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Samir Rafla- Arrhythmia in Heart Failure Causes, consequences and Management

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					Arrhythmia in Heart Failure
  Causes, Consequences and
        Management


 Prof. Samir Morcos Rafla, FESC

        Cardiology Department
          Alexandria Univ.
            Type of Arrhythmias
   Ventricular premature beat

   Non sustained VT

   Repetitive monomorphic VT

   Polymorphic VT

   VF, Sudden cardiac death

   Atrial fibrillation
      Spontaneous Ventricular Arrhythmias
   Types
    – Multiform premature ventricular contractions
    – Ventricular pairs
    – Non-sustained ventricular tachycardia
          80% to 95% of patients with severe DCM

   On 24-hour Holter monitoring
    – 53% of patients had greater than 500 premature ventricular contractions
    – 54% had ventricular pairs
    – 31% episodes of non-sustained ventricular tachycardia
       Ventricular Arrhythmia in DCM
   Markers of disease severity

    – Significant association between the presence of couplets

      NSVT or PVCS >1000/day and SCD


    – Combination of ventricular ectopy and EF<40% was

      especially predictive of SCD
                                                    (Circulation 2001)
           Pharmacological Treatment
   Inotropic agents
    – Beta agonist and phosphodiestrase inhibitors
          Increase mortality
    – Digoxin
          No change in mortality
   ACEI
    – Enalapril in ValHeft decrease mortality
   Beta blockers
    – Carvedilol          COPRINICS 64% mortality reduction
    – Bisoprolol          CIBIS     34% reduction in mortality
    – Metaprolol          MERIT HF 34% reduction in mortality
             Amiodarone in DCM
             Heart failure    Sudden                   27% reduction in
                                          Amiodarone
            (Classes II–IV)    death                     sudden death
GESICA
 (516)
             Enlarged heart    Total       Standard    28% reduction in
           (CXR) or EF<0.35   mortality    therapy      total mortality


CHF-STAT     Heart failure     Total                   No difference in
                                          Amiodarone
  (674)     (Classes II–IV)   mortality                 total mortality
    Tachycardia-mediated Cardiomyopathy
 An association between tachycardia and cardiomyopathy is well
  recognized
 Supraventricular tachyarrhythmias associated with reversible
  left ventricular dysfunction include
   – ectopic atrial tachycardia
   – nonparoxysmal junctional tachycardia
   – atrial fibrillation
 The development of cardiomyopathy has also been documented
  with ventricular tachyarrhythmias
Ischemic VT




Successful ablation of the VT by creation of a line of RF lesions within the isthmus
perpendicular to the mitral annulus.
                             Handling Amio. Rizk 6/05
1676 pts
Mean age: 60.1yrs
23% Women                           RRR=23%
                                    ARR=7%
70% Class II/ 30% Class III



                              G Bardy et Al, NEJM 2005
              ESC guidelines on diagnosis and treatment of CHF 2008
           Pacing/Resynchronization(CRT)
           Implantable Cardioverter Defibrillator (ICD)
   ICD therapy is recommended for secondary prevention in survivors of VF and patients
    with documented hemodynamically unstable VT and or VT with syncope, an
    LVEF<40%, on optimal medical therapy and with an expectation of survival with good
    functional status for more than 1 year (AVID, CIDS, CASH)

   ICD therapy for secondary prevention is recommended to reduce mortality in patients
    with LV dysfunction due to prior MI who are at least 40 days pot-MI, have a LVEF<35%,
    in NYHA Class II-III, receiving optimal medical therapy, and who have a resonable
    expectation of survival with good functional status for more than 1 year (MADIT I-II)

   ICD therapy for secondary prevention is recommended to reduce mortality in patients
    with non-ischemic or ischemic cardiomyopathy, with LVEF<35%, in NYHA Class II-III,
    receiving optimal medical therapy, and who have a resonable expectation of survival with
    good functional status for more than 1 year (SCD-HeFT)




                                                                        Eur Heart J 2008
Management of atrial fibrillation
   in heart failure patients
13
Consequences of Atrial Fibrillation
  Arrhythmia-associated symptoms
   LV function, exercise tolerance, and QOL
  Tachycardia-mediated cardiomyopathy
  2-fold  in cardiac mortality
  5-fold  in risk of stroke
  Significant burden to healthcare system
• Loss of atrial kick or transport
• Inability of ventricle to generate
  effective SV due to the too short
  cardiac cycle
• Worsening of MR and TR
• Triggering of LV arrhythmias
Management of AF in HF



