Ventricular tachycardia secondary prevention: Difference between revisions

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__NOTOC__
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{{Ventricular tachycardia}}
{{Ventricular tachycardia}}
{{CMG}}; '''Associate Editor-in Chief''': [[User:Avirupguha|Avirup Guha, M.B.B.S.]][mailto:avirup.guha@gmail.com]
{{CMG}}; '''Associate Editor-in Chief''': {{Sara.Zand}} [[User:Avirupguha|Avirup Guha, M.B.B.S.]][mailto:avirup.guha@gmail.com]
==Overview==
==Overview==
There are several landmark trials which have shown some evidence-based secondary prevention measures for ventricular tachycardia.
[[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]] was superior to [[antiarrhythmic]] drugs 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]], [[proarrhythmic]] medication effect may be corrected. [[ICD]] implantation improved outcome in well-tolerated [[VT]] and [[structurally heart disease]]. 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]].


==Landmark Clinical Trials: Trials of Secondary Prevention of Sudden Cardiac Death==
==[[Secondary prevention]]==
==='''CASCADE(The Cardiac Arrest in Seatle Conventional Versus Amiodarone Drug Evaluation study)<ref name="pmid8237833">{{cite journal| author=Greene HL| title=The CASCADE Study: randomized antiarrhythmic drug therapy in survivors of cardiac arrest in Seattle. CASCADE Investigators. | journal=Am J Cardiol | year= 1993 | volume= 72 | issue= 16 | pages= 70F-74F | pmid=8237833 | doi= | pmc= | url= }} </ref> '''===
[[Secondary prevention]] strategies following [[SCA]] and unstable [[VT]] include [[ICD]] implantation, and [[medications]].
* '''Strategy''': [[Amiodarone]] vs conventional therapy in patients with/without AICD
* Based on meta-analysis of [[AVID trial]] implantation of [[ICD]] for [[secondary prevention]] of [[ventricular arrhythmia]] was superior to [[antiarrhythmic]] drugs in [[patients]] who survived of [[sudden cardiac arrest]] or unstable [[VT]].<ref>{{cite journal|title=A Comparison of Antiarrhythmic-Drug Therapy with Implantable Defibrillators in Patients Resuscitated from Near-Fatal Ventricular Arrhythmias|journal=New England Journal of Medicine|volume=337|issue=22|year=1997|pages=1576–1584|issn=0028-4793|doi=10.1056/NEJM199711273372202}}</ref>


* '''Demographics''':  Total: 228 [[Amiodarone]]: 113 conventional antiarrhythmic drugs: 115([[quinidine]] (n=33), [[procainamide]] (n = 26), combination therapy (n = 17), [[flecainide]] (n = 12). AICD: 105 (Amiodarone: 53, Conventional therapy: 52)
* Before [[ICD]] implantation, the reversible causes of [[ventricular arrhythmia]] including [[myocardial ischemia]], [[electrolyte disturbance]], [[proarrhythmic]] medication effect may be corrected.<ref name="WyseFriedman2001">{{cite journal|last1=Wyse|first1=D.George|last2=Friedman|first2=Peter L|last3=Brodsky|first3=Michael A|last4=Beckman|first4=Karen J|last5=Carlson|first5=Mark D|last6=Curtis|first6=Anne B|last7=Hallstrom|first7=Alfred P|last8=Raitt|first8=Merritt H|last9=Wilkoff|first9=Bruce L|last10=Greene|first10=H.Leon|title=Life-threatening ventricular arrhythmias due to transient or correctable causes: high risk for death in follow-up|journal=Journal of the American College of Cardiology|volume=38|issue=6|year=2001|pages=1718–1724|issn=07351097|doi=10.1016/S0735-1097(01)01597-2}}</ref>


* '''Mean EF''': 35
* [[ICD]] implantation improved outcome in well-tolerated [[VT]] and [[structurally heart disease]].<ref name="RaittRenfroe2001">{{cite journal|last1=Raitt|first1=Merritt H.|last2=Renfroe|first2=Ellen Graham|last3=Epstein|first3=Andrew E.|last4=McAnulty|first4=John H.|last5=Mounsey|first5=Paul|last6=Steinberg|first6=Jonathan S.|last7=Lancaster|first7=Scott E.|last8=Jadonath|first8=Ram L.|last9=Hallstrom|first9=Alfred P.|title=“Stable” Ventricular Tachycardia Is Not a Benign Rhythm|journal=Circulation|volume=103|issue=2|year=2001|pages=244–252|issn=0009-7322|doi=10.1161/01.CIR.103.2.244}}</ref>


