JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO.

-, 2023
ª 2023 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

STATE-OF-THE-ART REVIEW

Management of Ventricular
Arrhythmias Worldwide
Comparison of the Latest ESC, AHA/ACC/HRS,
and CCS/CHRS Guidelines

Hilke Könemann, MD,a Christian Ellermann, MD,a Katja Zeppenfeld, MD, PHD,b Lars Eckardt, MDa

ABSTRACT

A new guideline for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death
has been published by the European Society of Cardiology. Beside the 2017 American Heart Association/American College
of Cardiology/Heart Rhythm Society guideline and the 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm
Society position statement, this guideline provides evidence-based recommendations for clinical practice. As these
recommendations are periodically updated integrating the latest scientific evidence, there are similarities in many
aspects. Nevertheless, notable differences in the recommendations can be found resulting from different scopes and
publication years, differences in data selection, interpretation, and weighing, and regional factors such as differing drug
availability. The aim of this paper is to compare specific recommendations to identify differences while acknowledging
the commonalities and to provide an overview of the status of current recommendations with a special emphasis on gaps
in evidence and future directions of research. Overall, the recent ESC guideline places a greater emphasis on the value of
cardiac magnetic resonance, genetic testing in cardiomyopathies and arrhythmia syndromes, and the use of risk
calculators for risk stratification. Further significant differences can be found regarding diagnostic criteria for genetic
arrhythmia syndromes, the management of hemodynamically well-tolerated ventricular tachycardia, and primary
preventive implantable cardioverter-defibrillator therapy. (J Am Coll Cardiol EP 2023;-:-–-) © 2023 by the American
College of Cardiology Foundation.

G uidelines for the management of patients

with ventricular arrhythmias (VAs) and the
prevention of sudden cardiac death (SCD)
are periodically updated integrating the latest scienti-
fic evidence and translating it into clinical practice.
Recently, the European Society of Cardiology (ESC)
has published new recommendations for the manage-
ment of patients with VA and the prevention of SCD.1
In 2020, the Canadian Cardiovascular Society (CCS)
collaborating with the Canadian Heart Rhythm Soci-
ety (CHRS) released a position statement on the
management of VA in patients with structural heart
disease (SHD), 2 while the latest guidelines of the
American Heart Association (AHA), the American
College of Cardiology (ACC), and the Heart Rhythm
Society (HRS) on this topic were published in 2017. 3
This review aims at comparing the recent ESC guide-
lines with the AHA/ACC/HRS and CCS/CHRS recom-
mendations. Although these recommendations are
partly developed on identical scientific evidence, dif-
ferences may arise, for instance, from different local
practice as well as diverging drug availability. As a

From the aDepartment of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany; and the bDepartment
of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the Author Center.

Manuscript received September 8, 2022; revised manuscript received December 5, 2022, accepted December 14, 2022.

ISSN 2405-500X/$36.00 https://doi.org/10.1016/j.jacep.2022.12.008

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2 Könemann et al
Comparison of International Guidelines on Ventricular Arrhythmias
ABBREVIATIONS novel concept for clinical practice, the latest
AND ACRONYMS
ESC guidelines discuss recommendations for
the evaluation of patients in various clinical
AAD = antiarrhythmic drug
scenarios such as the incidental finding of
BrS = Brugada syndrome
nonsustained ventricular
CMR = cardiac magnetic
(nsVT), first presentation of sustained mono-
resonance
morphic ventricular tachycardia (SMVT), or
CPVT = catecholaminergic
polymorphic ventricular
(aborted) SCD placing a stronger focus on
tachycardia clinical daily life situations with decision
LGE = late gadolinium making in specific settings and thereby
enhancement providing valuable practical guidance. Of
nsVT = nonsustained note, for the first time the ESC guideline
ventricular tachycardia
task force has published comprehensive sup-
SCD = sudden cardiac death plementary data including an overview and a
SHD = structural heart disease
discussion of the guideline
SMVT = sustained studies.
monomorphic ventricular
The ESC and AHA/ACC/HRS guidelines
tachycardia
additionally provide information on epide-
miology of SCD and antiarrhythmic drugs (AADs) in a
textbook-like manner. Besides, the ESC and AHA/
ACC/HRS guidelines use the ACCF/AHA methodology
to present the level of recommendation and evidence,
whereas the CCS/CHRS position statement uses the
GRADE (Grading of Recommendations, Assessment,
Development and Evaluation) system. While the ESC
and the collaborating AHA, ACC and HRS have
developed guidelines on the management of VA in
patients with and without specific SHD as well as VA
related to specific populations, the CCS/CHRS state-
ment is limited to the management of VA in patients
with SHD.
DIAGNOSTIC EVALUATION OF PATIENTS
WITH VAs AND SCD
While both the AHA/ACC/HRS and ESC guidelines
recommend a comprehensive autopsy in cases of
unexpected sudden death and additionally clinical
evaluation of first-degree relatives and genetic
testing and counselling as indicated by clinical find-
ings, only the recent ESC guideline contains detailed
recommendations on the evaluation of relatives of
(aborted) SCD victims. This includes ambulatory car-
diac rhythm monitoring and CMR (Class IIb), phar-
macological testing (Class IIa in case of suspected
Brugada syndrome [BrS], otherwise Class IIb) and
follow-up for children until adulthood (Class I), and
algorithms for the evaluation of SCD victims and their
relatives. This highlights the better understanding of
VT/SCD as a symptom of often familial disorders with
a constantly increasing role of genetic testing in
recent years. Therefore, the most recent ESC guide-
line emphasizes the value of genetic diagnostics more
strongly: both the ESC and AHA/ACC/HRS guidelines
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JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023
- 2023:-–-
HIGHLIGHTS

SCD is a global health issue, as it
accounts for approximately 50% of
tachycardia cardiovascular deaths.

The recent ESC guidelines highlight
genetic testing and imaging with CMR for
diagnostic evaluation and risk
stratification.

Value of secondary and primary
preventive ICD in patients with NICM (and
tolerated VT) decreased.

