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Summary for secondary care

Secondary Care Management of Cardiac Arrhythmias in Coronary Heart Disease

This specialist Guidelines summary covers the management of arrhythmias in cardiac arrest and the arrhythmias associated with acute coronary syndrome, chronic coronary heart disease/left ventricular dysfunction, and cardiac surgery. It also outlines the psychosocial issues for patients including the need for assessment, screening, and interventions.

This summary is intended for use by cardiac surgeons, cardiac nurse specialists, cardiologists, and clinical psychologists in a secondary care setting.

Please refer to the full guideline for a complete set of recommendations. For primary care recommendations, please refer to the Guidelines primary care summary.

Recommendations are marked with an [R] and good-practice points are marked with a [✓]; for further information about the ‘strength’ of recommendations, see the full guideline.

Arrhythmias Associated with Cardiac Arrest


[✓] Defibrillation should be administered in accordance with the Resuscitation Council (UK) guidelines 

[R] Defibrillation in patients with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) should be administered without delay for witnessed cardiac arrests and immediately following 2 minutes of cardiopulmonary resuscitation (CPR) for unwitnessed out-of-hospital cardiac arrests 

[R] Prompt defibrillation should be available throughout all healthcare facilities 

[R] All healthcare workers trained in CPR should also be trained, equipped, authorised, and encouraged to perform defibrillation. 

Adjunctive Therapies in the Peri-arrest Period

Refractory VT/VF

[R] Intravenous (IV) adrenaline/epinephrine should be used for the management of patients with refractory VT/VF 

[R] IV amiodarone should be considered for the management of patients with refractory VT/VF 

[✓] Adjuvant therapies should be administered in accordance with the Resuscitation Council (UK) guidelines. 

Asystole and Pulseless Electrical Activity During Cardiac Arrest

[R] Patients with cardiac arrest secondary to asystole or pulseless electrical activity should receive IV adrenaline/epinephrine. 

Therapeutic Hypothermia

[R] Therapeutic hypothermia should not routinely be administered to patients in the prehospital or inhospital setting after cardiac arrest. 

Bradycardia/Sinoatrial Dysfunction/Heart Block

[R] Atropine should be used in the treatment of patients with symptomatic bradycardia 

[R] When atropine is ineffective, consider IV administration of further positively chronotropic agents before transvenous pacing is instituted

[✓] Transcutaneous pacing should be followed as soon as possible by transvenous pacing unless the bradycardia has resolved. 

Polymorphic VT Associated with QT Prolongation

[R] Patients with polymorphic VT should be treated with IV magnesium sulphate (2 g over 10–15 minutes; 8 mmol, or 4 ml of 50% magnesium sulphate). QT-interval-prolonging drugs, if prescribed, should be withdrawn. If present, hypokalaemia should be corrected by potassium infusion 

[R] Overdrive suppression pacing should be considered to prevent relapse once the arrhythmia has been corrected. 

Arrhythmias Associated with Acute Coronary Syndrome

Atrial Fibrillation

Antiarrhythmic Drug Therapy/Cardioversion

[R] Class Ic antiarrhythmic drugs should not be used to treat atrial fibrillation (AF) in patients who have acute coronary syndrome (ACS)

[R] Patients with AF and haemodynamic compromise should have urgent synchronised direct current (DC) cardioversion or be considered for antiarrhythmic and rate-limiting therapy using:

  • IV amiodarone, or
  • digoxin, particularly in presence of severe left ventricular (LV) systolic dysfunction with heart failure 
[R] Patients with AF with a rapid ventricular rate, without haemodynamic compromise but with continuing ischaemia should be treated with one of:
  • IV beta blockade, in absence of contraindications
  • IV verapamil where there are contraindications to beta blockade and there is no LV systolic dysfunction
  • synchronised DC cardioversion 
[R] 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 

[✓] Where indicated, cardioversion should be performed under short-acting general anaesthesia or conscious sedation. 

Conduction Disturbances and Bradycardia

[R] In patients with symptomatic bradycardia/conduction disturbance, concurrent therapies which predispose to bradycardia (for example, beta-blockers, digoxin, verapamil) should be discontinued 

[R] Isolated first-degree heart block does not require treatment. Mobitz type 1 second-degree heart block usually does not cause haemodynamic compromise and, as such, rarely requires treatment 

[R] Temporary transvenous pacing should be instituted in patients with high grade atrioventricular (AV) block without a stable escape rhythm who are unresponsive to positively chronotropic agents 

[R] Temporary transvenous pacing should be considered for patients with:

  • sinus bradycardia (heart rate <40 bpm) associated with haemodynamic instability and unresponsive to atropine, other positively chronotropic agents (unless contraindicated), and withdrawal of any negatively chronotropic agents
  • alternating left and right bundle branch block, new bifascicular or trifascicular block 
[R] Sequential AV pacing should be considered for patients with AV block, right ventricular (RV) infarction, and cardiogenic shock 

[R] Permanent pacing is indicated for patients with persistent (>7 days post myocardial infarction [MI]) Mobitz type II second- or third-degree AV block 

[✓] All patients requiring a permanent pacemaker should be evaluated for an implantable cardioverter defibrillator (ICD) and/or biventricular pacing 

[✓] All patients with bundle branch block following MI should be evaluated for an ICD and/or cardiac resynchronisation therapy. 