* '''Result''': 13% more survival in patient population at the primary end point (total cardiac mortality, resuscitated cardiac arrest due to ventricular fibrillation, and syncopal Implanted defibrillator shocks) at the end of 6 years. (p=0.007). With AICD 16% survival more at the primary end point( shocks preceded by complete syncope)(p=0.032) conclusively showing superiority of Amidarone over convetional therapy in secondary prevention.
* [[VT ablation]] reduced recurrence of [[tachyarrhythmia]], but the effect on long-term [[mortality]] was unknown.<ref name="MauryBaratto2014">{{cite journal|last1=Maury|first1=P.|last2=Baratto|first2=F.|last3=Zeppenfeld|first3=K.|last4=Klein|first4=G.|last5=Delacretaz|first5=E.|last6=Sacher|first6=F.|last7=Pruvot|first7=E.|last8=Brigadeau|first8=F.|last9=Rollin|first9=A.|last10=Andronache|first10=M.|last11=Maccabelli|first11=G.|last12=Gawrysiak|first12=M.|last13=Brenner|first13=R.|last14=Forclaz|first14=A.|last15=Schlaepfer|first15=J.|last16=Lacroix|first16=D.|last17=Duparc|first17=A.|last18=Mondoly|first18=P.|last19=Bouisset|first19=F.|last20=Delay|first20=M.|last21=Hocini|first21=M.|last22=Derval|first22=N.|last23=Sadoul|first23=N.|last24=Magnin-Poull|first24=I.|last25=Klug|first25=D.|last26=Haissaguerre|first26=M.|last27=Jais|first27=P.|last28=Della Bella|first28=P.|last29=De Chillou|first29=C.|title=Radio-frequency ablation as primary management of well-tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%|journal=European Heart Journal|volume=35|issue=22|year=2014|pages=1479–1485|issn=0195-668X|doi=10.1093/eurheartj/ehu040}}</ref>


===''' ESVEM (Electrophysiologic Study Versus Electrocardiographic Monitoring for Selection of Antiarrhythmic Therapy of Ventricular Tachyarrhythmias)<ref name="pmid8332149">{{cite journal| author=Mason JW| title=A comparison of electrophysiologic testing with Holter monitoring to predict antiarrhythmic-drug efficacy for ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators. | journal=N Engl J Med | year= 1993 | volume= 329 | issue= 7 | pages= 445-51 | pmid=8332149 | doi=10.1056/NEJM199308123290701 | pmc= | url= }} </ref><ref name="pmid8332150">{{cite journal| author=Mason JW| title=A comparison of seven antiarrhythmic drugs in patients with ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators. | journal=N Engl J Med | year= 1993 | volume= 329 | issue= 7 | pages= 452-8 | pmid=8332150 | doi=10.1056/NEJM199308123290702 | pmc= | url= }} </ref> '''===
* 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]].
* '''Strategy''': EP testing and Holter monitor of 7 antiarrhythmics (imipramine, mexiletine, procainamide, quinidine, sotalol, pirmenol, propafenone)


* '''Demographics''':  486 patients were randomized and 296 patients were eventually followed up.
==[[Secondary prevention]] in [[patients]] with [[ischemic heart disease]]==


* '''Mean EF''': 33% in all 296 and 34% in Sotalol group
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for secondary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation  ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ 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.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Intermediate value statement, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ 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.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ 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
|-
|}
<span style="font-size:85%">'''Abbreviations:'''
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''ICD:''' [[ Implantable cardioverter defibrillator]]
</span>
<br>
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2017 AHA/ACC/HRS Guideline
|-
|}<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>


* '''Result''':  No difference between Holter- and EP-guided groups. Sotalol group had lowest recurrence rate of VT (risk ratio, 0.43; 95 percent confidence interval, 0.29 to 0.62; p<0.001), arrhythmic death (risk ratio, 0.50; 95 percent confidence interval, 0.26 to 0.96; P = 0.04), total death (risk ratio, 0.50; 95 percent confidence interval, 0.30 to 0.80; P = 0.004).


==='''AVID (The Antiarrhythmics versus Implantable Defibrillators)<ref name="pmid9411221">{{cite journal| author=| title=A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. | journal=N Engl J Med | year= 1997 | volume= 337 | issue= 22 | pages= 1576-83 | pmid=9411221 | doi=10.1056/NEJM199711273372202 | pmc= | url= }} </ref>'''===
* '''Strategy''': ICD vs medication either amiodarone or sotalol


* '''Demographics''': Total: 1016 ICD: 507 Medications (predominantly amiodarone): 509 (80% with ischemic heart disease)


* '''Mean EF''': 32 (inclusion<40)


* '''Result''': Relative risk reduction: 1-year: 39% ; 2-year: 27% ; 3-year: 31% (p = 0.02)


==='''CIDS (Canadian Implantable Defibrillator Study)<ref name="pmid10725290">{{cite journal| author=Connolly SJ, Gent M, Roberts RS, Dorian P, Roy D, Sheldon RS et al.| title=Canadian implantable defibrillator study (CIDS) : a randomized trial of the implantable cardioverter defibrillator against amiodarone. | journal=Circulation | year= 2000 | volume= 101 | issue= 11 | pages= 1297-302 | pmid=10725290 | doi= | pmc= | url= }} </ref>'''===
* '''Strategy''': ICD vs amiodarone


* '''Demographics''': Total: 659 ICD: 328 Amiodarone: 331 (82% with ischemic heart disease)  
{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=[[Secondary prevention]] in [[patients]] with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2017 AHA/ACC/HRS Guideline
|-
|}<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>


