1. 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

2. 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

3. Atrial Fibrillation (AF)
the most common arrhytmia in heart failure
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 th 4
SymCARD 2014
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005

4. % Patient with Atrial Fibrilation
Prevalence AF
AF is found in 6% of patients with mild heart failure and >40% of patients with advanced heart failure
0.6
0.5
0.4
0.3
0.2
0.1
Solv Rx
V-HeFT II
SOLVD Pre
CHF STAT
CIBIS II
Elite
AVID
Diamond
Gesica
OPTIME
Consensus
% Patient with Atrial Fibrilation
The incidence of atrial fibrillation in recent heart failure and arrhythmia trials
Thomas SA, et al. AACN Clin Iss 2001; 12(1):156–163.

5. Mechanism of AF in HF
January Ct, et al. Circulation;2015:129

6. ECG in Atrial Fibrillation (AF)

7. Classification and Management 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 th 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

8. Management 1.Rate Controlledth 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

9. th 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

10. Extreme case  AV node ablation and pacing may be required  CRT may be considered instead of conventional pacing th 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

11. th 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

12. th 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

13. Management 2.Rhythm Controlled
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 th 4
SymCARD 2014

14. Treatment
Amiodarone  the only antiarrhythmic that should be used in patient wth systolic HF Catheter Ablation as a rhythm control strategy in HF = uncertain th 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

15. Management 3.Thrombo-embolism Prophylaxis
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 th 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

16. th 4
SymCARD 2014

17. Ventricular Arrhytmias and Sudden Cardiac Death
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 th 4
SymCARD 2014
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005

18. Prevalence
In chronic dilated heart failure, the incidence of sudden death increases with the
severity of heart failure [30,73–81]. In patients with minimal-to-modest symptoms of heart
failure, the annual risk of sudden death ranges from 2% to 6% per year. Those with more
advanced symptoms, New York Heart Association functional class III to IV, have risk of
5% to 12% per year. As the severity of heart failure increases, deaths due to pump failure
increase to a greater extent than sudden deaths
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005

19. Monomorphic Ventricular Tachycardia Ischemic
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

20. Monomorphic Ventricular Tachycardia non 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

21. 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

22. th 4
SymCARD 2014
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847

23. Symptomatic Bradycardia and Atrioventricular Block
Indication for pacing
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
Because Right ventricular pacing may induced dysyncrony and worsen symptoms, CRT should be considered instead of conventional pacing in patient with HF-REF
Issues specific to HF th 4
SymCARD 2014

24. ECG in 3rd degree AV block

25. 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

26. 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

27. Thank You th 4
SymCARD 2014