Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Arrhythmias Associated with Cardiac Arrest
Primary Prevention of Sudden Cardiac Death
D - Efforts to prevent sudden cardiac death should include:
- Risk factor intervention in those individuals who are at high risk for coronary heart disease
- Health promotion measures and encouragement of moderate intensity physical activity in the general population.
Bystander Cardiopulmonary Resuscitation (CPR)
C - The number of lay people trained to initiate CPR in out-of-hospital cardiac arrest should be increased.
D - Lay people identified as having a high probability of witnessing a cardiac arrest should be offered CPR training
D - CPR should be taught as part of the school curriculum.
Defibrillation
B - Defibrillation in patients with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) should be administered without delay for witnessed cardiac arrests and immediately following two minutes of CPR for unwitnessed out-of-hospital cardiac arrests.
C - Prompt defibrillation should be available throughout all healthcare facilities.
C - All healthcare workers trained in CPR should also be trained, equipped, authorised and encouraged to perform defibrillation.
A - Automated external defibrillators should be used by trained first responders, with their use integrated within the emergency medical services system.
B - Automated external defibrillators should be sited in locations which have a high probability of a cardiac arrest event.
Adjunctive Therapies in the Peri-Arrest Period
D - Intravenous adrenaline/epinephrine should be used for the management of patients with refractory ventricular tachycardia/ventricular fibrillation (VT/VF).
A - Intravenous amiodarone should be considered for the management of refractory VT/VF.
D - Intravenous amiodarone, procainamide or sotalol should be used in the management of patients with haemodynamically stable VT.
D - Patients with polymorphic VT should be treated with intravenous magnesium. QT interval prolonging drugs, if prescribed, should be withdrawn. If present, hypokalaemia should be corrected by potassium infusion and bradycardia by temporary pacing or isoprenaline infusion.
D - Patients with cardiac arrest secondary to asystole or pulseless electrical activity should receive intravenous adrenaline/epinephrine.
C - Atropine should be used in the treatment of patients with symptomatic bradycardia.
D - Temporary transcutaneous pacing should be initiated quickly in patients not responding to atropine.
D - When atropine or transcutaneous pacing is ineffective consider adrenaline/epinephrine, dopamine, isoprenaline or aminophylline infusions before transvenous pacing is instituted.
Arrhythmias Associated with Acute Coronary Syndromes
Atrial Fibrillation (AF)
B - Class 1C anti-arrhythmic drugs should not be used in patients with AF in the setting of acute myocardial infarction (MI).
D - Patients with AF and haemodynamic compromise should have urgent synchronised direct current (DC) cardioversion or be considered for anti-arrhythmic and rate-limiting therapy using:
- Intravenous amiodarone
or
- Digoxin, particularly in presence of severe left ventricular (LV) systolic dysfunction with heart failure.
D - Patients with AF with a rapid ventricular response, without haemodynamic compromise but with continuing ischaemia should be treated with one of:
- Intravenous beta-blockade, in the absence of contraindications
- Intravenous verapamil where there are contraindications to beta blockade and there is no LV systolic dysfunction
- Synchronised DC cardioversion
D - Patients with AF without haemodynamic compromise or ischaemia should be treated with rate-limiting therapy, preferably a beta-blocker, and be considered for chemical cardioversion with amiodarone or DC cardioversion.
Conduction Disturbances and Bradycardia
D - In patients with symptomatic bradycardia/conduction disturbance, concurrent therapies which predispose to bradycardia (e.g., beta-lockers, digoxin, verapamil) should be discontinued.
D - Isolated first degree heart block/Mobitz type I second degree heart block require no treatment.
D - Transvenous temporary pacing should be considered for patients with:
- Sinus bradycardia (heart rate <40 beats per minute) associated with symptoms and unresponsive to atropine
- Alternating left and right bundle branch block
- Mobitz type II atrioventricular (AV) block with new bundle branch block
- Third degree AV block in inferior MI, if unresponsive to atropine and haemodynamically compromised, and in all cases of anterior MI
- Ventricular standstill
Transcutaneous pacing should be available to all patients with other atrioventricular and intraventricular conduction disturbances.
D - Permanent pacing is indicated for patients with persistent Mobitz type II second degree block, or persistent third degree AV block.
D - Permanent pacing should be considered for patients who have had transient second degree or third degree AV block with associated bundle branch block.
Ventricular Arrhythmias
C - Patients who have primary VF should be recognised as being at increased risk during their hospital stay, and medical therapy should be optimised.
D - Patients who have monomorphic VT following acute MI, or VF greater than 48 hours after infarction, should be recognised as being at increased short and long term risk and should be considered for revascularisation and implantable cardioverter defibrillator (ICD).
A - Routine use of anti-arrhythmic drugs is not recommended following MI.
B - Patients who have suffered a recent myocardial infarction and with left ventricular ejection fraction (LVEF) <0.40 and either diabetes or clinical signs of heart failure should receive eplerenone unless contraindicated by the presence of renal impairment or high potassium levels.
C - LV function should be assessed in all patients with acute MI during the index admission.
C - Non-invasive assessment of the risk of ventricular arrhythmias may be considered but is not routinely recommended.
C - Invasive electrophysiological studies are not routinely recommended for all patients post-MI.
Arrhythmias Associated with Chronic Coronary Heart Disease/Left Ventricular Dysfunction
Atrial Fibrillation
A - Amiodarone or sotalol treatment should be considered where prevention of atrial fibrillation recurrence is required on symptomatic grounds.
