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
...agnosis
Synco...
...esenting with syncope for which VA is documented,...
...2. Important Considerations in the Evaluation of...
Assessment
...ssessmen...
...ad ECG and Exercise Testing...
...ients with sustained, hemodynamically stable, wi...
...n patients with VA symptoms associa...
...ents with suspected or documented VA, a 12-lead...
...Electrocardiography...
...trocardiographic monitoring is useful to evaluate...
...planted Cardiac Monitors...
...sporadic symptoms (including syncope) suspecte...
...nvasive Cardiac Imaging...
...nts with known or suspected VA that may be associa...
...senting with VA who are suspected...
...markers...
...ith structural heart disease, measuremen...
...etic Counselling (Please refer to Cardiac Channe...
...ients and family members in whom gen...
...sive Imaging: Cardiac Catheteriza...
...ients who have recovered from unexplain...
...trophysiological Study...
...with ischemic cardiomyopathy, nonischemic c...
...nts who meet criteria for ICD impl...
...ysiological study is NOT recommended for risk str...
Treatment and Prevention
...reatment and Prev...
...armacological Characteristics of A...
...logical Prevention of SCD
...with heart failure with reduced ejection...
...rgery and Revascularization Procedures in Patien...
...sustained VA and survivors of SCA should be e...
...atients with anomalous origin of a coronary artery...
...ery for Arrhythmia Management...
...monomorphic VT refractory to antiarr...
...nomic Modulation...
...patients with symptomatic, non–life-threaten...
...s with VT/VF storm in whom a beta blocker,...
...nt of Cardiac Arrest...
...pulmonary resuscitation (CPR) should be perf...
...tients with hemodynamically unstable VA that persi...
...presenting with VA with hemodynamic instabili...
...ith polymorphic VT or VF with ST-elevation m...
...s with a wide-QRS tachycardia should be presumed...
...h hemodynamically stable VT, administration of i...
...th a witnessed cardiac arrest due to VF or polymor...
...polymorphic VT due to myocardial isc...
...patients with a recent MI who hav...
...ients in cardiac arrest, administration of epi...
...s with hemodynamically stable VT,...
...n patients with cardiac arrest, admin...
...ents with refractory VF not related to TdP, admin...
...n patients with suspected acute myocardial infarc...
...with a wide QRS complex tachycardia of...
...Management of Sustained Monomorphic...
...evention of SCD in Patients with Ische...
unstable VT (I,...
...table VT (I, B-NR)5...
...enous ICD provides intermediate value in...
...s with ischemic heart disease and unexplained...
...re 3. Secondary Prevention in Patients...
...ary Artery Spasm
...n patients with VA due to coronary arter...
...ents resuscitated from SCA due to coronary ar...
...ts resuscitated from SCA due to co...
...ary Prevention of SCD in Patients wi...
...patients with left ventricular ejection fractio...
...patients with LVEF of ≤30% that is...
...transvenous ICD provides high value...
...with NSVT due to prior MI, LVEF of ≤40% and in...
...ed patients with NYHA class IV symptoms w...
...s NOT indicated for NYHA class IV pa...
...mary Prevention of SCD in Patients With Ische...
...t VA in Patients With Ischemic Heart Disease...
...ients with ischemic heart disease and...
...rone (I, B-R)573...
...other antiarrhythmic medications (I,...
...with ischemic heart disease and ICD shocks...
...n patients with prior MI, class IC antiarrhyt...
...with incessant VT or VF, an ICD should NOT be im...
...n patients with ischemic heart dis...
...ment of Recurrent VA in Patients With Ischemic H...
...c Cardiomyopathy (NICM)...
In patients with suspected NICM from myocardial i...
...atients with suspected NICM, cardiac MRI wi...
...h NICM who develop conduction disease or left ven...
...dary Prevention of SCD in Patients With NI...
...nstable VT (I, B-R)5...
...VT (I, B-NR)573...
...patients with NICM who experience syncope pres...
