Management of Patients With Ventricular Arrythmias and the Prevention of Sudden Cardiac Death
Key Points
Key Points
Table 1. Table of Definitions of Commonly Used Terms in this Document
| Term | Definition or Description |
|---|---|
| Ventricular tachycardia (VT) | Cardiac arrhythmia of ≥3 consecutive complexes originating in the ventricles at a rate >100 bpm (cycle length: <600 ms). Types of VT:
 |
| Torsades de pointes (TdP) | TdP is polymorphic VT that occurs in the setting of a long-QT interval and is characterized by a waxing and waning QRS amplitude. It often has a long-short initiating sequence with a long coupling interval to the first VT beat and may present with salvos of nonsustained ventricular tachycardia (NSVT). The twisting of the points, although characteristic, may not always be seen, especially if the episode is nonsustained or if only a limited number of leads are available. TdP can result from bradycardia including high-grade atrioventricular (AV) block that leads to a long-short sequence initiating TdP.  |
| Ventricular flutter | A regular ventricular arrythmia (VA) ≈300 bpm (cycle length: 200 ms) with a sinusoidal, monomorphic appearance; no isoelectric interval between successive QRS complexes.  |
| Ventricular fibrillation (VF) | Rapid, grossly irregular electrical activity with marked variability in electrocardiographic waveform, ventricular rate usually >300 bpm (cycle length: <200 ms).  |
| Sudden cardiac arrest (SCA) | SCA is the sudden cessation of cardiac activity such that the victim becomes unresponsive, with either persisting gasping respirations or absence of any respiratory movements, and no signs of circulation as manifest by the absence of a perceptible pulse. An arrest is presumed to be of cardiac etiology unless it is known or likely to have been caused by trauma, drowning, respiratory failure or asphyxia, electrocution, drug overdose, or any other noncardiac cause. |
| Sudden cardiac death (SCD) | Sudden and unexpected death occurring within an hour of the onset of symptoms, or occurring in patients found dead within 24 h of being asymptomatic and presumably due to a cardiac arrhythmia or hemodynamic catastrophe. |
| VT/VF storm | VT/VF storm (electrical storm or arrhythmic storm) refers to a state of cardiac electrical instability that is defined by ≥3 episodes of sustained VT, VF, or appropriate shocks from an implantable cardioverter-defibrillator (ICD) within 24 h. |
| Primary prevention ICD | ICD placement with the intention of preventing SCD in a patient who has not had sustained VT or SCA but who is at an increased risk for these events. |
| Secondary prevention ICD | ICD placement in a patient with prior SCA, sustained VT, or syncope caused by VA. |
| Structural heart diseasea | This term encompasses ischemic heart disease (IHD), all types of cardiomyopathy, valvular heart disease, and adult congenital heart disease. |
| Cardiac channelopathy | Arrhythmogenic disease due to a genetic abnormality that results in dysfunction of a cardiac ion channel (e.g., long-QT syndrome [LQTS], catecholaminergic polymorphic ventricular tachycardia [CPVT]). |
Figure 1A. SCD Incidence and Total Events
Figure 1B. SCD and Clinical Subsets
Diagnosis
...gnosis...
...yncope
...resenting with syncope for which VA is document...
...ant Considerations in the Evaluation of Patient...
Assessment
...ssessment...
...ead ECG and Exercise Testing...
...with sustained, hemodynamically stable, wide...
...patients with VA symptoms associat...
...th suspected or documented VA, a 12-lea...
Ambulatory Electrocar...
...electrocardiographic monitoring is useful...
...lanted Cardiac Moni...
...atients with sporadic symptoms (including syncop...
...sive Cardiac Imaging...
...s with known or suspected VA that may be associa...
...enting with VA who are suspected of having struc...
...markers
In patients with structural heart disease, measu...
...netic Counselling (Please refer to Cardiac Channel...
...family members in whom genetic testing for risk...
...ging: Cardiac Catheterization...
...ients who have recovered from unexplained...
...trophysiological Study
In patients with ischemic cardiomyop...
...ients who meet criteria for ICD implanta...
...ophysiological study is NOT recommende...
Treatment and Prevention
...t and Prevention...
...macological Characteristics of Available Ant...
...ogical Prevention of SCD...
In patients with heart failure with reduced e...
...Revascularization Procedures in Pati...
...sustained VA and survivors of SCA sho...
...with anomalous origin of a coronary artery suspec...
Surgery for Arrhythmia...
...ents with monomorphic VT refractory to an...
...utonomic Modul...
...symptomatic, non–life-threatening VA,...
...patients with VT/VF storm in whom a beta b...
...t of Cardiac Arrest...
...monary resuscitation (CPR) should be perfor...
...ients with hemodynamically unstable VA that...
...ing with VA with hemodynamic instabi...
...ents with polymorphic VT or VF with ST-...
...th a wide-QRS tachycardia should be presu...
...with hemodynamically stable VT, administratio...
...ients with a witnessed cardiac arrest due t...
