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.
SeriesVentricular arrhythmias and sudden cardiac death
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
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