2015年ESC室性心律失常和心脏猝死预防管理指南

ESCGUIDELINES2015ESCGuidelinesforthemanagementofpatientswithventriculararrhythmiasandthepreventionofsuddencardiacdeathTheTaskForcefortheManagementofPatientswithVentricularArrhythmiasandthePreventionofSuddenCardiacDeathoftheEuropeanSocietyofCardiology(ESC)Endorsedby:AssociationforEuropeanPaediatricandCongenitalCardiology(AEPC)Authors/TaskForceMembers:SilviaG.Priori*(Chairperson)(Italy),CarinaBlomström-Lundqvist*(Co-chairperson)(Sweden),AndreaMazzanti†(Italy),NicoBloma(TheNetherlands),MartinBorggrefe(Germany),JohnCamm(UK),PerryMarkElliott(UK),DonnaFitzsimons(UK),RobertHatala(Slovakia),GerhardHindricks(Germany),PaulusKirchhof(UK/Germany),KeldKjeldsen(Denmark),Karl-HeinzKuck(Germany),AntonioHernandez-Madrid(Spain),NikolaosNikolaou(Greece),ToneM.Norekvål(Norway),ChristianSpaulding(France),andDirkJ.VanVeldhuisen(TheNetherlands)*Correspondingauthors:SilviaGiulianaPriori,DepartmentofMolecularMedicineUniversityofPavia,Cardiology&MolecularCardiology,IRCCSFondazioneSalvatoreMaugeri,ViaSalvatoreMaugeri10/10A,IT-27100Pavia,Italy,Tel:+390382592040,Fax:+390382592059,Email:silvia.priori@fsm.itCarinaBlomström-Lundqvist,DepartmentofCardiology,InstitutionofMedicalScience,UppsalaUniversity,SE-75185Uppsala,Sweden,Tel:+46186113113,Fax:+4618510243,Email:carina.blomstrom.lundqvist@akademiska.seaRepresentingtheAssociationforEuropeanPaediatricandCongenitalCardiology(AEPC).†AndreaMazzanti:Coordinator,affiliationlistedintheAppendix.ESCCommitteeforPracticeGuidelines(CPG)andNationalCardiacSocietiesdocumentreviewers:listedintheAppendix.ESCentitieshavingparticipatedinthedevelopmentofthisdocument:ESCAssociations:AcuteCardiovascularCareAssociation(ACCA),EuropeanAssociationofCardiovascularImaging(EACVI),EuropeanAssociationofPercutaneousCardiovascularInterventions(EAPCI),EuropeanHeartRhythmAssociation(EHRA),HeartFailureAssociation(HFA).ESCCouncils:CouncilforCardiologyPractice(CCP),CouncilonCardiovascularNursingandAlliedProfessions(CCNAP),CouncilonCardiovascularPrimaryCare(CCPC),CouncilonHypertension.ESCWorkingGroups:CardiacCellularElectrophysiology,CardiovascularPharmacotherapy,CardiovascularSurgery,Grown-upCongenitalHeartDisease,MyocardialandPericardialDiseases,PulmonaryCirculationandRightVentricularFunction,Thrombosis,ValvularHeartDisease.ThecontentoftheseEuropeanSocietyofCardiology(ESC)Guidelineshasbeenpublishedforpersonalandeducationaluseonly.Nocommercialuseisauthorized.NopartoftheESCGuidelinesmaybetranslatedorreproducedinanyformwithoutwrittenpermissionfromtheESC.PermissioncanbeobtaineduponsubmissionofawrittenrequesttoOxfordUniversityPress,thepublisheroftheEuropeanHeartJournalandthepartyauthorizedtohandlesuchpermissionsonbehalfoftheESC.Disclaimer:TheESCGuidelinesrepresenttheviewsoftheESCandwereproducedaftercarefulconsiderationofthescientificandmedicalknowledgeandtheevidenceavailableatthetimeoftheirpublication.TheESCisnotresponsibleintheeventofanycontradiction,discrepancyand/orambiguitybetweentheESCGuidelinesandanyotherofficialrecom-mendationsorguidelinesissuedbytherelevantpublichealthauthorities,inparticularinrelationtogooduseofhealthcareortherapeuticstrategies.Healthprofessionalsareencour-agedtotaketheESCGuidelinesfullyintoaccountwhenexercisingtheirclinicaljudgment,aswellasinthedeterminationandtheimplementationofpreventive,diagnosticortherapeuticmedicalstrategies;however,theESCGuidelinesdonotoverride,inanywaywhatsoever,theindividualresponsibilityofhealthprofessionalstomakeappropriateandaccuratedecisionsinconsiderationofeachpatient’shealthconditionandinconsultationwiththatpatientand,whereappropriateand/ornecessary,thepatient’scaregiver.NordotheESCGuidelinesexempthealthprofessionalsfromtakingintofullandcarefulconsiderationtherelevantofficialupdatedrecommendationsorguidelinesissuedbythecompetentpublichealthauthorities,inordertomanageeachpatient’scaseinlightofthescientificallyaccepteddatapursuanttotheirrespectiveethicalandprofessionalobligations.Itisalsothehealthprofessional’sresponsibilitytoverifytheapplicablerulesandregulationsrelatingtodrugsandmedicaldevicesatthetimeofprescription.