...ents with NICM who survive a cardiac...
...imary Prevention of SCD in Patients...
...patients with NICM, HF with NYHA c...
...patients with NICM due to a Lamin A/C mutation...
...atients with NICM, HF with NYHA clas...
...ients with medication-refractory NYHA class IV H...
...of Recurrent VA in Patients With NIC...
...ts with NICM and an ICD who experien...
...s with NICM and recurrent sustaine...
...6. Secondary and Primary Prevention of SCD in...
...ic Right Ventricular Cardiomyopat...
...selected first-degree relatives of patients with...
...h suspected arrhythmogenic right ventricu...
...ents with arrhythmogenic right ven...
...ients with arrhythmogenic right ventricular card...
...patients with a clinical diagnosis of arrh...
...n patients with clinically diagnosed or s...
...with arrhythmogenic right ventricul...
...h clinical evidence of arrhythmogenic right v...
...nts with arrhythmogenic right ventricular card...
...ients with suspected arrhythmogeni...
...patients with clinical evidence of arrhy...
...c Cardiomyopathy (HCM)...
...tients with HCM, SCD risk stratific...
...s with HCM who have survived an SCA due...
...t-degree relatives of patients with H...
...patients with polymorphic VT or VF with ST-elevat...
...first-degree relatives of patients with HCM...
...ts with clinically suspected or diagnosed HCM...
...mum LV wall thickness ≥30 mm (IIa, B-N...
...D in ≥1 first-degree relatives presu...
...episodes of unexplained syncope within the prece...
...ontaneous NSVT (IIa, C-LD)57...
...l blood pressure response with exercise (...
...T (IIb, B-NR)573...
...r an abnormal blood pressure response with exerc...
...ents with HCM and a history of sustained...
...th HCM, an invasive electrophysiologi...
...n patients with an identified HCM geno...
...linical Features Associated With Increased Risk...
...Prevention of SCD in Patients With HCM...
Myocarditis
...atients with life-threatening VT or VF associat...
...nts with giant cell myocarditis with...
...rdiac Sarcoidosis...
...th cardiac sarcoidosis who have sustain...
...with cardiac sarcoidosis and LVEF >35% w...
...h cardiac sarcoidosis and LVEF >35%,...
...ents with cardiac sarcoidosis who have an indicati...
...atients with cardiac sarcoidosis with fr...
...8. Prevention of SCD in Patients With Cardiac...
...FrEF
...s with HFrEF who are awaiting heart tra...
...VAD...
...tients with an LVAD and sustained VA, an ICD can b...
...After Heart Transplantatio...
In patients with a heart transplant...
...uromuscular Disorders
...n patients with neuromuscular disorders,...
...ents with Emery-Dreifuss and limb-gir...
...n patients with muscular dystrophy, follow-u...
...tients with myotonic dystrophy type 1...
...able 5. Neuromuscular Disorders Associated With...
Cardiac Channelopathies
...diac Channelopathies...
...Channelopathies...
...first-degree relatives of patients who have a caus...
...with a cardiac channelopathy and SCA, an ICD i...
...enital Long QT Syndrome
...patients with long QT syndrome with a resting QTc...
...high-risk patients with symptomatic long QT s...
...patients with LQTS and recurrent appropriat...
...patients with clinically diagnosed...
...ients with suspected LQTS, ambulatory electrocar...
...ymptomatic patients with LQTS and...
...tomatic patients with LQTS and a resting QTc >500...
In patients with LQTS, QT-prolonging med...
...only Used QT-Prolonging MedicationsHaving...
...ure 9. Prevention of SCD in Patien...
...Long-QT Syndrome Type 1...
...ure 11. Long-QT Syndrome...
...igure 12. Long-QT Syndro...
...ure 13. Exercise-Induced Polymorphic VT in Cate...
...gic Polymorphic Ventricular Tachycardia...
...with CPVT, a beta blocker is recommended. (I, B...
...patients with CPVT and recurrent sustain...
...ents with CPVT and with clinical VT or exertional...
