2017 aha/acc/hrs ventricular arrhythmias and sudden ... · subcutaneous implantable...
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2017 AHA/ACC/HRS Ventricular Arrhythmias and Sudden Cardiac Death Guideline
Eleftherios M Kallergis, MD, PhD, FESC
Cadiology Department - Heraklion University Hospital
Top Ten Messages
No actual or potential conflict of interest in relation to this program/presentation
Sudden Cardiac Death: A 2400-year-old Diagnosis?
“those who are subject to frequent and severe
fainting attacks without obvious cause
die suddenly”
The Scale of the Problem
The Scale of the Problem
NASPE 2001, CDC 2001, American Cancer Society 2001
Bayes de Luna et al. Am Heart J. 1989
Sudden Cardiac Death
6:02 AM
6:05 AM
6:07 AM
6:11 AM
An Unequal Fight
Winning Strategies
2017 AHA/ACC/HRS Guidelines
A depressed ventricular function remains the major risk marker for SCD
1
The majority of SCD victims…
Wellens et al, Eur Heart J. 2014
The role of other factors needs to be evaluated
Chough S, Int J Cardiol 2017
Genetic Testing and Counseling
COR LOE Recommendation for Genetic Counselling
I C-EO
1. In patients and family members in whom genetic testing for risk stratificationfor SCA/SCD is recommended, genetic counseling is beneficial.
COR LOE Recommendations for Idiopathic Polymorphic VT/VF
I B-NR
1. In young patients (<40 years of age) with unexplained SCA, unexplained neardrowning, or recurrent exertional syncope, who do not have ischemic or otherstructural heart disease, further evaluation for genetic arrhythmia syndromesis recommended.
2
Genetic Testing and Counseling
COR LOE Recommendations for Postmortem Evaluation of SCD
I B-NR1. In victims of SCD without obvious causes, a
standardized cardiac-specific autopsy isrecommended.
I B-NR
2. In first-degree relatives of SCD victims who were 40years of age or younger, cardiac evaluation isrecommended, with genetic counseling and genetictesting performed as indicated by clinical findings.
IIa B-NR
3. In victims of SCD with an autopsy that implicates apotentially heritable cardiomyopathy or absence ofstructural disease, suggesting a potential cardiacchannelopathy, postmortem genetic testing isreasonable.
IIa C-LD
4. In victims of SCD with a previously-identifiedphenotype for a genetic arrhythmia-associateddisorder, but without genotyping prior to death,postmortem genetic testing can be useful for thepurpose of family risk profiling.
The predisposition to die suddenly iswritten in the genes!
Give me your genetic card……I’ll give you the treatment
The importance of medical therapy for the prevention of SCD…
3
COR LOE Recommendation for Pharmacological Prevention of SCD
I A
1. In patients with HFrEF (LVEF ≤40%), treatment with a beta blocker, a
mineralocorticoid receptor antagonist and either an angiotensin-converting
enzyme inhibitor, an angiotensin-receptor blocker, or an angiotensin
receptor-neprilysin inhibitor is recommended to reduce SCD and all-cause
mortality.
New
Evidence-based medications can reduce the risk of SCD
2015 SCD ESC Guidelines 2016 HF ESC–ACC/AHA Guidelines
Evidence-based medications can reduce the risk of SCD
Shen et al, N Engl J Med 2017
The decline in the rate of SCD by 44% paralleled the increasing use of evidence-based pharmacotherapies
Time to Optimize Guideline-Directed Medical Therapy
DeFilippis et al; Circ Heart Fail. 2017
ICDs in Non-Ischaemic Cardiomyopathy
COR LOE Recommendations for Primary Prevention of SCD in Patients With NICM
I A1. In patients with NICM, HF with NYHA class II–III symptoms and an LVEF of 35%
or less, despite GDMT, an ICD is recommended if meaningful survival of greaterthan 1 year is expected.
IIa B-NR2. In patients with NICM due to a Lamin A/C mutation who have 2 or more risk
factors (NSVT, LVEF <45%, nonmissense mutation, and male sex), an ICD can bebeneficial if meaningful survival of greater than 1 year is expected.
4keep this recommendation Class I
The DANISH Dilemma...
➢ The occurrence of all cause mortality and SCD
were 5.0 and 1.8 events per 100 patient-years in
the control group vs. 4.4 and 0.9 events in the
ICD arm
➢ The number needed to treat to prevent one
death in a follow-up of 5.6 years was very high
(56 patients)
Køber L et al, N Engl J Med. 2016
DA
NIS
H s
tud
y
The DANISH Dilemma...
25% relative risk reduction in mortality with an ICD
Golwala H, et al. Circulation 2017, Al-Khatib SM et al. JAMA Cardiol. 2017
The DANISH Dilemma
❖ Patients with NICM are less prone to arrhythmia
➢Noncardiac causes of death accounted for 31% of the deaths
❖ Improved medical treatment for heart failure
❖ Frequent use of CRT
Our patients need doctors, not installers of devices
Ischaemic Heart Disease and Sustained Monomorphic VT
COR LOERecommendations for Treatment of Recurrent VA in Patients With Ischemic
Heart Disease
III: No Benefit
C-LD
In patients with ischemic heart disease and sustained monomorphic VT,
coronary revascularization alone is an ineffective therapy to prevent
recurrent VT.
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Specific therapies such as antiarrhythmic medications or
ablation
may be needed to prevent recurrence
Catheter Ablation is an Important Treatment Option
❖ The guideline provides updated recommendations on catheter ablation of
ventricular arrhythmias from the most benign (premature ventricular
contractions) to the most ominous (ventricular fibrillation).
