ESC updates guidelines for ventricular arrhythmia, sudden death

The 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 modified recommendations, and now charts and algorithms for managing patients with specific cardiovascular diseases.

The changes were presented at the 2022 Congress of the European Society of Cardiology (ESC) and the paper was simultaneously published online in the European journal of the heart.

“One thing is what we cardiologists do, but the reality is that sudden cardiac death happens in society, so secondary prevention at the scene is so important,” guidelines co-chair Jacob Tfelt- Hansen, MD, DMSc. lecoeur.org | Medscape Cardiology in an interview.

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

Automated external defibrillators (AEDs) should be placed in public places such as train stations, where cardiac arrests can occur; cardiopulmonary resuscitation (CPR) must be started by passers-by; and community training should be encouraged to increase use of CPR and AED by bystanders.

The guidelines also state that a mobile app to call for nearby volunteers to perform resuscitation before paramedics arrive should be considered (Class IIa), which has been used successfully 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 assessment for five commonly encountered scenarios involving ventricular arrhythmia in patients without previously known heart disease: 1) incidental finding of unsustained ventricular tachycardia; 2) first presentation of sustained monomorphic ventricular tachycardia; 3) survivor of sudden cardiac arrest; 4) victim of sudden cardiac death; and 5) relatives of people who died of sudden arrhythmia death syndrome.

Genetic testing, INN in dilated cardiomyopathy

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

If a patient with DCM presents at a younger age (

If the left ventricular ejection fraction is 35% or less after > 3 months of optimal medical treatment, 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 because the drugs reduce the rate of sudden cardiac death in this population”.

Beta-blockers

There are new recommendations regarding 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 hereditary disease,” noted Tfelt-Hansen.

That is: “Beta-blockers, ideally non-selective beta-blockers (nadolol or propranolol), are recommended in patients with SQTL with documented QT interval prolongation, to reduce the risk 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,” added Tfelt-Hansen, which shortens the duration 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 50, we recommend an autopsy including expert cardiac pathology and toxicology (Class I),” he said. Toxicology can determine if the patient died of an overdose rather than a genetic cause.

“We’ve downgraded our previous very strong pre-participation screening recommendation” from Class I to Class IIa, Tfelt-Hansen said.

Tools available on the 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. Overview of guidelines presented August 26.

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

The guidelines have been endorsed by the European Association of Pediatric and Congenital Cardiology. The author’s disclosures are available in a supplemental document at https://www.escardio.org/Guidelines.

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