Updates in the 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

The 2022 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias (VA) and the Prevention of Sudden Cardiac Death (SCD) include recommendations aimed at improving the quality of life of patients. Here is a summary of the new sections and concepts, as well as some of the updates contained in this document published by the European Society of Cardiology (ESC).

We have included the corresponding objective numbers so that you can easily locate the complete topic.

Diagnostic provocative tests (5.1.3.5). The Guidelines suggest the following intravenous tests:

Ajmaline. Indicated when there is a family history of Brugada Syndrome (BrS) or Sudden Arrhythmic Death Syndrome (SADS). Also recommended for patients with resuscitated cardiac arrest (CA) without structural heart disease (SHD).

Flecainide. Same conditions as for Ajmaline.

Epinephrine. Recommended for patients with

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) and those with resuscitated CA with or without SHD when an exercise test is not feasible. Also indicated in cases of a family history of SADS.

Acetylcholine. Used when there is suspicion of coronary vasospasm.

Genetic testing (5.1.4). The diagnostic utility of many previous genetic associations has been called into question. Therefore, the Guidelines do not recommend including questionable genes in routine diagnostic panels. Genetic and clinical testing should only be conducted by multidisciplinary teams that include professionals trained to provide counseling on the implications and uncertainty of results, as well as experienced cardiologists capable of directing testing toward the correct phenotype. A negative result does not exclude a diagnosis and should not be used for this purpose.

Diagnostic evaluation of the initial symptoms of ventricular arrhythmia in patients without known heart disease (5.2).Ventricular arrhythmias (VA) and sudden cardiac death (SCD) are commonly the initial manifestations of a previously unknown heart condition. The Guidelines suggest providing a comprehensive diagnostic evaluation for five common scenarios:

Scenario 1: Incidental finding of non-sustained ventricular tachycardia.

Scenario 2: Initial presentation of sustained monomorphic ventricular tachycardia.

Scenario 3: When the patient is a survivor of sudden cardiac arrest.

Scenario 4: When the patient is a victim of sudden death.

Scenario 5: Evaluation of relatives of individuals who died from sudden arrhythmic death syndrome.

Management of patients with electrical storm (6.1.3). These are some of the recommendations included in the Guidelines for these patients:

• Mild to moderate sedation is recommended in patients with electrical storm to alleviate psychological distress and reduce sympathetic tone.
• Antiarrhythmic therapy with beta-blockers (non-selective preferred), in combination with intravenous amiodarone, is recommended in patients with structural heart disease (SHD) and electrical storm unless contraindicated.
• Intravenous magnesium with potassium supplementation is recommended in patients with Torsades de Pointes (TdP).
• Isoproterenol or transvenous pacing to increase heart rate is recommended in patients with acquired Long QT Syndrome (LQTS) and recurrent TdP despite correction of precipitating conditions and magnesium.
• Catheter ablation is recommended in patients presenting with incessant ventricular tachycardia (VT) or electrical storm due to sustained monomorphic ventricular tachycardia (SMVT) refractory to antiarrhythmic drugs (AADs).

Special aspects of device therapy (6.2.3).

• Optimization of implantable cardioverter defibrillator (ICD) programming is recommended to avoid inappropriate and unnecessary therapies and to reduce mortality.
• In patients with single- or dual-chamber ICDs without indications for bradycardia pacing, it is recommended to minimize ventricular pacing.
• Prolonged detection settings are recommended, with duration criteria of at least 6-12 seconds or 30 intervals.
• In primary prevention ICD patients, it is recommended to program the slowest tachycardia therapy zone limit to ≥188 beats per minute.
• At least one antitachycardia pacing therapy is recommended for all tachycardia zones in patients with structural heart disease.
• Programming algorithms to discriminate between supraventricular tachycardia (SVT) and ventricular tachycardia (VT) for tachycardias with rates up to 230 beats per minute is recommended.
• Activation of lead failure alerts is recommended.
• Remote monitoring is recommended to reduce the incidence of inappropriate shocks.
• As the first attempt, burst antitachycardia pacing is recommended over ramp antitachycardia pacing.
• For subcutaneous implantable cardioverter defibrillators (S-ICDs), a dual detection zone configuration is recommended with activation of the discrimination algorithm in the lower conditional shock zone.

Here is a selection of some of the most relevant new recommendations:

Public basic life support and access to AEDs.It is recommended that public-access defibrillation be available in places where the likelihood of a cardiac arrest is higher. Promoting community training in basic life support is recommended to increase the rate of CPR performed by bystanders and the use of automated external defibrillators (AEDs).

Treatment of ventricular arrhythmia (VA). Continuous electrical cardioversion is recommended as the first-line treatment for patients presenting with tolerated sustained monomorphic ventricular tachycardia (SMVT), provided that the risk of anesthesia and sedation is low. Optimal medical treatment is indicated, including angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors (ARNIs), mineralocorticoid receptor antagonists (MRAs), beta-blockers, and sodium-glucose co-transporter 2 (SGLT2) inhibitors in all patients with heart failure and reduced ejection fraction (EF).

The implantation of an automatic defibrillator is recommended only in patients with an expectation of good-quality survival exceeding 1 year.

Coronary Artery Disease (CAD). In patients with coronary artery disease (CAD) and recurrent, symptomatic sustained monomorphic ventricular tachycardia (SMVT), or implantable cardioverter-defibrillator (ICD) shocks for SMVT despite chronic amiodarone therapy, catheter ablation is recommended instead of increasing antiarrhythmic drug therapy. In patients with anomalous aortic origin of a coronary artery and a history of aborted cardiac arrest, it is also recommended to perform cardiac stress testing during physical exercise, in addition to a cardiopulmonary exercise test after surgery.

Idiopathic Ventricular Fibrillation (IVF).It is recommended to diagnose idiopathic ventricular fibrillation in survivors of sudden cardiac arrest, preferably with documentation of VF, after excluding an underlying structural, channelopathic, metabolic, or toxicological aetiology.

Brugada syndrome (BrS).Genetic testing for the SCN5A gene is recommended for probands with Brugada Syndrome.

Short QT Syndrome (SQTS).The 2022 Guidelines suggest the suitability of genetic testing in patients diagnosed with SQTS.

We hope this information is useful for you to stay updated on the 2022 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.