The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

(LOE): A] plus ICD implantation in post-infarct
patients with nonsustained ventricular tachycardia
and EF = 35–40% [Level of Evidence (LOE): B]. The
guideline may be upgraded shortly.
At the time that the guidelines were written there
was accumulating good quality evidence that micro-
volt T wave alternans might be a good predictor of
sudden death and the need for ICD therapy. The
application of this diagnostic technique was there-
fore accorded a class IIa, level of evidence – a recom-
mendation for the identifi cation of subjects at risk
of sudden cardiac death. Subsequently, however,
several new trials have been published which do not
support this conclusion and this aspect of the guide-
line may be upgraded shortly.
These guidelines are concerned with the identifi ca-
tion of persons at risk of sudden cardiac death or those
suffering from ventricular arrhythmias. The majority
of the latter present with symptoms ranging from pal-
pitations to sudden death (Table 17.3), although some
with slower and shorter episodes of arrhythmia may be
asymptomatic. The identifi cation of patients at risk of

Table 17.2 ICD Indications – comparison between guidelines

Group of patients

ACC/AHA HF

2005 update

ESC HF

2005

ACC/AHA STEMI

2004

ACC/AHA/

NASPE for PM

and ICD

2002

ACC/AHA/ESC

ventricular arrhythmias

and sudden cardiac

death

2006

s/p MI, EF £ 30%,
NYHA II, III

Class I, LOE B Class IIb, LOE B Class IIa, LOE B Class IIa, LOE B s/p MI

EF = 30–40%*

NYHA II–III

Class I

LOE A

s/p MI, EF 30–35%,
NYHA II, III

Class IIa, LOE B Class I, LOE A Class IIa, LOE B N/A

s/p MI, EF 30–40%,
NSVT, positive EPS

N/A N/A Class I, LOE B Class IIb, LOE B

s/p MI, EF £ 30%,
NYHA I

Class IIa, LOE B N/A N/A N/A s/p MI, EF = 30–35%

NYHA I

Class IIa; LOE B

NICM, EF £ 30%,
NYHA II, III

Class I, LOE B Class I, LOE A N/A N/A LVEF = 30–35%
NYHA II-III
Class I
NICM, EF 30–35%, LOE B
NYHA II, III

Class IIa, LOE B Class I, LOE A N/A N/A

NICM, EF £ 30%,
NYHA I

Class IIb, LOE C N/A N/A N/A EF = 30–35%

Class IIb; LOE C

Table 17.3 Clinical presentations of patients with ventricular

arrhythmias and sudden cardiac death

• Asymptomatic individuals with or without electrocardiographic
  abnormalities


• Persons with symptoms potentially attributable to ventricular
  arrhythmias
   Palpitations
   Dyspnea
   Chest pain
   Syncope and presyncope


• Ventricular tachycardia that is hemodynamically stable


• Ventricular tachycardia that is not hemodynamically stable


• Cardiac arrest
   Asystolic (sinus arrest, atrioventricular block)
   Ventricular tachycardia
   Ventricular fi brillation
   Pulseless electrical activity