2017 Guideline for Management of Patients With Ventricular ...
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
?2017, American College of Cardiology B17213
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 Jos? 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 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
?2017, American College of Cardiology B17213
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
?2017, American College of Cardiology B17213
GUIDELINES MADE SIMPLE
VA/SCD
Back to Table of Contents
2017 Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Management of Sustained Monomorphic VT
Sustained Monomorphic VT
Stable
Hemodynamic stability
12-lead ECG, history & physical
Unstable
Direct current cardioversion
& ACLS
Consider disease speci c VTs
Cardioversion (Class I)
Structural heart disease
Yes
IV procainamide (Class IIa)
VT termination
No
Typical ECG morphology for idiopathic VA
IV amiodarone
or sotalol
Yes
(Class IIb)
Therapy guided by underlying heart disease
No
Cardioversion (Class I)
Verapamil sensitive VT*: verapamil or
Out ow tract VT: beta blocker for acute termination of VT (Class IIa)
Yes Yes
VT termination
No
Effective
No
Cardioversion (Class I)
Yes
Therapy to prevent recurrence preferred
Catheter ablation Verapamil or beta blocker
(Class I)
(Class IIa)
VT termination
No
Catheter ablation (Class I)
Sedation/anesthesia, reassess antiarrhythmic
therapeutic options, repeat cardioversion
*Known history of verapamil sensitive or classical electrocardiographic presentation. Figure 2
4
?2017, American College of Cardiology B17213
GUIDELINES MADE SIMPLE
VA/SCD
Back to Table of Contents
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 sustained spontaneous
monomorphic VT*
Ischemia warranting revascularization
Yes
No
Revascularize & reassess SCD risk (Class I)
ICD candidate Yes No
Cardiac syncope
LVEF 35% Yes No
ICD (Class I)
EP study (Class IIa)
Inducible VA
Yes No
ICD (Class I)
GDMT (Class I)
ICD (Class I)
Extended 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
?2017, American College of Cardiology B17213
5
GUIDELINES MADE SIMPLE
VA/SCD
Back to Table of Contents
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, LVEF 40%
MI 90 d after revascularization
NYHA class I LVEF 30%
NYHA class II or III LVEF 35%
LVEF 40%, NSVT, inducible sustained VT on
EP study
NYHA
class IV
candidate for
advanced HF therapy
Yes
ICD (Class I)*
Yes No
Yes No
ICD (Class I)
GDMT
ICD (Class IIa)
ICD should not be implanted
(Class III: No Bene t)
*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
?2017, American College of Cardiology B17213
6
GUIDELINES MADE SIMPLE
VA/SCD
Back to Table of Contents
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 VT/VF
Sustained monomorphic VT
Consider reversible
causes
Catheter ablation as rst-line therapy
(Class IIb)
Amiodarone or sotalol (Class I)
Drug, electrolyte induced ischemia
Treat for QT prolongation, discontinue offending medication, correct electrolytes (Class I)
Revascularize (Class I)
No reversible causes
Amiodarone (Class I)
Beta blockers or lidocaine (Class IIa)
Arrhythmia not controlled
Arrhythmia not controlled
IHD with frequent VT or
VT storm
Yes No
NICM
Identi able PVC triggers
Catheter ablation (Class I)
Catheter Catheter ablation ablation (Class IIa) (Class IIa)
Yes No
Catheter ablation (Class I)
Autonomic modulation (Class IIb)
*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
7
?2017, American College of Cardiology B17213
GUIDELINES MADE SIMPLE
VA/SCD
Back to Table of Contents
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
SCA survivor/ sustained VT (spontaneous/ inducible)
Yes
Symptoms
No
concerning
No
for VA
Yes
Class II-III HF and LVEF 35%
NICM due to
No
LMNA mutation and 2?
risk factors
Yes
Yes
ICD candidate*
Yes
ICD (Class I)
No
Amiodarone (Class IIb)
Arrhythmogenic syncope suspected
ICD candidate*
ICD candidate*
Yes Yes Etiology uncertain
ICD
EP study
ICD
(Class IIa) (Class IIa) (Class I)
No, due to newly diagnosed HF ( ................
................
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