1. Scope of the Position Statement
- Khairy P.
- Van Hare G.F.
- Balaji S.
- et al.
2. Position Statement Development
- Buxton A.E.
- Calkins H.
- Callans D.J.
- et al.
4. Incidence and Prognosis of Sustained VT/VF in Patients With SHD
5. Initial Evaluation and Management of SHD Patients With Sustained VT/VF
- 1.We recommend that all patients presenting with VT/VF undergo a comprehensive initial evaluation including a detailed history, physical examination, laboratory investigations, ECG, ICD interrogation (if present) and transthoracic echocardiography (Strong Recommendation, Low-Quality Evidence).
- 2.We recommend that CMR imaging be performed in patients who present with VT/VF when the initial evaluation has failed to establish the etiology of the underlying heart disease (Strong Recommendation, Moderate-Quality Evidence).
5.1 Management of hemodynamically unstable VT/VF
- Panchal A.R.
- Berg K.M.
- Kudenchuk P.J.
- et al.
- 3.We recommend the administration of I.V. amiodarone or lidocaine for acute treatment of patients with shock-refractory VT/VF (failure of at least 1 attempt at defibrillation) or patients with recurrent polymorphic VT/VF, unless there is a strong suspicion of torsade de pointes (Strong Recommendation, Moderate-Quality Evidence).
5.2 Electrical storm
- Kowey P.R.
- Levine J.H.
- Herre J.M.
- et al.
- 4.We recommend the use of β-blockade, preferably nonselective β-blockade, and I.V. amiodarone in patients with electrical storm in the setting of underlying SHD (Strong Recommendation, Moderate-Quality Evidence).
5.3 Stable monomorphic VT
- 5.We recommend electrical cardioversion or I.V. procainamide for the acute treatment of stable monomorphic VT in patients with SHD (Strong Recommendation, Moderate-Quality Evidence).
5.4 Polymorphic VT
6. Initiation of Long-Term Suppressive Therapy for Sustained VT/VF
6.1 Goals for initiating long-term suppressive therapy for VT/VF
6.2 First episode of sustained VT/VF
6.3 Recurrent sustained VT/VF
- 6.In patients with SHD and new or recurrent VT/VF, we recommend: (1) optimizing β-blocker dose in all patients; (2) optimizing ICD programming; and (3) consideration of initiation of additional suppressive therapy (either class III AAD therapy or catheter ablation), particularly in patients with VT/VF resulting in ICD shock(s), in those with a high burden of VT/VF, and in those with severe symptoms/hemodynamic compromise or psychosocial distress (Strong Recommendation, Low-Quality Evidence).
6.4 Electrical storm
- 7.We recommend optimizing β-blocker dose and using additional suppressive therapy (amiodarone or catheter ablation), in patients with SHD who present with electrical storm (Strong Recommendation, Moderate-Quality Evidence).
7. AAD Therapy for Long-Term Management of Sustained VT/VF
- 8.We recommend β-blocker therapy, titrated to a maximally tolerated dose (optimized dose), in patients with SHD with VT/VF (Strong Recommendation, Moderate-Quality Evidence).
|Drug||Starting dose||Target dose||Caution||Monitoring||Common and severe effects|
|Sotalol||40-80 mg BID||120-160 mg BID||Baseline prolonged QT||Laboratory||Fatigue|
Bradycardia (sinus bradycardia or atrial fibrillation with slow ventricular response)
Proarrhythmia (prolonged QT with torsade de pointes)
400 mg BID for 14 days (consider 400 mg TID for 8 days in inpatients)
200 mg daily
|200-400 mg daily||Concomitant digoxin administration (amiodarone increases serum digoxin concentration)|
Nausea or diarrhea (particularly with loading dose)
Bradycardia (sinus bradycardia or atrial fibrillation with slow ventricular response)
Pulmonary toxicity (pneumonitis or fibrosis—typically with long-term use)
- 9.If AAD therapy is chosen for suppressive therapy, we recommend that either sotalol or amiodarone be used as first-line AAD therapy for suppression of VT/VF in patients with SHD (Strong Recommendation, High-Quality Evidence).