...ents with polymorphic VT due to myocardial i...
...patients with a recent MI who have VT/VF that rep...
...s in cardiac arrest, administration of epi...
...with hemodynamically stable VT, adminis...
...ith cardiac arrest, administration...
...tients with refractory VF not related to Td...
...ents with suspected acute myocardial infarction (...
...atients with a wide QRS complex tachycardia of...
...anagement of Sustained Monomorphic VT...
...Prevention of SCD in Patients with Isch...
...ble VT (I, B-R)573...
...ble VT (I, B-NR)5...
...ICD provides intermediate value in...
...th ischemic heart disease and unexplained...
...3. Secondary Prevention in Patients Wit...
...ronary Artery Sp...
...with VA due to coronary artery spasm, treatmen...
...atients resuscitated from SCA due...
...suscitated from SCA due to coronary ar...
...Prevention of SCD in Patients with I...
...h left ventricular ejection fraction (LVEF)...
...tients with LVEF of ≤30% that is due to i...
...ransvenous ICD provides high value in the primary...
...atients with NSVT due to prior MI, LVEF of...
...hospitalized patients with NYHA class IV sympto...
...s NOT indicated for NYHA class IV patients...
Figure 4. Primary Prevention of SCD in Patient...
...current VA in Patients With Ischemic...
...with ischemic heart disease and recurrent...
...one (I, B-R)573...
...iarrhythmic medications (I, B-NR)573...
...atients with ischemic heart disease an...
...tients with prior MI, class IC antiarrhythmi...
...incessant VT or VF, an ICD should NOT...
...with ischemic heart disease and sustain...
Figure 5. Treatment of Recurrent VA in Patients Wi...
...mic Cardiomyopathy (NICM)...
...with suspected NICM from myocardia...
...ients with suspected NICM, cardiac MRI with late...
...patients with NICM who develop conduction disease...
...Prevention of SCD in Patients With NI...
...nstable VT (I, B-R)57...
...ble VT (I, B-NR)57...
...h NICM who experience syncope presumed to...
...ients with NICM who survive a card...
...ry Prevention of SCD in Patients With NICM...
...h NICM, HF with NYHA class II–III sympto...
...atients with NICM due to a Lamin A...
...ients with NICM, HF with NYHA class I symptom...
...medication-refractory NYHA class IV H...
...tment of Recurrent VA in Patients With...
...n patients with NICM and an ICD who exp...
...patients with NICM and recurrent sus...
...dary and Primary Prevention of SCD in Pat...
...c Right Ventricular Cardiomyopathy...
...ected first-degree relatives of patients with arr...
...patients with suspected arrhythmogenic right ven...
...with arrhythmogenic right ventric...
...with arrhythmogenic right ventricular cardiomyo...
...with a clinical diagnosis of arrhythmogeni...
...h clinically diagnosed or suspected arr...
In patients with arrhythmogenic right vent...
...ts with clinical evidence of arrhy...
...with arrhythmogenic right ventricular cardiomy...
In patients with suspected arrhythmogenic...
...patients with clinical evidence of arr...
...ertrophic Cardiomyopathy (H...
...atients with HCM, SCD risk stratificatio...
...nts with HCM who have survived an SCA due to VT...
...gree relatives of patients with HCM, an ECG a...
...ith polymorphic VT or VF with ST-elevation myoc...
...e relatives of patients with HCM due to a known c...
...tients with clinically suspected or diagnosed HCM...
...mum LV wall thickness ≥30 mm (IIa, B-NR)573...
...st-degree relatives presumably caused by...
...f unexplained syncope within the preceding 6 mon...
...ous NSVT (IIa, C-LD)573...
or an abnormal blood pressure response w...
NSVT (IIb, B-NR)573
...rmal blood pressure response with exer...
In patients with HCM and a history of sustained...
...with HCM, an invasive electrophysiological...
...ith an identified HCM genotype in the...
...linical Features Associated With Increa...
...ention of SCD in Patients With HC...
...ocarditis
...with life-threatening VT or VF associated with co...
...ents with giant cell myocarditis with...
...ardiac Sarcoidosis
...cardiac sarcoidosis who have sustaine...
...patients with cardiac sarcoidosis and LVE...
...th cardiac sarcoidosis and LVEF >35...
...ts with cardiac sarcoidosis who have an indica...
...ith cardiac sarcoidosis with frequent sympto...
...tion of SCD in Patients With Cardiac...
HFrE...
...ients with HFrEF who are awaiting heart tra...
LVA...
...atients with an LVAD and sustained VA, an I...
...D Use After Heart Transpla...
...atients with a heart transplant and severe allo...
...euromuscular Disor...
...tients with neuromuscular disorders,...
...patients with Emery-Dreifuss and limb-girdle t...
...h muscular dystrophy, follow-up for development...
...with myotonic dystrophy type 1 with...
.... Neuromuscular Disorders Associat...
Cardiac Channelopathies
...iac Channelopathies...
