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Heart Rhythm O2
Heart Rhythm O2
Heart Rhythm O2
2666-5018
Elsevier

S2666-5018(24)00151-X
10.1016/j.hroo.2024.05.006
Global Voices
The Alliance Against Sudden Death, a 17-year journey for an original initiative of the Inter-American Society of Cardiology
Márquez-Murillo Manlio F. MD manlio.marquez@gmail.com
∗∗
Bazbaz Adela MD ∗
Hernández Felipe RN †
González-Hermosillo Jesús Antonio MD, FACC ∗
∗ Instituto Nacional de Cardiología Ignacio Chavez, Mexico City, México
† Grupo Salvando Vidas, Mexico City, México
∗ Address reprint requests and correspondence: Dr Manlio F. Márquez-Murillo, Coordinator of the Alliance Against Sudden Death – Inter American Society of Cardiology, Juan Badiano 1, Belisario Domínguez Secc 16, Tlalpan, 14080 Ciudad de México, CDMX, Mexico. manlio.marquez@gmail.com
27 5 2024
8 2024
27 5 2024
5 8 515519
© 2024 Heart Rhythm Society. Published by Elsevier Inc.
2024
Heart Rhythm Society
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords

Sudden cardiac death
Cardiopulmonary resuscitation
Cardiac arrest
Long QT syndrome
Automated external defibrillator
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pmc Key Findings

▪ Governmental authorities in Latin America have not prioritized sudden cardiac death (SCD) as a significant public health concern.

▪ The Alliance’s objective is to advocate for accurate classification of SCD throughout Latin American countries to obtain precise statistics.

▪ Educating and raising awareness about SCD among the general population is essential for encouraging early medical intervention.

▪ Enhancing the utilization of cardiovascular implantable electronic devices may contribute to reducing the occurrence of SCD in Latin American countries.

Introduction

In February 2007, the Inter-American Society of Cardiology (IASC) formally established the Alliance Against Sudden Death. This initiative was led by doctors Marco A. Martínez-Rios, who held the position of IASC President at the time; Jesús Antonio González-Hermosillo, who served as the Secretary-Treasurer of the Society; and one of the authors (M.F.M.-M.), who was Coordinator of the IASC Electrocardiology Council during that period. The inaugural meeting took place in the headquarters of the IASC in Mexico City. It is important to mention that the IASC operated without governmental funding and relies on the support from nonprofit organizations to carry out its mission.

The primary objective of the Alliance was to facilitate coordination, among cardiological societies across the American continent, in the fight against sudden cardiac death (SCD), in order to homogenize quality standards of care. This goal was pursued through multiple actions, with the key focal points presented in Figure 1. Under the Presidency of Daniel Piñeiro, MD, the Alliance resumed its activities and he granted it the status of “Council.” The initiative was initially introduced in Mexico and has since been expanded to other affiliated countries, including Ecuador. Currently, we are in the process of integrating Bolivia and Costa Rica into the initiative this year. In fact, we are organizing an International Symposium on SCD in Costa Rica for September to kick off the Alliance's activities in the region. Our objective is to broaden the reach of this initiative to more countries with similar needs. It is worth noting that before the establishment of the Alliance, Mexico did not have any substantial initiatives focused on addressing SCD. A brief overview of SCD is given subsequently, followed by a summary of the main activities of the Alliance.Figure 1 Main goals and challenges of the Alliance Against Sudden Death. Proposed solutions are shown below each goal. AED = automated external defibrillator; CIED = cardiovascular implantable electronic device; CRT-D = cardiac resynchronization therapy with defibrillator; ICD = implantable cardioverter-defibrillator; NPO = nonprofit organization; SCD = sudden cardiac death.

SCD, a brief overview

SCD is defined as an episode of cardiorespiratory arrest that occurs unexpectedly and in people without a terminal illness.1 Only a few countries in Latin America have reported epidemiological data on SCD (Table 1). Given the absence of a Latin American registry for SCD, one of the primary objectives of the Alliance is to initiate such a registry, aiming to enhance our understanding of the prevalence and characteristics of SCD across the region.Table 1 Available data on the epidemiology of sudden cardiac death in Latin America.

