Elsevier

The Lancet

Volume 380, Issue 9852, 27 October–2 November 2012, Pages 1520-1529
The Lancet

Series
Ventricular arrhythmias and sudden cardiac death

https://doi.org/10.1016/S0140-6736(12)61413-5Get rights and content

Summary

Management strategies for ventricular arrhythmias are guided by the risk of sudden death and severity of symptoms. Patients with a substantial risk of sudden death usually need an implantable cardioverter defibrillator (ICD). Although ICDs effectively end most episodes of ventricular tachycardia or ventricular fibrillation and decrease mortality in specific populations of patients, they have inherent risks and limitations. Generally, antiarrhythmic drugs do not provide sufficient protection from sudden death, but do have a role in reducing arrhythmias that cause symptoms. Catheter ablation is likewise important for reducing the frequency of spontaneous arrhythmias and is curative for some patients, usually those with idiopathic arrhythmias and no heart disease. Arrhythmia surgery is now infrequent, offered by only a few specialised centres for refractory arrhythmias. Advances in understanding of genetic arrhythmia syndromes and in technology for mapping and ablation of ventricular arrhythmias, and enhanced algorithms in implantable devices for rhythm management, have contributed to improved outcomes.

Introduction

Ventricular arrhythmias are an important cause of morbidity and sudden death in almost all forms of heart disease. Assessment of the risk of sudden death and effective prevention are the main issues in patients with these arrhythmias. Presence of structural heart disease or genetic arrhythmia syndromes frequently impart a clinically significant risk, and in these cases an implantable cardioverter defibrillator (ICD) should be considered. ICDs effectively end most episodes of ventricular tachycardia or ventricular fibrillation and reduce total mortality in high-risk groups of patients who have not yet had a ventricular arrhythmia. Antiarrhythmic drugs and catheter ablation have important roles in reduction of symptomatic arrhythmias and shocks from ICDs. In this Series paper, we address common causes of ventricular arrhythmias and arrhythmic sudden death and approaches to management that are based on patient characteristics.

Section snippets

Sudden cardiac death

In Europe and North America, 50–100 sudden unexpected cardiac deaths occur per 100 000 population every year.1, 2 The incidence decreases from 1 per 1000 population for adults older than 35 years to 1 per 100 000 for those younger than 35 years.3 About half these events are attributable to ventricular tachycardia or ventricular fibrillation. For unclear reasons, the proportion of patients with pulseless electrical activity or asystole has increased over the past two decades.4 Overall, less than

Ventricular arrhythmias

Features identified by electrocardiogram (ECG) often suggest the mechanism and cardiac site of origin of ventricular tachycardia (figure 1).6 Ventricular tachycardia is often defined as sustained if it lasts longer than 30 s, produces syncope or cardiac arrest, or needs cardioversion or pacing from an ICD for cessation.

Polymorphic ventricular tachycardia has a continually changing QRS axis, suggesting a varying ventricular activation sequence (figure 1). A fixed anatomic substrate is not

General characteristics

Many single gene mutations have been identified that cause either arrhythmias and sudden death by disruption of cardiac ion channel function (channelopathies), or cardiomyopathy. Most mutations are uncommon, but when an otherwise healthy individual develops arrhythmia symptoms or after the sudden cardiac death of a relative, the first point of medical contact is often the family physician. The ECG is an important screening method, but abnormalities can be subtle and vary from day to day in some

Symptomatic arrhythmia

Ventricular arrhythmias might present with palpitations, presyncope, syncope, or cardiac arrest. Prognosis and risk of sudden death are largely determined by the nature of the underlying heart disease (figure 3). History and physical examination should focus on identification of heart disease. Potential aggravating factors should be sought and addressed, including electrolyte imbalances, stimulants such as caffeine and amphetamine analogues, and other drugs. An ECG often provides the first

Drug therapy for ventricular arrhythmias

Pharmacological therapies have an important role in the reduction of recurrent symptomatic arrhythmias.28 Many arrhythmias are provoked by exertion or aggravated by sympathetic stimulation, and respond favourably to β blockers. The favourable safety profile of these drugs makes them a first-line therapy for most symptomatic ventricular arrhythmias, despite reduced efficacy for arrhythmias associated with heart disease.

Membrane-active antiarrhythmic drugs that block cardiac ion channels have

ICDs

ICDs improve mortality in cardiac arrest survivors and in patients at risk for sudden death due to structural heart diseases.13, 50, 51 In all cases, ICDs are recommended only if the patient is expected to survive for at least 1 year with acceptable functional capacity.13 An ICD is appropriate, however, for patients with end-stage heart disease who are awaiting cardiac transplantation and are not in hospital, or who have left bundle branch block QRS prolongation such that they are likely to

Catheter ablation for ventricular tachycardia

Better understanding and definitions of cardiac anatomy from use of electroanatomic mapping systems, intracardiac echocardiography, and preacquired MRI or CT images incorporated into mapping systems (figure 4) are improving ablation therapy.6, 62 Percutaneous epicardial mapping and ablation achieved by insertion of a sheath and mapping catheter into the pericardial space is now possible.6, 63 Efficacy and risk of complications depends on the location of the ventricular tachycardia origin and

Future directions and conclusions

The primary focus of ventricular arrhythmia management is the assessment of subsequent risk of sudden death and its prevention, followed by management of symptomatic arrhythmias. Effective interventions have been defined for many common cardiac disorders, but assessment of risk in the rarer genetic syndromes is a challenge. Findings from ongoing studies continue to improve arrhythmia management and prevention of sudden death, and many advances are on the horizon. Treatments that specifically

Search strategy and selection criteria

We searched PubMed for articles published between Jan 1, 2005, and Dec 31, 2011, and the Cochrane library for those published between Jan 1, 2007, and Dec 31, 2011, with the search terms “Ventricular Tachycardia”, “Ventricular Arrhythmias”, or “Sudden Death” cross-referenced with “catheter ablation”, “implantable defibrillators”, and “specific diseases” for each section of the Series paper. We reviewed the reference lists of articles identified by the search and selected those deemed relevant.

