2017 guideline for management of patients with ventricular ......with ischemic heart disease or...
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2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
GUIDELINES MADE SIMPLEA Selection of Tables and Figures
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Sana M. Al-Khatib, MD, MHS, FACC, FAHA, FHRS, ChairWilliam G. Stevenson, MD, FACC, FAHA, FHRS, Vice Chair
Michael J. Ackerman, MD, PhDWilliam J. Bryant, JD, LLMDavid J. Callans, MD, FACC, FHRSAnne B. Curtis, MD, FACC, FAHA, FHRSBarbara J. Deal, MD, FACC, FAHATimm Dickfeld, MD, PhD, FHRSMichael E. Field, MD, FACC, FAHA, FHRSGregg C. Fonarow, MD, FACC, FAHA, FHFSAAnne M. Gillis, MD, FHRSMark A. Hlatky, MD, FACC, FAHAChristopher B. Granger, MD, FACC, FAHAStephen C. Hammill, MD, FACC, FHRSJosé A. Joglar, MD, FACC, FAHA, FHRSG. Neal Kay, MDDaniel D. Matlock, MD, MPHRobert J. Myerburg, MD, FACCRichard L. Page, MD, FACC, FAHA, FHRS
The purpose of the guideline is to provide a contemporary guideline for the management of adults who have ventricular arrhythmias (VA) or who are at risk for sudden cardiac death (SCD), including diseases and syndromes associated with a risk of SCD from VA. The 2017 guideline supersedes three guidelines; the entire ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death, and selected sections of the ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities and selected sections of the 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy.
The following resource contains selected Figures and Tables from the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. The resource is only an excerpt from the Guideline and the full publication should be reviewed for more figures and tables as well as important context.
CITATION: J Am Coll Cardiol. Oct 2017, 24390; DOI: 10.1016/j.jacc.2017.10.054
Writing Committee:
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac DeathA report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society
http://www.onlinejacc.org/content/early/2017/10/19/j.jacc.2017.10.054?_ga=2.211510997.1345933064.1510246660-295453537.1501613750
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2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
GUIDELINES MADE SIMPLE
Sustained Monomorphic VT
Management of Sustained Monomorphic VT ……………………………………………………………… 4
Ischemic Heart Disease
Secondary Prevention ……………………………………………………………………………………… 5
Primary Prevention of Sudden Cardiac Death …………………………………………………………… 6
Treatment of Recurrent Ventricular Arrhythmias ………………………………………………………… 7
Nonischemic Cardiomyopathy
Treatment of Recurrent Ventricular Arrhythmias ………………. ………………………………………… 7
Secondary and Primary Prevention of Sudden Cardiac Death ………………………………………… 8
Hypertrophic Cardiomyopathy
Major Clinical Features Associated with Increased Risk of Sudden Cardiac Death ………………… 9
Prevention of Sudden Cardiac Death …………………………………………………………………… 10
Long QT Syndrome
Prevention of Sudden Cardiac Death …………………………………………………………………… 11
Brugada Syndrome
Prevention of Sudden Cardiac Death …………………………………………………………………… 12
Adult Congenital Heart Disease
Prevention of Sudden Cardiac Death …………………………………………………………………… 13
Selected Table or Figure Page
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
No
No
No
No
NoYes
Yes
Yes
Yes
Verapamil or beta blocker(Class IIa)
IV procainamide(Class IIa)
IV amiodaroneor sotalol(Class IIb)
Verapamil sensitive VT*: verapamilor
Out�ow tract VT: beta blockerfor acute termination of VT
(Class IIa)
Catheter ablation(Class I)
Catheter ablation(Class I)
VTtermination
VTtermination
Sedation/anesthesia,reassess antiarrhythmic
therapeutic options,repeat cardioversion
Stable UnstableHemodynamicstability
Direct currentcardioversion
& ACLS
Sustained Monomorphic VT
VTtermination
Therapy guidedby underlyingheart disease
Effective
Therapy to prevent recurrence preferred
Typical ECGmorphology foridiopathic VA
Structuralheart disease
12-lead ECG,history & physical
Consider diseasespeci�c VTs
Cardioversion(Class I)
Cardioversion(Class I)
Yes
Cardioversion(Class I)
Management of Sustained Monomorphic VT
*Known history of verapamil sensitive or classical electrocardiographic presentation.Figure 2
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
ICD(Class I)
GDMT(Class I)
SCD survivor* orsustained spontaneous
monomorphic VT*
Cardiac syncope†
Secondary prevention in pts with IHD
ICD candidate‡
LVEF ≤35%
Ischemia warrantingrevascularization
Revascularize& reassessSCD risk(Class I) Yes
Yes No
No
ICD(Class I)
EP study(Class IIa)
Yes No
InducibleVA
ICD(Class I)
Extendedmonitoring
Yes No
Secondary Prevention of Sudden Cardiac Death in Patients with Ischemic Heart Disease
*Exclude reversible causes.†History consistent with an arrhythmic etiology for syncope.‡ICD candidacy as determined by functional status, life expectancy, or patient preference.Figure 3
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
ICD(Class I)
GDMT(Class I)
WCD(Class IIb)
ICD(Class I)*
Primary prevention in pts with IHD,LVEF ≤40%
EP study(especially inthe presence
of NSVT)
Reassess LVEF >40 d after MIand/or >90 d afterrevascularization
MI
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
NoYes
No