Latest guidelines value a more
underlying
patient-individual approach to ICD
therapy.
recommend genetic testing in patients with dilated
cardiomyopathy (DCM) with early development of
atrioventricular conduction delay or positive family
history of SCD in a first-degree relative, although age
limits for these recommendations differ. Only the ESC
guideline mentions specific genes (eg, LMNA, PLN,
FLNC) that should at least be included in genetic
testing and beyond that gives a Class IIa recommen-
dation for genetic testing for risk stratification in
sporadic cases. The ESC guideline additionally gives a
stronger recommendation of genetic counselling and
testing than the AHA/ACC/HRS guideline in patients
with clinically diagnosed or suspected arrhythmo-
genic right ventricular cardiomyopathy (ARVC) (ESC:
Class I, AHA: Class IIa) as well as in patients with BrS
(ESC: Class I, AHA: Class IIb) and (suspected) hyper-
trophic cardiomyopathy (HCM) (ESC: Class I, AHA:
Class IIa). In contrast, in first-degree relatives of HCM
patients with a known causative mutation, solely the
AHA/ACC/HRS guideline recommends genetic testing
in addition to clinical screening. These differences in
recommendations regarding genetics in particular
reflect the time difference in publication and thereby
underpin the dynamic of novel genetic insights. At
the same time, this dynamic goes in hand with a need
for an improved assessment of likely pathogenic
variants and genetic variants of uncertain
significance.
Notably, while the AHA/ACC/HRS guideline and
the CCS/CHRS position statement use the term non-
ischemic cardiomyopathy (NICM) synonymous with
dilated cardiomyopathy (DCM), the latest ESC guide-
line adds the category of hypokinetic nondilated
cardiomyopathy, which is characterized by left ven-
tricular (LV) dysfunction in the absence of dilatation.
Beyond the initial evaluation of patients presenting
JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023
- 2023:-–-
with VA consisting of electrocardiography (ECG),
echocardiography, coronary angiography and/or car-
diac magnetic resonance (CMR), the ESC guideline
suggests electroanatomical mapping and mapping-
guided biopsies on an individual basis for etiological
evaluation of VA. Although this may be only relevant
for a minority of patients with VA (eg, for the indi-
vidual patient with isolated cardiac sarcoidosis), it
highlights the intention of the ESC Task Force to
emphasize the importance of determining the un-
derlying etiology which is relevant for risk stratifica-
tion and treatment. After resuscitated cardiac arrest,
the ESC and CCS/CHRS recommend collection of
blood samples for potential toxicology and genetic
testing. Besides, the ESC guideline recommends
provocative testing if primary electrical disease is
suspected.
Overall, CMR has gained importance in the diag-
nostic evaluation of patients with VA. Both the AHA/
ACC/HRS and ESC guidelines highlight the value of
CMR for diagnosis and risk stratification in patients
with DCM or hypokinetic nondilated cardiomyopathy
as well as for the diagnosis of patients with suspected
ARVC. Yet, only the ESC guideline emphasizes CMR
as part of the diagnostic evaluation in HCM, in
inconclusive cases and in patients with suspected
premature ventricular contraction (PVC)–induced
cardiomyopathy to rule out underlying SHD. For
mitral valve prolapse with an estimated prevalence of
2% to 3%,4 both guidelines define criteria for an
arrhythmic mitral valve prolapse syndrome,5 yet
recommendations for risk stratification are not given,
as robust data are missing.
The diagnostic algorithms and criteria for primary
electrical diseases are more elaborated in the ESC
compared with the AHA/ACC/HRS guidelines. In
contrast to the AHA/ACC/HRS guideline, the ESC
gives specific recommendations on diagnostic criteria
(eg, for long QT syndrome [LQTS]: QTc interval
$480 ms, LQTS risk score >3, QTc interval $460 ms
with an arrhythmic syncope, presence of a known
pathogenic mutation).6 For the first time, the ESC
guideline discusses the Andersen-Tawil syndrome
(LQTS 7) separately from the other forms of LQTS, as
it may rather be a separate entity than a true sub-
entity of LQTS. Similarly, the ESC guidelines specify
the diagnostic criteria for BrS due to the high preva-
lence of an induced type 1 ECG pattern in healthy
individuals.7,8 In addition to the AHA/ACC/HRS
criteria that include a history of SCD due to ventric-
ular fibrillation (VF) or polymorphic VT and recent
unexplained syncope, the ESC gives a Class IIa
recommendation for the diagnosis of BrS in patients
with an induced type 1 Brugada ECG and nocturnal
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Könemann et al 3
Comparison of International Guidelines on Ventricular Arrhythmias
agonal respiration, a family history of BrS, or sudden
death under the age of 45 years with circumstances
that are suspicious for BrS. Of note, the implantation
of a loop recorder in BrS patients with unexplained
syncope for arrhythmia detection is recommended by
the ESC (Class IIa). However, no guidance is provided
regarding time periods of recording.
GENERAL ASPECTS OF THERAPIES FOR VAs
ACUTE MANAGEMENT. All 3 recommendations agree
that possible reversible underlying causes of VA
should be investigated. The recommendations of the
AHA/ACC/HRS guidelines place a stronger focus on
resuscitation measures as part of advanced life sup-
port in the case of hemodynamically not tolerated VT.
Direct current cardioversion is recommended as first-
line treatment for patients with hemodynamically not
tolerated VAs. While both the AHA/ACC/HRS and
CCS/CHRS recommend direct current cardioversion as
first-line therapy in patients with hemodynamically
tolerated VT, the ESC discusses a low anesthetic/
sedation risk for this intervention (Figure 1). Based on
results of the PROCAMIO (Randomized comparison of
intravenous procainamide vs. intravenous amiodar-
one for the acute treatment of tolerated wide QRS
tachycardia) trial,9 procainamide is preferred over
amiodarone for pharmacological termination of he-
modynamically tolerated VT. Of note, procainamide
and/or ajmaline, a new Class IIb recommendation for
stable VT in the latest ESC guideline, are not available
in many countries.
The setting of electrical storm has gained particular
importance in the ESC guidelines, which presents a
specific section on this topic. Whereas the recom-
mendations in the CCS/CHRS position statement
(only) differentiate between polymorphic VT/VF with
normal and prolonged QT interval and monomorphic
VT, the new ESC recommendations are more elabo-
rated with regard to the underlying heart disease. All
guidelines consider autonomic modulation respec-
tively cardiac sympathetic denervation in patients
with VT/VF storm refractory to drug treatment or
catheter ablation. Sedation to reduce sympathetic
tone is recommended by the ESC guideline (Class I),
while the AHA/ACC/HRS guideline and CCS/CHRS
position statement only mention it in their figures.
Both the ESC guideline and the CCS/CHRS consensus
paper recommend antiarrhythmic therapy with pref-
erably nonselective beta-blocker and intravenous
amiodarone in case of underlying SHD. 10 Overall, only
the ESC guideline explicitly suggests a multistage
treatment approach of electrical storm, consisting of
not only implantable cardioverter-defibrillator (ICD)
4 Könemann et al JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023
Comparison of International Guidelines on Ventricular Arrhythmias - 2023:-–-

F I G U R E 1 Acute Treatment of Sustained Wide QRS Complex Tachycardia

Comparison of recommendations of treatment algorithms for patients with sustained wide complex QRS tachycardia. Blue indicates the 2022 European Society of
Cardiology (ESC) guideline recommendations, red indicates the 2017 American Heart Association/American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS)
guideline recommendations, yellow indicates the 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society (CCS/CHRS) position statement recommen-
dations, and the arrow indicates the following step of the treatment algorithm. ECG ¼ electrocardiogram; SVT ¼ supraventricular tachycardia; VT ¼ ventricular
tachycardia.

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JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023
- 2023:-–-
reprogramming, drug treatment, and sedation, but
also catheter ablation, autonomic modulation, and
mechanical circulatory support in case of cardiogenic
shock.
LONG-TERM MANAGEMENT. In line with the latest
ESC and AHA/ACC/HRS guidelines for the manage-
11,12
ment of heart failure, the ESC has added sodium-
glucose cotransporter 2 inhibitors as standard heart
failure therapy. As expected, due to a lack of new
AADs, there is a large overlap between the guidelines
regarding AAD therapy. The use of AADs remains
essential as adjunctive therapy in symptomatic pa-
tients. Both guidelines highlight the lack of evidence
for AADs in reducing all-cause mortality, except for
beta-blockers. Sotalol and amiodarone are particu-
larly highlighted as first-line therapy. For the first
time, treatment algorithms or checklists for sodium-
channel blockers and drugs associated with QT pro-
longation are proposed in the ESC guideline to reduce
the associated proarrhythmic risk—a particular safety
13
concern.
DRUG THERAPY FOR VAs
The ESC guideline gives a stronger recommendation
than the AHA/ACC/HRS guideline (Class I vs Class IIa)
for intravenous beta-blocker therapy in patients with
ST-segment elevation myocardial infarction.14 For the
acute phase of acute coronary syndrome, the ESC
guideline as well as the CCS/CHRS position statement
recommend amiodarone and, if ineffective or con-
traindicated, lidocaine, in cases of recurrent VAs,
whereas the AHA/ACC/HRS guideline only recom-
mends amiodarone in hemodynamically unstable
patients after cardioversion. For patients with coro-
nary artery disease (CAD) or DCM and symptomatic
SMVT there is consensus on AAD treatment with
amiodarone or sotalol, although levels of recom-
mendations differ (for CAD: AHA: I, ESC: IIa, CCS:
strong recommendation; for DCM: AHA: IIa, ESC: IIa,
CCS: strong recommendation). Due to limited data on
the management of recurrent symptomatic VA in
HCM, the recommendations differ. While the ESC and
CCS/CHRS equally recommend beta-blocker therapy,
amiodarone, and sotalol, the AHA/ACC/HRS guideline
recommends the use of amiodarone only as an alter-
native to ICD therapy when an ICD is not feasible or
not favored by the patient.
Beta-blockers are integral part of the treatment of
patients with primary electrical diseases. While the
AHA/ACC/HRS guideline solely mentions beta-
blockers in general in this context, the ESC
guideline explicitly recommends nonselective
beta-blockers (nadolol or propranolol). The ESC and
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Könemann et al 5
Comparison of International Guidelines on Ventricular Arrhythmias
AHA/ACC/HRS guidelines also agree on beta-blocker
therapy in asymptomatic LQTS patients with a pro-
longed QT interval as well as in patients with cate-
cholaminergic polymorphic ventricular tachycardia
(CPVT). For CPVT patients with recurrent syncope,
sustained VT, or exertional PVC while on maximally
tolerated dose of beta-blockers, both guidelines
additionally recommend flecainide therapy.15,16
Furthermore, the ESC guideline highlights the value
of genotype-specific therapy (eg, avoidance of
genotype-specific triggers and mexiletine therapy in
LQT3 patients with a prolonged QT interval)—again
underlining the previously mentioned increasing role
of genetics in the most recent ESC guideline. Beta-
blocker therapy for ARVC patients is recommended
by both guidelines, yet AAD treatment is only rec-
ommended (Class IIa) in the ESC guideline 17,18 but is
supported by very recent retrospective data on the
role of flecainide in ARVC patients with an ICD. 19
Quinidine has been shown to prolong the QT in-
terval and to prevent VA in short QT syndrome (SQTS)
patients. 20,21 While the AHA/ACC/HRS recommends
antiarrhythmic therapy with quinidine in patients
with SQTS and recurrent VA, the ESC recommends its
use in specific clinical scenarios such as refusal or
contraindication for ICD and asymptomatic patients
with a family history of SCD considered to be at high
risk for VAs. Quinidine is mentioned as additional
therapy in patients with recurrent sustained VAs by
both guidelines.22 Of note, quinidine or verapamil are
also recommended by the ESC for acute suppression
of recurrent episodes of idiopathic VF.
ROLE OF DEVICE THERAPY
The guidelines and the position statement consider
ICD therapy to be essential in secondary prevention
of SCD, based on data from relatively old ICD
trials, 23-25 as well as in primary prevention of SCD in
patients at risk. The CCS/CHRS position statement
recommends ICD implantation in all patients with
SHD after the first episode of sustained VA, while
according to the ESC amiodarone may be considered
as an alternative to ICD therapy in specific clinical
situations (eg, when an indicated ICD is not avail-
able, contraindicated, or declined by the patient
[Class IIb]). The ESC and AHA/ACC/HRS guidelines
agree that the subcutaneous ICD should be consid-
ered as an alternative to transvenous defibrillators in
patients with an indication for an ICD without
pacing indication for bradycardia, resynchronization,
or VT termination (Class IIa), although the results
of the PRAETORIAN (PRospective, rAndomizEd
Comparison of subcuTaneOous and tRansvenous
6 Könemann et al JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023
Comparison of International Guidelines on Ventricular Arrhythmias - 2023:-–-

