2017 Guideline for Management of Patients With Ventricular ......with Ischemic Heart Disease or Nonischemic Cardiomyopathy *Management should start with ensuring that the ICD is programmed

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


Brugada Syndrome


Adult Congenital Heart Disease


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)


Yes


Management of Sustained Monomorphic VT

*Known history of verapamil sensitive or classical electrocardiographic presentation.Figure 2

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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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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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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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VA/SCD

Yes Yes Yes Yes

Etiology uncertain

If positive

No No No

YesNoYesNo, due to newly

diagnosed HF(

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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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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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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)


denervation and/or an ICD(Class I)


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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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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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

Documents

2017 Guideline for Management of Patients With Ventricular ......with Ischemic Heart Disease or Nonischemic Cardiomyopathy *Management should start with ensuring that the ICD is programmed