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Ventricular Arrhythmias in Acute Coronary Syndrome Patients: Therapy of Electrical Storm Tobias Willich* and Andreas Goette

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Ventricular Arrhythmias in Acute Coronary Syndrome Patients: Therapy of Electrical Storm Tobias Willich* and Andreas Goette Willich and Goette. Int J Crit Care Emerg Med 2015, 1:2 ISSN: 2474-3674 International Journal of Critical Care and Emergency Medicine Review Article: Open Access Ventricular Arrhythmias in Acute Coronary Syndrome Patients: Therapy of Electrical Storm Tobias Willich* and Andreas Goette Department of Cardiology and Intensive Care Medicine, St. Vincenz-Hospital, Germany *Corresponding author: Tobias Willich, Department of Cardiology and Intensive Care Medicine, St. Vincenz- Hospital, Am Busdorf 2, 33098 Paderborn, Germany, E-mail: [email protected] catecholaminergic polymorphic ventricular tachycardia (CPVT) and Abstract other genetic variants. The incidence of ES induced by ACS is difficult This review provides an overview of the available therapeutic to determine, because a great number of patients do not arrive alive options for acute care and management of malignant ventricular in hospitals [4,5]. arrhythmias (VA) such as ventricular tachycardia (VT), ventricular fibrillation (VF) and electrical storm (ES). As therapeutic options In ACS patients who arrive alive in hospital VA are common antiarrhythmic drug (AAD) therapy, implantable cardioverter during the early hours. According to recordings from implanted defibrillator therapy (ICD), radiofrequency catheter ablation (RFA) and neuroaxial modulation like stellate ganglion blockade or renal cardiac monitors, the incidence of non-sustained VT is 13%, of denervation are available. AAD therapy is limited. Amiodarone and sustained VT is 3%, and of VF is 3% in the early post myocardial- beta-blockers are the only option. An additional drug therapy with infarction period [6]. In another retrospective analysis of two ranolazine may be considered in specific subcohorts. The advantage randomized trials (GUSTO IIB and GUTSO III) sustained VA occurs of ICD therapy for long-term primary or secondary prophylactic in 6% of patients with ACS [7]. therapy has been well documented. ICD therapy is associated with significant reduction in mortality compared with AAD therapy. The increased prevalence of acute reperfusion strategies has RFA, stellate ganglion blockade and renal denervation are rather markedly reduced ES in patients with ACS during the last time. Also intended as therapeutically options for incessant VT/VF or ES. the use of angiotensin-converting enzyme inhibitors, angiotensin Keywords receptor blockers, beta-blockers and statins early after ACS has reduced the incidence of VA and ES [8]. Acute coronary syndrome, Ventricular arrhythmias, Electrical storm, Antiarrhythmic drug, Ranolazine, ICD therapy, Radiofrequency In the current setting of cardiac care units patients with sustained catheter ablation, Stellate ganglion blockade, Renal denervation, VA associated with an acute myocardial infarction are usually Left ventricular assist device characterized by the following features: severe and/or prolonged ischemia or arrhythmogenic substrates prior to the acute event. The Introduction main mechanisms are: Malignant ventricular arrhythmias (VA) encompass ventricular • Patients with cardiogenic shock or large severe acute tachycardia (VT) or ventricular fibrillation (VF). Three or more infarction for example by left main occlusion (cardiogenic shock). separate episodes of VT/VF occurring within 24 hours are defined • Patients with delayed reperfusion therapy mostly due to as electrical storm (ES). ES are the most dangerous heart rhythm delays between the first symptoms until transfer to an acute cardiac disturbance due to high risk of sudden cardiac death (SCD) [1]. SCD care center (late presenters). due to sustained VA is common in patients suffering from untreated acute coronary syndromes (ACS). The incidence of VA depends on • Patients in whom revascularization was not or only partially size of ischemic area, magnitude of autonomic imbalance, extend successful due to technical or anatomic difficulties (incomplete of acute strain as well as prior heart failure, reduced left ventricular revascularization). function (EF < 30%) and myocardial infarction. Patients with ST- • Patients with pre-existing reduced LV-function and elevation myocardial infarction have a 4-fold higher risk for VA myocardial scar due to prior myocardial infarction or heart failure than patients with non-ST-elevation myocardial infarction. The respectively cardiomyopathies (acquired cardiomyopathies). majority (90%) of VA in patients with ST-elevation myocardial infarction occurred within 48 hours, whereas 60% of VA in patients • Patients