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cardio.post-arrest.arvc-related.v1

Post-cardiac-arrest care — arrhythmogenic right-ventricular cardiomyopathy (ARVC; PKP2 / DSP desmosomal; exercise-induced VT/VF arrest)

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Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to arrhythmogenic right-ventricular cardiomyopathy (ARVC, also called arrhythmogenic cardiomyopathy ACM) as the etiology of the index out-of-hospital VF arrest. Primary genotypes: PKP2 plakophilin-2 (~30-45% — autosomal dominant), DSP desmoplakin (~15-25% — left-dominant variant common), DSG2 desmoglein-2 (~7-10%), JUP plakoglobin (~1-5% — Naxos cardiocutaneous syndrome with palmoplantar keratoderma + woolly hair), DSC2 desmocollin-2 (~1-2%), TMEM43 (~1-5% — founder Newfoundland), PLN phospholamban (~1-5% — left-dominant biventricular variant). Per 2020 Padua Criteria PMID 31676124 + HRS 2019 ARVC genetic statement PMID 31345875. Sister to cardio.post-arrest.cpvt-channelopathy.v1 — that is a FUNCTIONAL channelopathy (calcium-handling RYR2 / CASQ2 with NORMAL resting ECG, exercise-provoked bidirectional VT, structurally NORMAL heart). THIS dossier covers a STRUCTURAL cardiomyopathy — desmosomal disease with abnormal resting ECG (T-wave inversion V1-V3 + epsilon waves), structural RV abnormalities on cardiac MRI (regional WMA + dilation + dysfunction with fibrofatty replacement), and progressive disease where ENDURANCE EXERCISE IS BOTH TRIGGER AND DISEASE-MODIFIER (mechanical stress on weakened desmosomal junctions accelerates fibrofatty replacement per James 2013 + Saberniak 2014 + Sawant 2014). Both present as exercise-triggered VT in young patients but mechanism + workup + prognosis differ. Sister also to cardio.post-arrest.shockable-rhythm.v1 (generic VF/pVT framework — this engine specializes the ARVC channelopathy + Padua criteria + cardiac MRI + endurance-exercise avoidance arcs). CARDIAC MRI at 4-6 wk post-arrest is the GOLD-STANDARD non-invasive diagnostic — RV regional wall-motion abnormalities + RV dilation + RV dysfunction with fibrofatty replacement on T1 / late gadolinium enhancement; LV LGE in subepicardial / midwall pattern in left-dominant / biventricular ARVC (DSP, PLN); allows post-arrest stunning to resolve before baseline assessment; 2020 Padua Criteria application requires 2 major OR 1 major + 2 minor OR 4 minor across categories. Cascade family screening uses multimodality including cardiac MRI for relatives (ECG alone insufficient due to variable expressivity). LIFELONG AVOIDANCE OF ENDURANCE EXERCISE + COMPETITIVE SPORTS (HRS 2019 + ITF 2020 Class I — James 2013 PMID 23394677 + Saberniak 2014 PMID 24686442 + Sawant 2014 PMID 24385510) is THE most disease-modifying intervention. Endurance exercise dramatically accelerates fibrofatty replacement and disease progression with dose-response by hours/week and years of training; competitive cyclists, runners, triathletes, swimmers face the hardest counseling conversation (identity loss); recreational low-intensity activity ≤6 METs titrated to symptoms acceptable; mental health support critical for endurance athletes; medic-alert bracelet "ARVC — endurance exercise contraindicated" mandatory. Critical post-ROSC pharmacologic AVOIDS (signature departure from generic post-arrest care): CLASS I ANTIARRHYTHMICS (flecainide, propafenone) — proarrhythmic in scar substrate per CAST framework; HIGH-DOSE EPINEPHRINE / DOBUTAMINE — sympathomimetic stress on weakened desmosomes (substitute milrinone for inotropic support, vasopressin / phenylephrine for vasopressor); NSAIDs in HF (fluid retention + adverse RV remodeling); DIGOXIN (narrow therapeutic window in cardiomyopathy); ENDURANCE PHYSICAL ACTIVITY lifelong contraindication. Long-term pharmacology: β-BLOCKER FIRST-LINE LIFELONG (nadolol or metoprolol succinate; HRS 2019 IIa); SOTALOL 80-160 mg PO BID added for sustained VT or after ICD shocks (Class III + β-blocker dual mechanism; HRS 2017 + HRS 2019 IIa; renal dose-adjustment critical — AVOID if eGFR <40; QTc surveillance + K ≥4.5 + Mg ≥2.0 mandatory). ICD per HRS 2019 ARVC + ITF 2020 Class I as SECONDARY PREVENTION (sustained VT/VF survivor); subcutaneous