g logo sign red

Contents included in this summary

 

Overview

  • This Guidelines summary covers the key points for primary care, please refer to the full guideline for complete set of recommendations, including those on peri- and post-operative interventions 
  • Recommendations are marked up with an (R) and good-practice points are marked up with a (✓); for further information about the ‘strength’ of recommendations, see the SIGN 152 full guideline

1. Introduction

The need for a guideline

  • Coronary heart disease (CHD) is a major challenge to the health of the nation, affecting an estimated 2.3 million people across the United Kingdom (UK). CHD is the single biggest killer in Scotland and is responsible for 12% of all deaths, or around 6,700 deaths each year. Age-standardised death rates for CHD in Scotland are consistently among the highest seen across the UK
  • Coronary heart disease is associated with many cardiac arrhythmias, with wide-ranging clinical consequences. Arrhythmias are common during acute coronary syndrome (ACS), with ventricular tachyarrhythmias being an important cause of cardiac arrest and sudden cardiac deaths (SCD) in this context. Patients with chronic CHD, particularly those with left ventricular dysfunction and heart failure are also at risk of ventricular arrhythmia and SCD in the longer term. An increasing number of patients with CHD are also affected by atrial fibrillation (AF) which is associated with significant morbidity as well as an increased risk of stroke and death, particularly in patients with other comorbid conditions such as heart failure

Remit of the guideline

Overall objectives

  • This guideline provides evidence-based recommendations for the management of cardiac arrest and the arrhythmias associated with ACS, chronic CHD and cardiac surgery. It excludes arrhythmias not associated with CHD such as supraventricular tachycardias associated with accessory pathways or dual atrioventricular (AV) nodal physiology, arrhythmias caused by inherited ion channel disorders (e.g. long QT syndrome, Brugada syndrome) and arrhythmias associated with non-ischaemic cardiomyopathies
  • The rhythm management of AF is outlined in this guideline
  • Recommendations on antithrombotic prophylaxis for atrial fibrillation are contained in SIGN guideline 129 on antithrombotic therapy

2. Key recommendations

  • The following recommendations were highlighted by the guideline development group as the key clinical recommendations that should be prioritised for implementation

Arrhythmias associated with cardiac arrest

  • Efforts to prevent sudden cardiac death should include (R)
    • 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

Arrhythmias associated with acute coronary syndrome

  • All patients with ST-elevation acute coronary syndrome should undergo assessment of left ventricular (LV) function for risk stratification at least six weeks following the acute event (R)

Arrhythmias associated with chronic coronary heart disease/left ventricular dysfunction

  • Rate control is the recommended strategy for management of patients with well-tolerated atrial fibrillation (R)
  • In patients with permanent AF or persistent AF following a rate-control strategy and a resting heart rate >110 bpm, appropriate rate-control therapy should be instituted with an initial target of resting heart rate <110 bpm (R)
  • Implantable cardioverter defibrillators (ICD), cardiac resynchronisation therapy with defibrillator or cardiac resynchronisation therapy with pacing are recommended as treatment options for patients with heart failure with reduced ejection fraction, left ventricular ejection fraction (LVEF) ≤35% (R)
  • Patients with a primary-prevention ICD should have a single therapy zone programmed at a detection rate of 200 bpm (R)

3. Arrhythmias associated with cardiac arrest

Primary prevention of sudden cardiac death

  • Efforts to prevent sudden cardiac death should include (R)
    • 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 
  • See also SIGN guideline 149 on risk estimation and the prevention of cardiovascular disease

4. Arrhythmias associated with acute coronary syndrome

Atrial fibrillation

  • In patients with ACS treated with thrombolytic therapy, new atrial fibrillation occurs in 7–10% of cases. The majority of these patients will be in sinus rhythm by the time of hospital discharge regardless of treatment strategy
  • In ACS, atrial fibrillation occurs more commonly in those who are older, have greater haemodynamic disturbance (e.g. higher Killip class) and have left ventricular (LV) dysfunction. Atrial fibrillation is an independent risk factor for mortality. Stroke rates are increased in patients with AF

Prophylaxis

  • Recurrence of AF is observed in around 20% of patients. There is no evidence to support the use of prophylactic antiarrhythmic therapy in patients with ACS who have had AF but who have returned to sinus rhythm. Drugs which are used for their proven benefits on mortality, including beta-blockers and angiotensin converting enzyme (ACE) inhibitors, may also reduce the incidence of AF in patients with ACS