A - Rate control is the recommended strategy for management of patients with well tolerated atrial fibrillation.
A - Ventricular rate in AF should be controlled with beta blockers, rate-limiting calcium channel blockers (verapamil or diltiazem), or digoxin.
C - Digoxin does not control rate effectively during exercise and should be used as first line therapy only in people who are sedentary, or in overt heart failure.
C - In some people a combination of drugs may be required to control heart rate in atrial fibrillation. Options include the addition of digoxin to either a beta blocker or a rate limiting calcium channel blocker.
B - Ablation and pacing should be considered for patients with AF who remain severely symptomatic or have LV dysfunction in association with poor rate control or intolerance to rate control medication.
Ventricular Arrhythmias
C - Revascularisation should be considered in patients who have had sustained VT or VF.
A - Patients with moderate to severe LV dysfunction (e.g., ejection fraction <0.35), in New York Heart Association (NYHA) class I-III at least one month after myocardial infarction should be considered for ICD therapy.
B - Patients with spontaneous non-sustained ventricular tachycardia (especially if sustained ventricular tachycardia is inducible), severely impaired ejection fraction (<0.25) or prolonged QRS complex duration (>120ms) should be prioritised for ICD implantation.
A - Patients meeting criteria for ICD implantation who have prolonged QRS duration (>120ms) and NYHA class III-IV symptoms should be considered for cardiac resynchronisation therapy + defibrillator (CRT-D) therapy.
A - Patients surviving the following ventricular arrhythmias in the absence of acute ischaemia or treatable cause should be considered for ICD implantation:
- Cardiac arrest (VT or VF)
- VT with syncope or haemodynamic compromise
- VT without syncope if LVEF <0.35 (not NYHA IV)
A - Class 1 anti-arrhythmic drugs should not be used for treatment of premature ventricular beats or non-sustained VT in patients with previous MI.
A - Long term beta-blockers are recommended for routine use in post-MI patients without contraindications.
A - Amiodarone therapy is not recommended for post-MI patients or patients with congestive heart failure who do not have sustained ventricular arrhythmias or atrial fibrillation.
B - Sotalol therapy is not recommended for post-MI patients who do not have sustained ventricular arrhythmias or atrial fibrillation.
B - In patients who have recovered from an episode of sustained ventricular tachycardia (with or without cardiac arrest) who are not candidates for an ICD, amiodarone or sotalol should be considered.
A - Calcium channel blocker therapy is not recommended for reduction in sudden death or all-cause mortality in post-MI patients.
Arrhythmias Associated with Coronary Artery Bypass Graft Surgery (CABG)
Risk Factors
D - In patients undergoing coronary artery bypass graft surgery, age, previous AF and left ventricular ejection fraction should be considered when assessing risk of postoperative arrhythmia.
Prophylactic Interventions
A - Amiodarone may be used when prophylaxis for atrial fibrillation and ventricular arrhythmias is indicated following CABG surgery.
A - Beta-blockers including sotalol may be used when prophylaxis for atrial fibrillation is indicated following CABG surgery.
B - Verapamil and diltiazem may be used for prophylaxis of atrial fibrillation following CABG surgery.
B - Digoxin should not be used for prophylaxis of atrial fibrillation following CABG surgery.
C - Glucose-insulin-potassium regimens should not be used for prophylaxis of atrial fibrillation following CABG surgery.
A - Magnesium may be used when prophylaxis for atrial fibrillation and ventricular arrhythmias is indicated following CABG surgery.
A - The choice of anaesthetic agent or technique and analgesia should be based on factors other than atrial fibrillation prophylaxis.
A - The choice of whether or not to use cardiopulmonary bypass should be based on factors other than atrial fibrillation prophylaxis.
A - Atrial pacing may be used for prophylaxis of AF in patients who have atrial pacing wires placed for other indications.
A - Bonded cardiopulmonary bypass circuits should not be used on the basis of AF prophylaxis alone.
A - Defibrillators should not be routinely implanted in patients with a poor left ventricular ejection fraction at the time of coronary artery bypass graft surgery.
Treatments for Atrial Fibrillation
D - Patients with AF and haemodynamic compromise should have synchronized cardioversion.
- In the immediate postoperative period, patients with persistent AF without haemodynamic compromise should be treated with rate-limiting therapy.
- Patients with persistent AF should be considered for elective synchronized cardioversion.
Treatments for Ventricular Arrhythmias
D - Patients with VF or pulseless VT should be defibrillated immediately.
- Intravenous adrenaline/epinephrine should be used for the management of patients with refractory VT/VF.
- Sternal reopening, internal heart massage and internal defibrillation should be considered in patients with refractory VT/VF.
- Intravenous amiodarone should be considered for the management of patients with refractory VT/VF.
A - Biphasic defibrillation should be used to terminate ventricular fibrillation that occurs on declamping the aorta.
Psychosocial Issues
Psychosocial Assessment and Screening
D - Patients with chronic cardiac arrhythmias should be screened for anxiety or depressive disorders with referral to specialist mental health services where appropriate.
D - Selective cognitive screening should be available especially for post arrest and older cardiac patients experiencing persistent memory or other cognitive difficulties.
Psychosocial Issues for ICD Recipients
C - Psychosocial implications for people experiencing cardiac arrhythmias should be considered by all healthcare staff throughout assessment, treatment and care.
Psychosocial Interventions
B - Psychosocial intervention offered as part of a comprehensive rehabilitation programme should encompass a cognitive behavioural component.
Definitions:
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion
