What is sudden coronary death? Sudden death from acute coronary insufficiency: how to prevent? Sudden death causes emergency care.

Sudden cardiac death (SCD) is one of the most severe cardiac pathologies that usually develops in the presence of witnesses, occurs instantly or in a short period of time and has atherosclerotic lesions of the coronary arteries as the main cause.

The suddenness factor plays a decisive role in making such a diagnosis. As a rule, in the absence of signs of an impending threat to life, instant death occurs within a few minutes. A slower development of the pathology is also possible, when arrhythmia, heart pain and other complaints appear, and the patient dies in the first six hours from the moment they occur.

The greatest risk of sudden coronary death can be traced in people aged 45-70 who have some form of disturbance in the vessels, heart muscle, and its rhythm. Among young patients, there are 4 times more men, in old age, the male sex is susceptible to pathology 7 times more often. In the seventh decade of life, gender differences are smoothed out, and the ratio of men and women with this pathology becomes 2:1.

Most patients with sudden cardiac arrest finds themselves at home, a fifth of cases occur on the street or in public transport. Both there and there are witnesses to the attack, who can quickly call an ambulance, and then the likelihood of a positive outcome will be much higher.

Saving a life can depend on the actions of others, so you can’t just walk past a person who suddenly fell on the street or passed out on a bus. You should at least try to carry out basic cardiopulmonary resuscitation - indirect heart massage and artificial respiration, after calling the doctors for help. Cases of indifference are not uncommon, unfortunately, therefore, the percentage of unfavorable outcomes due to late resuscitation takes place.

Causes of sudden cardiac death

The causes that can cause acute coronary death are very numerous, but they are always associated with changes in the heart and its vessels. The lion's share of sudden deaths is caused by coronary heart disease, when fatty plaques form in the coronary arteries, impeding blood flow. The patient may not be aware of their presence, they may not present complaints as such, then they say that a completely healthy person suddenly died of a heart attack.

Another cause of cardiac arrest can be an acutely developed arrhythmia, in which proper hemodynamics is impossible, the organs suffer from hypoxia, and the heart itself cannot withstand the load and stops.

The causes of sudden cardiac death are:

Cardiac ischemia;
Congenital anomalies of the coronary arteries;
Arterial embolism in endocarditis, implanted artificial valves;
Spasm of the arteries of the heart, both against the background of atherosclerosis, and without it;
Hypertrophy of the heart muscle with hypertension, defect, cardiomyopathy;
Chronic heart failure;
Metabolic diseases (amyloidosis, hemochromatosis);
Congenital and acquired valve defects;
Injuries and tumors of the heart;
Physical overload;
Arrhythmias.

Risk factors are identified when the probability of acute coronary death becomes higher. The main such factors include ventricular tachycardia, an earlier episode of cardiac arrest, cases of loss of consciousness, a previous heart attack, a decrease in the left ventricular ejection fraction to 40% or less.

Secondary, but also significant conditions, under which the risk of sudden death is increased, are comorbidities, in particular, diabetes, hypertension, obesity, lipid metabolism disorders, myocardial hypertrophy, tachycardia of more than 90 beats per minute. Smokers are also at risk, those who neglect motor activity and, conversely, athletes. With excessive physical exertion, hypertrophy of the heart muscle occurs, a tendency to rhythm and conduction disturbances appears, therefore death from a heart attack is possible in physically healthy athletes during training, matches, and competitions.

For more careful monitoring and targeted examination, groups of people with a high risk of SCD have been identified. Among them:

Patients undergoing resuscitation for cardiac arrest or ventricular fibrillation;
Patients with chronic insufficiency and ischemia of the heart;
Individuals with electrical instability in the conduction system;
Those diagnosed with significant cardiac hypertrophy.

Depending on how quickly death occurred, instant cardiac death and fast death are distinguished. In the first case, it occurs in a matter of seconds and minutes, in the second - within the next six hours from the onset of the attack.

Signs of sudden cardiac death

In a quarter of all cases of sudden death of adults, there were no previous symptoms, it occurred without obvious reasons. Other patients noted a worsening of well-being in the form of: one to two weeks before the attack:

More frequent pain attacks in the region of the heart;
Increasing shortness of breath;
A noticeable decrease in efficiency, feelings of fatigue and fatigue;
More frequent episodes of arrhythmias and interruptions in the activity of the heart.

Before cardiovascular death, pain in the region of the heart sharply increases, many patients have time to complain about it and experience strong fear, as happens with myocardial infarction. Psychomotor agitation is possible, the patient grabs the region of the heart, breathes noisily and often, catches air with his mouth, sweating and reddening of the face are possible.

Nine out of ten cases of sudden coronary death occur outside the home, often against the background of a strong emotional experience, physical overload, but it happens that the patient dies from acute coronary pathology in his sleep.

With ventricular fibrillation and cardiac arrest against the background of an attack, severe weakness appears, dizziness begins, the patient loses consciousness and falls, breathing becomes noisy, convulsions are possible due to deep hypoxia of the brain tissue.

On examination, pallor of the skin is noted, the pupils dilate and stop responding to light, it is impossible to listen to heart sounds due to their absence, and the pulse on large vessels is also not determined. In a matter of minutes, clinical death occurs with all the signs characteristic of it. Since the heart does not contract, the blood supply to all internal organs is disrupted, therefore, within a few minutes after loss of consciousness and asystole, breathing stops.

The brain is most sensitive to lack of oxygen, and if the heart does not work, then 3-5 minutes are enough for irreversible changes to begin in its cells. This circumstance requires the immediate start of resuscitation, and the sooner chest compressions are provided, the higher the chances of survival and recovery.

Sudden death due to acute coronary insufficiency accompanies arterial atherosclerosis, then it is more often diagnosed in older people.

Among young people, such attacks can occur against the background of spasm of unchanged vessels, which is facilitated by the use of certain drugs (cocaine), hypothermia, excessive physical exertion. In such cases, the study will show no changes in the vessels of the heart, but myocardial hypertrophy may well be detected.

Signs of death from heart failure in acute coronary pathology will be pallor or cyanosis of the skin, a rapid increase in the liver and jugular veins, pulmonary edema is possible, which accompanies shortness of breath up to 40 respiratory movements per minute, severe anxiety and convulsions.

If the patient already suffered from chronic organ failure, but edema, cyanosis of the skin, an enlarged liver, and expanded borders of the heart during percussion can indicate the cardiac genesis of death. Often, when the ambulance team arrives, the patient's relatives themselves indicate the presence of a previous chronic illness, they can provide doctors' records and extracts from hospitals, then the issue of diagnosis is somewhat simplified.

Diagnosis of sudden death syndrome

Unfortunately, cases of post-mortem diagnosis of sudden death are not uncommon. Patients die suddenly, and doctors can only confirm the fact of a fatal outcome. The autopsy did not find any pronounced changes in the heart that could cause death. The unexpectedness of what happened and the absence of traumatic injuries speak in favor of the coronarogenic nature of the pathology.

After the arrival of the ambulance and before the start of resuscitation, the patient's condition is diagnosed, which by this time is already unconscious. Breathing is absent or too rare, convulsive, it is impossible to feel the pulse, heart sounds are not detected during auscultation, the pupils do not react to light.

The initial examination is carried out very quickly, usually a few minutes are enough to confirm the worst fears, after which the doctors immediately begin resuscitation.

An important instrumental method for diagnosing SCD is ECG. With ventricular fibrillation, erratic waves of contractions appear on the ECG, the heart rate is above two hundred per minute, soon these waves are replaced by a straight line, indicating cardiac arrest.

With ventricular flutter, the ECG record resembles a sinusoid, gradually giving way to erratic fibrillation waves and an isoline. Asystole characterizes cardiac arrest, so the cardiogram will only show a straight line.

With successful resuscitation at the prehospital stage, already in a hospital, the patient will have to undergo numerous laboratory examinations, starting with routine urine and blood tests and ending with a toxicological study for some drugs that can cause arrhythmia. 24-hour ECG monitoring, ultrasound examination of the heart, electrophysiological examination, and stress tests will definitely be carried out.

