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 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) 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

% 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.

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

ECG in Atrial Fibrillation (AF)

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

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

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

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

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

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

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

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

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

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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

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

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

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

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

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

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

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

Thank You th 4 SymCARD 2014