Secondary prevention of sudden cardiac death

Abstract

The prevention and treatment of sudden cardiac death (SCD) remains a significant public health challenge. For patients with a history of sudden death attributable to ventricular arrhythmia, implantable cardioverter-defibrillator (ICD) therapy is a mainstay of treatment, although these patients remain at high risk for recurrent ventricular arrhythmia and defibrillator therapies. In this review, we summarize landmark clinical trials evaluating the efficacy of ICD therapy in secondary prevention patients, review clinical outcomes including mode of death in survivors of SCD, and highlight the role for systematic diagnostic evaluation. We additionally discuss the invasive electrophysiological management of these patients, including ICD selection and programming as well as the role and timing of antiarrhythmic drug therapy and catheter ablation. Finally, we frame future challenges and needs to advance the care for secondary prevention patients.

Keywords: Cardiac arrest; Epidemiology; Implantable cardioverter-defibrillator; Prevention; Sudden death; Ventricular arrhythmia.

Figure 1

Systematic protocol for evaluation of secondary prevention patient. Shown is a proposed systematic protocol for the evaluation of a patient following an arrhythmic cardiac arrest. A: The illustration highlights the role of a postresuscitation electrocardiogram (ECG) and reflects the indication for urgent coronary angiography vs deferred coronary angiography. B: The illustration highlights the role for systematic imaging (echocardiography, cardiac magnetic resonance imaging [MRI]), ECG, and continuous telemetry in patients without an acute ischemic mechanism of ventricular arrhythmia. Etiologies of interest potentially suggested by various modalities are highlighted. C: The illustration emphasizes the role of targeted testing in secondary prevention patients, particularly those with normal left ventricular function and without an acute ischemic mechanism of arrhythmia. Provocative testing for Brugada syndrome and long QT syndrome, targeted genetic testing, and invasive electrophysiology testing (including programmed stimulation, voltage mapping, and voltage-guided endomyocardial biopsy) can play an important role in elucidating the etiology of arrhythmic arrest and subsequently guide management for patients and families. ARVC = arrhythmogenic right ventricular cardiomyopathy; CPVT = catecholaminergic polymorphic ventricular tachycardia; DCM = dilated cardiomyopathy; EP = electrophysiology; HCM = hypertrophic cardiomyopathy; LQTS = long QT syndrome; LVNCC = left ventricular noncompaction cardiomyopathy; MAD = mitral annular disjunction; MVP = mitral valve prolapse; PVC = premature ventricular contraction.