T A B L E 1 Recommendations on Primary Preventive ICD Therapy (Part 1)

AHA/ACC/HRS
ESC Guidelines Guidelines

Coronary artery disease

LVEF #35% þ NYHA functional Class II-III Class I Class I
LVEF #35% (ESC) / #30% (AHA) þ NYHA functional Class I Class IIa Class I
LVEF #40% þ nsVT þ inducible monomorphic VT Class IIa Class I
LVEF #40% þ unexplained syncope þ inducible monomorphic VT Class IIa Class I
NYHA functional Class IV candidates for advanced cardiac transplantation Class IIa Class IIa
heart failure therapy LVAD — Class IIa
Nonischemic cardiomyopathy
LVEF #35% þ NYHA functional Class II-II Class IIa Class I
LVEF #35% þ NYHA functional Class I — Class IIb
Dilated cardiomyopathy
Pathogenic mutation in LMNA gene þ 2 or more risk factors (nsVT, LVEF <45%, — Class IIa
nonmissense mutation, male sex)
Estimated 5-y risk of VA $10% þ nsVT or LVEF <50% Class IIa —
or AV conduction delay
LVEF >35% and $2 risk factors (syncope, LGE on CMR, inducible SMVT at PES, pathogenic mutations in PLN, Class IIa —
FLNC, and RBM20 genes)

Comparison of recommendations on primary preventive ICD therapy in patients with coronary artery disease, nonischemic cardiomyopathy, and dilated cardiomyopathy
according to the 2022 ESC and 2017 AHA/ACC/HRS Guidelines on the management of ventricular arrhythmias and prevention of sudden cardiac death.
ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; AV ¼ atrioventricular; ESC ¼ European Society of Cardiology; HRS ¼ Heart Rhythm Society;
ICD ¼ implantable cardioverter-defibrillator; LGE ¼ late gadolinium enhancement; LVAD ¼ left ventricular assist device; LVEF ¼ left ventricular ejection fraction;
nsVT ¼ nonsustained ventricular tachycardia; NYHA ¼ New York Heart Association; PES ¼ programmed electrical stimulation; SMVT ¼ sustained monomorphic ventricular
tachycardia; VA ¼ ventricular arrhythmia; VT ¼ ventricular tachycardia.

ImplANtable Cardioverter Defibrillator Therapy)
trial26 are only included in the ESC guidelines.
Beyond that, the AHA/ACC/HRS guideline provides a
Class I recommendation for implantation of a sub-
cutaneous ICD in patients without adequate vascular
access or high risk of infection. Yet, the long-term
safety and efficacy of the subcutaneous ICD re-
mains unknown and further research is needed on
this topic. Of note, despite the associated improved
patient outcome, solely the ESC guideline provides
specific recommendations for the optimization of
device programming, including recommendations
for subcutaneous ICD, with reference to the available
expert consensus papers.27,28
PRIMARY PREVENTION OF SCD WITH ICD. Primary
prevention of SCD is one of the most controversial
and extensively discussed topics in the ESC and AHA/
ACC/HRS guidelines, whereas it is not addressed in
the CCS/CHRS position statement (Table 1). Several
randomized controlled trials support ICD implanta-
tion for primary prevention of SCD in heart failure
patients with a left ventricular ejection fraction
(LVEF) #35% by reporting a significant mortality
29-31
reduction in these patients. For patients with
stable CAD, the ESC and AHA/ACC/HRS guidelines
agree on a Class I recommendation for ICD therapy in
patients with symptomatic heart failure (New York
Heart Association functional Class II-III) and
LVEF #35% despite $3 months of optimal medical
treatment. However, recommendations for asympto-
matic heart failure patients with CAD differ, as the
ESC guideline give a Class IIa recommendation based
on the results of the MADIT (Multicenter Automatic
Defibrillator Implantation Trial) II and SCD-HeFT
(Sudden Cardiac Death in Heart Failure Trial) trials,
while the AHA/ACC/HRS derives a Class I recom-
mendation from the MADIT I and II trials.29,31,32 For
CAD patients with LVEF #40%, documented nsVT,
and inducibility of SMVT, the AHA/ACC/HRS guide-
line gives a stronger recommendation for ICD therapy
(Class I) than the ESC (Class IIa).
Recommendations for primary preventive ICD
therapy in DCM patients with LVEF #35% differ, as
the AHA/ACC/HRS guideline gives a Class I recom-
mendation, while the ESC recommendation is weaker
(IIa). This is mainly due to the DANISH (Danish Study
to Assess the Efficacy of ICDs in Patients with Non-
ischemic Systolic Heart Failure on Mortality) trial,
which raised a question on the benefit of ICD therapy
in NICM,33 although both guidelines also refer to the
earlier randomized controlled trials that showed a
significant reduction of all-cause death by primary
preventive ICD implantation in DCM patients. 32,34-37
The AHA/ACC/HRS guideline highlights the results
of a meta-analysis that, after excluding patients with
cardiac resynchronization therapy or randomized to
AADs, showed a 25% relative risk reduction in mor-
tality with the ICD.38 Both guidelines recommend
primary preventive ICD implantation in patients with
a LMNA gene mutation with additional risk factors.

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JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023 Könemann et al 7
- 2023:-–- Comparison of International Guidelines on Ventricular Arrhythmias

T A B L E 2 Recommendations on Primary Preventive ICD Therapy (Part 2)

ESC AHA/ACC/HRS
Guidelines Guidelines

Arrhythmogenic right ventricular cardiomyopathy

Arrhythmic syncope Class IIa Class IIa
Moderate right (<40%) or left (<45%) ventricular dysfunction þ nsVT or inducible monomorphic VT Class IIa —
Significant right ventricular dysfunction with LVEF #35% — Class I
Significant right ventricular dysfunction with RVEF #35% Class IIa Class I
Hypertrophic cardiomyopathy
Maximum left ventricular wall thickness $30 mm — Class IIa
SCD in first-degree relative presumably due to HCM — Class IIa
Unexplained syncope — Class IIa
nsVT or abnormal blood pressure response during exercise þ additional SCD risk modifiers or high-risk features — Class IIa
nsVT or abnormal blood pressure response during exercise without additional SCD risk modifiers or high-risk — Class IIb
features
Estimated 5-year risk of sudden death based on the HCM Risk–SCD Calculator $6% Class IIa —
Estimated 5-year risk of sudden death based on HCM Risk–SCD Calculator ($4 to <6%) þ Class IIa —
-significant late gadolinium enhancement at CMR or
-LVEF <50% or
-abnormal blood pressure during exercise test or
-left ventricular apical aneurysm or
-presence of sarcomeric pathogenic mutation
Estimated 5-year risk of sudden death based on the HCM Risk- SCD Calculator $4 to <6% Class IIb —
Estimated 5-year risk of sudden death based on the HCM Risk- SCD Calculator <4% þ Class IIb —
- Significant late gadolinium enhancement at CMR or
-LVEF <50% or
-left ventricular apical aneurysm

Comparison of recommendations on primary preventive ICD therapy in patients with arrhythmogenic right ventricular cardiomyopathy and hypertrophic cardiomyopathy
according to the 2022 ESC and 2017 AHA/ACC/HRS Guidelines on the management of ventricular arrhythmias and prevention of sudden cardiac death.
CMR ¼ cardiac magnetic resonance; HCM ¼ hypertrophic cardiomyopathy; RVEF ¼ right ventricular ejection fraction; SCD ¼ sudden cardiac death; other abbreviations as in
Table 1.

