5.syncope SCD 2016

Syncope.
Sudden cardiac death

Dr. Radu Vtescu
Pacing and Clinical Electrophysiology Lab., Cardiology Department
Clinic Emergency Hospital Bucharest
Syncope
Definition: transient loss of consciousness,
associated with loss of postural tone, with
complete, rapid, spontaneous return to baseline
neurologic function requiring no resuscitative
efforts. The underlying mechanism is global
hypoperfusion (30% ) of both the cerebral cortices
or focal hypoperfusion of the reticular activating
system
NB!
>1/3 associated with trauma
!! cardiac syncope (1/3 SCD in 5 years!)
RV - Syncope. SCD 2016
Epidemiology
Sorteriades ES, et al. N Engl J Med 2002
Freed LA,, et al. Am J Cardiol 1997
- 2 peaks: 15years and >55 years (especially >70)

- ,,lifetime risk 1/3 !!!
History physical examination

context
during / after effort

at rest
postmictional
pain
orthostatism
dehydration
prodroms
palpitations
thoracic pain
vertigo
visual
marked fatigue
sympathetic : transpiration,
pallor, nausea
loss of consciousness and of
postural tone
pallor
absent / weak pulse
superficial respiration
tonico-clonic contractions (face,
superior extremities)
sfincterian control
midriatic pupils
loss of conjunctival reflexes
Etiology
Prevalence, percent
Men
Women
Cardiac
13.2
6.7
Stroke or transient ischemic attack
4.3
4.0
Seizure disorder
7.2
3.2
Vasovagal
19.8
22.2
Orthostatic hypotension
8.6
9.9
Medication
6.3
7.2
Other
9.5
6.1
Unknown
31.0
40.7
Etiology
Reflex (neurally mediated)
Orthostatic hTA
-Vasovagal:
-Primary autonomic failure:
Emotional stress: fear, pain, fobia (blood)
pure autonomic failure, multisystemic atrophia,
Orthostatic Stress
b. Parkinson, Lewy body dementia
-Situational:
-Secondary autonomic failure:
Respiratory stimuli: cough, sneeze
DM, amiloidosis, uremia, spinal lesions
G-I stimulation: swallowing, defecation, visceral
-drug-related orthostatic hTA:
pain
Alcohol, v-d, diuretics, phenotyazine,
Mictional
antidepresives
Effort
-Hypovolemia:
Postprandial
Others (laugh, weight lifting)
Hemorrhage, diarea, emesis, etc
-Carotidian
-Atipical
Cerebro-vascular: vascular steal

- ocluzive disease of brahiocephalic trunk: ASC, tr.-emb., arteritis
(Takayasu)
-subclavicular steal
Cardiac syncope
Arrhytmic:
Structural disease:
-Bradicardia:
-Cardiac:
fx SAN
valvulopaties / disfx valvular prosthesis, AMI,
AVB (II or III)
HOCM, intracardiac masses (mixoma, tumours,
PM/ICD malfunction
-Tachycardia:
Supraventricular
Ventricular (idiopatice, structural heart disease,
etc), pericardial disease/tamponade, cong.

coronary aN
-Others: DVT/PE, Ao disection, PHT
chanallopaties
-iatrogenic brady or tachyarrythmia
Etiology vs prognostic
Sorteriades ES, et al. N Engl J Med 2002
Risk stratification
High: structural heart disease
Intermediar
Low
young
wo comorbidities
ECG N
syncope
reflex
orthostatic
un-explained
10
Initial screening
History
Physical exam
BP clino/ortho
neurologic
Carotid Sinus Compression
ECG
11
Secondary screening
Ecocardiography
ECG monitoring
monitor ED
effort ECG
Holter
Tilt test
Biologic: myocardial necrosis, LV
dysfunction, inflammation, DVT/PE
12
Specific tests
coronary angiography
CT
adenosine
ILR: rare but severe, recurrent symptoms
EPS
SAN
BB
CAD
CMP: H, ARVD
chanallopaties: Brugada
13
Treatment
Objectives:
Recurrences prophylaxis
QoL
complications prophylaxis (head
trauma)
SCD prevention
14
Treatment
Reflex syncope:
Patient education
re-assurance
life-style
prodromes recognition
maneuvers for venous retour
triggers avoidance/elimination
15
16
Definition
Sudden cardiac death (SCD)
death by circulatory arrest, usualy due to
cardiac arrhythmia, ocurring in less than 1h
after symptoms debut
Sudden cardiac arrest (SCA)
circulatory arrest, usualy due to cardiac
arrhythmia, ocurring in less than 1h after
symptoms debut. Medical intervention
(usualy defibrillation) prevents death
17
le 3
Definitie - ESC 2015
Definitions of commonly used terms
Term
Sudden death
Non-traumatic, unexpected fatal event occurring within 1 hour of the onset of symptoms in an apparently healthy
subject.
If death is not witnessed, the
applies when the victim was in good health 24 hours before the event.
SUDS and SUDI
Sudden death without an apparent cause and in which an autopsy has not been performed in an adult (SUDS) or in an
infant <1 year of age (SUDI).
SCD
The term is used when:

