Ventricular arrhythmias & sudden cardiac death

Carina Blomstrom Lundqvist

Dept Cardiology, Uppsala, Sweden

www.escardio.org

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European Heart Journal 2015 doi/10.1093/eurheartj/ehv316

• The European update of the 2006 European/ American Guidelines focusing on preventing SCD in patients with VA

• 87 pages document; 809 references; 74 peer reviewers

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Autopsy and molecular autopsy in sudden death victims

• ~ 50% of cardiac arrests occur in individuals without known 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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NEW!- DNA analysis should be

a fundamental component of post

mortem assessment in SD victims, especially in

young.

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Screening patients with suspected or known ventricular arrhythmias

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Speaker

ECG

Holter

Event recorders

ILR – if conventional techniques fail

SAEG – diagnostic tool

Suspected ischemia or exercise induced VA

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Screening patients with suspected or known ventricular arrhythmias

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Echo for LV function

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Screening patients with suspected or known ventricular arrhythmias

EP study

• does not contribute to identify high risk patients in HCM (Class III).

• not indicated in channelopathies, debated in BrS.

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EP study- Post MI pats with arrhythmia

related symptoms- Syncope pats if suspected brady

or tachy arrhythmia

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Therapies for ventricular arrhythmias• Device therapy - Implantable cardioverter defibrillator

Meta-analysis of 3 trials (AVID, CIDS, CASH):

ICD therapy associated with 50% (95% CI:0.37-0.67, P=0.0001) reduction in arrhythmic mortality and 28% (95% CI:0.60-0.87, P=0.006) reduction in total mortality.

Moderately cost-effective.

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Speaker

ICD for secondary prevention of SCD and VT

– Same Class I Recommendation

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Device therapy - Subcutaneous ICD

• Effective in preventing SD.

• Data on long-term tolerability and safety arelacking.

• Not suitable for patients who require bradycardia pacing, CRT or suffer from tachyarrhythmias that can be terminated by ATP.

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NEW!May be considered as an ICD

alternative- venous access, infections, or

in young pats

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Device therapy - Wearable cardioverter defibrillator

• No prospective randomized trials.

• Many case series, & registries (manufacturer or independently) with successful use of WCD in a small proportion of pats at risk of potentially fatal VAs.

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NEW!May be consideredin pats at transient risk for SCD but not

suitable for ICD

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Early after myocardial infarction

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NEW!Re-assess LVEF 6-12 w post MI:

- Need for primary preventive ICD?

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Stable coronary artery disease after myocardial infarction with preserved EF

Re-assess LVEF 6-12 weeks after coronary revascularization - identify potential indications for primary prevention ICD.

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Interventional therapy - Catheter ablation

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Upgrade!Catheter ablation for incessant VT & electrical storms

NEW!Catheter ablation after

1st episode of sust. VT in pats with IHD.

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Therapies for patients with LV dysfunction with or without heart failure- Primary prevention of sudden cardiac death

2 large trials: primary prevention of SCD by ICD in patients with HF and reduced LVEF.

• SCD-HeFT; NYHA II-III, EF < 0.35. Mortality decreased 23% and absolute by 7% with ICD after 5 yrs (from 29% -22%).

• MADIT II; Post MI, EF < 0.30. Mortality decreased 31%, and absolute by 6 %.

• Meta-analysis: 5 primary prevention trials;

CAT, AMIOVIRT, DEFINITE, SCD-HeFT, COMPANION.

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ICD for primary prevention of SCD – Same Class I

Recommendation.

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This is a slight “change” from ESC HF GL 2012, which said:ICD therapy is not indicated in patients in NYHA class IV with severe, drug-

refractory, symptoms who are not candidates for CRT, a ventricular assist

device, or cardiac transplantation (because of a very limited life expectancy -

more likely to die from pump failure)

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Recommendation based on 2 (observational) studies with ~2000

ambulatory class IV patients listed for heart transplantation suggested survival benefit with ICD. Sandner SE, Circulation 2001 and Frohlich, Heart 2013

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Cardiac resynchronization therapy in the primary prevention of sudden death

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CRT to prevent SCD – Recommendation

Class I for LVEF <35%, LBBB and QRSd > 120 ms.

