The 2022 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias (VA) and the Prevention of Sudden Cardiac Death (SCD) include recommendations aimed at improving patients’ quality of life.
Here is a summary of the new sections, concepts, and updates from the European Society of Cardiology (ESC) document.
New Sections and Concepts in the 2022 ESC Guidelines
Diagnostic Provocative Tests (5.1.3.5)
The Guidelines suggest the following intravenous tests:
Ajmaline — Indicated when there is a family history of Brugada Syndrome (BrS) or Sudden Arrhythmic Death Syndrome (SADS). Also recommended for patients with resuscitated cardiac arrest (CA) without structural heart disease (SHD).
Flecainide — Same conditions as for Ajmaline.
Epinephrine — Recommended for patients with Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) and those with resuscitated CA when an exercise test is not feasible.
Acetylcholine — Used when there is suspicion of coronary vasospasm.
Genetic Testing (5.1.4)
The diagnostic utility of many previous genetic associations has been questioned. Therefore, the Guidelines do not recommend including questionable genes in routine panels.
Testing should be performed by multidisciplinary teams with expertise in genetic counseling and cardiology.
A negative result does not exclude a diagnosis and should not be used to rule out disease.
Diagnostic Evaluation of Initial Symptoms of Ventricular Arrhythmia (5.2)
Ventricular arrhythmias (VA) and sudden cardiac death (SCD) can often be the first manifestations of undiagnosed heart conditions.
The ESC recommends comprehensive evaluation for five common scenarios:
Incidental finding of non-sustained ventricular tachycardia.
Initial presentation of sustained monomorphic ventricular tachycardia.
Survivor of sudden cardiac arrest.
Victim of sudden death.
Relatives of individuals who died from sudden arrhythmic death syndrome.
Management of Patients with Electrical Storm (6.1.3)
Some recommendations include:
Sedation (mild to moderate) to alleviate distress and reduce sympathetic tone.
Beta-blockers (preferably non-selective) plus intravenous amiodarone for SHD patients unless contraindicated.
Magnesium and potassium supplementation for Torsades de Pointes (TdP).
Isoproterenol or transvenous pacing for acquired Long QT Syndrome (LQTS) with recurrent TdP.
Catheter ablation for incessant VT or electrical storm due to sustained monomorphic VT (SMVT) refractory to antiarrhythmic drugs.
Device Therapy (6.2.3)
Key recommendations:
Optimize ICD programming to avoid unnecessary therapies and reduce mortality.
Minimize ventricular pacing when not indicated.
Prolonged detection settings (6–12 seconds or ≥30 intervals).
Primary prevention ICDs: Program therapy zone ≥188 bpm.
Antitachycardia pacing (ATP) recommended for all tachycardia zones.
SVT/VT discrimination algorithms up to 230 bpm.
Lead failure alerts and remote monitoring activation.
Burst ATP preferred over ramp ATP.
S-ICDs: Dual detection zones with activated discrimination algorithm.
New 2022 Recommendations
Public Basic Life Support and AED Access
Public-access defibrillation should be available in high-risk locations.
Encouraging community training in basic life support is crucial to increase CPR rates and AED use by bystanders.
Treatment of Ventricular Arrhythmia (VA)
Continuous electrical cardioversion is first-line for tolerated sustained monomorphic VT (SMVT) if anesthesia risk is low.
Optimal medical therapy includes ACEIs, ARBs, ARNIs, MRAs, beta-blockers, and SGLT2 inhibitors for patients with heart failure and reduced ejection fraction.
ICD implantation recommended only when good-quality survival exceeds one year.
Coronary Artery Disease (CAD)
For patients with recurrent SMVT or ICD shocks despite amiodarone therapy:
Catheter ablation is preferred over increasing antiarrhythmic drugs.
Exercise and cardiopulmonary testing recommended post-surgery for anomalous aortic origin of coronary arteries.
Idiopathic Ventricular Fibrillation (IVF)
Diagnosis of idiopathic ventricular fibrillation should be made in survivors of sudden cardiac arrest, with VF documentation and after excluding structural, metabolic, or toxic causes.
Brugada Syndrome (BrS)
Genetic testing for the SCN5A gene is recommended for probands with Brugada Syndrome.
Short QT Syndrome (SQTS)
The 2022 ESC Guidelines suggest genetic testing in patients diagnosed with SQTS.
We hope this summary helps you stay informed about the 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.
References
2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.
European Society of Cardiology (ESC)