Clinical Review & Education
JAMA Cardiology Clinical Guidelines Synopsis
Management of Ventricular Arrhythmias
and Sudden Cardiac Death Risk Related to Ischemic
and Nonischemic Cardiomyopathy
Sana M. Al-Khatib, MD, MHS; William G. Stevenson, MD
GUIDELINE TITLE 2017 AHA/ACC/HRS Guideline for
Management of Patients With Ventricular Arrhythmias
and the Prevention of Sudden Cardiac Death
DEVELOPERS American Heart Association (AHA), American
College of Cardiology (ACC), and Heart Rhythm Society (HRS)
RELEASE DATE October 30, 2017 (online)
PRIOR VERSIONS September 5, 2006
FUNDING SOURCE AHA/ACC/HRS
TARGET POPULATION Adults with ventricular arrhythmias
(VAs) and/or at risk for sudden cardiac death (SCD)
MAJOR RECOMMENDATIONS:
• In patients with heart failure and a left-ventricular ejection frac-
tion or 40% or less, treatment with a β-blocker, a mineralocor-
ticoid receptor antagonist, and either an angiotensin-
converting enzyme inhibitor, an angiotensin-receptor blocker,
or an angiotensin receptor-neprilysin inhibitor is recommended
to reduce SCD and all-cause mortality (high-quality evidence).
• In patients with ischemic cardiomyopathy or nonischemic car-
diomyopathy (NICM) who either survive a cardiac arrest due to
a VA or experience hemodynamically unstable ventricular
tachycardia (VT) or stable VT not due to a reversible cause, an
implantable cardioverter defibrillator (ICD) is recommended
(moderate-quality evidence).
• In patients with ischemic cardiomyopathy and unexplained
syncope who have inducible, sustained monomorphic VT on
an electrophysiology study, an ICD is recommended (moder-
ate-quality evidence).
• In patients with VA resulting from coronary artery spasm,
maximally tolerated doses of a calcium channel blocker and
smoking cessation are recommended (moderate-quality evi-
dence). In such patients, if cardiac arrest occurs despite medi-
cal therapy or if medical therapy is not tolerated, an ICD is rea-
Summary of the Clinical Problem
Ventricular arrhythmias are a major cause of morbidity and mortal-
ity and they account for a substantial number of SCDs.1 Therefore,
it is imperative for clinicians to identify patients at risk of develop-
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sonable (moderate-quality evidence); however, even if medi-
cal therapy appears to be effective and well tolerated, adding
an ICD may be reasonable (moderate-quality evidence).
• In patients with a left-ventricular ejection fraction of 35% or
less due to ischemic cardiomyopathy who are at least 40
days post-myocardial infarction (MI) and at least 90 days
post-revascularization and in patients with NICM, and with
New York Heart Association (NYHA) class II or III heart failure
despite guideline-directed medical therapy, an ICD is recom-
mended (high-quality evidence).
• In patients with a left-ventricular ejection fraction of 30% or
less due to ischemic cardiomyopathy who are at least 40 days
post-MI and at least 90 days postrevascularization, and with
NYHA class I heart failure despite guideline-directed medical
therapy, an ICD is recommended (high-quality evidence).
• In nonhospitalized patients with NYHA class IV symptoms who
are candidates for cardiac transplantation or a left-ventricular
assist device, an ICD is reasonable (moderate-quality evidence).
• An ICD is not indicated in patients with medication-refrac-
tory NYHA class IV heart failure symptoms who are not also
candidates for advanced heart failure therapies (low-quality
evidence).
• In patients with ischemic cardiomyopathy or NICM and
recurrent VA causing ICD shocks, despite optimal ICD
programming and ongoing therapy with a β-blocker, amioda-
rone, or sotalol is useful (moderate-quality evidence).
• In patients with prior MI and recurrent symptomatic sus-
tained VT, or who present with VT storm and have failed or
are intolerant of antiarrhythmic medications, catheter abla-
tion is recommended (moderate-quality evidence); if such
patients have NICM, catheter ablation for VA can be useful
(moderate-quality evidence).
• In patients with ischemic cardiomyopathy and sustained
monomorphic VT, coronary revascularization alone is inef-
fective to prevent recurrent VT (low-quality evidence).
• In patients with NICM who experience unexplained syncope
and who do not meet indications for a primary prevention
ICD, an ICD or an electrophysiology study can be beneficial
(moderate-quality evidence).
ing VAs and SCD and to intervene promptly to reduce that risk. Pa-
tients with ischemic cardiomyopathy or NICM can be at a high risk
of VAs and SCD.1,2 Therefore, when such patients present with syn-
cope for which VA is documented or suspected, they should be hos-
(Reprinted) JAMA Cardiology Published online April 11, 2018 E1
 Clinical Review & Education JAMA Cardiology Clinical Guidelines Synopsis