Country	Study	Year(s)	Reported incidence or mortality	Total number of cases	
Brazil	Braggion-Santos et al, 201517	2006–2010	30/100,000 residents per year	899	
Mexico	Fiscal-Málaga et al, 201918	1998–2014	82 cases per year	1394	
Cuba	Ochoa Montes et al, 201519	1995–2014	7.8% of global mortality	1953	
Ochoa Montes et al, 202120	1995–2020	6.6% of global mortality	2252	
Argentina	Muratore et al, 200621	2006∗	0.126/1000 people	81	
∗ Prospective study conducted for 2 months (n = 1274).

SCD has been a great concern for cardiologists all over the world for a long time2 and usually is considered a public health problem by medical societies, but it is rarely recognized as such by health authorities (governments have their own agendas). To correctly make the diagnosis of SCD, such symptoms should not be present more than 1 hour before death (this time frame has been reduced from definitions that initially state as far as 24 hours).

Although there are several causes of SCD, even in Latin America most cases are due to structural heart disease, mainly ischemic heart disease.3, 4, 5 To a lesser extent, but still extremely important, the etiology can be an electrical disorder of the heart that in many cases is genetic, the “hereditary SCD syndromes.”6, 7, 8, 9, 10, 11

Prevention of SCD is based on 2 key aspects: (1) prevention of sequelae and complications of heart disease; and (2) for hereditary SCD syndromes, the correct identification of the cases and adequate risk stratification, together with screening of family members, which is mandatory.12

For cardiac arrest occurring in public spaces, treatment of ventricular fibrillation needs cardiopulmonary resuscitation (CPR) and an automated external defibrillator (AED), both key components of the out-of-hospital chain of survival of the American Heart Association (AHA). Success rates are higher when early defibrillation is administered,13 hence the importance of providing prompt medical care. CPR is essential because it widens the window of time to perform a successful external defibrillation. For individuals who have survived a cardiorespiratory arrest (“nonfatal cardiac arrest”), it is essential to control malignant ventricular arrhythmias with antiarrhythmic drugs, and devices such as the implantable cardioverter-defibrillator (ICD) or subcutaneous ICD.13, 14, 15 Unfortunately, implantation rates of ICD in most Latin American countries are less than expected.16

Main activities of the Alliance Against Sudden Death

In its first epoch, the Alliance focused on academic activities for medical professionals. Different programs were developed under the following names: “Cardiac stimulation in the 21st century,” “The basics of cardiac electrical stimulation,” and “Paradigms of Sudden Cardiac Death.” These symposia were presented throughout Mexico and were very well received by the medical community. Also, for health professionals, links of interest to websites with information on the main hereditary SCD syndromes were included on the IASC website. In addition, many reviews of medical articles related to SCD were carried out and posted on the IASC website.

Afterward, the Alliance extended academic activities to patients and the general public. In 2014, a formal collaboration with Grupo Salvando Vidas (Saving Lives Group), was established with the objective to promote CPR courses and the implementation of AED in public spaces. Through this collaboration, multiple CPR courses have been carried out, which were not only designed for medical and paramedical professionals, but also tailored for the general public (Table 2). Although many CPR courses have been carried out, the number of CPR-certified remains relatively low. The AHA certified courses require a fee, which acts as a barrier, limiting the access to the general population. Consequently, the Alliance aimed to prioritize basic CPR training without AHA certification, thereby avoiding the associated costs. However, to sustain and expand this efforts, additional support is essential, particularly through government funding.Table 2 Persons trained in basic cardiopulmonary resuscitation across the Mexican Republic who have received certificates endorsed by the Alliance Against Sudden Death—an initiative of the Inter-American Society of Cardiology

Year	Total number of certificates given	
2016	2360	
2017	4300	
2018	7300	
2019	10,130	
2020	5725	
2021	12,084	
2022	5605	
2023	10,104	

Furthermore, in that same year, a close collaboration was initiated with the Heartbeat International Foundation, now known as ForHearts Worldwide (https://forhearts.org/), a U.S.-based organization dedicated to donating pacemakers for people of limited resources. The specific goal of our collaboration was to identify hospitals in Central and Latin America eligible to receive such pacemaker donations.