Treatment of sudden cardiac death

Since cardiac arrest and respiratory failure occur in sudden cardiac death syndrome, the first step is to restore the functioning of the life support organs. Emergency care should be started as early as possible and includes cardiopulmonary resuscitation and immediate transport of the patient to a hospital.

At the prehospital stage, the possibilities of resuscitation are limited, usually it is carried out by emergency specialists who find the patient in a variety of conditions - on the street, at home, at the workplace. It is good if at the time of the attack there is a person nearby who owns her techniques - artificial respiration and chest compressions.

Video: performing basic cardiopulmonary resuscitation

The ambulance team, after diagnosing clinical death, begins an indirect heart massage and artificial ventilation of the lungs with an Ambu bag, provides access to a vein into which medications can be injected. In some cases, intratracheal or intracardiac administration of drugs is practiced. It is advisable to inject drugs into the trachea during its intubation, and the intracardiac method is used most rarely - if it is impossible to use others.

In parallel with the main resuscitation, an ECG is taken to clarify the causes of death, the type of arrhythmia and the nature of the heart's activity at the moment. If ventricular fibrillation is detected, then defibrillation will be the best method of stopping it, and if the necessary device is not at hand, then the specialist strikes the precordial region and continues resuscitation.

If a cardiac arrest is detected, there is no pulse, there is a straight line on the cardiogram, then during general resuscitation, adrenaline and atropine are administered to the patient in any available way at intervals of 3-5 minutes, antiarrhythmic drugs, cardiac stimulation is established, after 15 minutes sodium bicarbonate is added intravenously.

After placing the patient in the hospital, the struggle for his life continues. It is necessary to stabilize the condition and begin treatment of the pathology that caused the attack. You may need a surgical operation, the indications for which are determined by doctors in the hospital based on the results of examinations.

Conservative treatment includes the introduction of drugs to maintain pressure, heart function, and normalize electrolyte disturbances. For this purpose, beta-blockers, cardiac glycosides, antiarrhythmic drugs, antihypertensives or cardiotonic drugs, infusion therapy are prescribed:

Lidocaine for ventricular fibrillation;
Bradycardia is stopped by atropine or izadrin;
Hypotension serves as a reason for intravenous administration of dopamine;
Fresh frozen plasma, heparin, aspirin are indicated for DIC;
Piracetam is administered to improve brain function;
With hypokalemia - potassium chloride, polarizing mixtures.

Treatment in the post-resuscitation period lasts about a week. At this time, electrolyte disturbances, DIC, neurological disorders are likely, so the patient is placed in the intensive care unit for observation.

Surgical treatment may consist of radiofrequency ablation of the myocardium - with tachyarrhythmias, the efficiency reaches 90% or more. With a tendency to atrial fibrillation, a cardioverter-defibrillator is implanted. Diagnosed atherosclerosis of the arteries of the heart as a cause of sudden death requires coronary artery bypass grafting, with valvular heart disease, they are plastic.

Unfortunately, it is not always possible to provide resuscitation within the first few minutes, but if it was possible to bring the patient back to life, then the prognosis is relatively good. According to research data, the organs of persons who have suffered sudden cardiac death do not have significant and life-threatening changes, therefore, maintenance therapy in accordance with the underlying pathology allows you to live for a long time after coronary death.

Prevention of sudden coronary death is needed for people with chronic diseases of the cardiovascular system that can cause an attack, as well as for those who have already experienced it and have been successfully resuscitated.

A cardioverter-defibrillator may be implanted to prevent a heart attack, and is especially effective for serious arrhythmias. At the right moment, the device generates the impulse necessary for the heart and does not allow it to stop.

Cardiac arrhythmias require medical support. Beta-blockers, calcium channel blockers, products containing omega-3 fatty acids are prescribed. Surgical prophylaxis consists of operations aimed at eliminating arrhythmias - ablation, endocardial resection, cryodestruction.

Non-specific measures for the prevention of cardiac death are the same as for any other cardiac or vascular pathology - a healthy lifestyle, physical activity, giving up bad habits, proper nutrition.

Video: presentation on sudden cardiac death

Video: lecture on the prevention of sudden cardiac death

Sudden coronary death: causes, how to avoid

According to the definition of the World Health Organization, sudden death is a death that occurs within 6 hours against the background of the onset of symptoms of impaired cardiac detail in apparently healthy people or in people who already suffered from diseases of the cardiovascular system, but their condition was considered satisfactory. Due to the fact that such death occurs in almost 90% of cases in patients with signs of coronary heart disease, the term "sudden coronary death" was introduced to indicate the causes.

Such deaths always occur unexpectedly and do not depend on whether the deceased had previously had cardiac pathologies. They are caused by violations of the contraction of the ventricles. At autopsy, such persons do not reveal diseases of the internal organs that could cause death. In the study of coronary vessels, approximately 95% reveal the presence of narrowing caused by atherosclerotic plaques, which could provoke life-threatening arrhythmias. Recent thrombotic occlusions that can disrupt the activity of the heart are observed in 10-15% of victims.

Vivid examples of sudden coronary death can be cases of fatal outcomes of famous people. The first example is the death of a famous French tennis player. The fatal outcome came at night, and the 24-year-old man was found in his own apartment. An autopsy revealed cardiac arrest. Previously, the athlete did not suffer from diseases of this organ, and it was not possible to determine other causes of death. The second example is the death of a major businessman from Georgia. He was in his early 50s, had always endured all the difficulties of business and personal life, moved to live in London, was regularly examined and led a healthy lifestyle. The lethal outcome came quite suddenly and unexpectedly, against the background of full health. After the autopsy of the man's body, the causes that could lead to death were never found.

There are no exact statistics on sudden coronary death. According to WHO, it occurs in about 30 people per 1 million population. Observations show that it occurs more often in men, and the average age for this condition ranges from 60 years. In this article, we will acquaint you with the causes, possible precursors, symptoms, ways to provide emergency care and prevent sudden coronary death.

The reasons

Immediate causes

The cause of 3-4 out of 5 cases of sudden coronary death is ventricular fibrillation.

In 65-80% of cases, sudden coronary death is caused by primary ventricular fibrillation, in which these parts of the heart begin to contract very quickly and randomly (from 200 to 300-600 beats per minute). Because of this rhythm disturbance, the heart cannot pump blood, and the cessation of its circulation causes death.

In about 20-30% of cases, sudden coronary death is caused by bradyarrhythmia or ventricular asystole. Such rhythm disturbances also cause severe disturbance in blood circulation, which leads to death.

Approximately in 5-10% of cases, sudden onset of death is provoked by paroxysmal ventricular tachycardia. With such a rhythm disturbance, these chambers of the heart contract at a rate of 120-150 beats per minute. This provokes a significant overload of the myocardium, and its depletion causes circulatory arrest with subsequent death.

Risk factors

The likelihood of sudden coronary death may increase with some major and minor factors.

Main factors:

previous myocardial infarction;
previously transferred severe ventricular tachycardia or cardiac arrest;
decrease in the ejection fraction from the left ventricle (less than 40%);
episodes of unstable ventricular tachycardia or ventricular extrasystoles;
cases of loss of consciousness.

secondary factors:

smoking;
alcoholism;
obesity;
frequent and intense stressful situations;
arterial hypertension;
frequent pulse (more than 90 beats per minute);
left ventricular myocardial hypertrophy;
increased tone of the sympathetic nervous system, manifested by hypertension, dilated pupils and dry skin);
diabetes.

Any of the above conditions can increase the risk of sudden death. When several factors are combined, the risk of death increases significantly.

At-risk groups

The risk group includes patients:

who underwent resuscitation for ventricular fibrillation;
suffering from heart failure;
with electrical instability of the left ventricle;
with severe hypertrophy of the left ventricle;
with myocardial ischemia.

