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
...iagnosis
...yncope...
Patients presenting with syncope for...
...ortant Considerations in the Evaluation of...
Assessment
...essment...
...lead ECG and Exercise Testing...
...h sustained, hemodynamically stable...
...h VA symptoms associated with exertion, suspected...
...ients with suspected or documented VA, a 12-le...
...atory Electrocardiograp...
...tory electrocardiographic monitoring is useful to...
...planted Cardiac Monito...
...patients with sporadic symptoms (inc...
...ive Cardiac Imaging...
...ients with known or suspected VA that...
...ients presenting with VA who are suspected o...
...omarkers...
...h structural heart disease, measure...
...lling (Please refer to Cardiac Channelopathies...
...ients and family members in whom genetic...
...ve Imaging: Cardiac Catheterizat...
...have recovered from unexplained SCA,...
...ophysiological Stu...
...ents with ischemic cardiomyopathy, noni...
...s who meet criteria for ICD implant...
...ophysiological study is NOT recommended for ris...
Treatment and Prevention
...eatment and Preven...
...3. Pharmacological Characteristics of...
...acological Prevention of...
In patients with heart failure with r...
...urgery and Revascularization Procedures...
...ith sustained VA and survivors of S...
...ients with anomalous origin of a coronary...
...y for Arrhythmia Management...
...ts with monomorphic VT refractory to antiarrhythmi...
...utonomic Modul...
...patients with symptomatic, non–life...
...nts with VT/VF storm in whom a beta blo...
Management of Cardiac Arr...
...ardiopulmonary resuscitation (CPR) should be p...
...patients with hemodynamically unstable...
...senting with VA with hemodynamic instabili...
...patients with polymorphic VT or VF with ST-e...
...tients with a wide-QRS tachycardia should be pre...
...h hemodynamically stable VT, administrati...
...h a witnessed cardiac arrest due to VF or polym...
...polymorphic VT due to myocardial i...
...ients with a recent MI who have VT/VF...
...patients in cardiac arrest, administration of...
...ith hemodynamically stable VT, administration o...
...th cardiac arrest, administration of high-d...
...ts with refractory VF not related t...
...ts with suspected acute myocardial...
...ts with a wide QRS complex tachycar...
...Management of Sustained Monomorphic VT...
...ndary Prevention of SCD in Patients with Ischemic...
...ble VT (I, B-R)573...
...able VT (I, B-NR)573
...ransvenous ICD provides intermediate valu...
In patients with ischemic heart disease...
.... Secondary Prevention in Patients With Is...
...onary Artery Spasm
...ith VA due to coronary artery spasm, treatment wit...
...ients resuscitated from SCA due to coronar...
...scitated from SCA due to coronary artery spasm,...
...y Prevention of SCD in Patients wi...
...ith left ventricular ejection fraction (LVEF) o...
...patients with LVEF of ≤30% that is due...
...nous ICD provides high value in the primar...
...patients with NSVT due to prior MI, LVEF of...
...talized patients with NYHA class IV sy...
...indicated for NYHA class IV patients with medi...
...re 4. Primary Prevention of SCD in Patients...
...ent VA in Patients With Ischemic Heart Diseas...
...ients with ischemic heart disease and recurrent...
amiodarone (I, B-R)5...
...her antiarrhythmic medications (I,...
...s with ischemic heart disease and ICD shocks for...
...n patients with prior MI, class IC antiar...
...with incessant VT or VF, an ICD should NOT be imp...
...n patients with ischemic heart disease and s...
...eatment of Recurrent VA in Patients W...
Nonischemic Cardiomyopathy (NICM...
...n patients with suspected NICM from myocardial in...
...with suspected NICM, cardiac MRI with l...
...atients with NICM who develop cond...
...tion of SCD in Patients With NICM...
unstable VT (I, B-R...
...VT (I, B-NR)573
...th NICM who experience syncope presumed to be due...
...with NICM who survive a cardiac arrest, have sust...
...imary Prevention of SCD in Patients With NIC...
