2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of ...

13 Pages·2017·1.9 MB·English

2017 Guideline for Management of
Patients With Ventricular Arrhythmias and
the Prevention of Sudden Cardiac Death
GUIDELINES MADE SIMPLE
A Selection of Tables and Figures
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©2017,
2017 Guideline for Management of Patients With Ventricular
Arrhythmias and the Prevention of Sudden Cardiac Death
A report of the American College of Cardiology/American Heart Association Task Force on
Clinical Practice Guidelines and the Heart Rhythm Society
Writing Committee:
Sana M. Al-Khatib, MD, MHS, FACC, FAHA, FHRS, Chair
William G. Stevenson, MD, FACC, FAHA, FHRS, Vice Chair
Michael J. Ackerman, MD, PhD
William J. Bryant, JD, LLM
David J. Callans, MD, FACC, FHRS
Anne B. Curtis, MD, FACC, FAHA, FHRS
Barbara J. Deal, MD, FACC, FAHA
Timm Dickfeld, MD, PhD, FHRS
Michael E. Field, MD, FACC, FAHA, FHRS
Gregg C. Fonarow, MD, FACC, FAHA, FHFSA
Anne M. Gillis, MD, FHRS
Mark A. Hlatky, MD, FACC, FAHA
Christopher B. Granger, MD, FACC, FAHA
Stephen C. Hammill, MD, FACC, FHRS
José A. Joglar, MD, FACC, FAHA, FHRS
G. Neal Kay, MD
Daniel D. Matlock, MD, MPH
Robert J. Myerburg, MD, FACC
Richard 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 gy B17213
Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden olo
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Cardiac Death. The resource is only an excerpt from the Guideline and the full publication should Car
be reviewed for more figures and tables as well as important context. e of
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CITATION: J Am Coll Cardiol. Oct 2017, 24390; DOI: 10.1016/j.jacc.2017.10.054
2017 Guideline for Management of Patients With Ventricular
Arrhythmias and the Prevention of Sudden Cardiac Death
GUIDELINES MADE SIMPLE
Selected Table or Figure Page
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
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GUIDELINES MADE SIMPLE
VA/SCD
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Management of Sustained Monomorphic VT
Sustained Monomorphic VT
Direct current
Hemodynamic
Stable Unstable cardioversion
stability
& ACLS
12-lead ECG,
history & physical
Consider disease Cardioversion
specific VTs (Class I)
VT
Structural IV procainamide
Yes termination
heart disease (Class IIa)
No
IV amiodarone
or sotalol Yes No
(Class IIb)
Typical ECG
morphology for Therapy guided Cardioversion
idiopathic VA by underlying (Class I)
heart disease
VT
Verapamil sensitive VT*: verapamil
Yes termination
or
Outflow tract VT: beta blocker
for acute termination of VT Yes
No
(Class IIa)
Sedation/anesthesia,
Effective No Cardioversion VT reassess antiarrhythmic
(Class I) termination therapeutic options,
repeat cardioversion
Yes
No B17213
Therapy to prevent recurrence preferred gy
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Catheter ablation ol
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Catheter ablation Verapamil or beta blocker Coll
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*Known history of verapamil sensitive or classical electrocardiographic presentation. ©2017,
Figure 2
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GUIDELINES MADE SIMPLE
VA/SCD
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Secondary Prevention of Sudden Cardiac Death
in Patients with Ischemic Heart Disease
Secondary prevention in pts with IHD
SCD survivor* or Cardiac syncope†
sustained spontaneous
monomorphic VT*
LVEF ≤35%
Yes No
Ischemia warranting
revascularization
ICD EP study
(Class I) (Class IIa)
Yes No
Revascularize Inducible
& reassess ICD candidate‡ VA
SCD risk
(Class I) Yes No Yes No
ICD GDMT ICD Extended
(Class I) (Class I) (Class I) monitoring
*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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GUIDELINES MADE SIMPLE
VA/SCD
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Primary Prevention of Sudden Cardiac Death
in Patients with Ischemic Heart Disease
Primary prevention in pts with IHD,
EP study
LVEF ≤40%
(especially in Inducible ICD
Yes
the presence sustained (Class I)
of NSVT) VT
MI <40 d
and/or GDMT
Yes* No
revascularization (Class I)
<90 d
Reassess LVEF >40 d after MI
WCD
and/or >90 d after
(Class IIb)
No revascularization
NYHA NYHA NYHA
class I class II or III LVEF ≤40%, class IV
LVEF ≤30% LVEF ≤35% NSVT, inducible candidate for
sustained VT on advanced HF
EP study therapy†
Yes
Yes No Yes No
ICD
(Class I)* ICD ICD ICD should not
GDMT
(Class I) (Class IIa) be implanted
(Class III:
No Benefit)
*Scenarios exist for early ICD placement in select circumstances such as patients with a pacing indication or syncope.