A congenital, or acquired, potentially fatal cardiac condition was known to be present during life; OR
Autopsy has
a cardiac or vascular anomaly as the probable cause of the event; OR
by post-mortem examination and therefore an arrhythmic event
No obvious extra-cardiac causes have been
is a likely cause of death.
SADS and SIDS
Both autopsy and toxicology investigations are inconclusive, the heart is structurally normal at gross and histological
examination and non-cardiac aetiologies are excluded in adults (SADS) and in infants (SIDS).
Aborted cardiac
arrest
Unexpected circulatory arrest, occurring within 1 hour of onset of acute symptoms, which is reversed by successful
resuscitation manoeuvres (e.g.
Idiopathic ventricular
Clinical investigations are negative in a patient surviving an episode of ventricular
Primary prevention
of SCD
Therapies to reduce the risk of SCD in individuals who are at risk of SCD but have not yet experienced an aborted
cardiac arrest or life-threatening arrhythmias.
Secondary
prevention of SCD
Therapies to reduce the risk of SCD in patients who have already experienced an aborted cardiac arrest or lifethreatening arrhythmias.
18
How sudden is SCD?
Muller D et al Circulation 2006
19
Proportion of Patients, %
is extended to the 4 weeks preceding SCA. Second,

these symptoms seem to
bepain
frequently ignored or minChest
n = 90
40
Dyspnea
imized by patients in the
community, with at least two
Syncope or palpitations
0.84
thirds of affected patients
not seeking urgent medical
0.59
30
care, given that most symptoms recurred during the
n = 50
n = 49 24-hour period before
SCA. Finally, our findings sug0.120
20
gest thatnan
early
911
call
among patients with symp= 30
toms is associated
with betterESEARCH
survival because in most
RIGINAL
10
n = 13
patients,
symptoms
recurred
in
n
= 6the hours immediately
n
=
8
n=7
n=5
n=4
npreceding
=3
n = 2 the potential to
SCA. These findings
suggest
0
short-term
oftoSCA
with
h to
24 h
>1 dprevention
to 7 d >1 wk
4 wk in the future.
h enhance
Figure 1.1
Study
flow>1diagram.
The
term
sudden
has
classically
suggested that
due to
Presence of Symptoms Before SCA
collapse occurred without warning. Although previous
DifferInformation aboutcommunity-based
the timing of symptomstudies
onset wasthat
available
in 267 of the circuminvestigated
t for a
Sudden
arrest in persons
aged or palpitations. Er299 patients with
chestcardiac
pain, dyspnea,
or syncope
before
documented
the early warn35stances
to 65
y from
20022012
(n =have
1099)
5% CIs
ror bars correspond
to 95%
CIs.
SCASCA
= sudden
cardiac
arrest.
ing
symptoms
in
some
patients
(17,
18),
they were
STATA
mainly focused on symptoms occurring very shortly beAmong the 81 patients with symptoms who made a
0.78
fore SCA was witnessed. Further, findings were limited
911 call, 63 (78%) developed SCA before the arrival of
to those collected in the field by EMS providers and
0.170
emergency medical responders, whereas 18 (22%) had
underestimated
the
potential window for
e proSurvivors
(n = 114
[10%])
(n =probably
985 [90%])on
SCADecedents
in the ambulance
the way
to the
hospital.
Com0.75
timely intervention. Of note, most of our patients with
had
no
pared with patients who did not call 911 before SCA,
