A survey of survivors

Sudden death in the emergency department occurs frequently. Intervention by ED support staff may have a significant impact on the survivor's grief response. This study was undertaken to assess sudden death survivors' perceptions and satisfaction with their ED experience, as well as to identify potential weaknesses in their management. Family members of 66 patients who died in the ED from January 1980 to March 1985 were surveyed by telephone interview regarding the care they, as survivors, received while in the ED. Forty-seven of 66 (71%) were satisfied, 19 of 66 (29%) believed that their family received average or worse than average care. Thirty-seven of 66 (56%) survivors viewed the deceased in the ED; five regretted this. Twenty-nine survivors did not view; seven (24%) had regrets. Participants were questioned about attitudes expressed by the ED staff. Most responses were favorable, but a significant number thought the staff cold, unsympathetic, and not reassuring. Areas of apparent survivor dissatisfaction are discussed.

Generational differences in reactions to adolescent suicide

In order to assess generational differences in reactions to an adolescent suicide, college students (n = 56) and their parents (n = 112) were asked to respond to a fictitious report of an adolescent's either suicidal or non-suicidal death. Consistent with previous research, both generations said that (a) the suicidal youth was more psychologically disturbed than was the youth who died of a viral illness and (b) the youth's mother was more psychologically disturbed when he died of suicide than when he died of a viral illness. Also, both generations were more negative in reacting to suicidal death survivors than they were to viral illness death survivors. Some generational differences were obtained: Parents viewed the suicidal adolescent as more psychologically disturbed than did adolescents and yet, paradoxically, parents expected to experience less tension and to have less difficulty in expressing sympathy when visiting the survivors than did adolescents. It appears that parents are more pejorative, at least in terms of assessing the degree of psychological disturbance in the suicidally deceased adolescent, but at the same time they are more emotionally supportive to survivors. Consequently, other parents may be a more beneficial community support group for parental survivors of adolescent suicide than would be other adolescents.

The impact of transtelephonic documentation of arrhythmia on morbidity and mortality rate in sudden death survivors

A post hospital follow-up system based on predetermined antiarrhythmic strategies and telephone transmitters used to record ECGs was helpful in managing post hospital course and improved survival in patients with a history of out-of-hospital sudden death. All patients underwent therapy guided by serial electrophysiologic testing. Of the 47 patients, 19 used the telephone transmitter system and 28 did not. During follow-up, residual symptomatic and silent ventricular arrhythmia was documented in 78% of patients using telephone transmitters. Ventricular tachycardia was transmitted in six patients—all survived. During an average 15-month follow-up, 1 of 19 patients using the telephone transmitter system died vs 12 deaths among the 28 patients who did not use the system ( p < 0.005). These results were independent of ejection fraction, presence of congestive heart failure, amiodarone therapy, and the outcome on electrophysiologic therapy. Thus, patients with a history of out-of-hospital sudden death, discharged following electrophysiologic guided therapy, require repeated antiarrhythmic dose titration for side effects or residual ventricular arrhythmia. Prompt diagnosis and treatment of potentially fatal arrhythmia is crucial and feasible, especially with regular ECG checks through telephone transmission.

Automatic Implantable Cardioverter-Defibrillator: Techniques of Implantation and Results

An initial experience with use of the automatic implantable cardioverter-defibrillator (AICD) is described. Twelve patients received the device. One death has occurred during a mean follow-up of 15 months, and it was due to causes other than arrhythmias. Appropriate device discharge terminating a malignant arrhythmia occurred in 9 patients (75%). The observed survival (92%) far exceeds that to be expected in survivors of sudden death treated by conventional means. There have been no operative deaths. Morbidity has been minimal, although three reoperations were required in 2 patients because of lead dislodgment. The AICD has been demonstrated to be effective in treating patients at risk for sudden arrhythmic death. It can be employed safely with minimum morbidity using a variety of implantation techniques.

The rules of bereavement: Are suicidal deaths different?