Ventricular Arrhythmias

Ventricular Arrhythmias and ACS

[R] Patients who have primary VF should be recognised as being at increased risk during their hospital stay, and therapy should be optimised 

[R] Patients who have VF or haemodynamically significant VT more than 48 hours after infarction should be considered for an ICD. 

Prevention of Ventricular Arrhythmias and Sudden Death

[R] Patients who have suffered a recent myocardial infarction and have an LV ejection fraction (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).

Assessment of Risk of Sudden Death

[R] All patients with ST-elevation ACS should undergo assessment of LV function for risk stratification at least 6 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. 

Arrhythmias Associated with Chronic Coronary Heart Disease/LV Dysfunction

Atrial Fibrillation 

Please refer to the guideline for recommendations on antiarrhythmic drugs, rate versus rhythm control, and pharmacological therapies for rate control

Non-Pharmacological Therapies

Atrioventricular Node Ablation and Permanent Pacing

[✓] In patients with LV dysfunction being considered for pacing, any other indications for cardiac resynchronisation therapy with pacing (CRT-P) (that is, presence of heart failure, QRS duration, and morphology) and likely risks and benefits in the individual should be discussed prior to device implant. 

Catheter Ablation for AF

[R] Ablation and pacing should be considered for patients with AF who remain severely symptomatic or have LV dysfunction in association with poor rate control or intolerance to rate-control medication 

[R] Patients with highly symptomatic paroxysmal AF resistant to one or more antiarrhythmic drugs and little or no comorbidity should be referred to an arrhythmia specialist for consideration of ablation 

[R] Patients with symptomatic AF (paroxysmal or persistent), symptomatic heart failure and LV systolic dysfunction with an LVEF of 25–35% should be referred to an arrhythmia specialist for consideration of ablation 

[R] Catheter ablation techniques for AF should focus on electrical isolation of the pulmonary veins 

[R] An early ablation strategy should be considered for highly symptomatic patients with little or no comorbidity 

[R] Any patient with highly symptomatic persistent AF should be referred to an arrhythmia specialist and ablation may be useful in selected cases. 

Catheter Ablation for Atrial Flutter

[R] Patients who present with typical atrial flutter should be offered radiofrequency catheter ablation 

[✓] Patients presenting with atrial flutter are at high risk for AF in the medium term and decisions on antithrombotic therapy should take this into account 

[✓] Atrial flutter with 1:1 conduction to the ventricles is a potentially life-threatening condition and patients should be discussed with an electrophysiologist for consideration of urgent inpatient catheter ablation. 

Ventricular Arrhythmias

Revascularisation for Secondary Prevention of VT/VF

[R] Revascularisation should be considered in patients who have had sustained VT or VF 

[✓] 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 ICD therapy. 

ICD Therapy in Patients at Risk of Life-Threatening Arrhythmias (Primary Prevention)

The following recommendations are reproduced from SIGN 147: Management of chronic heart failure.

[R] ICDs, cardiac resynchronisation therapy with defibrillator, or CRT-P are recommended as treatment options for patients with heart failure with reduced ejection fraction, LVEF ≤35% 

[✓] Patients receiving cardiac resynchronisation therapy and/or an ICD should be offered pre- and postplacement counselling, including discussion of potential shocks from the device, and device deactivation. 

ICD Therapy in Patients Surviving Life-threatening Arrhythmias (Secondary Prevention)

[R] Patients surviving the following ventricular arrhythmias in the absence of acute ischaemia or treatable cause should be considered for ICD implantation:

  • cardiac arrest (VT or VF)
  • VT with syncope or haemodynamic compromise
  • VT without syncope if LVEF ≤35% (not New York Heart Association IV). 

Reducing Inappropriate Shocks Associated With ICD Therapy

[R]  Patients with a primary-prevention ICD should have a single therapy zone programmed at a detection rate of 200 bpm 

[✓] Consider extending detection intervals in patients with secondary-prevention ICDs. 

Please refer to the guideline for recommendations on antiarrhythmic drug therapy.

Sustained Monomorphic VT

For patients with sustained VT who are haemodynamically unstable, electrical cardioversion is the immediate treatment of choice.

[R] IV amiodarone should be considered in the management of patients with haemodynamically stable sustained monomorphic VT 

[✓] IV drug therapy for VT should ideally be given under expert guidance 

[✓] If a first IV drug fails to restore sinus rhythm, electrical cardioversion or antitachycardia pacing should be considered. 

Catheter Ablation for Recurrent Ventricular Arrhythmia/Electrical Storm

[R] Catheter ablation should be considered in patients with electrical storm, where maximal medical therapy and appropriate ICD reprogramming have failed to control the arrhythmia. 

