ESC 2022 Ventricular Arrhythmia Guidelines - Key takeaways
Europe: The European Society of Cardiology (ESC) has released updated guidelines on the management of patients with ventricular arrhythmias (VAs) and the prevention of sudden cardiac death (SCD). The guideline, published in the European Heart Journal, was developed by the task force of the ESC and endorsed by the Association for European Paediatric and Congenital Cardiology (AEPC).
The newly developed guidelines expand on the diagnostic evaluation at first presentation with VA in patients without known cardiac disease, provocative diagnostic and genetic testing, management of patients with an electrical storm, and some aspects of the device therapy.
Given below are the key recommendations from the update:
- It is recommended that public access to defibrillation is available at sites where cardiac arrest is more likely to occur and community training in basic life support is implemented to increase bystander cardiopulmonary resuscitation rate and automatic external defibrillator (AED) use. Mobile phone-based alerting of basic life support-trained bystander volunteers to assist nearby out-of-the-hospital cardiac arrest victims should be considered.
- In sudden cardiac arrest survivors with coronary artery spasms, implantation of an ICD should be considered. ICD therapy should also be considered in patients with CAD, New York Heart Association class I, and left ventricular ejection fraction (LVEF) ≤30% despite ≥3 months of optimal medical therapy. Likewise, ICD implantation should be considered in patients with CAD, LVEF ≤40% despite ≥3 months of optimal medical therapy, and nonsustained VT, if they are inducible for VT at electrophysiologic (EP) study.
- In patients with coronary artery disease (CAD) and recurrent, symptomatic, sustained monomorphic ventricular tachycardia (SMVT), or implantable cardioverter-defibrillator (ICD) shocks for SMVT despite chronic amiodarone therapy, catheter ablation is recommended in preference to escalating antiarrhythmic drug therapy.
- Catheter ablation as first-line treatment is recommended for symptomatic idiopathic VT and premature ventricular contractions (PVCs) from the right ventricular outflow tract (RVOT) or the left fascicles. Beta-blockers or non-dihydropyridine calcium channel blockers are indicated in symptomatic patients with idiopathic VT/PVCs from an origin other than the RVOT or the left fascicles. In patients with PVCs/VT and a presentation not typical for an idiopathic origin, cardiac magnetic resonance (CMR) should be considered, despite a normal echocardiogram. Beta-blockers, non-dihydropyridine calcium channel blockers, or flecainide should be considered when catheter ablation is not available, not desired, or is particularly risky. Catheter ablation or flecainide should be considered in symptomatic patients with idiopathic VT/PVCs from an origin other than the RVOT or the left fascicles.
- In patients with CAD and hemodynamically well-tolerated SMVT and preserved or mildly reduced EF (i.e., LVEF ≥40%), catheter ablation should be considered as an alternative to ICD therapy, provided that the ablation's established endpoints have been reached. Nota bene, the guideline document did not specify what those endpoints should be, but they would presumably include noninducibility of the clinical VT! Catheter ablation should be considered in patients with CAD and recurrent, symptomatic SMVT, or ICD shocks despite beta-blocker or sotalol treatment.
- In patients with clinically diagnosed long QT syndrome, genetic testing and genetic counseling are recommended. Beta-blockers, ideally nonselective (nadolol or propranolol) are recommended in long QT syndrome patients with documented QT interval prolongation to reduce risk of arrhythmic events.
- Isoproterenol infusion, verapamil, or quinidine for acute treatment of an electrical storm or recurrent ICD discharges should be considered in idiopathic VF.
- In patients with congenital heart disease presenting with sustained VAs, evaluation for residual lesions or new structural abnormalities is recommended.
- In patients with cardiac sarcoidosis who had LVEF >35% but significant LGE at CMR after resolution of acute inflammation, ICD implantation should be considered. In patients whose EF is 35-50% and minor LGE at CMR, after resolution of acute inflammation, programmed electrical stimulation for risk stratification should be considered. In patients with cardiac sarcoidosis, LVEF 35-50%, and inducible SMVT at EP study, ICD implantation should be considered. In patients with cardiac sarcoidosis and recurrent, symptomatic VA, an antiarrhythmic drug should be considered.
- In patients with hemodynamically not tolerated sustained VT or ventricular fibrillation (VF) during the acute or chronic phase of myocarditis, ICD implantation should be considered. In post-myocarditis patients with recurrent, symptomatic VT, antiarrhythmic drug treatment should be considered. Catheter ablation should be considered and post-myocarditis patients with recurrent symptomatic VT, or ICD shocks for VT in whom antiarrhythmic drugs are ineffective, not tolerated, or not desired.
- EP study is recommended in patients with myotonic dystrophy and palpitations, syncope suggestive of VA, or surviving a cardiac arrest. ICD implantation is recommended in patients with myotonic dystrophy and SMVT or aborted cardiac arrest not caused by bundle branch re-entrant VT. Invasive EP evaluation should be considered in patients with a sudden increase in the PR interval or QRS duration.
- In patients with LV noncompaction cardiomyopathy phenotype based on CMR or echo, implantation of an ICD for primary prevention of SCD should be considered to follow dilated cardiomyopathy recommendations. An ICD should be considered in patients with light chain amyloidosis or transthyretin-associated cardiac amyloidosis and hemodynamically not tolerated VT.
- MR with LGE is recommended in hypertrophic cardiomyopathy (HCM) patients for diagnostic workup. Genetic counseling and testing are also recommended. In a first-degree relative of a patient with HCM, ECG and echocardiogram are recommended. ICD implantation should be considered in HCM patients with an intermediate 5-year risk of SCD, and with: a) significant LGE at CMR; or b) LVEF <50%; or c) abnormal blood pressure response during exercise test; or d) LV apical aneurysm; or e) presence of a sarcomeric pathogenic mutation.
- In patients with suspected arrhythmogenic right ventricular cardiomyopathy (ARVC), CMR is recommended. In patients with a suspected or definite diagnosis of ARVC, genetic counseling and testing are recommended. ICD implantation should be considered in symptomatic patients with definite ARVC, moderate right or left ventricular dysfunction, and either nonsustained VT or inducibility of SMVT at the EP study.
- CMR with late gadolinium enhancement (LGE) should be considered in dilated cardiomyopathy for assessing etiology and the risk of VA and SCD. ICD implantation should be considered in dilated cardiomyopathy and hypokinetic nondilated cardiomyopathy patients with an LVEF <50% and ≥2 risk factors (syncope; LGE on CMR; inducible as monomorphic VT at EP study; pathogenic mutations in LMNA, PLN, FLNC, and RBM20 genes).
- Genetic testing is recommended in patients with dilated cardiomyopathy and atrioventricular (AV) conduction delay at ≤50 years of age, or those who have a family history of dilated cardiomyopathy or SCD in the first-degree relative (at age ≤50 years). In a first-degree relative of a dilated cardiomyopathy or hypokinetic nondilated cardiomyopathy patient, an electrocardiogram (ECG) and an echocardiogram are recommended if 1) the index patient was diagnosed under 50 years of age or has clinical features suggestive of inherited cause, or 2) there is a family history of dilated cardiomyopathy or premature unexpected sudden death.
- In nonresponders to cardiac resynchronization therapy with frequent, predominantly monomorphic PVCs limiting optimal biventricular pacing despite pharmacological therapy, catheter ablation or antiarrhythmic drugs should be considered.
- In patients with an unexplained reduced EF and a PVC burden of ≥10%, PVC-induced cardiomyopathy should be considered. In patients with suspected PVC-induced cardiomyopathy, CMR should be considered. In patients with cardiomyopathy suspected to be caused by frequent and predominantly monomorphic PVCs, catheter ablation is recommended.
The guideline also provides additional recommendations for the management of patients with congenital heart disease, idiopathic VF, acquired long QT syndrome, Brugada syndrome, early repolarization syndrome, catecholaminergic polymorphic VT, and short QT syndrome.
Reference:
2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: Developed by the task force for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death of the European Society of Cardiology (ESC) Endorsed by the Association for European Paediatric and Congenital Cardiology (AEPC), European Heart Journal, 2022;, ehac262, https://doi.org/10.1093/eurheartj/ehac262
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