What diseases and conditions most often cause sudden coronary death

Most often, sudden coronary death occurs in the presence of the following diseases and conditions:

hypertrophic cardiomyopathy;
dilated cardiomyopathy;
arrhythmogenic dysplasia of the right ventricle;
mitral valve prolapse;
aortic stenosis;
acute myocarditis;
anomalies of the coronary arteries;
Wolff-Parkinson-White syndrome (WPW);
Burgada's syndrome;
cardiac tamponade;
"sports heart";
dissection of an aortic aneurysm;
TELA;
idiopathic ventricular tachycardia;
long QT syndrome;
cocaine intoxication;
taking medications that can cause arrhythmia;
pronounced violation of the electrolyte balance of calcium, potassium, magnesium and sodium;
congenital diverticula of the left ventricle;
neoplasms of the heart;
sarcoidosis;
amyloidosis;
obstructive sleep apnea (stopping breathing during sleep).

Forms of sudden coronary death

Sudden coronary death can be:

clinical - accompanied by a lack of breathing, circulation and consciousness, but the patient can be resuscitated;
biological - accompanied by a lack of breathing, circulation and consciousness, but the victim can no longer be resuscitated.

Depending on the rate of onset, sudden coronary death can be:

instant - death occurs in a few seconds;
fast - death occurs within 1 hour.

According to the observations of experts, instantaneous sudden coronary death occurs in almost every fourth death due to such a lethal outcome.

Symptoms

Harbingers

In some cases, 1-2 weeks before a sudden death, so-called precursors occur: fatigue, sleep disturbances, and some other symptoms.

Sudden coronary death rarely occurs in people without heart pathologies and most often in such cases is not accompanied by any signs of deterioration in general well-being. Such symptoms may not appear in many patients with coronary diseases. However, in some cases, the following signs may become harbingers of a sudden death:

increased fatigue;
sleep disorders;
sensations of pressure or pain of a compressive or oppressive nature behind the sternum;
increased feeling of suffocation;
heaviness in the shoulders;
quickening or slowing of the heart rate;
hypotension;
cyanosis.

Most often, the precursors of sudden coronary death are felt by patients who have already suffered a myocardial infarction. They can appear in 1-2 weeks, expressed both in a general deterioration in well-being, and in signs of angio pain. In other cases, they are observed much less often or absent altogether.

Main symptoms

Usually, the occurrence of such a condition is in no way connected with the previous increased psycho-emotional or physical stress. With the onset of sudden coronary death, a person loses consciousness, his breathing first becomes frequent and noisy, and then slows down. The dying person has convulsions, the pulse disappears.

After 1-2 minutes, breathing stops, the pupils dilate and stop responding to light. Irreversible changes in the brain with sudden coronary death occur 3 minutes after the cessation of blood circulation.

Diagnostic measures with the appearance of the above signs should be carried out already in the very first seconds of their appearance, because. in the absence of such measures, it may not be possible to resuscitate a dying person in time.

To identify signs of sudden coronary death, it is necessary:

make sure that there is no pulse on the carotid artery;
check consciousness - the victim will not respond to pinches or blows to the face;
make sure that the pupils do not react to light - they will be dilated, but will not increase in diameter under the influence of light;
measure blood pressure - when death occurs, it will not be determined.

Even the presence of the first three diagnostic data described above will indicate the onset of clinical sudden coronary death. When they are detected, urgent resuscitation measures must be initiated.

In almost 60% of cases, such deaths occur not in a medical institution, but at home, at work and other places. This greatly complicates the timely detection of such a condition and the provision of first aid to the victim.

Urgent care

Resuscitation should be carried out in the first 3-5 minutes after the detection of signs of clinical sudden death. For this you need:

Call an ambulance if the patient is not in a medical facility.
Restore airway patency. The victim should be laid on a hard horizontal surface, tilt his head back and put forward the lower jaw. Next, you need to open his mouth, make sure that there are no objects interfering with breathing. If necessary, remove vomit with a tissue and remove the tongue if it blocks the airways.
Start artificial respiration "mouth to mouth" or mechanical ventilation (if the patient is in a hospital).
Restore circulation. In the conditions of a medical institution, defibrillation is performed for this. If the patient is not in the hospital, then a precordial blow should first be applied - a punch to a point in the middle of the sternum. After that, you can proceed to an indirect heart massage. Put the palm of one hand on the sternum, cover it with the other palm and begin to press the chest. If resuscitation is performed by one person, then for every 15 pressures, 2 breaths should be taken. If 2 people are involved in saving the patient, then for every 5 pressures, 1 breath is taken.

Every 3 minutes, it is necessary to check the effectiveness of emergency care - the reaction of pupils to light, the presence of breathing and pulse. If the reaction of the pupils to light is determined, but breathing does not appear, then resuscitation should be continued until the ambulance arrives. Restoration of breathing can be a reason to stop chest compressions and artificial respiration, since the appearance of oxygen in the blood contributes to the activation of the brain.

After successful resuscitation, the patient is hospitalized in a specialized cardiac intensive care unit or cardiology department. In a hospital setting, specialists will be able to establish the causes of sudden coronary death, draw up a plan for effective treatment and prevention.

Possible complications in survivors

Even with successful cardiopulmonary resuscitation, survivors of sudden coronary death may experience the following complications of this condition:

chest injuries due to resuscitation;
serious deviations in the activity of the brain due to the death of some of its areas;
disorders of blood circulation and functioning of the heart.

It is impossible to predict the possibility and severity of complications after sudden death. Their appearance depends not only on the quality of cardiopulmonary resuscitation, but also on the individual characteristics of the patient's body.

How to avoid sudden coronary death

One of the most important measures to prevent sudden coronary death is to give up bad habits, in particular, smoking.

The main measures to prevent the onset of such deaths are aimed at the timely detection and treatment of people suffering from cardiovascular diseases, and social work with the population, aimed at familiarizing themselves with the groups and risk factors for such deaths.

Patients who are at risk of sudden coronary death are recommended to:

Timely visits to the doctor and the implementation of all his recommendations for treatment, prevention and follow-up.
Rejection of bad habits.
Proper nutrition.
The fight against stress.
Optimum mode of work and rest.
Compliance with the recommendations on the maximum permissible physical activity.

Patients at risk and their relatives must be informed about the likelihood of such a complication of the disease as the onset of sudden coronary death. This information will make the patient more attentive to his health, and his environment will be able to master the skills of cardiopulmonary resuscitation and will be ready to perform such activities.

beta blockers;
calcium channel blockers;
antiplatelet agents;
antioxidants;
Omega-3, etc.

implantation of a cardioverter-defibrillator;
radiofrequency ablation of ventricular arrhythmias;
operations to restore normal coronary circulation: angioplasty, stenting, coronary artery bypass grafting;
aneurysmectomy;
circular endocardial resection;
extended endocardial resection (may be combined with cryodestruction).

For the prevention of sudden coronary death, the rest of the people are recommended to lead a healthy lifestyle, regularly undergo preventive examinations (ECG, Echo-KG, etc.), which allow detecting heart pathologies at the earliest stages. In addition, you should consult a doctor in a timely manner if you experience discomfort or pain in the heart, arterial hypertension and pulse disorders.

Of no small importance in the prevention of sudden coronary death is familiarization and training of the population in the skills of cardiopulmonary resuscitation. Its timely and correct implementation increases the chances of survival of the victim.

Cardiologist Sevda Bayramova talks about sudden coronary death:

Watch this video on YouTube

Dr. Dale Adler, a Harvard cardiologist, explains who is at risk for sudden coronary death:

Watch this video on YouTube

Each organ of the human body performs a specific function. In the structural hierarchy, the heart occupies one of the leading positions in ensuring viability.

If there is a violation of cardiac activity, there is a risk of developing threatening conditions. About 80% of circulatory arrest is associated with the occurrence of ventricular fibrillation, the remaining violations are associated with asystole and electromechanical dissociation.

The causes on the basis of which acute coronary insufficiency and sudden death occur are the primary factor that triggers a cascade of pathological mechanisms.

The essence of pathology

Acute coronary insufficiency is a condition in which the myocardial demand for oxygen and nutrients exceeds the supply of important substances.