ICD considered if no pacing indication. CATHETER ABLATION (combined endo + epicardial substrate ablation) at expert ARVC center for refractory storm or recurrent ICD shocks despite sotalol — endocardial alone insufficient because scar is epicardial / midwall in ARVC. LV-dominant / biventricular phenotype (DSP, PLN variants) requires GDMT 4-pillar HF management overlay (ARNI + β-blocker + MRA + SGLT2i) with advanced HF therapies including transplant evaluation for end-stage. Inherits manifest + design-brief pointer from parent cardio.post-arrest.core.v1; specializes the Padua-criteria application + cardiac MRI + channelopathy workup + family screening (multimodality with cardiac MRI for relatives) + endurance-exercise avoidance + β-blocker + sotalol + ICD + catheter ablation + biventricular HF management arcs. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers: recurrent VT post-ROSC ARVC storm-bridge with catheter ablation referral, inadvertent class I antiarrhythmic administered post-ROSC (CAST framework violation), ICD eligibility evaluation as secondary prevention, cascade family screening with cardiac MRI referral required (multimodality screening), endurance-exercise-avoidance counseling critical (THE most disease-modifying intervention with mental health support for endurance athletes facing identity loss). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute Phase E wave 25.

Entry points (6)

  • symptom
    ROSC after out-of-hospital VF arrest with known ARVC (prior diagnosis, prior ICD, prior syncope, family history) or with sentinel pre-arrest narrative — exercise-induced collapse in young patient (often endurance athlete) with characteristic ECG changes (T-wave inversion V1-V3 beyond age 14, epsilon waves)
    rosc_after_oohca_with_known_or_suspected_arvc
  • imaging
    Post-ROSC 12-lead ECG with T-wave inversion in V1-V3 beyond age 14 (Padua MAJOR criterion) ± epsilon waves V1-V3 (Padua MAJOR criterion; ~30% sensitivity) ± prolonged terminal activation duration ≥55 ms — pivot to ARVC-specific workup including cardiac MRI
    post_rosc_ecg_t_wave_inversion_v1_v3_with_or_without_epsilon_waves
  • history
    Witnessed arrest during exercise (running, cycling, swimming, competitive sports — particularly endurance athletes) in young patient (childhood through young adulthood) — high pretest probability for ARVC; endurance exercise both trigger and disease-modifier (accelerates fibrofatty replacement)
    witnessed_exercise_induced_arrest_in_young_patient_or_endurance_athlete
  • history
    Family history of sudden death <35 y, known ARVC in first-degree relative, or familial pattern of exercise-induced syncope / arrhythmia — autosomal dominant PKP2 most common (~30-45%); offer genetic panel + cascade screening with cardiac MRI for relatives
    family_history_sudden_death_under_35_or_known_arvc
  • history
    Prior unexplained exercise-induced palpitations or syncope, or documented sustained / non-sustained VT with LBBB superior axis morphology (RV-origin VT — Padua MAJOR criterion) pre-arrest — strong pretest probability for ARVC; missed-opportunity diagnosis
    prior_unexplained_palpitations_syncope_or_documented_lbbb_superior_axis_vt_pre_arrest
  • imaging
    Bedside echo showing RV regional wall-motion abnormality (free-wall aneurysm, akinetic outflow tract), RV dilation, or RV dysfunction (RVEF reduced) — Padua MAJOR criterion if meeting thresholds; pivots from generic post-arrest care toward ARVC-specific cardiac MRI scheduling for 4-6 wk
    echo_with_rv_regional_wma_dilation_dysfunction

Required inputs (26)

  • agerequired
    demographic • used at CONTEXT
    ARVC typically manifests in young adulthood (median age first event ~25-40 y; rare in childhood under age 12 — but cascade family-screening can identify pediatric carriers); pediatric resuscitation modifications below age 8; ICD device-size considerations + endurance-sport counseling are particularly difficult conversations in young athletes
  • sexrequired
    demographic • used at CONTEXT
    Male predominance ~3:1 — male sex + endurance exercise both worsen phenotype expression even at same genotype; informs cascade-screening prioritization