Arrhythmias Associated With Coronary Artery Bypass Graft Surgery

​​​Risk Factors

[R] In patients undergoing coronary artery bypass graft (CABG) surgery, age, previous AF, and LVEF should be considered when assessing risk of postoperative arrhythmia. 

Prophylactic Interventions

Although prophylaxis is effective in reducing the incidence of AF, the evidence is conflicting as to whether it decreases the incidence of stroke or mortality or shortens hospital stay.

Pharmacological Therapies


[R] Amiodarone may be used when prophylaxis for AF and ventricular arrhythmias is indicated following CABG surgery 

[R] Beta-blockers, including sotalol, may be used when prophylaxis for AF is indicated following CABG surgery 

[✓] Preoperative beta-blocker therapy should be reintroduced as soon as safe to do so after surgery. 

Calcium Channel Blockers

[R] Verapamil and diltiazem may be used for prophylaxis of AF following CABG surgery. 


[R] Digoxin should not be used for prophylaxis of AF following CABG surgery. 


[R] Glucose-insulin-potassium regimens should not be used for prophylaxis of AF following CABG surgery. 

Manipulation of Blood Electrolytes

[R] Magnesium may be used when prophylaxis for AF and ventricular arrhythmias is indicated following CABG surgery 

[✓] Blood levels of potassium and calcium should be measured frequently following CABG surgery and corrected if necessary. 

Anaesthesia and Analgesia

[R] The choice of anaesthetic agent or technique and analgesia should be based on factors other than AF prophylaxis.

Surgical Techniques

Off-pump Surgery

[R] The choice of whether or not to use cardiopulmonary bypass should be based on factors other than AF prophylaxis. 

Atrial Pacing

[R] Atrial pacing may be used for prophylaxis of AF in patients who have atrial pacing wires placed for other indications. 

Bonded Cardiopulmonary Bypass Circuits

[R] Bonded cardiopulmonary bypass circuits should not be used on the basis of AF prophylaxis alone. 

Defibrillator Implantation

[R] Defibrillators should not be routinely implanted in patients with a poor LVEF at the time of CABG surgery. 

Treatments for AF

Pharmacological Therapies

[R] In the immediate postoperative period, patients with persistent AF should be treated with a rhythm-control strategy 

[✓] Whatever pharmacological therapy is used for treatment of AF, the need for continuing treatment should be reviewed within 6 weeks of hospital discharge. 


[✓] Anticoagulation should be considered on a case-by-case basis for patients with AF following CABG where it is anticipated that the AF is likely to persist. 

DC Cardioversion


  • Patients with AF and haemodynamic compromise should have synchronised cardioversion 
  • Patients with persistent AF should be considered for elective synchronised cardioversion. 

Surgical Ablation

[R] Patients who are referred for cardiac surgery and who have a history of AF (paroxysmal or persistent) should routinely be considered for surgical ablation as a concomitant procedure 

[R] Surgical ablation should involve electrical isolation of the pulmonary veins with or without other lesions 

[✓] The decision as to whether or not to perform concomitant AF ablation should be discussed with the patient prior to cardiac surgery 

[✓] In patients who have undergone surgical ablation and are clinically free of atrial arrhythmias postoperatively, the decision on whether or not to discontinue antithrombotic therapy should take into account the patient’s CHA2DS2-VASc score and the risk of stroke if the patient were to develop recurrent AF. 

Treatments for Ventricular Arrhythmias


  • Patients with VF or pulseless VT should be defibrillated immediately 
  • IV adrenaline/epinephrine should be used for the management of patients with refractory VT/VF 
  • Sternal reopening, internal heart massage, and internal defibrillation should be considered in patients with refractory VT/VF 
  • IV amiodarone should be considered for the management of patients with refractory VT/VF 
  • Cardiac tamponade following CABG surgery is a cause of cardiac arrest and should be considered as a differential diagnosis 
  • Should other methods fail, sternal reopening should be performed promptly for cardiac arrest if the patient is in critical care and within 24 hours of surgery 
  • The ability to institute cardiopulmonary bypass in the critical care area should be available in all units undertaking CABG surgery 

[✓] Telemetric electrocardiogram monitoring of patients in the general ward allows early detection and treatment of patients in VT/VF 

[✓] Patients suffering VT/VF >48 hours after CABG should be considered for ICD implantation. 

Preoperative Information

[✓] Preoperative information/education, including that related to arrhythmias, should be tailored to individual patient’s needs. 

Psychosocial Issues

Psychosocial Assessment and Screening

[R] 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. 

Psychosocial Issues for ICD Recipients

[R] Psychosocial implications for people experiencing cardiac arrhythmias should be considered by all healthcare staff throughout assessment, treatment, and care 

[✓] Psychosocial support for patients experiencing cardiac arrhythmias should not be restricted to recipients of ICDs. 

Psychosocial Interventions

[R] Psychosocial interventions offered as part of a comprehensive rehabilitation programme should encompass a cognitive behavioural component.