Download 2015 ESC Guidelines for the management of patients with

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)
European Heart Journal 2015
doi/10.1093/eurheartj/ehv316
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www.escardio.org
European Heart Journal 2015 doi/10.1093/eurheartj/ehv316
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The 2015 ESC Guidelines for the management of
VA and prevention of SCD
• To describe and explain the epidemiology and pathophysiology of
ventricular arrhythmias and SCD
• To provide an up-to-date summary on current knowledge but also –
and even more important – of current knowledge gaps
• To come up with the best consensus on available and reasonable
diagnostics and therapies
• To provide practical and clinical help to identify patients at risk for
ventricular arrhythmia and sudden cardiac death.
• To guide the management of VA and SCD and thereby promoting
the best outcome to improve quality of life and reduce the burden of
SCD
• To raise further awareness on the global threat of SCD.
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II
100
AOP
0
II
100
AOP
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Autopsy and molecular autopsy in sudden death
victims
• ~ 50% of cardiac arrests occur in individuals without known heart
disease, but most suffer from concealed ischaemic heart disease.
• Every time a heritable disease is identified in a deceased individual,
the relatives may be at risk of being affected and dying suddenly.
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Diagnostic workup in patients presenting with sustained
ventricular tachycardia or ventricular fibrillation
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Diagnostic workup in patients presenting with sustained
ventricular tachycardia or ventricular fibrillation
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Speaker
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Diagnostic workup in patients presenting with sustained
ventricular tachycardia or ventricular fibrillation
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Speaker
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Therapies for ventricular arrhythmias
• Pharmacotherapy for VA and prevention of SCD
• With the exception of beta-blockers, currently
available AAD have not been shown in RCT to be
effective in primary management of patients with
life-threatening VA or in prevention of SCD.
• Each drug has a significant potential for causing
adverse events, including pro-arrhythmia.
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Antiarrhythmic drugs for the prevention of SCD
0.4
amiodaron vs. Placebo
ICD therapie vs. Placebo
HR
1.06
0.77
97.5% CI P-value
0.86, 1.30 0.53
0.62, 0.96 0.007
mortality
0.3
0.2
amiodaron
0.1
placebo
ICD
0
12
24
36
0
follow-up (months)
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Bardy GH, N Engl J Med 2005
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60
Primary prevention of SCD with the ICD
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The subcutaneous ICD
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• Device therapy - Subcutaneous cardioverter defibrillator
• SC defibrillators are effective in preventing SD.
• Data on long-term tolerability and safety are currently lacking.
• The device is not suitable for patients who require bradycardia
pacing, CRT or those who suffer from tachyarrhythmias that can
be easily terminated by ATP.
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• Device therapy - Wearable cardioverter defibrillator
• No prospective randomized trials evaluating the device have been
reported.
• Many case reports, case series, & registries (held by manufacturer
or independently) have reported successful use of WCD in a
relatively small proportion of patients at risk of potentially fatal VAs.
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Diagnostic workup in patients with sustained ventricular
arrhythmias and ACS.
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Sustained VT in structural heart disease:
drugs or ablation?
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Sustained ventricular tachycardia
- Drug therapy
- Catheter ablation
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Catheter ablation of ventricular tachycardia
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Interventional therapy - Catheter ablation
•
Scar-related VT - typically monomorphic.
•
12-lead ECG recording of clinical VT can aid ablation procedure.
•
VT related to post-myocardial scar - better outcome of catheter ablation
than VT due to non-ischaemic CMP.
•
•
Procedure-related mortality ranges from 0% - 3%.
VT in patients without overt structural heart disease most commonly from
RVOT or LVOT.
•
Catheter ablation - high rate of procedural success; rate of SCD generally low.
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Outfow tract ventricular arrhythmias
AP
LL
*
PV
*
TA
*
AP
AV
*
*
GCV
*
MV
CS
RVOT/PA
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LVOT/AO
CS/EPI
Tanner et al., JACC 2005
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VT and VF in structurally normal hearts
• Outflow tract ventricular tachycardia
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Catheter ablation of ventricular fibrillation
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Haissaguerre M et al. Lancet 2002; 359:677–678
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Idiopathic ventricular fibrillation
Short-coupled torsade de pointes
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Drug-related pro-arrhythmia
• Should be suspected if an inherited or acquired arrhythmogenic
substrate has been excluded and patient is treated with agents
known to alter electrical properties of the heart (e.g. inducing QT
prolongation) or causing electrolyte abnormalities.
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To do and to not do messages
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ESC Pocket Guidelines application available!
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European Heart Journal 2015 doi/10.1093/eurheartj/ehv316