  • witnessed_arrest_with_exercise_trigger_or_endurance_athlete_historyrequired
    history • used at CONTEXT
    Trigger pattern is highly informative — exercise trigger (especially endurance training history: cycling, running, swimming, triathlon) is the ARVC signature; informs lifelong endurance-exercise avoidance counseling (THE most disease-modifying intervention); drives genetic panel + cardiac MRI referral
  • time_to_cpr_minrequired
    history • used at CONTEXT
    CPR within 1 min dramatically improves outcome; CAHP/OHCA score input
  • time_to_aed_defibrillation_minrequired
    history • used at CONTEXT
    AED within 3 min → 50%+ survival; venue AED program (sports field, gym, race venue) presence is dominant prognostic factor + suggests exercise-trigger context
  • initial_rhythmrequired
    history • used at CONTEXT
    VF most common terminal rhythm; sustained / non-sustained VT with LBBB superior axis morphology (RV-origin VT) is Padua MAJOR criterion when documented pre-arrest; informs storm-suppression bridge planning + ablation candidacy
  • family_history_sudden_death_or_known_arvcrequired
    history • used at CONTEXT
    Family history of SCD <35 y, known ARVC (autosomal dominant PKP2 in ~30-45%; DSP in ~15-25%; others rare), or familial pattern of exercise-induced arrhythmia is critical input — drives cascade cardiac-MRI + ECG + Holter + exercise-stress + genotyping screening of relatives
  • endurance_exercise_history_lifetime_doserequired
    history • used at CONTEXT
    Lifetime endurance exercise dose (years of competitive cycling, running, triathlon, swimming) directly correlates with phenotype severity per Saberniak 2014 + James 2013 — quantify hours/week and years; informs disease-modifier counseling
  • pre_arrest_medication_listrequired
    history • used at CONTEXT
    Comprehensive medication review; class I antiarrhythmics generally avoided in structural heart disease (CAST framework — proarrhythmic in scar substrate); document baseline meds
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target post-ROSC; SCAI staging if shock; cautious vasopressor (minimize epinephrine + dobutamine load on weakened desmosomal junctions); biventricular ARVC may have HF physiology
  • hrrequired
    vital • used at TREATMENT
    β-blocker initiation depends on rate; monomorphic VT often LBBB superior axis morphology in ARVC
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33–37.5 °C × 24 h (TTM2 PMID 34133859); shivering control during rewarm to minimize sympathetic load on weakened desmosomes
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92–98% (AHA 2020 Class IIa)
  • ecg_12_lead_serial_with_t_wave_inversion_and_epsilon_wave_assessmentrequired
    imaging • used at INITIAL_WORKUP
    Serial 12-lead ECG documenting T-wave inversion V1-V3 beyond age 14 (Padua MAJOR), epsilon waves V1-V3 (~30% sensitivity; Padua MAJOR — best seen on Fontaine bipolar leads), prolonged terminal activation duration ≥55 ms (Padua minor), QRS fragmentation; baseline for ICD planning + ablation substrate mapping
  • tte_high_resolution_with_rv_focused_assessmentrequired
    imaging • used at INITIAL_WORKUP
    STAT echo with RV-focused assessment — RV regional wall-motion abnormality (free-wall aneurysm, akinetic outflow tract), RV dilation (RVOT PLAX ≥32 mm or RVOT PSAX ≥36 mm at end-diastole = Padua MAJOR), RV dysfunction (RVEF reduced); LV size + function for biventricular involvement; structural finding pivots toward ARVC-specific cardiac MRI
  • cardiac_mri_at_4_to_6_wk_with_late_gadolinium_enhancementrequired
    imaging • used at FOLLOWUP
    Cardiac MRI at 4–6 wk post-arrest GOLD STANDARD diagnostic — RV regional wall-motion abnormalities + RV dilation + RV dysfunction with fibrofatty replacement on T1 / late gadolinium enhancement (Padua MAJOR criterion when meeting thresholds); LV LGE in subepicardial / midwall pattern in left-dominant / biventricular ARVC (DSP, PLN); allows post-arrest stunning to resolve before baseline assessment
  • signal_averaged_ecg_late_potentials
    imaging • used at FOLLOWUP
    Signal-averaged ECG (SAECG) — late potentials (filtered QRS duration >114 ms; LAS40 >38 ms; RMS40 <20 µV) is Padua MINOR criterion; useful screening adjunct but cardiac MRI more sensitive
