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.^[1]^[2]
CPR and use of automated external defibrillators (AED) increase the chances of survival with improved [[neurological] and functional outcomes ^[3] ^[4] ^[5] ^[6] ^[7] ^[8] ^[9].
Acute termination of acute coronary syndrome (ACS) can be achieved through defibrillation or electrical cardioversion ^[10] ^[11].

2022 ESC Guidelines for the management of patients with ventricular arrythymias and the prevention of sudden cardiac death ^[12]

Recommendations for public basic life support and access to automated external defibrillators
Class I (Level of Evidence: B)
It is recommended that public access defibrillation be available at sites where cardiac arrest is more likely to occur.
Class I (Level of Evidence: B)
Prompt CPR by bystanders is recommended at out-of-hospital cardiac arrest.
Class I (Level of Evidence: B)
It is recommended to promote community training in basic life support to increase bystander CPR rate and AED use.
Class IIa (Level of Evidence: B)
Mobile phone-based alerting of basic life support-trained bystander volunteers to assist nearby out-of-hospital cardiac arrest victims should be considered.

Recommendations for treatment of sudden cardiac death in patients with coronary anomalies
Class I (Level of Evidence: C)
Surgery is recommended in patients with anomalous aortic origin of a coronary artery with cardiac arrest, syncope suspected to be due to ventricular arrhythmias, or angina when other causes have been [[excluded.
Class IIa (Level of Evidence: C)
Surgery should be considered in asymptomatic patients with anomalous aortic organ of a coronary artery and evidence of myocardial ischemia or abnormal aortic origin f the left anatomy.

Recommendations for the management of patients with idiopathic premature ventricular complexes/ ventricular tachycardia
Class I (Level of Evidence: B)
Catheter ablation as first-line treatment is recommended for symptomatic idiopathic ventricular tachycardia (VT)/ premature ventricular complex (PVCs) from the right ventricular outflow tract (RVOT) or the left fascicles.
Class I (Level of Evidence: C)
Beta blockers or non-dihydropiridine calcium channel blockers (CCBs) are indicated in symptomatic patients with idiopathic VT/ PVCs from an origin other than the RVOT or the left fascicles.
Class IIa (Level of Evidence: B)
Beta blockers, non-dihydropiridine CCBs, or flecainide should be considered when catheter ablation is not available, desired, or is particularly risky in symptomatic patients with idiopathic VT/ PVCs from the RVOT or the left fascicle.
Class IIa (Level of Evidence: C)
Catheter ablation or flecainide should be considered in symptomatic patients with idiopathic VT/ PVCs from an origin other than the RVOT or the left fascicles.
Class IIb (Level of Evidence: B)
Catheter ablation may be considered for idiopathic] VT/PVCs in asymptomatic patients with repeatedly more than 20% of PVCs per day at follow-up.
Class III (Level of Evidence: C)
Catheter ablation od idiopathic VT/PVCs is not recommended in children <5 years of age or <10 kg weight except when previous medical therapy fails or when VT is not hemodynamically tolerated.
Class III (Level of Evidence: C)
Amiodarone as a first-line treatment is not recommended in [patients]] with idiopathic VTs/ PVCs.
Class III (Level of Evidence: C)
Verapamil is not recommended in children < 1 year of age with PVC/ VT, particularly if they have signs of heart failure or concurrent use of other anti-arrhythmic drugs.

Recommendations for the management of patients with premature ventricular complex-induced or premature ventricular complex-aggravated cardiomyopathy
Class I (Level of Evidence: C)
In patients with a cardiomyopathy suspected to be caused by frequent and predominately monomorphic PVCs, catheter ablation is recommended.
Class IIa (Level of Evidence: C)
In patients with a cardiomyopathy suspected to be caused by frequent and predominately monomorphic PVCs, treatment with AADs should be considered if catheter ablation is not desired, suspected to be high-risk, or unsuccessful.
Class IIa (Level of Evidence: B)
In patients with structural heart disease (SHD) in whom predominately monomorphic frequent PVCs are suspected to be contributing to the cardiomyopathy, AAD (amiodarone) treatment or catheter ablation should be considered.
Class IIa (Level of Evidence: C)
In non-responders to cardiac resynchronization therapy (CRT) with frequent, predominately monomorphic PVCs limiting optimal biventricular pacing despite pharmacological therapy, catheter ablation or AADs should be considered.

Recommendations for diagnosis of ventricular arrhythmias in arrhythmogenic right ventricular cardiomyopathy

Class IIb (Level of Evidence: C)

Beta-blocker therapy may be considered in all patients with a definite diagnosis of ARVC.