In 2016, the Alliance actively participated in open sessions organized by the Mexican Senate, to raise public awareness about SCD. Additionally, it played a crucial role in the formulation of legislation for cardioprotected spaces/territories, which finally resulted in an approved law by the Mexican Senate in 2022. However, as of now, this legal regulation is still awaiting final publication in the Official Journal of the Federation (such publication is the only way to make this law mandatory). In the same year, the Alliance contributed in establishing the “Un Latido Más por Martina” Foundation (“One More Beat for Martina”). This not-for-profit organization is affiliated to the Sudden Arrhythmic Death Syndromes Foundation.

In 2021, and considering that only early CPR and defibrillation can improve the rate of recovery from a witnessed cardiac arrest, a donation program of AEDs was initiated by the Alliance with the participation of Grupo Salvando Vidas. To facilitate the acquisition of AEDs, 3 companies (Nihon Kohden, Schiller, and Biomédica de México) offered preferential prices. The proposed scheme was to donate 1 AED for every 35 participants who attended a CPR course. This really represented a shift of paradigm, in which instead of first selling AED and then provide the CPR course, the inverse strategy was adopted: people who took the CPR course received the AED for free. This was a very successful program, with 32 donations made in only 2 years.

To continue with the Alliance’s goals, collaboration agreements with civil associations were established. Specifically, regarding long QT syndrome (LQTS), the Alliance introduced an information brochure designed for patients and relatives with LQTS, which was adapted from the Sudden Arrhythmic Death Syndromes Foundation, along with a list of prohibited medications in LQTS adapted from “QTdrugs” (now “CredibleMeds“). This information is still provided to LQTS patients at the National Institute of Cardiology in Mexico City.

Together with Grupo Salvando Vidas, the Alliance participated in a “CPR marathon” in Mexico City in the year 2022, involving approximately 450 people, a massive activity organized by the local government. In July 2023, the Alliance and Grupo Salvando Vidas, conducted a CPR course during the 30th IASC Congress that took place in Panama. This free course involved a total of 85 participants, with the support of 5 Mexican instructors from Grupo Salvando Vidas, and 80 mannequins for the corresponding practice. An example of such massive training courses is shown in Figure 2.Figure 2 Massive cardiopulmonary resuscitation courses imparted by Grupo Salvando Vidas and the Alliance Against Sudden Death.

Future perspectives

The Alliance aims to create a Latin American registry for hereditary syndromes of SCD, with the intention of systematically gathering data for in-depth analysis and contributing valuable insights to the existing literature in this field. In collaboration with IASC Community Council, our actions in the near future include the expansion of the AED donation program to encompass Central and South American countries who could benefit from it. This expansion is envisioned to significantly boost emergency response capabilities on a broader scale. Finally, the Alliance wants to invite all cardiological societies affiliated to the IASC, to develop similar information brochures on LQTS, according to their countries’ needs. The following specific strategies are considered in a near future: (1) secure funding, to invite again and coordinate all device companies in a common effort to support the Alliance; (2) involve cardiovascular health foundations, in order to develop a broad SCD awareness; (3) increase CPR AHA-certified individuals through a collaboration with AHA Latin America coordination; and (4) promote a culture of cardioprotection in Latin America.

Conclusion

Under the direction and supervision of the IASC, the actions of the Alliance Against Sudden Death represent a significant step toward enhancing prevention of SCD in Latin America. By bringing together diverse expertise and resources from the IASC Community Council and the Academy Council, the Alliance will continue providing education on the prevention of SCD, promoting the establishment of cardioprotected areas, and advocating the prioritization of early intervention in the context of cardiac arrest.

Acknowledgments

The authors express their gratitude to those who have been instrumental in this project's success, including all past-presidents of the Inter-American Society of Cardiology (IASC), the actual IASC President, Adrián Baranchuk, MD, and Araceli Delgado, CEO of IASC. This is an official publication of the IASC, authorized by the IASC Academy Council.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosures

The authors have no conflicts to disclose.