  • holter_24_to_48_hr
    imaging • used at FOLLOWUP
    24-48 hr ambulatory monitoring quantifying PVC burden (>500/24 h = Padua MINOR; >1000/24 h higher specificity); non-sustained / sustained VT episodes; informs ICD planning + ablation candidacy
  • exercise_stress_test_at_inherited_arrhythmia_center_post_stabilization
    imaging • used at FOLLOWUP
    Exercise stress test under EP supervision post-stabilization — quantifies exercise-induced ectopy + non-sustained / sustained VT; informs activity counseling + risk stratification; performed at inherited-arrhythmia center
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Often modestly elevated from arrest + CPR; rise pattern helps differentiate from ACS-mediated arrest; primary ARVC arrest typically negative or modest
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + post-arrest perfusion debt; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438; CardShock PMID 26333869)
  • creatininerequired
    lab • used at CONTEXT
    eGFR for sotalol dose adjustment (renally cleared — proarrhythmic in CKD; reduce dose or avoid if eGFR <40); β-blocker also dose-adjusted
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    K target ≥4.0 standard (≥4.5 if on sotalol — sotalol is QT-prolonging Class III); replacement to suppress polymorphic VT recurrence
  • magnesiumrequired
    lab • used at INITIAL_WORKUP
    Mg target ≥2.0 standard; replacement to suppress polymorphic VT recurrence
  • genetic_panel_pkp2_dsp_dsg2_jup_dsc2_tmem43_pln_expandedrequired
    lab • used at FOLLOWUP
    Targeted gene panel — PKP2 core (~30-45% positive — autosomal dominant); expanded panel DSP (~15-25%; left-dominant variant common), DSG2 (~7-10%), JUP (~1-5%; Naxos cardiocutaneous syndrome), DSC2 (~1-2%), TMEM43 (~1-5%; founder Newfoundland), PLN (~1-5%; biventricular left-dominant), CDH2, TJP1; per HRS 2019 ARVC genetic statement PMID 31345875; informs prognosis + cascade testing
  • cxr_post_cprrequired
    imaging • used at INITIAL_WORKUP
    Rib fractures from CPR; pneumothorax; aspiration; baseline for ICD lead placement planning; cardiomegaly assessment

12-phase flow (12)

  1. 1FRAME
    Recognize post-ROSC + exercise-induced arrest in young patient + characteristic ECG (T-wave inversion V1-V3 beyond age 14, epsilon waves) + RV abnormalities on echo as ARVC-arrest cohort; pivot from generic post-arrest care to channelopathy-specific endurance-exercise avoidance + cardiac MRI scheduling + Padua criteria application; route to parent cardio.post-arrest.core.v1 for TTM + neuroprog while specializing on cardiac MRI + family screening + β-blocker + sotalol + ICD + catheter ablation + LV-dominant management arcs
    inputs: witnessed_arrest_with_exercise_trigger_or_endurance_athlete_history, ecg_12_lead_serial_with_t_wave_inversion_and_epsilon_wave_assessment, tte_high_resolution_with_rv_focused_assessment
    advance: ARVC high pretest probability confirmed + structural disease screen initiated + cardiac MRI scheduled
  2. 2ENTRY
    Standard ACLS for index arrest; immediate scene CPR + AED deployment; transport to PCI-capable + EP-capable facility; activate EP + inherited-arrhythmia center early; document endurance exercise history (years competitive cycling, running, triathlon, swimming — quantify hours/week)
    inputs: age, time_to_cpr_min, time_to_aed_defibrillation_min, endurance_exercise_history_lifetime_dose
    advance: ACLS + AED + transport + EP team activation + exercise history documented
  3. 3CONTEXT
    Trigger pattern (exercise — especially endurance training: cycling, running, swimming, triathlon — is the ARVC signature); time-to-CPR; time-to-AED; initial rhythm (VF most common; LBBB superior axis VT documented pre-arrest is Padua MAJOR); family history of SCD <35 y or known ARVC; lifetime endurance exercise dose (Saberniak 2014 dose-response); pre-arrest medication review
    inputs: sex, initial_rhythm, family_history_sudden_death_or_known_arvc, pre_arrest_medication_list, sbp, hr, core_temp, spo2, creatinine
    advance: context + family history + endurance exercise dose + trigger pattern documented
