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
2 www.escardio.org European Heart Journal 2015 doi/10.1093/eurheartj/ehv316
3 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. • www.escardio.org
II 100 AOP 0
II 100 AOP 0
6 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. www.escardio.org
Diagnostic workup in patients presenting with sustained ventricular tachycardia or ventricular fibrillation www.escardio.org
8 Diagnostic workup in patients presenting with sustained ventricular tachycardia or ventricular fibrillation www.escardio.org Speaker
9 Diagnostic workup in patients presenting with sustained ventricular tachycardia or ventricular fibrillation www.escardio.org Speaker
10 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. www.escardio.org
Antiarrhythmic drugs for the prevention of SCD 0.4 HR 97.5% CI P-value amiodaron vs. Placebo 1.06 0.86, 1.30 0.53 ICD therapie vs. Placebo 0.77 0.62, 0.96 0.007 0.3 mortality 0.2 amiodaron 0.1 placebo ICD 0 0 60 12 24 36 48 follow-up (months) www.escardio.org Bardy GH, N Engl J Med 2005
Primary prevention of SCD with the ICD www.escardio.org
The subcutaneous ICD www.escardio.org
14 • 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. www.escardio.org
15 • 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. www.escardio.org
16 Diagnostic workup in patients with sustained ventricular arrhythmias and ACS. www.escardio.org
Sustained VT in structural heart disease: drugs or ablation? www.escardio.org
18 Sustained ventricular tachycardia - Drug therapy - Catheter ablation www.escardio.org
Catheter ablation of ventricular tachycardia www.escardio.org
20 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. • www.escardio.org
Outfow tract ventricular arrhythmias AP LL AP * * AV PV * * * * MV TA GCV CS RVOT/PA LVOT/AO CS/EPI Tanner et al., JACC 2005 www.escardio.org
22 VT and VF in structurally normal hearts • Outflow tract ventricular tachycardia www.escardio.org
Catheter ablation of ventricular fibrillation Haissaguerre M et al . Lancet 2002; 359:677 – 678 www.escardio.org
24 Idiopathic ventricular fibrillation Short-coupled torsade de pointes www.escardio.org
25 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. www.escardio.org
26 To do and to not do messages www.escardio.org
27 ESC Pocket Guidelines application available! European Heart Journal 2015 doi/10.1093/eurheartj/ehv316 www.escardio.org
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