8. Catheter Ablation for the Treatment of Sustained VT in Patients With SHD
8.1 Patient selection
8.1.1 Ischemic cardiomyopathy
- 10.We suggest that catheter ablation can be considered, in selected patients, as first-line suppressive therapy, in addition to β-blocker therapy, for patients with ischemic cardiomyopathy (previous MI) and monomorphic VT (Conditional Recommendation, Low-Quality Evidence).
- 11.We recommend catheter ablation of monomorphic VT in patients with ischemic cardiomyopathy (previous MI) in whom treatment with sotalol or amiodarone has been ineffective (Strong Recommendation, High-Quality Evidence).
8.1.2 Nonischemic cardiomyopathy
- 12.We recommend catheter ablation of monomorphic VT in patients with nonischemic cardiomyopathy in whom treatment with sotalol or amiodarone has been ineffective (Strong Recommendation, Low-Quality Evidence).
8.1.3 Epicardial mapping and ablation
- Berruezo A.
- Acosta J.
- Fernandez-Armenta J.
- et al.
9. ICD Programming in Patients With Sustained VT/VF in the Setting of SHD
|Zone||Rate cutoff||Detection intervals/time||Therapy|
|VF||> 250 BPM (240 msec)||Medtronic: 30/40 intervals|
Abbott: 30 intervals
Boston Scientific: 2.5 s
Biotronik: 30/40 intervals
MicroPort CRM: 20 cycles, 6/8 majority
|Shocks with ATP during charge|
|Fast VT||188-250 BPM (320-240 msec)||Medtronic: 30/40 intervals|
Abbott: 30 intervals
Boston Scientific: 12 s
Biotronik: 30 intervals
MicroPort CRM: 20 cycles, 6/8 majority
|1-4 ATP bursts followed by shocks|
|Slow VT||10-20 BPM slower than slowest documented VT|
|Medtronic: 32-36 intervals|
Abbott: 30 intervals
Boston Scientific: 60 s
Biotronik: 30 intervals
MicroPort CRM: 30 cycles, 6/8 majority
Shocks are optional and may be omitted for slow VT
- Kloppe A.
- Proclemer A.
- Arenal A.
- et al.
- Wathen M.S.
- DeGroot P.J.
- Sweeney M.O.
- et al.
- Santini M.
- Lunati M.
- Defaye P.
- et al.
10. Suppression of VT/VF When Initial Therapy Is Ineffective (Second- and Third-Line Therapy)
10.1 Second- and third-line antiarrhythmic therapy
10.1.2 Dofetilide (not currently available in Canada)
10.1.3 Class 1C agents
- 13.We suggest that mexiletine (given in addition to amiodarone) or dofetilide can be used in patients with SHD and refractory VT/VF who are not candidates or in whom therapy with sotalol, amiodarone, or catheter ablation has failed (Conditional Recommendation, Low-Quality Evidence).
10.2 Emerging and alternate ablation modalities
10.3 Cardiac sympathectomy
- 14.We suggest that bipolar radiofrequency ablation, extendable/retractable radiofrequency needle ablation, stereotactic ablative radiotherapy, and sympathectomy may be considered for treatment of VT/VF after failure of one or more standard ablation procedures and after failure of amiodarone therapy (Conditional Recommendation, Low-Quality Evidence).
11. Psychosocial Care of Patients With VT/VF
11.1 Preimplantation and stable postimplantation patients
- 15.We recommend frequent systematic assessment of psychological status in all patients with SHD and VT/VF, and recommend referral for treatment of such distress when identified (Strong Recommendation, Low-Quality Evidence).
11.2 Special populations; ICD generator change in frail/elderly patients
11.3 End of life
- 16.In patients with VT/VF, we recommend ongoing incorporation of patient values and preferences in goals of care discussions, including ICD tachycardia therapy deactivation or ICD replacement with a pacemaker, particularly at times of ICD generator replacement or changes in clinical status (Strong Recommendation, Low-Quality Evidence).
12. Conclusion/Future Directions/Knowledge Gaps
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The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.