Sudden cardiac death post arrest care and prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

See also Post cardiac arrest syndrome care pathway


Effective measures for the primary prevention of sudden cardiac death in individuals who are at risk of SCD but have not yet experienced an aborted cardiac arrest or life-threatening arrhythmias include ICD implantation based on the guideline. Secondary prevention strategy following aborted sudden cardiac death include revascularization in patients with ischemic heart disease and ICD implantation in patients with reduced left ventricular ejection fraction who had an experience of lethal arrhythmia. The optimal approach to prevention of SCD following ST-elevation MI (STEMI) has been evaluated in multiple randomized trials. In general, post-STEMI patients should be treated with evidence-based therapies that have been associated with a reduction in SCD including beta-blockers, ACE-inhibitors (or ARBs in patients who are ACEI intolerant) and statins. In patients who have symptomatic congestive heart failure (CHF), an aldosterone antagonist may be a reasonable additional therapy. Despite the intuitive benefits of antiarrhythmic, amiodarone and sotalol have not been shown to reduce all-cause mortality following STEMI, although amiodarone may be useful in reducing the frequency of shocks in patients with ICDs who have unacceptably high rates of shock. In general terms, ICD placement is indicated in those patients with a reduced left ventricular ejection fraction at 40 days post-MI and/or 3 months following revascularization (PCI or CABG) for STEMI given the survival benefits in this population.

Post Arrest Care and prevention


2017AHA/ACC/HRS Guideline for management of sudden cardiac arrest and ventricular arrhythmia

Abbreviations: MI: Myocardial infarction; VT: Ventricular tachycardia; VF: Ventricular fibrillation; LVEF: Left ventricular ejection fraction; ICD: Implantable cardioverter defibrillator; NYHA: New York Heart Association functional classification; LVAD: Left ventricular assist device; EPS: Electrophysiology study

Recommendations for primary prevention of sudden cardiac death in ischemic heart disease
ICD implantation (Class I, Level of Evidence A):

❑ In patients with LVEF≤ 35% and NYHA class 2,3 heart failure despite medical therapy, at least 40 days post MI or 90 days post revascularization with life expectancy > 1 year
1 year

ICD implantation (Class I, Level of Evidence B) :

❑ In patients with LVEF ≤ 40% and nonsustained VT due to prior MI or VT ,VF inducible in EPS with life expectancy >1 year

ICD implantation : (Class IIa, Level of Evidence B)

❑ In patients with NYHA class 4 who are candidates for cardiac transplantation or LVAD with life expectancy > 1 year

(Class III, Level of Evidence C)

ICD is not beneficial in patients with NYHA class 4 despite optimal medical therapy who are not candidates for cardiac transplantation or LVAD

Abbreviations: IHD: Ischemic heart disease; VT: Ventricular tachycardia; SCD: Sudden cardiac death; SCA: Sudden cardiac arrest; ICD: [Implantable cardioverter defibrillator[]]; EPS: Electrophysiologic study

Secondary prevention in patients with IHD
SCA survivor or sustained monomorph VT
Cardiac syncope
Yes: revascularization, reassessment about SCD risk (class1)
NO:ICD candidate
Yes:ICD (class1)
NO: medical therapy (class1)
NO:EP study (class 2a)
Ventriculat arrhythmia induction
Yes: ICD (class1)
NO: monitoring

Timing of Sudden Cardiac Death Following ST-elevation MI

Patients with STEMI are at risk of sudden cardiac death. The timing of sudden cardiac death following STEMI is as follows:

Medical Therapy to Prevent Sudden Death Following STEMI

Beta Blockers

ACE Inhibitor

Angiotensin II Receptor Blockers (ARBs)

Statin Therapy

Aldosterone Antagonists


Induced Hypothermia to Improve Neurological Outcome


Prevention of Sudden Death and Implantable Cardioverter Defibrillators Following STEMI

Consensus and CMS Indications for ICD Placement

The following are clear Grade 1 A or CMS supported recommendations for placement of an ICD:

Role of Electrophysiology Testing

  • Inducibiity and pharmacologic suppression of VT/VF on [[electrophysiologic studies] is no longer deemed to be relevant based upon the MUSTT study [17] and the MADITT I study [18].
  • Importantly, lack of inducibility on electrophysiological testing should not preclude implantation of an ICD.

The Benefit of ICD Implantation May Be Greater in Patients with a QRS Duration > 120 msec

  • In both SCD-HeFT and MADIT II, the reduction in SCD was greater in patients with a QRS duration > 120 msec.

Wearable Defibrillators

In patients with a large MI with a low EF who are awaiting permanent ICD implantation, the use of a wearable defibrillator is a reasonable strategy.

Cardiac resynchronization therapy (CRT) Combined with ICD Placement

Based upon the results of the COMPANION trial it is reasonable to place a combined ICD / CRT device in patients with the following:

See also


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