Besides, the ESC guideline refers to a risk calculator
for patients with LMNA mutations39 and additionally
recommends ICD implantation in DCM patients
without a LMNA gene mutation when a combination
of risk factors is present, including late gadolinium
enhancement (LGE) on CMR for instance. Note-
worthy, only the AHA/ACC/HRS guideline gives a IIb
recommendation for primary preventive ICD im-
plantation in asymptomatic NICM patients with
LVEF #35%.
For risk stratification and the decision on primary
preventive ICD implantation in ARVC patients, both
guidelines consider different markers for increased
risk of SCD, including severe ventricular dysfunction
and arrhythmogenic syncope, although the criteria
proposed in the ESC guidelines seem to be less strict
as ICD implantation is also recommended in cases of
symptomatic patients, specifically presyncope or
palpitations suggestive for VAs, moderate ventricular
dysfunction in combination with nsVT, or inducible
SMVT (Table 2).
Both guidelines recommend periodic evaluation of
the 5-year risk of SCD in HCM patients. In contrast to
the AHA/ACC/HRS guideline that considers different
SCD risk factors, recommendations of the ESC
guideline are based on the estimated 5-year SCD risk
calculated by the HCM Risk-SCD Calculator 40 in
combination with additional risk factors including
significant LGE, LV dysfunction, abnormal blood
pressure during exercise, and specific pathogenic
mutations. Overall, the risk factors (maximum LV
wall thickness, family history of SCD, documented
nsVT, unexplained syncope) considered in the
respective guidelines are similar, but the ESC HCM
risk score also includes age, left atrial size, and the
maximum pressure gradient in the LV outflow tract,
whereas the AHA/ACC/HRS guideline only mentions
these and other risk factors and risk modifiers
separately.
In symptomatic LQTS patients with intolerance to
beta-blocker and genotype-specific therapies, pri-
mary preventive ICD implantation or left cardiac
sympathetic denervation (LCSD) should be consid-
ered although according to the ESC guideline LCSD is
not an alternative to ICD implantation for high-risk
patients. 41 Additionally, the ESC guideline has
implemented the 1-2-3-LQTS-Risk calculator for
assessing high-risk features in asymptomatic LQTS

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8 Könemann et al JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023
Comparison of International Guidelines on Ventricular Arrhythmias - 2023:-–-

T A B L E 3 Recommendations on Primary Preventive ICD Therapy (Part 3)

AHA/ACC/HRS
ESC Guidelines Guidelines

Congenital long QT syndrome

Symptomatic high-risk patients þ ineffectiveness or intolerance of beta-blocker therapya (high risk: QTc — Class I
>500 ms, genotypes LQTS 2 and LQTS 3, LQTS 2 females, <40 years, onset of symptoms <10 years,
recurrent syncope)
Unexplained syncope during beta-blockera and genotype-specific therapy Class I —
Symptomatic patients þ intolerance or contraindication of beta-blockera and genotype-specific therapy Class IIa —
Asymptomatic patients with QTc >500 ms during beta-blockera treatment — Class IIb
Asymptomatic patients with high risk profile according to 1-2-3- LQTS -Risk calculator Class IIb —
Catecholaminergic polymorphic ventricular tachycardia
Syncope during beta-blockera treatment — Class I
Syncope during combined beta-blockera and flecainide treatment Class IIa —
Brugada syndrome
Spontaneous type 1 Brugada ECG þ recent history of syncope presumed due to ventricular arrhythmia Class IIa Class I
Asymptomatic patients with inducible ventricular fibrillation Class IIb —

Comparison of recommendations on primary preventive ICD therapy in patients with ion channelopathies according to the 2022 ESC and 2017 AHA/ACC/HRS Guidelines on the
management of ventricular arrhythmias and prevention of sudden cardiac death. aESC guideline: preferably nonselective beta-blocker (nadolol or propranolol)
ECG ¼ electrocardiogram; LQTS ¼ long QT syndrome; other abbreviations as in Table 1.

patients 42 and gives a Class IIb recommendation for
ICD implantation in high-risk patients. In contrast,
the AHA/ACC/HRS guideline only considers a QT in-
terval >500 milliseconds while receiving beta-blocker
therapy as a high-risk feature and recommends LCSD
and/or ICD implantation for primary prevention of
SCD (Table 3).
The recommendation for ICD implantation in CPVT
patients with arrhythmogenic syncope is stronger in
the AHA/ACC/HRS than the ESC guidelines (Class I vs
Class IIa). The ESC guideline requires ongoing flecai-
nide therapy in addition to treatment with the highest
tolerated dose of beta-blocker. Both guidelines agree
that LCSD is not an alternative to ICD therapy in high-
risk patients, although LCSD can be an additional
therapy reducing the frequency of VAs in CPVT
patients.43 Similarly, the recommendation for ICD
implantation in BrS patients and a history of an
arrhythmic syncope is stronger according to the AHA/
ACC/HRS than to the ESC guideline (Class I vs Class
IIa). Only the ESC guideline gives a recommendation
for ICD therapy for asymptomatic BrS patients with a
spontaneous type I ECG with inducible VT (Class IIb).
In SQTS patients solely the ESC guideline recommends
ICD implantation in patients with arrhythmic syncope.
SECONDARY PREVENTION OF SCD WITH ICD. Gen-
erally, there is consensus on ICD implantation in
patients with documented VF or hemodynamically
not-tolerated VT in the absence of reversible causes.
However, recommendations regarding ICD therapy in
case of hemodynamically well-tolerated VT differ.
The CCS/CHRS position statement recommends ICD
implantation for all patients with sustained VT and
SHD, including hemodynamically not tolerated VT.
Notably, a meta-analysis of the early secondary pre-
ventive ICD trials did not show survival benefit by ICD
therapy in patients with moderately reduced LVEF. 44
In addition to the recommendation of ICD implanta-
tion in patients with CAD, LVEF $40% and hemody-
namically well-tolerated VT the ESC guideline states
that catheter ablation may be an alternative to ICD
therapy (Class IIa),45 acknowledging that treatment of
a well-tolerated VT in patients with preserved or
mildly reduced LVEF does not equal SCD prevention.
The recommendation for ICD implantation in NICM
patients with hemodynamically tolerated SMVT is
weaker in the ESC than the AHA/ACC/HRS guideline
(ESC: Class IIa, AHA: I), as the AHA/ACC/HRS guide-
line refers to the results of a retrospective analysis of
patients from the AVID (Antiarrhythmics Versus
Implantable Defibrillators) registry with an equal total
mortality rate in patients with hemodynamically
tolerated and unstable VT. 46 However, the AVID trial
mainly included patients with CAD (81%) and only
very few patients with DCM and stable VT. 23 Simi-
larly, for ARVC patients with hemodynamically
tolerated VT, the ESC guideline recommendation for
ICD implantation (Class IIa) is weaker than the AHA/
ACC/HRS guideline recommendation (Class I).
Although both the AHA/ACC/HRS and ESC guidelines
mention the high proportion of SMVT in ARVC pa-
tients, only the ESC guideline explicitly recommends
the use of devices with an antitachycardia pacing
function. On the other hand, only the ESC guideline
recommends (Class IIa) ICD implantation in patients

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JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023 Könemann et al 9
- 2023:-–- Comparison of International Guidelines on Ventricular Arrhythmias