No reversible causesischemiaDrug, electrolyte induced
Yes
Catheterablation(Class I)
Catheter ablationas �rst-line therapy
(Class IIb)
Amiodaroneor sotalol(Class I)
Amiodarone(Class I)
Revascularize(Class I)
Treat for QT prolongation,discontinue offending
medication,correct electrolytes
(Class I)
Catheterablation
(Class IIa)
Beta blockersor lidocaine(Class IIa)
Catheterablation(Class I)
Autonomicmodulation(Class IIb)
Identi�ablePVC triggers
Arrhythmianot controlled
Arrhythmianot controlled
Sustainedmonomorphic VT
ICD with VT/VFrecurrent arrhythmia*
PolymorphicVT/VF
Considerreversible
causes
IHD withfrequent VT or
VT stormNICM
Catheterablation
(Class IIa)
Treatment of Recurrent Ventricular Arrhythmias in Patients with Ischemic Heart Disease or Nonischemic Cardiomyopathy
*Management should start with ensuring that the ICD is programmed appropriately and that potential precipitating causes, including heart failure exacerbation, are addressed. For information regarding optimal ICD programming, refer to the 2015 HRS/EHRA/APHRS/ SOLAECE expert consensus statement (“Wilkoff BL, Fauchier L, Stiles MK, et al. 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing. J Arrhythm. 2016;32:1-28).Figure 5
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
Yes Yes Yes Yes
Etiology uncertain
If positive
No No No
YesNoYesNo, due to newly
diagnosed HF(
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
• Survival from a cardiac arrest due to VT or VF
• Spontaneous sustained VT causing syncope or hemodynamic compromise
• Family history of SCD associated with HCM
• LV wall thickness ≥30 mm
• Unexplained syncope within 6 mo
• NSVT ≥3 beats
• Abnormal blood pressure response during exercise†
• 5 y ago
• LV aneurysm
• LVEF 20 mm Hg during exertion.‡There is a lack of agreement in the literature that these modifiers independently convey an increase risk of SCD in patients with HCM; however, a risk modifier when combined with a risk factor often identifies a patient with HCM at increased risk for SCD beyond the risk conveyed by the risk factor alone.§A small subset of patients with an LVEF
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
Yes
No
NoYes
Yes No
ICD(Class I)
Patients with HCM
SCD survivor;sustained VT
ICDcandidate*
Yes
Family Hx SCD;LVWT >30 mm;syncope
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
Recurrent ICDshocks for VT
ICD(Class I)
Beta blocker(Class I)
Beta blocker(Class I)
LQTS
QTc 500 ms
Resuscitatedcardiac arrest
Persistent symptomsand/or other high-risk
features†
Beta blocker(Class IIa)
Treatment intensi�cation:additional medications,left cardiac sympathetic
denervation(Class I)
Treatment intensi�cation:additional medications,left cardiac sympathetic
denervation and/or an ICD(Class I)
Treatment intensi�cation:additional medications,left cardiac sympathetic
denervation and/or an ICD(Class IIb)
ICDcandidate*
QT prolonging drugs/hypokalemia/
hypomagnesemia(Class III: Harm)
Prevention of Sudden Cardiac Deathin Patients with Long QT Syndrome
*ICD candidacy as determined by functional status, life expectancy, or patient preference.†High-risk patients with LQTS include those with QTc >500 ms, genotypes LQT2 and LQT3, females with genotype LQT2,
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
Documented orsuspected Brugada
syndrome
Genotyping(Class IIb)
Spontaneous Type IBrugada ECG
Suspected Brugada syndromewithout Type I ECG
Lifestye changes:1. Avoid Brugada aggravating drugs2. Treat fever3. Avoid excessive alcohol4. Avoid cocaine
Cardiac arrest,recent unexplained
syncope
Recurrent VT,VF storm
Positive
ICDcandidate*
Quinidine orcatheter ablation
(Class I)
Quinidine orcatheter ablation
(Class I)
ICD(Class I)
Observewithout therapy
EP study for riskstrati�cation(Class IIb)
NoNo
Yes
Pharmacologicchallenge(Class IIa)
Genetic counselling formutation speci�c
genotyping of 1º relatives(Class I)
Yes
Yes
Prevention of Sudden Cardiac Deathin Patients with Brugada Syndrome
*ICD candidacy as determined by functional status, life expectancy, or patient preference.Figure 14
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Back to Table of ContentsGUIDELINES MADE SIMPLE 2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
VA/SCD
Adults with repaired TOFand frequent or complex VA
ACHD with documented orsuspected life-threatening VA
Initial presentation:resuscitated
cardiac arrest
ACHD with high-riskfeatures*
and frequent VA†
Evaluation andtreatment (if appropriate)for residual anatomic orcoronary abnormalities
(Class I)
ICD(Class I)
Recurrentsustained VT
ICD(Class IIa)
Catheterablation
(Class IIa)
EP study(Class IIa)
Sustained VT
Induciblesustained VT/VF
if positive
EP study(Class IIa)
ICD(Class IIa)
Beta blocker(Class IIa)
Unexplained syncopeand at least moderate ventricular
dysfunction or markedhypertrophy
Prevention of Sudden Cardiac Deathin Patients with Adult Congenital Heart Disease
*High-risk features: prior palliative systemic to pulmonary shunts, unexplained syncope, frequent PVC, atrial tachycardia, QRS duration ≥180 ms, decreased LVEF or diastolic dysfunction, dilated right ventricle, severe pulmonary regurgitation or stenosis, or elevated levels of BNP.†Frequent VA refers to frequent PVCs and/or nonsustained VT.Figure 16