symptoms who eventually developed SCA did not call
study
0.72
those who called had witnesses more often (P = 0.001),
911. This is a noteworthy finding because most patients
pt for
a higher proportion
of bystander cardiopulmonary reSymptom
Symptom
(>90%)
who had symptoms during
the days and weeks
0.69
suscitation (P = assessment
0.001), and
a higher rate
of initially
assessment
not
beforepossible
SCAnot
also had recurrent
symptoms
in the hours
shockable rhythm (P = 0.02).
possible
0.010
before
the
event. Not surprisingly,
patients
(n = 242
[25%])
(n = 18
[16%])CI, with continSurvival to hospital discharge was 32.1%
(95%
uous symptoms or with known heart disease seem
21.8% to 42.4%) compared with 6.0% (CI, 3.5% to 8.5%)
more likely to call 911, probably because of a better
0.50
in patients who did not call 911 (P < 0.001). After adawareness of warning signs. However, two thirds of
0.31
d
justment for differences in patients and resuscitation
0.56
such patients did not call 911, so there is room for imvariables, and multiple imputation for missing data, a
0.29
provement (19).
ere
0.110in911 call remained significantly associated with survival
Our findings
emphasizeSymptoms
the need to encourage efhospiSymptoms
symptomsdischarge
symptoms
toNo
hospital
(odds No
ratio
[OR], 4.82 [CI, 2.23 to
that
target
public
of SCA as a largely
(n = 383
[52%])
(n = 360 [48%]) forts
(n = 47 [49%])
(n = 49
[51%])awareness
a0.140
were
10.43]; P < 0.001) (Appendix Table 3, available at www
fatal
event.
It
is
important
to
reinforce
knowledge of
ecause
.annals.org). A sensitivity analysis using complete-case
prodromal
symptoms
of
SCA
in
the
general
public and
gure 1
analysis found a significant association (OR, 3.27 [CI,
in
patients
affected
by
heart
disease
and
their
family
s.org).
0.160
1.37 to 7.79]; P = 0.008) as did analyses that controlled
members.
The
recent
impressive
advances
in
mobile
he abfor potential confounding due to the hospital (OR, 3.35
No 911
telecommunication
technologies
could help improve
No 911
e time
911 call and periods before
911 call
[CI, 1.47 to call
7.65]; P = 0.004)
and
call
the
management
of
patients
with
SCA
ed.
Per(n = 55)
(n = 26)who have warne area
(n
=
21)
after
2005
(OR,
5.64
[CI,
2.59
to
12.43];
P
=
0.001).
(n
=
328)
f known
ing symptoms, potentially affording a unique opportunesses
nity for early intervention (6). This may be particularly
ng
indata.
the
DISCUSSIONhelpful in patients with known heart disease because
ts); inMarijon
E.,
Uy-Evanado
A,
et al. Ann Intern
Med. 2016
instant transmission
To our knowledge,
this study isofthepoint-of-care
first compre-electrocardios, witdocugrams
and
the development
of automated
Characteristics
ofofSymptoms
and
hensive
evaluation
symptoms
in
theTemporal
4 weeks
preced- algorithms
onspe-
(n ! 81)
Study period
20022005
20062009
20102012
(n ! 349)
0.41
52 (64.2)
18 (22.2)
11 (13.6)
Demographic data
Mean age (SD), y
Male
198 (56.7)
103 (29.5)
48 (13.8)
54.2 (7)
52.2 (8)
61 (75.3) 259 (74.2)
0.020
0.84
Timing of SCA
Night (midnight5:59 a.m.)
Morning (6:0011:59 a.m.)
Afternoon (noon5:59 p.m.)
Evening (6:0011:59 p.m.)
Missing
11 (17.7)
16 (25.8)
20 (32.3)
15 (24.2)
19
29 (17.0)
55 (32.1)
42 (24.6)
45 (26.3)
178
Known heart disease