T A B L E 4 Main Recommendations for Clinical Scenarios for Catheter Ablation

ESC Guidelines AHA/ACC/HRS Guidelines CCS/CHRS Position Statement

Acute treatment of ventricular arrhythmias

Drug-refractory incessant VT or electrical storm due to SMVT in CAD patients Class I Class I Strong recommendation
Moderate-quality evidence
Drug-refractory incessant VT or electrical storm due to SMVT in patients with other Class I Class I Strong recommendation
structural heart disease Moderate-quality evidence
Recurrent episodes of polymorphic VT/VF triggered by a similar PVC, nonresponsive Class IIa — —
to medical treatment or coronary revascularization
Long-term treatment of ventricular arrhythmias
Coronary heart disease
Alternative to ICD therapy if hemodynamically tolerated SMVT, LVEF $40% Class IIa — —
First-line suppressive therapy for SMVT, LVEF $40% Class IIa Class IIb Conditional recommendation
Low-quality evidence
First-line suppressive therapy for SMVT, LVEF <40% Class IIb Class IIb Conditional recommendation
Low-quality evidence
Recurrent SMVT despite chronic amiodarone therapy Class I Class I Strong recommendation
High-quality evidence
Recurrent SMVT despite chronic other AAD therapy (ESC: beta-blockers or sotalol) Class IIa Class I Strong recommendation
High-quality evidence
Dilated cardiomyopathy
Recurrent SMVT after failure of AAD treatment Class IIa Class IIa Strong recommendation
Low-quality evidence
Hypertrophic cardiomyopathy
Recurrent SMVT after failure of AAD treatment Class IIb — Strong recommendation
Low-quality evidence
Arrhythmogenic right ventricular cardiomyopathy
Recurrent SMVT after failure of beta-blocker treatment Class IIa Class IIa Strong recommendation
Low-quality evidence
Brugada syndrome
Recurrent ICD shocks without drug therapy — Class I —
Recurrent ICD shocks refractory to drug therapy Class IIa Class I —

Recommendations for catheter ablation according to the 2022 ESC and 2017 AHA/ACC/HRS Guidelines on the management of ventricular arrhythmias and prevention of sudden cardiac death and the
CCS/CHRS position statement on the management of ventricular arrhythmias in patients with structural heart disease. Clinical scenarios for catheter ablation in the acute and long-term management of
ventricular arrhythmias.
AAD ¼ antiarrhythmic drug; CAD ¼ coronary artery disease; PVC ¼ premature ventricular contractions; SMVT ¼ sustained monomorphic ventricular tachycardia; VF ¼ ventricular fibrillation; other
abbreviations as in Table 1.

with hemodynamically tolerated SMVT in HCM pa-
tients based on consensus expert opinion.
INTERVENTIONAL THERAPY: ROLE OF
CATHETER ABLATION
STRUCTURAL HEART DISEASE. Catheter ablation of
recurrent, drug-refractory VA is recommended by
ESC, AHA/ACC/HRS, and CCS/CHRS as part of the
acute treatment strategy (Table 4), especially for CAD
patients. In patients with incessant VA or an electrical
storm not acutely suppressible by AADs, catheter
ablation is recommended (Class I) in both guidelines
and the position statement. The ESC guideline high-
lights catheter ablation of PVCs if recurrent episodes
of polymorphic VT/VF are triggered by a similar,
drug-refractory PVC (Class IIa). Similarly, patients
with symptomatic recurrences of VT or VF in whom
AADs are ineffective, not tolerated, or not desired are
considered for catheter ablation by all 3 publications
(Table 4). Only the AHA/ACC/HRS guideline gives a
IIb recommendation for surgical ablation in cases of
refractory monomorphic VT, whereas the ESC guide-
line mentions this technique as a bailout strategy
along with radiotherapy ablation.
Although catheter ablation is an important pillar of
long-term management of patients with recurrent VA,
specific recommendations differ significantly. Both
the ESC and CCS/CHRS recommend AAD therapy and
catheter ablation equally in CAD patients with
recurrent symptomatic SMVT (CCS: strong recom-
mendation, ESC: Class IIa), while the AHA/ACC/HRS
guideline gives a stronger recommendation for AAD
therapy (Class I vs IIb for catheter ablation). The
novel ESC guideline recommends ablation in patients
with CAD and recurrent symptomatic VA on amio-
darone (Class I) because it was shown to be superior
to escalation of antiarrhythmic therapy. 47 The ESC
guideline also addresses ablation therapy after the
first episode of VT (Class IIb) to reduce VT and/or

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10 Könemann et al
Comparison of International Guidelines on Ventricular Arrhythmias
ICD interventions.48,49 Besides, the CCS/CHRS
particularly gives a recommendation for ablation as
first-line therapy in ischemic cardiomyopathy. This
reflects the debate regarding the “perfect” timing of
VT ablation. The ongoing VANISH2 (Ventricular
Tachycardia Ablation versus Escalated Antiar-
rhythmic Drug Therapy in Ischemic Heart Disease 2)
(NCT02830360) trial will address the question
whether catheter ablation is superior to AADs as first-
line therapy in patients with prior myocardial
infarction, ICD, and sustained VT. The competing
mortality risks from VT and decompensated heart
failure may argue for early ablation before occurrence
of an electrical storm or decompensation. Until now,
data on prognostic benefit of VT ablation in SHD is
scarce and the best timing for VT ablation in the in-
dividual patient remains to be determined.48,49
Due to their publication dates, results of 3 RCTs
have not been included in the available guidelines.
The recently published SURVIVE-VT (Substrate
Ablation vs Antiarrhythmic Drug Therapy for Symp-
tomatic Ventricular Tachycardia) trial showed that VT
ablation as first-line therapy reduced the composite
endpoint of cardiovascular death, appropriate ICD
shock, hospitalization due to heart failure, or severe
treatment-related complications compared with
AADs in ICD patients with ischemic cardiomyopathy
and ICD shocks for SMVT. However, the results were
mainly driven by a difference in severe treatment
complications. 50 In addition, the recently published
PARTITA (Does Timing of VT Ablation Affect Prog-
nosis in Patients With an Implantable Cardioverter-
defibrillator?) trial,51 in which VT ablation after a first
appropriate shock was associated with a reduced risk
of the composite endpoint of total mortality or hos-
pitalization for worsening heart failure, also provides
promising support for considering ablation after the
first ICD shock, though the link between ablation and
survival is uncertain. Of the observed 8 deaths in the
control arm, 3 were noncardiac (1 sepsis, 2 cancer),
only 3 had cardiac causes (2 worsening heart failure,
1 fatal cardiac arrest), and 2 were of unknown cause.
Finally, recently PAUSE-SCD (Pan-Asia United States
Prevention of Sudden Cardiac Death) reported a
reduction of the composite endpoint of VT recur-
rence, cardiovascular hospitalization, and death by
early ablation performed at the time of ICD implan-
tation in ischemic and NICM.52 Nevertheless, data for
NICM patients are (still) less positive, as PAUSE-SCD
showed a tendency of a poorer outcome after abla-
tion in this patient group. Overall, the previously
mentioned novel data provide support for
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JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023
- 2023:-–-
consideration of an early VT ablation in clinical prac-
tice, particularly in patients with ischemic cardiomy-
opathy. In line with these data, the AHA/ACC/HRS and
ESC recommendations for ablation of symptomatic
recurrent SMVT in DCM and HCM53,54 are weaker than
for ischemic cardiomyopathy. In contrast, the CCS/
CHRS states equal recommendations for ischemic
cardiomyopathy and NICM. For patients with DCM,
the AHA/ACC/HRS, ESC, and CCS/CHRS agree on
ablation in case of ineffectiveness, contraindication,
or intolerance to AADs. For HCM patients, only the
ESC guideline recommends ablation therapy under
such circumstances. While both guidelines recom-
mend catheter ablation of the arrhythmogenic
epicardial right ventricular outflow tract (RVOT) sub-
strate and/or of PVC triggering VF in BrS patients with
recurrent ICD shocks, solely the AHA/ACC/HRS
guideline proposes ablation along with quinidine as
an alternative to ICD implantation for patients who
have contraindications or decline an ICD.
The increased relevance of catheter ablation in the
ESC guidelines is further reflected by the Class IIa
recommendations in patients with SHD with sus-
pected PVC-aggravated CM and in nonresponders to
cardiac resynchronization therapy with reduced
biventricular pacing due to frequent PVC.
IDIOPATHIC VF/VT AND PVCs. In idiopathic VF, both
guidelines recommend ablation of PVCs triggering
recurrent episodes, although the recommendation is
stronger in the AHA/ACC/HRS than in the ESC
guideline, which recommends catheter ablation only
as second-line therapy (Table 5).
Both the AHA/ACC/HRS and ESC guidelines
recommend ablation of symptomatic RVOT PVCs. In
contrast to the ESC recommendation of catheter
ablation as first-line therapy for RVOT and fascicular
PVCs/VT, the AHA/ACC/HRS guideline gives a Class I
recommendation for the use of beta-blocker and
nondihydropyridine calcium-channel blocker and
recommends ablation as second-line therapy after
failed drug treatment. 55 For the treatment of sus-
pected PVC-induced cardiomyopathy, the ESC
guideline recommends catheter ablation as first-line
therapy and only recommends AAD therapy if cath-
eter ablation is not desired or is considered unprom-
ising or risky, whereas the AHA/ACC/HRS guideline
considers ablation only when AAD treatment is inef-
fective or impossible. Although both the ESC and
AHA/ACC/HRS guidelines prefer treatment with beta-
blockers or nondihydropyridine calcium-channel
blockers over catheter ablation in patients with
JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023 Könemann et al 11
- 2023:-–- Comparison of International Guidelines on Ventricular Arrhythmias

