Expert Opinion

Comment on the ESC Guidelines 2022 for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

Abstract

The European Society of Cardiology guidelines for the management of sudden cardiac death and ventricular arrhythmias have been updated. Additions and amendments range from clinical management to invasive procedures, and provide new perspectives on integrated management, genetic testing, stratification of risk, arrhythmia ablation and device therapy among others. Significant improvements have been made, which will result in better care for patients and families.

Disclosure:DCC is president of the Spanish Heart Rhythm Association and is a section editor of European Cardiology Review; this did not influence peer review.

Received:

Accepted:

Published online:

Correspondence Details:David Calvo Cuervo, Arrhythmia Unit, Hospital Universitario Clínico San Carlos, Calle del Prof Martín Lagos, S/N, 28040 Madrid, Spain. E: dcalvo307@secardiologia.es

Open Access:

This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

Sudden cardiac death (SCD) and ventricular arrhythmias (VA) are responsible for a significant proportion of deaths, so have a tremendous impact not only on patients and medical practice but also on families, the health authorities and the general population, and are often featured on social media.

Stratification of risk in patients, their relatives and the healthy population remains a major challenge, with the scientific community continuously committed to providing new knowledge.

The new edition of the ESC guidelines on VA and SCD condenses most of the more recent advances in relation to these conditions.1 Maybe the most influential of its updates, with direct translation into clinical practice, could be summarised as:

  • Clinical and imaging variables other than left ventricle ejection fraction are being recognised as strong predictors of VA and SCD for many specific pathologies. This is especially the case for dilated and hypokinetic non-dilated cardiomyopathy of inherited aetiology, inflammatory disease (e.g. cardiac sarcoidosis), infiltrative diseases and neuromuscular disorders. We can now see that the dominance of ejection fraction as the definitive predictor is approaching its end, despite it remaining a pillar of risk stratification.
  • New conditions in secondary prevention are now open for discussion in terms of VA ablation as a potential solution. That means avoiding ICD in patients with chronic ischaemic cardiomyopathy and myocarditis if ejection fraction is outside the limits for usual ICD implantation (>40%), provided that appropriate endpoints of the ablation procedure are reached. Still under evaluation, this is a promising therapeutic approach with the potential to avoid the myriad of complications and psychophysical problems experienced by patients who have an ICD implanted.
  • Genetic testing is highlighted as a powerful tool for diagnosis and stratification of risk depending on the nature of the pathology.2 Closely linked to family screening, both are pillars of clinical management of SCD victims and survivors, with an emphasis on molecular autopsy and DNA extraction. This section is a call to attention for clinicians and health authorities to take action in this area, with efforts to develop working networks that have the ability to provide efficient diagnosis, which will have major implications for patients and their families.
  • No less important, the guidelines promote for the first time, with the highest recommendation (class I), the usefulness of community training in basic life support (e.g. to children at school with repeated programmes) and, by virtue of their potential benefits, automated external defibrillators being accessible at sites where cardiac arrest is more likely to occur. This is another important call to attention for clinicians, health authorities, governments and the general population.

Of course, there are a significant number of additional items that readers will notice. However, even this recently published good work misses some data. The results of simultaneously published trials regarding the value of VA ablation over antiarrhythmic drugs means some statements in the present guideline are obsolete.3 Nonetheless, the overall recommendations will help to improve management and the stratification of risk.

References

  1. Zeppenfeld K, Tfelt-Hansen J, Riva M de, et al. 2022 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022:ehac262.
    Crossref | PubMed
  2. Escobar-Lopez L, Ochoa JP, Mirelis JG, et al. Association of genetic variants with outcomes in patients with nonischemic dilated cardiomyopathy. J Am Coll Cardiol 2021;78:1682–99.
    Crossref | PubMed
  3. Arenal Á, Ávila P, Jiménez-Candil J, et al. Substrate ablation vs antiarrhythmic drug therapy for symptomatic ventricular tachycardia. J Am Coll Cardiol 2022;79:1441–53.
    Crossref | PubMed