...NICM, HF with NYHA class II–III sy...
...with NICM due to a Lamin A/C mutation who have...
...nts with NICM, HF with NYHA class I s...
...patients with medication-refractory NY...
...of Recurrent VA in Patients With NI...
...patients with NICM and an ICD who experience...
...s with NICM and recurrent sustained monomo...
...e 6. Secondary and Primary Preventi...
...hythmogenic Right Ventricular Cardiomyop...
...selected first-degree relatives of p...
...th suspected arrhythmogenic right...
...atients with arrhythmogenic right ventricular card...
...ients with arrhythmogenic right ventricular cardi...
...with a clinical diagnosis of arrhyth...
...ts with clinically diagnosed or suspecte...
...with arrhythmogenic right ventricular car...
...with clinical evidence of arrhythmog...
...ents with arrhythmogenic right ventricular c...
...tients with suspected arrhythmogenic right ven...
...matic patients with clinical evidence of arrhythm...
...ic Cardiomyopathy (HCM)...
...tients with HCM, SCD risk stratification sho...
In patients with HCM who have survived an SCA d...
...t-degree relatives of patients with HCM,...
...with polymorphic VT or VF with ST-elevation myo...
...t-degree relatives of patients with...
...with clinically suspected or diagnosed HCM, gen...
...V wall thickness ≥30 mm (IIa, B-NR)573...
...≥1 first-degree relatives presumably caused...
...s of unexplained syncope within the preced...
...ous NSVT (IIa, C-LD)573...
...abnormal blood pressure response with exercis...
...IIb, B-NR)573...
...rmal blood pressure response with exe...
...HCM and a history of sustained VT or VF, amiodaro...
...ients with HCM, an invasive electrophysiological...
...s with an identified HCM genotype in t...
...le 4. Major Clinical Features Associated With Inc...
...tion of SCD in Patients With HCM...
...yocardit...
...n patients with life-threatening VT or VF a...
...giant cell myocarditis with VF or hemodynami...
...iac Sarcoidosis
...ients with cardiac sarcoidosis who ha...
...cardiac sarcoidosis and LVEF >35% who hav...
...ts with cardiac sarcoidosis and LVEF >...
...ients with cardiac sarcoidosis who have an in...
...s with cardiac sarcoidosis with frequen...
...tion of SCD in Patients With Cardiac Sarcoidosis...
...FrEF
...patients with HFrEF who are awaiting...
LVAD
...h an LVAD and sustained VA, an ICD can be be...
ICD Use After Heart Transpla...
...s with a heart transplant and severe allo...
...omuscular Disorders...
...with neuromuscular disorders, primary and se...
...atients with Emery-Dreifuss and limb-g...
...with muscular dystrophy, follow-up for d...
...atients with myotonic dystrophy type 1 with...
...e 5. Neuromuscular Disorders Associated...
Cardiac Channelopathies
...ardiac Channelopathie...
...ac Channelopathies...
...gree relatives of patients who have a causativ...
...s with a cardiac channelopathy and SCA, an...
...enital Long QT Syndro...
In patients with long QT syndrome with a r...
In high-risk patients with symptomatic long QT sy...
...n patients with LQTS and recurrent appropriate ICD...
...ients with clinically diagnosed LQTS, genetic co...
...ients with suspected LQTS, ambulatory electro...
...atic patients with LQTS and a resting QTc...
...omatic patients with LQTS and a resting QTc...
...with LQTS, QT-prolonging medications are poten...
...ble 6. Commonly Used QT-Prolonging Medicatio...
...ure 9. Prevention of SCD in Patients With Long QT...
...Long-QT Syndrome Type 1
...1. Long-QT Syndrome Typ...
...Long-QT Syndrome Type 3...
...ure 13. Exercise-Induced Polymorphi...
...minergic Polymorphic Ventricular Tachycard...
...patients with CPVT, a beta blocker is rec...
...ients with CPVT and recurrent sustained VT or syn...
...n patients with CPVT and with clinical VT or e...
