Abstract

HomeCirculationVol. 138, No. 132017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUB2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society Sana M. Al-Khatib, MD, MHS, FACC, FAHA, FHRS, William G. Stevenson, MD, FACC, FAHA, FHRS, Michael J. Ackerman, MD, PhD, William J. Bryant, JD, LLM, David J. Callans, MD, FACC, FHRS, Anne B. Curtis, MD, FACC, FAHA, FHRS, Barbara J. Deal, MD, FACC, FAHA, Timm Dickfeld, MD, PhD, FHRS, Michael E. Field, MD, FACC, FAHA, FHRS, Gregg C. Fonarow, MD, FACC, FAHA, FHFSA, Anne M. Gillis, MD, FHRS, Christopher B. Granger, MD, FACC, FAHA, Stephen C. Hammill, MD, FACC, FHRS, Mark A. Hlatky, MD, FACC, FAHA, José A. Joglar, MD, FACC, FAHA, FHRS, G. Neal Kay, MD, Daniel D. Matlock, MD, MPH, Robert J. Myerburg, MD, FACC and Richard L. Page, MD, FACC, FAHA, FHRS Sana M. Al-KhatibSana M. Al-Khatib , William G. StevensonWilliam G. Stevenson , Michael J. AckermanMichael J. Ackerman , William J. BryantWilliam J. Bryant , David J. CallansDavid J. Callans , Anne B. CurtisAnne B. Curtis , Barbara J. DealBarbara J. Deal , Timm DickfeldTimm Dickfeld , Michael E. FieldMichael E. Field , Gregg C. FonarowGregg C. Fonarow , Anne M. GillisAnne M. Gillis , Christopher B. GrangerChristopher B. Granger , Stephen C. HammillStephen C. Hammill , Mark A. HlatkyMark A. Hlatky , José A. JoglarJosé A. Joglar , G. Neal KayG. Neal Kay , Daniel D. MatlockDaniel D. Matlock , Robert J. MyerburgRobert J. Myerburg and Richard L. PageRichard L. Page Originally published1 Aug 2018https://doi.org/10.1161/CIR.0000000000000548Circulation. 2018;138:e210–e271is corrected byCorrection to: 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm SocietyOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 1, 2018: Ahead of Print Table of ContentsPreamble e2111. Introduction e2131.1. Methodology and Evidence Review e2131.2. Organization of the Writing Committee e2131.3. Document Review and Approval e2141.4. Scope of the Guideline e2141.5. Abbreviations e2172. Epidemiology e2172.1. General Concepts e2172.1.1. Premature Ventricular Complexes and Nonsustained VT e2172.1.2. VT and VF During ACS e2192.1.3. Sustained VT and VF Not Associated With ACS e2192.2. Sudden Cardiac Death e2192.2.1. Incidence of SCD e2192.2.2. Population Subgroups and Risk Prediction e2203. General Evaluation of Patients With Documented or Suspected VA e2213.1. History and Physical Examination e2213.2. Noninvasive Evaluation e2223.2.1. 12-lead ECG and Exercise Testing e2223.2.2. Ambulatory Electrocardiography e2223.2.3. Implanted Cardiac Monitors e2223.2.4. Noninvasive Cardiac Imaging e2223.2.5. Biomarkers e2223.2.6. Genetic Considerations in Arrhythmia Syndromes e2223.3. Invasive Testing e2223.3.1. Invasive Cardiac Imaging: Cardiac Catheterization or CT Angiography e2223.3.2. Electrophysiological Study for VA e2234. Therapies for Treatment or Prevention of VA e2234.1. Medication Therapy e2234.2. Preventing SCD With HF Medications e2254.3. Surgery and Revascularization Procedures in Patients With Ischemic Heart Disease e2254.3.1. Surgery for Arrhythmia Management e2264.4. Autonomic Modulation e2265. Acute Management of Specific VA e2266. Ongoing Management of VA and SCD Risk Related to Specific Disease States e2286.1. Ischemic Heart Disease e2286.1.1. Secondary Prevention of SCD in Patients With Ischemic Heart Disease e2286.1.2. Primary Prevention of SCD in Patients With Ischemic Heart Disease e2296.1.3. Treatment and Prevention of Recurrent VA in Patients With Ischemic Heart Disease e2306.2. Nonischemic Cardiomyopathy e2316.2.1. Secondary Prevention of SCD in Patients With NICM e2316.2.2. Primary Prevention of SCD in Patients With NICM e2316.2.3. Treatment of Recurrent VA in Patients With NICM e2316.3. Arrhythmogenic Right Ventricular Cardiomyopathy e2326.4. Hypertrophic Cardiomyopathy e2336.5. Myocarditis e2356.6. Cardiac Sarcoidosis e2356.7. Heart Failure e2366.7.1. HF With Reduced Ejection Fraction e2366.7.2. Left Ventricular Assist Device e2366.7.3. ICD Use After Heart Transplantation e2366.8. Neuromuscular Disorders e2366.9. Cardiac Channelopathies e2376.9.1. Specific Cardiac Channelopathy Syndromes e2377. VA in the Structurally Normal Heart e2427.1. Outflow Tract and Atrioventricular Annular VA e2427.2. Papillary Muscle VA e2427.3. Interfascicular Reentrant VT (Belhassen Tachycardia) e2427.4. Idiopathic Polymorphic VT/VF e2428. PVC-Induced Cardiomyopathy e2439. VA and SCD Related to Specific Populations e2439.1. Pregnancy e2439.2. Older Patients With Comorbidities e2439.3. Medication-Induced Arrhythmias e2439.4. Adult Congenital Heart Disease e24310. Defibrillators Other than Transvenous ICDs e24610.1. Subcutaneous Implantable Cardioverter-Defibrillator e24610.2. Wearable Cardioverter-Defibrillator e24611. Special Considerations for Catheter Ablation e24612. Postmortem Evaluation of SCD e24613. Terminal Care e24614. Shared Decision-Making e24715. Cost and Value Considerations e24716. Quality of Life e24817. Evidence Gaps and