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Challenging cases in acute heart Challenging cases in acute heart failure: Arrhythmias failure: Arrhythmias

ØØ Antonis S. Manolis, MDAntonis S. Manolis, MDØØ 3 3rdrd Department of Cardiology Department of CardiologyØØ Athens University School of MedicineAthens University School of MedicineØØ Athens, Greece Athens, Greece

Conflict of Interest: none

HFA Meeting 2015

● Nonadherence with medication regimen, sodium and/or fluid restriction● Acute myocardial ischemia● Uncorrected high blood pressure ● AF and other arrhythmias● Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem, beta blockers)● Pulmonary embolus● Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones, NSAIDs)● Excessive alcohol or illicit drug use● Endocrine abnormalities (e.g., DM, hyperthyroidism, hypothyroidism)● Concurrent infections (e.g., pneumonia, viral illnesses)● Additional acute CV disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection)

Common Factors That Precipitate Acute Decompensated HF

2013 ACCF/AHA Heart Failure Guideline

Precipitants &Precipitants & causes of acute causes of acute heart failureheart failure

ESC Guidelines for HF 2012

Initial assessment of patient with Initial assessment of patient with suspected acute heart failuresuspected acute heart failure

ESC Guidelines for HF 2012

Arrhythmias in Acute/Decompensated HFArrhythmias in Acute/Decompensated HF

Study No of Pts AF / Flu VT / VF

EPICAL, 1999 499 26%* (non-SR)

EuroHeart HF, 2003 11327 42% (9% rapid VR) 8% (15% Sync)

Swiss Registry, 2005

312 29% (15% new AF/ triggered HF)

OPTIMIZE-HF, 2008 48612 31% (precipitating factor: 13.5%)

5.5%

IMPACT-HF, 2005 567 35% (8% of AF caused AHF)

11.5%

ADHERE, 2005 105388 31% 8% / 1%

Italian Survey, 2006 2807 28.4%

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AF in Heart FailureAF in Heart Failure

ØØAF AF is the is the most common arrhythmia in HF most common arrhythmia in HF ØØ Its onset may lead to Its onset may lead to worsening of Sxworsening of Sx, an , an ↑ risk of thrombo-↑ risk of thrombo-

embolicembolic complications, & complications, & poorer long-term outcomespoorer long-term outcomes

ØØPotential Potential precipitating factors precipitating factors & co-morbidity should be & co-morbidity should be identified &, if possible, corrected, e.g. identified &, if possible, corrected, e.g.

ØØ ●● electrolyte abnormalities, electrolyte abnormalities, ● ● hyperthyroidism,hyperthyroidism, ● ● alcohol alcohol consumption, consumption, ● ● MV disease, MV disease, ● ● acute ischemia, acute ischemia, ● ● cardiac cardiac surgery, surgery, ● ● acute pulm. disease, acute pulm. disease, ● ● infection, infection, ● ● uncontrolled HTNuncontrolled HTN

ØØBackground HF Rx Background HF Rx should be carefully re-evaluated & should be carefully re-evaluated & optimizedoptimized

Prevalence of AF in HF trialsPrevalence of AF in HF trials

↑ AF prevalence in pts with more advanced CHF AF in 40%-50% of pts in NYHA IV c/w 10% of pts with class II CHF predisposes to AF, & AF may worsen prognosis of CHFPrecautions for specific CHF-related SE (TdP) when treating AFCHF: 1 of most powerful independent predictors of AF (6-fold↑)Overall, AF affects ~15% - 30% of pts with clinically overt CHF

J CE 2002;13:399-405

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AF & Acute Heart FailureAF & Acute Heart Failure

ØØAF is a AF is a commoncommon rhythm in pts with acute rhythm in pts with acute decompensated heart failure (ADHF) decompensated heart failure (ADHF)

ØØRegistry & trial data indicate that Registry & trial data indicate that 20% to 35% 20% to 35% of of pts with ADHF who are admitted to the hospital will pts with ADHF who are admitted to the hospital will be in AF at presentationbe in AF at presentation

ØØIn about In about one third one third of these pts, the AF will be of of these pts, the AF will be of recent onset recent onset

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Acute Heart Failure: ArrhythmiasAcute Heart Failure: ArrhythmiasØØ The The OPTIME-CHF (Outcomes of a Prospective Trial of IV Milrinone Outcomes of a Prospective Trial of IV Milrinone

for Exacerbations) for Exacerbations) study: study: 949 pts 949 pts with decompensated HFwith decompensated HFØØ 2 groups based on occurrence of a 2 groups based on occurrence of a new arrhythmic eventnew arrhythmic eventØØ 59 new arrhythmic events occurring in 59 new arrhythmic events occurring in 6%6% ØØOf these, Of these, 49% were atrial fibrillation / flutter49% were atrial fibrillation / flutterØØPPrimary endpoint: rimary endpoint: days hospitalized days hospitalized for CV causes within 60 for CV causes within 60

d after randomization was 30.9±22.7 for those in arrhythmia d after randomization was 30.9±22.7 for those in arrhythmia gp & 11.3±12.7 d for those with no arrhythmias (gp & 11.3±12.7 d for those with no arrhythmias (PP =0 .0001).  =0 .0001).