* '''Mean EF''': <35
==[[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.<ref name="pmid20671373">{{cite journal |vauthors= |title=Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version |journal=Circ J |volume=74 |issue=8 |pages=1745–62 |date=August 2010 |pmid=20671373 |doi=10.1253/circj.cj-10-74-0802 |url=}}</ref>
* [[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.<ref name="MorikawaMizuno2010">{{cite journal|last1=Morikawa|first1=Yoshinobu|last2=Mizuno|first2=Yuji|last3=Yasue|first3=Hirofumi|title=Letter by Morikawa et al Regarding Article, “Coronary Artery Spasm: A 2009 Update”|journal=Circulation|volume=121|issue=3|year=2010|issn=0009-7322|doi=10.1161/CIR.0b013e3181ce1bcc}}</ref>


* '''Result''': Relative risk reduction: 20% (p = 0.142)


==='''CASH (Cardiac Arrest Study Hamburg)<ref name="pmid10942742">{{cite journal| author=Kuck KH, Cappato R, Siebels J, Rüppel R| title=Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest : the Cardiac Arrest Study Hamburg (CASH). | journal=Circulation | year= 2000 | volume= 102 | issue= 7 | pages= 748-54 | pmid=10942742 | doi= | pmc= | url= }} </ref>'''===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
* '''Strategy''': ICD vs amiodarone vs beta blocker
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for secondary prevention of sudden cardiac death in coronary spasm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation  ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ 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<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ 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<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ 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
|-
|}
<span style="font-size:85%">'''Abbreviations:'''
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''SCA:''' [[Sudden cardiac arrest]]
</span>
<br>
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2017 AHA/ACC/HRS Guideline
|-
|}


* '''Demographics''': Total: 288 (74% with ischemic heart disease) ICD: 99 Amiodarone: 92 Metoprolol: 97
==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.<ref name="SaxonWiener1995">{{cite journal|last1=Saxon|first1=Leslie A.|last2=Wiener|first2=Isaac|last3=Natterson|first3=Paul D.|last4=Laks|first4=Hillel|last5=Drinkwater|first5=Davis|last6=Stevenson|first6=William G.X.|title=Monomorphic versus polymorphic ventricular tachycardia after coronary artery bypass grafting|journal=The American Journal of Cardiology|volume=75|issue=5|year=1995|pages=403–405|issn=00029149|doi=10.1016/S0002-9149(99)80566-9}}</ref>


* '''Mean EF''': 45
* [[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.<ref name="VakilFlorea2016">{{cite journal|last1=Vakil|first1=Kairav|last2=Florea|first2=Viorel|last3=Koene|first3=Ryan|last4=Kealhofer|first4=Jessica Voight|last5=Anand|first5=Inderjit|last6=Adabag|first6=Selcuk|title=Effect of Coronary Artery Bypass Grafting on Left Ventricular Ejection Fraction in Men Eligible for Implantable Cardioverter–Defibrillator|journal=The American Journal of Cardiology|volume=117|issue=6|year=2016|pages=957–960|issn=00029149|doi=10.1016/j.amjcard.2015.12.029}}</ref>


* '''Result''': Relative risk reduction at 5 years: 23% (p = 0.081)
* In [[patients]] with high burden of [[non-sustained VT]] and [[LV]] dysfunction, [[electrophysiology study]] for risk stratification and determination the need for [[ICD]] is recommended. <ref name="MittalLomnitz2002">{{cite journal|last1=Mittal|first1=Suneet|last2=Lomnitz|first2=David J.|last3=Mirchandani|first3=Sunil|last4=Stein|first4=Kenneth M.|last5=Markowitz|first5=Steven M.|last6=Slotwiner|first6=David J.|last7=Iwai|first7=Sei|last8=Das|first8=Mithilesh K.|last9=Lerman|first9=Bruce B.|title=Prognostic Significance of Nonsustained Ventricular Tachycardia After Revascularization|journal=Journal of Cardiovascular Electrophysiology|volume=13|issue=4|year=2002|pages=342–346|issn=1045-3873|doi=10.1046/j.1540-8167.2002.00342.x}}</ref><ref name="Bigger1997">{{cite journal|last1=Bigger|first1=J. Thomas|title=Prophylactic Use of Implanted Cardiac Defibrillators in Patients at High Risk for Ventricular Arrhythmias after Coronary-Artery Bypass Graft Surgery|journal=New England Journal of Medicine|volume=337|issue=22|year=1997|pages=1569–1575|issn=0028-4793|doi=10.1056/NEJM199711273372201}}</ref>
 