The severity of the process is characterized by the sudden onset of a shortage of the necessary components.

Since the work of the heart muscle requires high energy consumption, reserve reserves are quickly exhausted in the myocardium and cells begin to die primarily from a lack of oxygen. Dead tissue is not able to perform its function. The site of necrosis, located in the path of the conduction system of the heart, provokes the occurrence of arrhythmia. Cell death, covering a large part of the myocardium, entails a direct violation of the contractile function. Thus, acute coronary insufficiency is a dangerous condition, on the basis of which sudden cardiac arrest can quickly occur.

What can cause

Most cases of acute insufficient blood supply to the myocardium occur against the background of an existing chronic pathology:

The presence of blood clots in the venous bed (varicose veins). The detached clot closes the lumen of the artery, disrupts the blood flow of this zone. This mechanism is observed in any thromboembolism, but is most dangerous in the case of overlapping of the pulmonary, cerebral and coronary vessels.
Atherosclerotic lesions of the coronary branches narrow the lumen of the arteries. The impact of additional factors (spasm, trauma, local inflammation) leads to complete blockage of the vessel.
Stress, alcohol, nicotine intoxication lead to the release of biologically active substances, leading to the occurrence of coronary spasm.
Mechanical compression of the coronary arteries from the outside with a nearby tumor or metastasis.
Coronary arteritis (due to initial edema and subsequent sclerotic wall changes after recovery).
Vascular injury.

Possible outcomes

Ischemic changes due to impaired cardiac blood supply may not have significant clinical manifestations. With further aggravation of the situation, an increase in symptoms occurs up to the development of threatening conditions.

An extreme option for a sharp deterioration in the condition is sudden coronary death.

Manifestations of insufficiency of coronary circulation

Clinical variability in insular coronary insufficiency depends on the level and degree of ischemia.

Significant manifestations are noted in the form of angina pectoris. Patients note chest pains of varying degrees of intensity, with possible irradiation to the scapula, shoulder, shoulder girdle and hand.

Symptoms may be excessively pronounced, lasting more than an hour. At the same time, patients are covered by a feeling of panic, fear of dying.

Such a clinic makes it possible to suspect an incipient heart attack.

Deficiency of blood supply to the myocardium further leads to the development of heart failure, which is accompanied by pallor of the skin, cyanosis.

Stagnation of blood in the lungs leads to sweating of the plasma into the alveoli, pulmonary edema develops, which aggravates the situation.

Insufficient supply of oxygen to the brain turns into a critical loss of consciousness.

If the blood supply to the myocardium is completely and rapidly cut off, the heart becomes incapable of adequate contraction. Sudden coronary death develops without a previous visible deterioration in the condition.

Priority Actions

Treatment of cardiovascular disorders is divided into stages. The initial and simple, carried out with a minimum set of medicines is the provision of self-help.

The lack of qualified skills does not detract from the importance of the activities.

Often timely taking the necessary pills at the very beginning of clinical manifestations becomes a salvation for the patient.

It should be noted that all existing universal self-help algorithms are the basis for drawing up an individual action plan for a particular patient.

For a patient with chronic cardiac pathology, advice on self-help in emergency situations is provided by his attending physician.

Among the basic medicines, nitroglycerin in tablet form or spray is used, aspirin or clopidogrel is indicated for the prevention of complications.

In the medicine cabinet of patients with arterial hypertension should be antihypertensive drugs (enalapril, anaprilin).

Resuscitation measures

Acute coronary insufficiency can cause sudden clinical death. Any person who witnesses a circulatory arrest can save the victim's life. To do this, it is enough to master the basic skills of cardiopulmonary resuscitation.

First of all, if such a situation arises, you should call the number "03" or "112". Depending on the mobile operator of the calling person, ambulance numbers are dialed as "030" for MTS, Megafon, Tele-2 and "003" for Beeline.

The assisting hands are placed on the lower third of the sternum, straightened at the elbows, the hands are crossed and compressions begin. The depth of pressure is about 1/3–1/2 of the chest (5–6 cm for an adult victim). They try to achieve a frequency of compressions up to 100 times per minute.

Cardiac massage is accompanied by mechanical ventilation with a frequency of 30 pressures per 2 breaths. When performing with two people, it is important to remember that the person performing the compressions must count down the compressions in reverse order, starting from 5, this is done out loud. Such an organization helps to coordinate the actions of both rescuers.

Further actions

Sudden coronary death, with adequate initial measures and a favorable set of circumstances, may not lead to the development of biological dying of the organism.

But before the patient's condition stabilizes and improves, the patient needs qualified medical care.

Paramedics, and then doctors, administer intravenous infusion of drugs, it may be necessary to use thrombolytic drugs, connect apparatus oxygenation and implement other intensive care measures.

Every year, a huge number of deaths from sudden cardiac arrest are recorded, even among relatively young people.

Preventive measures help prevent the development of threatening conditions, so it is important to timely identify existing deviations, observe the exercise regime, proper nutrition and give up bad habits.

Sudden coronary death is an extremely dangerous condition, which is the cessation of the work of the heart. With the timely provision of first aid, it is possible to restore its activity and bring the person to consciousness. Sudden coronary death is always associated with some internal pathology and often has certain precursors.

It is customary to distinguish 3 main causes of sudden coronary death. Each of them accounts for a certain proportion of cases:

Primary ventricular fibrillation of the heart - 70-75% of cases. With this diagnosis, the ventricles contract with an intensity of up to 500 beats per minute. The result of this is the impossibility of a full-fledged pumping of blood by the heart;
Bradiametry and asystole of the ventricles of the heart - 20-25% of cases. Pathological decrease in the number of contractions at a rate of 60 beats per minute;
Paroxysmal ventricular tachycardia - 5-10% of cases. The number of contractions reaches 200 per minute.

Provoking factors can be:

myocardial infarction;
Imbalance of vegetative tone;
hypokalemia;
Hypomagnesemia;
Severe tachycardia;
Ventricular extrasystole;
toxic factors.

All of these pathologies are serious and, as a rule, do not go unnoticed.

At-risk groups

There are certain groups of people in whom the risk of sudden coronary death may be related to their health status or lifestyle. These include the following events:

Hypertension, expressed in pathologically elevated blood pressure;
Left ventricular hypertrophy;
Heart failure;
Rapid heart rate of 90 beats per minute and above;
Postponed myocardial infarction;
Postponed cardiac resuscitation;
Diabetes;
Obesity;
Abuse of bad habits: smoking, alcohol;
Unstable mental state under the influence of stressful situations.

In those people who are suitable for several of these factors at once, the risk accordingly increases even more.

Clinical manifestations

All clinical symptoms of the syndrome of sudden coronary death can be divided into 2 groups: precursors and immediate signs at the time of the attack.

Harbingers

The first group, namely the harbingers of the patient's possible imminent death, include:

Impaired breathing, which can be expressed in its delay;
Tachycardia - rapid heartbeat;
Bradycardia - slow heartbeat;
Poorly palpable pulse;
Pathologically low blood pressure;
Cyanosis;
Pain in the chest area, as a rule, of a pressing nature;
The appearance of fluid in the lungs.

Unfortunately, not all these phenomena are taken seriously by people and immediately seek medical help. For example, a large number consider tachycardia, if it is not expressed acutely, not a terrible pathology.

Also among the harbingers that may not cause concern are increased fatigue and sleep disturbance. Patients may perceive these signs as the result of hard work or heavy physical exertion.

The main symptoms of an attack

The second group, which includes specific signs that indicate an attack in a patient, include:

Body cramps;
Disturbed breathing. It looks like this: at first it is noisy and deep, and then it begins to weaken sharply;
Loss of consciousness;
Dilated pupils of the eyes.

It is worth pointing out that 25% of patients die from sudden coronary death syndrome instantly, that is, without these signs.

After the heart has stopped, there are 3 minutes until irreversible processes in the brain and spinal cord begin.

