Top Things to Know: 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
Published: October 30, 2017
- Sudden Cardiac Arrest, and its most common consequence, sudden cardiac death, constitute major public health problems, accounting for approximately 50% of all cardiovascular deaths.
- Implantable cardioverter-defibrillator (ICDs) are the mainstay therapy for protecting high risk patients from sudden cardiac death. A depressed ventricular function remains the major risk marker for sudden cardiac death in patients with heart disease who have not had a sustained ventricular arrhythmia. ICDs are not warranted for patients who are not expected to survive one year with good quality of life.
- The guideline highlights the importance of medical therapy for the prevention of SCD in patients with heart failure.
- There is much-needed guidance on the use of ICDs in patients with non-ischemic cardiomyopathy. Patients with dilated cardiomyopathy whose heart is functioning at 35% or less capacity and who are on good medical therapy should be counseled about an implantable defibrillator.
- For the first time, recommendations on terminal care are highlighted in the guideline. In patients with refractory heart failure symptoms, refractory sustained life-threatening arrhythmias, or nearing the end of life from other illness, clinicians should discuss defibrillator shock deactivation and consider the patient’s goals and preferences.
- Specific risk assessment for sudden death is warranted in patients with cardiomyopathies with important specific considerations in patients with hypertrophic cardiomyopathy, sarcoidosis, arrhythmogenic cardiomyopathy and neuromuscular disease.
- This is the first guideline to include value statements based off cost-effectiveness data. A level of value was assigned to 2 recommendations in this guideline.
- There are numerous recommendations on genetic counseling and genetic testing that should help inform clinical practice. Genetic testing is refining the identification of sudden death syndromes and is helpful in guiding therapy in some specific syndromes. The guideline highlights that genetic testing can have profound implications for patients and their families and should be combined with genetic counseling. There is also emphasis that sudden cardiac death in the young should prompt a careful evaluation with autopsy and evaluation of family members for potential arrhythmogenic genetic syndromes.
- The importance of shared decision making and patient centered care is endorsed and emphasized in this guideline, as part of the general care of patients at risk of VA and SCD.
- Several knowledge gaps need to be addressed, despite the numerous advances in risk stratification for SCD and prevention and treatment of SCD and VA. Increasing research funding in this area, through existing and new mechanisms is critically important.
Citation
Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published online ahead of print October 30, 2017]. Circulation. doi: 10.1161/CIR.0000000000000549.