T A B L E 5 Main Recommendations for the Treatment of Patients With Idiopathic PVCs/VT

Calcium-
Channel
Catheter Ablation Beta-Blockers Antagonists Class Ic AAD Amiodarone

ESC AHA ESC AHA ESC AHA ESC AHA ESC AHA

RVOT/fascicular PVC/VT I (first line) I (second line) IIa I IIa I IIa — III —
Symptomatic, normal LV function
PVC/VT other than RVOT/fascicular IIa — I I I I IIa IIa III —
Symptomatic, normal LV function
RVOT/fascicular PVC/VT I I (second line) IIa IIa IIIa — IIbb IIa IIa IIa
LV dysfunction
PVC/VT other than RVOT/fascicular I I (second line) IIa IIa IIIa — IIbb IIa IIa IIa
LV dysfunction
PVC burden >20%, asymptomatic, normal LV function IIb — — — — — — — III —

Comparison of recommendations regarding the treatment of patients with idiopathic premature ventricular contractions and idiopathic ventricular tachycardia according to 2022 ESC and 2017 AHA/ACC/HRS
Guidelines (mentioned in the Table as AHA). aIntravenous calcium-channel blockers. bFlecainide in selected patients (only moderate LV dysfunction).
LV ¼ left ventricular; RVOT ¼ right ventricular outflow tract; other abbreviations as in Tables 1 and 4.

idiopathic left ventricular PVCs, only the ESC guide-
line equally recommends ablation or Class Ic AADs in
symptomatic patients with PVCs from an origin other
than the RVOT or left fascicles, while the AHA/ACC/
HRS guideline recommends AAD therapy in this sce-
nario. Besides, the ESC guideline gives a Class IIb
recommendation for catheter ablation in asymptom-
atic patients with a PVC burden >20%, whereas
the AHA/ACC/HRS guideline does not recommend
treatment of asymptomatic individuals.
GAPS IN EVIDENCE
Besides, VAs are well known to worsen prognosis
in patients with SHD. However, data on a prognostic
role of AAD therapy and/or catheter ablation of VT are
still lacking, although the evidence for reduction of
VT episodes, ICD interventions, and recurrent elec-
trical storms by catheter ablation has increased over
recent years. Neural networks and artificial intelli-
gence may perhaps improve screening to detect in-
dividuals at risk for SCD allowing a personalized
sudden death management and identification of
candidates for antiarrhythmic therapy such as VT
ablation in the (near) future.

The gaps in evidence in the field of VA and prevention CONCLUSIONS

of SCD remain important challenges for the future.
Compared with the latest AHA/ACC/HRS guideline 3
and the previous ESC guideline,56 several gaps in
evidence have been narrowed in the recent ESC
guideline. The upgrading of public basic life support
and access to automatic external defibrillators reflect
eg, initiatives to improve survival of sudden death
victims. Still, more than half of sudden death victims
have preserved LV function and the identification
patients at risk of SCD who have preserved LV func-
tion remains the challenge of the future. The current
ESC guideline might be a starting point to an even
more personalized medicine in risk stratification but
there are still many gaps regarding risk stratification.
The role of ICD therapy eg in the presence of
improved heart failure therapy and changing, more
elderly patient populations with often multiple
comorbidities not represented in the pivotal ICD trials
is still an important open issue. In this context, the
definite role of LGE-CMR but also genetic testing for
risk stratification with individualized criteria needs to
be investigated in randomized trials.
The latest guidelines of the AHA/ACC/HRS and ESC
and the CCS/CHRS position statement on the man-
agement of VA and prevention of sudden cardiac
death show broad consensus in many aspects,
although the different scope of the position state-
ment compared with the more comprehensive
guidelines is relevant. The Central Illustration pro-
vides a condensed overview of the novel aspects of
the ESC guidelines as compared with the AHA/ACC/
HRS and CCS/CHRS guidelines. Differences in the
respective recommendations are provided and are
partly related to different publication years. Overall,
the most recent ESC guideline places greater
emphasis on cardiac imaging with CMR in the diag-
nosis and risk stratification of SHD as well as on ge-
netic testing and counselling on the results of
patients with suspected inherited cardiomyopathies
and arrhythmia syndromes. Besides, calculators for
risk stratification are given greater weight. For the
first time, the ESC guidelines incorporate recom-
mendations for the evaluation of patients presenting

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12 Könemann et al JACC: CLINICAL ELECTROPHYSIOLOGY VOL. -, NO. -, 2023
Comparison of International Guidelines on Ventricular Arrhythmias - 2023:-–-

C E NT R AL IL L U STR AT IO N Overview of Main Differences in Recommendations and New Aspects

New aspects and developments of recommendations of the recent ESC guideline

compared to AHA/ACC/HRS guidelines and CCS/CHRS position statement

Risk Stratification and

Diagnostic Evaluation Drug Therapy Catheter Ablation
Device Therapy

Recommendations on evaluation of SCD risk calculators for HCM, First-line therapy in idiopathic
Updated heart failure therapy
relatives of SCD victims DCM, LQTS RVOT and fascicular PVC/VT

vs.

Preferred therapy in CAD patients

Increased relevance of New algorithms for antiarrhythmic Recommendations for optimization
with chronic amiodarone therapy
genetic testing drug therapy of ICD programming
and recurrent VA

≤35% vs.

Non-selective beta-blockers in Downgrade of LVEF as risk marker Alternative to ICD implantation in

Focus on cardiac MRI
primary electrical diseases (especially in DCM) selected patients with ICM

Additional Novel Aspects

Recommendations for diagnostic

Focus on public basic life support New section on management of Comprehensive supplementary
evaluation according to different
and AED electrical storm data
clinical scenarios

Könemann H, et al. J Am Coll Cardiol EP. 2023;-(-):-–-.

Overview of comparison of the current European Society of Cardiology (ESC) guideline recommendations, new aspects, and developments with the American Heart
Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines and the Canadian Cardiovascular Society/Canadian Heart Rhythm Society
(CCS/CHRS) position statement on the management of ventricular arrhythmias. AED ¼ automated external defibrillator; CAD ¼ coronary artery disease; DCM ¼ dilated
cardiomyopathy; HCM ¼ hypertrophic cardiomyopathy; ICD ¼ implantable cardioverter-defibrillator; ICM ¼ ischemic cardiomyopathy; LQTS ¼ long QT syndrome;
LVEF ¼ left ventricular ejection fraction; MRI ¼ magnetic resonance imaging; PVC ¼ premature ventricular contraction; RVOT ¼ right ventricular outflow tract;
SCD ¼ sudden cardiac death; VA ¼ ventricular arrhythmia; VT ¼ ventricular tachycardia.

in distinct clinical scenarios of VA. Further differ-
ences between the publications can be found in
diagnostic criteria for genetic arrhythmia syndromes
and the recommendations on management of hemo-
dynamically well-tolerated VT in patients with SHD
and primary preventive ICD therapy
patients. The recommendations of the new ESC
guideline also illustrate the increased relevance of
catheter ablation of VA. This is further supported by
recent RCTs that seem to provide evidence for posi-
tive effects of ablation not only on VT burden and
worsening of heart failure, but also on survival. More
studies are needed to clarify the risk benefit relation
in NICM of VT ablation with novel strategies/technologies, or
earlier timing of ablation with regard to survival in
patients with cardiomyopathies. For now, careful

