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Arrhytmia In Heart Failure. Dr. Muhammad Fadil , SpJP Department of Cardiology and Vascular Medicine Medicine Faculty of Universitas Andalas / Dr. M. Djamil Hospital Padang. th. 4. SymCARD . 2014. Introduction. - PowerPoint PPT Presentation
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Arrhytmia In Heart Failure
Dr. Muhammad Fadil, SpJPDepartment of Cardiology and Vascular Medicine
Medicine Faculty of Universitas Andalas/ Dr. M. Djamil HospitalPadang
SymCARD 20144 th
Introduction In heart failure patient population, cardiac arrhythmias
frequently contribute to worsened symptoms, periodic decompensations, and increased mortality
Arrhythmia recognition and management is an important aspect of caring for these patients
Chronic heart failure predisposes to both supraventricular and ventricular arrhythmias
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005
Atrial Fibrillation (AF)
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the most common arrhytmia in heart failureAF
The potential adverse effects: Loss of A-V synchrony, rapid or
slow ventricular rate responses May lead to worsening of
symptoms Atrial fibrillation has been
associated with increased mortality and more frequent hospitalizations
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005
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SOLVD Pr
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CHF STAT
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% Patient with Atrial Fibrilation
Prevalence AF
The incidence of atrial fibrillation in recent heart failure and arrhythmia trials
AF is found in 6% of patients with mild heart failure and >40% of
patients with advanced heart failure
Thomas SA, et al. AACN Clin Iss 2001; 12(1):156–163.
Mechanism of AF in HF
January Ct, et al. Circulation;2015:129
ECG in Atrial Fibrillation (AF)
The following issues need to be considered in patients with HF and AF, especially first episode of AF or paroxysmal AF:
Identification of correctable causes Identification of potential precipitating factors as this may determine
whether a rhythm-control strategy is preferred to a rate –control strategy Assesment for thromboembolism prophylaxis
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Classification and Management AF
Management1.Rate Controlled
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Extreme case AV node ablation and pacing may be required CRT may be considered instead of conventional pacing
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847
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thMcMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847
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In patients with Chronic HF, a rhythm-control strategy has not been demonstrated to be superior to a rate-control strategy in reducing mortality or morbidity
In patient with Acute HF with haemodynamic instability emergency cardioversion
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Management2.Rhythm Controlled
Amiodarone the only antiarrhythmic that should be used in patient wth systolic HF
Catheter Ablation as a rhythm control strategy in HF = uncertain
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Treatment
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847
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Most patients with systolic HF will have a risk score consistent with a firm indication for (score≥2) or preference for an oral
anticoagulant (score=1) although bleeding risk must also be considered
Management3.Thrombo-embolism Prophylaxis
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847
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Ventricular Arrhytmias and Sudden Cardiac Death
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Sudden cardiac death : 20% to 50% of the mortality in HF
Ventricular arrhythmias are a major etiology, and implantable defibrillators (ICDs) are warranted for many high-risk patients
Bradyarrhythmias caused 41% of in-hospital unexpected cardiac arrests
Conduction disease associated with heart failure, myocardial ischemia, antiarrhythmic and beta-adrenergic blocking drugs, and hyperkalemia are important potential etiologies
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005
Prevalence
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005
Monomorphic Ventricular TachycardiaIschemic
Mechanisme of VT Patients with Ischemic Cardiomyopathy typically have
large areas of infarction. Surviving myocyte bundles present within the infarction create channels for conduction set up reentry circuits VT
VT is typically monomorphic, with each QRS complex resembling the preceding and following QRS complex
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005
Monomorphic Ventricular Tachycardianon ischemic
Mechanisme of VT Patients with non Ischemic Cardiomyopathy who
develop sustained monomorphic VT, most have evidence of large areas of ventricular scar associated with a reentry circuit
The scar may be a consequence of replacement fibrosis from the myopathic process itself or due to infarcts from embolism of left ventricular or atrial thrombus to a coronary artery.
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005
Polymorphic Ventricular Tachycardia
Associated with QT interval prolongation is referred to as torsades de pointes. Any cause of QT interval prolongation can cause torsades de Pointes
Mechanisme of VT Electrophysiological changes that accompany ventricular
hypertrophy in chronic heart failure may increase susceptibility to torsades de pointes
Torsades de pointes is often ‘‘bradycardia-dependent’’ or ‘‘pause dependent,’’ with a characteristic initiating sequence
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005
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Indication for pacing
Issues specific to
HF
1. Before implanting a conventional pace maker in a patient with HF-REF, consider whether there is an indication for ICD, CRT-P or CRT-D
2. Because Right ventricular pacing may induced dysyncrony and worsen symptoms, CRT should be considered instead of conventional pacing in patient with HF-REF
Symptomatic Bradycardia and Atrioventricular Block
ECG in 3rd degree AV block
Take Home Messages In the heart failure patient population, cardiac arrhythmias
frequently contribute to worsened symptoms, periodic decompensations, and increased mortality
Atrial fibrillation and ventricular arrhythmias are common in heart failure patient
Take Home Messages Sudden cardiac death risk varies depending on etiology of
heart failure and other clinical features
Arrhythmia management in the heart failure population is complex, requiring careful integration of varied strategies including medication and procedures
Treatment of arrhythmia in patient with heart failure will decrease hospitalization and mortality
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Thank You
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