Maiden multidisciplinary recommendations on the management of arrhythmias in patients with acute coronary syndromes (ACS) have been published in EP Europace.
The position paper was written jointly by the European Heart Rhythm Association (EHRA), the Acute Cardiovascular Care Association (ACCA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), all of the ESC.
Professor Bulent Gorenek (Turkey), chairperson of the task force, said: "Sudden cardiac death is the leading cause of death in Europe, the US and other developed countries. These deaths are mainly due to cardiac arrhythmias. This is the first document to provide clear recommendations on how to manage patients with ACS who develop arrhythmias. This topic has received limited coverage in guidelines and at congresses, and clinicians have many unanswered questions."
He added: "During the last decade the clinical approach to arrhythmia management in ACS has changed. Previously, antiarrhythmic drugs were the mainstay of treatment but today interventions in the cardiac catheterisation lab are preferred. This shift has been so substantial that EHRA, ACCA and the EAPCI established a task force to define the current position."
The position paper provides recommendations on how to identify ACS patients at risk for arrhythmias and how to manage tachy- and bradyarrhythmias using drugs, devices and catheter-based approaches.
Clear guidance is provided on the use of antiarrhythmic drugs in patients with ACS and ventricular arrhythmias. Amiodarone is recommended as the first line antiarrhythmic drug, with lidocaine added as second line if necessary. In patients with ACS without ventricular arrhythmias, the paper says that prophylactic antiarrhythmic drug treatment should not be administered.
Professor Gorenek said: "The use of antiarrhythmic drugs for the treatment of sustained ventricular arrhythmias in ACS has been the subject of strong debate. No big randomised trials have been conducted on this topic. Our recommendations will help clinicians prescribe the most appropriate antiarrhythmic drug for the situation."
Another controversial area was the use of triple therapy (dual antiplatelet therapy and oral anticoagulation) in patients with ACS who develop atrial fibrillation. Professor Gorenek said: "Triple therapy is underused by clinicians which goes against current guidelines. We clarify when triple therapy should be used and for how long, and provide clear messages on the use of the non-vitamin K antagonist oral anticoagulants (NOACs)."
Novel detailed recommendations are given on the use of antithrombotic therapy in patients with atrial fibrillation and ACS, catheter ablation in ACS patients with sustained ventricular arrhythmias, and management of patients with arrhythmias who are undergoing primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI).
An entire chapter is devoted to the management of arrhythmias in patients with acute myocardial infarction and cardiogenic shock. The document says that "regardless of the type of arrhythmia, treatment of the underlying cardiogenic shock with prompt revascularisation should be done as the primary procedure and should not be delayed by arrhythmia treatment".
Professor Gorenek said: "The management of patients with ACS and cardiac arrhythmias requires a multidisciplinary approach involving specialists in acute cardiac care, interventional cardiology and electrophysiology. The recommendations in this document should help all clinicians who manage these patients to provide the best treatment available."