&TheEuropeanSocietyofCardiologyandtheEuropeanRespiratorySociety2015.Allrightsreserved.Forpermissionspleaseemail:journals.permissions@oup.com.EuropeanHeartJournaldoi:10.1093/eurheartj/ehv316EuropeanHeartJournalAdvanceAccesspublishedAugust29,2015byguestonAugust29,2015DownloadedfromDocumentReviewers:PhilippeKolh(CPGReviewCoordinator)(Belgium),GregoryY.H.Lip(CPGReviewCoordinator)(UK),StefanAgewall(Norway),GonzaloBarón-Esquivias(Spain),GiuseppeBoriani(Italy),WernerBudts(Belgium),HéctorBueno(Spain),DavideCapodanno(Italy),ScipioneCarerj(Italy),MariaG.Crespo-Leiro(Spain),MartinCzerny(Switzerland),ChristiDeaton(UK),DobromirDobrev(Germany),ÇetinErol(Turkey),MaurizioGalderisi(Italy),BulentGorenek(Turkey),ThomasKriebel(Germany),PierLambiase(UK),PatrizioLancellotti(Belgium),DeirdreA.Lane(UK),IreneLang(Austria),AthanasiosJ.Manolis(Greece),JoaoMorais(Portugal),JavierMoreno(Spain),MassimoF.Piepoli(Italy),FransH.Rutten(TheNetherlands),BeataSredniawa(Poland),JoseL.Zamorano(Spain),andFaiezZannad(France)ThedisclosureformsofallexpertsinvolvedinthedevelopmentoftheseguidelinesareavailableontheESCwebsitehttp://www.escardio.org/guidelines------------------------------------------------------------------------------------------------------------------------------------------------------KeywordsAcutecoronarysyndrome†Cardiacresynchronizationtherapy†Cardiomyopathy†Congenitalheartdisease†Defibrillator†Guidelines†Heartfailure†Implantablecardioverterdefibrillator†Myocardialinfarction†Resuscitation†Stablecoronaryarterydisease†Suddencardiacdeath†Tachycardia†Valvularheartdisease†VentriculararrhythmiaTableofContentsAbbreviationsandacronyms........................41.Preamble...................................52.Introduction.................................62.1Structureoftheguidelines....................73.Definitions,epidemiologyandfutureperspectivesforthepreventionofsuddencardiacdeath....................73.1Epidemiologyofsuddencardiacdeath.............73.1.1Causesofsuddencardiacdeathindifferentagegroups..................................83.2Autopsyandmolecularautopsyinsuddendeathvictims.83.3Riskpredictionofsuddencardiacdeath...........83.3.1Individualswithoutknownheartdisease........93.3.2Patientswithischaemicheartdisease..........93.3.3Patientswithinheritablearrhythmogenicdiseases..93.4Preventionofsuddencardiacdeathinspecialsettings..93.4.1Screeningthegeneralpopulationfortheriskofsuddencardiacdeath.........................93.4.2Screeningfamilymembersofsuddendeathvictims..................................103.4.3Screeningpatientswithdocumentedorsuspectedventriculararrhythmias.......................103.4.3.1Clinicalhistory......................103.4.3.2Non-invasiveandinvasiveevaluation........114.Therapiesforventriculararrhythmias................144.1Treatmentofunderlyingheartdisease............144.2Pharmacotherapyforventriculararrhythmiaandpreventionofsuddencardiacdeath.................154.2.1Generalmanagement....................154.2.2Anti-arrhythmicdrugs....................154.2.2.1Beta-blockers.......................154.2.2.2Amiodarone.......................154.2.2.3Sotalol/d-sotalol.....................174.2.2.4Combinationtherapy..................174.2.3Patientswithacardioverterdefibrillator........174.2.4Electrolytes...........................174.2.5Otherdrugtherapy......................174.3Devicetherapy...........................174.3.1Implantablecardioverterdefibrillator..........174.3.1.1Secondarypreventionofsuddencardiacdeathandventriculartachycardia...................184.3.2Subcutaneousimplantablecardioverterdefibrillator...............................184.3.3Wearablecardioverterdefibrillator...........194.3.4Publicaccessdefibrillation.................194.4Acutetreatementofsustainedventriculararrhythmias..204.5Interventionaltherapy.......................224.5.1Catheterablation.......................224.5.1.1Patientswithscar-relatedheartdisease......224.5.1.2Patientswithoutovertstructuralheartdisease.224.5.2Anti-arrhythmicsurgery...................234.6Psychosocialimpactofimplantablecardioverterdefibrillatortreatment.........................235.Managementofventriculararrhythmiasandpreventionofsuddencardiacdeathincoronaryarterydisease...........245.1Acutecoronarysyndromes...................245.1.1Ventriculararrhythmiasassociatedwithacutecoronarysyndromes........................245.1.2Preventionandmanagementofsuddencardiacdeathassociatedwithacutecoronarysyndromes:pre-hospitalphase...................................245.1.3Preventionofsuddencardiacdeathassociatedwithacutecoronarysyndromes:in-hospitalphase.........245.1.3.1Ventriculararrhythmiasinacutecoronarysyndromes..............................265.1.3.2Useofanti-arrhythmicdrugsinacutecoronarysyndromes—generalconsiderations.............26ESCGuidelinesPage2of87byguestonAugust29,2015Downloadedfrom5.1.3.3Patientswithacutecoronarysyndromesandnoventriculararrhythmias......................265.1.3.4Prematureventricularcomplexes..........265.1.3.5SustainedVTandVF..................265.1.3.6Catheterablationofrecurrentsustainedventriculartachycardia,recurrentventricularfibrillation,andelectricalstorm........................265.1.3.7Extracorporealsupportdevices...........275.1.3.8Bradycardiaandheartblock.............275.1.4Theprognosticroleofearlyventricularfibrillation..275.2Earlyaftermyocardialinfarction................275.2.1Riskstratificationforsuddencardiacdeath.......275.2.2Timingofimplantablecardioverterdefibrillatorplacementaftermyocardialinfarction—assessmentofleftventriculardysfunctionbeforeandafterdischarge......275.3Stablecoronaryarterydiseaseaftermyocardialinfarctionwithpreservedejectionfraction...................285.3.1Riskstratification.......................285.3.2Recommendationsforoptimalstrategy.........285.3.3Useofanti-arrhythmicdrugs................285.3.4Catheterablation.......................296.Therapiesforpatientswithleftventriculardysfunction,withorwithoutheartfailure.............................296.1Primarypreventionofsuddencardiacdeath.........296.1.1Drugs...............................296.1.2Implantablecardioverterdefibrillators..........306.1.3ImplantablecardioverterdefibrillatorsinpatientswithNewYorkHeartAssociationclassIVlistedforhearttransplantation.............................316.1.4Cardiacresynchronizationtherapy............316.1.4.1HeartfailurewithreducedleftventricularejectionfractionandNewYorkHeartAssociationclassIII/ambulatoryclassIV......................316.1.4.2Heartfailurewithreducedleftventricularejectionfractionbutmildsymptoms(NewYorkHeartAssociationclassII)........................336.2Prematureventricularcomplexesinpatientswithstructuralheartdisease/leftventriculardysfunction.......336.3Sustainedventriculartachycardia................336.3.1Drugtherapy..........................336.3.2Catheterablation.......................346.3.2.1Patientswithleftventriculardysfunction.....346.3.2.2Bundlebranchre-entranttachycardia.......356.3.3Implantablecardioverterdefibrillator..........357.Cardiomyopathies.............................357.1Dilatedcardiomyopathy......................357.1.1Definitions,epidemiology,andsurvivaldata......357.1.2Approachtoriskstratificationandmanagement...357.1.2.1Trialsofimplantablecardioverterdefibrillatortherapyindilatedcardiomyopathy..............367.1.2.2Primaryprophylaxis...................367.1.2.3Secondaryprophylaxis.................377.1.2.4Cause-specificmortality................377.1.2.5Managementofventriculararrhythmiaindilatedcardiomyopathy..........................377.1.2.6Ablationofventriculartachycardia.........377.2Hypertrophiccardiomyopathy..................377.2.1Definitions,epidemiology,andsurvivaldata......377.2.2Approachtoriskstratificationandmanagement...377.2.3Ventriculararrhythmiasinhypertrophiccardiomyopathy............................387.2.4Approachtoriskstratificationandmanagementinadultspatients