Diagnostics

It is necessary to diagnose coronary death immediately at the time of deterioration of the victim's condition. Otherwise, inevitable death from acute coronary insufficiency.

This must be done very quickly, otherwise there will be no time for resuscitation.

Signs of coronary death are:

Loss of consciousness in the victim. He does not answer the question and does not respond to any physical influences;
Lack of pupillary response to light;
Absence of a palpable pulse;
Inability to determine the level of blood pressure.

If the victim has these symptoms, it is urgent to start providing first aid to him.

Urgent care

Emergency care for sudden coronary death is very important. The life of a person depends on their correctness and timeliness. If suddenly a nearby person becomes ill and the symptoms are very similar to the state of coronary death, it is urgent to act. The steps to be taken should look like this:

Call an ambulance. It is best if another person does this, since every minute is precious;
Make sure the person is unconscious. If he is able to answer questions, then the surest solution is to simply lay him down, provide fresh air and monitor his condition until the ambulance arrives. If he is not conscious, then it is necessary to begin to carry out resuscitation;
The victim is laid on a flat horizontal surface and his airways are released. For this: the head is thrown back, and with a free hand, its lower jaw is pushed to the top. If necessary, they pull out the sunken tongue or remove interfering vomit;
They are convinced that breathing is absent or it is disturbed and does not correspond to normal;
Begin to carry out a closed heart massage. Its mechanism lies in the fact that the palm of the hand is placed on the chest of the victim, the second palm is placed on top of it and rhythmic pressure is started. The depth of pressure should be approximately 5 centimeters. With the wrong actions, you can damage the chest;
Closed heart massage can be effectively combined with mouth-to-mouth artificial respiration. It consists in the fact that the person conducting resuscitation takes a deep breath and exhales it into the victim's mouth. It is recommended to take 2 breaths every 15 compressions.
Every 3-4 minutes, the condition of the victim should be checked. If his breathing is restored and he regains consciousness, then you can stop resuscitation and provide him with a comfortable and safe position until the ambulance arrives. If the condition does not improve, then heart massage and artificial respiration should be done until the ambulance arrives.

If sudden coronary death syndrome occurred within the walls of a medical institution, then, as a rule, resuscitation is carried out using a defibrillator.

Unfortunately, if during an attack there are no people nearby who are able to provide assistance, the patient is likely to suffer a sudden death.

Possible Complications

Sudden coronary death is a very serious and dangerous condition of the body. Fortunately, it can be reversible and, with timely medical assistance, the victim can be brought back to consciousness. The big disadvantage is that those who managed to survive after an attack almost always have consequences of a different nature.

Possible complications include:

being in a coma;
Violations of the central nervous system;
The death of some parts of the brain, as a result of which it ceases to perform certain functions;
Circulatory disorders;
Pathology of the heart;
Damage to the ribs due to a violation of the technique of resuscitation.

In this case, it is very difficult to say what the risk is in each individual case. First of all, it all depends on the condition of the victim, his immune system and the characteristics of the body, and how soon the resuscitation was carried out.

Recovery can take a very long time. The role in this, in addition to the individual characteristics of the patient, will also depend on his own efforts and, of course, the professionalism of the doctors who will carry out the treatment.

Prevention

Probably, few people think about the prevention of such a condition as sudden coronary death. Most often, awareness comes when the place has already had some kind of attack associated with the work of the heart.

Still, I would like people to take the risk of this phenomenon more seriously and adhere to preventive recommendations until there are already violations in the body. In order to reduce the risk of coronary death, as well as related pathologies, the following tips should be followed:

Adhere to a healthy lifestyle: give up bad habits;
Do sport. It could be swimming or even gymnastics. Or you can just take daily walks;
Avoid stressful situations;
Stick to proper nutrition and avoid obesity. Nutrition should be balanced and contain all substances important for the body: proteins, fats, carbohydrates, vitamins, microminerals;
Comply with work and rest schedules. Wear and tear is one of the popular causes of impaired heart function;
Timely treatment of diseases and prevention of their transition to a chronic form.

In order to prevent the state of sudden coronary death, it is necessary to periodically undergo a preventive medical examination. Those people who are at risk, you need to approach this item especially seriously.

Every year, approximately 15% of the adult population of our country dies from various heart diseases. One of the most common cases is sudden coronary death (SCD), or in other words, unexpected cardiac arrest. This disease most often affects men under the age of 55 years. Sometimes a sudden cessation of cardiac activity is recorded in children under three years of age, and is one case in a hundred thousand.

Sudden coronary death occurs due to malfunctions in the electrical heart system. These disorders lead to very rapid contractions of the heart, which in turn provoke atrial and ventricular flutter and fibrillation. As a result of failures, blood stops flowing to vital organs.

Without proper medical care, the death of the patient occurs within a few minutes. Cardiopulmonary resuscitation, which is performed manually or with portable defibrillators, can bring him back to life.

The principle of resuscitation is that under the action of squeezing the chest and filling the lungs with air through the mouth, the patient receives oxygen to nourish the brain and restore cardiac activity.

Classification and forms

A person can die not only from a long illness. A striking example of this is sudden coronary death. This condition becomes a consequence of violations of the contractile functions of the left and right ventricles of the heart.

The International Classification of Diseases divides sudden coronary death into two forms:

Clinical VKS. This form allows you to bring the patient back to life, even if he is unconscious and his breathing is not heard.
Biological VKS. Carrying out cardiopulmonary resuscitation in such a situation will not help to save the patient.

This disease has even been assigned a special code - ICD-10.

Based on the speed of onset, this state is divided into instant and fast. In the first case, a lethal outcome is noted after a few seconds. If death occurs within an hour, then we are talking about a quick form.

Causes

Having understood what acute coronary death is, an important issue for patients suffering from cardiovascular diseases remains to determine the reasons why this happens. The main factors provoking the occurrence of VKS include:

aortocoronary heart attack, resulting in damage to the middle muscle layer of the heart - myocardium;
the presence of coronary heart disease (CHD), which increases the risk of sudden cardiac death by 80%;
insufficient levels of potassium and magnesium in the body;
primary and secondary case of cardiomyopathy, contributing to the deterioration of the pumping function of the heart;
unhealthy lifestyle, alcoholism, overweight, diabetes;
congenital heart defects, cases of instant cardiac death in relatives;
coronary arteriosclerosis.

Knowing the causes of acute coronary death, it is necessary to do everything possible to prevent the development of VCS.

Symptoms of sudden coronary death

Pathoanatomy highlights several characteristic symptoms for this condition, including:

strong heartbeat;
increasing shortness of breath;
attacks of pain near the heart;
a noticeable decrease in performance;
fast fatiguability;
frequent attacks of arrhythmia;
sudden dizziness;
loss of consciousness.

Some of these signs are especially common in people who have experienced a heart attack. They should definitely be regarded as harbingers of an approaching threat. They indicate an exacerbation of pathologies of the cardiovascular system. Therefore, at the first symptoms of impending danger, you should seek medical help as soon as possible. Otherwise, all this can end badly.

Diagnostics

An important diagnostic measure for identifying problems in the work of the heart is the ECG. If VCS is suspected, the patient's electrocardiogram shows erratic, undulating contractions during fibrillation. In this case, the heart rate can reach 200 beats per minute. When a straight line appears instead of waves, this indicates cardiac arrest.

If resuscitation was successful, then the patient will have to undergo multiple laboratory tests in the hospital. In addition to donating blood and urine, a toxicological test can be carried out regarding drugs that can provoke an arrhythmia.

It is mandatory to perform coronary angiography, daily ECG monitoring, ultrasound of the heart, electrophysiological examination and stress testing.

Treatment

Only emergency care for sudden coronary death will help bring a person back to life. The patient must be placed on a solid base and the carotid artery checked. If respiratory arrest is observed, heart massage should be alternated with artificial ventilation of the lungs. Resuscitation involves applying a single blow in the middle of the sternum.

The emergency action algorithm is as follows:

indirect heart massage (up to 90 pressures in 60 seconds);
artificial respiration (30 seconds);
defibrillation requiring the use of special equipment;
intravenous supply of adrenaline and "Lidocaine" through the inserted catheter.

