New Guidelines Focus on Ventricular Arrhythmias, Sudden Cardiac Death Prevention
The ACC, along with the American Heart Association and the Heart Rhythm Society, have published new guidelines for the treatment of adult patients with ventricular arrhythmias (VA) or who are at risk for sudden cardiac death. The new guidelines replace the 2006 ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.
Overall, the new guidelines provide recommendations regarding general evaluation of patients with documented or suspected VA; treatments, therapies and prevention of VA; acute management of specific VA; and VA in the structurally normal heart. They also provide guidance on VA and sudden cardiac death related to special populations, including athletes, pregnancy, older patients with comorbidities, valvular heart disease, adult congenital heart disease, etc.
Recommendations on the use of implantable cardiac defibrillators (ICDs) in patients with left ventricular assist devices, use of subcutaneous ICDs, and the role of catheter ablation of ventricular arrhythmias are also provided in the new guidelines. Of note, “recommendations for interventional therapies, including ablation and the implantation of devices, apply only if these therapies can be implemented by qualified clinicians, such that outcomes consistent with published literature are a reasonable expectation.” In addition, all recommendations related to ICDs require that a patient have a chance of meaningful survival of greater than one year before one is considered.
Ongoing management of VA and sudden cardiac death risk related to specific disease states is also covered in the new guidelines. For example, much needed guidance on the use of ICDs in non-ischemic cardiomyopathy (NICM) patients is included. The DANISH trial had raised questions about the role of primary prevention ICDs in this patient population. In general, the authors note that it is “imperative” for all patients with NICM to be on guideline-directed management and therapy for heart failure for at least three months before primary prevention ICD is offered.
Other highlights include several recommendations on genetic counseling and genetic testing to help inform clinical practice. The guidelines also stress the importance of a shared decision-making approach to treatment decisions that takes into account a patient’s health goals, preferences and values. For ICDs, patients should be informed of their individual risk of sudden cardiac death and non-sudden death from heart failure or non-cardiac conditions, and the effectiveness and potential complications of the ICD. In patients nearing the end of life from other illness, clinicians should discuss ICD shock deactivation as they reassess their patients’ goals and preferences.
For the first time, these new guidelines also include a section on cost and value considerations, specifically involving strength of evidence surrounding ICDs and cost-effectiveness. For example, a transvenous ICD is recommended to provide high value in the primary prevention of sudden cardiac death, particularly when a patient’s risk of death due to VA is “deemed high and the risk of non-arrhythmic death (either cardiac or non-cardiac) is deemed low” based on comorbidities and functional status. Similarly, a transvenous ICD is recommended to provide intermediate value in the secondary prevention of SCD.
Moving forward, the guideline authors acknowledge that despite the substantial progress in recognizing individuals at risk for sudden cardiac death and the prevention and treatment of sudden cardiac death and ventricular arrhythmias, more research is still needed to better define which patients among all currently ICD-eligible patients are most likely to benefit from an ICD, to define the role of the ICD in patient subgroups not well-represented in the pivotal ICD trials. Additionally, there is a need to develop approaches to prevent sudden death in the large population of patients who do not meet present indications for an ICD, but account for most cases of sudden cardiac death. They highlight the critical need for research funding in these areas.
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