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Ventricular arrhythmias

Key sources
The following summarized guidelines for the evaluation and management of ventricular arrhythmias are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2022), the American Heart Association (AHA/HRS/ACC 2018), and the American College of Endocrinology (ACE/AACE 2016).
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Guidelines

1.Diagnostic investigations

Electrocardiogram: as per ESC 2022 guidelines, obtain a baseline 12-lead ECG and record the VA on a 12-lead ECG whenever possible in patients with newly documented VA (frequent premature ventricular complexes, nonsustained ventricular tachycardia, sustained monomorphic ventricular tachycardia).
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  • Holter monitoring

  • Implantable cardiac monitors

  • Echocardiography

  • Cardiac MRI

  • Natriuretic peptides

  • Genetic testing

  • Psychosocial assessment

  • Evaluation for reversible causes

  • Evaluation of premature ventricular complexes

  • Evaluation of PVC-induced cardiomyopathy

  • Evaluation of idiopathic ventricular tachycardia/VF

  • Evaluation of sudden cardiac arrest survivors

  • Evaluation of SCD victims

  • Evaluation of relatives of sudden arrhythmic death syndrome decedents

2.Diagnostic procedures

Electrophysiology study: as per ESC 2022 guidelines, consider obtaining electrophysiological testing, electroanatomical mapping, and performing mapping-guided biopsies for etiological evaluation in patients presenting with a first sustained monomorphic ventricular tachycardia episode.
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3.Medical management

Shared decision-making
Adopt a shared decision-making approach for treatment decisions in patients with VA or at increased risk for SCD based on the best available evidence as well as the patient's health goals, preferences, and values.
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Inform patients considering implantation of a new ICD or replacement of an existing ICD for a low battery about their individual risk of SCD and non-sudden death from HF or non-cardiac conditions, and the effectiveness, safety and potential complications of the ICD in light of their health goals, preferences, and values.
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  • Withdrawal of offending agents

  • Management of cardiac arrest

  • Management of sustained ventricular tachycardia

  • Management of electrical storm

  • Management of idiopathic ventricular tachycardia/VF

  • Management of premature ventricular complexes

  • Management of PVC-induced cardiomyopathy

  • Management of HF

  • Beta-blockers

  • Antiarrhythmic agents

  • Intravenous amiodarone

  • Intravenous procainamide

  • Intravenous magnesium

  • Intravenous sotalol

  • Intravenous CCBs

  • End-of-life care

4.Nonpharmacologic interventions

Cardiopulmonary resuscitation: as per ESC 2022 guidelines, perform prompt CPR by bystanders at out-of-hospital cardiac arrest.
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5.Therapeutic procedures

Implantable cardioverter-defibrillator, indications: consider assessing the need for ICD implantation based on an individual evaluation of the risk of subsequent VA/SCD despite a possible correctable cause for the presenting VA.
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  • ICD (technical considerations)

  • ICD (optimization of device programming)

  • Wearable cardioverter-defibrillator

  • Catheter ablation (acute management)

  • Catheter ablation (secondary prevention)

  • Catheter ablation (concomitant treatment)

6.Specific circumstances

Athletes: consider obtaining pre-participation cardiovascular evaluation in competitive athletes.
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  • Elderly patients

  • Pregnant patients

  • Patients with obesity

  • Heart transplant recipients

  • Patients with outflow tract VA

  • Patients with papillary muscle VA

  • Patients with interfascicular reentrant ventricular tachycardia

  • Patients with medication-induced arrhythmia

  • Patients with ACS

  • Patients with coronary artery spasm

  • Patients with coronary artery disease (evaluation)

  • Patients with coronary artery disease (management)

  • Patients with coronary artery disease (primary prevention of SCD)

  • Patients with coronary artery disease (secondary prevention of SCD)

  • Patients with coronary artery disease (management of recurrent VA)

  • Patients with coronary anomalies

  • Patients with dilated cardiomyopathy (evaluation)

  • Patients with dilated cardiomyopathy (primary prevention of SCD)

  • Patients with dilated cardiomyopathy (secondary prevention of SCD)

  • Patients with nonischemic cardiomyopathy (evaluation)

  • Patients with nonischemic cardiomyopathy (primary prevention of SCD)

  • Patients with nonischemic cardiomyopathy (secondary prevention of SCD)

  • Patients with nonischemic cardiomyopathy (management of recurrent VA)

  • Patients with arrhythmogenic RV cardiomyopathy (evaluation)

  • Patients with arrhythmogenic RV cardiomyopathy (primary prevention of SCD)

  • Patients with arrhythmogenic RV cardiomyopathy (secondary prevention of SCD)

  • Patients with HCM (evaluation)

  • Patients with HCM (primary prevention of SCD)

  • Patients with HCM (secondary prevention of SCD)

  • Patients with LV non-compaction cardiomyopathy

  • Patients with neuromuscular disorders (evaluation)

  • Patients with neuromuscular disorders (management)

  • Patients with myocarditis

  • Patients with cardiac amyloidosis

  • Patients with cardiac sarcoidosis (primary prevention of SCD)

  • Patients with cardiac sarcoidosis (secondary prevention of SCD)

  • Patients with Chagas cardiomyopathy

  • Patients with VHD

  • Patients with congenital heart disease (evaluation)

  • Patients with congenital heart disease (management)

  • Patients with long QT syndrome (evaluation)

  • Patients with long QT syndrome (management)

  • Patients with Andersen-Tawil syndrome (evaluation)

  • Patients with Andersen-Tawil syndrome (management)

  • Patients with short QT syndrome (evaluation)

  • Patients with short QT syndrome (management)

  • Patients with Brugada syndrome (evaluation)

  • Patients with Brugada syndrome (management)

  • Patients with early repolarization pattern (evaluation)

  • Patients with early repolarization pattern (management)

  • Patients with catecholaminergic polymorphic ventricular tachycardia (evaluation)

  • Patients with catecholaminergic polymorphic ventricular tachycardia (management)

7.Quality improvement

Public access defibrillation
Ensure public access defibrillation is available at sites where cardiac arrest is more likely to occur.
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Promote community training in basic life support to increase bystander CPR rate and automated external defibrillator use.
B