==[[Secondary prevention]] in [[non-ischemic cardiomyopathy]]==
==Landmark Clinical Trials: Trials of Primary Prevention of Sudden Cardiac Death==
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
===''' BHAT  ( β-Blocker Heart Attack Trial)<ref name="pmid7038157">{{cite journal| author=| title=A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results. | journal=JAMA | year= 1982 | volume= 247 | issue= 12 | pages= 1707-14 | pmid=7038157 | doi= | pmc= | url= }} </ref>'''===
|-
* '''Strategy''' : multicenter, randomized, double-blind, and placebo-controlled trial designed to test whether the regular administration of propranolol hydrochloride to men and women who had experienced at least one myocardial infarction would result in a significant reduction in total mortality during a two- to four-year period.
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for secondary prevention of sudden cardiac death in non-ischemic cardiomyopathy'''
 
|-
* '''Demographics''': Total: 3837, Propanolol: 1916, Placebo: 1921 persons, five to 21 days after the infarction.
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation  ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
 
|-
* '''Mean EF''':
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
 
❑ [[ICD]] implantation is recommended in survivors of [[SCA]] or hemodynamically unstable [[VT]] or sustained [[VT]] not related to reversible causes, if life expectancy is more than 1 year<br>
* '''Result''': Total mortality during the average 25-month follow-up period was 7.2% in the propranolol group and 9.8% in the placebo group. Arteriosclerotic heart disease (ASHD) mortality was 6.2% in the propranolol group and 8.5% in the placebo group.  
|-
 
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''ICD implantation, EPS study ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
==='''CAST (The Cardiac Arrhythmia Suppression Trial)<ref name="pmid1900101">{{cite journal| author=Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH et al.| title=Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. | journal=N Engl J Med | year= 1991 | volume= 324 | issue= 12 | pages= 781-8 | pmid=1900101 | doi=10.1056/NEJM199103213241201 | pmc= | url= }} </ref><ref name="pmid1377359">{{cite journal| author=| title=Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. The Cardiac Arrhythmia Suppression Trial II Investigators. | journal=N Engl J Med | year= 1992 | volume= 327 | issue= 4 | pages= 227-33 | pmid=1377359 | doi=10.1056/NEJM199207233270403 | pmc= | url= }} </ref>'''===
|-
* '''Strategy''': Suppression of ventricular ectopy after a myocardial infarction reduces the incidence of sudden death, patients in whom ventricular ectopy could be suppressed with encainide, flecainide, or moricizine were randomly assigned to receive either active drug or placebo
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
 
❑ In the presence of [[syncope]] presumed due to [[ventricular arrhythmia]], [[ICD]] or [[EPS]] study for risk stratification of [[SCD]] is recommended if survival is more than 1 year<br>
* '''Demographics''': Total: 1498 patients,Encainide+Placebo: 857(432 to active drug and 425 to placebo), Flecainide+Placebo: 641 (323 to active drug and 318 to placebo).
|-
 
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Amiodarone : ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]])'''
* '''Mean EF''': ≤40%
|-
 
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
* '''Result''': 89 patients had died: 59 of arrhythmia (43 receiving drug vs. 16 receiving placebo; P = 0.0004), 22 of nonarrhythmic cardiac causes (17 receiving drug vs. 5 receiving placebo; P = 0.01), and 8 of noncardiac causes (3 receiving drug vs. 5 receiving placebo). Almost all cardiac deaths not due to arrhythmia were attributed to acute myocardial infarction with shock (11 patients receiving drug and 3 receiving placebo) or to chronic congestive heart failure (4 receiving drug and 2 receiving placebo). There were no differences between the patients receiving active drug and those receiving placebo in the incidence of nonlethal disqualifying ventricular tachycardia, proarrhythmia, syncope, need for a permanent pacemaker, congestive heart failure, recurrent myocardial infarction, angina, or need for coronary-artery bypass grafting or angioplasty.
❑ In survival of [[SCA]], or sustained [[VT]], or symptomatic [[ ventricular arrhythmia]] who are ineligible for [[ICD]] implantation  due to limited life expectancy or inaccessible venous sites, [[amiodarone]] is recommended
 
|-
==='''CHF-STAT (Congestive heart failure: Survival trial of antiarrhythmic therapy)<ref name="pmid7539890">{{cite journal| author=Singh SN, Fletcher RD, Fisher SG, Singh BN, Lewis HD, Deedwania PC et al.| title=Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. | journal=N Engl J Med | year= 1995 | volume= 333 | issue= 2 | pages= 77-82 | pmid=7539890 | doi=10.1056/NEJM199507133330201 | pmc= | url= }} </ref>'''===
|}
 
<span style="font-size:85%">'''Abbreviations:'''
* '''Demographics''':  Total: 674, Amiodarone: 336, Placebo: 338
'''ICD:''' [[Implantable cardioverter defibrillator]];
 
'''SCA:''' [[Sudden cardiac arrest]];
* '''Strategy''': to determine whether Amiodarone can reduce overall mortality in patients with congestive heart failure and asymptomatic ventricular arrhythmias.
'''NICM''' [[Non ischemic cardiomyopathy]];
 
'''EPS''' [[Electrophysiology study]];
* '''Mean EF''': ≤40%, ≥10 PVCs/hr
'''SCD''' [[Sudden cardiac death]];
 
'''VT''' [[Ventricular tachycardia]]
* '''Result''': The rate of sudden death was 15% in the Amiodarone group and 19% in the placebo group in Ischemic Cardiomyopathy group (P=0.43). Reduction in overall mortality among the patients with nonischemic cardiomyopathy who received Amiodarone (P =0.07).
</span>
 