ØØMortalityMortality during hospitalization was 26% in arrhythmia gp & during hospitalization was 26% in arrhythmia gp & 1.8% in the no arrhythmia group (1.8% in the no arrhythmia group (PP =o .001).  =o .001).

ØØDeath or hospitalization at 60 d was also worse in the Death or hospitalization at 60 d was also worse in the arrhythmia group (35 vs 8.2%; 57 vs 34%, both arrhythmia group (35 vs 8.2%; 57 vs 34%, both PP = 0.001) = 0.001)

ØØ NNew arrhythmias: an independent risk factor for primary ew arrhythmias: an independent risk factor for primary endpoint & death at 60 daysendpoint & death at 60 daysBenza et al, J Card Fail 2004;10(4):279-84.

Kaplan-Meier estimates Kaplan-Meier estimates of survival of survival in the first 60 days after in the first 60 days after the index the index hospitalization for hospitalization for both groups of patients. An both groups of patients. An early risk of death within early risk of death within 30 days 30 days is clearly depicted is clearly depicted forfor

those those patients with a patients with a new arrhythmianew arrhythmia..OPTIME-CHF: Impact of Arrhythmias in Acute Heart Failure

N=949

JCF 2004

Impact of Arrhythmias in Acute

Heart Failure

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OPTIME-CHFOPTIME-CHF

ØØNew arrhythmia during an exacerbation of New arrhythmia during an exacerbation of HF HF identifies a identifies a high-risk group high-risk group with higher with higher intrahospital & 60-day morbidity & mortalityintrahospital & 60-day morbidity & mortality

Impact of AF on Impact of AF on mortalitymortality & & readmissionreadmission in in older adults hospitalized with HFolder adults hospitalized with HF

Eur J Heart Failure 2004; 6 : 421–426

Pts with AF had a 52% ↑ risk of 4-year mortality (adjusted HRs1.52). AF was also a/w higher risk of readmission (unadjusted HRs1.64). However, the association lost its statistical significance after adjustment for various pt & care variables (adjusted HR2.09)

4-y survival declined by 24% in pts with AF (29% vs 38% for those without AF; P=0.008).

After adjustment for various pt & care variables, 4-y MR risk ↑

by 52% (adjusted HRs 1.52).

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AF & Acute Heart FailureAF & Acute Heart Failure

ØØAF & worsening HF AF & worsening HF interactinteract in a dangerous pattern in a dangerous pattern

ØØAdverse effects of AF Adverse effects of AF in pts with HF may include in pts with HF may include ● ● loss of atrial transport, loss of atrial transport, ● ● rapidrapid & irregular & irregular VRVRs, & s, & ● ● toxic effects of toxic effects of AADs / AADs / AF can cause acute HF

ØØWorsened heart failureWorsened heart failure, in turn, leads to , in turn, leads to ● ● increased atrial stretch & increased atrial stretch & ● ● heightened sympathetic heightened sympathetic tone tone / / Acute HF can precipitate AF

ØØThese latter changes make the These latter changes make the AF more resistant AF more resistant to to treatment using either a rate-control or a rhythm-treatment using either a rate-control or a rhythm-control control strategystrategy

● AF may be chronic and not directly related to the acute HF decompensation

(1) Dx to be confirmed by (1) Dx to be confirmed by ECGECG Check Check electrolyteselectrolytes & review & review CXRCXR Attempt to establish the etiology Attempt to establish the etiology of acute of acute hemodynamic instabilityhemodynamic instability (2) initiation of (2) initiation of anticoagulationanticoagulation should not delay any emergency should not delay any emergency interventionintervention(3) Urgent (3) Urgent rate control rate control c IV Rx c IV Rx should be with (a) b-blockers, should be with (a) b-blockers, Dig Dig or or rate-limiting Ca++ antagonists, rate-limiting Ca++ antagonists, (b) amiodarone, where b-blockers (b) amiodarone, where b-blockers or Ca++ antagonists are or Ca++ antagonists are contraindicated or ineffective.contraindicated or ineffective. (4)Where there is a delay in (4)Where there is a delay in organising organising electrical CVelectrical CV, , IVIVamiodaroneamiodarone should be usedshould be used

Hemodynamically unstable AF Rx algorithm

Mann et al, Heart 2007;93:45–47

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AF in ADHFAF in ADHF

ØDifficult to determine whether AF is the cause or result of acute decompensated HF (ADHF).

ØA reliable history of palpitations that clearly precede the decompensation suggests but does not prove that AF was the cause of the pulmonary edema

ØThe treatment of AF depends upon whether or not it is associated with significant hemodynamic instability and whether or not it is believed to be the precipitant of HF decompensation.

Ø In some pts c AF & ADHF, effective treatment of pulmonary edema results in slowing of the ventricular rate or spontaneous reversion of the arrhythmia.