  4. 4RED_FLAGS
    Recurrent VT/VF post-ROSC suggests ongoing storm physiology — sotalol bridge + magnesium + β-blocker; LV-dominant / biventricular phenotype with HF / cardiogenic shock → route to HF + CS engines; minimize stress on weakened desmosomal junctions (cautious dobutamine + epinephrine); consider catheter ablation referral at expert center for refractory storm
    inputs: sbp, hr, ecg_12_lead_serial_with_t_wave_inversion_and_epsilon_wave_assessment
    actions: cardiogenic_shock, wide_complex_tach
    advance: red flags screened + storm-bridge route decided + LV-dominant / biventricular HF overlay screened
  5. 5INITIAL_WORKUP
    Serial 12-lead ECG documenting T-wave inversion V1-V3 beyond age 14 + epsilon waves + prolonged terminal activation; STAT echo with RV-focused assessment (RV regional WMA, RV dilation, RV dysfunction) + LV assessment (biventricular involvement); troponin (rule out ischemic mimic); BMP + Mg + Ca; CBC; ABG; CXR; comprehensive medication audit; CARDIAC MRI SCHEDULED for 4-6 wk (gold-standard diagnostic — allows post-arrest stunning to resolve)
    inputs: ecg_12_lead_serial_with_t_wave_inversion_and_epsilon_wave_assessment, tte_high_resolution_with_rv_focused_assessment, troponin, lactate, potassium, magnesium, cxr_post_cpr
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + ARVC pretest probability refined + structural / ischemic causes assessed + cardiac MRI scheduled + electrolytes optimized
  6. 6BRANCHING_WORKUP
    Genetic panel referral (PKP2 core; expanded DSP, DSG2, JUP, DSC2, TMEM43, PLN if family history positive or biventricular phenotype); EP consult for ICD planning (sustained VT/VF survivor = HRS 2019 ARVC + ITF 2020 Class I); LV-dominant / biventricular phenotype → HF management overlay (DSP, PLN suggest biventricular ARVC with HF physiology); STEMI on post-ROSC ECG (extremely rare in primary ARVC) → cath; recurrent VT storm → catheter ablation at expert center (combined endo + epicardial — endocardial alone insufficient because scar is epicardial / midwall in ARVC); cascade-screening referral for relatives (ECG + echo + cardiac MRI + Holter + signal-averaged ECG + exercise stress test + genotyping)
    actions: acs_pathway, wide_complex_tach
    advance: branching decisions made + genetic referral placed + cardiac MRI scheduled + EP plan documented + LV-dominant overlay screened + cascade-screening referral placed
  7. 7DIFFERENTIAL
    ARVC (T-wave inversion V1-V3 beyond age 14 + epsilon waves + RV regional WMA + structurally abnormal heart on cardiac MRI with fibrofatty replacement; exercise trigger; PKP2 / DSP autosomal dominant) vs CPVT (functional channelopathy — calcium-handling RYR2 / CASQ2; NORMAL resting ECG; bidirectional VT on exercise stress test; structurally NORMAL heart) vs Brugada (Type 1 V1-V3 coved ST + sleep / fever trigger; sodium channelopathy) vs sarcoidosis (multifocal LGE on cardiac MRI + extracardiac involvement — granulomas; PET-CT for metabolic activity) vs RVOT idiopathic VT (LBBB inferior axis VT in structurally normal heart — distinct from ARVC LBBB superior axis) vs Uhl anomaly (rare congenital RV dysplasia — distinct phenotype) vs idiopathic VF — this differential drives long-term plan + family screening
    inputs: family_history_sudden_death_or_known_arvc, witnessed_arrest_with_exercise_trigger_or_endurance_athlete_history, endurance_exercise_history_lifetime_dose
    advance: ARVC vs CPVT vs sarcoidosis vs alternative classification + cardiac MRI + Padua criteria application + genetic plan documented
  8. 8RISK_STRATIFICATION
    CAHP/OHCA scores apply (witnessed + bystander CPR + low-flow time + initial rhythm); SCAI shock stage if hemodynamic instability; HEART score not directly applicable (ARVC cohort low ACS pretest); HRS 2019 ARVC + ITF 2020 ICD class — sustained VT/VF survivor = Class I (this population by definition meets ICD criteria); 2020 Padua criteria application requires 2 major OR 1 major + 2 minor OR 4 minor across categories; Cadrin-Tourigny 2019 risk model for primary prevention (not applicable here — this is secondary prevention)
    inputs: initial_rhythm, time_to_cpr_min, time_to_aed_defibrillation_min, sbp, lactate
