- Describe your topic.
- In patients with ischemic cardiomyopathy and ventricular tachycardia, is catheter ablation superior to other strategies, such as antiarrhythmic drug therapy or control, in terms of mortality, ventricular tachycardia recurrence, and complications? In patients with normal hearts and premature ventricular complexes or ventricular tachycardia, is catheter ablation superior to other strategies, such as antiarrhythmic drug therapy or control, in terms of mortality, arrhythmia recurrence, emergence or progression of heart disease, and complications? In patients with other subtypes of cardiomyopathy, including nonischemic cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, arrhythmogenic right ventricular cardiomyopathy, and ventricular tachycardia, is catheter ablation superior to other strategies, such as antiarrhythmic drug therapy or control, in terms of mortality, ventricular tachycardia recurrence, disease progression, and complications? Relevant groups of patients are those with ventricular tachycardia, with or without cardiomyopathy, coronary artery disease, and prior myocardial infarction. Both sexes are affected, with an earlier average age of onset in men, but greater total numbers of women potentially affected. Age range of affected patients is from the twenties to very old age, with no upper limit; however, the majority of cases are seen in the over 65 age group. Coexisting diagnoses include coronary artery disease, prior myocardial infarction (including silent), nonischemic cardiomyopathy, hypertension, hyperlipidemia, diabetes, peripheral arterial disease, stroke, sleep apnea, chronic obstructive pulmonary disease, and other cardiac conditions such as sarcoidosis, hypertrophic cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy.
- Describe why this topic is important.
- Sudden cardiac death is an important public health problem, causing over 200,000 deaths annually in the United States. The most common cause of sudden cardiac death is ventricular tachyarrhythmia due to coronary artery disease. Implantable cardioverter-defibrillators (ICDs) are implanted in certain patients at risk of, or who have survived, sudden cardiac arrest. Although ICDs improve survival, shocks delivered by these devices to terminate ventricular tachycardia are painful, impair quality of life, and are associated with higher mortality. Antiarrhythmic drugs are used to reduce ICD shocks but come with a risk of serious, including fatal, side effects, and are often poorly tolerated. Catheter ablation of ventricular tachycardia is increasingly used to treat the arrhythmia, especially in patients with prior myocardial infarction in which the pathological substrate is well characterized and in patients with normal hearts in whom success rates are high and the procedure is potentially curative. Several observational series and small- to medium-sized randomized controlled trials have suggested that ablation can decrease the number of episodes of ventricular tachycardia and ICD shocks compared with antiarrhythmic drug therapy or usual care, either with or without an ICD. Whether this translates to an improvement in other outcomes, such as hospital admissions, quality of life, costs, and ultimately, mortality, is less clear. Catheter ablation of ventricular tachycardia is perhaps the fastest growing ablation procedure in the United States. It is a complex procedure, involving significant resource utilization, and a risk of major complications of up to 8–10%. Therefore, appropriate use of this technique is important to patients and to society at large.
- Tell us why you are suggesting this topic.
- Target date.
- Describe what you are doing currently and what you are hoping will change because of a new evidence report.
- How will you or your group use the information from a new evidence report?
- Given the issues outlined above, a firm evidence basis is essential in order to make recommendations and guidelines for the performance of this procedure. Although a small number of randomized controlled trials have been published in this area, direct comparison is difficult due to varying study design, comparator arms, and populations. Several trials are ongoing but are not expected to be completed for several years to come, whereas others have been terminated due to difficulties in enrollment as is frequent in trials involving invasive procedures. Three meta-analyses have been published, all before the publication of the largest randomized controlled trial in this field (VANISH, Sapp et al. New Engl J Med 2016), and all addressing ventricular tachycardia in patients with ischemic cardiomyopathy. Our Society, in partnership with others, intends to produce a guideline document on catheter ablation of ventricular tachycardia over the next two years. A systematic review would greatly enhance the evidence basis available and provide a firmer basis for guideline recommendations. This would help our members, physicians who perform this procedure, and patients to make more informed decisions when considering this procedure. It is also an opportunity to disseminate best practices and promote quality in the care of patients with ventricular tachycardia.
- How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?
- Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?
- • American College of Cardiology • American Heart Association • European Heart Rhythm Association • Japanese Heart Rhythm Society • Asia Pacific Heart Rhythm Society • Latin American Heart Rhythm Society (formerly SOLAECE) • Sociedade Brasileira de Arritmias Cardíacas • European Society of Cardiology • Heart Failure Society of America. Thomas Getchius is the Clinical Documents Manager at the Heart Rhythm Society. He also currently serves as the Chair of the Guidelines International Network, North American Community and recently rotated off as Chair of the Council of Medical Specialty Society’s Clinical Practice Guideline Component Group. Edmond Cronin is an Attending Cardiac Electrophysiologist at Hartford Hospital and Assistant Professor at the University of Connecticut School of Medicine. His clinical and research interests include catheter ablation of ventricular tachycardia. Julia H. Indik is the Chair of the Scientific and Clinical Documents Committee of the Heart Rhythm Society. She is an electrophysiologist and holder of the Flinn Foundation and American Heart Association Endowed Chair in Electrophysiology at the University of Arizona where she is a Professor of Medicine. She has served on several writing committees of clinical practice documents, including as Chair of the recently published 2017 HRS Expert Consensus Statement on Magnetic Resonance Imaging and Radiation Exposure in Patients with Cardiovascular Implantable Electronic Devices. Kristen Patton is a Professor of Medicine at the University of Washington and the Director of the Cardiac Electrophysiology Fellowship Program. Her research interests include risk stratification and management of sudden cardiac death with a focus on rare cardiomyopathies and inherited arrhythmia disorders. David Callans is the Associate Director of the Electrophysiology Program at the University of Pennsylvania Health Systems and Professor of Medicine at the Perelman School of Medicine, University of Pennsylvania. His research interests include the ventricular tachycardia in the setting of structural heart disease from both a clinical/interventional standpoint and at a more mechanistic level. Niraj Varma trained in cardiac electrophysiology with Mark Josephson, Harvard Medical School, and since then has had 20 years of experience in ablation for ventricular arrhythmias. He has led large multicenter randomized clinical trials and chaired consensus documents for the Heart Rhythm Society and the International Society for Holter and Noninvasive Electrocardiology (ISHNE).
- Information About You:
-
- Provide a description of your role or perspective
- If you are you making a suggestion on behalf of an organization, please state the name of the organization
- The Heart Rhythm Society (HRS) is the leading resource on cardiac pacing and electrophysiology. This organization represents medical, allied health, and science professionals from more than 70 countri
- Please tell us how you heard about the Effective Health Care Program
- Mr. Getchius has served as a Key Informant on two previous AHRQ EPC projects (AHRQ Publication No. 17-EHC005-EF. Rockville, MD: Agency for Healthcare Research and Quality, March 2017 AND AHRQ Publication No. 15-EHC012-EF. Rockville, MD: Agency for Healthcare Research and Quality, April 2015) and worked with the American Academy of Neurology (his former employer) to submit systematic review proposals.