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JACC: CLINICAL ELECTROPHYSIOLOGY VOL.
- 2023:-–-
individual risk benefit evaluation
appraisal of the discussed guidelines should guide
diagnosis and therapy of ventricular arrhythmias.
FUNDING SUPPORT AND AUTHOR DISCLOSURES
Dr Eckardt has received lecture fees from Abbott, Bayer, Boston Sci-
entific, Daiichi Sankyo, Medtronic, Biotronik, Sanofi Aventis, and
Bristol Myers Squibb. authors have reported that they have no re-
lationships relevant to the contents of this paper to disclose.
REFERENCES
1. Zeppenfeld K, Tfelt-Hansen J, de Riva M, et al.
2022 ESC Guidelines for the management of pa-
tients with ventricular arrhythmias and the pre-
vention of sudden cardiac death. Eur Heart J.
2022;43(40):3997–4126.
2. Deyell MW, AbdelWahab A, Angaran P, et al.
2020 Canadian Cardiovascular Society/Canadian
Heart Rhythm Society Position Statement on the
management of ventricular tachycardia and fibril-
lation in patients with structural heart disease. Can
J Cardiol. 2020;36(6):822–836.
3. Al-Khatib SM, Stevenson WG, Ackerman MJ,
et al. 2017 AHA/ACC/HRS Guideline for manage-
ment of patients with ventricular arrhythmias and
the prevention of sudden cardiac death: a report
of the American College of Cardiology/American
Heart Association Task Force on Clinical Practice
Guidelines and the Heart Rhythm Society. Circu-
lation. 2018;138(13):e272–e391.
4. Nishimura RA, McGoon MD, Shub C, Miller FA,
Ilstrup DM, Tajik AJ. Echocardiographically docu-
mented mitral-valve prolapse. Long-term follow-
up of 237 patients. N Engl J Med. 1985;313(21):
1305–1309.
5. Miller MA, Dukkipati SR, Turagam M, Liao SL,
Adams DH, Reddy VY. Arrhythmic mitral valve
prolapse: JACC Review Topic of the Week. J Am
Coll Cardiol. 2018;72(23 Pt A):2904–2914.
6. Schwartz PJ, Moss AJ, Vincent GM,
Crampton RS. Diagnostic criteria for the long QT
syndrome. An update. Circulation. 1993;88(2):
782–784.
7. Adler A, Rosso R, Chorin E, Havakuk O,
Antzelevitch C, Viskin S. Risk stratification in Bru-
gada syndrome: clinical characteristics, electro-
cardiographic parameters, and auxiliary testing.
Heart Rhythm. 2016;13(1):299–310.
8. Hasdemir C, Payzin S, Kocabas U, et al. High
prevalence of concealed Brugada syndrome in
patients with atrioventricular nodal reentrant
tachycardia. Heart Rhythm. 2015;12(7):1584–1594.
9. Ortiz M, Martín A, Arribas F, et al. Randomized
comparison of intravenous procainamide vs.
intravenous amiodarone for the acute treatment
of tolerated wide QRS tachycardia: the PROCAMIO
study. Eur Heart J. 2017;38(17):1329–1335.
10. Chatzidou S, Kontogiannis C, Tsilimigras DI,
et al. Propranolol versus metoprolol for treatment
of electrical storm in patients with implantable
cardioverter-defibrillator. J Am Coll Cardiol.
2018;71(17):1897–1906.
Downloaded for Anonymous User (n/a) at R4L.Myanmar from ClinicalKey.com by Elsevier on May 23, 2023. For
personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
-, NO. -, 2023
Comparison of International Guidelines on Ventricular Arrhythmias
and critical Dr Zeppenfeld received research funding from Biosense Webster
(research electrophysiology). All other authors have reported that
they have no relationships relevant to the contents of this paper to
disclose.
ADDRESS FOR
Könemann, Klinik für Kardiologie II – Rhythmologie,
Universitätsklinikum
Campus 1, 48149 Münster, Germany. E-mail: hilke.
koenemann@ukmuenster.de.
11. McDonagh TA, Metra M, Adamo M, et al. 2021
ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure. Eur Heart J.
2021;42(36):3599–3726.
12. Heidenreich PA, Bozkurt B, Aguilar D, et al.
2022 AHA/ACC/HFSA Guideline for the manage-
ment of heart failure: a report of the American
College of Cardiology/American Heart Association
Joint Committee on Clinical Practice Guidelines.
Circulation. 2022;145(18):e895–e1032.
13. Frommeyer G, Eckardt L. Drug-induced proar-
rhythmia: risk factors and electrophysiological
mechanisms. Nat Rev Cardiol. 2016;13(1):36–47.
14. Piccini JP, Hranitzky PM, Kilaru R, et al. Rela-
tion of mortality to failure to prescribe beta
blockers acutely in patients with sustained ven-
tricular tachycardia and ventricular fibrillation
following acute myocardial infarction (from the
VALsartan In Acute myocardial iNfarcTion trial
VALIANT Registry). Am J Cardiol. 2008;102(11):
1427–1432.
15. van der Werf C, Kannankeril PJ, Sacher F, et al.
Flecainide therapy reduces exercise-induced ven-
tricular arrhythmias in patients with catechol-
aminergic polymorphic ventricular tachycardia.
J Am Coll Cardiol. 2011;57(22):2244–2254.
16. Watanabe H, van der Werf C, Roses-Noguer F,
et al. Effects of flecainide on exercise-induced
ventricular arrhythmias and recurrences in
genotype-negative patients with catecholamin-
ergic polymorphic ventricular tachycardia. Heart
Rhythm. 2013;10(4):542–547.
17. Ermakov S, Gerstenfeld EP, Svetlichnaya Y,
Scheinman MM. Use of flecainide in combination
antiarrhythmic therapy in patients with arrhyth-
mogenic right ventricular cardiomyopathy. Heart
Rhythm. 2017;14(4):564–569.
18. Mahida S, Venlet J, Saguner AM, et al. Ablation
compared with drug therapy for recurrent ven-
tricular tachycardia in arrhythmogenic right ven-
tricular cardiomyopathy: results from a 1443.
multicenter study. Heart Rhythm. 2019;16(4):536–
543.
19. Rolland T, Badenco N, Maupain C, et al. Safety
and efficacy of flecainide associated with beta-
blockers in arrhythmogenic right ventricular car-
diomyopathy. Europace. 2022;24(2):278–284.
20. Mazzanti A, Maragna R, Vacanti G, et al.
Hydroquinidine prevents life-threatening
arrhythmic events in patients with short QT syn-
drome. J Am Coll Cardiol. 2017;70(24):3010–3015.
Könemann et al 13
CORRESPONDENCE: Dr Hilke
Münster, Albert-Schweitzer
21. El-Battrawy I, Besler J, Li X, et al. Impact of
antiarrhythmic drugs on the outcome of short QT
syndrome. Front Pharmacol. 2019;10:771.
22. Belhassen B, Rahkovich M, Michowitz Y,
Glick A, Viskin S. Management of Brugada syn-
drome: thirty-three-year experience using elec-
trophysiologically guided therapy with Class 1A
antiarrhythmic drugs. Circ Arrhythm Electrophysiol.
2015;8(6):1393–1402.
23. Antiarrhythmics versus Implantable De-
fibrillators (AVID) Investigators. A comparison of
antiarrhythmic-drug therapy with implantable
defibrillators in patients resuscitated from near-
fatal ventricular arrhythmias. N Engl J Med.
1997;337(22):1576–1583.
24. Connolly SJ, Gent M, Roberts RS, et al. Cana-
dian implantable defibrillator study (CIDS) : a
randomized trial of the implantable cardioverter
defibrillator against amiodarone. Circulation.
2000;101(11):1297–1302.
25. Kuck KH, Cappato R, Siebels J, Rüppel R.
Randomized comparison of antiarrhythmic drug
therapy with implantable defibrillators in patients
resuscitated from cardiac arrest: the Cardiac Arrest
Study Hamburg (CASH). Circulation. 2000;102(7):
748–754.
26. Knops RE, Olde Nordkamp LRA, Delnoy P-
PHM, et al. Subcutaneous or transvenous defi-
brillator therapy. N Engl J Med. 2020;383(6):526–
536.
27. Wilkoff BL, Fauchier L, Stiles MK, et al. 2015
HRS/EHRA/APHRS/SOLAECE expert consensus
