Ventricular tachycardia secondary prevention
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in Chief: Sara Zand, M.D.[2] Avirup Guha, M.B.B.S.[3]
Overview
Overview
Secondary prevention strategies following SCA and unstable VT include ICD implantation, and medications. Based on meta-analysis of AVID trial implantation of ICD for secondary prevention of ventricular arrhythmia was superior to antiarrhythmic drugs in patients who survived of sudden cardiac arrest or unstable VT. Before ICD implantation, the reversible causes of ventricular arrhythmia including myocardial ischemia, electrolyte disturbance, proarrhythmic medication effect may be corrected. ICD implantation improved outcome in well-tolerated VT and structurally heart disease. Among patients with ischemia heart disease and syncope due to inducible sustained monomorphic VT, ICD is recommended even if there is not other criteria for primary prevention.
Secondary prevention
Secondary prevention strategies following SCA and unstable VT include ICD implantation, and medications.
- Based on meta-analysis of AVID trial implantation of ICD for secondary prevention of ventricular arrhythmia was superior to antiarrhythmic drugs in patients who survived of sudden cardiac arrest or unstable VT.[1]
- Before ICD implantation, the reversible causes of ventricular arrhythmia including myocardial ischemia, electrolyte disturbance, proarrhythmic medication effect may be corrected.[2]
- ICD implantation improved outcome in well-tolerated VT and structurally heart disease.[3]
- VT ablation reduced recurrence of tachyarrhythmia, but the effect on long-term mortality was unknown.[4]
- Among patients with ischemia heart disease and syncope due to inducible sustained monomorphic VT, ICD is recommended even if there is not other criteria for primary prevention implantation of ICD.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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For Secondary Prevention of Coronary Artery Disease click here.
In medicine, prevention is any activity which reduces the burden of mortality or morbidity from disease. This takes place at primary, secondary and tertiary prevention levels.
- Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures.
- Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms.
- Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.
Prevention of substance use
In the area of substance-related harms, a number of prevention typologies have been proposed.
Gordon (1987) in the area of disease prevention, and later Kumpfer and Baxley (1997) in the area of substance use proposed a three-tiered preventive intervention classification system: universal, selective and indicated prevention. Amongst others, this typology has gained favour and is used by a.o. the US Institute of Medicine, the NIDA and the European Monitoring Centre for Drugs and Drug Addiction.
- Universal prevention addresses the entire population (national, local community, school, district) and aim to prevent or delay the abuse of alcohol, tobacco, and other drugs. All individuals, without screening, are provided with information and skills necessary to prevent the problem.
- Selective prevention focuses on groups whose risk of developing problems of alcohol abuse or dependence is above average. The subgroups may be distinguished by characteristics such as age, gender, family history, or economic status. For example, drug campaigns in recreational settings.
- Indicated prevention involves a screening process, and aims to identify individuals who exhibit early signs of substance abuse and other problem behaviours. Identifiers may include falling grades among students, known problem consumption or conduct disorders, alienation from parents, school, and positive peer groups etc.
Outside the scope of this three-tier model is Environmental prevention. Environmental prevention approaches are typically managed at the regulatory or community level, and focus on interventions to deter drug consumption. Prohibition and bans (e.g. smoking workplace bans, alcohol advertising bans) may be viewed as the ultimate environmental restriction. However, in practice environmental preventions programmes embrace various initiatives at the macro and micro level, from government monopolies for alcohol sales, through roadside sobriety or drug tests, worker/pupil/student drug testing, increased policing in sensitive settings (near schools, at rock festivals), and legislative guidelines aimed at precipitating punishments (warnings, penalties, fines).
References
- Gordon, R. (1987), ‘An operational classification of disease prevention’, in Steinberg, J. A. and Silverman, M. M. (eds.), Preventing Mental Disorders, Rockville, MD: U.S. Department of Health and Human Services, 1987.
- Kumpfer, K. L., and Baxley, G. B. (1997), ‘Drug abuse prevention: What works?’, National Institute on Drug Abuse, Rockville.
