Ventricular tachycardia secondary prevention
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in Chief: Sara Zand, M.D.[2] Avirup Guha, M.B.B.S.[3]
Overview
Secondary prevention
Secondary prevention strategies following SCA and unstable VT include ICD implantation, and medications.
- Based on meta-analysis of AVID trial implantation of ICD for secondary prevention of ventricular arrhythmia improved survival compared with antiarrhythmic in patients who survived of sudden cardiac arrest or unstable VT.
- Before ICD implantation, the reversible causes of ventricular arrhythmia including myocardial ischemia, electrolyte disturbance, proarrhythmiac medication effect may be corrected.
- ICD implantation improved outcome in well-tolerated VT and structurally heart disease.
- VT ablation reduced recurrence, but the effect on long-term mortality was unknown.
- Among patients with ischemia heart disease and syncope due to inducible sustained monomorphic VT, ICD is recommended even if there is not other criteria for primary prevention implantation of ICD.
Secondary prevention in patients with ischemic heart disease
| Recommendations for secondary prevention of sudden cardiac death in ischemic heart disease |
| ICD implantation (Class I, Level of Evidence B): |
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❑ In patients with IHD and survivors of SCD due to VT, VF or hermodynamically unstable VT or incessant VT with irreversible cause, ICD should be implanted if survival is more than 1 year. |
| ICD implantation (Intermediate value statement, Level of Evidence B) : |
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❑ In patients with higher risk of death due to ventricular arrhythmia and lower risk of non cardiac death due to other comorbidities, ICD implantation has intermediate value. |
| ICD implantation : (Class I, Level of Evidence B) |
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❑ In patients with IHD and unexplained syncope with induction of sustained monomorphic VT in EPS, ICD implantation is recommended if life expectancy is more than 1 year |
Abbreviations:
VT: Ventricular tachycardia;
VF: Ventricular fibrillation;
ICD: Implantable cardioverter defibrillator
| Secondary prevention in patients with IHD | |||||||||||||||||||||||||||||||||||||||||||||
| SCA survivor or sustained monomorph VT | Cardiac syncope | ||||||||||||||||||||||||||||||||||||||||||||
| Ischemia | LVEF≤35% | ||||||||||||||||||||||||||||||||||||||||||||
| Yes: revascularization, reassessment about SCD risk (class1) | NO:ICD candidate | ||||||||||||||||||||||||||||||||||||||||||||
| Yes:ICD (class1) | NO: medical therapy (class1) | Yes:ICD (CLASS1) | NO:EP study (class 2a) | ||||||||||||||||||||||||||||||||||||||||||
| Ventriculat arrhythmia induction | |||||||||||||||||||||||||||||||||||||||||||||
| Yes: ICD (class1) | NO: monitoring | ||||||||||||||||||||||||||||||||||||||||||||
Secondary prevention in patients with coronary spasm
- Coronary artery spasm is due to vasomotor dysfunction and may occur in the presence or absence of atherosclerosis process.[1]
- Vasospasm mat lead to ventricular arrhythmia, syncope, and sudden cardiac death.
- Prevention of vasospasm may include smoking cessation and using dihyropyridine calcium channel blocker with or without nitrate.
- In the presence of recurrent ventricular arrhythmia in spite of maximum doses of medications or survivors of SCA, implantation of ICD is recommended.[2]
| Recommendations for secondary prevention of sudden cardiac death in coronary spasm |
| ICD implantation (Class I, Level of Evidence B): |
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❑ In patients with ventricular arrhythmia due to coronary artery spasm, vasodilator such as calcium channel blocker with maximum tolerated doses smoking cessation and is recommended |
| ICD implantation (Class IIa, Level of Evidence B) : |
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❑ In survival of SCA due to coronary artery spasm with ineffective or not tolerated medications, ICD implantation is recommended if the survival is more than 1 year |
| ICD implantation : (Class IIb, Level of Evidence B) |
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❑ In survival of SCA due to coronary artery spasm, ICD implantation in addition to medical therapy is recommended if life expectancy is more than 1 year |
Abbreviations:
ICD: Implantable cardioverter defibrillator;
SCA: Sudden cardiac arrest
Post CABG,VT/VF
- Ventricular tachycardia rarely occur within 24 hours after CABG due to the transient effects of reperfusion, electrolyte and acid-base disturbances, and the use of inotrope.
- VF or poly morphic VT in the postoperative period may be the manifestation of myocardial ischemia and [[mechanical complications] and acute electrolyte or acid base disturbances and graft patency should be warranted.[3]
- Monomorphic VT may be related to , prior MI, ventricular scar, LV dysfunction, and placement of a bypass graft across a noncollateralized occluded coronary vessel to a chronic infarct zone.
- Among patients without sustained VT, VF and presence of LV dysfunction, reassessment of LV function 3 months after CABG for decision about ICD implantation is recommended.[4]
- In patients with high burden of non-sustained VT and LV dysfunction, electrophysiology study for risk stratification is recommended. [5]
References
- ↑ "Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version". Circ J. 74 (8): 1745–62. August 2010. doi:10.1253/circj.cj-10-74-0802. PMID 20671373.
- ↑ Morikawa, Yoshinobu; Mizuno, Yuji; Yasue, Hirofumi (2010). "Letter by Morikawa et al Regarding Article, "Coronary Artery Spasm: A 2009 Update"". Circulation. 121 (3). doi:10.1161/CIR.0b013e3181ce1bcc. ISSN 0009-7322.
- ↑ Saxon, Leslie A.; Wiener, Isaac; Natterson, Paul D.; Laks, Hillel; Drinkwater, Davis; Stevenson, William G.X. (1995). "Monomorphic versus polymorphic ventricular tachycardia after coronary artery bypass grafting". The American Journal of Cardiology. 75 (5): 403–405. doi:10.1016/S0002-9149(99)80566-9. ISSN 0002-9149.
- ↑ Vakil, Kairav; Florea, Viorel; Koene, Ryan; Kealhofer, Jessica Voight; Anand, Inderjit; Adabag, Selcuk (2016). "Effect of Coronary Artery Bypass Grafting on Left Ventricular Ejection Fraction in Men Eligible for Implantable Cardioverter–Defibrillator". The American Journal of Cardiology. 117 (6): 957–960. doi:10.1016/j.amjcard.2015.12.029. ISSN 0002-9149.
- ↑ Mittal, Suneet; Lomnitz, David J.; Mirchandani, Sunil; Stein, Kenneth M.; Markowitz, Steven M.; Slotwiner, David J.; Iwai, Sei; Das, Mithilesh K.; Lerman, Bruce B. (2002). "Prognostic Significance of Nonsustained Ventricular Tachycardia After Revascularization". Journal of Cardiovascular Electrophysiology. 13 (4): 342–346. doi:10.1046/j.1540-8167.2002.00342.x. ISSN 1045-3873.