Ventricular tachycardia future or investigational therapies
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Overview
In recent years, the results of pharmacologic therapy for preventing VAs are disappointing. Therapy limitations are due to variable efficacy, pro-arrhythmic effects, patient compliance, and adverse effects from long-term therapy. in patients with ICDs, adjuvant suppressive therapy as amiodarone and sotalol have been shown to reduce the rate of recurrent VT when compared with beta-blockers or placebo. Pharmacologic therapy (amiodarone or sotalol) with or without adjunctive catheter ablation are recommended by the current guidelines to prevent VT/VF recurrence and reducing ICD shocks
Future or investigational studies
In recent years, the results of pharmacologic therapy for preventing VAs are disappointing. Therapy limitations are due to variable efficacy, pro-arrhythmic effects, patient compliance, and adverse effects from long-term therapy. in patients with ICDs, adjuvant suppressive therapy as amiodarone and sotalol have been shown to reduce the rate of recurrent VT when compared with beta-blockers or placebo. Pharmacologic therapy (amiodarone or sotalol) with or without adjunctive catheter ablation are recommended by the current guidelines to prevent VT/VF recurrence and reducing ICD shocks[1]
The goals of management of VAs include:
- Symptom relief (including syncope, worsening heart failure, and ischemic chest pain),
- Improving quality of life, * Reducing implantable cardioverter defibrillator (ICD) shocks,
- Preventing deterioration of left ventricular function
- Reducing risk of arrhythmic death
- Improving overall survival7–10. Treatment of underlying medical conditions, the cardiac disorders, the presence of heart failure, the cause for the arrhythmias, consequences of the VAs, and the risks and benefits of the therapeutic pharmacological or invasive strategy[2]
Recent research and clinical advances allowed to tailor the approach to VA management on the basis of the underlying etiology with higher efficacy. These advances have been focused on:
- The development of diagnostic modalities and imaging tools to identify the arrhythmogenic substrate responsible for VT (focal or scar)
- Genetic screening for markers of channelopathies, and
- Superior mapping and ablation technologies[2][3]
Non-invasive imaging and diagnostic modalities
Over the past 100 years, cardiologists rely on the following to diagnose VT:
ECG, monitoring strategies, and limited intracardiac electrodes
As the mechanism of VT better understood and defined, the following non-invasive imaging modalities have become an integral part of the diagnostic and management strategy:
echocardiography
cardiac computed tomography (CT)
cardiac magnetic resonance imaging (MRI) (CMR)
nuclear studies
The 2015 European Society of Cardiology Guidelines have extended a class IIa recommendation to perform CMR or CT in patients where echocardiography fails to provide accurate assessment of ventricular function or underlying structural changes that may be arrhythmogenic, such as the scar size, distribution, and transmurality
The information derived from these tests not only is important to identify those with structural heart disease, assess left and right ventricular function, and risk-stratify those at highest risk of inducible VT/VF on the basis of scar size in order to select the patients who would derive the most benefit from an ICD but also serves as a guide for planning ablation procedures
inherited cardiomyopathies and channelopathies
Future of medical management of VT in structural heart disease
future of implantable device therapy
Invasive mapping and catheter ablation
References
- ↑ Batul SA, Olshansky B, Fisher JD, Gopinathannair R (2017). "Recent advances in the management of ventricular tachyarrhythmias". F1000Res. 6: 1027. doi:10.12688/f1000research.11202.1. PMC 5497814. PMID 28721212.
- ↑ 2.0 2.1 Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J; et al. (2015). "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). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC)". Eur Heart J. 36 (41): 2793–2867. doi:10.1093/eurheartj/ehv316. PMID 26320108.
- ↑ Priori SG, Wilde AA, Horie M, Cho Y, Behr ER, Berul C; et al. (2013). "HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013". Heart Rhythm. 10 (12): 1932–63. doi:10.1016/j.hrthm.2013.05.014. PMID 24011539.