2017 AHA/ACC/HRS Ventricular Arrhythmias and Sudden Cardiac Death Guideline. Top Ten Messages. Eleftherios M Kallergis, MD, PhD, FESC

Transcription

1 2017 AHA/ACC/HRS Ventricular Arrhythmias and Sudden Cardiac Death Guideline Top Ten Messages Eleftherios M Kallergis, MD, PhD, FESC Cadiology Department - Heraklion University Hospital

2 No actual or potential conflict of interest in relation to this program/presentation

3 Sudden Cardiac Death: A 2400-year-old Diagnosis? those who are subject to frequent and severe fainting attacks without obvious cause die suddenly

4 The Scale of the Problem

5 The Scale of the Problem NASPE 2001, CDC 2001, American Cancer Society 2001

6 Sudden Cardiac Death 6:02 AM 6:05 AM 6:07 AM 6:11 AM Bayes de Luna et al. Am Heart J. 1989

7 An Unequal Fight

8 Winning Strategies

9 2017 AHA/ACC/HRS Guidelines

10 A depressed ventricular function remains the major risk marker for SCD 1

11 The majority of SCD victims Wellens et al, Eur Heart J. 2014

12 The role of other factors needs to be evaluated Chough S, Int J Cardiol 2017

13 2 Genetic Testing and Counseling COR LOE Recommendation for Genetic Counselling 1. In patients and family members in whom genetic testing for risk stratification I C-EO for SCA/SCD is recommended, genetic counseling is beneficial. COR LOE Recommendations for Idiopathic Polymorphic VT/VF 1. In young patients (<40 years of age) with unexplained SCA, unexplained near I B-NR drowning, or recurrent exertional syncope, who do not have ischemic or other structural heart disease, further evaluation for genetic arrhythmia syndromes is recommended.

14 Genetic Testing and Counseling COR LOE Recommendations for Postmortem Evaluation of SCD 1. In victims of SCD without obvious causes, a I B-NR standardized cardiac-specific autopsy is recommended. 2. In first-degree relatives of SCD victims who were 40 I B-NR years of age or younger, cardiac evaluation is recommended, with genetic counseling and genetic testing performed as indicated by clinical findings. 3. In victims of SCD with an autopsy that implicates a potentially heritable cardiomyopathy or absence of IIa B-NR structural disease, suggesting a potential cardiac channelopathy, postmortem genetic testing is reasonable. 4. In victims of SCD with a previously-identified phenotype for a genetic arrhythmia-associated IIa C-LD disorder, but without genotyping prior to death, postmortem genetic testing can be useful for the purpose of family risk profiling.

15 The predisposition to die suddenly is written in the genes!

16 Give me your genetic card I ll give you the treatment

17 3 The importance of medical therapy for the prevention of SCD COR LOE Recommendation for Pharmacological Prevention of SCD New 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.

18 Evidence-based medications can reduce the risk of SCD 2015 SCD ESC Guidelines 2016 HF ESC ACC/AHA Guidelines

19 Evidence-based medications can reduce the risk of SCD The decline in the rate of SCD by 44% paralleled the increasing use of evidence-based pharmacotherapies Shen et al, N Engl J Med 2017

20 Time to Optimize Guideline-Directed Medical Therapy DeFilippis et al; Circ Heart Fail. 2017

21 4 ICDs in Non-Ischaemic Cardiomyopathy keep this recommendation Class I COR LOE Recommendations for Primary Prevention of SCD in Patients With NICM 1. In patients with NICM, HF with NYHA class II III symptoms and an LVEF of 35% I A or less, despite GDMT, an ICD is recommended if meaningful survival of greater than 1 year is expected. 2. In patients with NICM due to a Lamin A/C mutation who have 2 or more risk IIa B-NR factors (NSVT, LVEF <45%, nonmissense mutation, and male sex), an ICD can be beneficial if meaningful survival of greater than 1 year is expected.

22 DANISH study 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

23 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

24 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

25 Ischaemic Heart Disease and Sustained Monomorphic VT 5 COR III: No Benefit LOE C-LD Recommendations for Treatment of Recurrent VA in Patients With Ischemic Heart Disease In patients with ischemic heart disease and sustained monomorphic VT, coronary recurrent VT. revascularization alone is an ineffective therapy to prevent Specific therapies such as antiarrhythmic medications or ablation may be needed to prevent recurrence

26 Catheter Ablation is an Important Treatment Option 6 The guideline provides updated recommendations on catheter ablation of ventricular arrhythmias from the most benign (premature ventricular contractions) to the most ominous (ventricular fibrillation).

