Download Tachycardia Induced Cardiomyopathy

TACHYCARDIA INDUCED
CARDIOMYOPATHY
Javier E. Banchs M.D.
Associate Professor of Medicine
Penn State Hershey Heart & Vascular Institute
Case 1
• 34 year old man with history of
tachycardia x 6 months, nausea and
vomiting
• Elevated liver function tests
• Hypotension during sedation for EGD
• Ejection Fraction 20% by Echo, normal
coronary arteries
ECG
132 ppm
1
On IV amiodarone
115 ppm
RAO
LAO
I
II
RAA
p
3
HB2
d
MAPp
MAPd
p
6
5
CS 4
3
2
d
200 ms
2
LSPV
LAA
MA
LIPV
1 month later
Case 1 – follow up
• Discharged on beta blockers and
diuretics
• Progressive clinical improvement
• Normal ejection fraction in 3 months
3
Case 2
• 37 year old woman 36 weeks pregnant
with progressive dyspnea and EF 20%
• History of tachycardia during pregnancy
follow ups
ECG
4
Case 2
• Temporary response to IV Ibutilide
followed by hypotension and
cardiogenic shock after 48 hours on
Flecainide
• Urgent C Section
Case 2
• 2 days later EP study demonstrates
Permanent Junctional Reciprocating
Tachycardia (PJRT)
• Successful ablation in the proxymal
coronary sinus
Discharged on heart failure
therapy
5
Case 2 – follow up
• EF 40% in 3 months and 55% in 6 with
resolution of symptoms
Case 3
• 62 year old woman with history of CAD
and prior PCI
• Referred for ICD due to recent
deterioration of EF to 30-35% and
progressive dyspnea
6
Case 3
SVC
RAA
CS
IVC
Case 3
• EF 6 months after ablation = 45%
7
Case 4
• 47 year old woman with hypothyroidism
and 1 month of dyspnea, palpitations and
chest pressure admitted with pulmonary
edema and hypotension
• Transferred to our institutions for
transplant evaluation with suspicion of viral
cardiomyopathy
• Normal coronary arteries and EF 30%
ECG
8
ECG after ablation
Case 4 – follow up
• Symptoms resolution
• EF normalized 2 months later
• Atrial fibrillation recurrence with heart
failure symptoms 6 years later with
evidence of diastolic heart failure
9
Heart Failure
• 5.7 million in USA
• Cause of death in more than 55.000 people a
year
• 50% of patients diagnosed with heart failure die
within the first 5 years after diagnosis
• USA cost: 34.4 billons/year
Roger VL et al. Heart disease and stroke statistics—2012 update: a
report from the American Heart Association. Circulation.
2012;125(1):e2–220
Tachycardia Induced
Cardiomyopathy
• Gossage AM, Braxton Hicks JA. On
auricular fibrillation. QJM 1913; 6:435–
440
• Brill IC. Auricular fibrillation with
congestive failure and no other
evidence of organic heart disease. Am
Heart J 1937; 13:175–182
Tachycardia Induced
Cardiomyopathy
• Animal model for heart failure
– Atrial stimulation at 330 bpm in dogs > 3 weeks
– Biventricular failure, chamber dilatation, hypoperfusion, fluid retention, pulmonary congestion,
neuro-hormonal activation, myocardial
remodeling, apoptosis and myocardial fibrosis
– Partially reversible in 4 weeks off stimulation
Whipple GH et al. Reversible congestive heart failure due to chronic rapid
stimulation of the normal heart. Proc N Engl Cardiovasc Soc 1962; 20:39–40
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LOW EJECTION FRACTION
DIASTOLIC DYSFUNCTION
LOW CARDIAC OUTPUT
ATRIAL AND VENTRICULAR
DILATATION
MITRAL REGURGITATION
Apoptosis in dog hearts after 1,3 and 4 weeks of
atrial stimulation
Moe GW, Armstrong P. Pacing-induced heart failure: a model to study the
mechanism of disease progression and novel therapy in heart failure.
