AHA/ACC Report Recommends 10 Measures to Prevent Sudden Cardiac Death

The American Heart Association (AHA) and American College of Cardiology (ACC) have released a new report outlining a series of 10 quality metrics and performance measures for the prevention of sudden cardiac death.

“Sudden cardiac death is the most common mode of death in the United States,” Sana Al-Khatib, MD (Duke University, Durham, NC), told TCTMD. “I have devoted most of my career to the study of sudden cardiac death, and it has really troubled me that despite the importance of this issue, there really were not any performance measures related to sudden cardiac death to speak of.”

Al-Khatib co-chaired the writing committee that included clinicians with expertise in electrophysiology, interventional cardiology, general cardiology, and emergency medicine, all tasked with identifying metrics that could be used to assess the quality of care for the prevention of sudden cardiac death.

The recommendations, published online recently in the Journal of the American College of Cardiology, were divided into quality measures and performance measures. Quality measures are those that may be useful for local quality improvement but are not yet appropriate for public reporting or pay-for-performance programs. Performance measures, meanwhile, “are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement,” the document explains.

Performance measures were:

• Smoking cessation intervention in patients who suffered sudden cardiac arrest, have a life-threatening ventricular arrhythmia, or are at risk for sudden cardiac death.
• Use of implantable cardioverter defibrillators (ICDs) for prevention of sudden cardiac death in patients with heart failure and reduced ejection fraction who have an anticipated survival of more than 1 year.
• Referring for cardiopulmonary resuscitation (CPR) and automated external defibrillator education those family members of patients who are hospitalized with known heart conditions that increase the risk of sudden cardiac arrest.
• Counseling first-degree relatives of survivors of sudden cardiac arrest associated with an inheritable condition about the need for screening for the inheritable condition.  

Quality measures were:

• Screening for family history of sudden cardiac death.
• Screening for asymptomatic left ventricular dysfunction among individuals who have a strong family history of cardiomyopathy and sudden cardiac death.
• Use of guideline-directed medical therapy for prevention of sudden cardiac death in patients with heart failure and reduced ejection fraction.
• Use of guideline-directed medical therapy for prevention of sudden cardiac death in patients with heart attack and reduced ejection fraction.
• Documenting the absence of reversible causes of ventricular tachycardia/ventricular fibrillation cardiac arrest and/or sustained ventricular tachycardia before a secondary-prevention ICD is placed.
• Counseling eligible patients about an ICD.

Take Action

All of these measures, according to Al-Khatib, are equally important. However, she did highlight a few for use by clinicians who are looking to take immediate action.

“The first one on the list is smoking cessation among patients that suffered sudden cardiac arrest,” Al-Khatib said. “This one is so important to have on our radar and implement in clinical practice.”

In addition, she emphasized the use of ICDs for prevention of sudden cardiac death in patients with heart failure or reduced ejection fraction. “We are among many groups that have proven that defibrillators are underutilized,” Al-Khatib said. “It is truly time for us to be thinking about making this a performance measure. Anytime a healthcare provider sees a patient who might be eligible for ICD, [they should be] engaging them in a discussion and, hopefully, offering them one.”

Finally, clinicians can make sure that patients who are at risk for sudden cardiac death because of heart failure or reduced ejection fraction are offered the appropriate medications, she suggested. “This is in the control of every healthcare provider, and there is no reason why we are not at least considering the use of medications, certainly before even offering an ICD.”

Further Investigation

“The writers have done a good job dividing the things that people should be doing into performance guidelines, which would go into pay-for-performance programs and so forth, and quality measures,” said John D. Fisher, MD, chair of the ACC’s Electrophysiology Section Leadership Council, who commented on the guidelines for TCTMD.

Fisher also pointed to two areas of interest that the writing group considered including in the report but ultimately did not, deciding that they require further investigation.

The first area was researching any links between sudden cardiac death and certain diseases or syndromes. The second was the use of cardiovascular screening among competitive athletes. These raise questions, he said, over whether athletes should be screened at school, whether kids should be able to play sports without having some level of screening, and how much training an average person should have in CPR.

“This document,” Fisher said, “asks the readers to be thinking about future steps, most of which are very reasonable, and gets you to think to yourself, ‘That is a good idea. Why haven’t we done that already?”