Vt

1. c
1

2. Definitions
• Syncope;
2

3. Incessant VT: Continuous for hours despite therapy
Frequent VT: >30/ hour
Very Frequent VT: > 10000 - 20000 / day 3

4. ACS
• Polymorphic mostly
• Monomorphic
Not ACS
4

5. General evaluation documented or
suspected VT
1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
5

6. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
• HISTORY
• FAMILY HOSTORY
• EXAMINATION
6

7. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
Stable VT 12 Lead ECG during WCT
 12 Lead ECG Sinus
ETT for Exercise induced arrhythmias
1.Symptoms on exertion
2.IHD
3.CPVT
7

8. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
Symptoms
are caused by VA
8

9. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
Sporadic Symptoms
9

10. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
ECHO for structure and function
CT / MRI
10

11. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
BNP
NT Pro-BNP
For predicting SCA and SCD
11

12. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
Patients and family
Counselling
For those with
Recommended Genetic testing
See expert concensus document
12

13. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
SCA
13

14. General evaluation documented or
suspected VT1. Syncope
2. ECG / ETT
3. Ambulatory ECG
4. Implantable monitor
5. Imaging
6. Biomarkers
7. Genetic
8. Cath / CCTA
9. EP
Risk assessment in
1. ICM
2. NICM
3. ACHD
Not candidates for Primary ICD
1. ICD CANDIDIATES
2. LONG QT
3. SHORT QT
4. CPVT
5. Early Repolarization Syndrome
14

15. Therapies for Prevention
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
15

16. Therapies for Prevention
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
Only Beta Blockers have survival benefit
(RCT proven)
16

17. Therapies for Prevention
• Some special uses
• Atenolol ARVC , LQTs
• Ditiazem RVOT VT, LVT
• Verapamil RVOT VT, LVT
• Flecainide CPVT
• Mexiletine LQT3, T
• Nadolol LQTs, CPVT
• PropranololLQTs
• Quinidine T, sQT, B
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
17

18. Therapies for Prevention
BB reduce mortality in
• HFrEF
• MI
• Polymorphic VT after MI
• Acute BB in MI increase mortality
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
18

19. Therapies for Prevention
In patients taking diuretics monitor both
• Potassium
• Magnessium
Replace both if deficient
IV Mg post MI  No mortality benefit at 30 days
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
19

20. Therapies for Prevention
PUFA
Initial studies showed mortality benefit and less SCD
Later studies showed no benefit, no harm
Statins
Benefit in IHD MADIT-CRT, SCD-HeFT, AVID, DEFINITE
No Benefit in HF Rosuvastatin in CORONA, GISSI-HF
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
20

21. Therapies for Prevention
HFrEF ( <40%)
1. BB
2. ACE/ARB/ARNI
3. MRA
Reduce risk of SCD
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
21

22. Therapies for Prevention
External
Transvenous
Implantable (SQ)
wearable
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
22

23. Therapies for Prevention
Monomorphic refractory VT
After Meds and catheter ablation fail
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
23

24. Therapies for Prevention
• Non life threatening VT
BB
• VT / VF storm  BB + other meds + catheter fail 
Cardiac sympathetic denervation
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
24

25. Therapies for Prevention
• VA / SCA
• Anomalous origin of coronary is the cause
• Medicines
• Defibs
• Catheter Ablation
• Surgical Ablation
• Autonomic Modulation
• Revasc.
BUT Revasc alone is not enough in case of prior MI and Monomorphic VT
25

26. Acute Management Of VA / Cardiac
Arrest
• CPRACLS
• IV Amiodarone after 1 max energy shock
• DCC
• STEMI + Polymorphic VT  Urgent C.Angiogram + Revasc.
• WCT is VT if unclear
• Stable VT  IV Procainamide (not in unstable)
• VF/ polymorph VT  CPR+ Defib + Adrenaline fail  LIDOCAINE
• Polymorphic VT due to Ischemia  IV BB ( trials on ACLS vs BB )
• Recent MI with VT/VF Storm despite DCC and Meds  IV BB
• Adrenaline 1mg every 3-5 min
• Stable VT  IV Amio / Sotalol
• HIGH dose Adrenaline
• Mg ( without torsades )
• Prophylactic lidocaine
• Verapamil/diltiazem
26