<br>
===''' SWORD (The Survival With Oral d-Sotalol trial)<ref name="pmid8691967">{{cite journal| author=Waldo AL, Camm AJ, deRuyter H, Friedman PL, MacNeil DJ, Pauls JF et al.| title=Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. The SWORD Investigators. Survival With Oral d-Sotalol. | journal=Lancet | year= 1996 | volume= 348 | issue= 9019 | pages= 7-12 | pmid=8691967 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8691967  }} </ref>'''===
{|
* '''Strategy''':  whether d-sotalol, could reduce all-cause mortality in patients with Left ventricular dysfunction after myocardial infarction .
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2017 AHA/ACC/HRS Guideline
 
|-
* '''Demographics''': Total : 3121, d-Sotalol : 1549, placebo : 1572
|}
 
* '''Mean EF''': 40%
 
* '''Result''':  Mortality : d-sotalol: 78 deaths (5.0%), Placebo: 48 deaths (3.1%) (relative risk 1.65 [95% CI 115–2.36], p=0.006). Presumed arrhythmic deaths (relative risk 1.77 [1.15–2.74], p=0.008). The effect was greater in patients with a left ventricular ejection fraction of 31–40% than in those with lower (≤30%) ejection fractions (relative risk 4.0 vs 1.2, p=0.007).
 
==='''MADIT I (Multicenter Automatic Defibrillator Implantation Trial)<ref name="pmid8960472">{{cite journal| author=Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H et al.| title=Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. | journal=N Engl J Med | year= 1996 | volume= 335 | issue= 26 | pages= 1933-40 | pmid=8960472 | doi=10.1056/NEJM199612263352601 | pmc= | url= }} </ref>'''===
* '''Strategy''': Conventional medical therapy vs ICD in patients with clinical NSVT and inducible VT during EPS that is not suppressible with procainamide
 
* '''Demographics''': Medical therapy: 101 ICD arm: 95
 
* '''Mean EF''': 35
 
* '''Result''': RR reduction in mortality in favor of ICD; 95% CI: 0.26-0.82; p = 0.009
 
==='''GESICA (the Gruppo de Estudo de la Sobrevida en la Insuficiencia Cardiaca en Argentina)<ref name="pmid8989129">{{cite journal| author=Doval HC, Nul DR, Grancelli HO, Varini SD, Soifer S, Corrado G et al.| title=Nonsustained ventricular tachycardia in severe heart failure. Independent marker of increased mortality due to sudden death. GESICA-GEMA Investigators. | journal=Circulation | year= 1996 | volume= 94 | issue= 12 | pages= 3198-203 | pmid=8989129 | doi= | pmc= | url= }} </ref>'''===
* '''Strategy''': To determine the prognostic value of nonsustained ventricular tachycardia (NSVT) in total mortality in severe congestive heart failure (CHF) and predictive value of NSVT as a marker for sudden death or death due to progressive heart failure.
 
* '''Demographics''':  Total: 516, NSVT: 173 (33.5%), No NSVT: and 343 (66.5
 
* '''Mean EF''':
 
* '''Result''': Efficacy Study: Mortality - NSVT: 87(50.3%) No NSVT: (30.9%) (RR = 1.69 (95% confidence interval [CI], 1.27 to 2.24; P<.0002; Cox proportional hazard analysis was 1.62 (95% CI, 1.22 to 2.16; P<.001)). Sudden death – No NSVT: 8.7%, NSVT: 23.7% (RR, 2.77; 95% CI, 1.78 to 4.44; P<.001). Progressive heart failure death – No NSVT: 17.5%, NSVT: 20.8% (P=.22). Couplets prediction of total all-cause mortality: RR, 1.81; 95% CI, 1.22 to 2.66; P<.002 ; sudden death: RR, 3.37; 95% CI, 1.57 to 7.25; P<.0005. Couplets±NSVT prediction of sudden death: RR, 10.1; 95% CI, 1.91 to 52.7; P<.01.
 
==='''EMIAT (The European Myocardial Infarct Amiodarone Trial)<ref name="pmid9078197">{{cite journal| author=Julian DG, Camm AJ, Frangin G, Janse MJ, Munoz A, Schwartz PJ et al.| title=Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. European Myocardial Infarct Amiodarone Trial Investigators. | journal=Lancet | year= 1997 | volume= 349 | issue= 9053 | pages= 667-74 | pmid=9078197 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9078197  }} </ref>'''===
* '''Strategy''': Amiodarone effect on reduction of mortality in patients of myocardial infarction with impaired ventricular function, irrespective of whether they had ventricular arrhythmias.
 
* '''Demographics''': Total: 1486, Amiodarone : 743, Placebo : 743
 
* '''Mean EF''': <40%
 
* '''Result''': Amiodarone group, there was a 35% risk reduction (95% CI 0–58, p=0.05) in arrhythmic deaths.
 