.............................387.2.5Approachtoriskstratificationandmanagementinpaediatricpatients...........................387.2.6Preventionofsuddencardiacdeath...........387.2.6.1Drugsandlifestyleadvice...............387.2.6.2Implantablecardioverterdefibrillators.......397.3Arrhythmogenicrightventricularcardiomyopathy.....397.3.1Definitions,epidemiology,andsurvival.........397.3.2Approachtoriskstratificationandmanagement....397.3.3Ventriculararrhythmiasinarrhythmogenicrightventricularcardiomyopathy....................397.3.3.1Treatmentofventriculararrhythmia.......407.3.3.2Exerciserestriction...................407.3.3.3Implantablecardioverterdefibrillators.......407.4Infiltrativecardiomyopathies...................407.4.1Cardiacamyloidosis.....................407.5Restrictivecardiomyopathy....................407.6Othercardiomyopathies.....................417.6.1Left-ventricularnon-compaction.............417.6.2Chagas’cardiomyopathy...................418.Inheritedprimaryarrhythmiasyndromes..............418.1LongQTsyndrome........................418.1.1Definitionsandepidemiology...............418.1.2Approachtoriskstratificationandmanagement...428.2ShortQTsyndrome........................438.2.1Definitionsandepidemiology...............438.2.2Approachtoriskstratificationandmanagement...438.3Brugadasyndrome.........................448.3.1Definitionsandepidemiology...............448.3.2Approachtoriskstratificationandmanagement...448.4Catecholaminergicpolymorphicventriculartachycardia.458.4.1Definitionsandepidemiology...............458.4.2Approachtoriskstratificationandmanagement...458.5Earlyrepolarizationsyndrome..................468.5.1Definitionsandepidemiology...............469.Paediatricarrhythmiasandcongenitalheartdisease.......469.1Managementofventriculararrhythmiasinchildrenwithastructurallynormalheart........................469.2Suddencardiacdeathandventriculararrhythmiasinpatientswithcongenitalheartdisease................479.3Implantablecardioverterdefibrillatortherapyinpaediatricpatients...................................4810.Ventriculartachycardiasandventricularfibrillationinstructurallynormalhearts..........................4910.1Outflowtractventriculartachycardias............4910.1.1Rightventricularoutflowtracttachycardias.....5010.1.2Leftventricularoutflowtracttachycardias......5010.1.3Aorticcuspventriculartachycardias..........50ESCGuidelinesPage3of87byguestonAugust29,2015Downloadedfrom10.1.4Epicardialoutflowtractventriculartachycardias..5010.1.5Others(includingpulmonaryarteries).........5010.2Ventriculartachycardiasofmiscellaneousorigin.....5010.2.1Idiopathicleftventriculartachycardia..........5110.2.2Papillarymuscleventriculartachycardia........5110.2.3Annularventriculartachycardia(mitralandtricuspid)................................5110.3Idiopathicventricularfibrillation................5110.4Short-coupledtorsadedepointes..............5211.Inflammatory,rheumaticandvalvularheartdiseases......5211.1Myocarditis.............................5311.1.1Acuteandfulminantmyocarditis............5311.1.2Myocarditisleadingtoinflammatorycardiomyopathy............................5411.2Endocarditis.............................5411.3Rheumaticheartdisease.....................5411.4Pericarditis.............................5411.5Cardiacsarcoidosis........................5411.6Valvularheartdisease......................5512.Arrhythmicriskinselectedpopulations..............5512.1Psychiatricpatients........................5512.1.1Epidemiology.........................5612.1.2Diagnosis...........................5612.1.3Treatment...........................5612.2Neurologicalpatients.......................5712.2.1Suddenunexplaineddeathinepilepsy.........5712.2.2Neuromusculardisorders.................5712.3Pregnantpatients.........................5812.3.1Arrhythmiasnotrelatedtoperipartumcardiomyopathy............................5812.3.1.1Epidemiology......................5812.3.1.2Diagnosis.........................