...ugada Syndrome
...ptomatic patients with only inducible type 1 Brug...
...th Brugada syndrome with spontaneous type 1 Bru...
...atients with Brugada syndrome expe...
...th spontaneous type 1 Brugada electrocardio...
...nts with suspected Brugada syndrome in...
...s with asymptomatic Brugada syndrome...
...nts with suspected or established Bru...
...14. Prevention of SCD in Patients With Brugada...
...15. Brugada Syndrome...
...larization “J-wave” Synd...
...asymptomatic patients with an early...
...with early repolarization pattern on ECG and...
...ients with early repolarization pa...
Short QT Syn...
...asymptomatic patients with a short QTc i...
In patients with SQTS who have a cardiac arrest...
...n patients with SQTS and recurrent sustaine...
...patients with SQTS and VT/VF storm, isoprot...
...ents with SQTS, genetic testing may be...
Other Conditions
Other Conditi...
...e Structurally Normal Heart...
...ts with symptomatic PVCs in an othe...
...nts with symptomatic VA in an otherwise normal h...
...low Tract VA
...h symptomatic outflow tract VA in an otherwise no...
...with symptomatic outflow tract VT in an othe...
...uscle VA (PVCs and VT)...
...ith symptomatic VA arising from the papillary...
...lar Reentrant VT (Belhassen Tachycardia)...
...atients with verapamil-sensitive, idiopathic L...
...ith sustained hemodynamically tolerat...
...nts with recurrent verapamil-sensitive idio...
...diopathic Polymorphic VT/VF...
...ng patients (...
...uscitated from SCA due to idiopathic polymorp...
...tients with recurrent episodes of idiopathic VF...
...-Induced Cardiomyopathy...
...patients who require arrhythmia suppressi...
...nts with PVC-induced cardiomyopathy, pharmac...
...regnan...
...mothers with LQTS, a beta blocker should be c...
...gnant patient with sustained VA, electri...
...pregnant patients needing an ICD or...
...lder Patients With Comorbid...
...der patients and those with significant c...
...on-Induced Arrhythmias...
...goxin...
...inistration of digoxin antibodies is recommended...
...uced QT Prolongation and TdP...
...nts with recurrent TdP associated with acquired...
...or patients with QT prolongation due t...
For patients with TdP associated wi...
...el Blocker–Related Toxicity...
...ients taking sodium channel blockers...
...ts with congenital or acquired LQTS, Q...
...ngenital Heart Diseas...
...ents with repaired complex congenital heart diseas...
...tients with adult congenital heart diseas...
...n patients with adult congenital heart disease...
...nts with adult congenital heart disease...
...ts with repaired tetralogy of Fallot ph...
...adults with repaired tetralogy of Fa...
...th adult congenital heart disease wit...
...adults with repaired severe complexity adult c...
...with repaired moderate or severe co...
...atients with adult congenital heart dis...
...with adult congenital heart disease and sev...
...enital Heart Disease: Risk Factors for VA/SCDHavin...
...16. Prevention of SCD in Patients With A...
Subcutaneous Implantable Cardioverter-Defibrillato...
...patients who meet criteria for an ICD who h...
...o meet indication for an ICD, implantation of a...
...with an indication for bradycardi...
...rable Cardioverter-Defibrillator...
...ts with an ICD and a history of SCA or sustained V...
...t an increased risk of SCD but who are not inelig...
...theter Ablati...
...th bundle-branch reentrant VT, cathe...
...th structural heart disease who have faile...
...mortem Evaluation of...
...CD without obvious causes, a standardized...
...relatives of SCD victims who were 40 y...
...victims of SCD with an autopsy that implic...
In victims of SCD with a previously identified phe...
...rminal Ca...
...he time of ICD implantation or repla...
...with refractory HF symptoms, refractory sustained...
...d Decision-Making...
...th VA or at increased risk for SCD, c...
...ring implantation of a new ICD or replac...
.... Incremental Cost-Effectiveness of ICD...