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New ESC Guidelines published on the management of ventricular arrhythmias and prevention of sudden cardiac death

ESC Congress News 2015 - London

The new ESC Guidelines for the management of patients with ventricular arrhythmias (VA) and the prevention of sudden cardiac death (SCD), written by 18 Task Force members and supported by 810 references, are very broad and comprehensive. The document had 74 peer reviewers, and it was our privilege to act as review coordinators.

Sudden Cardiac Death and Resuscitation
Acute Cardiac Care

Access the Guidelines here

Philippe Kolh Professor of Biochemistry and Physiology University of Liège Liège, Belgium Gregory Y H Lip Professor of Cardiovascular Medicine University of Birmingham United KingdomThe new ESC Guidelines for the management of patients with ventricular arrhythmias (VA) and the prevention of sudden cardiac death (SCD), written by 18 Task Force members and supported by 810 references, are very broad and comprehensive. The document had 74 peer reviewers, and it was our privilege to act as review coordinators.

The importance and timeliness of these guidelines cannot be overestimated. Indeed, although cardiovascular mortality has decreased in high-income countries, cardiovascular diseases are responsible for approximately 17 million deaths every year in the world, approximately 25% of which are SCD.

The risk of SCD is higher in men than in women, and it increases with age because of the higher prevalence of coronary artery disease (CAD). Cardiac diseases associated with SCD differ in young and older individuals. In the young, there is a predominance of channelopathies and cardiomyopathies, myocarditis and substance abuse, while in older populations chronic degenerative diseases, such as CAD, valvular heart diseases and heart failure, predominate.

The first part of the document, which comprises 14 sections, covers epidemiology and future perspectives for the prevention of SCD. Therapies for VA, including pharmacotherapy, device implantation and interventional treatment, are then broadly discussed. Specific chapters cover the management of VA and prevention of SCD in patients with CAD, left ventricular dysfunction with or without HF, cardiomyopathies, or structurally normal hearts.

A specific section provides recommendations for patients with inherited primary arrhythmia syndromes, including long QT, short QT, Brugada, and early repolarisation syndromes. A subsequent chapter covers arrhythmias in paediatric and adult patients with congenital heart disease. A large section provides recommendation in selected populations, such as athletes, psychiatric, neurological, or pregnant patients, those with obstructive sleep apnoea, or patients with Wolff-Parkinson-White syndrome. The guidelines end with a list of significant gaps in evidence, which will certainly stimulate future research.

Let us emphasise some particular sections of this document. The guidelines have a well developed section on the screening of families in which there is a sudden death, and the workup of patients at high risk. Currently, as the authors emphasise, only 40% of family members are screened, partially due to a lack of adequate screening infrastructure, but also because of the anxiety and distress associated with personal experience. Indications for autopsy and molecular autopsy in sudden death victims are also detailed.

With the exception of beta-blockers, the guidelines emphasise that currently available anti-arrhythmic drugs have not been shown in randomised trials to be effective in the primary management of patients with life-threatening VA or in prevention of SCD, while each drug has a significant potential for causing adverse events, including pro-arrhythmia.

In addition to recommendations on ICDs, in line with previous guidelines and with an excellent discussion of current evidence, there are, for the first time, recommendations on subcutaneous ICD and wearable cardioverter defibrillators. Public access defibrillation is also covered. Interventional therapy, through catheter ablation or anti-arrhythmic surgery, is well addressed.

Of note, the CRT chapter deserves particular attention, with a good discussion on whether left bundle branch block (LBBB) /non-LBBB morphologies are important discriminators or if the absolute QRS duration is most important. Recommendations on the use of CRT for the primary prevention of SCD are provided, according to the New York Heart Association functional class of the patient and the presence of sinus rhythm vs. atrial fibrillation.

Useful algorithms provide a practical approach to investigation and management. Sections on the cardiomyopathies and channelopathies in the guidelines are comprehensive and detailed.

In conclusion, these ESC Guidelines are timely, considering the new insights into the natural history of diseases predisposing to SCD and the completion of major studies likely to have an impact on management strategies for heart failure involving both drug and device therapies. With a clinical perspective, the document is appropriately divided in sections covering specific topics, with emphasis on the need for risk evaluation schemes and treatments tailored in consideration of co-morbidities, limitation of life expectancy and other circumstances.

Access all ESC Clinical Practice Guidelines here

Notes to editor

About the European Society of Cardiology
The European Society of Cardiology (ESC) represents more than 90 000 cardiology professionals across Europe and worldwide. Its mission is to reduce the burden of cardiovascular disease in Europe.
About ESC Congress 2015
ESC Congress is the world’s largest and most influential cardiovascular event contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2015 takes place 29 August to 2 September at ExCel London in London, UK. Access the scientific programme.

To access all the scientific resources from the sessions during the congress, visit ESC Congress 365.