      Rate control strategy

      Rhythm control strategy
N Engl J Med 2008; 358: 2667-2677
                           R


    Rate control                    Rhythm control



• BB, digoxin                         • CV + AADs
• AVN Ablation + PM                     (Amio 82%)

            N Engl J Med 2008; 358: 2667-2677
                     Mean FU 37 months




Death from cardiovascular cause (primary endpoint)
        Roy D et al. N Engl J Med 2008; 358: 2667-2677
Management of AF in HF


   When onset of AF in pts with HF is not
 clearly associated with symptoms worsening,
        a rate control strategy may be
            an appropriate option
 Management of AF in HF



      An initial attempt at maintaining SR
is justified in HF pts whose AF onset is associated
    with severe hemodynamic deterioration
“Rate control” strategy



      AV node depressant drugs

      “Ablate & Pace”
“Rhythm control” strategy



     Antiarrhythmic drugs

     Upstream therapy

     Catheter ablation
Olshansky B et al. J Am Coll Cardiol
         2004; 43: 1201-8
         Left Ventricular-Based Cardiac Stimulation
   Post AV Nodal Ablation Evaluation (The PAVE Study)
RAHUL N. DOSHI, M.D.*, EMILE G. DAOUD, M.D.**, CHRISTOPHER FELLOWS, M.D.†,
  KYONG TURK, M.D.‡, AURELIO DURAN, M.D.§, MOHAMED H. HAMDAN, M.D.¶,
               andLUIS A. PIRES, M.D.†† for the PAVE Study Group




               J Cardiovasc Electrophysiol 2005;
                          16: 1160-5
                        PAVE study


                        BV
                                                    LV Ejection fraction
                        RV
                                                                           BV



                                                                           RV
6 minute walk testing




    Doshi RN et al. J Cardiovasc Electrophysiol 2005; 16: 1160-5
ACC/AHA/ESC AF Management Circulation 2006; 114; e257-e354
Singh SN et al. N Engl J Med 1995; 333: 77-82
   Amiodarone Discontinuation
   Due to Major Adverse Effects


 Amio Metanalysis   41%   at 2 yrs

 CTAF               18%   at 16 m

 PIAF               25%   at 1 yr

 AFFIRM             12.3% at 1 yr
Management of AF in HF


   When AADs and upstream therapy are
ineffective and pts remain highly symptomatic,
      transcatheter ablation of AF in LA
          may be a valuable option
N Engl J Med 2008; 359: 1778-85
PABA-CHF


    No AF recurrences at 6 months

88% after 2nd procedure and on AADs
71% after 2nd procedure and off AADs


   Khan MN et al. N Engl J Med 2008; 359: 1778-85
Conclusions (1)


  The treatment of patients with AF and HF
 should be individualized and the risk benefit ratio
 of the different therapeutic options carefully
 considered

  Anticoagulation and rate control are crucial in
 all patients with AF and HF.
Conclusions (2)

 Pharmacologic rhythm control offers no survival
benefit over rate control, and should be used only in
highly symptomatic patients

 Catheter ablation of AF may be a good alternative
in selected patients. However, the important question
of whether it has the potential to prolong life is still
unresolved
Management of AF in HF


   As far as regards anticoagulation,
 warfarin, with an INR target of 2 to 3,
should be prescribed to all pts with AF &
HF, and continued even if SR is restored
Management of AF in HF


   As far as regards anticoagulation,
 warfarin, with an INR target of 2 to 3,
should be prescribed to all pts with AF &
HF, and continued even if SR is restored
        New pharmacological agents
1.   The multichannel blocker dronedarone (Sanofi Aventis,
     Paris, France). Dronedarone is a noniodinated benzofurane
     derivative that is similar chemically to amiodarone. It has
     both the ability to slow the ventricular rate during
     persistent AF and to maintain sinus rhythm and it lacks
     the typical multiple and often severe side effects of
     amiodarone



                                                           38
         Hybrid Therapy Approaches
Drugs + Electric Cardioversion
      Restoration of SR
      Maintenance of SR after Cardioversion

Drugs + Catheter Ablation
      Linear Ablation:
             Ablation of the Cavotricuspid Isthmus
             RA Linear ablations
      Focal Ablation
             PV disconnection (Haissaguerre’s approach)
             (Pappone’s approach)
      AVN ablation= Ablate and Pace

Drugs + Pacemakers
            AF Pace-Termination                           39
            AF Pace-Prevention
Photo by Fady Samir Rafla




                            40

				
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