This handout is for post-cardiac-arrest care — arrhythmogenic right-ventricular cardiomyopathy (arvc; pkp2 / dsp desmosomal; exercise-induced vt/vf arrest). Your care team identified this based on: 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).
Other reasons your team may use this plan: 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; 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); 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.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| nadolol | ARVC long-term: nadolol 1-1.5 mg/kg/d PO daily (alternative to metoprolol succinate; long half-life advantage) | PO | daily; lifelong | HRS 2019 ARVC PMID 31345875 IIa + HRS 2017 PMID 28219760 — β-blocker first-line for arrhythmia suppression in ARVC; nadolol or metoprolol succinate equivalent options |
| metoprolol succinate | ARVC long-term alternate: metoprolol succinate 25-200 mg PO daily titrated | PO | daily; lifelong | HRS 2019 ARVC IIa; preferred in LV-dominant / biventricular phenotype with HF (β1-selective, GDMT pillar) |
| sotalol | ARVC sustained VT or post-ICD-shock: sotalol 80-160 mg PO BID (renal dose-adjustment if eGFR <60; AVOID if eGFR <40) | PO | BID | HRS 2017 IIa + HRS 2019 ARVC IIa — Class III + β-blocker dual mechanism; QTc surveillance mandatory; K ≥4.5 + Mg ≥2.0 mandatory; renal dose-adjustment critical |
| magnesium sulfate | 2 g IV over 5–15 min then 2 g/h infusion supportive for polymorphic VT + shivering suppression during TTM rewarm | IV | continuous | AHA 2020 ACLS supportive for polymorphic VT; mandatory target ≥2.0 with sotalol initiation (QT prolongation safety) |
| potassium chloride | 20–40 mEq IV/PO until K ≥4.0 standard (≥4.5 mandatory if on sotalol) | IV/PO | PRN until target sustained | Standard polymorphic VT supportive therapy; mandatory ≥4.5 with sotalol (Class III QT-prolonging) |
| norepinephrine | 0.05–0.5 µg/kg/min titrate MAP ≥65; cautious in ARVC (sympathomimetic load on weakened desmosomes); minimize dose; substitute vasopressin or phenylephrine when feasible | IV | continuous | SOAP-II PMID 20200382; first-line post-ROSC vasoactive; in ARVC use lowest effective dose to minimize sympathomimetic stress on desmosomal junctions |
| vasopressin | 0.03 U/min IV fixed dose (catecholamine-sparing alternative) | IV | continuous | Non-adrenergic vasopressor preferred adjunct in ARVC to minimize sympathomimetic stress on weakened desmosomes |
| milrinone | 0.125–0.5 µg/kg/min IV (catecholamine-sparing inotrope alternative for biventricular ARVC with HF) | IV | continuous | PDE3 pathway — non-catecholamine inotrope; preferred substitute for dobutamine in ARVC to minimize sympathomimetic stress; particularly useful in biventricular phenotype with HF |
| epinephrine | 1 mg IV q3–5 min during arrest only (ACLS standard); minimize post-ROSC infusion if alternative | IV | standard ACLS only | AHA 2020 ACLS — standard arrest pathway; minimize post-ROSC infusion to limit sympathomimetic load |
| propofol | 5–50 µg/kg/min; titrate RASS | IV | continuous | PADIS 2018; preferred sedative for post-ROSC TTM (no specific ARVC contraindication unlike Brugada) |
| fentanyl | 25–200 µg/h | IV | continuous | PADIS 2018; preferred opioid for analgesia + shivering suppression during TTM rewarm |
| dexmedetomidine | 0.2–1.4 µg/kg/h; no bolus | IV | continuous | PADIS 2018; α2 agonist actually REDUCES central sympathetic outflow — useful in ARVC for shivering suppression + delirium prevention |
| acetaminophen | 650 mg PO/PR/IV q6h PRN | PO/PR/IV | q6h PRN | Standard analgesia / antipyresis; AVOID NSAIDs (fluid retention + RV adverse remodeling concern in ARVC HF) |
| lidocaine | 1–1.5 mg/kg IV bolus then 1–4 mg/min infusion bridge for refractory polymorphic VT during arrest pathway | IV | continuous bridge | AHA 2020 ACLS standard polymorphic VT bridge; acceptable in ARVC (unlike Brugada where contraindicated); β-blocker + sotalol preferred long-term |
| amiodarone | 150-300 mg IV bolus then 1 mg/min × 6 h then 0.5 mg/min × 18 h for refractory VT bridge | IV | continuous bridge | AHA 2020 ACLS for VT/VF; acceptable bridge in ARVC; long-term sotalol preferred per HRS 2019 IIa |
Plan: ARVC post-arrest phenotype — standard post-ROSC bundle with cautious sympathomimetic minimization + LONG-TERM β-blocker + sotalol for sustained VT or post-ICD-shock + ICD pathway (HRS 2019 ARVC + ITF 2020 Class I as secondary prevention) + catheter ablation for refractory storm at expert ARVC center + LIFELONG endurance-exercise avoidance + cascade family screening with cardiac MRI
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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 (the four foundational heart-failure medications 4-pillar) with advanced HF therapies including transplant for end-stage; medic-alert bracelet "ARVC — endurance exercise contraindicated"; PTSD / mental health screen
Guideline: 2020 Padua Criteria (Corrado PMID 31676124) + HRS 2019 ARVC genetic / management statement (Towbin PMID 31345875) + ITF 2020 ICD therapy in ARVC (Cadrin-Tourigny PMID 30852048) + HRS 2017 Inherited Arrhythmia Syndromes (Al-Khatib PMID 28219760) + AHA 2020 ACLS / Post-Cardiac-Arrest Care + TTM2 + Sandroni 2021 ERC-ESICM neuroprog + James 2013 / Saberniak 2014 / Sawant 2014 endurance exercise as disease modifier + ESC 2022 VA / SCD prevention