Future Research Needs e248Appendix 1: Author Relationships With Industry and Other Entities (Relevant) e267Appendix 2: Reviewer Relationships With Industry and Other Entities (Comprehensive) e269PreambleSince 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA.Intended UsePractice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations may have a global impact. Although guidelines may be used to inform regulatory or payer decisions, their intent is to improve patients' quality of care and align with patients' interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.Clinical ImplementationGuideline-recommended management is effective only when followed by healthcare providers and patients. Adherence to recommendations can be enhanced by shared decision-making between healthcare providers and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities.Methodology and ModernizationThe ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations including the Institute of MedicineP-1,P-2 and on the basis of internal reevaluation. Similarly, the presentation and delivery of guidelines are reevaluated and modified on the basis of evolving technologies and other factors to facilitate optimal dissemination of information at the point of care to healthcare professionals.Toward this goal, this guideline heralds the evolved format of presenting guideline recommendations and associated text called "modular knowledge chunk format." Each modular "chunk" includes a table of related recommendations, a brief synopsis, recommendation-specific supportive text, and when appropriate, flow diagrams or additional tables. References are provided within the modular chunk itself to facilitate quick review. This format also will facilitate seamless updating of guidelines with focused updates as new evidence is published, and content tagging for rapid electronic retrieval of related recommendations on a topic of interest. This evolved format was instituted when this guideline was near completion; therefore the current document represents a transitional formatting that best suits the text as written. Future guidelines will fully implement this format, including provisions for limiting the amount of text in a guideline.Recognizing the importance of cost–value considerations in certain guidelines, when appropriate and feasible, an analysis of the value of a medication, device, or intervention may be performed in accordance with the ACC/AHA methodology.P-3To ensure that guideline recommendations remain current, new data are reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year cycles. Publication of new, potentially practice-changing study results that are relevant to an existing or new medication, device, or management strategy will prompt evaluation by the Task Force, in consultation with the relevant guideline writing committee, to determine whether a focused update should be commissioned. For additional information and policies regarding guideline development, we encourage readers to consult the ACC/AHA guideline methodology manualP-4 and other methodology articles.P-5–P-8Selection of Writing Committee MembersThe Task Force strives to avoid bias by selecting experts from a broad array of backgrounds. Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice. The Task Force may also invite organizations and professional societies with related interests and expertise to participate as partners, collaborators, or endorsers.Relationships With Industry and Other EntitiesThe ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence. The complete relationships with industry and other entities (RWI) policy can be found online. Appendix 1 of the current document lists writing committee members' relevant RWI. For the purposes of full transparency, writing committee members' comprehensive disclosure information is available online, as is the comprehensive disclosure information for the Task Force.Evidence Review and Evidence Review CommitteesWhen developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data.P-4–P-7 Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited.An independent evidence review committee (ERC) is commissioned when there are ≥1 questions deemed of utmost clinical importance that merit formal systematic review. This systematic review will strive to determine which patients are most likely to benefit from a test, medication, device, or treatment strategy and to what degree. Criteria for commissioning an ERC and formal systematic review include: a) the absence of a current authoritative systematic review; b) the feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline; c) the relevance to a substantial number of patients; and d) the likelihood that the findings can be translated into actionable recommendations. ERC members may include methodologists, epidemiologists, healthcare providers, and biostatisticians. When a formal systematic review has been commissioned, the recommendations developed by the writing