The present article describes two studies designed to identify some of the rules that may govern interactions with bereaved persons and whether those rules are different for suicidal deaths, as compared with death by accident or natural causes. In the first study, with university students, 28 rules were identified. The pattern of results suggests that the rules for suicide are more constraining; that is, judgments about the existence of social rules tend to be more inclusive and extreme, in a “should not do” direction, when the death is suicidal. In the second study, with adult citizens, 13 possible rules were examined. The pattern of results confirmed the findings obtained in the first study — that interacting with the survivors of a suicidal death was seen as a more constraining situation with a predominance of proscriptive rules. It was suggested that while individuals may feel greater compassion for the survivors of suicide, they may avoid the situation for fear of violating one of the proscriptive rules.

Long-term follow-up of survivors of prehospital sudden cardiac death treated with coronary bypass surgery

Although coronary artery bypass surgery is beneficial to patients with severe coronary artery disease, its role in preventing the recurrence of prehospital cardiac arrest in patients is not clear. In this article, we report on the long-term follow-up of 49 survivors of prehospital coronary arrest who had coronary artery bypass surgery. Prior to their prehospital cardiac arrest, 14% of the patients had a history of unstable angina. Coronary angiograms obtained after prehospital cardiac arrest showed that 71% of the patients had three-vessel coronary artery disease and 6% had single-vessel disease. The mean left ventricular ejection fraction was 45%. There were four postoperative deaths; three were caused by pump failure, and one was caused by refractory ventricular arrhythmias. After a maximum follow-up period of 102 months (mean of 55.4 months), there were seven cardiac deaths; five of the patients died of recurrent ventricular fibrillation, and two patients; deaths were related to refractory heart failure. Actuarial analyses of the 49 patients showed that the probability of survival at 6 months, 1 year, 2 years, 3 years, and 5 years was 92%, 92%, 89%, 82%, and 72%, respectively. After surgery, 35 of the 45 patients who were discharged from the hospital were asymptomatic, and 23 of the 32 patients who were employed when their prehospital cardiac arrest occurred returned to their employment. We concluded that coronary artery by pass surgery is beneficial to certain survivors of prehospital sudden death. After surgery, most patients are asymptomatic and capable of returning to their employment and the recurrence of prehospital sudden death is low.

Mode of stimulation versus response: Validation of a protocol for induction of ventricular tachycardia

Electrophysiologic studies were prospectively performed in 91 consecutive patients referred for evaluation of sustained ventricular tachycardia or sudden cardiac death. Fifty-two patients had a history of sustained ventricular tachycardia and 39 patients had a history of sudden cardiac death. The identical stimulation protocol was used in all patients. The stepwise protocol involved atrial pacing, burst ventricular pacing, single, double, and triple extrastimuli during ventricular pacing. Stimulation was performed at the right ventricular apex at two and five times diastolic threshold. Using this protocol, ventricular tachycardia was inducible in 48 (92%) of the 52 patients with a history of sustained ventricular tachycardia and in 28 (72%) of 39 patients with a history of sudden cardiac death ( p < 0.02). The use of a third extrastimulus increased the yield of inducible ventricular tachycardia by 37% in patients with a history of sustained ventricular tachycardia and by 25% in patients with a history of sudden cardiac death. Stimulation at five times diastolic threshold and stimulation from the right ventricular outflow tract added a 15% increment in overall yield of inducible ventricular tachycardia in patients with a history of sustained ventricular tachycardia, and a 26% increment in yield in patients with a history of sudden cardiac death. Forty-four (92%) of the 48 inducible patients in the sustained ventricular tachycardia group had inducible monomorphic ventricular tachycardia as compared to 19 (68%) of 28 patients in the sudden cardiac death group ( p < 0.02). The use of such a stimulation protocol with a hierarchy of intensity, which includes triple extrastimuli and stimulation at five times diastolic threshold, obviates the need for left ventricular stimulation in the majority of patients with previously documented sustained ventricular arrhythmias. This protocol appears to produce a low incidence of artifactual arrhythmias in patients with previously documented sustained ventricular tachycardia. The significance of inducible polymorphic ventricular tachycardia in sudden death survivors is uncertain.

