2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

Glenn N. Levine, MD, FACC, FAHA, Chair Patrick T. O’Gara, MD, MACC, FAHA, Chair-Elect Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair ¶Former Task Force member; current member during the writing effort. Sana M. Al-Khatib, MD, MHS, FACC, FAHA Joshua A. Beckman, MD, MS, FAHA Kim K. Birtcher, MS, PharmD, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA ¶Former Task Force member; current member during the writing effort. Ralph G. Brindis, MD, MPH, MACC ¶Former Task Force member; current member during the writing effort. Joaquin E. Cigarroa, MD, FACC Anita Deswal, MD, MPH, FACC, FAHA Lesley H. Curtis, PhD, FAHA ¶Former Task Force member; current member during the writing effort. Lee A. Fleisher, MD, FACC, FAHA Federico Gentile, MD, FACC Samuel Gidding, MD, FAHA ¶Former Task Force member; current member during the writing effort. Zachary D. Goldberger, MD, MS, FACC, FAHA Mark A. Hlatky, MD, FACC, FAHA John Ikonomidis, MD, PhD, FAHA José A. Joglar, MD, FACC, FAHA Laura Mauri, MD, MSc, FAHA Barbara Riegel, PhD, RN, FAHA Susan J. Pressler, PhD, RN, FAHA ¶Former Task Force member; current member during the writing effort. Duminda N. Wijeysundera, MD, PhD Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. The ACC and AHA sponsor the development and publication of guidelines without commercial support, and members of each organization volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA. Practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations may have a global impact. Although guidelines may be used to inform regulatory or payer decisions, their intent is to improve patients’ quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment. Guideline-recommended management is effective only when followed by healthcare providers and patients. Adherence to recommendations can be enhanced by shared decision-making between healthcare providers and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities. The ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations including the Institute of Medicine (P-1Committee on Standards for Developing Trustworthy Clinical Practice GuidelinesInstitute of Medicine (U.S.)Clinical Practice Guidelines We Can Trust. National Academies Press, Washington, DC2011Google Scholar, P-2Committee on Standards for Systematic Reviews of Comparative Effectiveness ResearchInstitute of Medicine (U.S.)Finding What Works in Health Care: Standards for Systematic Reviews. National Academies Press, Washington, DC2011Google Scholar) and on the basis of internal reevaluation. Similarly, the presentation and delivery of guidelines are reevaluated and modified on the basis of evolving technologies and other factors to facilitate optimal dissemination of information at the point of care to healthcare professionals. Toward this goal, this guideline heralds the introduction of an evolved format of presenting guideline recommendations and associated text called the “modular knowledge chunk format”. Each modular “chunk” includes a table of related recommendations, a brief synopsis, recommendation-specific supportive text and, when appropriate, flow diagrams or additional tables. References are provided within the modular chunk itself to facilitate quick review. This format also will facilitate seamless updating of guidelines with focused updates as new evidence is published, and content tagging for rapid electronic retrieval of related recommendations on a topic of interest. This evolved format was instituted when this guideline was near completion; therefore, the current document represents a transitional formatting that best suits the text as written. Future guidelines will fully implement this format, including provisions for limiting the amount of text in a guideline. Recognizing the importance of cost–value considerations in certain guidelines, when appropriate and feasible, an analysis of the value of a medication, device, or intervention may be performed in accordance with the ACC/AHA methodology (P-3Anderson J.L. Heidenreich P.A. Barnett P.G. et al.ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2304-2322Crossref PubMed Scopus (133) Google Scholar). To ensure that guideline recommendations remain current, new data are reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year cycles. Publication of new, potentially practice-changing study results that are relevant to an existing or new medication, device, or management strategy will prompt evaluation by the Task Force, in consultation with the relevant guideline writing committee, to determine whether a focused update should be commissioned. For additional information and policies regarding guideline development, we encourage readers to consult the ACC/AHA guideline methodology manual (P-4ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. American College of Cardiology and American Heart Association, 2010. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. Accessed October 1, 2017.Google Scholar) and other methodology articles (P-5Arnett D.K. Goodman R.A. Halperin J.L. et al.AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart Association, American College of Cardiology, and U.S. Department of Health and Human Services.J Am Coll Cardiol. 2014; 64: 1851-1856Crossref PubMed Scopus (56) Google Scholar, P-6Halperin J.L. Levine G.N. Al-Khatib S.M. et al.Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2016; 67: 1572-1574Crossref PubMed Google Scholar, P-7Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 64: 1373-1384Crossref PubMed Scopus (68) Google Scholar, P-8Jacobs A.K. Kushner F.G. Ettinger S.M. et al.ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 61: 213-265Crossref PubMed Scopus (0) Google Scholar). The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds. Writing committee members represent different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice. The Task Force may also invite organizations and professional societies with related interests and expertise to participate as partners, collaborators, or endorsers. The ACC and AHA have rigorous policies and methods to ensure that guidelines are developed without bias or improper influence. The complete relationships with industry and other entities (RWI) policy can be found online. Appendix 1 of the current document lists writing committee members’ relevant RWI. For the purposes of full transparency, writing committee members’ comprehensive disclosure information is available online, as is the comprehensive disclosure information for the Task Force. When developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data (P-4ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. American College of Cardiology and American Heart Association, 2010. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. Accessed October 1, 2017.Google Scholar, P-5Arnett D.K. Goodman R.A. Halperin J.L. et al.AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart Association, American College of Cardiology, and U.S. Department of Health and Human Services.J Am Coll Cardiol. 2014; 64: 1851-1856Crossref PubMed Scopus (56) Google Scholar, P-6Halperin J.L. Levine G.N. Al-Khatib S.M. et al.Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2016; 67: 1572-1574Crossref PubMed Google Scholar, P-7Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 64: 1373-1384Crossref PubMed Scopus (68) Google Scholar). Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited. An independent evidence review committee (ERC) is commissioned when there are ≥1 questions deemed of utmost clinical importance that merit formal systematic review. This systematic review will strive to determine which patients are most likely to benefit from a test, medication, device, or treatment strategy and to what degree. Criteria for commissioning an ERC and formal systematic review include: a) the absence of a current authoritative systematic review; b) the feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline; c) the relevance to a substantial number of patients; and d) the likelihood that the findings can be translated into actionable recommendations. ERC members may include methodologists, epidemiologists, healthcare providers, and biostatisticians. When a formal systematic review has been commissioned, the recommendations developed by the writing committee on the basis of the systematic review are marked with “SR”. The term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and pharmacological and procedural treatments. For these and all recommended medication treatment regimens, the reader should confirm the dosage by reviewing product insert material and evaluate the treatment regimen for contraindications and interactions. The recommendations are limited to medications, devices, and treatments approved for clinical use in the United States. The Class of Recommendation (COR) indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1) (P-4ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. American College of Cardiology and American Heart Association, 2010. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. Accessed October 1, 2017.Google Scholar, P-6Halperin J.L. Levine G.N. Al-Khatib S.M. et al.Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2016; 67: 1572-1574Crossref PubMed Google Scholar, P-8Jacobs A.K. Kushner F.G. Ettinger S.M. et al.ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 61: 213-265Crossref PubMed Scopus (0) Google Scholar).Table 1Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015) Open table in a new tab Glenn N. Levine, MD, FACC, FAHA Chair, ACC/AHA Task Force on Clinical Practice Guidelines The recommendations listed in this clinical practice guideline are, whenever possible, evidence-based. An initial extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted from April 2016 to September 2016. Key search words included, but were not limited, to the following: sudden cardiac death, ventricular tachycardia, ventricular fibrillation, premature ventricular contractions, implantable cardioverter-defibrillator, subcutaneous implantable cardioverter-defibrillator, wearable cardioverter-defibrillator, and catheter ablation. Additional relevant studies published through March 2017, during the guideline writing process, were also considered by the writing committee, and added to the evidence tables when appropriate. The final evidence tables are included in the Online Data Supplement and summarize the evidence used by the writing committee to formulate recommendations. Additionally, the writing committee reviewed documents related to ventricular arrhythmias (VA) and sudden cardiac death (SCD) previously published by the ACC, AHA, and the Heart Rhythm Society (HRS). References selected and published in this document are representative and not all-inclusive. As noted in the Preamble, an independent ERC was commissioned to perform a formal systematic review of 2 important clinical questions for which clear