...rdiac Channelopathi...
...st-degree relatives of patients wh...
...ts with a cardiac channelopathy and SCA, an ICD i...
...ital Long QT Syndrome
...patients with long QT syndrome with a re...
...k patients with symptomatic long QT syndrome in wh...
...ents with LQTS and recurrent appropriate ICD shoc...
...ents with clinically diagnosed LQTS, ge...
...patients with suspected LQTS, ambulatory elec...
...c patients with LQTS and a resting Q...
...mptomatic patients with LQTS and a resti...
...LQTS, QT-prolonging medications are potent...
...monly Used QT-Prolonging Medication...
...revention of SCD in Patients With Long...
...Long-QT Syndrome Type 1...
...11. Long-QT Syndrome Ty...
...Long-QT Syndrome Type 3...
...Exercise-Induced Polymorphic VT in...
...olaminergic Polymorphic Ventricular Tachycardia...
...th CPVT, a beta blocker is recommended. (I,...
...n patients with CPVT and recurrent sustain...
...ts with CPVT and with clinical VT or exertio...
Brugada Syndrome
...ymptomatic patients with only inducible...
...with Brugada syndrome with spontaneous type 1...
...with Brugada syndrome experiencing re...
...nts with spontaneous type 1 Brugada...
...th suspected Brugada syndrome in the absence of...
...ients with asymptomatic Brugada syndrome and...
...th suspected or established Brugada...
...14. Prevention of SCD in Patients Wit...
...ure 15. Brugada Syndrom...
...Repolarization “J-wave” Syndrome...
...tic patients with an early repolar...
...ith early repolarization pattern on ECG and cardia...
...patients with early repolarization patte...
...rt QT Syndrome...
...matic patients with a short QTc inter...
...n patients with SQTS who have a cardiac arre...
...patients with SQTS and recurrent sustained...
...patients with SQTS and VT/VF storm, isoprote...
...atients with SQTS, genetic testing may be consider...
Other Conditions
Other Conditi...
...Structurally Normal Heart...
...ts with symptomatic PVCs in an otherwise normal h...
...with symptomatic VA in an otherwise no...
...ow Tract VA...
...ients with symptomatic outflow tract VA in a...
In patients with symptomatic outflow tr...
...illary Muscle VA (PVCs and V...
In patients with symptomatic VA arisi...
...Reentrant VT (Belhassen Tachycardia)...
In patients with verapamil-sensitive,...
...ts with sustained hemodynamically to...
...with recurrent verapamil-sensitive id...
...athic Polymorphic V...
...ng patients (...
...ts resuscitated from SCA due to idiopat...
...with recurrent episodes of idiopathic VF initi...
...uced Cardiomyopathy...
...or patients who require arrhythmia suppression fo...
...with PVC-induced cardiomyopathy, ph...
...regnan...
In mothers with LQTS, a beta blocker sho...
...t patient with sustained VA, electrical car...
...t patients needing an ICD or VT ab...
...atients With Comorbidities...
...tients and those with significant comorbiditi...
...-Induced Arrhythmias
...goxin
...stration of digoxin antibodies is recomme...
...ation-Induced QT Prolongation and TdP...
...nts with recurrent TdP associated with...
...nts with QT prolongation due to a medicat...
...h TdP associated with acquired QT prolongation, po...
...nnel Blocker–Related Toxicity
...tients taking sodium channel blockers who present...
...atients with congenital or acquired LQTS,...
...Congenital Heart Dise...
...t patients with repaired complex congenita...
...ts with adult congenital heart disease and co...
...ients with adult congenital heart disease and he...
...adult congenital heart disease with SCA due...
In adults with repaired tetralogy of Fallo...
...ith repaired tetralogy of Fallot physiolo...
...nts with adult congenital heart disease wit...
...repaired severe complexity adult co...
...patients with repaired moderate or...
...patients with adult congenital heart disease a...
...atients with adult congenital heart disease an...
...Congenital Heart Disease: Risk Factors for VA/S...
...e 16. Prevention of SCD in Patients With Adult...
...eous Implantable Cardioverter-Defibrillat...
...ts who meet criteria for an ICD who h...
...ients who meet indication for an ICD, impl...
...h an indication for bradycardia pacing or CRT,...
...arable Cardioverter-Defibri...
...with an ICD and a history of SCA or sustained...
...at an increased risk of SCD but who are not...
...heter Ablation...
...ith bundle-branch reentrant VT, ca...
...patients with structural heart disease...
...rtem Evaluation of SCD...
...ims of SCD without obvious causes,...
...st-degree relatives of SCD victims wh...
...f SCD with an autopsy that implicates a po...
...f SCD with a previously identified phe...
...inal Care...
...of ICD implantation or replacement, and during...
...atients with refractory HF symptoms, refrac...
...ed Decision-Mak...
...patients with VA or at increased risk for S...
...ts considering implantation of a new ICD or rep...
...emental Cost-Effectiveness of ICD by Years of L...