1 Aritmia in Heart Failure DR Fadil

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)
the most common arrhytmia in

AF 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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4 SymCARD 2014
Prevalence AF AF is found in 6of patients with
mild heart failure and >40of
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):156163.
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, 17871847 4 SymCARD 2014
Management
1.Rate Controlled
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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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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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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
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Management
3.Thrombo-embolism Prophylaxis
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
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4 SymCARD 2014
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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4 SymCARD 2014
Prevalence
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
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.
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
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Symptomatic Bradycardia and Atrioventricular Block
Indication for pacing
1. Before implanting a conventional pace

Issues
Issuesspecific
specific maker in a patient with HF-REF, consider
to
toHF
HF 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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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
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4 SymCARD 2014

1 Aritmia in Heart Failure DR Fadil

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1 Aritmia in Heart Failure DR Fadil

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Arrhytmia In Heart

Arrhythmia recognition and management is an important

Chronic heart failure predisposes to both supraventricular

the most common arrhytmia in

The potential adverse effects:

January Ct, et al. Circulation;2015:129

The following issues need to be considered in patients

Amiodarone the only

Catheter Ablation as a rhythm control

Ventricular arrhythmias are a major etiology, and implantable

Bradyarrhythmias caused 41% of in-hospital unexpected cardiac arrests

Conduction disease associated with heart failure, myocardial ischemia,

VT is typically monomorphic, with each QRS complex

The scar may be a consequence of replacement fibrosis from

Associated with QT interval prolongation is referred to as torsades de

Torsades de pointes is often bradycardia-dependent or pause

Indication for pacing

1. Before implanting a conventional pace

Atrial fibrillation and ventricular arrhythmias are common in heart

Arrhythmia management in the heart failure population is complex,

Treatment of arrhythmia in patient with heart failure will decrease

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