2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

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)

European Heart Journal 2015

doi/10.1093/eurheartj/ehv316

www.escardio.org

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European Heart Journal 2015 doi/10.1093/eurheartj/ehv316

www.escardio.org

The 2015 ESC Guidelines for the management of VA and prevention of SCD

• To describe and explain the epidemiology and pathophysiology of ventricular arrhythmias and SCD

• To provide an up-to-date summary on current knowledge but also –and even more important – of current knowledge gaps

• To come up with the best consensus on available and reasonable diagnostics and therapies

• To provide practical and clinical help to identify patients at risk for ventricular arrhythmia and sudden cardiac death.

• To guide the management of VA and SCD and thereby promoting the best outcome to improve quality of life and reduce the burden of SCD

• To raise further awareness on the global threat of SCD.

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II

AOP

100

0

II

AOP

100

0

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Autopsy and molecular autopsy in sudden death victims

• ~ 50% of cardiac arrests occur in individuals without known heart disease, but most suffer from concealed ischaemic heart disease.

• Every time a heritable disease is identified in a deceased individual, the relatives may be at risk of being affected and dying suddenly.

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Diagnostic workup in patients presenting with sustained ventricular tachycardia or ventricular fibrillation

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Diagnostic workup in patients presenting with sustained ventricular tachycardia or ventricular fibrillation

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Speaker

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Diagnostic workup in patients presenting with sustained ventricular tachycardia or ventricular fibrillation

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Therapies for ventricular arrhythmias• Pharmacotherapy for VA and prevention of SCD

• With the exception of beta-blockers, currently available AAD have not been shown in RCT to be effective in primary management of patients with life-threatening VA or in prevention of SCD.

• Each drug has a significant potential for causing adverse events, including pro-arrhythmia.

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Antiarrhythmic drugs for the prevention of SCD

amiodaron vs. Placebo

ICD therapie vs. Placebo

HR 97.5% CI P-value

1.06 0.86, 1.30 0.53

0.77 0.62, 0.96 0.007

follow-up (months)

0

12 24 36 48 60

0

0.1

0.2

0.3

0.4m

ort

alit

y

amiodaron

placebo

ICD

Bardy GH, N Engl J Med 2005

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Primary prevention of SCD with the ICD

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The subcutaneous ICD

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• Device therapy - Subcutaneous cardioverter defibrillator

• SC defibrillators are effective in preventing SD.

• Data on long-term tolerability and safety are currently lacking.

• The device is not suitable for patients who require bradycardia pacing, CRT or those who suffer from tachyarrhythmias that can be easily terminated by ATP.

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• Device therapy - Wearable cardioverter defibrillator

• No prospective randomized trials evaluating the device have been reported.

• Many case reports, case series, & registries (held by manufacturer or independently) have reported successful use of WCD in a relatively small proportion of patients at risk of potentially fatal VAs.

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Diagnostic workup in patients with sustained ventriculararrhythmias and ACS.

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Sustained VT in structural heart disease:drugs or ablation?

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Sustained ventricular tachycardia- Drug therapy

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- Catheter ablation

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Catheter ablation of ventricular tachycardia

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Interventional therapy - Catheter ablation

• Scar-related VT - typically monomorphic.

• 12-lead ECG recording of clinical VT can aid ablation procedure.

• VT related to post-myocardial scar - better outcome of catheter ablation than VT due to non-ischaemic CMP.

• Procedure-related mortality ranges from 0% - 3%.

• VT in patients without overt structural heart disease most commonly from RVOT or LVOT.

• Catheter ablation - high rate of procedural success; rate of SCD generally low.

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Outfow tract ventricular arrhythmias

RVOT/PA LVOT/AO CS/EPI

AP APLL

TA

PV

MV

AV

CS

GCV**

**

**

Tanner et al., JACC 2005

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VT and VF in structurally normal hearts• Outflow tract ventricular tachycardia

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Catheter ablation of ventricular fibrillation

Haissaguerre M et al. Lancet 2002; 359:677–678

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Idiopathic ventricular fibrillation

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Short-coupled torsade de pointes

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Drug-related pro-arrhythmia

• Should be suspected if an inherited or acquired arrhythmogenic substrate has been excluded and patient is treated with agents known to alter electrical properties of the heart (e.g. inducing QT prolongation) or causing electrolyte abnormalities.

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To do and to not do messages

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ESC Pocket Guidelines application available!

European Heart Journal 2015 doi/10.1093/eurheartj/ehv316