Key Points from

VAs & SCD

Guidelines
Asst. Prof. Sarawuth Limprasert, MD
Phramongkutklao Hospital

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Public BLS and access to AEDs

● Survival rates of OHCA victims continue to remain alarmingly low

with an overall survival rate of <15%
● Bystander CPR + public access defibrillators → better outcome and
survival of OHCA patients

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Yan S, et al. Critical care 2020;24:61.
Hallstrom AP, et al. N Engl J Med 2004;351:637–46.
Kragholm K, et al. N Engl J Med 2017;376:1737–47.
Nakashima T, et al. Lancet 2019;394:2255–62.
Pollack RA, et al. Circulation 2018;137:2104–13.
Public BLS and access to AEDs
Public access AEDs

Bystanders CPR

Community BLS training

Mobile phone-based
alerting of BLS-trained
volunteers

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
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Definition of electrical storm

● ≥3 episodes of sustained VA occurring within 24 h

● Require either ATP or cardioversion/defibrillation
● Each event separated by at least 5 min

Consequence

● Psychological disorder
● HF decompression
● Increase mortality

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
Deep sedation/intubation
Catheter ablation

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Overdrive pacing
2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
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Genetic counselling and testing
● Genetic testing becomes routine part of the care in patients with
genetic cardiomyopathies and arrhythmia syndromes → impact for
both prognosis and treatment
● Generally, genetic testing is recommended when a condition with a
likely genetic basis and a risk of VA and SCD is diagnosed in a living
or deceased patient
○ DCM/HNDCM + Other risk factors or a FH of DCM
○ Sporadic cases under suspicious circumstances for an inherited
etiology e.g. ARVC, HCM, LQTS, Andersen-Tawil syndrome, BrS,
CPVT, and SQTS
○ Focused genetic testing in ERS and idiopathic VF

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 Living or deceased individual

Pathogenic / Likely pathogenic →

Genetic testing in first-degree and symptomatic relatives

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Increasing relevance of CMRI
● CMR not only for diagnostic evaluation of patients with newly
documented VA
○ when SHD not related to coronary artery disease is suspected
○ frequent PVCs
○ VT that are not typical for an idiopathic origin
● CMR in all survivors of SCA without a clear underlying cause &
relatives of decedents of SADS
● Notably, LGE on CMR is not (yet) recommended as an additional risk
marker in the HCM risk calculator, despite its association with an
increased risk of VAs

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Algorithms for AAD therapy
● AAD remain integral part of the m agement of VA as adjunctive
therapy, especially for symptomatic patients with frequent VA
● The recent guideline for the first time includes algorithms for
evaluation and follow-up of patients requiring sodium channel
blocking agents and QT-prolonging drugs
● At the same time AAD carry the risk of adverse events, e.g.
proarrhythmia

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 Algorithms for
AAD therapy
a
http://www.brugadadrugs.org

c
Co-administration of drugs with AV nodal
blocking effect in patients with AF or AFL

d
In ICD carriers, a higher risk of drug-induced
pro-arrhythmia might be accepted

f
A ΔQRS >25% is not an absolute cut-off value
but dependent on QRS width before drug
initiation and individualized patient risk–benefit
considerations

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
 Algorithms for
AAD therapy

a
http://www.crediblemeds.org

b
If strong indication and no alternative
treatment, consult a specialist

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
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Increasing value of catheter ablation in the
management of VA

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Hilke Könemann, et al. Europace. 2023 May 19;25(5):euad091.
Increasing value of catheter ablation in the
management of VA

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Hilke Könemann, et al. Europace. 2023 May 19;25(5):euad091.
Increasing value of catheter ablation in the
management of VA

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Hilke Könemann, et al. Europace. 2023 May 19;25(5):euad091.
Increasing value of catheter ablation in the
management of VA

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Hilke Könemann, et al. Europace. 2023 May 19;25(5):euad091.
Increasing value of catheter ablation in the
management of VA

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Hilke Könemann, et al. Europace. 2023 May 19;25(5):euad091.
Increasing value of catheter ablation in the
management of VA

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Hilke Könemann, et al. Europace. 2023 May 19;25(5):euad091.
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Algorithms for AAD therapy
● Generally, these new recommendations blaze a trail from a strong
focus on left ventricular function to ‘new’ risk markers which are also
taken into consideration for refining the SCD risk in patients with
intermediate risk

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†
Pathogenic mutations in LMNA, PLN, FLNC, and RBM20 genes

Hilke Könemann, et al. Europace. 2023 May 19;25(5):euad091.

Programmed
Electrical
Stimulation
(PES)

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
Programmed Electrical Stimulation (PES)

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
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HCM Risk-Kids model for SCD in childhood
HCM

https://hcmriskkids.org/

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
 https://lmna-risk-vta.fr/

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
https://1-2-3-lqt.unipv.it/

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2022 ESC Guidelines for the management of patients with VAs and the prevention of SCD
 CONCLUSION

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Conclusion - Key Points
● BLS training → Bystanders CPR + AEDs
● Electrical storm
○ Definition
○ Cause?
■ Inappropriate/Unnecessary ICD therapy → ICD programming
○ Therapy
■ Treat cause & consider catheter ablation
■ Medication
■ Overdrive pacing
■ Deep sedation/intubation
■ MCS

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■ Autonomic modulation
Conclusion - Key Points
● Genetic counselling and testing
○ Living or deceased individual
○ Pathogenic / Likely pathogenic → Genetic testing in first-degree
and symptomatic relatives
● Sodium channel blocker agents / drug associated with QT
prolongation
○ Contraindication/Precaution
○ Consider to change/reduce dose
■ Sodium channel blocker: △QRS >25% or
abnormal exercise test → new BBB, △QRS >25%, or QRS >130 ms
■ Drug associated QT prolongation: QT >500 ms

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Conclusion - Key Points
● Catheter ablation
○ Sustained VAs triggered by a PVC
○ CAD
■ Recurrent SMVT or ICD shocks despite medication
(amiodarone, beta-blocker, sotalol)
■ Hemodynamically well-tolerated SMVT + LVEF ≥40% (as an
alternative to ICD)
■ Before or immediately after ICD implantation
○ DCM/HNDC: BBRVT
○ Post TAVI: BBRVT
○ BrS: recurrent appropriate ICD shocks

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○ Idiopathic PVCs/VT: asymptomatic + PVC burden >20%
Conclusion - Key Points
● PES
○ CAD + LVEF 36-40% + NSVT or unexplained syncope
○ DCM/HNDCM: one of risk factors
○ ARVC + moderate RV or LV dysfunction
○ Asymptomatic spontaneous type I Brugada ECG

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THANK YOU
Q&A?
sarawuthlim@pmk.ac.th

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