==='''CAMIAT (The Cardiac Arrhythmia Suppression Trial)<ref name="pmid9078198">{{cite journal| author=Cairns JA, Connolly SJ, Roberts R, Gent M| title=Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators. | journal=Lancet | year= 1997 | volume= 349 | issue= 9053 | pages= 675-82 | pmid=9078198 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9078198  }} </ref>'''===
* '''Strategy''': To assess the effect of amiodarone on the risk of resuscitated ventricular fibrillation or arrhythmic death among survivors of myocardial infarction with frequent or repetitive VPDs (≥10 VPDs per h or ≥1 run of ventricular tachycardia).
 
* '''Demographics''': Total : 1202, Amiodarone :  606, Placebo: 596
 
* '''Mean EF''':
 
* '''Result''': Efficacy Analysis: resuscitated ventricular fibrillation or arrhythmic death – Placebo : 31 (6.0%) Amiodarone : 15 (3.3%) (relative-risk reduction 48.5% [95% CI 4.5 to 72.2], p=0.016). Intention-to-treat analysis: primary outcome events Placebo : 24 (6.9%) Amiodarone : 15 (4.5 (38.2% [95% CI –2.1 to 62.6], p=0.029). The absolute-risk reductions were greatest among patients with congestive heart failure or a history of myocardial infarction.
 
==='''CABG-PATCH (Coronary Artery Bypass Graft (CABG) Patch Trial)<ref name="pmid10086963">{{cite journal| author=Bigger JT, Whang W, Rottman JN, Kleiger RE, Gottlieb CD, Namerow PB et al.| title=Mechanisms of death in the CABG Patch trial: a randomized trial of implantable cardiac defibrillator prophylaxis in patients at high risk of death after coronary artery bypass graft surgery. | journal=Circulation | year= 1999 | volume= 99 | issue= 11 | pages= 1416-21 | pmid=10086963 | doi= | pmc= | url= }} </ref>'''===
* '''Strategy''': CAD patients undergoing CABG with abnormal signal averaged ECG randomized to ICD or control group
 
* '''Demographics''': ICD epicardial: 446 Control arm: 45 Total: 900 30days and revascularization > 90 days) randomized 3:2 to ICD vs conventional medical therapy ICD: 42 Conventional medical therapy: 490
 
* '''Mean EF''': 30
 
* '''Result''': 31% RR reduction in favor of ICD; 95% CI: 0.51-0.93; p = 0.16
 
==='''MUSTT (the Multicenter Unsustained Tachycardia Trial)<ref name="pmid10601507">{{cite journal| author=Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G| title=A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. | journal=N Engl J Med | year= 1999 | volume= 341 | issue= 25 | pages= 1882-90 | pmid=10601507 | doi=10.1056/NEJM199912163412503 | pmc= | url= }} </ref> '''===
* '''Strategy''': Electrophysiologically guided antiarrhythmic therapy would reduce the risk of sudden death among patients with coronary artery disease, a left ventricular ejection fraction of 40 percent or less, and asymptomatic, unsustained ventricular tachycardia
 
* '''Demographics''': 704 patients who underwent randomization, 351 were assigned to receive electrophysiologically guided therapy and 353 were assigned to receive no antiarrhythmic therapy.
 
* '''Mean EF''': LVEF <40% + NSVT
 
* '''Result''': Efficacy Study:  Cardiac Arrest or Death from Arrhythmia - EP guided therapy = 25% no antiarrhythmic therapy = 32% (RR=0.73, CI=0.53-0.99). Cardiac arrest or death from arrhythmia - Treatment with Defibrillators vs w/o Defibrillator Treatment (RR=0.24; CI=0.13-0.45; P<0.001).
 
==='''MADIT II (Multicenter Automatic Defibrillator Implantation Trial - II)<ref name="pmid11907286">{{cite journal| author=Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS et al.| title=Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 12 | pages= 877-83 | pmid=11907286 | doi=10.1056/NEJMoa013474 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11907286  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12418821 Review in: ACP J Club. 2002 Nov-Dec;137(3):81] </ref>'''===
* '''Strategy''': To evaluate the effect of an implantable defibrillator on survival in patients with reduced left ventricular function after myocardial infarction are at risk for life threatening ventricular arrhythmias.
 
* '''Demographics''': Total: 1232, ICD: 742, Conventional Medical Therapy: 490 patients
 
* '''Mean EF''': ≤30% >10 PVCs/hr or couplets
 
* '''Result''': Efficacy Study: Mortality – Conventional Medical Therapy: 19.8%, ICD: 14.2%(HR 0.69 (95 CI= 0.51-0.93, P=0.016).
 
==='''AMIOVIRT (Amiodarone versus Implantable Defibrillator)<ref name="pmid12767651">{{cite journal| author=Strickberger SA, Hummel JD, Bartlett TG, Frumin HI, Schuger CD, Beau SL et al.| title=Amiodarone versus implantable cardioverter-defibrillator:randomized trial in patients with nonischemic dilated cardiomyopathy and asymptomatic nonsustained ventricular tachycardia--AMIOVIRT. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1707-12 | pmid=12767651 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767651  }} </ref>'''===
* '''Strategy''': Nonischemic dilated cardiomyopathy patients with nonsustained VT, randomized to ICD vs amiodarone
 
