2015 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

BySteven Lome, MD

Year Released: 2015

Society: European Society of Cardiology (ESC)

Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC)

Update Info:

European update to the American College of Cardiology (ACC)/American Heart Association (AHA)/ESC 2006 Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.

Summary:

Cardiovascular (CV) mortality has decreased across high-income countries in the past 2 decades as preventive measures to reduce the burden of coronary artery disease (CAD) and heart failure (HF) have been adopted.

Despite the decrease in mortality, approximately 17 million deaths attributed to cardiovascular diseases (CVD) occur worldwide each year. Approximately 25% of those deaths are a result of sudden cardiac death (SCD).

SCD occurs more frequently in men than in women, with rates ranging from 1.4 per 100,000 person-years in women to 6.68 per 100,000 person-years in men. Approximately 50% of cardiac arrests occur in individuals without a known heart disease, but most have undiagnosed ischemic heart disease.

Screening

The authors of the guidelines have acknowledged that the cost-benefit assessment of electrocardiographic (ECG) population screening is largely influenced by the cost of identifying a single affected individual.

Estimates in the United States suggest costs for screening athletes — a large population — range from $300 million to $2 billion per year. Overall, the authors write that they cannot provide recommendations for population screening because the consequences of screening strategies that detect a still-undefined number of “false positives” and miss an unknown percentage of affected cases have not been established. However, the authors identify that the inability to derive a recommendation from the evidence obtained from existing screening programs illustrates the need for further work to collect quantitative data on the cost-benefit profile of performing ECG screening in different populations and in different health care systems and settings.

The guidelines do support the existing recommendations for pre-participation screening in athletes.

Family screening of first-degree relatives of victims of sudden death is recommended. The guidelines state it is an important intervention to identify individuals at risk, advise on available treatment and adequately prevent sudden death.

Therapies

The guidelines recommend cardiac resynchronization therapy (CRT) to reduce all-cause mortality in patients with a left ventricular ejection fraction (LVEF) ≤ 35% and left bundle branch block (LBBB) despite at least 3 months of optimal pharmacological therapy, and for those who are expected to survive at least 1 year with good functional status.

Additionally, pharmacological therapy with angiotensin-converting enzyme (ACE) inhibitors, beta-blockers and mineralocorticoid receptor antagonists (MRAs) is recommended in patients with HF with systolic dysfunction (LVEF ≤ 35%-40%) to reduce total mortality and SCD.