with inherited arrhythmogenic cardiomyopathies with non-ST-elevation myocardial infarction occurred after 48 hours or genetic predispositions (inherited cardiomyopathies). [2,3]. Incidence is further increased by inherited cardiomyopathies All this groups of patients with ACS are at increased risk of like long-QT-syndrome (LQTS), short-QT-syndrome, Wolff- sustained VA. Parkinson-White syndrome, Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy, The initiation of VA in patients with ACS depends on the Citation: Willich T, Goette A (2015) Ventricular Arrhythmias in Acute Coronary Syndrome Patients: Therapy of Electrical Storm. Int J Crit Care Emerg Med 1:006 ClinMed Received: August 11, 2015: Accepted: September 18, 2015: Published: September 21, 2015 International Library Copyright: © 2015 Willich T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. underlying disease and other concomitant diseases. The main compression-ventilation ratio of 30:2 is recommended; once an common dominant mechanisms are intramural re-entry in ischemia advanced airway has been inserted a continuous compression should and triggered activity in reperfusion [9-12]. The prognostic be performed without pauses for ventilation. It is recommended to significance of early (48 h) VF or sustained VT in patients with acute minimize interruptions in chest compressions. Whether a period of myocardial infarction is still controversial. In patients with acute CPR should be performed before defibrillation in VF is the subject myocardial infarction, early VF/VT identified those at increased risk of intense debate. There is insufficient evidence to recommend any for 30-day mortality (22% vs. 5%) as compared to those without VF/ specific waveform for defibrillation [22,24,25]. There is still no data VT [13]. showing that any drug improve long-term outcome after cardiac arrest [26]. Specific treatment of sustained or recurrent VA in patients with ACS In patients with cardiac arrest and in which an adequate circulation cannot be recovered, it is reasonable to use a mechanical During the last decade, recommendations and management of chest compression devices. A percutaneous LV assist device (LVAD) ACS and arrhythmias have changed significantly. The preferred first- or extracorporeal membrane oxygenation (ECMO) may be useful line management of patients with ACS is cardiac catheterization and as a bridge to recovery, in gaining time to implement and assist percutaneous coronary interventional therapy. Medical drug therapy appropriate therapies and prolonging survival [27]. This does not and thrombolysis of ACS has become less important. Treatment of apply to intra-aortic balloon pump (IABP). A recent meta-analysis VA consists of application of antiarrhythmic drugs (AAD), which shows overall no effect on the risk of in-hospital and long-term have limited efficacy in longtime. Therefore, interventional therapies mortality and trend toward a higher risk of in-hospital death with for treatment of VA are increasingly gaining importance. IABP support [28]. Primary treatment Drug treatment AAD is used in the acute and chronic treatment of VA. This use Beta-blockers and amiodarone were the only anti-arrhythmic has declined in recent years, since AAD may cause adverse events in drugs without severe pro-arrhythmic effects in patients with reduced patients with ischemic heart disease and are less effective in reducing left ventricular (LV)-function or coronary heart disease and therefore mortality than implantable cardioverter defibrillator (ICD) [14-16]. the first choices for AAD therapy of VA in patients with ACS. Although now non-drug therapies become more important AAD Beta-Blockade is an important treatment, which reduce the risk of provide a therapeutic option for the treatment in the acute setting recurrent VA by more than 50% [8,18,29]. The combination of beta- and are also used to treat refractory VA in ICD patients. But only blockers to amiodarone appears to reduce mortality [30,31]. limited data exists from clinical trials concerning the use of AAD in ACS. In general it can be said that controlled randomized trials In a systematic review of 5 studies (3 prospective, n = 93 patients; comparing different AAD in ACS are completely lacking. In ACS the 2 retrospective, n = 173 patients) in stable monomorphic VT (without affected myocardium in a time dependent-manner has different and acute myocardial infarction) all drugs are relatively ineffective to varying degrees of ischemia and reperfusion. This affects significantly convert stable sustained VT to sinus rhythm (about 20-40%) [32]. the occurrence of arrhythmias and the effects of AAD. Almost all The comparison between the medications shows, that amiodarone, AAD act in either in a voltage or rate-dependent matter, some ADD procainamide,
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