27 The Randomized VANISH trial Sapp JL, et al. N Engl J Med. 2016

28 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 or declining ventricular function suspected to be due to frequent PVCs (generally >15% of beats and predominately of 1 morphology) and for whom antiarrhythmic medications are ineffective, not tolerated, or not the 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 recurrent arrhythmias, and improve symptoms and LV function.

29 Catheter Ablation in Brugada Syndrome COR LOE Recommendations for Brugada Syndrome 3. In patients with Brugada syndrome experiencing recurrent ICD shocks I B-NR for polymorphic VT, intensification of therapy with quinidine or catheter ablation is recommended. COR LOE Recommendations for Brugada Syndrome I B-NR 4. In patients with spontaneous type 1 Brugada electrocardiographic pattern and symptomatic VA who either are not candidates for or decline an ICD, quinidine or catheter ablation is recommended. Pappone et al. Circulation: Arrhythmia and Electrophysiology. 2017

30 7 Different Types of Defibrillators are Reviewed COR I IIa LOE B-NR B-NR Recommendations for Subcutaneous Implantable Cardioverter- Defibrillator 1. In patients who meet criteria for an ICD who have inadequate vascular access or are at high risk for infection, and in whom pacing for bradycardia or VT termination or as part of CRT is neither needed nor anticipated, a subcutaneous implantable cardioverter-defibrillator is recommended. 2. In patients who meet indication for an ICD, implantation of a subcutaneous implantable cardioverter-defibrillator is reasonable if pacing for bradycardia or VT termination or as part 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 is required, a subcutaneous implantable cardioverterdefibrillator should not be implanted.

31 Wearable Cardioverter-Defibrillator COR IIa IIb LOE B-NR B-NR Recommendations for Wearable Cardioverter-Defibrillator 1. In patients with an ICD and a history of SCA or sustained VA in whom removal of the ICD is required (as with infection), the wearable cardioverter-defibrillator is reasonable for the prevention of SCD 2. In patients at an increased risk of SCD but who are not ineligible for an ICD, such as awaiting cardiac transplant, having an LVEF of 35% or less and are within 40 days from an MI, or have newly diagnosed NICM, revascularization within the past 90 days, myocarditis or secondary cardiomyopathy or a systemic infection, wearable cardioverter-defibrillator may be reasonable.

32 The importance of shared decision making 8 COR LOE Recommendations for Shared Decision-Making I I B-NR 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. 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.

33 Terminal Care 9 New COR LOE Recommendations for Terminal Care I I C-EO 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. 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.

34 Terminal Care

35 Cost and Value Considerations 10 COR LOE Value Statement: Intermediate Value (LOE: B-R) Recommendations for Secondary Prevention of SCD in Patients With Ischemic Heart Disease 2. A transvenous ICD provides intermediate value in the secondary prevention of SCD particularly when the patient s risk of death due to a VA is deemed high and the risk of nonarrhythmic death (either cardiac or noncardiac) is deemed low based on the patient s burden of comorbidities and functional status. New COR LOE Value Statement: High Value (LOE: B-R) Recommendations for Primary Prevention of SCD in Patients With Ischemic Heart Disease 3. A transvenous ICD provides high value in the primary prevention of SCD particularly when the patient s risk of death due to a VA is deemed high and the risk of nonarrhythmic death (either cardiac or noncardiac) is deemed low based on the patient s burden of comorbidities and functional status.

36 ICDs Primary and Secondary Prevention trials

37 Cost and Value Considerations

38 However Despite Guidelines

39 Sudden Cardiac Death Remains a Daunting Problem

40 Risk Assessment Identifies Only a Very Small Portion of all Future Cardiac Arrests Wellens et al, Eur Heart J. 2014

41 Appropriate ICD Therapies in RCTs only a 20-30% receive an appropriate therapy during a follow up 4-5 years Exner D, Curr Opinion Cardiol 2008

42 Appropriate ICD Therapies in Real - World Setting Sabbag et al, Heart Rhythm 2015

43 Prognostic Models for Assessing SCD: Hopeless Case? Inability to identify most cardiac arrest victims before the event

44 The Development of Minimally Invasive Devices

45 The Development of Better Strategies