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.

5

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).

6

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 .

7

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

8

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

10

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…