    actions: calc.map, calc.sofa, calc.ckd_epi_2021, calc.cha2ds2vasc, calc.heart
    advance: risk class + ICD eligibility + Padua criteria assessment + structural workup status documented
  9. 9TREATMENT
    Standard post-ROSC bundle (vasopressor → MAP ≥65 with cautious epinephrine + dobutamine; lung-protective vent; sedation; TTM 33-37.5 °C × 24 h with shivering control); K + Mg repletion (K ≥4.0 standard, ≥4.5 if on sotalol; Mg ≥2.0); LV-dominant / biventricular phenotype with HF / CS overlay → HF management (diuretics, GDMT 4-pillar — but minimize sympathomimetic inotropic load on weakened desmosomal junctions). LONG-TERM (initiate before discharge): β-BLOCKER (nadolol 1-1.5 mg/kg/d or metoprolol succinate 25-200 mg/d titrated; HRS 2019 ARVC IIa); SOTALOL 80-160 mg PO BID for sustained VT or after ICD shocks (HRS 2017 IIa — Class III + β-blocker dual mechanism; renal dose-adjustment if eGFR <40); ICD per HRS 2019 + ITF 2020 Class I (sustained VT/VF survivor); CATHETER ABLATION at expert center for refractory storm (combined endo + epicardial — endocardial alone insufficient); LV-dominant / biventricular HF management with GDMT 4-pillar; AVOID class I antiarrhythmics (flecainide, propafenone — proarrhythmic in scar); AVOID lifelong endurance exercise + competitive sports
    inputs: sbp, hr, core_temp, spo2, creatinine, potassium, magnesium
    actions: protocol.cardiogenic_shock
    advance: post-ROSC bundle + electrolyte optimization + long-term β-blocker + sotalol initiation + ICD pathway + endurance-exercise-avoidance counseling documented
  10. 10DISPOSITION
    CICU at EP-capable + inherited-arrhythmia-capable center for cardiac surveillance + ICD planning + catheter ablation referral planning; transfer to expert ARVC ablation center for refractory storm; HF / advanced HF center referral if biventricular phenotype with significant LV dysfunction
    advance: unit + service-line ownership assigned + EP follow-up booked + ablation-center transfer planned if needed + advanced HF transfer planned if biventricular
  11. 11MONITORING
    Continuous telemetry × 48–72 h; A-line; multimodal neuroprog ≥72 h post-rewarm (Sandroni 2021 PMID 33745427); serial ECG q4–6 h × 24 h then q6–8 h × 48 h; if on sotalol QT q4-6 h with K ≥4.5 mandatory; daily medication audit; β-blocker initiation logging; cascade-screening referral status documented
    inputs: ecg_12_lead_serial_with_t_wave_inversion_and_epsilon_wave_assessment, potassium, magnesium
    actions: panel.cardiac, panel.renal
    advance: monitoring + neuroprog + ECG + sotalol QT surveillance + drug audit cadence documented
  12. 12FOLLOWUP
    Cardiology + EP / inherited-arrhythmia clinic at 2–4 wks; CARDIAC MRI at 4–6 wk (gold-standard diagnostic; allows post-arrest stunning to resolve); GENETIC PANEL completed (PKP2/DSP/DSG2/JUP/DSC2/TMEM43/PLN); 2020 PADUA CRITERIA application + classification (definite ARVC, borderline, possible); CASCADE FAMILY SCREENING — first-degree relatives ECG + echo + cardiac MRI + signal-averaged ECG + 24-h Holter + exercise stress test + genotyping at proband mutation; β-blocker maintenance + sotalol if indicated; ICD interrogation q3–6 mo; CATHETER ABLATION at expert ARVC ablation center for refractory storm or recurrent ICD shocks despite sotalol (combined endo + epicardial substrate ablation); LIFELONG AVOIDANCE OF ENDURANCE EXERCISE + COMPETITIVE SPORTS (HRS 2019 + ITF 2020 Class I — THE most disease-modifying intervention; James 2013 + Saberniak 2014 + Sawant 2014); recreational low-intensity activity ≤6 METs titrated to symptoms; LV-dominant / biventricular phenotype HF management overlay (GDMT 4-pillar) with advanced HF therapies including transplant for end-stage; medic-alert bracelet "ARVC — endurance exercise contraindicated"; PTSD / mental health screen
    inputs: cardiac_mri_at_4_to_6_wk_with_late_gadolinium_enhancement, genetic_panel_pkp2_dsp_dsg2_jup_dsc2_tmem43_pln_expanded
    advance: cardiology + EP follow-up + cardiac MRI + Padua criteria classification + genetic panel + cascade family screening + ICD + β-blocker + sotalol + endurance-exercise avoidance + LV-dominant HF management + mental health all booked / documented