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Sudden Cardiac Death Preceded by Warning Signs

  • Authors: News Author: Michael O'Riordan
    CME Author:
    Désirée Lie, MD, MSEd
  • CME Released: 9/5/2006; Reviewed and Renewed: 9/5/2007
  • Valid for credit through: 9/5/2008
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Target Audience and Goal Statement

This article is intended for primary care clinicians, cardiologists, emergency technicians, and other specialists who encounter patients presenting with sudden cardiac death.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Describe the most likely location, symptoms, and causes of sudden cardiac death.
  • Describe the duration of symptoms preceding and predictors of survival for sudden cardiac death.


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  • Michael O'Riordan

    Michael O'Riordan is a journalist for Medscape. Before becoming a journalist for, now part of the WebMD Professional Network, he worked for WebMD Canada. Michael studied at Queen's University in Kingston and the University of Toronto and has a master's degree in journalism from the University of British Columbia, where he specialized in medical reporting. He can be contacted at [email protected]


    Disclosure: Michael O’Riordan has disclosed no relevant financial relationships.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor of Family Medicine; Director, Division of Faculty Development, University of California, Irvine School of Medicine, Irvine, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

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Sudden Cardiac Death Preceded by Warning Signs

Authors: News Author: Michael O'Riordan CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME Released: 9/5/2006; Reviewed and Renewed: 9/5/2007

Valid for credit through: 9/5/2008


September 5, 2006 — In a study published in the September 4 Rapid Access issue of Circulation, investigators question how sudden is cardiac death and say their findings suggest that death might not emerge "suddenly out of the blue." Rather, they report that cardiac death is often preceded by symptoms of heart disease for more than an hour, suggesting that many patients have known cardiac disease before the fatal event.

"In conclusion, our data show that 'sudden cardiac death' is not nearly as sudden in most cases as the term may suggest. Warning symptoms that precede sudden cardiac death are present for a surprisingly long time in many patients. These symptoms are misinterpreted, suppressed, or denied despite the presence of a preexisting cardiac disease or cardiac risk factors," write Dirk Müller, MD, from the Universitätsmedizin Berlin in Berlin, Germany, and colleagues. The group also adds: "These findings suggest that educating the public, patients, and relatives to recognize and respond to symptoms of heart disease holds promise for reducing mortality attributed to sudden death."

To develop a better understanding of the circumstances of sudden cardiac death, with an intention of developing preventive measures and proper reactions to the impending events, Müller and colleagues collected information on cases of out-of-hospital sudden cardiac death in the emergency medical system of Berlin, Germany. At their center, a physician-manned mobile intensive care unit and rescue helicopter covered approximately 10% of the 3.5 million inhabitants of the city. During a case of sudden cardiac arrest, the emergency physician interviewed all available bystanders and witnesses via questionnaire. The questionnaire, developed during a previous pilot study, was used to obtain the patient's medical history, medication use, and any preceding signs or symptoms, as well as their duration.

Of 5831 rescue missions during a 1-year period, 406 involved patients with presumed cardiac arrest. In 72%, the arrest occurred at home, and in 67%, the arrest occurred in the presence of an eyewitness. Information on symptoms immediately preceding the event was available in 80% of all patients (n = 323), including 274 cases of witnessed cardiac arrest. Bystanders performed a resuscitation effort in just 57 patients, of whom 13 survived to discharge. Of those without bystander cardiopulmonary resuscitation (CPR), just 13 (3.72%) of 349 patients survived to discharge.

Information on the medical history was available in 352 patients. Of these, 106 had a history of coronary heart disease documented by angiography, while another 127 subjects had coronary disease as suggested by angina pectoris or antianginal medications. Approximately 10% of subjects had a history of hypertension. Regarding symptoms preceding the arrest, angina was present in 22% of patients with known symptoms for an average of 2 hours prior. Dyspnea, nausea/vomiting, and dizziness or syncope were other commonly reported symptoms.

Table 1. Type and Duration of Symptoms Preceding Arrest in Patients With Known Symptoms (N = 323)*

Symptoms Number (%) Duration, minute (range)
Angina pectoris 80 (22 120 (20 - 630)
Dyspnea 61 (15) 30 (10 - 375)
Nausea/vomiting 27 (7) 120 (20 - 420)
Dizziness/syncope 21 (5) 10 (5 - 60)
Other 23 (6) 60 (10 - 300)
No symptoms 103 (25) NA
*NA indicates not available. Source: Circulation. Published online September 4, 2006

Table 2. Type and Duration of Symptoms in Patients With a Witnessed Arrest (N = 274)

Symptoms Number (%) Duration, minute (range)
Angina pectoris 69 (25) 120 (15 - 495)
Dyspnea 47 (17) 10 (10 - 180)
Nausea/vomiting 19 (7) 90 (5 - 240)
Dizziness/syncope 18 (7) 10 (5 - 60)
Other 23 (8) 60 (10 - 270)
No symptoms 71 (26) NA
*NA indicates not available. Source: Circulation. Published online September 4, 2006

"The hypothesis that the majority of cases of sudden cardiac death will seemingly occur at random in an apparently healthy or at least very low-risk population is, however, not supported by the findings of the present investigation," write the authors. "In the present study, the majority of patients in an unselected population had a history of documented cardiac disease or at least typical symptoms of coronary heart disease or relevant risk factors that exposed them to an obviously increased risk."

The group notes that vast majority of sudden death occurs in the home, rather than in public places where a defibrillator might be available. Additionally, the study points to a low bystander resuscitation rate. These data underscore the importance of training in CPR and might explain the limited efficacy of public access defibrillation programs in combating sudden death, the authors write.

Circulation. Published online September 4, 2006.

The complete contents of Heartwire , a professional news service of WebMD, can be found at, a Web site for cardiovascular healthcare professionals.