References (85)

  • S Kumar et al.

    Electrophysiology-guided defibrillator implantation early after ST-elevation myocardial infarction

    Heart Rhythm

    (2010)
  • S Kumar et al.

    Effect of reperfusion time on inducible ventricular tachycardia early and spontaneous ventricular arrhythmias late after ST elevation myocardial infarction treated with primary percutaneous coronary intervention

    Heart Rhythm

    (2011)
  • B Olshansky et al.

    Syncope predicts the outcome of cardiomyopathy patients: analysis of the SCD-HeFT study

    J Am Coll Cardiol

    (2008)
  • JB van Rees et al.

    Inappropriate implantable cardioverter-defibrillator shocks: incidence, predictors, and impact on mortality

    J Am Coll Cardiol

    (2011)
  • J Mallidi et al.

    Meta-analysis of catheter ablation as an adjunct to medical therapy for treatment of ventricular tachycardia in patients with structural heart disease

    Heart Rhythm

    (2011)
  • B Schmidt et al.

    Catheter ablation for ventricular tachycardia after failed endocardial ablation: epicardial substrate or inappropriate endocardial ablation?

    Heart Rhythm

    (2010)
  • I Kosmidou et al.

    Role of repeat procedures for catheter ablation of postinfarction ventricular tachycardia

    Heart Rhythm

    (2011)
  • AP Wijnmaalen et al.

    Catheter ablation of ventricular tachycardia after left ventricular reconstructive surgery for ischemic cardiomyopathy

    Heart Rhythm

    (2012)
  • S Knecht et al.

    Long-term follow-up of idiopathic ventricular fibrillation ablation: a multicenter study

    J Am Coll Cardiol

    (2009)
  • C van der Werf et al.

    Flecainide therapy reduces exercise-induced ventricular arrhythmias in patients with catecholaminergic polymorphic ventricular tachycardia

    J Am Coll Cardiol

    (2011)
  • Y Michowitz et al.

    Hybrid procedures for epicardial catheter ablation of ventricular tachycardia: value of surgical access

    Heart Rhythm

    (2010)
  • E Perez-David et al.

    Noninvasive identification of ventricular tachycardia-related conducting channels using contrast-enhanced magnetic resonance imaging in patients with chronic myocardial infarction: comparison of signal intensity scar mapping and endocardial voltage mapping

    J Am Coll Cardiol

    (2011)
  • GI Fishman et al.

    Sudden cardiac death prediction and prevention: report from a National Heart, Lung, and Blood Institute and Heart Rhythm Society Workshop

    Circulation

    (2010)
  • JJ Goldberger et al.

    Risk stratification for arrhythmic sudden cardiac death: identifying the roadblocks

    Circulation

    (2011)
  • MJ Junttila et al.

    Risk markers of sudden cardiac death in standard 12-lead electrocardiograms

    Ann Med

    (2011)
  • C Teodorescu et al.

    Factors associated with pulseless electric activity versus ventricular fibrillation: the Oregon sudden unexpected death study

    Circulation

    (2010)
  • G Nichol et al.

    Regional variation in out-of-hospital cardiac arrest incidence and outcome

    JAMA

    (2008)
  • EM Aliot et al.

    EHRA/HRS expert consensus on catheter ablation of ventricular arrhythmias

    Europace

    (2009)
  • DM Roden

    Clinical practice: long-QT syndrome

    N Engl J Med

    (2008)
  • MJ Ackerman et al.

    HRS/EHRA expert consensus statement on the state of genetic testing for the channelopathies and cardiomyopathies: this document was developed as a partnership between the Heart Rhythm Society (HRS) and the European Heart Rhythm Association (EHRA)

    Europace

    (2011)
  • M Cerrone et al.

    Genetics of sudden death: focus on inherited channelopathies

    Eur Heart J

    (2011)
  • GM Vincent et al.

    High efficacy of beta-blockers in long-QT syndrome type 1: contribution of noncompliance and QT-prolonging drugs to the occurrence of beta-blocker treatment “failures”

    Circulation

    (2009)
  • AE Epstein et al.

    ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons

    Circulation

    (2008)
  • K Nademanee et al.

    Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium

    Circulation

    (2011)
  • N Derval et al.

    Prevalence and characteristics of early repolarization in the CASPER registry: cardiac arrest survivors with preserved ejection fraction registry

    J Am Coll Cardiol

    (2012)
  • AA Wilde et al.

    Left cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia

    N Engl J Med

    (2008)
  • A Barsheshet et al.

    Genetics of sudden cardiac death

    Curr Cardiol Rep

    (2011)
  • I Christiaans et al.

    Manifest disease, risk factors for sudden cardiac death, and cardiac events in a large nationwide cohort of predictively tested hypertrophic cardiomyopathy mutation carriers: determining the best cardiological screening strategy

    Eur Heart J

    (2011)
  • BJ Gersh et al.

    2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

    Circulation

    (2011)
  • RA Leonardi et al.

    Meta-analyses of septal reduction therapies for obstructive hypertrophic cardiomyopathy: comparative rates of overall mortality and sudden cardiac death after treatment

    Circ Cardiovasc Interv

    (2010)
  • FI Marcus et al.

    Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria

    Circulation

    (2010)
  • D Jacoby et al.

    Genetics of inherited cardiomyopathy

    Eur Heart J

    (2012)
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