pitalized for evaluation, monitoring, and management. The workup
of patients presenting with symptoms suggestive of VAs should in-
clude a 12-lead electrocardiogram; ambulatory electrocardio-
graphic monitoring, and if needed, an implantable loop recorder; and
noninvasive and/or invasive
imaging studies to assess heart
Supplemental content function and rule out ischemic
heart disease when indicated.2
In some patients, an electrophysiology study may be needed.2 Even
in the absence of symptoms, some patients with ischemic cardio-
myopathy or NICM warrant implantation of an ICD to reduce the risk
of SCD.2
Characteristics of the Guideline Source
This guideline was developed by the AHA, the ACC, and the HRS.2
The guideline writing committee comprised 19 members: 12 adult
electrophysiologists, 1 pediatric electrophysiologist, 1 pediatric car-
diologist, 3 general cardiologists (1 with expertise in heart failure), 1
geriatrician with expertise in shared decision making, and 1 patient/
consumer representative.
All recommendations in the guideline document were
assigned a class of recommendation and a level of evidence.2 The
class of recommendation is a measure of the strength of the rec-
ommendation that is determined by an assessment of the esti-
mated benefit vis-à-vis the risk; a class I recommendation indi-
cates that the benefit of an intervention far exceeds its risk, class
IIa indicates that the benefit of the intervention moderately
exceeds the risk, class IIb indicates that the benefit may not
exceed the risk, and class III signifies that the benefit is equivalent
to or is exceeded by the risk. The level of evidence appraises the
quality of the scientific evidence that supports the intervention.
The level of evidence can be A (evidence from high-quality ran-
domized clinical trials), B-R (evidence from moderate-quality ran-
domized clinical trials), B-NR (evidence from well-designed, non-
randomized studies), C-LD (evidence from randomized or
nonrandomized studies with limitations of design or execution), or
C-EO (expert opinion based on clinical practice).2 The chair and a
majority of the guideline-writing committee members had no rel-
evant relations with industry.
Evidence Base
For the ongoing management of therapy for patients with ischemic
cardiomyopathy or NICM who have VAs or are at risk of SCD, the rec-
ommendations covered the importance of excluding reversible
causes for VAs (eg, ischemia), pharmacologic treatment, an ICD (or
a subcutaneous ICD in some patients), and catheter ablation. An ex-
tensive review of the literature was conducted through March 2017.
To be reviewed, studies had to involve human participants, be pub-
lished in English, and be indexed in MEDLINE (through PubMed),
EMBASE, the Cochrane Library, or the Agency for Healthcare Re-
search and Quality. Studies resulting from the literature search were
systematically reviewed.2
Of 29 recommendations involving the ongoing management of
therapy for patients with ischemic cardiomyopathy or NICM who
have VAs or are at risk of SCD, 12 were class I recommendations, 8
were class IIa recommendations, 4 were class IIb recommenda-
tions, and 5 were class III recommendations. Of the 12 class I rec-
ommendations, 4 had a level of evidence A, 2 had a level of evi-
dence B-R, 3 had a combination of level of evidence B-R and B-NR,
and 3 had a level of evidence B-NR. Of the 29 recommendations, 4
were supported by high-quality evidence and 19 were supported by
moderate-quality evidence.2
Benefits and Harms
The benefits and risks of each therapy were carefully considered. The
main recommendations on the ongoing management of therapy for
patients with ischemic cardiomyopathy or NICM who have VAs or
are at risk of SCD are presented in the Supplement.2
Discussion
The majority of recommendations for the ongoing management of
therapy for patients with ischemic cardiomyopathy or NICM were
based on high- and moderate-quality evidence that should inform
clinical practice for many years.2
Areas in Need of Future Study or Ongoing Research
Areas in need of future research include the identification of pa-
tients who are most likely to benefit from an ICD among ICD-
eligible patients, characterizing the role of the ICD in patient sub-
groups not included in the pivotal ICD randomized clinical trials,
finding methods to identify and treat patients at high individual risk
for SCD who are not identified by current ICD eligibility criteria; de-
termining the best approach to patients who need elective ICD gen-
erator replacement due to battery depletion, but who may no lon-
ger be at low risk for SCA due to a significant improvement in left
ventricular ejection fraction; and obtaining more data on the effi-
cacy and effectiveness of the subcutaneous ICD, compared with
transvenous ICDs. In addition, randomized clinical trials on cath-
eter ablation of VT are needed to evaluate procedural end points,
mortality, quality of life, and cost.

ARTICLE INFORMATION
Author Affiliations: Division of Cardiology and
Duke Clinical Research Institute, Duke University
Hospital, Durham, North Carolina (Al-Khatib);
Cardiovascular Division, Vanderbilt University
Medical Center, Nashville, Tennessee (Stevenson).
Corresponding Author: Sana M. Al-Khatib, MD,
MHS, Duke Clinical Research Institute, 2400 Pratt
Street, Durham, NC 27705 (sana.alkhatib@duke
.edu).
Published Online: April 11, 2018.
doi:10.1001/jamacardio.2018.0016
Conflict of Interest Disclosures: Both authors 2. Al-Khatib SM, Stevenson WG, Ackerman MJ,
have completed and submitted the ICMJE Form for et al. AHA/ACC/HRS guideline for management of
Disclosure of Potential Conflicts of Interest. Dr patients with ventricular arrhythmias and the
Stevenson reports having received consultation prevention of sudden cardiac death [published
fees from St Jude Medical and speaking fees from online October 30, 2017]. Circulation.
Boston Scientific. He is a coholder of a patent for
needle ablation consigned to Brigham Hospital. No
other disclosures are reported.
REFERENCES
1. Myerburg RJ, Goldberger JJ. Sudden cardiac
arrest risk assessment: population science and the
individual risk mandate. JAMA Cardiol. 2017;2(6):
689-694.

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