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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
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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)
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
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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
AF is found in 6% of patients with mild
heart failure and >40% of patients with
advanced heart failure
% Patient with Atrial Fibrilation
0.6
0.5
0.4
0.3
0.2
0.1
0
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
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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847
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Management
1.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
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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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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847
SymCARD 2014
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
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Treatment
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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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847
SymCARD 2014
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
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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
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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 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
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McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847
SymCARD 2014
Symptomatic Bradycardia and Atrioventricular Block
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
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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
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