Important points to remember (the '10 commandments'):
The risk of VA/SCD increases with age. However, the age at presentation, the 'age peak' and the subtype of VA potentially leading to SCD, is different for different diseases (Figure 1).
Survival rate remains low after out-of-hospital cardiac arrest. Early implementation of resuscitative interventions is pivotal to improve survival. It is important to increase the availability of public access defibrillators at sites where cardiac arrest is more likely to occur and to promote community training in basic life support, especially in schools.
Sudden cardiac arrest survivors should undergo systematic examination overseen by a multidisciplinary team, to identify the cause of cardiac arrest and those at risk of an inherited cardiac disease that would warrant a familiar evaluation.
Investigation of unexpected sudden death (SD) should be made a public health priority. A comprehensive autopsy is recommended, ideally, in all cases of unexpected SD, and always in those <50 years of age.
Genetic testing is increasingly available. Risk stratification, including genetic findings, exists for several diseases and risk calculators have been developed (i.e. long QT syndrome (LQTS), lamin A/C cardiomyopathies). However, genetic and clinical testing should be undertaken only by multidisciplinary teams including professionals with skills to counsel on the implications and the uncertainty of results and experienced cardiologists able to direct testing.
Risk prediction based on a single parameter does not consider the potential combined effect and interactions between factors. In patients with dilated cardiomyopathy/hypokinetic nondilated cardiomyopathy, indication for primary prevention implantable cardioverter defibrillator (ICD) implantation should not be restricted to an left ventricular ejection fraction (LVEF) ≤35%. The clinical presentation and results of additional tests (i.e. cardiac magnetic resonance imaging, genetic testing) are important to consider.
Idiopathic premature ventricular contractions (PVCs) or VT are a diagnosis per exclusion. Cardiac magnetic resonance is important if initial evaluation is inconclusive or the presentation is atypical, and in patients with an unexplained reduced LVEF and a PVC burden of ≥10%. For symptomatic idiopathic PVC/VT from right ventricular outflow tract or left ventricular fascicle and for PVC-induced cardiomyopathy catheter ablation is first-line treatment.
Catheter ablation is first-line treatment for recurrent VT in patients after myocardial infarction on amiodaron treatment.
In patients with a preserved or mildly reduced LVEF after prior myocardial infarction presenting with a haemodynamically tolerated VT, either VT ablation performed in experienced centres or ICD implantation are treatment options requiring shared decision-making.
Medical treatment has been specified for some diseases. Non-selective beta-blockers Nadolol or propranolol are the preferred beta-blockers in LQTS and catecholaminergic polymorphic ventricular tachycardia patients.
Figure 1.
Central illustration from ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death (European Heart Journal 2022, Barcelona and online; https://doi.org/10.1093/eurheartj/ehac262).
Funding
All authors declare no funding for this contribution.
Eur Heart J. 2023;44(3):176-177. © 2023 Oxford University Press
Copyright 2007 European Society of Cardiology. Published by Oxford University Press. All rights reserved.