27. Sub Cutaneous - Defibs
• If Indication for PACING or CRT or ATP
• Inadequate vascular access / high risk for
infection
• Otherwise
27

28. Wearable Defib
• REMOVAL OF ICD
– ICD + SCA/VA ( 2ndry Prevention )
• Not indication for ICD but Risk of SCD
– Within 40/90 days with EF<35
– Transplant candidates
– Myocarditis
– Secondary CM
– Systemic Infection
28

29. Catheter Ablation
• Bundle Branch Reentrant VT
• Epicardial Ablation for SHD with failed
endocardial ablation
29

30. Post Mortem
• Cardiac specific autopsy for SCD
• SCD <40y
– Cardiac evaluation
– Genetic counselling
– Genetic testing of 1st degree RELATIVES
• Post Mortem Genetic testing ( if confirm OR clue on autopsy)
30

31. Terminal Care
• Inform that it can be DEACTIVATED any time
– At time of implatantion
• End of Life/ Terminally ill  Discuss
Deactivation
31

32. Shared Decision
• Shared Decision ( health goals & evidence )
• Inform Risk of SCD and non sudden DEATH,
Effectiveness, Complications
32

33. Specific Conditions: Ongoing
Management
1. IHD
2. NICM
3. ARVC
4. HCM
5. Myocarditis
6. Sarcoidosis
7. HF
8. NM disorders
9. LQT
10. sQT
11. Brugada
12. CPVT
13. J wave
14. IF ( LVT )
15. OT VTs
16. PM
17. IP VT
18. PVC – induced CM
19. Athletes
20. Pregnancy
21. CKD
22. Elderly
23. Meds induced
24. ACHD
33

34. IHD
• ICD
Primary Prevention
Secondary Prevention
Coronary Spasm
Post CABG • 40/90 days post MI/ Revsc.
• GDMT
• Survival >1 yr
NYHA II-III
EF < 35
NYHA I
EF < 30
NSVT
EF <40
EP inducible
NYHA IV
LVAD/T
NYHA IV
NO LVAD/T
ECG; ECHO; SYMPTOMS
34

35. IHDPrimary Prevention
Secondary Prevention
Coronary Spasm
Post CABG
35

36. IHDPrimary Prevention
Secondary Prevention
Coronary Spasm
Post CABG
36

37. IHDPrimary Prevention
Secondary Prevention
Coronary Spasm
Post CABG
ICD for
SCA/VT
No reversible Cause
Syncope
EP
inducible
Question. What If MI presents with SCA
Will you put ICD or wait? 37

38. IHDPrimary Prevention
Secondary Prevention
Coronary Spasm
Post CABG
38

39. IHDPrimary Prevention
Secondary Prevention
Coronary Spasm
Post CABG RECURRENT VA despite Beta Blockers
• AMIODARONE / SOTALOL
• STORM & failed Amiodarone or others  Catheter Ablation
• Catheter Ablation as 1st Line
• Class 1c drugs
• ICD for Incessant VT
• ReVasc alone for Monomorphic VT
39

40. IHDPrimary Prevention
Secondary Prevention
Coronary Spasm
Post CABG
40

41. IHDPrimary Prevention
Secondary Prevention
Coronary Spasm
Post CABG
• Ca Ch. Blocker
• Smoking cessation
Trial used
1. Diltiazem
2. Verapamil
3. Amlodipine
4. Nifedipine
Ineffective medical therapy ICD
ICD in addition to Medical therapy
41

42. IHDPrimary Prevention
Secondary Prevention
Coronary Spasm
Post CABG
POLYMORPHIC (Treat the Cause : Ischemia)
MONOMORPHIC (Scar/graft for CTO)
Same recommendations for SCA/VA
Only LV dysfuntion NSVT with LV dysfunction
EP inducible ICD
Reasses LV after 3 Months
LV improves
EARLY POST CABG PHASE
WCD meanwhile
VERY EARLY
Within 24 hours is due to Reperfusion
Acid base/electrolytes
42

43. NICM
VERY EARLY
Within 24 hours is due to Reperfusion
Acid base/electrolytes
MRI for risk of SCA/SCD
Suspected infiltration  MRI
NICM + Conduction disease / LV dys / FH of SCD + <40 yo  Genetic counselling and Testing
43