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The Randomized VANISH trial
Sapp JL, et al. N Engl J Med. 2016
Catheter Ablation is an Important Treatment Option
COR LOE Recommendations for PVC-Induced Cardiomyopathy
I B-NR
1. For patients who require arrhythmia suppression for symptoms ordeclining ventricular function suspected to be due to frequent PVCs(generally >15% of beats and predominately of 1 morphology) and forwhom antiarrhythmic medications are ineffective, not tolerated, or notthe patient’s preference, catheter ablation is useful.
IIa B-NR
2. In patients with PVC-induced cardiomyopathy, pharmacologic treatment(e.g. beta blocker, amiodarone) is reasonable to reduce recurrentarrhythmias, and improve symptoms and LV function.
Catheter Ablation in Brugada Syndrome
COR LOE Recommendations for Brugada Syndrome
I B-NR
3. In patients with Brugada syndrome experiencing recurrent ICD shocksfor polymorphic VT, intensification of therapy with quinidine orcatheter ablation is recommended.
COR LOE Recommendations for Brugada Syndrome
I B-NR
4. In patients with spontaneous type 1 Brugada electrocardiographicpattern and symptomatic VA who either are not candidates for ordecline an ICD, quinidine or catheter ablation is recommended.
Pappone et al. Circulation: Arrhythmia and Electrophysiology. 2017
Different Types of Defibrillators are Reviewed
COR LOERecommendations for Subcutaneous Implantable Cardioverter-
Defibrillator
I B-NR
1. In patients who meet criteria for an ICD who haveinadequate vascular access or are at high risk for infection,and in whom pacing for bradycardia or VT termination or aspart of CRT is neither needed nor anticipated, asubcutaneous implantable cardioverter-defibrillator isrecommended.
IIa B-NR
2. In patients who meet indication for an ICD, implantation of asubcutaneous implantable cardioverter-defibrillator isreasonable if pacing for bradycardia or VT termination or aspart of CRT is neither needed nor anticipated.
III: Harm
B-NR
3. In patients with an indication for bradycardia pacing or CRT,or for whom antitachycardia pacing for VT termination isrequired, a subcutaneous implantable cardioverter-defibrillator should not be implanted .
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Wearable Cardioverter-Defibrillator
COR LOERecommendations for Wearable Cardioverter-Defibrillator
IIa B-NR
1. In patients with an ICD and a history of SCA or sustainedVA in whom removal of the ICD is required (as withinfection), the wearable cardioverter-defibrillator isreasonable for the prevention of SCD
IIb B-NR
2. In patients at an increased risk of SCD but who are notineligible for an ICD, such as awaiting cardiac transplant,having an LVEF of 35% or less and are within 40 daysfrom an MI, or have newly diagnosed NICM,revascularization within the past 90 days, myocarditis orsecondary cardiomyopathy or a systemic infection,wearable cardioverter-defibrillator may be reasonable.
The importance of shared decision making
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COR LOE Recommendations for Shared Decision-Making
I B-NR
1. In patients with VA or at increased risk for SCD, clinicians
should adopt a shared decision-making approach in
which treatment decisions are based not only on the best
available evidence but also on the patients’ health goals,
preferences, and values.
I B-NR
2. Patients considering implantation of a new ICD or
replacement of an existing ICD for a low battery should
be informed of their individual risk of SCD and
nonsudden death from HF or noncardiac conditions and
the effectiveness, safety, and potential complications of
the ICD in light of their health goals, preferences and
values.
Terminal Care
COR LOE Recommendations for Terminal Care
I C-EO
1. At the time of ICD implantation or replacement, and
during advance care planning, patients should be
informed that their ICD shock therapy can be
deactivated at any time if it is consistent with their
goals and preferences.
I C-EO
2. In patients with refractory HF symptoms, refractory
sustained VA, or nearing the end of life from other
illness, clinicians should discuss ICD shock
deactivation and consider the patients’ goals and
preferences.
9New
Terminal Care
Cost and Value Considerations
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COR LOERecommendations for Secondary Prevention of SCD in Patients With
Ischemic Heart Disease
Value Statement: Intermediate Value
(LOE: B-R)
2. A transvenous ICD provides intermediate value in the secondaryprevention of SCD particularly when the patient’s risk of death due toa VA is deemed high and the risk of nonarrhythmic death (eithercardiac or noncardiac) is deemed low based on the patient’s burdenof comorbidities and functional status.
COR LOERecommendations for Primary Prevention of SCD in Patients With
Ischemic Heart Disease
Value Statement: High Value(LOE: B-R)
3. A transvenous ICD provides high value in the primary prevention ofSCD particularly when the patient’s risk of death due to a VA isdeemed high and the risk of nonarrhythmic death (either cardiac ornoncardiac) is deemed low based on the patient’s burden ofcomorbidities and functional status.
New
ICDs Primary and Secondary Prevention trials
Cost and Value Considerations
However…Despite Guidelines…
…Sudden Cardiac Death Remains a Daunting Problem
Risk Assessment Identifies Only a Very Small Portion of allFuture Cardiac Arrests…
Wellens et al, Eur Heart J. 2014
Appropriate ICD Therapies in RCTs
Exner D, Curr Opinion Cardiol 2008
only a 20-30% receive an appropriate therapy during a follow up 4-5 years
Appropriate ICD Therapies in Real - World Setting
Sabbag et al, Heart Rhythm 2015
Prognostic Models for Assessing SCD: Hopeless Case?
❖ Inability to identify most cardiac arrest victims before the event…
The Development of Minimally Invasive Devices
The Development of Better Strategies…