Cardiovascular Research 42 (1999) 591 –599
11
Tachycardia Induced
Cardiomyopathy
• Heart failure resulting from abnormal atrial
or ventricular rate elevation without other
dientifiable cause
• Variable progression - could depend on
rate and duration of the tachycardia
• Tachycardia may or may not be evident at
the time of presentation
• Reversible
Tachycardia Induced
Cardiomyopathy
• Clinical presentation:
– Systolic heart failure (dilated
cardiomyopathy)
• Dyspnea, edema, low output
– Tachycardia
• Palpitations, syncope
– Asymptomatic
Etiology
• Atrial fibrillation & atrial flutter
• Incessant atrial tachycardia
• Ventricular tachycardia and frequent
premature ventricular complexes
• Permanent junctional reciprocating
tachycardia (PJRT)
• Artificial stimulation
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Treatment
Treatment
DIAGNOSIS
Treatment
DIAGNOSIS
13
Treatment
DIAGNOSIS
• Rate Control
–
–
–
–
Treatment
Beta blockers
Calcium channel blockers
Digoxin
Optimal heart rate?
• Arrhythmia suppression
– Ablation
– Antiarrhythmic drugs
• Management of predisposing condition
– Thyrotoxicosis
– Pheochromocytoma
Case 5
• 24 year old man with long history of
PVCs and minimal symptoms
• Clinical follow up for 2 years with normal
echocardiogram
• Most recent echocardiogram shows
minimal dilatation of the LV and EF 50%
14
ECG
15
Post Ablation
16
Case 5 – follow up
• Symptoms resolved
• Normal EF
Outflow Tract PVCs
Yarlagadda RK. Et al. Circulation. 2005;112:1092-1097
Outflow Tract PVCs
Yarlagadda RK. Et al. Circulation. 2005;112:1092-1097
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Outflow Tract PVCs
• Ablation or pharmacological suppression
indicated for symptomatic ventricular
tachycardia with or without syncope
• 10.000 to 20.000 (15%) PVCs in 24 hours
could lead to LV dilatation and systolic
dysfunction
• Frequent PVCs in the asymptomatic patient:
monitor for symptoms & echocardiography
versus pharmacological suppression or
ablation
The Heart Failure Patient
ATRIAL
FIBRILLATION
PVCS
VENTRICULAR
DYSSYNCHRONY
DEVICE
THERAPY
SYMPATHETIC
TONE
VENTRICULAR
TACHYCARDIA
The Heart Failure Patient
ATRIAL
FIBRILLATION
PVCs
VENTRICULAR
DYSSYNCHRONY
DEVICE
THERAPY
SYMPATHETIC
TONE
VENTRICULAR
TACHYCARDIA
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VVI 40
DDDR 70
DAVID trial Wilkoff BL. Et al. JAMA. 2002;288(24):3115-3123
DAVID II trial Wilkoff BL. J Am Coll Cardiol 2009;53:872–80
EF before and after PVI - 50 patients with dilated CM and
EF <55%
J Cardiovasc Electrophysiol. 2007 Jan;18(1):9-14
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Meta-analysis A fib ablation in patients with heart failure. Change in EF
before and after A fib ablation
Dagres N. et al J Card Fail. 2011 Nov;17(11):964-70
80 heart failure patients with frequent PVCs treated with ablation
Panela D. et al. J Am Coll Cardiol. 2013 Sep 24;62(13):1195-202
65 patients withheart failure CRT and > 10.000 PVCs in 24
hours treated with ablation
Lakkireddy D. et al. J Am Coll Cardiol. 2012 Oct 16;60(16):1531-9
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The Heart Failure Patient
• Is the cardiomyopathy caused by
tachycardia?
• How long should we treat with beta
blockers and ACE-I/ARB
• Optimization of atrial fibrillation therapy
• Management of PVCs and VT
Who is at risk?
• Relationship between stress induced and
tachycardia induced cardiomyopathy
• Common etiology for tachycardia and
cardiomyopathy
• Genotype and environmental factors
• Is atrial fibrillation a localized form of
tachycardia induced cardiomyopathy?
• Is the cardiomyopathy really reversible?
Conclusions
• The diagnosis of tachycardia induced
cardiomyopathy should be suspected in
patients with heart failure and tachycardia
• The clinical syndrome is reversible
• Aggressive management of
supraventricular and ventricular
tachycardia may prevent heart failure
progression
21
Conclusions
• Treatment for frequent PVCs should be
considered with evidence of ventricular
remodeling or heart failure symptoms
• Further research is needed to better
understand the etiology of cardiac
arrhythmias and the pathophysiology of
tachycardia induced cardiomyopathy
22