5912.3.1.3Treatment.......................5912.3.2Arrhythmiasrelatedtoperipartumcardiomyopathy5912.4Obstructivesleepapnoea....................6012.4.1Bradyarrhythmiasand–tachyarrhythmias.......6012.4.1.1Epidemiology......................6012.4.1.2Diagnosis.........................6012.4.1.3Treatment........................6012.5Drug-relatedpro-arrhythmia..................6012.5.1Drug–substrateinteraction,duetounderlyingdiseasesubstrate...........................6012.5.2Drug–druginteraction(duetospecificdrugsandcombinations).............................6112.5.3Pro-arrhythmicriskofanti-arrhythmicdrugs.....6112.5.4Pro-arrhythmiaduetotriggeringfactors.......6112.6Suddencardiacdeathafterhearttransplantation....6112.7Suddencardiacdeathinathletes...............6112.8Wolff–Parkinson–Whitesyndrome.............6212.9Preventionofsuddencardiacdeathintheelderly....6412.10End-of-lifeissues.........................6413.Gapsinevidence.............................6414.Todoandnottodomessagesfromtheguidelines.......6515.Webaddenda...............................6616.Appendix..................................6617.References.................................67AbbreviationsandacronymsACCAmericanCollegeofCardiologyACEangiotensin-convertingenzymeACSacutecoronarysyndromeAFatrialfibrillationAGNESArrhythmiaGeneticsintheNetherlandsAHAAmericanHeartAssociationAMIOVIRTAMIOdaroneVersusImplantablecardiover-ter-defibrillator:RandomizedTrialinpatientswithnon-ischaemicdilatedcardiomyopathyandasymptomaticnon-sustainedventriculartachycardiaARBangiotensinIIreceptorblockerARVCarrhythmogenicrightventricularcardiomyopathyAVatrio-ventricularAVIDAntiarrhythmicdrugsVersusImplantableDefibrillatorBrSBrugadaSyndromeCADcoronaryarterydiseaseCARE-HFCArdiacREsynchronization–HeartFailureCASHCardiacArrestStudyHamburgCASTCardiacArrhythmiaSuppressionTrialCATCArdiomyopathyTrialCHDcongenitalheartdiseaseCIconfidenceintervalCIDSCanadianImplantableDefibrillatorStudyCMRcardiacmagneticresonanceCOMPANIONComparisonofMedicalTherapy,Pacing,andDefibrillationinHeartFailureCPGCommitteeforPracticeGuidelinesCPVTcatecholaminergicpolymorphicventriculartachycardiaCRTcardiacresynchronizationtherapyCRT-DcardiacresynchronizationtherapydefibrillatorCRT-PcardiacresynchronizationtherapypacemakerCTcomputedtomographyDCMdilatedcardiomyopathyDEFINITEDEFIbrillatorsinNon-Ischemiccardiomyop-athyTreatmentEvaluationDFTdefibrillationthresholdDIAMONDDanishInvestigatorsofArrhythmiaandMortalityoNDofetilideECGelectrocardiogram/electrocardiographicEHRAEuropeanHeartRhythmAssociationEPSelectrophysiologicalstudyESCEuropeanSocietyofCardiologyGWASgenome-wideassociationstudyHCMhypertrophiccardiomyopathyHFheartfailureHFpEFheartfailurewithpreservedejectionfractionHFrEFheartfailurewithreducedejectionfractionHRhazardratioi.v.intravenousESCGuidelinesPage4of87byguestonAugust29,2015DownloadedfromICDimplantablecardioverterdefibrillatorILCORInternationalLiaisonCommitteeOnResuscitationIRISImmediateRiskstratificationImprovesSurvivalLBBBleftbundlebranchblockLMNAlaminA/CLQTSlongQTsyndromeLQTS1longQTsyndrometype1LQTS2longQTsyndrometype2LQTS3longQTsyndrometype3LVleftventricle/leftventricularLVEFleftventricularejectionfractionLVOTleftventricularoutflowtractMADITMulticenterAutomaticDefibrillatorImplant-ationTrialMIRACLEMulticenterInSyncRandomizedClinicalEvaluationMRAmineralocorticoidreceptorantagonistmsmillisecondMUSTTMulticenterUnSustainedTachycardiaTrialNSTEMInon–ST-segmentelevationmyocardialinfarctionNSVTnon-sustainedventriculartachycardiaNYHANewYorkHeartAssociationOPTICOptimalPharmacologicalTherapyInCardio-verterdefibrillatorpatientsORoddsratioOToutflowtractPRESERVE-EFriskstratificationinpatientswithpreservedejectionfractionPVCprematureventricularcomplexPVSprogrammedventricularstimulationQTccorrectedQTRAFTResynchronization–DefibrillationforAmbu-latoryHeartFailureTrialRBBBrightbundlebranchblockRCTrandomizedcontrolledtrialREVERSEREsynchronizationreVErsesRemodelinginSystolicleftvEntriculardysfuncti