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

^[2]

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)

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

↑ Priori, Silvia G.; Blomström-Lundqvist, Carina; Mazzanti, Andrea; Blom, Nico; Borggrefe, Martin; Camm, John; Elliott, Perry Mark; Fitzsimons, Donna; Hatala, Robert; Hindricks, Gerhard; Kirchhof, Paulus; Kjeldsen, Keld; Kuck, Karl-Heinz; Hernandez-Madrid, Antonio; Nikolaou, Nikolaos; Norekvål, Tone M.; Spaulding, Christian; Van Veldhuisen, Dirk J. (2015). "2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". European Heart Journal. 36 (41): 2793–2867. doi:10.1093/eurheartj/ehv316. ISSN 0195-668X.
↑ ^2.0 ^2.1 Al-Khatib, Sana M.; Stevenson, William G.; Ackerman, Michael J.; Bryant, William J.; Callans, David J.; Curtis, Anne B.; Deal, Barbara J.; Dickfeld, Timm; Field, Michael E.; Fonarow, Gregg C.; Gillis, Anne M.; Granger, Christopher B.; Hammill, Stephen C.; Hlatky, Mark A.; Joglar, José A.; Kay, G. Neal; Matlock, Daniel D.; Myerburg, Robert J.; Page, Richard L. (2018). "2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death". Circulation. 138 (13). doi:10.1161/CIR.0000000000000549. ISSN 0009-7322.
↑ Yan S, Gan Y, Jiang N, Wang R, Chen Y, Luo Z; et al. (2020). "The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis". Crit Care. 24 (1): 61. doi:10.1186/s13054-020-2773-2. PMC 7036236 Check |pmc= value (help). PMID 32087741 Check |pmid= value (help).
↑ Hallstrom AP, Ornato JP, Weisfeldt M, Travers A, Christenson J, McBurnie MA; et al. (2004). "Public-access defibrillation and survival after out-of-hospital cardiac arrest". N Engl J Med. 351 (7): 637–46. doi:10.1056/NEJMoa040566. PMID 15306665. Review in: ACP J Club. 2005 Jan-Feb;142(1):2 Review in: Evid Based Nurs. 2005 Apr;8(2):50
↑ Nakashima T, Noguchi T, Tahara Y, Nishimura K, Yasuda S, Onozuka D; et al. (2019). "Public-access defibrillation and neurological outcomes in patients with out-of-hospital cardiac arrest in Japan: a population-based cohort study". Lancet. 394 (10216): 2255–2262. doi:10.1016/S0140-6736(19)32488-2. PMID 31862250.
↑ Pollack RA, Brown SP, Rea T, Aufderheide T, Barbic D, Buick JE; et al. (2018). "Impact of Bystander Automated External Defibrillator Use on Survival and Functional Outcomes in Shockable Observed Public Cardiac Arrests". Circulation. 137 (20): 2104–2113. doi:10.1161/CIRCULATIONAHA.117.030700. PMC 5953778. PMID 29483086.
↑ Kragholm K, Wissenberg M, Mortensen RN, Hansen SM, Malta Hansen C, Thorsteinsson K; et al. (2017). "Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest". N Engl J Med. 376 (18): 1737–1747. doi:10.1056/NEJMoa1601891. PMID 28467879.
↑ Kitamura T, Kiyohara K, Sakai T, Matsuyama T, Hatakeyama T, Shimamoto T; et al. (2016). "Public-Access Defibrillation and Out-of-Hospital Cardiac Arrest in Japan". N Engl J Med. 375 (17): 1649–1659. doi:10.1056/NEJMsa1600011. PMID 27783922.
↑ Hasselqvist-Ax I, Riva G, Herlitz J, Rosenqvist M, Hollenberg J, Nordberg P; et al. (2015). "Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest". N Engl J Med. 372 (24): 2307–15. doi:10.1056/NEJMoa1405796. PMID 26061835.
↑ Kalarus Z, Svendsen JH, Capodanno D, Dan GA, De Maria E, Gorenek B; et al. (2019). "Cardiac arrhythmias in the emergency settings of acute coronary syndrome and revascularization: an European Heart Rhythm Association (EHRA) consensus document, endorsed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Acute Cardiovascular Care Association (ACCA)". Europace. 21 (10): 1603–1604. doi:10.1093/europace/euz163. PMID 31353412.
↑ Rankin AC, Rae AP, Cobbe SM (1987). "Misuse of intravenous verapamil in patients with ventricular tachycardia". Lancet. 2 (8557): 472–4. doi:10.1016/s0140-6736(87)91790-9. PMID 2887775.
↑ Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA; et al. (2022). "2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". Eur Heart J. 43 (40): 3997–4126. doi:10.1093/eurheartj/ehac262. PMID 36017572 Check |pmid= value (help).