* '''Demographics''': ICD: 51 Amiodarone: 52 Total: 103
 
* '''Mean EF''': 35
 
* '''Result''': No significant difference in survival
 
==='''DEFINITE (Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation)<ref name="pmid15152060">{{cite journal| author=Kadish A, Dyer A, Daubert JP, Quigg R, Estes NA, Anderson KP et al.| title=Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 21 | pages= 2151-8 | pmid=15152060 | doi=10.1056/NEJMoa033088 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15152060  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15518445 Review in: ACP J Club. 2004 Nov-Dec;141(3):61] </ref>'''===
* '''Strategy''': Nonischemic dilated cardiomyopathy patients with nonsustained VT, randomized to ICD vs standard medical therapy
 
* '''Demographics''': Singlechamber ICD: 229 Standard medical therapy: 229 Total: 458 120 ms) in both ischemic and nonischemic causes 1520 randomized in 1:2:2 ratio to receive optimum pharmacological therapy, biventricular pacemaker alone or biventricular pacemaker defibrillator
 
*'''Mean EF''': 35
 
* '''Result''': Combined end point of hospitalization and death reduced by the pacemaker alone 34% (p = 0.002) and pacemaker-ICD by 40% (p = 0.001). Secondary end point all-cause mortality reduced by defibrillator by RR-36% (p = 0.003) but not by pacemaker alone. RR: 24% (p = 0.059)
 
==='''DINAMIT (Defibrillator in Acute Myocardial Infarction Trial)<ref name="pmid15590950">{{cite journal| author=Hohnloser SH, Kuck KH, Dorian P, Roberts RS, Hampton JR, Hatala R et al.| title=Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 24 | pages= 2481-8 | pmid=15590950 | doi=10.1056/NEJMoa041489 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15590950  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15862057 Review in: ACP J Club. 2005 May-Jun;142(3):58] </ref>'''===
 
* '''Strategy''': Benefit of an ICD early after an MI within 6-40 days towards reduction of mortality when compared with medical therapy
 
* '''Demographics''': ICD: 332 Control: 342 Total: 674
 
* '''Mean EF''': 35
 
* '''Result''': 62 deaths in the ICD group and 58 in the control group (p = 0.66; CI: 0.76-1.55). Arrhythmic causes were less in the ICD group but nonarrhythmic causes were significantly higher and thus overall mortality was not significantly different
 
==='''COMPANION (The Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure trial )<ref name="pmid15152059">{{cite journal| author=Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T et al.| title=Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 21 | pages= 2140-50 | pmid=15152059 | doi=10.1056/NEJMoa032423 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15152059  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15518444 Review in: ACP J Club. 2004 Nov-Dec;141(3):60] </ref>'''===
* '''Strategy''': Prophylactic cardiac-resynchronization therapy in the form of biventricular stimulation with a pacemaker with or without a defibrillator would reduce the risk of death and hospitalization among patients with advanced chronic heart failure and intraventricular conduction delays.
 
* '''Demographics''': Total: 1520, Optimal Pharmacologic Therapy: 308, Cardiac- Resynchronization Therapy:  Pacemaker=617, Pacemaker– Defibrillator=595
 
* '''Mean EF''': Ischemic or nonischemic CM NYHA Class III-IV QRS ≥120 msec
 
* '''Result''': Efficacy Study: Pacemaker group - Primary end point mortality reduction (hazard ratio, 0.81; P=0.014), Pacemaker–defibrillator group (hazard ratio, 0.80; P=0.01). Primary end point mortality reduction: 34% - Pacemaker group (P<0.002), 40% - Pacemaker–Defibrillator group (P<0.001). Secondary end point mortality reduction: 24% - Pacemaker group (P=0.059), 36% - Pacemaker–Defibrillator group (P=0.003).
 
==='''SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial)<ref name="pmid15659722">{{cite journal| author=Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R et al.| title=Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 3 | pages= 225-37 | pmid=15659722 | doi=10.1056/NEJMoa043399 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15659722  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15989294 Review in: ACP J Club. 2005 Jul-Aug;143(1):6] </ref>'''===
* '''Strategy''': To assess prognostic effect of ICD vs amiodarone vs placebo in class II and III heart failure regardless of etiology.
 
* '''Demographics''': Conventional therapy and placebo: 847 Conventional therapy and amiodarone: 845 Conventional therapy and single lead, shock only ICD: 829 Total: 2521
 
* '''Mean EF''': 35 (ischemic etiology patients 52% and nonischemic etiology 48%)
 
* '''Result''': Amiodarone and placebo outcome were comparable. ICD arm absolute risk reduction: 7.2% after 5 years; RR: 23% (p = 0.007)
 
==='''MADIT-CRT(Multicenter automatic defibrillator implantation trial-cardiac resynchronization therapy)'''<ref name="pmid19723701">{{cite journal| author=Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP et al.| title=Cardiac-resynchronization therapy for the prevention of heart-failure events. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 14 | pages= 1329-38 | pmid=19723701 | doi=10.1056/NEJMoa0906431 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19723701  }} </ref>===
* '''Strategy''': To determine whether cardiac-resynchronization therapy (CRT) with biventricular pacing would reduce the risk of death or heart-failure events in patients with mild cardiac symptoms, a reduced ejection fraction, and a wide QRS complex.
 