See also
Secondary prevention in patients with ischemic heart disease
| Recommendations for secondary prevention of sudden cardiac death in ischemic heart disease |
| ICD implantation (Class I, Level of Evidence B): |
|
❑ In patients with IHD and survivors of SCD due to VT, VF or hermodynamically unstable VT or incessant VT with irreversible cause, ICD should be implanted if survival is more than 1 year. |
| ICD implantation (Intermediate value statement, Level of Evidence B) : |
|
❑ In patients with higher risk of death due to ventricular arrhythmia and lower risk of non cardiac death due to other comorbidities, ICD implantation has intermediate value. |
| ICD implantation : (Class I, Level of Evidence B) |
|
❑ In patients with IHD and unexplained syncope with induction of sustained monomorphic VT in EPS, ICD implantation is recommended if life expectancy is more than 1 year |
Abbreviations:
VT: Ventricular tachycardia;
VF: Ventricular fibrillation;
ICD: Implantable cardioverter defibrillator
| The above table adopted from 2017 AHA/ACC/HRS Guideline |
|---|
| Secondary prevention in patients with IHD | |||||||||||||||||||||||||||||||||||||||||||||
| SCA survivor or sustained monomorph VT | Cardiac syncope | ||||||||||||||||||||||||||||||||||||||||||||
| Ischemia | LVEF≤35% | ||||||||||||||||||||||||||||||||||||||||||||
| Yes: revascularization, reassessment about SCD risk (class1) | NO:ICD candidate | ||||||||||||||||||||||||||||||||||||||||||||
| Yes:ICD (class1) | NO: medical therapy (class1) | Yes:ICD (CLASS1) | NO:EP study (class 2a) | ||||||||||||||||||||||||||||||||||||||||||
| Ventriculat arrhythmia induction | |||||||||||||||||||||||||||||||||||||||||||||
| Yes: ICD (class1) | NO: monitoring | ||||||||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2017 AHA/ACC/HRS Guideline |
|---|
Secondary prevention in patients with coronary spasm
- Coronary artery spasm is due to vasomotor dysfunction and may occur in the presence or absence of atherosclerosis process.[6]
- Vasospasm mat lead to ventricular arrhythmia, syncope, and sudden cardiac death.
- Prevention of vasospasm may include smoking cessation and using dihyropyridine calcium channel blocker with or without nitrate.
- In the presence of recurrent ventricular arrhythmia in spite of maximum doses of medications or survivors of SCA, implantation of ICD is recommended.[7]
| Recommendations for secondary prevention of sudden cardiac death in coronary spasm |
| ICD implantation (Class I, Level of Evidence B): |
|
❑ In patients with ventricular arrhythmia due to coronary artery spasm, vasodilator such as calcium channel blocker with maximum tolerated doses smoking cessation and is recommended |
| ICD implantation (Class IIa, Level of Evidence B) : |
|
❑ In survival of SCA due to coronary artery spasm with ineffective or not tolerated medications, ICD implantation is recommended if the survival is more than 1 year |
| ICD implantation : (Class IIb, Level of Evidence B) |
|
❑ In survival of SCA due to coronary artery spasm, ICD implantation in addition to medical therapy is recommended if life expectancy is more than 1 year |
Abbreviations:
ICD: Implantable cardioverter defibrillator;
SCA: Sudden cardiac arrest
| The above table adopted from 2017 AHA/ACC/HRS Guideline |
|---|
Post CABG,VT/VF
- Ventricular tachycardia rarely occur within 24 hours after CABG due to the transient effects of reperfusion, electrolyte and acid-base disturbances, and the use of inotrope.
- VF or poly morphic VT in the postoperative period may be the manifestation of myocardial ischemia and mechanical complications and acute electrolyte or acid base disturbances and graft patency should be warranted.[8]
- Monomorphic VT may be related to , prior MI, ventricular scar, LV dysfunction, and placement of a bypass graft across a noncollateralized occluded coronary vessel to a chronic infarct zone.
- Among patients without sustained VT, VF and presence of LV dysfunction, reassessment of LV function 3 months after CABG for decision about ICD implantation is recommended.[9]
- In patients with high burden of non-sustained VT and LV dysfunction, electrophysiology study for risk stratification and determination the need for ICD is recommended. [10][11]
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Mohammed A. Sbeih, M.D. [2]; Anahita Deylamsalehi, M.D.[3]; Cafer Zorkun, M.D., Ph.D. [4]; Varun Kumar, M.B.B.S. [5] Prince Tano Djan, BSc, MBChB [6]
Synonyms and keywords: Coronary artery bypass grafting, and colloquially heart bypass, bypass, bypass surgery, open heart surgery, or CABG (pronounced like cabbage), aortocoronary bypass (ACB). The term Coronary Artery Graft Surgery (CAGS) is often used outside the United States and should not be confused with Coronary Angiography (CAG). OPCAB refers to Off-pump coronary artery bypass, a procedure during which the patient is not placed on extracorporeal circulation (“the pump”).
Coronary artery bypass surgery (CABG) is a surgical revascularization procedure that is used to circumvent or bypass blockages in the epicardial coronary arteries associated with acute coronary syndromes (including ST elevation MI, non ST elevation MI, unstable angina) and stable angina. The technique was pioneered by Argentine cardiac surgeon René Favaloro at the Cleveland Clinic in the late 1960s. As part of the procedure, arteries or veins from elsewhere in the patient‘s body are grafted from the aorta to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass. However, recent advances allow the procedure to be performed with the heart beating and through smaller incisions. Currently, about 500,000 Coronary artery bypass surgery (CABG) are performed in the United States each year.
