The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

Ventricular arrhythmia and sudden
cardiac death related to specifi c
pathology

Left ventricular dysfunction due to prior
myocardial infarction
Recommendations
Class I
1 Aggressive attempts should be made to treat HF
that may be present in some patients with LV dys-
function due to prior MI and ventricular tachyar-
rhythmias. (Level of Evidence: C)
2 Aggressive attempts should be made to treat myo-
cardial ischemia that may be present in some pati-
ents with ventricular tachyarrhythmias. (Level of
Evidence: C)
3 Coronary revascularization is indicated to reduce
the risk of SCD in patients with VF when direct,
clear evidence of acute myocardial ischemia is docu-
mented to immediately precede the onset of VF.
(Level of Evidence: B)
4 If coronary revascularization cannot be carried
out and there is evidence of prior MI and signifi cant
LV dysfunction, the primary therapy of patients
resuscitated from VF should be the ICD in patients
who are receiving chronic optimal medical therapy
and those who have reasonable expectation of sur-
vival with a good functional status for more than 1
year. (Level of Evidence: A) (Fig. 17.2).

5 ICD therapy is recommended for primary pre-

vention to reduce total mortality by a reduction in

SCD in patients with LV dysfunction due to prior

MI who are at least 40 days post-MI, have an LVEF

less than or equal to 30% to 40% are NYHA func-

tional class II or III, are receiving chronic optimal

medical therapy, and who have reasonable expecta-

tion of survival with a good functional status for

more than 1 year. (Level of Evidence: A) (Figs 17.3–

17.5; Table 17.4) [16–25].

6 The ICD is effective therapy to reduce mortality

by a reduction in SCD in patients with LV dysfunc-

tion due to prior MI who present with hemody-

namically unstable sustained VT, are receiving

chronic optimal medical therapy, and who have rea-

sonable expectation of survival with a good func-

tional status for more than 1 year. (Level of Evidence:

A) (Fig. 17.2) [26–29].

Class IIa

1 Implantation of an ICD is reasonable in patients

with LV dysfunction due to prior MI who are at least 40

days post-MI, have an LVEF of less than or equal to

30% to 35%, are NYHA functional class I on chronic

optimal medical therapy, and who have reasonable

expectation of survival with a good functional status

for more than 1 year. (Level of Evidence: B) (Fig. 17.3).

2 Amiodarone, often in combination with

beta-blockers, can be useful for patients with LV

0.6 0.8 1.0 1.2 1.4

AVID

0.4 1.6

1997

N = 1016

0.62

Hazard ratio

ICD better

1.8

Other features

CASH

2000

N = 191

CIDS

2000

N = 659

0.82

Aborted cardiac arrest

or syncope

Trial Name, Pub Year

Aborted cardiac arrest

0.83

Aborted cardiac arrest

HR:0.73 (0.59,0.89)

p = 0.0023

Meta

Fig. 17.2 Summary of the results of secondary prevention ICD trials The hazard ratio for the three individual trials and the meta analysis are
plotted. AVID, Antiarrhythmics Versus Implantable Defi brillators; CASH, Cardiac Arrest Study Hamburg; CIDS, Canadian Implantable
Defi brillator Study; meta, meta-analysis reported by Connelly et al.