CAD
45 (55.6)
28 (34.8)
114 (32.7)
77 (22.1)
Type of symptoms
Chest pain
Dyspnea
Syncope/palpitation
Others
Missing
45 (55.6)
23 (28.4)
6 (7.4)
7 (8.6)
0
154 (44.6)
55 (15.9)
16 (4.6)
120 (34.8)
4
Onset of symptoms
1 h
1 d
1 wk
1 mo
Missing
21 (28.8)
32 (43.8)
17 (23.3)
3 (4.1)
8
57 (17.9)
142 (44.5)
108 (33.8)
12 (3.8)
30
Home occurrence
Missing
49 (60.5)
0
278 (79.7)
2
<0.001
Witnessed status
No witness
Witnessed without CPR
Witnessed with CPR
Missing
74 (91.4)
7 (8.6)
43 (53.1)
31 (38.3)
0
182 (52.6)
164 (47.4)
135 (39.0)
47 (13.6)
3
<0.001
Mean time from call to EMS

arrival (SD), min
Missing
6.9 (4)
0.90
<0.001
0.010
<0.001
0.56
Rhythm
Ventricular fibrillation/tachycardia
Pulseless electrical activity
Asystole
Missing
7.0 (3)
16
133
42 (58.4)
25 (34.7)
5 (6.9)
10
112 (45.7)
60 (24.5)
73 (29.8)
103
0.67
0.020
20
Size of the issue: SUA
Stroke3
167,366
450,000
Lung
cancer
Breast cancer
AIDS1
1
2
3
4
157,400
40,600
42,156
MSC 4
#1 Killer
U.SA.
U.S. Census Bureau, Statistical Abstract of the United States: 2001.

American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.
2006 Heart and Stroke Statistical Update, American Heart Association.
Circulation. 2001;104:2158-2163.
RV - Syncope. SCD 2016 21
Major causes of death

1
SUA 1999
Septicemie
Nefrite
SCD is outweighted only by

combined mortality from all
cancer types
Alzheimer
Grip/pneumonie
Diabet
Accidente/atac armat
B.P.C.O
Boli cerebrovasculare
Alte cauze cardiace

MSC
All cancers
0%
5%
10%
15%
20%
25%
1 National
2
Vital Statistics Report, Vol 49 (11), Oct. 12, 2001

MMWR. State-specific mortality from sudden cardiac death US 1999.Feb 15, 2002;51:123-126.
RV - Syncope. SCD 2016 22
Survival SCA
only 17-25% of SCD/SCA resuscitated
Discharged:
SUA & Canada 5%
Vestern Europe 5%
Restul of the world << 1%
23
Evolution SCD
Fox CS et al Circulation 2004

24
Evolution SCD survivals
Rea TD et al Circulation 2003

25
Etiology SCD
CHD
atherosclerosis
MI (acute and old/scar)
UA
coronary embolies
non-ASC coronary disease
arteritis
dissections
congenital anomalies
coronary spasm
Non-isch. struct. heart disease
CMP (D, H, ARVD)

Miocarditis
Ao dissection
Valvulopathies
Congenital heart disease
cardiac tamponade
Cardiac rupture
Heart diseases wo structural

involvement
idiopathic VF
Brugada
LQT/SQT
WPW
complete AVB
familial SCD
Chest trauma (commotio cordis)
noncardiac
PE
intracranial haemorrhage
Drawning
Pickwick (OSA)
Drug poissoning
Upper aiwais obstruction
Sudden infant death syndrome
26
Huikuri HV, Castellanos A, Myerburg RJ. N Engl J Med 2001
27
Myerburg RJ. J Cardiovasc Electrophysiol 2001.
28
12%
Other Cardiac
Cause
88%
Arrhythmic
Cause
Albert CM. Circulation 2003
MSC
mechanism
VT
62%
TdP
13%
Bradycardia
17%
Primary VF
8%
Bays de Luna A. Am Heart J 1989
29
Survival
asistole
50%
50 minute
10% 0-2%
electromechanical dissociation
25%
20 minute
23% 6%
VT/VF
25%
30 minute
40% 34%
Muller D et al Circulation 2006
30
SCD: succesful resuscitation vs. time*

% Succes (*Nonlinear )
succes rate with 7 - 10% for each minute of delay

100
90
80
70
60
50
40
30
20
10
Timp (minute)
Cummins RO. Annals Emerg Med. 1989;18:1269-1275.
31
Risc stratification
Necessary?
32
SCD subgroups
General population
High coronary risk
History of coronary
event
LVEF <35%, CHF
SCD-HeFT
Previous cardiac
arrest
MADIT-II
AVID, CIDS, CASH

