Prevention of VT and sudden cardiac death: the new recommendations

The 2022 ESC guideline for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death (SCD) comprises more than 150 new recommendations, alongside numerous modifications of previous ones. These changes stand for the vast amount of new evidence on risk stratification, diagnostics, and treatment advances since 2015.

The updated guidelines not only contain new recommendations on general aspects, structural heart disease, and primary electrical disease [1–3]; novel sections and concepts for e.g. genetic testing, provocative diagnostic tests, and management of patients with electrical storm were included. Guideline co-chairs Prof. Katja Zeppenfeld (Leiden University Medical Center, the Netherlands) and Prof. Jacob Tfelt-Hansen (Copenhagen University Hospital, Denmark) highlighted selected sections and recommendations.

One very important component influencing survival rates of out-of-hospital cardiac arrest, is instant resuscitation. Thus, new recommendations have been issued to improve basic life support in this setting:

• Availability of public access defibrillation at sites where cardiac arrest is more likely to occur (class I)
• Prompt cardio-pulmonary resuscitation (CPR) by bystanders and promotion of community training in basic life support to increase rates of bystander CPR and use of automated external defibrillators (class I)
• Consideration of mobile phone-based alerting of basic life support-trained bystander volunteers to assist nearby victims of out-of-hospital cardiac arrest (class IIa)

“We have developed algorithms for the evaluation of patients with an incidental finding of a non-sustained (NS) ventricular tachycardia (VT), of patients presenting with a first monomorphic VT episode, of sudden cardiac arrest (SCA) survivors, sudden death victims, but also of relatives of sudden death descendants,” Prof. Zeppenfeld outlined a variety of topics within the guidelines.

“In a patient with a first monomorphic sustained ventricular tachycardia (SMVT) episode, recording the 12-lead ECG of the VT whenever possible and after VT termination a stable 12-lead ECG and an echocardiogram are class I recommendations,” noted Prof. Zeppenfeld. In acute management of regular wide QRS complex tachycardia, direct current cardioversion is a new class I recommendation for patients with tolerated SMVT episode, if low anaesthetic risk.

The recommendations also include a new class I indication for catheter ablation as first-line therapy for symptomatic idiopathic VT/premature ventricular complexes (PVCs) from the right ventricular outflow tract or the left fascicles (class I). In case of other origins of symptomatic idiopathic VT/PVCs there is an indication for beta-blocker and non-dihydropyridine calcium-channel blockers (class I) or catheter ablation/flecainide (class IIa). Catheter ablation has been upgraded to class I for patients with suspected PVC-induced (>10% burden) cardiomyopathy.

“In patients with chronic coronary artery disease (CAD), risk stratification still relies on the ejection fraction determined 6–12 weeks after the acute event,” Prof. Zeppenfeld noted. Programmed electrical stimulation in previous STEMI and unexplained syncope after non-invasive evaluation in chronic CAD has been upgraded to class I.

In patients carrying an ICD and CAD plus recurrent symptomatic SMVT/ICD shocks for SMVT, catheter ablation is preferred over escalating anti-arrhythmic drugs in patients already on amiodarone in the same situation (class I). “In patients who are not on amiodarone yet, either catheter ablation or beta-blocker replacement by sotalol or adding amiodarone to beta-blocker treatment are IIa indications and the options need to be discussed with the patient,” Prof. Zeppenfeld further explained.

Guidance for VA/SCD risk stratification and primary prevention is also provided for patients with dilated and hypokinetic non-dilated cardiomyopathy (DCM and HNDCM), e.g.:

• Cardiac MRI with late gadolinium enhancement should be considered to assess aetiology and risk (class IIa)
• Genetic testing (including the LMNA, PLN, RBM20, FLNC genes) is recommended in DCM/HNDCM patients with a first-degree relative <50 years with atrioventricular conduction delay (class I)

Recommendations on DCM/HNDCM also highlight that indications for ICD implantation for primary prevention have been broadened and are no longer limited to patients with an LVEF ≤35%. Readers should consider this for patients with DCM and HNDCM.

News in primary electrical disease

Prof. Tfelt-Hansen gave an overview about the sections on selected primary electric diseases, featuring long QT syndrome (LQTS), Brugada syndrome, early repolarisation syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), and idiopathic ventricular fibrillation (VF), the latter including:

• Diagnosis of idiopathic VF in an SCA survivor preferably with documentation of VF after exclusion of an underlying structural, channelopathic, metabolic, or toxicological aetiology
• Consideration of isoproterenol infusions, verapamil, or quinidine for acute treatment of electrical storm/recurrent ICD discharges (class IIa)
• Consideration of quinidine for chronic therapy to suppress an electrical storm/recurrent ICD discharges (class IIa)

As for genetics in general, there is now a class I indication for testing and counselling on consequences by an expert multidisciplinary team. Specifically, genetic testing and counselling is recommended for patients with clinically diagnosed LQTS, clinical suspicion/diagnosis of CPVT, as well as testing for SCN5A gene in Brugada syndrome (all class I).

Further new class I and IIa recommendations on LQTS are:

• Beta-blockers, ideally non-selective beta-blockers (nadolol or propranolol) in LQTS patients with documented QT interval prolongation, to reduce risk of arrhythmic events (class I)
• Mexiletine is indicated in LQTS patients with a prolonged QT interval (class I)
• In LQTS, it should be considered to calculate the arrhythmic risk before initiation of therapy based on the genotype and the duration of QTc interval (class IIa)

In Brugada syndrome patients with recurrent appropriate ICD shocks refractory to drug therapy, catheter ablation has been upgraded from class IIb to class IIa, for triggering PVCs and/or right ventricular outflow tract epicardial substrate. Considering the implantation of a loop recorder is a new IIa recommendation in case of Brugada syndrome patients with unexplained syncope.

Early repolarisation (ERP) is an ECG pattern that can be benign and it is more prevalent in young men and athletes. An indication for diagnosis of ERP is a J-point elevation of ≥1 mm in 2 adjacent inferior and/or lateral ECG leads (class I). On the other hand, a diagnosis of early repolarisation syndrome is recommended in patients resuscitated from unexplained VF/PVT in the presence of ERP (class I). In terms of treatment, ICD implantation is recommended in patients with early repolarisation syndrome who have survived a cardiac arrest (class I).

Finally, the ESC recommendations document calls for action with a general recommendation for comprehensive autopsies in all cases of unexpected sudden death and always in persons under 50 years of age (class I).

1. Presentations in Session: “2022 ESC Guidelines Overview”, ESC Congress 2022, Barcelona, Spain, 26–29 August.
2. Presentations in Session: “2022 ESC Guidelines for the management of patients with ventricular arrhythmias and prevention of sudden cardiac death”, ESC Congress 2022, Barcelona, Spain, 26–29 August.
3. Zeppenfeld K, et al. Eur Heart J. 2022 Aug 26;ehac262. doi: 10.1093/eurheartj/ehac262. Online ahead of print.

 

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Posted on 27 October 2022