Sudden Cardiac Death ( SCD )



Sudden cardiac death, “defined as an unheralded, fatal outcome in an individual with previously stable clinical status, with symptoms occurring less then one hour [prior to] demise,” is a major public health concern and a potential professional liability risk. SCD occurs in 300,000 to 450,000 individuals per year in the United States, and in a study of vital statistics from 1998, SCD accounted for 63 percent of total deaths occurring out of hospital, in the emergency department or as dead-on-arrival.

SCD rates are strongly associated with coronary artery disease (CAD) and it is logical to apply CAD risk factors to predict SCD. However, SCD is not limited to CAD sufferers, and for different medical reasons can occur in other populations, such as youth and athletics. Despite extensive medical research on this topic, the mechanisms leading to SCD are still not completely understood and, as a result, prevention (outside the traditional CAD life-style modification strategies) remains controversial.

According to a recent article in the British medical journal Heart, current management of SCD is wrought with two overlapping problems:

• “We have a very limited ability to prevent SCD and must therefore depend on risk prediction and prophylactic implantation of an [implantable cardioverter-defibrillator].

• We are unable to predict SCD risk in patients with preserved ventricular function despite the fact that these patients account for approximately 50% of SCD victims.”

From a professional liability perspective, it is important then, to identify those patients who can be predicted to be at risk for SCD. Because CAD and its comorbidities account for the majority of SCD cases, it is obvious to begin with such patients (e.g., patients with a previous MI or who have been diagnosed with congestive heart failure). In managing this high-risk category of patients, physicians are encouraged to communicate honestly and directly about SCD and what can be done to mitigate risk. Patient education materials can be used to support conversations between the physician and patient (and or his or her family), and medical records documentation is evidence that verbal or written communication occurred.

It is more difficult to identify at-risk patients who do not have a known cardiac condition. There has been recent media attention on “healthy” pediatric-aged athletes who experienced sudden death on the playing flied or shortly after. This has lead to an increased emphasis on performing preparticipation sports evaluations to screen for unknown cardiovascular disease. While the physical work-up in asymptomatic patients for certain cardiovascular abnormalities can be unimpressive, the key to performing a thorough evaluation is taking a good history. Thoroughly documenting the detailed personal and family history will guide the physician’s approach to further work-up. As always the detailed history, physical examination findings and decision-making rationale to pursue (or not to pursue) specialized testing shows adherence to the standard of care.

In conclusion, while prevention and treatment for SCD remains complicated and limited, candid physician-patient communication, comprehensive history-taking and complete documentation are the fundamental elements of avoiding (or defending) a future malpractice claim.