literature and prior guideline consensus were felt to be lacking or limited (Table 2). The results of the ERC review were considered by the writing committee for incorporation into this guideline. Concurrent with this process, writing committee members evaluated other published data relevant to the guideline. The findings of the ERC and the writing committee members were formally presented and discussed, then guideline recommendations were developed. The “Systematic Review for the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death” is published in conjunction with this guideline (S1.4-1Kusumoto F.M. Bailey K.R. Chaouki A.S. et al.Systematic review for the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2017 Oct 25; ([E-pub ahead of print])Google Scholar).Table 2Systematic Review Questions on SCD PreventionQuestion NumberQuestionSection Number1For asymptomatic patients with Brugada syndrome, what is the association between an abnormal programmed ventricular stimulation study and SCD and other arrhythmia endpoints?7.9.1.32What is the impact of ICD implantation for primary prevention in older patients and patients with significant comorbidities?10.3ICD = implantable cardioverter-defibrillator; SCD = sudden cardiac death. Open table in a new tab ICD = implantable cardioverter-defibrillator; SCD = sudden cardiac death. The ACC and AHA have acknowledged the importance of value in health care and have called for eventual development of a Level of Value for clinical practice recommendations (S1.4-2Anderson J.L. Heidenreich P.A. Barnett P.G. et al.ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2304-2322Crossref PubMed Scopus (133) Google Scholar). Available cost-effectiveness data were determined to be sufficient to support 2 specific recommendations in this guideline (see Sections 7.1.1 and 7.1.2). As a result, a Level of Value was assigned to those 2 recommendations on the basis of the “ACC/AHA Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures,” as shown in Table 3 (S1.4-2Anderson J.L. Heidenreich P.A. Barnett P.G. et al.ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2304-2322Crossref PubMed Scopus (133) Google Scholar). Available quality of life (QoL) data were deemed to be insufficient to support specific recommendations in this guideline.Table 3Proposed Integration of Level of Value Into Clinical Practice Guideline Recommendations∗Dollar amounts used in this table are based on U.S. GDP data from 2012 and were obtained from WHO-CHOICE Cost-Effectiveness Thresholds (S1.4-3).Level of ValueHigh value: Better outcomes at lower cost or ICER <$50,000 per QALY gainedIntermediate value: $50,000 to <$150,000 per QALY gainedLow value: ≥$150,000 per QALY gainedUncertain value: Value examined but data are insufficient to draw a conclusion because of no studies, low-quality studies, conflicting studies, or prior studies that are no longer relevantNot assessed: Value not assessed by the writing committeeProposed abbreviations for each value recommendation:Level of Value: H to indicate high value; I, intermediate value; L, low value; U, uncertain value; and NA, value not assessedGDP = gross domestic product; ICER = incremental cost-effectiveness ratio; QALY = quality-adjusted life-years; WHO-CHOICE = World Health Organization Choosing Interventions that are Cost-Effective. Reproduced from Anderson et al. S1.4-2Anderson J.L. Heidenreich P.A. Barnett P.G. et al.ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2304-2322Crossref PubMed Scopus (133) Google Scholar.∗ Dollar amounts used in this table are based on U.S. GDP data from 2012 and were obtained from WHO-CHOICE Cost-Effectiveness Thresholds S1.4-3World Health Organization. CHOosing Interventions that are Cost Effective (WHO-CHOICE): cost-effectiveness thresholds. Available at: http://www.who.int/choice/en/. Accessed March 26, 2013.Google Scholar. Open table in a new tab GDP = gross domestic product; ICER = incremental cost-effectiveness ratio; QALY = quality-adjusted life-years; WHO-CHOICE = World Health Organization Choosing Interventions that are Cost-Effective. Reproduced from Anderson et al. S1.4-2Anderson J.L. Heidenreich P.A. Barnett P.G. et al.ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 63: 2304-2322Crossref PubMed Scopus (133) Google Scholar. The writing committee consisted of cardiac electrophysiologists (including those specialized in pediatrics), general adult and pediatric cardiologists (including those specialized in critical care and acute coronary syndromes [ACS], genetic cardiology, heart failure, and cost-effectiveness analyses), a geriatrician with expertise in terminal care and shared decision-making, and a lay representative, in addition to representatives from the ACC, AHA, HRS, and the Heart Failure Society of America (HFSA). This document was reviewed by 2 official reviewers nominated by the ACC, AHA, and HRS; 1 official lay reviewer nominated by the AHA; 1 organizational reviewer nominated by the HFSA; and 28 individual content reviewers. Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 2). This document was approved for publication by the governing bodies of the ACC, the AHA, and the HRS; and endorsed by the HFSA. The purpose of this AHA/ACC/HRS document is to provide a contemporary guideline for the management of adults who have VA or who are at risk for SCD, including diseases and syndromes associated with a risk of SCD from VA. This guideline supersedes the “ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death” (S1.4-4Zipes D.P. Camm A.J. Borggrefe M. et al.ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.J Am Coll Cardiol. 2006; 48: e247-e346Crossref PubMed Scopus (0) Google Scholar). It also supersedes some sections of the “ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities” (S1.4-5Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al.ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons.J Am Coll Cardiol. 2008; 51: e1-e62Crossref PubMed Scopus (0) Google Scholar), specifically those sections on indications for the implantable cardioverter-defibrillator (ICD); and, it updates the SCD prevention recommendations in the “2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy” (S1.4-6Gersh B.J. Maron B.J. Bonow R.O. et al.2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am Coll Cardiol. 2011; 58: e212-e260Crossref PubMed Scopus (488) Google Scholar). Some recommendations from the earlier guidelines have been updated as warranted by new evidence or a better understanding of existing evidence, and irrelevant or overlapping recommendations were deleted or modified. In the current guideline, sudden cardiac arrest (SCA) is defined as the “sudden cessation of cardiac activity so that the victim becomes unresponsive, with no normal breathing and no signs of circulation” (S1.4-7Buxton A.E. Calkins H. Callans D.J. et al.ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology).J Am Coll Cardiol. 2006; 48: 2360-2396Crossref PubMed Scopus (52) Google Scholar). If corrective measures are not taken rapidly, this condition progresses to SCD. Cardiac arrest is used to signify an event that can be reversed, usually by cardiopulmonary resuscitation (CPR), administration of medications and/or defibrillation or cardioversion. SCA and SCD can result from causes other than VA, such as bradyarrhythmias, electromechanical dissociation, pulmonary embolism, intracranial hemorrhage, and aortic dissection; however, the scope of this document includes only SCA and SCD due to VA. This guideline includes indications for ICDs for the treatment of VA and prevention of SCD, but it does not delve into details on individual device selection and programming, including considerations relevant to cardiac resynchronization therapy (CRT), bradycardia pacing, and hemodynamic monitoring. These important aspects of ICD management have been covered in an HRS expert consensus statement (S1.4-8Wilkoff B.L. Fauchier L. Stiles M.K. et al.2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing.J Arrhythm. 2016; 32: 1-28Crossref PubMed Google Scholar). An AHA science advisory discusses the use of wearable cardioverter-defibrillators (S1.4-9Piccini Sr., J.P. Allen L.A. Kudenchuk P.J. et al.Wearable cardioverter-defibrillator therapy for the prevention of sudden cardiac death: a science advisory from the American Heart Association.Circulation. 2016; 133: 1715-1727Crossref PubMed Google Scholar). The findings of that document were reviewed; however, recommendations on this topic were developed independently of that document. This guideline includes indications for catheter ablation of VA, but does not provide recommendations on specific techniques or ablation technologies, which were beyond the scope of this document. Recommendations for interventional therapies, including ablation and the implantation of devices, apply only if these therapies can be implemented by qualified clinicians, such that outcomes consistent with published literature are a reasonable expectation. The writing committee agreed that a high degree of expertise was particularly important for performance of catheter ablation of VA, and this point is further emphasized in relevant sections. In addition, all recommendations related to ICDs require that meaningful survival of >1 year is expected; meaningful survival means that a patient has a reasonable quality of life and functional status. Although this document is aimed at the adult population (≥18 years of age) and offers no specific recommendations for pediatric patients, some of the literature on pediatric patients was examined. In some cases, the data from pediatric patients beyond infancy helped to inform this guideline. The writing committee recognized the importance of shared decision-making and patient-centered care and, when possible, it endeavored to formulate recommendations relevant to these important concepts. The importance of a shared decision-making process in which the patient, family, and clinicians discuss risks and benefits of diagnostic and treatment options and consider the patients’ personal preferences is emphasized (see Section 15). In developing this guideline, the writing committee reviewed previously published guidelines and related statements. Table 4 contains a list of guidelines and statements deemed pertinent to this writing effort and is intended for use as a resource, obviating repetition of existing guideline recommendations.Table 4Associated Guidelines and StatementsTitleOrganizationPublication Year (Reference)GuidelinesSyncopeACC/AHA/HRS2017 S1.4-10Shen W.K. Sheldon R.S. Benditt D.G. et al.2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2017; 70: e39-e110Crossref PubMed Scopus (13) Google ScholarHeart failureACCF/AHA2017 S1.4-11Yancy C.W. Jessup M. Bozkurt B. et al.2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.J Am Coll Cardiol. 2017; 70: 776-803Crossref PubMed Scopus (112) Google Scholar 2016 S1.4-12Yancy C.W. Jessup M. Bozkurt B. et al.2016 ACC/AHA