Elsevier

Heart Rhythm

Volume 15, Issue 10, October 2018, Pages e73-e189
Heart Rhythm

News From the Heart Rhythm Society
2017 AHA/ACC/HRS 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

https://doi.org/10.1016/j.hrthm.2017.10.036Get rights and content

Section snippets

ACC/AHA Task Force Members

Glenn N. Levine, MD, FACC, FAHA, Chair

Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect

Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair

Sana M. Al-Khatib, MD, MHS, FACC, FAHA

Joshua A. Beckman, MD, MS, FAHA

Kim K. Birtcher, MS, PharmD, AACC

Biykem Bozkurt, MD, PhD, FACC, FAHA¶

Ralph G. Brindis, MD, MPH, MACC¶

Joaquin E. Cigarroa, MD, FACC

Anita Deswal, MD, MPH, FACC, FAHA

Lesley H. Curtis, PhD, FAHA¶

Lee A. Fleisher, MD, FACC, FAHA

Federico Gentile, MD, FACC

Samuel Gidding, MD, FAHA¶

Zachary D.

Preamble

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization

General Concepts

Table 5

VA include a spectrum that ranges from premature ventricular complex (PVC) to ventricular fibrillation (VF), with a clinical presentation that ranges from a total lack of symptoms to cardiac arrest. Most life-threatening VA are associated with ischemic heart disease, particularly in older patients (S2.2.2-1). The risks of VA and SCD vary in specific populations with different underlying cardiac conditions, and with specific family history and genetic variants, and this variation has

Cellular Mechanisms and Substrates

Mechanisms of VA include enhanced normal automaticity, abnormal automaticity, triggered activity induced by early or late afterdepolarizations, and reentry S3.4-1, S3.4-2, S3.4-3. Reentry requires a trigger to initiate the arrhythmia and a substrate to sustain it. The trigger may be a PVC, which may be due to automaticity. The substrate may be structural remodeling secondary to an underlying disease process, and often includes a scar secondary to a prior MI or surgical repair, or patchy

History and Physical Examination

Recommendation for Syncope

Referenced studies that support the recommendation are summarized in Online Data Supplement 1.

CORLOERecommendation
IB-NR
  • 1.

    Patients presenting with syncope for which VA is documented, or thought to be a likely cause, should be hospitalized for evaluation, monitoring, and management S4.1-1, S4.1-2, S4.1-3, S4.1-4.

This section covers practices that are well accepted, and a new recommendation was determined to only be warranted for syncope.

Table 6

Synopsis

VA can produce a

Medication Therapy

With the exception of beta blockers (e.g., metoprolol succinate, carvedilol), there is no evidence from RCTs that antiarrhythmic medications for VA improve survival when given for the primary or secondary prevention of SCD. However, the use of these medications is essential in some patients to control arrhythmias and improve symptoms. Medication use for VA is discussed, and any recommendations are listed, in subsequent sections. Further, medication-induced proarrhythmia is addressed in Section

Acute Management of Specific VA

Recommendations for Management of Cardiac Arrest

References that support the recommendations are summarized in Online Data Supplement 15 and 16.

CORLOERecommendations
IA
  • 1.

    CPR should be performed in patients in cardiac arrest according to published basic and advanced cardiovascular life support algorithms S6-1, S6-2, S6-3.

IA
  • 2.

    In patients with hemodynamically unstable VA that persist or recur after a maximal energy shock, intravenous amiodarone should be administered to attempt to achieve a stable

Secondary Prevention of SCD in Patients With Ischemic Heart Disease

Recommendations for Secondary Prevention of SCD in Patients With Ischemic Heart Disease

References that support the recommendations are summarized in Online Data Supplement 17 and 18.

CORLOERecommendations
IB-R B-NR
  • 1.

    In patients with ischemic heart disease, who either survive SCA due to VT/VF or experience hemodynamically unstable VT (LOE: B-R) S7.1.1-1, S7.1.1-2, S7.1.1-3, S7.1.1-4 or stable sustained VT (LOE: B-NR) (S7.1.1-5) not due to reversible causes, an ICD is recommended if meaningful

VA in the Structurally Normal Heart

Recommendations for VA in the Structurally Normal Heart

References that support the recommendations are summarized in Online Data Supplement 45.

CORLOERecommendations
IB-R
  • 1.

    In patients with symptomatic PVCs in an otherwise normal heart, treatment with a beta blocker or nondihydropyradine calcium channel blocker is useful to reduce recurrent arrhythmias and improve symptoms S8-1, S8-2.

IIaB-R
  • 2.

    In patients with symptomatic VA in an otherwise normal heart, treatment with an antiarrhythmic medication is

PVC-Induced Cardiomyopathy

Recommendations for PVC-Induced Cardiomyopathy

References that support the recommendations are summarized in Online Data Supplement 50.

CORLOERecommendations
IB-NR
  • 1.

    For patients who require arrhythmia suppression for symptoms or declining ventricular function suspected to be due to frequent PVCs (generally >15% of beats and predominately of 1 morphology) and for whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation is useful S9-1, S9-2.

