ESC Updates Guidelines for Ventricular Arrhythmia, Sudden Death

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New European Society of Cardiology (ESC) guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death contain a variety of updates since the 2015 edition — including 140 new recommendations and 20 changed recommendations, and now tables and algorithms for managing patients with specific cardiovascular diseases.   

The changes were presented at the European Society of Cardiology (ESC) Congress 2022 and the document was simultaneously published online in the European Heart Journal.

“One thing is what we cardiologists do, but really, sudden cardiac death occurs in society, so therefore secondary prevention at the scene is so important,” guideline cochairperson, Jacob Tfelt-Hansen, MD, DMSc, told theheart.org | Medscape Cardiology in an interview.

The guidelines contain three strong Class I recommendations to improve survival in out-of-hospital cardiac arrest, said Tfelt-Hansen, from Copenhagen University Hospital, Denmark.

Automated external defibrillators (AEDs) should be placed in public areas such as train stations, where cardiac arrests can occur; cardiac pulmonary resuscitation (CPR) should be started by bystanders; and community training should be promoted to increase bystander CPR and AED use.

The guidelines also say that a mobile app to call on nearby volunteers to perform resuscitation before the arrival of paramedics should be considered (Class IIa), something that has been successfully used in Denmark, Tfelt-Hansen noted.  

He highlighted several new concepts and recommendations in the guidelines.

Five Clinical Scenarios

In a new section, the guidelines provide a comprehensive diagnostic evaluation for five frequently encountered scenarios involving ventricular arrhythmia in patients without previously known cardiac disease: 1) incidental finding of a nonsustained ventricular tachycardia; 2) first presentation of sustained monomorphic ventricular tachycardia; 3) sudden cardiac arrest survivor; 4) sudden cardiac death victim; and 5) relatives of sudden arrhythmic death syndrome decedents.

Genetic Testing, ICDs in Dilated Cardiomyopathy

The guidelines provide insights on genetic testing, including examples for different diseases, such as dilated cardiomyopathy (DCM).

If a patient with DCM presents at younger age (< 50 years) with atrioventricular block or if the patient has a family history of DCM or sudden cardiac death at young age, genetic testing is a Class I recommendation.  

If left ventricular ejection fraction is 35% or lower after > 3 months of optimal medical therapy, implantation of an implantable cardioverter defibrillator (ICD) should be considered in patients with DCM and symptomatic heart failure (NYHA class II-II). This is now a Class IIa recommendation, downgraded from the Class I recommendation in the 2015 guidelines, Tfelt-Hansen said, “due to the DANISH study and also to the fact that drugs are lowering the rate of sudden cardiac death in this population.”

Beta-Blockers

There are new recommendations concerning the treatment of ventricular arrhythmias, the role of ablation, and the diagnosis of Brugada syndrome.

“We have a new Class I recommendation to prescribe beta blockers and ideally non-selective beta blockers in patients with rare diseases long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT), a heritable disorder,” Tfelt-Hansen noted.

That is: “Beta-blockers, ideally non-selective beta-blockers (nadolol or propranolol), are recommended in LQTS patients with documented QT interval prolongation, to reduce risk of arrhythmic event (Class I),” and “in all patients with a clinical diagnosis of CPVT (Class I).”

In patients with clinically diagnosed LQTS and CPVT, genetic testing and genetic counseling are recommended. 

“If you have a special subtype of long QT called long QT3, and a sodium channel gene, we have a new recommendation for mexiletine — a genotype dependent form of treatment,” Tfelt-Hansen added, which reduces the length of QT interval and the number of arrhythmic events.

Autopsy and Sports

“Ideally in all cases of sudden cardiac death, but at least in those under age 50, we recommend an autopsy including expert cardiac pathology, and toxicology (Class I),” he said. Toxicology can identify if the patient died of an overdose rather than a genetic cause.

“We have downgraded our previous very strong recommendation of preparticipation screening,” going from Class I to Class IIa, Tfelt-Hansen said.

Tools Available on ESC Website

The guidelines include clinical flowcharts that provide step-by-step patient risk stratification and management, and there is also a pocket guidelines app, all available on the ESC website.

European Society of Cardiology (ESC) Congress 2022. Guideline overview presented August 26.

Eur Heart J. Published online August 26, 2022. Full text  

The guidelines were endorsed by the Association for European Paediatric and Congenital Cardiology. The author disclosures are available in a supplementary document at https://www.escardio.org/Guidelines.

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