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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e819

9.2 Electrical Complications and Prevention of

Sudden Cardiac Death After ACS Recommendations for Electrical Complications and Prevention of Sudden Cardiac Death After ACS Referenced studies that support recommendations are summarized in the Evidence Table. COR LOE Recommendations Ventricular Arrhythmias

1 A 1 In patients post MI, implantable cardioverter-

defibrillator (ICD) implantation is recommended in selected patients with an LVEF ≤40% (Table 17) at least 40 days post MI and at least 90 days postrevascularization to reduce death.*1–4

2a C-EO 2 In patients post ACS, ICD implantation is

reasonable in patients with clinically relevant ventricular arrhythmias >48 hours and within 40 days post MI to improve survival.*5,6

2b B-R 3 In patients early after MI, usefulness of a

temporary wearable cardioverter-defibrillator is uncertain in patients with an LVEF ≤35% to improve survival.7

Bradyarrhythmias

1 B-NR 4 In patients presenting with an AMI with sustained

evidence of second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, alternating bundle-branch block, or third-degree atrioventricular block (persistent or infranodal), permanent pacing is indicated.†8,9

*Adapted from the “2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.” †Adapted from the “2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay.” Synopsis

Electrical complications in patients with ACS may create challenges in clinical management due to consideration for the need of anticoagulant therapy in patients who develop atrial fibrillation (AF) or flutter and possible need for antiarrhythmic therapy and electrophysiologic interventions. Many of these considerations have been addressed in depth in separate guideline documents.10 Generally, arrhythmic complications increase both morbidity and mortality rates in patients after ACS. Patients who present with AMI with reduced LVEF (≤40%) have increased risk of new-onset AF, bradyarrhythmias, and ventricular arrhythmias.11,12 This risk appears to be increased in those patients who are not revascularized or receive fibrinolytic therapy compared with those who undergo PCI.11

Recommendation-Specific Supportive Text

1 Ventricular arrhythmias are common after ACS

and more common in patients with reduced LVEF. MADIT II (Multicenter Automatic Defibrillator Implantation Trial) demonstrated a 31% reduction in all-cause mortality (HR, 0.69 [95% CI, 0.51- 0.93]) for prophylactic implantation of a cardiac defibrillator in patients with an LVEF ≤30% who were at least 30 days after MI or 3 months after revascularization for MI and had an anticipated life expectancy longer than 1 year.2 A mortality benefit

Figure 9. Clinical Characteristics of Mechanical Complications of Acute Myocardial Infarction. Contained rupture is the preferred term for an entity sometimes referred to as pseudoaneurysm. HF indicates heart failure; LA, left atrium; LV, left ventricle; and MR, mitral regurgitation. Modified with permission from Damluji et al.26 Copyright 2025 Devon Medical Art.

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