It typically takes a guideline-writing committee 3 years to prepare recommendations for evidence-based care. By the time the guideline is released publicly, some of the recommendations are already outdated. That’s not the case with the new guideline on ventricular arrhythmias (VAs) and prevention of sudden cardiac death (SCD), according to session moderators at the American Heart Association’s (AHA) Scientific Sessions held November 11 to 15, 2017, in Anaheim, CA.
Sana Al-Khatib, MD, of Duke, chaired the guideline-writing committee and was instrumental in facilitating the release of the new guideline from the American College of Cardiology (ACC), AHA, and Heart Rhythm Society (HRS). It took just 18 months for the committee to produce the first comprehensive guideline on VA and SCD since those published in 2006. The 2017 update was issued on October 30, 2017.
VA has numerous manifestations, including premature ventricular complexes, ventricular tachycardia, torsades de pointes, ventricular fibrillation, and sudden cardiac arrest. VA often occurs in patients with ischemic heart disease (IHD), particularly older adults.
According to Al-Khatib, the 2017 ACC/AHA/HRS guideline on the management of VAs and prevention of SCD uses a modernized organization called “modular knowledge chunk format,” which enables a quick review of pertinent information on VAs with different disease states (eg, ischemic heart disease, nonischemic cardiomyopathy). In addition, each section begins with a table of recommendations, followed by evidence supporting those recommendations to accentuate the usability of the guideline as a reference document.
Previous guidelines related to VA and SCD may have unintentionally subordinated medical treatment regimens to device therapy, said Al-Khatib. “We emphasize the role that evidence-based medications have in the treatment of heart failure. We developed a recommendation to make sure that patients are taking guideline-directed medications for [this condition]," Al-Khatib said.
Other features of the 2017 ACC/AHA/HRS guideline include tables delineating risk factors, potentially modifiable risks, and high-risk subsets for VA or SCD in specific disease states, such as hypertrophic cardiomyopathy. It also includes diagrams that can help clinicians determine when patients should be offered a device, such as an implantable cardioverter-defibrillator (ICD), and when patients should be considered for catheter ablation. Cardiac resynchronization therapy is not addressed in the 2017 update.
Of note, the writing committee maintains the class I recommendation for ICD use for the primary prevention of SCD in patients with nonischemic cardiomyopathy. Al-Khatib noted that maintaining this recommendation might seem controversial, given recent data from a study that seemed to question the risks and benefits of ICDs in this patient population. “Our recommendation is based on nuances in the Danish study as well as several meta-analyses that show a significant 25% reduction in all-cause mortality with an ICD,” Al-Khatib explained.
The new guideline also discusses several issues that are likely to be increasingly encountered in clinical practice, including:
- Genetic counseling and screening
- Site of catheter ablation in VA treatment
- Prevention of SCD in adult patients with congenital heart disease
- Use of new devices therapies, such as the subcutaneous ICD and wearable cardioverter-defibrillator
- Use of an ICD in patients awaiting a heart transplant or implanted with a left ventricular assist device
- Use of an ICD in elderly patients with comorbidities
- Terminal care
- Shared decision making
In addition, the 2017 ACC/AHA/HRS guideline incorporates value statements for the first time. Value statements reflect the interplay of outcomes and treatment cost. A high value is assigned to treatments that provide better outcomes at lower costs, with intermediate value indicating $50,000 to less than $150,000 per quality-adjusted life-year gained. The 2017 guideline places a high value on the primary prevention of SCD in patients with IHD and an intermediate value on secondary prevention in the same patient population.
Source: Al-Khatib SM. Introduction of the 2017 ACC/AHA/HRS guideline on the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: what is new? Presented at: American Heart Association Scientific Sessions 2017; November 11-15, 2017; Anaheim, CA. Abstract EA.CVS.752.