committee on the basis of the systematic review are marked with "SR."Guideline-Directed Management and TherapyThe term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and pharmacological and procedural treatments. For these and all recommended medication treatment regimens, the reader should confirm the dosage by reviewing product insert material and evaluate the treatment regimen for contraindications and interactions. The recommendations are limited to medications, devices, and treatments approved for clinical use in the United States.Class of Recommendation and Level of EvidenceThe Class of Recommendation (COR) indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1).P-4,P-6,P-8Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)The reader is encouraged to consult the full-text guidelineP-9 for additional guidance and details about the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. The executive summary contains mainly the recommendations.Glenn N. Levine, MD, FACC, FAHAChair, ACC/AHA Task Force on Clinical Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this clinical practice guideline are, whenever possible, evidence-based. An initial extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted from April 2016 to September 2016. Key search words included, but were not limited, to the following: sudden cardiac death, ventricular tachycardia, ventricular fibrillation, premature ventricular contractions, implantable cardioverter-defibrillator, subcutaneous implantable cardioverter-defibrillator, wearable cardioverter-defibrillator, and catheter ablation. Additional relevant studies published through March 2017, during the guideline writing process, were also considered by the writing committee, and added to the evidence tables when appropriate. The final evidence tables are included in the Online Data Supplement and summarize the evidence used by the writing committee to formulate recommendations. Additionally, the writing committee reviewed documents related to ventricular arrhythmias (VA) and sudden cardiac death (SCD) previously published by the ACC, AHA, and the Heart Rhythm Society (HRS). References selected and published in this document are representative and not all-inclusive.As noted in the Preamble, an independent ERC was commissioned to perform a formal systematic review of 2 important clinical questions for which clear literature and prior guideline consensus were felt to be lacking or limited (Table 2). The results of the ERC review were considered by the writing committee for incorporation into this guideline. Concurrent with this process, writing committee members evaluated other published data relevant to the guideline. The findings of the ERC and the writing committee members were formally presented and discussed, then guideline recommendations were developed. The "Systematic Review for the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death" is published in conjunction with this guideline.S1.4-1Table 2. Systematic Review Questions on SCD PreventionQuestion NumberQuestionSection Number1For asymptomatic patients with Brugada syndrome, what is the association between an abnormal programmed ventricular stimulation study and SCD and other arrhythmia endpoints?6.9.1.3.2What is the impact of ICD implantation for primary prevention in older patients and patients with significant comorbidities?9.2.ICD indicates implantable cardioverter-defibrillator; and SCD, sudden cardiac death.The ACC and AHA have acknowledged the importance of value in health care and have called for eventual development of a Level of Value for clinical practice recommendations.S1.4-2 Available cost-effectiveness data were determined to be sufficient to support 2 specific recommendations in this guideline (see Sections 7.1.1 and 7.1.2). As a result, a Level of Value was assigned to those 2 recommendations on the basis of the "ACC/AHA Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures," as shown in Table 3.S1.4-2 Available quality of life (QoL) data were deemed to be insufficient to support specific recommendations in this guideline.Table 3. Proposed Integration of Level of Value Into Clinical Practice Guideline Recommendations*Level of ValueHigh value: Better outcomes at lower cost or ICER 1 year is expected; meaningful survival means that a patient has a reasonable quality of life and functional status.Although this document is aimed at the adult population (≥18 years of age) and offers no specific recommendations for pediatric patients, some of the literature on pediatric patients was examined. In some cases, the data from pediatric patients beyond infancy helped to inform this guideline.The writing committee recognized the importance of shared decision-making and patient-centered care and, when possible, it endeavored to formulate recommendations relevant to these important concepts. The importance of a shared decision-making process in which the patient, family, and clinicians discuss