Brugada Syn...
...n asymptomatic patients with only inducible type...
...h Brugada syndrome with spontaneous type...
...nts with Brugada syndrome experiencing rec...
...s with spontaneous type 1 Brugada electroca...
...ents with suspected Brugada syndrome in the absen...
In patients with asymptomatic Brugada s...
In patients with suspected or established Br...
...ention of SCD in Patients With Brugada...
Figure 15. Brugada...
...y Repolarization “J-wave” Synd...
...atic patients with an early repolarization patte...
...with early repolarization pattern on ECG...
...ith early repolarization pattern on...
...ort QT Syndrom...
...mptomatic patients with a short QTc interval,...
...h SQTS who have a cardiac arrest or...
...ith SQTS and recurrent sustained VA, treatment...
...h SQTS and VT/VF storm, isoproterenol infusion ca...
...th SQTS, genetic testing may be conside...
Other Conditions
...Conditions...
...Structurally Normal Hear...
...ents with symptomatic PVCs in an otherwise nor...
...ith symptomatic VA in an otherwise normal h...
Outflow Trac...
...s with symptomatic outflow tract VA in an oth...
...with symptomatic outflow tract VT in an otherwise...
Papillary Muscle VA (PV...
...th symptomatic VA arising from the papillar...
...ar Reentrant VT (Belhassen Tachycardia)...
...tients with verapamil-sensitive, idiopathi...
...th sustained hemodynamically tolerated verapami...
...tients with recurrent verapamil-sens...
...pathic Polymorphic VT/V...
In young patient...
...tients resuscitated from SCA due to id...
...s with recurrent episodes of idiopathic VF initia...
...-Induced Cardiomyopath...
...atients who require arrhythmia suppression fo...
...with PVC-induced cardiomyopathy, pharmac...
...gnancy
...LQTS, a beta blocker should be continued during...
...pregnant patient with sustained VA, electrical ca...
In pregnant patients needing an ICD or V...
...der Patients With Comorbiditi...
...ents and those with significant comorbidities,...
...cation-Induced Arrhy...
...goxin...
...istration of digoxin antibodies is recomme...
Medication-Induced QT Prolongation an...
...s with recurrent TdP associated with acquired QT...
...ts with QT prolongation due to a medicati...
...ients with TdP associated with acquired QT prolo...
...Channel Blocker–Related Toxic...
...aking sodium channel blockers who pre...
...congenital or acquired LQTS, QT-prol...
...t Congenital Heart Disease...
...ith repaired complex congenital heart disease p...
...s with adult congenital heart disease and c...
...with adult congenital heart disease and...
...h adult congenital heart disease with SCA due to...
...dults with repaired tetralogy of Fal...
...th repaired tetralogy of Fallot physiology a...
...ith adult congenital heart disease with recurren...
...ults with repaired severe complexity adult...
...repaired moderate or severe complexity adult con...
...s with adult congenital heart disease and...
In patients with adult congenital heart disease...
...genital Heart Disease: Risk Factor...
...vention of SCD in Patients With Adult Congen...
...Implantable Cardioverter-Defibrillator...
...who meet criteria for an ICD who have inadequate v...
...tients who meet indication for an ICD, impl...
...tients with an indication for bradycardia paci...
...ardioverter-Defibrillator...
...ts with an ICD and a history of SCA or sustai...
...atients at an increased risk of SCD b...
...heter Ablation...
...ients with bundle-branch reentrant VT, cath...
...ents with structural heart disease who have fai...
...m Evaluation of SCD...
...CD without obvious causes, a standardi...
...irst-degree relatives of SCD victims who...
...f SCD with an autopsy that implicates a...
...ims of SCD with a previously identif...
Terminal Car...
At the time of ICD implantation or repla...
...with refractory HF symptoms, refractory su...
...ed Decision-Making...
...patients with VA or at increased risk...
...onsidering implantation of a new I...
...Incremental Cost-Effectiveness of ICD by Y...