With LBBB

Without LBBB

Change from ESC HF GL 2012, which only referred to pats with QRS

>150 ms (IIa-A recommendation) and gave no recommendation for

pats with QRS 120-150 ms.

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QRS duration and outcome in CRT studies

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>150 ms

120-150 ms

Sipahi et al. Arch Intern Med 2011

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CRT in HF with narrow QRS (<130 ms)

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Ruschitzka, EchoCRT Study; NEJM 2013

BUT

Females only 30%

Mean QRSd 105 ms

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Primary outcome events, stratified by QRSd.

Primary composite outcome of death or HF hospitalization in pats randomized to CRT-ON and -OFF, stratified by QRSd.

QRS duration and outcome in CRT studies

Steffel, EchoCRT substudy , EHJ 2015

BUT - Females only 20%

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CRT in HF patients with Atrial Fibrillation

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This is a slight change from ESC

HF GL 2012, which included

conventional pacing criteria and

had IIa/IIb-C recommendation

irrespective of QRS duration

CRT considered in perm. AF pats if;

1. Ventricular pacing is required or patient otherwise meets CRT criteria

2. Near 100% ventricular pacing achieved with CRT (with ablation or drugs)

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CRT in the primary prevention of SCD, SR, mild HF

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Speaker

Upper part is similar to ESC HF GL 2012, but lower part was

IIa-A and is now IIb-A recommendation

MADIT-CRT study; NYHA I-II, LVEF ≤30% QRSd≥ 130 ms.

RAFT trial: NYHA class II-III, LVEF ≤30%, QRSd≥ 120 ms (or paced QRSd≥200 ms).

CRT for prevention of SCD Mild HF, SR, LVEF < 30%, LBBB and QRS d > 130 ms.

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MADIT-CRT long-term: LBBB vs non-LBBB

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Goldenberg et al. Long-term survival MADIT-CRT, NEJM 2014

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Cardiomyopathies

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1. Dilated cardiomyopathy (DCM)

Secondary

prevention

Primary

prevention

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2. Hypertrophic cardiomyopathy (HCM)

Life style

SCD Risk

calculator

Secondary

Prevention

NO EPSTUDY

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3. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

Secondary

Prevention

Life style

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3. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

Secondary

Prevention

Primary

Prevention

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VT and VF in structurally normal hearts

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• VT and VF in structurally normal hearts

• Outflow tract ventricular tachycardia

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Conclusions

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Compared to ESC (ACC-AHA) 2006 GL on Management

of VA and Prevention of SCD significant changes are

present.

• Content

• User-friendly format

• Studies needed to better identify pats at higher risk

of death and those who would benefit most of CRT

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Majority of patients needs cardiac resuscitation

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Sustained ventricular tachycardia

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- Catheter ablation

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Ventricular tachycardias of miscellaneous origin:

- idiopathic LV tachycardia - papillary muscle VT - annular VT (mitral-tricuspid).

www.escardio.orgSipahi et al. Arch Intern Med 2011

QRS duration and outcome in CRT studies

• Meta-regression analysis - impact of QRS d on effect of CRT on events. Each circle = QRS subgroup within a trial. Sizes of circles ~ sample size.

• Dashed line = log risk ratio (RR) of 0 (ie, RR, 1.00) = no net benefit/harm.

• The further circles are below 0 line, the larger the clinical benefit.

Significant relationship between

QRS d at baseline and log RR

(slope, −0.07 [95% CI, −0.10 to

−0.04]; z=−4.60) (P.001).

QRS ranges <150 ms did not

benefit from CRT (black circles,

log risk ratio close to 0). Clinical

benefit appeared when QRSd >

150 ms were included (gray

circles) and became more

prominent with increasing QRS d

(white circles).

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Bundle branch re-entrant tachycardia

• Bundle branch tachycardia - rare macro-re-entry tachycardia; right bundle branch as anterograde and left bundle branch as retrograde limb.

• 12-lead ECG: LBBB morphology, left-axis deviation.

• Often associated with CMP.

• Catheter ablation of one of bundle branches is curative.

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• Device therapy - Public access defibrillator

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