IIa

Athletes

In athletes, VAs range from isolated PVCs, couplets, and NSVT, to sustained VT and SCA leading to SCD (S10.1-1). Infrequent PVCs and short runs of repetitive NSVT, especially in the absence of structural heart disease, are more common in nonathletes, but they are generally benign, requiring only a limited workup and rarely lead to disqualification for sports S10.1-2, S10.1-3. In contrast, longer runs of NSVT, especially when exercise-induced, and sustained VT and SCA/SCD are infrequent, but

Subcutaneous Implantable Cardioverter-Defibrillator

Recommendations for Subcutaneous Implantable Cardioverter-Defibrillator

References that support the recommendations are summarized in Online Data Supplement 55.

CORLOERecommendations
IB-NR
  • 1.

    In patients who meet criteria for an ICD who have inadequate vascular access or are at high risk for infection, and in whom pacing for bradycardia or VT termination or as part of CRT is neither needed nor anticipated, a subcutaneous implantable cardioverter-defibrillator is recommended S11.1-1, S11.1-2, S11.1-3,

Special Considerations for Catheter Ablation

Recommendations for Catheter Ablation

References that support the recommendations are summarized in Online Data Supplement 57.

CORLOERecommendations
IC-LD
  • 1.

    In patients with bundle-branch reentrant VT, catheter ablation is useful for reducing the risk of recurrent VT and ICD shocks S12-1, S12-2, S12-3.

IIaB-NR
  • 2.

    In patients with structural heart disease who have failed endocardial catheter ablation, epicardial catheter ablation can be useful for reducing the risk of recurrent monomorphic VT S12-4, S12-5,

Postmortem Evaluation of SCD

Recommendations for Postmortem Evaluation of SCD

References that support the recommendations are summarized in Online Data Supplement 58.

CORLOERecommendations
IB-NR
  • 1.

    In victims of SCD without obvious causes, a standardized cardiac-specific autopsy is recommended S13-1, S13-2.

IB-NR
  • 2.

    In first-degree relatives of SCD victims who were 40 years of age or younger, cardiac evaluation is recommended, with genetic counseling and genetic testing performed as indicated by clinical findings (S13-3).

IIaB-NR
  • 3.

    In

Terminal Care

Recommendations for Terminal Care

References that support the recommendations are summarized in Online Data Supplement 59.

CORLOERecommendations
IC-EO
  • 1.

    At the time of ICD implantation or replacement, and during advance care planning, patients should be informed that their ICD shock therapy can be deactivated at any time if it is consistent with their goals and preferences.

IC-EO
  • 2.

    In patients with refractory HF symptoms, refractory sustained VA, or nearing the end of life from other illness, clinicians

Shared Decision-Making

Recommendations for Shared Decision-Making

References that support the recommendations are summarized in Online Data Supplement 60.

CORLOERecommendations
IB-NR
  • 1.

    In patients with VA or at increased risk for SCD, clinicians should adopt a shared decision-making approach in which treatment decisions are based not only on the best available evidence but also on the patients’ health goals, preferences, and values S15-1, S15-2, S15-3, S15-4, S15-5.

IB-NR
  • 2.

    Patients considering implantation of a new ICD or

Cost and Value Considerations

The key principles of value assessment as part of clinical practice guidelines have been discussed in detail (S16-1). Economic outcomes of clinical management strategies can be documented empirically using the same research designs as used in establishing clinical outcomes, including RCTs and observational comparisons. In addition, simulation models are often used to assess the value of management strategies, because the standard for cost-effectiveness studies is to compare life-time outcomes,

Quality of Life

ICD implantation has not had a significant effect on QoL in the overall population of patients enrolled in RCTs S17-1, S17-2, S17-3. Several studies have, however, demonstrated that the subset of patients who receive inappropriate ICD shocks have worse QoL than patients who have an ICD but have not had inappropriate shocks (S17-2). Because an ICD is designed to prevent SCD rather than to reduce symptoms, it would not be expected to improve QoL or functional status directly, but may have

Evidence Gaps and Future Research Needs

Despite the numerous advances in risk stratification for SCD and prevention and treatment of SCD and VA, many gaps in knowledge remain. These gaps include:

  • Identification of patients who are most likely to benefit from an ICD among all ICD-eligible patients. The role of novel markers (including genetic and imaging markers) and combinations of markers should be studied.

  • Characterizing the role of the ICD in patient subgroups not well-represented in the pivotal ICD trials. Such subgroups include

Presidents and Staff

American College of Cardiology

Mary Norine Walsh, MD, FACC, President

Shalom Jacobovitz, Chief Executive Officer

William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publishing

Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing

American College of Cardiology/American Heart Association

Katherine A. Sheehan, PhD, Director, Guideline Strategy and Operations

Abdul R. Abdullah, MD, Science and Medicine Advisor

Sam Shahid, MBBS, MPH,

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Developed in Collaboration With the Heart Failure Society of America

This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, and the Heart Rhythm Society in September 2017, and the American Heart Association Executive Committee in October 2017.

The Heart Rhythm Society requests that this document be cited as follows: Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm Society 2018; e73-e189.

This article has been copublished in the Journal of the American College of Cardiology and Circulation.

Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (professional.heart.org), and the Heart Rhythm Society (www.hrsonline.org). For copies of this document, please contact the Elsevier Inc. Reprint Department via fax (212-633-3820) or e-mail ([email protected]).

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the Heart Rhythm Society. Requests may be completed online via the Elsevier site (http://www.elsevier.com/about/policies/author-agreement/obtaining-permission).

Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.

ACC/AHA Representative.

HRS Representative.

§

ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative.

ACC/AHA Task Force on Clinical Practice Guidelines Liaison.

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