MADIT I - MUSTT
Hystory of MI, low EF,

VT
0
10
20
25
30
Incidence of Sudden Death

(% of group)
Myerburg RJ. Circulation 1998.
100,000 200,000 300,000

No. of Sudden Deaths
Per Year
33
Myerburg RJ. J Cardiovasc Electrophysiol 2001.
34
Risk stratification
Substrate
family history
Age
Sex
SCA
CHD (MI, UA)
Personality
Indicators of LV fx
Symptoms
Sincope
CHF
Trigger
EP parameters
Autonomic imbalance
HR rest/effort
HRV
HRT
BRS
AV conduction
QRSw
SAECG
EPS
Repolarisation dispersion
QT dispersion
MTWA
LVEF
LV mass
Natriuretic hormones
35
CHF
Kannel WB et al, Am Hear J 1998

36
Functional capacity vs type of death
NYHA III
NYHA II
12%
NYHA IV
26%
33%
24%
64%
59%
56%
15%
11%
N = 103
N = 103
N = 27
CHF
Other
Sudden Death
MERIT-HF Study Group Lancet 1999

37
SCD vs LVEF in patients with CHF
% SCA Victims
7.5%
7
6
5.1%
5
4
2.8%
3
2
1.4%
LVEF
0
0-30%
31-40%
41-50%
>50%
Gorgels APM Eur Heart J 2003
RV - Syncope. SCD
38
SCD vs LVEF in asymptomatic

LVD patients
Wang TJ et al. Circulation 2003

39
Whang W et al TOVA, Circulation 2005
40
SCD vs LVH
Haider AW et al. J Am Coll Cardiol 1998

41
SCD vs natriuretic hormones
Tapanainen JN et al. J Am Coll Cardiol 2004

42
HR and SCD risk
Jouven X et al. N Engl J Med 2002

43
QRSw vs SCD
Baldasseroni S et al, Am Hear J 2002

44
dQRS120 msec
dQRS<120 msec
Moss AJ, Circulation 2005
45
SCD Prophylaxis
Corection of ischemia
Revascularisation
B
inflammation and/or plaque rupture

prevention
Statines
ACEI
Aspirin
Autonomic balance
Beta-blocker
ACEI
Arrhythmia prevention
B
Amiodarone
polyunsaturated fatty acids (fish oil)?
Ablative therapy
percutaneous (catheter)
surgical
Arrhythmia termination
ICDs
AEDs
of LV systolic fx
ACEI
B
Prevention of cardiac remodeling and

collagen formation
aldosterone receptors blockers
ACEI
46
Mortality
Trial
ACE-I Controls
RR (95% CI)
Chronic CHF
CONSENSUS I
39%
0.56 (0.34 - 0.91)
54%
SOLVD (Treatment)
35%
40%
0.82 (0.70 - 0.97)
16%
SOLVD (Prevention) 15%
0.92 (0.79 - 1.08)
Post- MI
SAVE
AIRE
TRACE
SMILE
Mean
20%
17%
35%
6.5%
21%
25%
23%
42%
8.3%
25%
0.81 (0.68 - 0.97)

0.73 (0.60 - 0.89)
0.78 (0.67 - 0.91)
0.78 (0.52 - 1.12)
47
Automated External Defibrillator

AED
Automatic rhythm
analysis
determine
apropiateness of
an external shock
Visual and sound
alerts for guiding
48
Survival after introduction of AEDs

30
26%
Before Early DF
After Early DF
VF Survival
25
19%
20
17%
15
10
11%
10%
7%
3%
4%
4%
3%
0
King County,
WA
Iowa
SE Minnesota NE Minnesota
Wisconsin
Ornato JP. Community experience in treating out-of-hospital cardiac arrest. In: Akhtar M.
Sudden Cardiac Death. Baltimore, Md: Williams & Wilkins; 1994.
49
Implantable cardioverter-defibrillator ICD

? Defibrilattion
? Cardioversion
? Antitachycardic pacing
Ventricular lead
Atrial & Ventricular lead