Caring for Survivors of Sudden Death in the Emergency Ward

Frequently, emergency physicians have to interact with family and friends of persons who have died suddenly, often unexpectedly. These interactions are in complex ways difficult for both emergency ward (EW) staff and for survivors of sudden death. It may be that the way in which this crisis is managed will be a major determinant in how these survivors will remember the incident of sudden death, and how they will cope with it psychologically and physiologically.

Relationship of specific coronary lesions and regional left ventricular dysfunction to prognosis in survivors of sudden cardiac death

We prospectively evaluated the relationship of specific coronary arterial and left ventricular segments to subsequent clinical outcome in 80 persons who were survivors of sudden cardiac death and had failed conventional antiarrhythmic therapy. There were 68 men and 12 women with an average age of 51 years who were treated with investigational antiarrhythmic agents, randered asymptomatic, and followed for 16 ± 14 (SD) months. At the end of the study 48 patients (60%) were alive and asymptomatic while 32 (40%) had experienced either recurrent syncope (five) or sudden cardiac death (27). The independent relationship of clinical and angiographic variables was performed in a univariate fashion using a Kaplan-Meier survival analysis and then multivariate logistic analysis was used to simultaneously consider all clinical and arteriographic variables. The results reconfirmed the importance of ejection fraction and left ventricular filling pressure on outcome. However, coronary arterial and left ventricular segmental analyses provided additional predictive power. Specifically, the survival outcome was found to be inversely related to the degree of proximal left anterior coronary (LAD) arterial narrowing: at 1 year 90% of patients with minimal LAD narrowing were alive/asymptomatic in contrast with 70% who had partial and 40% who had complete proximal LAD obstruction ( p < 0.005). Analysis of the posterobasal left ventricular segment wall motion demonstrated that 100% of patients with minimal dysfunction were alive/asymptomatic at 1 year, whereas only 52% of patients with severe dysfunction were alive ( p < 0.001). A multivariate analysis using both LAD narrowing and posterobasal dysfunction correctly predicted 39 of 43 patients (91%) who were alive and 11 of 15 patients (73%) who were dead/syncopal, for a predictive accuracy of 86%. These results suggest that specific segmental cardiac lesions may accurately identify subsets of sudden cardiac death survivors who are at either exceptionally high or low risk for subsequent arrhythmic events. Application of this approach to patient management may permit improvements in the individual risk-benefit ratio of therapy.

Long-term survival after prehospital sudden cardiac death

One hundred thiry-nine survivors of prehospital sudden cardiac death were followed after their hospital discharge. Eighty patients were studied with coronary angiography and cardiac catheterization; 34 of these underwent coronary bypass surgery. After a maximum follow-up of 105 months, 89 patients were still alive. The probability of survival at 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years was 88%, 86%, 78%, 70%, 63%, and 59%, respectively. Of the 43 cardiac deaths, 37 (86%) were secondary to documented recurrent ventricular fibrillation or occurred suddenly. Twelve percent of the total population had recurrent ventricular fibrillation in the first year following the initial cardiac arrest, 16% within 2 years, and 22% within 3 years. Of the 37 survivors dying from recurrent ventricular fibrillation, 32% died within the first 3 months following hospital discharge, 46% in the first year, 64% within 2 years, and 78% within the first 3 years. Most survivors were capable of resuming normal activities after hospital discharge. Only 7% demonstrated permanent neurologic impairment. Sixty-eight percent of the patients who were employed at the time of their prehospital sudden cardiac arrest returned to full-time employment. In the subset of 34 surgically treated patients, there have been six (18%) cardiac deaths. Four of these deaths were related to recurrent ventricular fibrillation, with one of these deaths occurring in the immediate postoperative period. The other three deaths related to recurrent ventricular fibrillation occurred 36 months (two deaths) and 49 months following the initial prehospital cardiac arrest.