Pathophysiology
Saphenous Vein Graft Disease | Other Non-Atherosclerotic Saphenous Vein Graft Diseases
CABG in Patients with Acute MI | CABG in Patients with Ventricular Arrhythmias | Emergency CABG after Failed PCI | CABG in Association with Other Cardiac Procedures | Heart Team Approach to Revascularization Decisions | Revascularization of Left Main CAD to Improve Survival | Revascularization of Non-Left Main CAD to Improve Survival | Revascularization to Improve Symptoms | CABG in Left Ventricular Dysfunction
Imaging in the patient undergoing CABG
Chest x-ray | Coronary Angiography | CT Angiography | MRI Angiography | Trans-Esophageal Echocardiography | Epiaortic Ultrasound
Aspirin and Clopidogrel | Beta-Blockers | ACE Inhibitors/ARBs | Management of Hyperlipidemia | Management of Mediastinitis/Perioperative Infection | Percutaneous Coronary Intervention (PCI) To Treat Saphenous Vein Graft Failure | Maintaining Glucose Level | Coronary artery bypass surgery bleeding/transfusion | Management of Dysrhythmias | Smoking Cessation | Perioperative Management of Myocardial Dysfunction | Perioperative Carotid Artery Noninvasive Screening
Electrocardiographic Monitoring | Pulmonary Artery Catheterization | Central Nervous System Monitoring
Anesthetic Considerations | The Traditional Coronary Artery Bypass Grafting Procedure (Simplified) | Minimally Invasive CABG | Conduits Used for Bypass | Videos on Saphenous Vein-Graft Harvesting | Videos on Coronary Artery Bypass Surgery | Cardiopulmonary Bypass
Postoperative Antiplatelet Therapy
Special Scenarios
Anomalous Coronary Arteries | Chronic Obstructive Pulmonary Disease/Respiratory Insufficiency | Existing Renal Disease | Concomitant Valvular Disease | Previous Cardiac Surgery | Menopause | Carotid Disease Evaluation Before Surgery
Related Chapters
- CABG
- Hybrid bypass
- Off-Pump Coronary Artery Bypass Surgery (OPCAB)
- Minimally invasive direct coronary artery bypass surgery (MIDCAB)
- Cardiothoracic surgery
- Dressler’s syndrome
- Hybrid bypass
External Links
- Advances in Cardiovascular Surgery and Cardiothoracic Surgical Procedures
- Cardiothoracic Surgery Notes an online interactive review developed by residents in cardiothoracic surgery
- Contenidos de Enfermería y Cirugía Cardiaca
- CTSNet: The Cardiothoracic Surgery Network
- Curso de Enfermería y Cirugía Cardiaca
- Heart Assist Devices
- LVAD Simulator
- Perfusion Line
- The CardioThoracic Surgery Network: Residents Section
- The Implantable Artificial Heart Project
- The Virtual Textbook Of Extracorporeal Technology
- Yale: Introduction to Cardiothoracic Imaging
References
Secondary prevention in non-ischemic cardiomyopathy
| Recommendations for secondary prevention of sudden cardiac death in non-ischemic cardiomyopathy |
| ICD implantation (Class I, Level of Evidence B): |
|
❑ ICD implantation is recommended in survivors of SCA or hemodynamically unstable VT or sustained VT not related to reversible causes, if life expectancy is more than 1 year |
| ICD implantation, EPS study (Class IIa, Level of Evidence B) : |
|
❑ In the presence of syncope presumed due to ventricular arrhythmia, ICD or EPS study for risk stratification of SCD is recommended if survival is more than 1 year |
| Amiodarone : (Class IIb, Level of Evidence B) |
|
❑ In survival of SCA, or sustained VT, or symptomatic ventricular arrhythmia who are ineligible for ICD implantation due to limited life expectancy or inaccessible venous sites, amiodarone is recommended |
Abbreviations:
ICD: Implantable cardioverter defibrillator;
SCA: Sudden cardiac arrest;
NICM Non ischemic cardiomyopathy;
EPS Electrophysiology study;
SCD Sudden cardiac death;
VT Ventricular tachycardia
| The above table adopted from 2017 AHA/ACC/HRS Guideline |
|---|
References
References
- ↑ “A Comparison of Antiarrhythmic-Drug Therapy with Implantable Defibrillators in Patients Resuscitated from Near-Fatal Ventricular Arrhythmias”. New England Journal of Medicine. 337 (22): 1576–1584. 1997. doi:10.1056/NEJM199711273372202. ISSN 0028-4793.