†Advanced HF therapy includes CRT, cardiac transplant, and LVAD.
Figure 4
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GUIDELINES MADE SIMPLE
VA/SCD
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Treatment of Recurrent Ventricular Arrhythmias in Patients
with Ischemic Heart Disease or Nonischemic Cardiomyopathy
ICD with VT/VF
recurrent arrhythmia*
Polymorphic Sustained
VT/VF monomorphic VT
Consider
reversible Catheter ablation Amiodarone
causes as first-line therapy or sotalol
(Class IIb) (Class I)
Drug, electrolyte induced ischemia No reversible causes
Arrhythmia
not controlled
Treat for QT prolongation, Revascularize Amiodarone Beta blockers
discontinue offending (Class I) (Class I) or lidocaine
medication, (Class IIa)
correct electrolytes
IHD with
(Class I)
frequent VT or NICM
Arrhythmia VT storm
not controlled
Yes No
Catheter Catheter Catheter
ablation ablation ablation
Identifiable
(Class I) (Class IIa) (Class IIa)
PVC triggers
Yes No
Catheter Autonomic B17213
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*Management should start with ensuring that the ICD is programmed appropriately and that potential precipitating causes, including olle
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heart failure exacerbation, are addressed. For information regarding optimal ICD programming, refer to the 2015 HRS/EHRA/APHRS/ n
SOLAECE expert consensus statement (“Wilkoff BL, Fauchier L, Stiles MK, et al. 2015 HRS/EHRA/APHRS/SOLAECE expert consensus erica
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F isgtuartee m5 ent on optimal implantable cardioverter-defibrillator programming and testing. J Arrhythm. 2016;32:1-28). ©2017, A
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GUIDELINES MADE SIMPLE
VA/SCD
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Secondary and Primary Prevention of Sudden Cardiac Death
in Patients with a Nonischemic Cardiomyopathy
Patients with NICM
Class
SCA survivor/ II-III NICM due to
Symptoms
sustained VT No concerning No HF and No LMNA mutation
(spontaneous/ and 2º
for VA LVEF ≤35%
inducible) risk factors
Yes Yes Yes Yes
ICD ICD ICD
Arrhythmogenic
candidate* candidate* candidate*
syncope
suspected
Yes No, due to newly Yes
diagnosed HF
Yes No Yes Etiology uncertain
(<3 mo GDMT)
or not on optimal
ICD Amiodarone ICD EP study ICD ICD
GDMT
(Class I) (Class IIb) (Class IIa) (Class IIa) (Class I) (Class IIa)
If positive
If LVEF ≤35%
and WCD
Class II-III (Class IIb)
HF
Reassess
LVEF ≥3mo
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*ICD candidacy as determined by functional status, life expectancy or patient preference. olo
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GUIDELINES MADE SIMPLE
VA/SCD
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Major Clinical Features Associated with Increased Risk of
Sudden Cardiac Death in Patients with Hypertrophic Cardiomyopathy
Established Risk Factors*
• 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†
Potential Risk Modifiers‡
• <30 y
• Delayed hyperenhancement on cardiac MRI
• LVOT obstruction
• Syncope >5 y ago
High-risk Subsets§‡
• LV aneurysm
• LVEF <50%
*There is general agreement in the literature that these factors independently convey an increased risk
for SCD in patients with HCM.
†Decrease in blood pressure of 20 mm Hg or failure to increase systolic blood pressure >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 <50% (end-stage disease) or an LV aneurysm warrant
consideration for ICD implantation.
Table 8
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GUIDELINES MADE SIMPLE
VA/SCD
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Prevention of Sudden Cardiac Death
in Patients with Hypertrophic Cardiomyopathy
Patients with HCM
NSVT;
Family Hx SCD;
SCD survivor; abnormal BP
No LVWT >30 mm; No
sustained VT response to
syncope <6 mo
exercise
Yes Yes Yes No
ICD ICD SCD
candidate* (Class IIa) risk modifier†
present
Yes No Yes No
ICD
ICD Amiodarone ICD ICD (Class III:
(Class I) (Class IIb) (Class IIa) (Class IIb) No Benefit)
*ICD candidacy as determined by functional status, life expectancy, or patient preference.
†Risk modifiers: Age <30 y, late gadolinium enhancement on cardiac MRI, LVOT obstruction, LV aneurysm, syncope >5 y.
Figure 7
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