European Heart Journal Advance Access published August 29, 2015 European Heart Journal ESC GUIDELINES doi:10.1093/eurheartj/ehv316 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 Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC) Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC) Authors/Task Force Members: Silvia G. Priori* (Chairperson) (Italy), Carina Blomstro¨ m-Lundqvist* (Co-chairperson) (Sweden), Andrea Mazzanti† (Italy), Nico Bloma (The Netherlands), Martin Borggrefe (Germany), John Camm (UK), Perry Mark Elliott (UK), Donna Fitzsimons (UK), Robert Hatala (Slovakia), Gerhard Hindricks (Germany), Paulus Kirchhof (UK/Germany), Keld Kjeldsen (Denmark), Karl-Heinz Kuck (Germany), Antonio Hernandez-Madrid (Spain), Nikolaos Nikolaou (Greece), Tone M. Norekva˚l (Norway), Christian Spaulding (France), and Dirk J. Van Veldhuisen (The Netherlands) * Corresponding authors: Silvia Giuliana Priori, Department of Molecular Medicine University of Pavia, Cardiology & Molecular Cardiology, IRCCS Fondazione Salvatore Maugeri, Via Salvatore Maugeri 10/10A, IT-27100 Pavia, Italy, Tel: +39 0382 592 040, Fax: +39 0382 592 059, Email: [email protected] Carina Blomstro¨m-Lundqvist, Department of Cardiology, Institution of Medical Science, Uppsala University, SE-751 85 Uppsala, Sweden, Tel: +46 18 611 3113, Fax: +46 18 510 243, Email: [email protected] aRepresenting the Association for European Paediatric and Congenital Cardiology (AEPC). †Andrea Mazzanti: Coordinator, affiliation listed in the Appendix. ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers: listed in the Appendix. ESC entities having participated in the development of this document: ESC Associations: Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA). ESC Councils: Council for Cardiology Practice (CCP), Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council on Cardiovascular Primary Care (CCPC), Council on Hypertension. ESC Working Groups: Cardiac Cellular Electrophysiology, Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Grown-up Congenital Heart Disease, Myocardial and Pericardial Diseases, Pulmonary Circulation and Right Ventricular Function, Thrombosis, Valvular Heart Disease. The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer: The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom- mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour- aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. & The European Society of Cardiology and the European Respiratory Society 2015. All rights reserved. For permissions please email: [email protected]. Page 2 of 87 ESC Guidelines Document Reviewers: Philippe Kolh (CPG Review Coordinator) (Belgium), Gregory Y. H. Lip (CPG Review Coordinator) (UK), Stefan Agewall (Norway), Gonzalo Baro´ n-Esquivias (Spain), Giuseppe Boriani (Italy), Werner Budts (Belgium), He´ctor Bueno (Spain), Davide Capodanno (Italy), Scipione Carerj (Italy), Maria G. Crespo-Leiro (Spain), Martin Czerny (Switzerland), Christi Deaton (UK), Dobromir Dobrev (Germany), Çetin Erol (Turkey), Maurizio Galderisi (Italy), Bulent Gorenek (Turkey), Thomas Kriebel (Germany), Pier Lambiase (UK), Patrizio Lancellotti (Belgium), Deirdre A. Lane (UK), Irene Lang (Austria), Athanasios J. Manolis (Greece), Joao Morais (Portugal), Javier Moreno (Spain), Massimo F. Piepoli (Italy), Frans H. Rutten (The Netherlands), Beata Sredniawa (Poland), Jose L. Zamorano (Spain), and Faiez Zannad (France) The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines ------------------------------------------------------------------------------------------------------------------------------------------------------ Keywords Acute coronary syndrome † Cardiac resynchronization therapy † Cardiomyopathy † Congenital heart disease † Defibrillator † Guidelines † Heart failure † Implantable cardioverter defibrillator † Myocardial infarction † Resuscitation † Stable coronary artery disease † Sudden cardiac death † Tachycardia † Valvular heart disease † Ventricular arrhythmia Table of Contents 4.2.2.4 Combination therapy . 17 4.2.3 Patients with a cardioverter defibrillator . 17 Abbreviations and acronyms . 4 4.2.4 Electrolytes . 17 1. Preamble . 5 4.2.5 Other drug therapy . 17 2. Introduction . 6 4.3 Device therapy . 17 2.1 Structure of the guidelines . 7 4.3.1 Implantable cardioverter defibrillator . 17 3. Definitions, epidemiology and future perspectives for the 4.3.1.1 Secondary prevention of sudden cardiac death prevention of sudden cardiac death . 7 and ventricular tachycardia . 18 3.1 Epidemiology of sudden cardiac death . 7 4.3.2 Subcutaneous implantable cardioverter 3.1.1 Causes of sudden cardiac death in different age defibrillator . 18 groups . 8 4.3.3 Wearable cardioverter defibrillator . 19 3.2 Autopsy and molecular autopsy in sudden death victims . 8 4.3.4 Public access defibrillation . 19 3.3 Risk prediction of sudden cardiac death . 8 4.4 Acute treatement of sustained ventricular arrhythmias . 20 3.3.1 Individuals without known heart disease . 9 4.5 Interventional therapy . 22 3.3.2 Patients with ischaemic heart disease . 9 4.5.1 Catheter ablation . 22 3.3.3 Patients with inheritable arrhythmogenic diseases . 9 4.5.1.1 Patients with scar-related heart disease . 22 3.4 Prevention of sudden cardiac death in special settings . 9 4.5.1.2 Patients without overt structural heart disease . 22 3.4.1 Screening the general population for the risk of 4.5.2 Anti-arrhythmic surgery . 23 sudden cardiac death . 9 4.6 Psychosocial impact of implantable cardioverter 3.4.2 Screening family members of sudden death defibrillator treatment . 23 victims . 10 5. Management of ventricular arrhythmias and prevention of 3.4.3 Screening patients with documented or suspected sudden cardiac death in coronary artery disease . 24 ventricular arrhythmias . 10 5.1 Acute coronary syndromes . 24 3.4.3.1 Clinical history . 10 5.1.1 Ventricular arrhythmias associated with acute 3.4.3.2 Non-invasive and invasive evaluation . 11 coronary syndromes . 24 4. Therapies for ventricular arrhythmias . 14 5.1.2 Prevention and management of sudden cardiac death 4.1 Treatment of underlying heart disease . 14 associated with acute coronary syndromes: pre-hospital 4.2 Pharmacotherapy for ventricular arrhythmia and phase . 24 prevention of sudden cardiac death . 15 5.1.3 Prevention of sudden cardiac death associated with 4.2.1 General management . 15 acute coronary syndromes: in-hospital phase . 24 4.2.2 Anti-arrhythmic drugs . 15 5.1.3.1 Ventricular arrhythmias in acute coronary 4.2.2.1 Beta-blockers . 15 syndromes . 26 4.2.2.2 Amiodarone . 15 5.1.3.2 Use of anti-arrhythmic drugs in acute coronary 4.2.2.3 Sotalol/d-sotalol . 17 syndromes—general considerations . 26 ESC Guidelines Page 3 of 87 5.1.3.3 Patients with acute coronary syndromes and no 7.1.2.6 Ablation of ventricular tachycardia . 37 ventricular arrhythmias . 26 7.2 Hypertrophic cardiomyopathy . 37 5.1.3.4 Premature ventricular complexes . 26 7.2.1 Definitions, epidemiology, and survival data . 37 5.1.3.5 Sustained VT and VF . 26 7.2.2 Approach to risk stratification and management . 37 5.1.3.6 Catheter ablation of recurrent sustained 7.2.3 Ventricular arrhythmias