Sudden cardiac death urgent treatment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Sara Zand, M.D.[2] Edzel Lorraine Co, DMD, MD[3]

Overview

The mainstay of therapy for patients with cardiac arrest is starting cardiopulmonary resuscitation (CPR) with minimizing interruption in chest compression. The rhythm should be reassessed. If the rhythm is ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), the shock should be delivered immediately. If the rhythm is asystole or pulseless electrical activity (PEA), CPR should be resumed. Advanced life support (ALS) should be kept with minimizing interruption in chest compression including: advanced airway, continuous chest compressions, capnography, intravenous (IV) intraosseous/ (IO) access, vasopressors, and antiarrhythmic therapy. This can address reversible causes such as hypoxia, hypovolemia,hypothermia, hyperkalemia, hypokalemia,acidosis, tension pneumothorax, tamponade, toxins (benzodiazepines, alcohol, opiates, tricyclics, barbiturates, betablockers, calcium channel blockers), thrombosis ST elevation myocardial infarction (STEMI, and massive pulmonary thromboembolism). The following should be considered immediately in post cardiac arrest patients: 12–lead electrocardiogram (ECG) ,perfusion/reperfusion in patients with acute myocardial infarction,(AMI), oxygenation and ventilation, temperature controlling, and treatment of reversible causes. Management of patients in post-cardiac arrest status include treatment of the underlying disorder, hemodynamic stability, respiratory support, and control of neurologic complications.

Urgent Treatment

Medical Therapy

• The mainstay of therapy for patients with cardiac arrest is starting cardiopulmonary resuscitation (CPR) with minimizing interruption in chest compression.
• Acute termination of acute coronary syndrome (ACS) can be achieved through defibrillation or electrical cardioversion .

2022 ESC Guidelines for the management of patients with ventricular arrythymias and the prevention of sudden cardiac death

Class I (Level of Evidence: A)

ICD therapy is recommended in patients with coronary artery disease (CAD), symptomatic heart failure (NYHA class II=III), and LVEF less than or equal to 35% despite 3 months of OMT.

Class I (Level of Evidence: B)

Genetic testing is recommended when a condition is diagnosed in a living or deceased individual with a likely genetic basis and a risk of ventricular arrhythmia (VA), and sudden cardiac death (SCD).

Class I (Level of Evidence: C)

When a putative causative variant is first identified evaluation for pathogenicity is recommended using an internationally accepted framework.

2017AHA/ACC/HRS Guideline for management of sudden cardiac arrest and ventricular arrhythmia

Recommendations for management of cardiac arrest

CPR (Class I, Level of Evidence A):

❑ CPR should be done according to basic and advanced cardiovascular life support algorithms

Amiodarone (Class I, Level of Evidence A) :

❑ In the recurrence of ventricular arrhythmia after maximum energy shock delivery and unstable hemodynamic, amiodarone should de infused

Direct current cardioversion : (Class I, Level of Evidence A)

❑ In ventricular arrhythmia and unstable hemodynamic, direct current cardioversion should be delivered

Revascularization:(Class I, Level of Evidence B)

❑ In patients with polymorphic VT and VF and evidence of acute STEMI in ECG, coronary angiography and emergency revascularization is advised

Wide QRS tachycardia: (Class I, Level of Evidence C)

❑ Wide QRS tachycardia should be considered as VT if the diagnosis is unclear

Intravenous procainamide (Class 2a, Level of Evidence A):

❑ In hemodynamically stable VT, intravenous procainamide is recommended

Intravenous lidocaine : (Class 2a, Level of Evidence B)

❑ Lidocaine is recommended in witness cardiac arrest due to polymorphic VT, VF unresponsed to CPR, defibrillation or vasopressor therapy

Intravenous betablocker : (Class 2a, Level of Evidence B)

❑ In polymorphic VT due to myocardial ischemia, intravenous betablocker maybe helpful

Intravenous Epinephrine : (Class 2b, Level of Evidence A)

❑ In cardiac arrest administration of 1 mg epinephrine every 3-5 minutes during CPR is recommended

Intravenous amiodarone : (Class 2b, Level of Evidence B)

❑ In hemodynamic stable VT, infusion of amiodarone or sotalole maybe considered

High dose of intravenous epinephrine : (Class III , Level of Evidence A)

❑ In cardiac arrest, administration of high dose epinephrine>1 mg bolouses is not beneficial ❑ In refractory VF not related to torsades de pointes, administration of intravenous magnesium is not beneficial

Intravenous amiodarone : (Class III , Level of Evidence B)

❑In acute myocardial infarction, prophylactic administration of lidocaine or amiodarone for prevention of VT is harmful

Intravenous verapamil, diltiazem : (Class III , Level of Evidence C)

❑ In a wide QRS tachycardia with unknown origin, administration of verapamil and diltiazem is harmful

Sustained monomorphic VT

Hemodynamic stability

Stable

Unstable

12-Lead ECG, history, physical exam

Dirrect current cardioversion,ACLS

Notifying disease causing VT

Cardioversion(class1)

VT termination

Structural heart disease

Intravenous procainamide (class2a)

Yes, therapy of underlying heart disease

NO, cardioversion (class1)

NO, Ideopathic VT

Intravenous amiodarone or sotalole (class2b)

VT termination

Verapamil sensitive VT: Verapamil outflow tract VT: betablocker (class2a)

Effective

Non effective: cardioversion

Yes,therapy of underlying heart disease

NO, Sedation ,anesthesia, reassessing antiarrhythmic therapy, repeating cardioversion

Therapy to prevent recurrence of VT

No VT termination

Catheter ablation (class1)

Catheter ablation (class1)

Verapamil , betablocker (class2a)

Intervention

Catheter ablation can only be performed for patients with sustained monomorphic ventricular tachycardia based on these characteristics:

• Incessant VT or electrical storm due to myocardial scar tissue
• Sustained VT and recurrent ICD shock in ischemic heart disease

References

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