44. NICM
VERY EARLY
Within 24 hours is due to Reperfusion
Acid base/electrolytesPrimary Prevention ICD
Secondary Prevention
Recurrent
EF<35
NYHA II-III
NYHA IV
No LVAD/T
EF<35
NYHA I
Lamin A/C
Mutation plus
2 risk factors
• NSVT
• EF<45
• Nonmissense
• male
Should be on GDMT for 3 Months
Meanwhile WCD
44

45. NICM
VERY EARLY
Within 24 hours is due to Reperfusion
Acid base/electrolytesPrimary Prevention ICD
Secondary Prevention
Recurrent
SCA
NO reversible Cause
Syncope  EP +
SCA but
Inelligible for ICD
 Amiodarone
EP has less Value than in IHD.
Some prefer ICD even if EP is negative
45

46. NICM
VERY EARLY
Within 24 hours is due to Reperfusion
Acid base/electrolytesPrimary Prevention ICD
Secondary Prevention
Recurrent
RECURRENT VA despite Beta Blockers
• AMIODARONE / SOTALOL
• STORM & failed Amiodarone or others  Catheter Ablation
OPTIC TRIAL: most benefit with BB+A
46

47. • Myocarditis
• Sarcoidosis
• LVAD
• Transplant
• REFER
• GCM + GDMT+ SCA ICD
47

48. • Myocarditis
• Sarcoidosis
• LVAD
• Transplant SCA / EF < 35  ICD
Syncope / Scar ( MRI/PET)/PPM ICD
EP
Immunosuppression
Don’t put PPM alone; put ICD
48

49. • Myocarditis
• Sarcoidosis
• LVAD
• Transplant
VA  ICD
49

50. • Myocarditis
• Sarcoidosis
• LVAD
• Transplant
2ndry  same indications
Vasculopathy + LV dysfunction  ICD
50

51. Genetic diseases
VERY EARLY
Within 24 hours is due to Reperfusion
Acid base/electrolytes
ARVC
HCM
NMD
SCA  ICD
Genetic counselling and testing of patient
Genetic counselling and testing of 1st RELATIVES
Suspected ARVC
• MRI
• SAECG
SCA/ LVEF /RVEF<35
• BB
• Avoid Exercise
• ICD
• Genetic
LVEF >35
• BB
• EP
Syncope
ICD
51

52. Genetic diseases
VERY EARLY
Within 24 hours is due to Reperfusion
Acid base/electrolytes
ARVC
HCM
NMD
SCA  ICD
Genetic counselling and testing of patient
Genetic counselling and testing of 1st RELATIVES
Risk Stratification
RELATIVESECG + ECHO
Established risk factor
• LVWT > 30mm
• Syncope < 6 m
• FH of SCD
NSVT/ abnormal ETT
+HIGH RISK or
RISK MODIFIER
• ANEURYSM
• <30 yo
• HOCM
• Syncope >5 y
• MRI
NO RISK Factor even if Gene +  ICD
52
NSVT/ abnormal ETT
Without HIGH RISK or
RISK MODIFIER
Amiodarone
If no ICD
EP

53. Genetic diseases
VERY EARLY
Within 24 hours is due to Reperfusion
Acid base/electrolytes
ARVC
HCM
NMD
Same as NICM
Emery- Dreifuss & Limb Girdle Type 1B  ICD
Follow up even asymptomatic
MD 1 + PPM  ICD ( like Sarcoidosis )
53

54. Channelopathies• Brugada
• CPVT
• LQT
• sQT
• J wave
SCA  ICD
Genetic counselling and testing of 1st RELATIVES
NO ICD for Asymptomatic low risk even with FH
NO Primary Prevention ICD
GeneticC/T of Pt
OBSERVE
SCA ICD
Recurrent  Quinidine / Ablation
NO ICD Quinidine / Ablation
EP for asymptomatic
Not in any other ch.pathy
54

55. Channelopathies• Brugada
• CPVT
• LQT
• sQT
• J wave
SCA  ICD
Genetic counselling and testing of 1st RELATIVES
NO ICD for Asymptomatic low risk even with FH
NO Primary Prevention ICD
GeneticC/T of Pt
BB
Recurrent despite BB ICD/ Denervation / Inc. MEDS
55