- ↑ Wyse, D.George; Friedman, Peter L; Brodsky, Michael A; Beckman, Karen J; Carlson, Mark D; Curtis, Anne B; Hallstrom, Alfred P; Raitt, Merritt H; Wilkoff, Bruce L; Greene, H.Leon (2001). “Life-threatening ventricular arrhythmias due to transient or correctable causes: high risk for death in follow-up”. Journal of the American College of Cardiology. 38 (6): 1718–1724. doi:10.1016/S0735-1097(01)01597-2. ISSN 0735-1097.
- ↑ Raitt, Merritt H.; Renfroe, Ellen Graham; Epstein, Andrew E.; McAnulty, John H.; Mounsey, Paul; Steinberg, Jonathan S.; Lancaster, Scott E.; Jadonath, Ram L.; Hallstrom, Alfred P. (2001). ““Stable” Ventricular Tachycardia Is Not a Benign Rhythm”. Circulation. 103 (2): 244–252. doi:10.1161/01.CIR.103.2.244. ISSN 0009-7322.
- ↑ Maury, P.; Baratto, F.; Zeppenfeld, K.; Klein, G.; Delacretaz, E.; Sacher, F.; Pruvot, E.; Brigadeau, F.; Rollin, A.; Andronache, M.; Maccabelli, G.; Gawrysiak, M.; Brenner, R.; Forclaz, A.; Schlaepfer, J.; Lacroix, D.; Duparc, A.; Mondoly, P.; Bouisset, F.; Delay, M.; Hocini, M.; Derval, N.; Sadoul, N.; Magnin-Poull, I.; Klug, D.; Haissaguerre, M.; Jais, P.; Della Bella, P.; De Chillou, C. (2014). “Radio-frequency ablation as primary management of well-tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%”. European Heart Journal. 35 (22): 1479–1485. doi:10.1093/eurheartj/ehu040. ISSN 0195-668X.
- ↑ 5.0 5.1 Al-Khatib, Sana M.; Stevenson, William G.; Ackerman, Michael J.; Bryant, William J.; Callans, David J.; Curtis, Anne B.; Deal, Barbara J.; Dickfeld, Timm; Field, Michael E.; Fonarow, Gregg C.; Gillis, Anne M.; Granger, Christopher B.; Hammill, Stephen C.; Hlatky, Mark A.; Joglar, José A.; Kay, G. Neal; Matlock, Daniel D.; Myerburg, Robert J.; Page, Richard L. (2018). “2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death”. Circulation. 138 (13). doi:10.1161/CIR.0000000000000549. ISSN 0009-7322.
- ↑ “Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version”. Circ J. 74 (8): 1745–62. August 2010. doi:10.1253/circj.cj-10-74-0802. PMID 20671373.
- ↑ Morikawa, Yoshinobu; Mizuno, Yuji; Yasue, Hirofumi (2010). “Letter by Morikawa et al Regarding Article, “Coronary Artery Spasm: A 2009 Update““. Circulation. 121 (3). doi:10.1161/CIR.0b013e3181ce1bcc. ISSN 0009-7322.
- ↑ Saxon, Leslie A.; Wiener, Isaac; Natterson, Paul D.; Laks, Hillel; Drinkwater, Davis; Stevenson, William G.X. (1995). “Monomorphic versus polymorphic ventricular tachycardia after coronary artery bypass grafting”. The American Journal of Cardiology. 75 (5): 403–405. doi:10.1016/S0002-9149(99)80566-9. ISSN 0002-9149.
- ↑ Vakil, Kairav; Florea, Viorel; Koene, Ryan; Kealhofer, Jessica Voight; Anand, Inderjit; Adabag, Selcuk (2016). “Effect of Coronary Artery Bypass Grafting on Left Ventricular Ejection Fraction in Men Eligible for Implantable Cardioverter–Defibrillator”. The American Journal of Cardiology. 117 (6): 957–960. doi:10.1016/j.amjcard.2015.12.029. ISSN 0002-9149.
- ↑ Mittal, Suneet; Lomnitz, David J.; Mirchandani, Sunil; Stein, Kenneth M.; Markowitz, Steven M.; Slotwiner, David J.; Iwai, Sei; Das, Mithilesh K.; Lerman, Bruce B. (2002). “Prognostic Significance of Nonsustained Ventricular Tachycardia After Revascularization”. Journal of Cardiovascular Electrophysiology. 13 (4): 342–346. doi:10.1046/j.1540-8167.2002.00342.x. ISSN 1045-3873.
- ↑ Bigger, J. Thomas (1997). “Prophylactic Use of Implanted Cardiac Defibrillators in Patients at High Risk for Ventricular Arrhythmias after Coronary-Artery Bypass Graft Surgery”. New England Journal of Medicine. 337 (22): 1569–1575. doi:10.1056/NEJM199711273372201. ISSN 0028-4793.
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