Authorship

All authors attest they meet the current ICMJE criteria for authorship.
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References

1 Colín L. Muerte súbita. El papel del estudio electrofisiológico Arch Cardiol Mex 72 2002 S39 S46 12001869
2 Meneses Hoyos J. Electrocardiogramme de l'agonie humaine Arch Mal Coeur Vaiss 43 1950 934 942 14790977
3 Meneses Hoyos J. Mecanismo de producción de la oclusión coronaria súbita por trombosis arterioesclerosa Medicina (Mex) 37 1957 52 55 13407327
4 González-Hermosillo J. La Muerte Súbita de Origen Arrítmico. Editorial Intersistemas SA de CV 1998
5 Márquez-Murillo M.F. Férez Santander S.M. Cardiopatía Isquémica Crónica 1st ed. 2000 Editorial Intersistemas SA de CV
6 Márquez M.F. Mecanismos arritmogénicos en la isquemia y la reperfusión miocardica Feréz Santander S.M. Lupi-Herrera E. El comportamiento del miocardio en la isquemia y en la reperfusión 1st ed. 2004 Elsevier 387 409
7 Barajas-Martínez H. Hu D. Antzelevitch C. Bases genéticas y moleculares del síndrome de Brugada mediado por canales de sodio Arch Cardiol Mex 83 2013 295 302 24269159
8 González-Melchor L, Villarreal-Molina T, Iturralde-Torres P, Medeiros-Domingo A. Muerte súbita cardiaca en el corazón estructuralmente normal: una actualización. Arch Cardiol Mex 84:293–304.
9 Dorantes M. Marrero R. Méndez A. Castro J. Vázquez A. Historia familiar de muerte súbita por fibrilación ventricular idiopática Arch Cardiol Mex 84 2014 57 59 24631049
10 Márquez M.F. Cruz-Robles D. Ines-Real S. Vargas-Alarcón G. Cárdenas M. Next generation sequencing for molecular confirmation of hereditary sudden cardiac death syndromes Arch Cardiol Mex 85 2015 68 72 25661095
11 Wilde A.A. Semsarian C. Márquez M.F. European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society (APHRS)/Latin American Heart Rhythm Society (LAHRS) expert consensus statement on the state of genetic testing for cardiac diseases Europace 24 2022 1307 1367 35373836
12 Rodríguez-Reyes H. Muñoz Gutiérrez M. Márquez M.F. Muerte súbita cardiaca. Estratificación de riesgo, prevención y tratamiento Arch Cardiol Mex 85 2015 329 336 26253348
13 Márquez M.F. The quest for the evidence of effectiveness of implantable cardioverter-defibrillators in long QT syndrome J Am Coll Cardiol 78 2021 2089 2091 34794690
14 Tejeda-Mollinedo W. Díaz-Tostado S. Gómez-Flores J. Nava-Townsend S. Levinstein-Jacinto M. Márquez M.F. Excellent response to β-1 adrenergic receptor blockade (metoprolol) and exercise restriction in high-risk type 1 long QT syndrome. A 22-year follow-up Heart Rhythm Case Rep 8 2021 191 194
15 Márquez-Murillo M.F. Chávez-Gutiérrez C.A. Díaz-Tostado S. Bustillos-García G. Gómez-Flores J. Nava-Townsend S. Use of subcutaneous cardioverter-defibrillator. First cases reported from National Institute of Cardiology Ignacio Chávez-Mexico Arch Cardiol Mex 93 2023 276 283 37553114
16 Gonzalez-Zuelgaray J. Pellizon O. Muratore C.A. Lack of current implantable cardioverter defibrillator guidelines application for primary prevention of sudden cardiac death in Latin American patients with heart failure: a cross-sectional study Europace 15 2013 236 242 22968848
17 Braggion-Santos M.F. Volpe G.J. Pazin-Filho A. Maciel B.C. Marin-Neto J.A. Schmidt A. Sudden cardiac death in Brazil: a community-based autopsy series (2006-2010) Arq Bras Cardiol 104 2015 120 127 25424162
18 Fiscal-Málaga A.G. Sosa-Cruz H. Calderón-Garcidueñas A.L. Sudden death report in Mexico (1998-2014) Arch Cardiol Mex 89 2019 167 171
19 Ochoa Montes L.A. Tamayo Vicente N.D. González Lugo L.M. Resultados del Grupo de Investigación en Muerte Súbita, 20 años después de su creación Rev Cub Salud Publica 41 2015 298 323
20 Ochoa Montes L.A. Araujo González R.E. González Lugo M. Ferrer Marrero D. Tamayo Vicente N.D. Instrumentos para la investigación de la muerte súbita cardiovascular Rev Cuba Invest Biomed 40 2021 e1233
21 Muratore C. Belziti C. Gant López J. Incidencia y variables asociadas con la muerte súbita en una población general. Subanálisis del estudio PRISMA Rev Argent Cardiol 74 2006 441 446