Antiarrhythmic drug therapy/cardioversion

  • There is limited evidence on the use of amiodarone in patients with AF following ACS
  • Class Ic antiarrhythmic drugs should not be used to treat AF in patients who have ACS (R)
  • Patients with AF and haemodynamic compromise should have urgent synchronised DC cardioversion or be considered for antiarrhythmic and rate-limiting therapy using (R)
    • intravenous amiodarone 
      or
    • digoxin, particularly in presence of severe LV systolic dysfunction with heart failure
  • Patients with AF with a rapid ventricular rate, without haemodynamic compromise but with continuing ischaemia should be treated with one of (R):
    • intravenous beta blockade, in absence of contraindications
    • intravenous verapamil where there are contraindications to beta blockade and there is no LV systolic dysfunction
    • synchronised DC cardioversion
  • 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 (R)

Ventricular arrhythmias

Ventricular arrhythmias and ACS

  • Sustained ventricular arrhythmias, venous thrombosis (VT) and/or (VF), occur in up to 20% of patients with acute coronary syndrome

Prevention of ventricular arrhythmias and sudden death

Antiarrhythmic drugs

  • Routine use of antiarrhythmic drugs is not recommended following ACS (R)

Omega-3 fatty acid supplements

  • Omega-3 fatty acid supplements should not be offered for reduction of CVD risk (R)
  • As fish consumption may help to reduce intake of (saturated) fat from meat, and may have a role in reducing fatal CHD with low risk of adverse effects, individuals should be advised to follow Government dietary guidelines to consume two 140 g portions of fish per week, one of which should be an oily fish (✓)

Aldosterone-receptor antagonists

  • Patients who have suffered a recent myocardial infarction and have an LVEF ≤40% and either diabetes or clinical signs of heart failure should receive eplerenone unless contraindicated by the presence of renal impairment (chronic kidney disease stage ≥4–5) and/or elevated serum potassium concentration (K+ >5.0 mmol/l) (R)

Assessment of risk of sudden death

  • Following ACS, sudden death is a continuing cause of mortality (7–10% at two years; up to 50% of total mortality), with the greatest risk being in the first 30 days (1.4% per month), declining during follow up (0.14% per month after two years). The risk is associated with LV dysfunction, but sudden death can also occur in patients with preserved LV function following ACS. Left ventricular dysfunction is also a risk factor for non-sudden cardiac death
  • All patients with ST-elevation acute coronary syndrome should undergo assessment of LV function for risk stratification at least six weeks following the acute event (R)
  • Non-invasive assessment of the risk of ventricular arrhythmias beyond LV function may be considered but is not routinely recommended (R)
  • Invasive electrophysiological studies are not routinely recommended for patients after ACS (R)

5. Arrhythmias associated with chronic coronary heart disease/left ventricular dysfunction

Atrial fibrillation

Antiarrhythmic drugs

  • Amiodarone or sotalol treatment should be considered where prevention of atrial fibrillation recurrence is required on symptomatic grounds (R)
    • Patients with arrhythmias successfully controlled on amiodarone should have the dose titrated down to the lowest effective level (✓)
    • Patients taking amiodarone should have thyroid and liver function measured at baseline and at six monthly intervals. A chest X-ray should be considered prior to initiating therapy (✓)
    • Patients with new or increasing cough or breathlessness during amiodarone therapy should be promptly referred for respiratory evaluation (✓)
    • Patients receiving amiodarone therapy should be provided with information on potential side-effects (✓)
  • Dronedarone should be considered for prevention of atrial fibrillation recurrence in patients who are unable to tolerate, or who have failed to respond to amiodarone or sotalol and who do not have left ventricular systolic dysfunction or heart failure (R)
    • Patients taking dronedarone should have liver function measured before treatment, after one week, after one month, then monthly for six months, at nine and 12 months and periodically thereafter (✓)
    • Patients taking dronedarone should have an ECG at least every six months to exclude permanent AF (✓)
    • Patients taking dronedarone should be evaluated for symptoms of heart failure, should be advised to report symptoms of heart failure and should be monitored for the development of left ventricular systolic dysfunction (✓)

Rate versus rhythm control

  • Management of atrial fibrillation may be by either rate control or rhythm control. Rate control is typically achieved using pharmacological therapies to limit atrioventricular nodal (AVN) conduction and reduce ventricular rate, but in some patients AVN ablation and pacing may be required (see full guideline, section 5.1.5). Rhythm control can be achieved using a combination of antiarrhythmic drugs, DC cardioversion and left atrial catheter ablation
  • Rate control is the recommended strategy for management of patients with well-tolerated atrial fibrillation ()
  • Patients with AF in combination with heart failure and a reduced ejection fraction should receive evidence-based therapy for heart failure and an individualised approach to AF management. In cases where AF is thought to be the primary cause of heart failure with a reduced ejection fraction, a rhythm-control strategy should be prioritised (✓)