? brady detection
? antibradycardia pacing
50
ICD decrease mortality with ~ 40%

both in secondary and primary prevention
40
30
51%
73%
Control
54%
ICD
39%
20%
38%
20
36%
31%
41%
23%
10
0
Secondary Prevention
Primary Prevention
51
Al-Khatib SM et al, Am Heart J 2005
52
Clinical History
Angina pectoris or shortness of breath
Family history of premature SCD (age <40 years) or ealy-onset heart disease
ECG during tachycardia
Other transient
cause e.g.
Drugs
Electrolytes
Chest trauma
Acute ischemia
(STEMI, NSTEMI)
ECG
Echocardiogram
History and
Family history a
Urgent angiogram
and
revascularisation
Reverse
transient cause
Evaluate for
cardiovascular
diseases
ECG
Echocardiogram / CMR
History
Other tests
Evaluate for
complete
reversal of
cause
Secondary
prevention for
SCD (ACEi,
beta-blockers, statin,
antiplatelets)
Re-evaluate
LVEF
610 weeks
after event
Consider ICD
according to
secondary
prevention
Structural heart disease

and congenital heart
diseases
suspected (e.g. Stable CAD,
sarcoidosis, aortic valve
disease, DCM)
Sudden death victims

Autopsy in collaboration with pathologists
Obtain blood and tissue samples
Molecular autopsy after autopsy
Offer family councelling and support
Refer family for cardiology / SCD workup
No detectable
heart disease
Inherited
arrhythmogenic
disease or
cardiomyopathy
suspected
Further patient assessment, e.g.b

Stress test, Holter 48 hours,
Consider coronary angiogram
Refer patients to experienced centers for risk evaluation,
catheter ablation, drugs and ICD
Drug challenges, EPS
CMR, CT, myocardial biopsy
Signal averaged ECG, TOE based on suspected disease
Treatment of underlying
heart disease (e.g. valve
repair, medication)
Assess risk for SCD
Specific treatment
Genetic testing
Family screening
Assess risk for SCD
Consider to
obtain second opinion
on cause of
VT/VF
53
However...
2/3 of patients with SCD had pre-existing proved/suspected
heart disease
3/4 of SCD at home
100% witnessed
90% had symptoms at least 10 before SCD (mean 1h !!)
Resuscitation attempted by witnesses: 8-23%
Survival:
25% if witneeses attempt BLS

4% if ambulance is waited
Key: Population education

54

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Syncope.

Sudden cardiac death

RV - Syncope. SCD 2016

Sorteriades ES, et al. N Engl J Med 2002

Freed LA,, et al. Am J Cardiol 1997

- 2 peaks: 15years and >55 years (especially >70)

RV - Syncope. SCD 2016

History physical examination

during / after effort

loss of consciousness and of

RV - Syncope. SCD 2016

Stroke or transient ischemic attack

-Primary autonomic failure:

Emotional stress: fear, pain, fobia (blood)

pure autonomic failure, multisystemic atrophia,

b. Parkinson, Lewy body dementia

-Secondary autonomic failure:

Respiratory stimuli: cough, sneeze

DM, amiloidosis, uremia, spinal lesions

G-I stimulation: swallowing, defecation, visceral

-drug-related orthostatic hTA:

Alcohol, v-d, diuretics, phenotyazine,

Hemorrhage, diarea, emesis, etc

Cerebro-vascular: vascular steal

RV - Syncope. SCD 2016

valvulopaties / disfx valvular prosthesis, AMI,

AVB (II or III)

HOCM, intracardiac masses (mixoma, tumours,

etc), pericardial disease/tamponade, cong.

-iatrogenic brady or tachyarrythmia

RV - Syncope. SCD 2016

Sorteriades ES, et al. N Engl J Med 2002

RV - Syncope. SCD 2016

RV - Syncope. SCD 2016

RV - Syncope. SCD 2016

RV - Syncope. SCD 2016

RV - Syncope. SCD 2016

Definitie - ESC 2015

Definitions of commonly used terms

SUDS and SUDI

The term is used when:

SADS and SIDS

Clinical investigations are negative in a patient surviving an episode of ventricular

RV - Syncope. SCD 2016

How sudden is SCD?

Muller D et al Circulation 2006

RV - Syncope. SCD 2016

is extended to the 4 weeks preceding SCA. Second,

Known heart disease

Mean time from call to EMS

RV - Syncope. SCD 2016

Size of the issue: SUA

U.S. Census Bureau, Statistical Abstract of the United States: 2001.

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Major causes of death

SCD is outweighted only by

Alte cauze cardiace

Vital Statistics Report, Vol 49 (11), Oct. 12, 2001

RV - Syncope. SCD 2016 22

Fox CS et al Circulation 2004

Evolution SCD survivals

Rea TD et al Circulation 2003

Non-isch. struct. heart disease