Template:WH Template:WS

[PrioriBlomström-Lundqvist2015-1] Priori, Silvia G.; Blomström-Lundqvist, Carina; Mazzanti, Andrea; Blom, Nico; Borggrefe, Martin; Camm, John; Elliott, Perry Mark; Fitzsimons, Donna; Hatala, Robert; Hindricks, Gerhard; Kirchhof, Paulus; Kjeldsen, Keld; Kuck, Karl-Heinz; Hernandez-Madrid, Antonio; Nikolaou, Nikolaos; Norekvål, Tone M.; Spaulding, Christian; Van Veldhuisen, Dirk J. (2015). "2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". European Heart Journal. 36 (41): 2793–2867. doi:10.1093/eurheartj/ehv316. ISSN 0195-668X.

[Al-KhatibStevenson2018-2] 2.0 ^2.1 Al-Khatib, Sana M.; Stevenson, William G.; Ackerman, Michael J.; Bryant, William J.; Callans, David J.; Curtis, Anne B.; Deal, Barbara J.; Dickfeld, Timm; Field, Michael E.; Fonarow, Gregg C.; Gillis, Anne M.; Granger, Christopher B.; Hammill, Stephen C.; Hlatky, Mark A.; Joglar, José A.; Kay, G. Neal; Matlock, Daniel D.; Myerburg, Robert J.; Page, Richard L. (2018). "2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death". Circulation. 138 (13). doi:10.1161/CIR.0000000000000549. ISSN 0009-7322.

[pmid32087741-3] Yan S, Gan Y, Jiang N, Wang R, Chen Y, Luo Z; et al. (2020). "The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis". Crit Care. 24 (1): 61. doi:10.1186/s13054-020-2773-2. PMC 7036236 Check |pmc= value (help). PMID 32087741 Check |pmid= value (help).

[pmid15306665-4] Hallstrom AP, Ornato JP, Weisfeldt M, Travers A, Christenson J, McBurnie MA; et al. (2004). "Public-access defibrillation and survival after out-of-hospital cardiac arrest". N Engl J Med. 351 (7): 637–46. doi:10.1056/NEJMoa040566. PMID 15306665. Review in: ACP J Club. 2005 Jan-Feb;142(1):2 Review in: Evid Based Nurs. 2005 Apr;8(2):50

[pmid31862250-5] Nakashima T, Noguchi T, Tahara Y, Nishimura K, Yasuda S, Onozuka D; et al. (2019). "Public-access defibrillation and neurological outcomes in patients with out-of-hospital cardiac arrest in Japan: a population-based cohort study". Lancet. 394 (10216): 2255–2262. doi:10.1016/S0140-6736(19)32488-2. PMID 31862250.

[pmid29483086-6] Pollack RA, Brown SP, Rea T, Aufderheide T, Barbic D, Buick JE; et al. (2018). "Impact of Bystander Automated External Defibrillator Use on Survival and Functional Outcomes in Shockable Observed Public Cardiac Arrests". Circulation. 137 (20): 2104–2113. doi:10.1161/CIRCULATIONAHA.117.030700. PMC 5953778. PMID 29483086.

[pmid28467879-7] Kragholm K, Wissenberg M, Mortensen RN, Hansen SM, Malta Hansen C, Thorsteinsson K; et al. (2017). "Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest". N Engl J Med. 376 (18): 1737–1747. doi:10.1056/NEJMoa1601891. PMID 28467879.

[pmid27783922-8] Kitamura T, Kiyohara K, Sakai T, Matsuyama T, Hatakeyama T, Shimamoto T; et al. (2016). "Public-Access Defibrillation and Out-of-Hospital Cardiac Arrest in Japan". N Engl J Med. 375 (17): 1649–1659. doi:10.1056/NEJMsa1600011. PMID 27783922.

[pmid26061835-9] Hasselqvist-Ax I, Riva G, Herlitz J, Rosenqvist M, Hollenberg J, Nordberg P; et al. (2015). "Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest". N Engl J Med. 372 (24): 2307–15. doi:10.1056/NEJMoa1405796. PMID 26061835.

[pmid31353412-10] Kalarus Z, Svendsen JH, Capodanno D, Dan GA, De Maria E, Gorenek B; et al. (2019). "Cardiac arrhythmias in the emergency settings of acute coronary syndrome and revascularization: an European Heart Rhythm Association (EHRA) consensus document, endorsed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Acute Cardiovascular Care Association (ACCA)". Europace. 21 (10): 1603–1604. doi:10.1093/europace/euz163. PMID 31353412.

[pmid2887775-11] Rankin AC, Rae AP, Cobbe SM (1987). "Misuse of intravenous verapamil in patients with ventricular tachycardia". Lancet. 2 (8557): 472–4. doi:10.1016/s0140-6736(87)91790-9. PMID 2887775.

[pmid36017572-12] Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA; et al. (2022). "2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". Eur Heart J. 43 (40): 3997–4126. doi:10.1093/eurheartj/ehac262. PMID 36017572 Check |pmid= value (help).

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