Arrhythmias and Heart Failure Dr Chris Lang Consultant Cardiologist and Electrophysiologist Royal Infirmary of Edinburgh

Transcription

1 Arrhythmias and Heart Failure Dr Chris Lang Consultant Cardiologist and Electrophysiologist Royal Infirmary of Edinburgh

2 Arrhythmias and Heart Failure Ventricular Supraventricular VT/VF Primary prevention ICDs in at risk individuals Atrial Fibrillation Atrial Flutter Atrial tachycardia Reentrant SVTs Secondary Prevention Medical therapy Ablation

3 Ventricular Arrhythmias in Heart Failure VAs common in HF patients Poorly tolerated Frequently life threatening ICDs are normally implanted in surviviors of VT/VF NNT= 10 at 3y AVID trial, NEJM 1997

4 Primary Prevention of SAD in Heart Failure Identifying patients at risk of SAD LV ejection fraction Ischaemic vs NICM Non-sustained VT Syncope/presyncope SCD-HeFT Bardy et al, N Engl J Med 2005; 352:

5 DANISH Trial Non-ischaemic cardiomyopathy only Randomised to optimum med therapy + CRT if indicated or OMT + ICD/CRTD Overall no additional benefit from ICD Small benefit in patients <59yo NEJM 2016

6 DANISH Trial Kober et al NEJM 2016

7 DANISH Trial Kober et al NEJM 2016

8 Scar on MRI and Risk of SCD Klem et al, JACC 2012

9 Primary prevention ICDs in SCD: Patients most likely to benefit LVEF <30% Ischaemic cardiomyopathy All patients NYHA I-III should be considered Dilated/non-ischaemic cardiomyopathy Very young (<60) or significant scar on MRI

10 Medical Therapy for Ventricular Arrhythmias in HF Beta-blockers Consistently shown to reduce sudden death in HF Meta-analysis demonstrated 33% RRR in patients treated with BB (Gobari et al, BMC Cardiovasc Disorders 2013) Amiodarone No effect in primary prevention trials (possibly worse outcome in some groups)

11 Secondary Prevention of VAs in HF Class I antiarrhythmics Negatively inotropic Pro-arrhythmic Used cautiously and infrequently Introduced as inpatient in refractory VT Amiodarone Mildly negatively inotropic Can be effective in VT Often results in slower VT Sometimes harder to terminate with anti-tachy pacing from ICD

12 Arrhythmias and Heart Failure Heart failure causes arrhythmias Arrhythmias cause heart failure

13 Atrial Fibrillation

14 Total Hospitalization Days Based on Presenting Arrhythmia AF Atrial Flutter Cardiac arrest Conduction disease Junctional Premature beats Sick sinus syndrome VF VT Unspecified 0 Presenting Arrhythmia Camm AJ. Am J Cardiol. 1996;78(8A):3-11.

15 Atrial Fibrillation in Heart Failure Incredibly common Symptoms and prognosis worsen Management can be challenging Fewer medication options Often recurs post cardioversion

16 Rate control vs Rhythm Control Rate control Beta-blockers Digoxin (amiodarone) Pace and ablate Rhythm Control Cardioversion Amiodarone AF ablation

17 Rate vs Rhythm AFFIRM 2002 (atrial fibrillation follow-up investigation of rhythm management) patients in each arm Randomised to warfarin and rate control with digoxin, beta-blockers etc or rhythm control with AAD and repeated cardioversions 14% had RF ablation for atrial flutter High risk population Follow-up 3.5 years

18 AFFIRM

19 AFFIRM Results No difference in primary endpoint of survival between groups Post-hoc analysis of survival according to rhythm showed: 1. Sinus rhythm was associated with improved survival (HR 0.5) 2. That AAD (Class I or III) was associated with worse survival (HR 1.5) 3. SR and AAD cancelled each other out in terms of survival 4. Some patients thought to be in SR stopped OAC and had strokes 5. Pursuit of SR per se with AAD conveys no survival advantage and is not worthwhile in asymptomatic or minimally symptomatic patients

20 Pace and Ablate in PAF and CAF

21 Minutes Objective Benefits of Catheter Ablation of AV Nodal Conduction and Permanent Pacemaker Implantation Treadmill exercise performance before and after procedure. All patients were in rateadaptive pacing mode for follow-up. 1 0 Pre Post Kay GN. Am J Cardiol. 1988;62:

22 MHIQ PGWB Subjective Benefits of Catheter Ablation of AV Node and Permanent Pacemaker Implantation Pre Post 30 Pre Post McMaster Health Index Questionnaire physical dimension scores before and after procedure. High score = better functional capacity. Psychological General Well-Being Index scores before and after procedure. High score = greater perception of health and well-being. Kay GN. Am J Cardiol. 1988;62:

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24 AF Ablation a.k.a. Pulmonary Vein Isolation

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26 Atrial Flutter Common right atrial arrhythmia Easily curable with RF Ablation Restores atrial contribution May be replaced by AF in up to 50% patients in long term

27 Atrial Tachycardia A focal arrhythmia arising from atrial tissue P waves usually discrete on ECG (c.f. flutter) If persistent will aggravate heart failure Can be a primary cause of cardiomyopathy (tachycardiomyopathy)

28 Atrial Tachycardia: Case Study 69yo male with background of Guillain Barré syndrome Gross oedema and hypotension Commenced IV diuretics Noted to have sinus tachycardia Preliminary Dx idiopathic dilated cardiomyopathy

29 Atrial Tachycardia: Case study

30 Atrial Tachycardia: Case Study EP Study Earliest atrial activation on interatrial septum/svc junction RF ablation caused HR to drop from 120 to 45 bpm (on ivabradine and bisoprolol) Treated for 48h with IV isoprenaline and BB/Ivabradine stopped BP improved Diuresis accelerated Discharged

31 Atrial Tachycardia: Case Study Follow-up 3 months:lv dimensions improved with 30% reduction in LV size Ejection fraction 35% (from 10%) 6 months: MRI LVEF 49% (normal >55%)

32 Reentrant SVT AV node reentry/accessory pathway mediated SVT Usually short dramatic paroxysms Occasionally can be slow and prolonged Prolonged episodes of slow tachycardias can lead to cardiac dysfunction RF ablation is treatment of choice in most patients

33 Conclusions Ventricular arrhythmias are a leading cause of death in HF patients ICDs can offer significant survival benefit in at risk patients Post infarct patients benefit most DCM patients with scar on MRI benefit Benefit doubtful in older DCM patients without scar VT ablation has a role in patients with ICD therapies Amiodarone and mexiletine are main AAD for recurrent VT

34 Conclusions AF associated with worse outcome in HF patients AF is a cause of HF in many patients Maintaining SR is beneficial AF ablation proven to be superior to AAD LVEF improves substantially with restoration of SR in many Consider referring early for AF ablation

35 Conclusions Persistent SVTs esp atrial tachy can cause heart failure Suspect atrial tachycardia in patients with persistent tachycardia over 100bpm Atrial flutter should be ablated in all patients with HF Refer for consideration of ablation

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