Ventricular tachycardia secondary prevention
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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.
- 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.[1]
- Before ICD implantation, the reversible causes of ventricular arrhythmia including myocardial ischemia, electrolyte disturbance, proarrhythmic medication effect may be corrected.[2]
- ICD implantation improved outcome in well-tolerated VT and structurally heart disease.[3]
- VT ablation reduced recurrence of tachyarrhythmia, but the effect on long-term mortality was unknown.[4]
- 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.
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): |
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❑ 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) : |
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❑ 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) |
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❑ 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 |
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| 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 |
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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.[6]
- 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.[7]
| Recommendations for secondary prevention of sudden cardiac death in coronary spasm |
| ICD implantation (Class I, Level of Evidence B): |
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❑ 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) : |
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❑ 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) |
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❑ 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 |
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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.[8]
- 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.[9]
- 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. [10][11]
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): |
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❑ 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) : |
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❑ 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) |
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❑ 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 |
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References
- ↑ "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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 5.0 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.
- ↑ "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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.