In the absence of a proper result, the patient is administered "Ornid", "Novocainamide", "Magnesium sulfate". With asystole, an emergency administration of the drug "Atropine" is required.

If a person managed to avoid a sudden death, further therapy involves the prevention of relapse.

Disease prevention

Informing patients at risk, as well as their family members, about the possible consequences of this dangerous condition can be considered as preventive methods for preventing VCS.

The principles of prevention are as follows:

taking care of your health;
timely intake of prescribed medications;
compliance with medical recommendations.

Pharmacological support helps to achieve a good effect. As a rule, patients with heart disease are prescribed antioxidants and beta-blockers. Of the drugs, Aspirin, Curantil, Preductal can be used.

At the same time, it is very important to give up bad habits, if possible, avoid stress and excessive physical exertion. In the presence of cardiac pathologies, the patient should not stay in rooms where it is too stuffy for a long time.

Complications

Even a successful resuscitation is not a guarantee that a person will not experience complications after VKS. Most often they appear as:

circulatory disorders;
failures in the work of the heart;
disorders of the nervous system;
chest trauma.

It is almost impossible to predict the severity of complications. Their occurrence largely depends on the quality of the resuscitation and the individual characteristics of the human body.

Forecast

Coronary death is a reversible condition, but subject to emergency medical care. Many patients after cardiac arrest suffer from CNS disorders. Some patients remain in a coma. In such situations, the prognosis depends on the following factors:

the quality of resuscitation;
the state of health of the patient before the cessation of cardiac activity;
the time interval from the onset of cardiac arrest to the start of resuscitation.

To avoid such problems, patients should lead a healthy lifestyle, attend exercise therapy classes and follow the instructions of the attending physician. It is very important to eat right, observe the regime of work and rest. Such simple recommendations will help you feel good and eliminate the risk of acute coronary death.

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Version: Directory of Diseases MedElement

Sudden cardiac death so described (I46.1)

Cardiology

general information

Short description

Sudden cardiac death - it is a non-violent death caused by heart disease and manifested by sudden loss of consciousness within 1 hour of the onset of acute symptoms. Prior heart disease may or may not be known, but death is always unexpected. Attention!

Sudden cardiac death includes cases of sudden cessation of cardiac activity, which are characterized by the following symptoms:

Death occurred in the presence of witnesses within one hour of the onset of the first dangerous symptoms;

The patient's condition before the onset of death was assessed by others as stable and not causing serious unrest;

The death occurred under circumstances excluding its other causes (injury, violent death, other fatal diseases).

Classification

Depending on the duration of the interval between the onset of a heart attack and the moment of death, there are:

Instant cardiac death (the patient dies within a few seconds, that is, almost instantly);

Rapid cardiac death (the patient dies within 1 hour).

Etiology and pathogenesis

Most common causes of sudden cardiac death in young people:
- inflammatory diseases of the myocardium;
- cardiomyopathy;
- long QT interval syndrome;
- heart defects (in particular, narrowing of the aortic orifice);
- anomalies of the thoracic aorta in Marfan's syndrome;
- anomalies of the coronary arteries;
- violations of the heart rhythm and conduction;
- rarely - undiagnosed coronary atherosclerosis. Attention!

The main factors provoking sudden cardiac death among young people:
- physical extreme overstrain (for example, during sports competitions);
- the use of alcohol and drugs (for example, cocaine causes a strong and prolonged spasm of the coronary arteries up to the development of myocardial infarction);
- alcoholic excesses (especially the use of alcoholic surrogates);
- taking certain drugs (for example, tricyclic antidepressants can cause a significant delay in the conduction of excitation);
- Severe electrolyte disturbances.

In persons over 40 years of age, especially in the elderly and the elderly, the main etiological factor in sudden cardiac death is coronary heart disease (CHD). In this case, we are talking, as a rule, about severe stenosing atherosclerosis of two or three main coronary arteries.
Autopsy of such patients usually reveals erosions or tears in atherosclerotic plaques, signs of aseptic inflammation and plaque instability, mural thrombosis of the coronary arteries, and significant myocardial hypertrophy. In 25-30% of patients, foci of necrosis are found in the myocardium.

Basic pathophysiological mechanisms

A specific pattern of sudden cardiac death has been identified, observed due to the close interaction of structural and functional elements: under the influence of functional disorders, destabilization of structural elements occurs.

Structural disorders include:
- myocardial infarction (the most common structural category);
- myocardial hypertrophy;
- cardiomyopathy;
- Structural electrical disorders (additional pathways in Wolff-Parkinson-White syndrome).

Functional disorders:
- transient ischemia and myocardial perfusion;
- systemic factors (hemodynamic disturbances, acidosis, hypoxemia, electrolyte disturbances);
- neurophysiological interactions (dysfunction of the autonomic nervous system that regulates the work of the heart);
- toxic effects (cardiotoxic and prorhythmic substances).

Electrical instability of the myocardium (ventricular fibrillation or flutter) occurs as a result of the fact that risk factors from the category of structural disorders interact with one or more provoking functional factors.

Mechanisms that can cause sudden cardiac death:

1. ventricular fibrillation- n the most common mechanism (noted in 90% of cases). Chaotic excitation of individual muscle fibers and the absence of coordinated whole ventricular contractions are characteristic; irregular, chaotic movement of the wave of excitation.

2. - coordinated contractions of the ventricles are noted, but their frequency is so high (250-300 / min.) That there is no systolic ejection of blood into the aorta. Ventricular flutter is caused by a steady circular motion of the re-entry excitation wave impulse, which is localized in the ventricles.

3. Asystole of the heart- complete cessation of cardiac activity. Asystole is caused by a violation of the automatism function of pacemakers of the 1st, 2nd, 3rd order (weakness, stop of the sinus node with depletion or lack of function of the underlying drivers).

4. Electromechanical dissociation of the heart - the cessation of the pumping function of the left ventricle with the preservation of signs of electrical activity of the heart (gradually depleted sinus, junctional rhythm or rhythm turning into asystole).

Epidemiology

Prevalence sign: Common

Sex ratio (m/f): 2

Approximately 80% of sudden cardiac death cases are due to ischemic heart disease (Mazur N. A., 1999). This type of sudden death may also be referred to as sudden coronary death (SCD).

Distinguish two age-related types of sudden cardiac death:

Among newborns (in the first 6 months of life);
- in adults (aged 45-75 years).
The frequency of sudden cardiac death among newborns is about 0.1-0.3%.
Between the ages of 1-13 years, only 1 in 5 sudden deaths are due to heart disease; at the age of 14-21 this figure rises to 30%.
In middle and old age, sudden cardiac death is recorded in 88% of all cases of sudden death.

There are also gender differences in the incidence of sudden cardiac death.
In young and middle-aged men, sudden cardiac death is observed 4 times more often than in women.
In men aged 45-64 years, sudden cardiac death is recorded 7 times more often than in women.
At the age of 65-74 years, the frequency of sudden cardiac death in men and women is noted in the ratio of 2:1.

Thus, the incidence of sudden cardiac death increases with age and is higher in men than in women.

Factors and risk groups

Numerous population-based studies have identified group of risk factors sudden coronary death(VCS) that are common with coronary heart disease (CHD):

Elderly age;

Male gender;

Family history of CAD;

Elevated low-density lipoprotein (LDL) cholesterol levels;

hypertension;

Smoking;

Diabetes.

Risk Factors - Independent Predictors of VCS in IHD Patients:

1. Increase in heart rate at rest.

2. Prolongation and increase in the dispersion of the QT interval (evidence of electrical inhomogeneity of the myocardium, an increase in the heterogeneity of repolarization and a tendency to ventricular fibrillation).

3. Decrease in heart rate variability (indicates an imbalance in autonomic regulation with a decrease in the activity of the parasympathetic division and, as a result, a decrease in the threshold of ventricular fibrillation).

