Pharmacologic therapy in survivors of sudden cardiac arrest
- Philip J Podrid, MD, FACC
Philip J Podrid, MD, FACC
- Professor of Medicine, Professor of Pharmacology and Experimental Therapeutics
- Boston University School of Medicine
- Lecturer, Harvard Medical School
- Section Editors
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Samuel Lévy, MD
Samuel Lévy, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Cardiology
- University of Marseille, France
Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) refer to the sudden cessation of cardiac activity with hemodynamic collapse, typically due to sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). The event is referred to as SCA (or aborted SCD) if an intervention (eg, defibrillation) or spontaneous reversion restores circulation, while the SCD terminology is employed if the patient dies. However, the use of SCD to describe both fatal and nonfatal cardiac arrest often persists by convention. (See "Overview of sudden cardiac arrest and sudden cardiac death", section on 'Definitions'.)
The treatment of SCA consists of acute resuscitation using standardized advanced cardiac life-support protocols, followed by therapy to prevent recurrent arrhythmias and SCD. Patients who survive SCA caused by VT/VF not due to a reversible cause generally receive an implantable cardioverter-defibrillator (ICD). Antiarrhythmic drugs are used in select patients as adjunctive therapy, or as primary therapy when an ICD is not indicated or refused by the patient. This approach, endorsed by numerous professional societies, is based on the significant survival benefit of patients receiving an ICD compared with antiarrhythmic drugs alone or no therapy.
This topic will review the role of pharmacologic therapy in survivors of SCA, with an emphasis on the role of antiarrhythmic drugs. Issues related to the acute management of SCA, the evaluation of survivors, and the utility of an ICD, arrhythmic surgery, or radiofrequency ablation are discussed separately. (See "Advanced cardiac life support (ACLS) in adults" and "Evaluation of the survivor of sudden cardiac arrest" and "Secondary prevention of sudden cardiac death in heart failure and cardiomyopathy".)
INDICATIONS FOR PHARMACOLOGIC THERAPY
Nearly all survivors of sudden cardiac arrest (SCA) without a reversible cause should be evaluated for placement of an implantable cardioverter-defibrillator (ICD). Because an ICD treats, but does not prevent, arrhythmias, patients who have arrhythmias with symptoms or device discharges may require adjunctive antiarrhythmic therapy.
In addition to ICD therapy for survivors of SCA, there are three main indications for concomitant antiarrhythmic drug therapy [1-3]:
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- INDICATIONS FOR PHARMACOLOGIC THERAPY
- CHOICE OF PHARMACOLOGIC THERAPY
- Empiric versus guided pharmacologic therapy
- Beta blockers
- Antiarrhythmic drugs
- - Efficacy
- - Administration
- Treatment of breakthrough arrhythmias
- IMPACT ON ICD THERAPIES
- Alterations in DFTs
- VT rate slowing
- SUMMARY AND RECOMMENDATIONS