Sandbox: Ventricular Arrhythmias ACC -2017

Template:Ventricular Arrhythmias ACC -2017 Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

History and Physical Examination

Class I

"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. (Level of Evidence: B-NR) "

12-lead ECG and Exercise Testing

Class I

"1. In patients with sustained, hemodynamically stable, wide complex tachycardia, a 12-lead ECG during tachycardia should be obtained. (Level of Evidence: B-NR) "

"2. In patients with VA symptoms associated with exertion, suspected ischemic heart disease, or catecholaminergic polymorphic ventricular tachycardia, exercise treadmill testing is useful to assess for exercise-induced VA. (Level of Evidence: B-NR) "

"3. In patients with suspected or documented VA, a 12-lead ECG should be obtained in sinus rhythm to look for evidence of heart disease. (Level of Evidence: B-NR) "

Ambulatory Electrocardiography

"1. Ambulatory electrocardiographic monitoring is useful to evaluate whether symptoms, including palpitations, presyncope, or syncope, are caused by VA. (Level of Evidence: B-NR) "

Implanted Cardiac Monitors

Class IIa

"1. In patients with sporadic symptoms (including syncope) suspected to be related to VA, implanted cardiac monitors can be useful. (Level of Evidence: B-R) "

Noninvasive Cardiac Imaging

Class I

"1. In patients with known or suspected VA that may be associated with underlying structural heart disease or a risk of SCA, echocardiography is recommended for evaluation of cardiac structure and function. (Level of Evidence: B-NR) "

Class IIa

"1. In patients presenting with VA who are suspected of having structural heart disease, cardiac magnetic resonance imaging (MRI) or computed tomography (CT) can be useful to detect and characterize underlying structural heart disease. (Level of Evidence: C-EO) "

Biomarkers

Class IIa

"1. In patients presenting with VA who are suspected of having structural heart disease, cardiac magnetic resonance imaging (MRI) or computed tomography (CT) can be useful to detect and characterize underlying structural heart disease. (Level of Evidence: B-NR) "

Genetic Considerations in Arrhythmia Syndromes

Class I

"1. In patients and family members in whom genetic testing for risk stratification for SCA or SCD is recommended, genetic counselling in beneficial. (Level of Evidence: C-EO) "

Invasive Cardiac Imaging: Cardiac Catheterization or CT Angiography

"1. In patients who have recovered from unexplained SCA, CT or invasive coronary angiography is useful to confirm the presence or absence of ischemic heart disease and guide decisions for myocardial revascularization. (Level of Evidence: C-EO) "

Electrophysiological Study for VA

Class IIa

"1. In patients with ischemic cardiomyopathy, NICM, or adult congenital heart disease who have syncope or other VA symptoms and who do not meet indications for a primary prevention ICD, an electrophysiological study can be useful for assessing the risk of sustained VT. (Level of Evidence: B-R) "

Class III - No Benefit

"1. In patients who meet criteria for ICD implantation, an electrophysiological study for the sole reason of inducing VA is not indicated for risk stratification. (Level of Evidence: B-R) "

"1. In patients who meet criteria for ICD implantation, an electrophysiological study for the sole reason of inducing VA is not indicated for risk stratification. (Level of Evidence: B-NR) "

Preventing SCD With HF Medications

Class I

"1. In patients with HFrEF (LVEF ≤40%), treatment with a beta blocker, a mineralocorticoid receptor antagonist and either an angiotensin-converting enzyme inhibitor, an angiotensin-receptor blocker, or an angiotensin receptor- neprilysin inhibitor is recommended to reduce SCD and all-cause mortality. (Level of Evidence: A) "

Surgery and Revascularization Procedures in Patients With Ischemic Heart Disease

Class I

"1. Patients with sustained VA and survivors of SCA should be evaluated for ischemic heart disease, and should be revascularized as appropriate. (Level of Evidence: B-NR) "

"1. In patients with anomalous origin of a coronary artery suspected to be the cause of SCA, repair or revascularization is recommended. (Level of Evidence: C-EO) "

Surgery for Arrhythmia Management

Class IIb

"1. In patients with monomorphic VT refractory to antiarrhythmic medications and attempts at catheter ablation, surgical ablation may be reasonable. (Level of Evidence: C-LD) "

Autonomic Modulation

Class IIa

"1. In patients with symptomatic, non–life-threatening VA, treatment with a beta blocker is reasonable. (Level of Evidence: C-LD) "

Class IIb

"1. In patients with VT/VF storm in whom a beta blocker, other antiarrhythmic medications, and catheter ablation are ineffective, not tolerated, or not possible, cardiac sympathetic denervation may be reasonable. (Level of Evidence: C-LD) "

Acute Management of Specific Ventricular Arrhythmia

Recommendations for Management of Cardiac Arrest

Class I

"1. CPR should be performed in patients in cardiac arrest. according to published basic and advanced cardiovascular life support algorithms. (Level of Evidence: A) "

"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 rhythm after further defibrillation. (Level of Evidence: A) "

"3. Patients presenting with VA with hemodynamic instability should undergo direct current cardioversion. (Level of Evidence: A) "

"4. In patients with polymorphic VT or VF with ST-elevation MI, angiography with emergency revascularization is recommended. (Level of Evidence: B-NR) "

"5. Patients with a wide-QRS tachycardia should be presumed to have VT if the diagnosis is unclear. (Level of Evidence: C-EO) "

Class IIa

"1. In patients with hemodynamically stable VT, administration of intravenous procainamide can be useful to attempt to terminate VT. (Level of Evidence: A) "

"2. In patients with a witnessed cardiac arrest due to VF or polymorphic VT that is unresponsive to CPR, defibrillation, and vasopressor therapy, intravenous lidocaine can be beneficia. (Level of Evidence: B-R) "

"3. In patients with polymorphic VT due to myocardial ischemia, intravenous beta blockers can be useful. (Level of Evidence: B-R) "

"4. In patients with a recent MI who have VT/VF that repeatedly recurs despite direct current cardioversion and antiarrhythmic medications (VT/VF storm), an intravenous beta blocker can be useful. (Level of Evidence: B-NR) "

Class IIb

"1. In patients in cardiac arrest, administration of epinephrine (1 mg every 3 to 5 minutes) during CPR may be reasonable. (Level of Evidence: A) "

"2. In patients with hemodynamically stable VT, administration of intravenous amiodarone or sotalol may be considered to attempt to terminate VT. (Level of Evidence: B-R) "

Class III - No Benefit

"1. In patients with cardiac arrest,administration of high-dose epinephrine (>1mg boluses) compared with standard doses is not beneficial. (Level of Evidence: A) "

"2. In patients with cardiac arrest,administration of high-dose epinephrine (>1mg boluses) compared with standard doses is not beneficial. (Level of Evidence: A) "

Class III - Harm

"3. In patients with suspected AMI, prophylactic administration of lidocaine or high dose amiodarone for the prevention of VT is potentially harmful. (Level of Evidence: B-R) "

"4. In patients with a wide QRS complex tachycardia of unknown origin, calcium channel blockers (e.g., verapamil and diltiazem) are potentially harmful . (Level of Evidence: C-LD) "