4. Genetic predisposition (long QT syndrome, Brugada syndrome, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, catecholaminergic polymorphic ventricular tachycardia).

5. Left ventricular hypertrophy (determinants are age, overweight and body type, arterial hypertension, hyperglycemia, genetic predisposition).

6. ECG changes (voltage criteria for left ventricular hypertrophy, ST segment depression and T wave inversion).

7. Alcohol abuse (leads to prolongation of the QT interval).

8. Diet (regular consumption of seafood containing ω-3-polyunsaturated fatty acids reduces the risk of VKS).

9. Excessive physical overexertion (potentiates the effect of other predictors).

Predictors of VCS associated with clinical manifestations of coronary artery disease:

1. Myocardial ischemia and related conditions (hibernating or stunned myocardium).

2. History of myocardial infarction (VCS can occur in 10% of patients who have had a myocardial infarction, and in the next 2.5 years, while a new episode of ischemia may be an important cause).

3. Ineffectiveness of thrombolytic therapy in the acute period of myocardial infarction (patency of the infarcted coronary artery grade 0-1 according to TIMI-1).

4. Reduction of the left ventricular ejection fraction below 40% and III-IV functional class of heart failure (NYHA).

5. High-risk unstable angina.

6. Ventricular fibrillation in history.

Clinical picture

Clinical Criteria for Diagnosis

Lack of consciousness; lack of breathing or sudden onset of agonal type breathing (noisy, rapid breathing); absence of a pulse in the carotid arteries; dilated pupils (if drugs were not taken, neuroleptanalgesia was not performed, anesthesia was not given, there is no hypoglycemia; change in skin color, the appearance of a pale gray color of the skin of the face

Symptoms, course

Irreversible changes in the cells of the cerebral cortex occur approximately 3 minutes after a sudden cessation of blood circulation. For this reason, the diagnosis of sudden death and the provision of emergency care must be prompt.

Ventricular fibrillation always comes on suddenly. 3-4 seconds after its onset, dizziness and weakness occur, after 15-20 seconds the patient loses consciousness, after 40 seconds characteristic convulsions develop - a single tonic contraction of skeletal muscles. At the same time ( after 40 - 45 seconds) the pupils begin to expand, reaching a maximum size after 1.5 minutes.
The maximum expansion of the pupils indicates that half of the time has passed, during which the restoration of brain cells is possible.

Frequent and noisy breathing gradually becomes less frequent and stops at the 2nd minute of clinical death.

The diagnosis of sudden death should be made immediately, within 10-15 seconds (no precious time should be wasted measuring blood pressure, looking for a pulse on the radial artery, listening to heart sounds, recording an ECG).

The pulse is determined only on the carotid artery. To do this, the index and middle fingers of the doctor are located on the patient's larynx, and then, sliding to the side, without strong pressure, they probe the side surface of the neck at the inner edge of m.sternocleidomastoideus Sternocleidomastoid muscle
at the level of the upper edge of the thyroid cartilage.

Diagnostics

At the moment of clinical death of the patient, the following changes are recorded on the ECG monitor.

1. ventricular fibrillation: random, irregular, sharply deformed waves of various heights, widths and shapes, reflecting the excitation of individual muscle fibers of the ventricles.
Initially, fibrillation waves are usually high-amplitude, occurring at a frequency of about 600/min. The prognosis for defibrillation at this stage is more favorable than for the next stage.
Then the flicker waves become low-amplitude with a wave frequency of up to 1000 and more per 1 minute. The duration of this stage is about 2-3 minutes, after which the duration of the flicker waves increases, their amplitude and frequency decrease (up to 300-400/min.). Defibrillation at this stage is no longer always effective.
Ventricular fibrillation is in many cases preceded by episodes of paroxysmal ventricular tachycardia Ventricular paroxysmal tachycardia (VT) - in most cases, this is a sudden onset and just as suddenly ending attack of increased ventricular contractions up to 150-180 bpm. per minute (less often - more than 200 beats per minute or within 100–120 beats per minute), usually while maintaining the correct regular heart rate.
, sometimes - bidirectional ventricular tachycardia (pirouette type). Before the development of ventricular fibrillation, frequent polytopic and early extrasystoles (type R to T) are often recorded.

2.When ventricular flutter The ECG registers a curve resembling a sinusoid with frequent rhythmic, wide, rather large and similar waves, reflecting the excitation of the ventricles. Isolation of the QRS complex, ST interval, T wave is impossible, there is no isoline. Usually, the flutter of the ventricles turns into their flicker. The ECG picture of ventricular flutter is shown in fig. one.

Rice. 1. Ventricular flutter

3. When heart asystole The ECG registers an isoline, there are no waves or teeth.

4.When electromechanical dissociation of the heart on the ECG, a rare sinus, nodal rhythm may be noted, turning into a rhythm, which is then replaced by asystole. An example of an ECG during electromechanical dissociation of the heart is shown in Fig. 2.

Rice. 2. ECG with electromechanical dissociation of the heart

Differential Diagnosis

During resuscitation, it must be borne in mind that a clinical picture similar to signs of sudden death in ventricular fibrillation can also be observed in cases of asystole, severe bradycardia, electromechanical dissociation during rupture and cardiac tamponade, or pulmonary embolism (PE).

With immediate registration of the ECG, it is relatively easy to conduct an emergency differential diagnosis.

When ventricular fibrillation a characteristic curve is observed on the ECG. To register the complete absence of electrical activity of the heart (asystole) and delimit it from the atonic stage of ventricular fibrillation, confirmation is required in at least two ECG leads.

At cardiac tamponade or acute PE blood circulation stops, and the electrical activity of the heart in the first minutes is preserved (electromechanical dissociation), gradually fading.

If immediate ECG recording is not possible, they are guided by how the onset of clinical death proceeds, as well as by the reaction to closed heart massage and artificial ventilation of the lungs.

At ventricular fibrillation effective contractions of the heart are not recorded and clinical death always develops suddenly, simultaneously. Its clinical onset is accompanied by a typical single tonic contraction of the skeletal muscles. Breathing is maintained for 1-2 minutes in the absence of consciousness and pulse on the carotid arteries.
In the case of advanced SA- or AV-blockade, a gradual development of circulatory disorders is observed, as a result of which the symptoms are extended in time: first, clouding of consciousness is noted, after - motor excitation with a groan, wheezing, then - tonic-clonic convulsions (Morgagni-Adams-Stokes syndrome). ).

At acute form of massive PE Clinical death occurs suddenly, usually at the moment of physical exertion. The first manifestations are often respiratory arrest and a sharp cyanosis of the skin of the upper half of the body.

Cardiac tamponade, as a rule, is observed against the background of severe pain syndrome. Sudden circulatory arrest occurs, there is no consciousness, there is no pulse on the carotid arteries, breathing persists for 1-3 minutes and gradually fades, there is no convulsive syndrome.

In patients with ventricular fibrillation, there is a clear positive reaction to timely and correct cardiopulmonary resuscitation (CPR), while a short-term cessation of resuscitation measures has a rapid negative trend.

In patients with Morgagni-Adams-Stokes syndrome, timely initiated closed heart massage (or rhythmic tapping on the sternum - "fist rhythm") improves blood circulation and respiration, and consciousness begins to recover. After CPR is stopped, positive effects persist for some period.

With PE, the response to resuscitation is fuzzy; as a rule, a sufficiently long CPR is required to obtain a positive result.

In patients with cardiac tamponade, achieving a positive effect due to cardiopulmonary resuscitation is impossible even for a short period; symptoms of hypostasis in the underlying sections are rapidly increasing.

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Treatment

Emergency care algorithm for sudden cardiac death

1. If it is impossible to conduct immediate defibrillation, it is necessary to produce a precordial shock.

2. In the absence of signs of blood circulation, make an indirect heart massage (60 times per 1 minute with a ratio of the duration of compression and decompression of 1: 1), after laying the patient on a hard, flat surface with the head thrown back as much as possible and legs raised; ensure defibrillation is possible as soon as possible.