56. Channelopathies• Brugada
• CPVT
• LQT
• sQT
• J wave
SCA  ICD
Genetic counselling and testing of 1st RELATIVES
NO ICD for Asymptomatic low risk even with FH
Primary Prevention ICD
GeneticC/T of Pt
ECG lying/standing/ ETT
<470 BB
>470 BB
>500 Despite BB  Inc MEDS/ Denerve/ ICD
Recurrent VA despite BB ICD/ Denervation / Inc. MEDS
Recurrent VA after ICD & BB  Denerve/ Inc MEDS
QT Pr. DRUGS 56

57. Channelopathies• Brugada
• CPVT
• LQT
• sQT
• J wave
SCA  ICD
Genetic counselling and testing of 1st RELATIVES
NO ICD for Asymptomatic low risk even with FH
NO Primary Prevention ICD
GeneticC/T of Pt
OBSERVE
Recurrent  quinidine
Storm Isoprpterenol infusion
57

58. Channelopathies• Brugada
• CPVT
• LQT
• sQT
• J wave
SCA  ICD
Genetic counselling and testing of 1st RELATIVES
NO ICD for Asymptomatic low risk even with FH
NO Primary Prevention ICD
GeneticC/T of Pt
OBSERVE
58

59. Disease Primary Prevevntion CLASS Secondary Prevention CLASS
HCM
FH of SCD Iia
SCA
SYNCOPE
I
LVWT>30mm Iia
NSVT/BP
with HIGH RISK/MODIFIER
Iia
NSVT/BP Iib
ARC RVEF/LVEF<35% I
SCA I
Syncope Iia
LQT
High Risk despite BB I
SCA I
>500 IIb
CPVT
SCA I
Syncope
VT Despite BB
I
Brugada
SCA
Syncope
I
J wave SCA I
sQT SCA I
SARCOIDOSIS
LVEF<35% I SCA I
Scar ( MRI/ PET ) IIa
Syncope IIaPPM indication IIa
EP inducible IIa
HF Waiting for transplant IIa Cause dependent
NMD
Emery-Dreifuss/L-G 1B IIa
as NICM
MD 1 PPM indication IIb
59

60. Normal Heart
• Outflow Tract / Annular
• Inter Fascicular
• Papillary Muscle
• Idiopathic Polymorphic Symptomatic PVC  BB/ CCB
Fail VA Anti arrhythmic
Symptomatic meds fail  Ablation
60

61. Normal Heart
• Outflow Tract / Annular
• Inter Fascicular
• Papillary Muscle
• Idiopathic Polymorphic Symptomatic PVC  BB/ CCB
Fail VA Anti arrhythmic
Symptomatic meds fail  Ablation
• IV VERAPAMIL for Termination
• Chronic Verapamil
61

62. Normal Heart
• Outflow Tract / Annular
• Inter Fascicular
• Papillary Muscle
• Idiopathic Polymorphic Symptomatic PVC  BB/ CCB
Fail VA Anti arrhythmic
Symptomatic meds fail  Ablation
62

63. Normal Heart
• Outflow Tract / Annular
• Inter Fascicular
• Papillary Muscle
• Idiopathic Polymorphic
SCAICD
Recurrent  Ablation
If <40  do genetic workup
63

64. PVC induced CMP
Symptomatic PVC  BB/ AMIODARONE
Symptomatic meds fail  Ablation
64

65. • Pregnancy
• CKD
• Valvular
• Old Age
• Meds
• ACHD
Continue BB
ICD ABLATION after 1st trimester
DCC safe
65

66. • Pregnancy
• CKD
• Valvular
• Old Age
• Meds
• ACHD
Indivisualize
66

67. • Pregnancy
• CKD
• Valvular
• Old Age
• Meds
• ACHD
GDMT
67

68. • Pregnancy
• CKD
• Valvular
• Old Age
• Meds
• ACHD
ICD IF INDICATED
68

69. • Pregnancy
• CKD
• Valvular
• Old Age
• Meds
• ACHD
DIG FAB FOR VA
Mg for tdp
Mg fail  Pacing/Isoproterenol
K—> 4
Mg >2
QT pr
69

70. • Pregnancy
• CKD
• Valvular
• Old Age
• Meds
• ACHD
TOF + VAICD
TOF + HIGH RISK  EP
SCA ICD after treatment of residual
Recurrent Ablation
Repaired severe BB
Repaired + Syncope+ LV dys ICD / EP
LVEF <35 + GDMT  ICD
Prophylactic meds
Repair the residual by cath or surgery
Evaluate for coronary anomalies
70

71. Bye bye
71