Pharmacological therapies for rate control

  • In patients with permanent AF or persistent AF following a rate-control strategy and a resting heart rate >110 bpm, appropriate rate-control therapy should be instituted with an initial target of resting heart rate <110 bpm (R)
  • Ventricular rate in AF should be controlled with beta-blockers, rate-limiting calcium channel blockers (verapamil or diltiazem), or digoxin and combination therapy may be required (R)
  • Digoxin does not control rate effectively during exercise and should be used as first-line therapy only in people who are sedentary, or have overt heart failure (R)
  • A combination of digoxin with either a beta-blocker or diltiazem should be considered to control heart rate in patients with atrial fibrillation (R)
  • Patients with AF who remain severely symptomatic despite adequate rate control should be considered for rhythm control or for stricter rate control if their heart rate remains 80–110 bpm at rest (✓)
  • Thyrotoxicosis should be ruled out in patients with AF and a poorly-controlled ventricular rate (✓)

Ventricular arrhythmias

Revascularisation for secondary prevention of VT/VF

  • Revascularisation should be considered in patients who have had sustained ventricular tachycardia (VT) or VF (R)
  • Patients with previous sustained VT/VF should undergo assessment for inducible ischaemia by stress testing or myocardial perfusion imaging followed, if appropriate, by coronary arteriography and revascularisation. These patients should all be considered for implantable cardioverter defibrillator therapy (✓)

Antiarrhythmic drug therapy

Class I antiarrhythmic drugs

  • Class I antiarrhythmic drugs should not be used for treatment of premature ventricular beats or non-sustained VT in patients with previous MI (R)

Beta-blockers

  • Long-term beta-blockers are recommended for routine use in patients following ACS without contraindications (R)

Amiodarone and sotalol

  • Amiodarone therapy is not recommended for patients following ACS or patients with congestive heart failure who do not have sustained ventricular arrhythmias or atrial fibrillation (R)
  • Sotalol therapy is not recommended for patients following ACS who do not have sustained ventricular arrhythmias or atrial fibrillation (R)
  • 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 (R)

Calcium channel blockers

  • Calcium channel blocker therapy in post-MI patients does not reduce all-cause mortality
  • Calcium channel blocker therapy is not recommended for reduction in sudden death or all-cause mortality in patients following ACS (R)

6. Arrhythmias associated with coronary artery bypass graft surgery

  • Atrial fibrillation is a common complication of coronary artery bypass graft (CABG) surgery, occurring in 17–53% patients. In over 90% of patients, the condition is self limiting within four to six weeks of surgery

Prophylactic interventions

Pharmacological therapies

Amiodarone/beta-blockers

  • Amiodarone may be used when prophylaxis for atrial fibrillation and ventricular arrhythmias is indicated following CABG surgery (R)
  • Beta-blockers including sotalol may be used when prophylaxis for atrial fibrillation is indicated following CABG surgery (R)
  • Preoperative beta-blocker therapy should be reintroduced as soon as safe to do so after surgery (✓)

Calcium channel blockers

  • Verapamil and diltiazem may be used for prophylaxis of atrial fibrillation following CABG surgery (R)

Digoxin

  • Digoxin should not be used for prophylaxis of atrial fibrillation following CABG surgery (R)

Glucose-insulin-potassium

  • Glucose-insulin-potassium regimens should not be used for prophylaxis of atrial fibrillation following CABG surgery (R)

n-3-polyunsaturated fatty acids

  • In one RCT, n-3-polyunsaturated fatty acids (PUFAs) (2 g/day) administered for five days preoperatively and postoperatively until the day of hospital discharge reduced the incidence of postoperative AF following elective CABG and reduced hospital stay. This single study (n=160) provides insufficient evidence on which to base a recommendation

Manipulation of blood electrolytes

  • Magnesium may be used when prophylaxis for atrial fibrillation and ventricular arrhythmias is indicated following CABG surgery (R)
  • Blood levels of potassium and calcium should be measured frequently following CABG surgery and corrected if necessary (✓)

7. Psychosocial issues

Psychosocial assessment and screening

  • Patients with chronic cardiac arrhythmias and cardiac arrest should be screened for anxiety or depressive disorders with referral to specialist psychology services where appropriate (R)
  • Selective cognitive screening should be available especially after a cardiac arrest and for older cardiac patients experiencing persistent memory or other cognitive difficulties (R)

Psychosocial issues for ICD recipients

  • Psychosocial implications for people experiencing cardiac arrhythmias should be considered by all healthcare staff throughout assessment, treatment and care (R)
  • Psychosocial support for patients experiencing cardiac arrhythmias should not be restricted to recipients of ICDs (✓)

Psychosocial interventions

  • Psychosocial interventions offered as part of a comprehensive rehabilitation programme should encompass a cognitive behavioural component (R)

Scottish Intercollegiate Guidelines Network (SIGN). Cardiac arrhythmias in coronary heart disease. Edinburgh: SIGN; 2018. (SIGN publication no. 152).

Available at: www.sign.ac.uk/sign-152-arrhythmias.html