3. It is necessary to ensure the patency of the respiratory tract: throw back the patient's head, push his lower jaw forward and open his mouth; in the presence of spontaneous breathing - turn your head to one side.

4. Start artificial lung ventilation (ALV) mouth to mouth or through a special mask using an Ambu bag (the ratio of massage movements and breathing is 30:2); do not interrupt heart massage and ventilation for more than 10 seconds.

5. Catheterize a central or peripheral vein and set up an intravenous drug delivery system.

6. Under constant control, carry out resuscitation measures to improve the color of the skin, constriction of the pupils and the appearance of their reaction to light, the resumption or improvement of spontaneous breathing, the appearance of a pulse on the carotid arteries.

7. Inject adrenaline intravenously at 1 mg, at least 1 time in 3-5 minutes.

8. Connect a heart monitor and defibrillator, evaluate the heart rate.

9. With ventricular fibrillation or ventricular tachycardia:

Defibrillation 200 J;

Carry out closed heart massage and mechanical ventilation in pauses between discharges;

In the absence of effect - repeated defibrillation 300 J;

In the absence of effect - after 2 minutes, repeated defibrillation 360 J;

In the absence of effect - amiodarone 300 mg intravenously in 5% glucose solution, after 2 minutes - defibrillation 360 J;

If there is no effect - after 5 minutes - amiodarone 150 mg intravenously in 5% glucose solution, after 2 minutes - defibrillation 360 J;

- with no effectlidocaine 1.5 mg/kg, after 2 minutes - defibrillation 360 J;

In the absence of effect - after 3 minutes - lidocaine 1.5 mg / kg, after 2 minutes - defibrillation 360 J;

In the absence of effect - novocainamide 1000 mg, after 2 minutes - defibrillation 360 J.

With the initial spindle-shaped ventricular tachycardia, it is necessary to introduce magnesium sulfate 1-2 g intravenously slowly.

10. With asystole:

10.1 If the assessment of the electrical activity of the heart is not possible (it is impossible to exclude the atonic stage of ventricular fibrillation, it is impossible to quickly connect an ECG monitor or an electrocardiograph), you should proceed as in case of ventricular fibrillation (point 9).

10.2 If asystole is confirmed in two ECG leads, atropine should be administered every 3-5 minutes at 1 mg until an effect or a total dose of 0.04 mg / kg is obtained, in addition to cardiopulmonary resuscitation. Transthoracic or transvenous pacing should be initiated as soon as possible. 240-480 mg of aminophylline.

11. If there are signs of blood circulation, continue mechanical ventilation (control every minute).

Time should not be wasted trying to provide oxygenation if the doctor observes the patient within 1 minute after the development of the collapse. An immediate hard blow to the precordial region of the chest (shock defibrillation) is sometimes effective and should be attempted. In rare cases, when the cause of the circulatory collapse was ventricular tachycardia, and the patient is conscious by the time the doctor arrives, strong coughing movements can interrupt the arrhythmia.

If it is not possible to restore circulation immediately, then an attempt should be made to perform electrical defibrillation without wasting time recording an ECG using an electrocardiograph. For this, portable defibrillators can be used, allowing ECG recording directly through their electrodes.
It is best to use devices with automatic selection of the discharge voltage depending on the tissue resistance. This makes it possible to minimize the dangers associated with the use of unreasonably large shocks, while at the same time avoiding ineffectively small shocks in patients with higher than expected tissue resistance.
Before applying the discharge, one defibrillator electrode is placed above the zone of cardiac dullness, and the second - under the right clavicle (or under the left shoulder blade if the second electrode is dorsal). Between the electrodes and the skin, wipes moistened with isotonic sodium chloride solution are laid or special conductive pastes are used.
At the moment of applying the discharge, the electrodes are pressed against the chest with force (within the framework of safety precautions, the possibility of others touching the patient should be excluded).

If these measures are unsuccessful, it is necessary to start external cardiac massage and carry out full cardiopulmonary resuscitation with rapid recovery and maintaining good airway patency.

External cardiac massage

External cardiac massage, developed by Kouwenhoven, is carried out in order to restore perfusion of vital organs by successive chest compressions with the hands.

Important aspects:

1. If efforts to bring the patient to his senses, calling him by name and shaking his shoulders, are unsuccessful, the patient should be laid on his back on a hard surface (preferably on a wooden shield).

2. To open and maintain airway patency, tilt the patient's head back, then, pressing hard on the patient's forehead, press the lower jaw with the fingers of the other hand and push it forward so that the chin rises up.

3. If there is no pulse on the carotid arteries for 5 seconds, chest compressions should be started. Methodology: the proximal part of the palm of one hand is placed in the lower part of the sternum in the middle, two fingers above the xiphoid process in order to avoid damage to the liver, then the other hand lies on the first, covering it with fingers.

4. Squeeze the sternum, shifting it by 3-5 cm, should be at a frequency of 1 time per 1 second, so that there is enough time to fill the ventricle.

5. The torso of the resuscitator should be above the chest of the victim so that the applied force is approximately 50 kg; the elbows should be straightened.

6. Compression and relaxation of the chest should take 50% of the entire cycle. Compressing too quickly creates a pressure wave (palpated over the carotid or femoral arteries), but little blood is ejected.

7. Massage should not be interrupted for more than 10 seconds, since cardiac output increases gradually during the first 8-10 compressions. Even a short stop of massage has an extremely negative effect.

8. The compression to ventilation ratio for adults should be 30:2.

Each compression of the chest from the outside causes the inevitable restriction of venous return to some extent. Thus, during external massage, the optimally achievable cardiac index can reach a maximum of 40% of the lower limit of normal values. This is significantly lower than the values observed in most patients after the restoration of their spontaneous ventricular contractions. In this regard, the early restoration of an effective heart rate is of fundamental importance.

Termination of cardiac massage is possible only when effective heart contractions provide a clear pulse and systemic blood pressure.

External cardiac massage has certain disadvantages because it can lead to complications such as rib fractures, hemopericardium and tamponade, hemothorax, pneumothorax, fat embolism, liver injury, rupture of the spleen with the development of late occult bleeding. But the danger of such complications can be minimized if resuscitation measures are correctly performed, timely recognition and further adequate actions are taken.

With prolonged cardiopulmonary resuscitation, the acid-base balance should be corrected by intravenous administration of sodium bicarbonate at an initial dose of 1 meq/kg. Half of this dose should be repeated every 10-12 minutes in accordance with the results of regularly determined arterial pH.

In the case when an effective heart rhythm is restored, but again quickly transforms into ventricular tachycardia or fibrillation, it is necessary to enter an intravenous bolus of 1 mg / kg of lidocaine, followed by an intravenous infusion at a rate of 1-5 mg / kg for 1 hour, repeating defibrillation.

Evaluation of the effectiveness of resuscitation measures

The ineffectiveness of the resuscitation carried out is evidenced by the lack of consciousness, spontaneous breathing, electrical activity of the heart, as well as the most dilated pupils without reaction to light. In these cases, the termination of resuscitation is possible not earlier than 30 minutes after the ineffectiveness of the measures was detected, but not from the moment of sudden cardiac death.

Forecast

The likelihood of recurrent sudden cardiac death insurviving patients is quite high.

Prevention

Primary prevention of sudden coronary death(VCS) in patients with coronary artery disease includes medical and social activities carried out in persons at high risk of its onset.

A set of measures for primary prevention:

1. Impact on the main risk factors for coronary artery disease and VCS.

2. The use of drugs without electrophysiological properties that affect the mechanisms of development of VCS and have proven their effectiveness in the course of clinical trials: ACE inhibitors, aldosterone receptor blockers Aldosterone is the main mineralocorticosteroid hormone of the adrenal cortex in humans.
, ω-3 polyunsaturated fatty acids (reduce the risk of VCS by 45%; have an antiarrhythmic effect due to interaction with sodium, potassium and calcium channels; contribute to the normalization of heart rate variability), statins. Showing thrombolytic therapy in acute myocardial infarction, antithrombotic therapy.