Arrhytmia In Heart Failure Dr. Muhammad Fadil, SpJP Department
of Cardiology and Vascular Medicine Medicine Faculty of Universitas
Andalas/ Dr. M. Djamil Hospital Padang SymCARD2014 4 th
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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
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Atrial Fibrillation (AF) SymCARD 2014 th the most common
arrhytmia in heart failure AF 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 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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0.60.50.40.30.20.10 Solv Rx V-HeFT II SOLVD Pre CHF STAT CIBIS
II EliteAVID Diamond GesicaOPTIME Consensus % Patient with Atrial
Fibrilation 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):156163.
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Mechanism of AF in HF January Ct, et al.
Circulation;2015:129
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ECG in Atrial Fibrillation (AF)
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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 SymCARD 2014 th McMurray
JJV, et al. European Heart Journal (2012) 33, 17871847
Classification and Management AF
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Management 1.Rate Controlled SymCARD 2014 th McMurray JJV, et
al. European Heart Journal (2012) 33, 17871847
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SymCARD 2014 th McMurray JJV, et al. European Heart Journal
(2012) 33, 17871847
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SymCARD 2014 th 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,
17871847
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SymCARD 2014 th McMurray JJV, et al. European Heart Journal
(2012) 33, 17871847
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SymCARD 2014 th McMurray JJV, et al. European Heart Journal
(2012) 33, 17871847
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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 SymCARD 2014 th
Management 2.Rhythm Controlled
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Amiodarone the only antiarrhythmic that should be used in
patient wth systolic HF Catheter Ablation as a rhythm control
strategy in HF = uncertain SymCARD 2014 th Treatment McMurray JJV,
et al. European Heart Journal (2012) 33, 17871847
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SymCARD 2014 th Most patients with systolic HF will have a risk
score consistent with a firm indication for (score2) or preference
for an oral anticoagulant (score=1) although bleeding risk must
also be considered Management 3.Thrombo-embolism Prophylaxis
McMurray JJV, et al. European Heart Journal (2012) 33,
17871847
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SymCARD 2014 th
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Ventricular Arrhytmias and Sudden Cardiac Death SymCARD 2014 th
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
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Prevalence Tedrow U and Stevenson WG. Management of Atrial and
Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York.
2005
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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
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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
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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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SymCARD 2014 th McMurray JJV, et al. European Heart Journal
(2012) 33, 17871847
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SymCARD 2014 th 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
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ECG in 3 rd degree AV block
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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
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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