Arrhytmia In Heart Failure

Arrhytmia In Heart Failure

Dr. Muhammad Fadil, SpJP

Department of Cardiology and Vascular Medicine

Medicine Faculty of Universitas Andalas/ Dr. M. Djamil Hospital

Padang

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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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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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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

Classification and Management AF

Management1.Rate Controlled

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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

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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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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

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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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

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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