* '''Demographics''':  Total: 1820, CRT + ICD = 1089, ICD alone = 731
 
* '''Mean EF''': <30%
 
* '''Result''': Efficacy study: CRT-ICD primary end point mortality = 17.2%, ICD-only group = 25.3% HR=0.66; 95% CI = 0.52-0.84, p=0.001.


==References==
==References==

Latest revision as of 09:09, 27 May 2021

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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 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 was superior to antiarrhythmic drugs 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, proarrhythmic medication effect may be corrected. ICD implantation improved outcome in well-tolerated VT and structurally heart disease. 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.

Secondary prevention

Secondary prevention strategies following SCA and unstable VT include ICD implantation, and medications.

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):

❑ 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) :

❑ 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)

❑ 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

The above table adopted from 2017 AHA/ACC/HRS Guideline

[5]




 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The above algorithm adopted from 2017 AHA/ACC/HRS Guideline

[5]

Secondary prevention in patients with coronary spasm


Recommendations for secondary prevention of sudden cardiac death in coronary spasm
ICD implantation (Class I, Level of Evidence B):

❑ 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) :

❑ 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)

❑ 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

The above table adopted from 2017 AHA/ACC/HRS Guideline

Post CABG,VT/VF

Secondary prevention in non-ischemic cardiomyopathy

Recommendations for secondary prevention of sudden cardiac death in non-ischemic cardiomyopathy
ICD implantation (Class I, Level of Evidence B):

❑ ICD implantation is recommended in survivors of SCA or hemodynamically unstable VT or sustained VT not related to reversible causes, if life expectancy is more than 1 year

ICD implantation, EPS study (Class IIa, Level of Evidence B) :

❑ In the presence of syncope presumed due to ventricular arrhythmia, ICD or EPS study for risk stratification of SCD is recommended if survival is more than 1 year

Amiodarone : (Class IIb, Level of Evidence B)

❑ In survival of SCA, or sustained VT, or symptomatic ventricular arrhythmia who are ineligible for ICD implantation due to limited life expectancy or inaccessible venous sites, amiodarone is recommended

Abbreviations: ICD: Implantable cardioverter defibrillator; SCA: Sudden cardiac arrest; NICM Non ischemic cardiomyopathy; EPS Electrophysiology study; SCD Sudden cardiac death; VT Ventricular tachycardia

The above table adopted from 2017 AHA/ACC/HRS Guideline

References

  1. ↑ "A Comparison of Antiarrhythmic-Drug Therapy with Implantable Defibrillators in Patients Resuscitated from Near-Fatal Ventricular Arrhythmias". New England Journal of Medicine. 337 (22): 1576–1584. 1997. doi:10.1056/NEJM199711273372202. ISSN 0028-4793.
  2. ↑ Wyse, D.George; Friedman, Peter L; Brodsky, Michael A; Beckman, Karen J; Carlson, Mark D; Curtis, Anne B; Hallstrom, Alfred P; Raitt, Merritt H; Wilkoff, Bruce L; Greene, H.Leon (2001). "Life-threatening ventricular arrhythmias due to transient or correctable causes: high risk for death in follow-up". Journal of the American College of Cardiology. 38 (6): 1718–1724. doi:10.1016/S0735-1097(01)01597-2. ISSN 0735-1097.
  3. ↑ Raitt, Merritt H.; Renfroe, Ellen Graham; Epstein, Andrew E.; McAnulty, John H.; Mounsey, Paul; Steinberg, Jonathan S.; Lancaster, Scott E.; Jadonath, Ram L.; Hallstrom, Alfred P. (2001). ""Stable" Ventricular Tachycardia Is Not a Benign Rhythm". Circulation. 103 (2): 244–252. doi:10.1161/01.CIR.103.2.244. ISSN 0009-7322.
  4. ↑ Maury, P.; Baratto, F.; Zeppenfeld, K.; Klein, G.; Delacretaz, E.; Sacher, F.; Pruvot, E.; Brigadeau, F.; Rollin, A.; Andronache, M.; Maccabelli, G.; Gawrysiak, M.; Brenner, R.; Forclaz, A.; Schlaepfer, J.; Lacroix, D.; Duparc, A.; Mondoly, P.; Bouisset, F.; Delay, M.; Hocini, M.; Derval, N.; Sadoul, N.; Magnin-Poull, I.; Klug, D.; Haissaguerre, M.; Jais, P.; Della Bella, P.; De Chillou, C. (2014). "Radio-frequency ablation as primary management of well-tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%". European Heart Journal. 35 (22): 1479–1485. doi:10.1093/eurheartj/ehu040. ISSN 0195-668X.
  5. ↑ 5.0 5.1 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.
  6. ↑ "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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ Bigger, J. Thomas (1997). "Prophylactic Use of Implanted Cardiac Defibrillators in Patients at High Risk for Ventricular Arrhythmias after Coronary-Artery Bypass Graft Surgery". New England Journal of Medicine. 337 (22): 1569–1575. doi:10.1056/NEJM199711273372201. ISSN 0028-4793.


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