statement on optimal implantable cardioverter-
defibrillator programming and testing. Europace.
2016;18(2):159–183.
28. Stiles MK, Fauchier L, Morillo CA, Wilkoff BL.
2019 HRS/EHRA/APHRS/LAHRS focused update to
2015 expert consensus statement on optimal
implantable cardioverter-defibrillator program-
ming and testing. Europace. 2019;21(9):1442–
29. Moss AJ, Hall WJ, Cannom DS, et al. Improved
survival with an implanted defibrillator in patients
with coronary disease at high risk for ventricular
arrhythmia. Multicenter Automatic Defibrillator
Implantation Trial Investigators. N Engl J Med.
1996;335(26):1933–1940.
30. Buxton AE, Lee KL, Fisher JD, Josephson ME,
Prystowsky EN, Hafley G. A randomized study of
the prevention of sudden death in patients with
coronary artery disease. Multicenter Unsustained
14 Könemann et al
Comparison of International Guidelines on Ventricular Arrhythmias
Tachycardia Trial Investigators. N Engl J Med.
1999;341(25):1882–1890.
31. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic
implantation of a defibrillator in patients with
myocardial infarction and reduced ejection frac-
tion. N Engl J Med. 2002;346(12):877–883.
32. Bardy GH, Lee KL, Mark DB, et al. Amiodarone
or an implantable cardioverter-defibrillator for
congestive heart failure. N Engl J Med.
2005;352(3):225–237.
33. Køber L, Thune JJ, Nielsen JC, et al. Defibril-
lator implantation in patients with nonischemic
systolic heart failure. N Engl J Med. 2016;375(13):
1221–1230.
34. Bänsch D, Antz M, Boczor S, et al. Primary
prevention of sudden cardiac death in idiopathic
dilated cardiomyopathy: the Cardiomyopathy Trial
(CAT). Circulation. 2002;105(12):1453–1458.
35. Kadish A, Dyer A, Daubert JP, et al. Prophy-
lactic defibrillator implantation in patients with
nonischemic dilated cardiomyopathy. N Engl J
Med. 2004;350(21):2151–2158.
36. Strickberger SA, Hummel JD, Bartlett TG, et al.
Amiodarone versus implantable cardioverter-
defibrillator: randomized trial in patients
with nonischemic dilated cardiomyopathy and
asymptomatic nonsustained ventricular tachy-
cardia—AMIOVIRT. J Am Coll Cardiol. 2003;41(10):
1707–1712.
37. Desai AS, Fang JC, Maisel WH, Baughman KL.
Implantable defibrillators for the prevention of
mortality in patients with nonischemic cardiomy-
opathy: a meta-analysis of randomized controlled
trials. JAMA. 2004;292(23):2874–2879.
38. Al-Khatib SM, Fonarow GC, Joglar JA, et al.
Primary prevention implantable cardioverter de-
fibrillators in patients with nonischemic cardio-
myopathy: a meta-analysis. JAMA Cardiol.
2017;2(6):685–688.
39. Wahbi K, Ben Yaou R, Gandjbakhch E, et al.
Development and validation of a new risk predic-
tion score for life-threatening ventricular tachy-
arrhythmias in laminopathies. Circulation.
2019;140(4):293–302.
40. O’Mahony C, Jichi F, Pavlou M, et al. A novel
clinical risk prediction model for sudden cardiac
Downloaded for Anonymous User (n/a) at R4L.Myanmar from ClinicalKey.com by Elsevier on May 23, 2023. For
personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
JACC: CLINICAL ELECTROPHYSIOLOGY VOL.
death in hypertrophic cardiomyopathy (HCM risk-
SCD). Eur Heart J. 2014;35(30):2010–2020.
41. Bos JM, Bos KM, Johnson JN, Moir C,
Ackerman MJ. Left cardiac sympathetic denerva-
tion in long QT syndrome: analysis of therapeutic
nonresponders. Circ Arrhythm Electrophysiol.
2013;6(4):705–711.
42. Mazzanti A, Trancuccio A, Kukavica D, et al.
Independent validation and clinical implications of
the risk prediction model for long QT syndrome
(1-2-3-LQTS-Risk). Europace. 2022;24(4):614–
619.
43. Ferrari GM de, Dusi V, Spazzolini C, et al.
Clinical management of catecholaminergic poly-
morphic ventricular tachycardia: the role of left
cardiac sympathetic denervation. Circulation.
2015;131(25):2185–2193.
44. Connolly SJ, Hallstrom AP, Cappato R, et al.
Meta-analysis of the implantable cardioverter
defibrillator secondary prevention trials. AVID,
CASH and CIDS studies. Antiarrhythmics vs
Implantable Defibrillator study. Cardiac Arrest
Study Hamburg Canadian Implantable Defibrillator
Study. Eur Heart J. 2000;21(24):2071–2078.
45. Maury P, Baratto F, Zeppenfeld K, et al. Radio-
frequency ablation as primary management of
well-tolerated sustained monomorphic ventricular
tachycardia in patients with structural heart dis-
ease and left ventricular ejection fraction over 30.
Eur Heart J. 2014;35(22):1479–1485.
46. Raitt MH, Renfroe EG, Epstein AE, et al.
“Stable” ventricular tachycardia is not a benign
rhythm: insights from the Antiarrhythmics versus
Implantable Defibrillators (AVID) registry. Circu-
lation. 2001;103(2):244–252.
47. Sapp JL, Wells GA, Parkash R, et al. Ventricular
tachycardia ablation versus escalation of antiar-
rhythmic drugs. N Engl J Med. 2016;375(2):111–
121.
48. Reddy VY, Reynolds MR, Neuzil P, et al. Pro-
phylactic catheter ablation for the prevention of
defibrillator therapy. N Engl J Med. 2007;357(26):
2657–2665.
49. Willems S, Tilz RR, Steven D, et al. Preventive
or Deferred Ablation of Ventricular Tachycardia in
Patients With Ischemic Cardiomyopathy and
Implantable Defibrillator (BERLIN VT): a multi-
-, NO. -, 2023
- 2023:-–-
center randomized trial. Circulation. 2020;141(13):
1057–1067.
50. Arenal Á, Ávila P, Jiménez-Candil J, et al.
Substrate ablation vs antiarrhythmic drug therapy
for symptomatic ventricular tachycardia. J Am Coll
Cardiol. 2022;79(15):1441–1453.
51. Della Bella P, Baratto F, Vergara P, et al. Does
timing of ventricular tachycardia ablation affect
prognosis in patients with an implantable car-
dioverter defibrillator? Results from the multi-
center randomized PARTITA trial. Circulation.
2022;145(25):1829–1838.
52. Tung R, Xue Y, Chen M, et al. First-line cath-
eter ablation of monomorphic ventricular tachy-
cardia in cardiomyopathy concurrent with
defibrillator implantation: the PAUSE-SCD ran-
domized trial. Circulation. 2022;145(25):1839–
1849.
53. Dukkipati SR, d’Avila A, Soejima K, et al. Long-
term outcomes of combined epicardial and endo-
cardial ablation of monomorphic ventricular
tachycardia related to hypertrophic cardiomyopa-
thy. Circ Arrhythm Electrophysiol. 2011;4(2):185–
194.
54. Igarashi M, Nogami A, Kurosaki K, et al. Radi-
ofrequency catheter ablation of ventricular
tachycardia in patients with hypertrophic cardio-
myopathy and apical aneurysm. J Am Coll Cardiol
EP. 2018;4(3):339–350.
55. Ling Z, Liu Z, Su L, et al. Radiofrequency
ablation versus antiarrhythmic medication for
treatment of ventricular premature beats from the
right ventricular outflow tract: prospective ran-
domized study. Circ Arrhythm Electrophysiol.
2014;7(2):237–243.
56. Priori SG, Blomström-Lundqvist C, Mazzanti A,
et al. 2015 ESC Guidelines for the management of
patients with ventricular arrhythmias and the
prevention of sudden cardiac death: the Task
Force for the Management of Patients with Ven-
tricular Arrhythmias and the Prevention of Sudden
Cardiac Death of the European Society of Cardi-
ology (ESC). Eur Heart J. 2015;36(41):2793–2867.
KEY WORDS AHA/ACC/HRS, CCS,
comparison, ESC, guidelines, ventricular
arrhythmias