risks and benefits of diagnostic and treatment options and consider the patients' personal preferences is emphasized (see Section 15).In developing this guideline, the writing committee reviewed previously published guidelines and related statements. Table 4 contains a list of guidelines and statements deemed pertinent to this writing effort and is intended for use as a resource, obviating repetition of existing guideline recommendations.Table 4. Associated Guidelines and StatementsTitleOrganizationPublication Year (Reference)Guidelines SyncopeACC/AHA/HRS2017S1.4-10 Heart failureACCF/AHA2017S1.4-11 2016,S1.4-12 and 2013S1.4-13 Valvular heart diseaseAHA/ACC2017S1.4-14 and 2014S1.4-15 Supraventricular tachycardiaACC/AHA/HRS2015S1.4-16 Ventricular arrhythmias and the prevention of sudden cardiac deathESC2015S1.4-17 Guidelines for cardiopulmonary resuscitation and emergency cardiovascular careAHA2015S1.4-18 Atrial fibrillationAHA/ACC/HRS2014S1.4-19 Non–ST-elevation acute coronary syndromesAHA/ACC2014S1.4-20 Assessment of cardiovascular riskACC/AHA2013S1.4-21 ST-elevation myocardial infarctionACCF/AHA2013S1.4-22 Acute myocardial infarction in patients presenting with ST-segment elevationESC2012S1.4-23 Device-based therapies for cardiac rhythm abnormalitiesACCF/AHA/HRS2012S1.4-24 Coronary artery bypass graft surgeryACCF/AHA2011S1.4-25 Hypertrophic cardiomyopathyACCF/AHA2011S1.4-6 Percutaneous coronary interventionACCF/AHA/SCAI2011S1.4-26 Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular diseaseAHA/ACCF2011S1.4-27Scientific Statements Wearable cardioverter-defibrillator therapy for the prevention of sudden cardiac deathAHA2016S1.4-9 Optimal implantable cardioverter defibrillator programming and testingHRS/EHRA/APHRS/SOLAECE2016S1.4-8 Treatment of cardiac arrest: current status and future directions: strategies to improve cardiac arrest survivalIOM2015S1.4-28 Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalitiesACC/AHA2015S1.4-29 Ventricular arrhythmiasEHRA/HRS/APHRS2014S1.4-30 Arrhythmias in adult congenital heart diseasePACES/HRS2014S1.4-31 Implantable cardioverter-defibrillator therapy in patients who are not included or not well represented in clinical trialsHRS/ACC/AHA2014S1.4-32 Cardiac sarcoidosisHRS2014S1.4-33 Inherited primary arrhythmia syndromesHRS/EHRA/APHRS2013S1.4-34ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; APHRS, Asia Pacific Heart Rhythm Society; EHRA, European Heart Rhythm Association; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; PACES, Pediatric and Congenital Electrophysiology Society; SCAI, Society for Cardiovascular Angiography and Interventions; and, SOLAECE, Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia.During final production review of the guidelines, several recommendations were refined to better reflect the data and current recommended medical practice. These refinements were reviewed and approved by the writing committee, the Task Force, and ACC, AHA, and HRS organizational leadership. These recommendations were:Section 6.1.1., recommendation 1Section 6.1.3., recommendation 2Section 6.2.1., recommendation 1Section 6.9.1.4., recommendation 2Section 9.4., recommendation 6Readers should refer to these sections for the updated text.1.5. AbbreviationsAbbreviationMeaning/PhraseACSacute coronary syndromeCPRcardiopulmonary resuscitationCRTcardiac resynchronization therapyECGelectrocardiogramERCevidence review committeeGDMTguideline-directed management and therapyHCMhypertrophic cardiomyopathyHFheart failureHFpEFheart failure with preserved ejection fractionHFrEFheart failure with reduced ejection fractionICDimplantable cardioverter-defibrillatorLVleft ventricularLVADleft ventricular assist deviceLVEFleft ventricular ejection fractionMImyocardial infarctionNICMnonischemic cardiomyopathyNSVTnonsustained ventricular tachycardiaPCIpercutaneous coronary interventionPVCpremature ventricular complexQoLquality of lifeRCTrandomized controlled trialRVOTright ventricular outflow tractSCAsudden cardiac arrestSCDsudden cardiac deathVAventricular arrhythmiaVTventricular tachycardia2. Epidemiology2.1. General ConceptsTable 5. Table of Definitions of Commonly Used Terms in this DocumentTermDefinition or DescriptionVentricular tachycardiaS2.2.2-2Cardiac arrhythmia of ≥3 consecutive complexes originating in the ventricles at a rate >100 bpm (cycle length: 30 s or requiring termination due to hemodynamic compromise in 300 bpm (cycle length: <200 ms).Sudden cardiac arrestS2.2.2-2SCA is the sudden cessation of cardiac activity such that the victim becomes unresponsive, with either persisting gasping respirations or absence of any respiratory movements, and no signs of circulation as manifest by the absence of a perceptible pulse. An arrest is presumed to be of cardiac etiology unless it is known or likely to have been caused by trauma, drowning, respiratory failure or asphyxia, electrocution, drug overdose, or any other noncardiac cause.Sudden cardiac deathS2.2.2-2S