Ø If AF persists, it is treated in the same fashion as AF in other situations

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AF / AF / Rate ControlRate ControlØ Rate control is often the preferred initial strategy

for the following reasons:● Because acute HF can precipitate AF, CV prior to resolution of acute HF will often be followed by early recurrence of AF● AF is often a chronic condition that is not contributing to

the acute decompensationØHowever, if a rate control strategy is selected, the negative

inotropic effects of β-blockers & Ca++ channel blockers can be problematic in pts with systolic dysfunction

ØFor this reason, short-acting IV formulations of such drugs (eg, esmolol or diltiazem) are often used.

Ø In addition, digoxin is also potentially useful in this setting, although its use has lessened considerably due to toxicity issues and slow onset of action

ØAmiodarone can be considered

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Restoration of SRRestoration of SR

ØRestoration of sinus rhythm (SR) should be considered in the following settings:

● If AF is associated with hypotension or evidence of cardiogenic shock

● If AF is clearly the cause for pulmonary edema● If the response to effective therapy of pulmonary edema is

slow or suboptimal

ØHeparin should be started prior to cardioversion if possible

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Initial AssessmentInitial AssessmentØØThe The clinical history clinical history provides critical information provides critical information

that should be used to guide Rxthat should be used to guide RxØØ5 key questions 5 key questions should be asked before starting should be asked before starting

RxRx● ● Does the pt have an Does the pt have an ICD or pacemaker ICD or pacemaker in place?in place?● ● Does the pt have preserved or reduced Does the pt have preserved or reduced systolic systolic

functionfunction at the baseline? at the baseline?● ● What is the What is the durationduration of the AF episode? of the AF episode?● ● Is the pt already on Is the pt already on drugsdrugs for rhythm or rate for rhythm or rate

control & anticoagulation?control & anticoagulation?● ● What What concomitant disorders concomitant disorders are present?are present?

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ØØMany pts who present with ADHF will have ICDs Many pts who present with ADHF will have ICDs ØØInappropriate ICD therapy Inappropriate ICD therapy during AF episodes is during AF episodes is

both undesirable & dangerousboth undesirable & dangerousØØIf pt has an ICD, If pt has an ICD, interrogation & reprogramming interrogation & reprogramming of of

ICD to ICD to minimizeminimize risk for risk for inappropriate therapy inappropriate therapy should be performed as soon as possible should be performed as soon as possible

ØØUsually, rate & duration of arrhythmia that triggers Usually, rate & duration of arrhythmia that triggers VT or VF detection VT or VF detection should be ↑, & SVTA should be ↑, & SVTA discriminators should be activated if availablediscriminators should be activated if available

ØØWith With dual-chamber or biventricular devicesdual-chamber or biventricular devices, the , the atrial tachyarrhythmia pacing response should be atrial tachyarrhythmia pacing response should be set to eliminate inappropriate set to eliminate inappropriate high-rate atrial high-rate atrial trackingtracking

Initial AssessmentInitial Assessment

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Rate Control vs Rate Control vs Rhythm ControlRhythm ControlØØAF episode AF episode durationduration will affect decisions about will affect decisions about

advisability & potential for advisability & potential for CV CV & selection of agents for & selection of agents for rhythm or rate controlrhythm or rate control

ØØ3 scenarios are commonly encountered 3 scenarios are commonly encountered ØØSome Some pts will present shortly after the onset of AFpts will present shortly after the onset of AFØØEither the AF episode itself has rapidly precipitated HF Either the AF episode itself has rapidly precipitated HF

in a previously stable pt or worsening HF has triggered in a previously stable pt or worsening HF has triggered an acute episode of AF an acute episode of AF

ØØIn these pts, In these pts, potential potential for successful for successful early restoration of early restoration of SR SR is high if the HF Sx can be is high if the HF Sx can be controlledcontrolled

ØØA second A second pattern: pattern: onset of onset of AF AF unknown or >48 hunknown or >48 hØØ candidates for a candidates for a later CV later CV attempt attempt vsvs rate control rate control

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ØØOptimal rest Optimal rest VR<100 bpm VR<100 bpm desirable/ may not be achievable desirable/ may not be achievable until volume overload & hypoxia corrected / More realistic until volume overload & hypoxia corrected / More realistic target target <120 bpm <120 bpm @ first hrs of Rx@ first hrs of Rx

ØØDigoxinDigoxin should be first rate-control agent considered, but in should be first rate-control agent considered, but in pts c pers. ↑ sympathetic tone, it may have little effectpts c pers. ↑ sympathetic tone, it may have little effect

ØØ If pt already taking dig, additional doses may be dangerous If pt already taking dig, additional doses may be dangerous & should be avoided, unless low serum dig level (<0.5 & should be avoided, unless low serum dig level (<0.5 ng/mL) can be confirmedng/mL) can be confirmed

ØØCautious Cautious addition of addition of IV -blockerIV -blocker, e.g. esmolol (, e.g. esmolol (500 500 μμg/kg/ g/kg/ 1min1min),or, if systolic function preserved, ),or, if systolic function preserved, diltiazemdiltiazem

ØØ If If rate control along with relief of volume overload & rate control along with relief of volume overload & dyspnea dyspnea can be achieved, can be achieved, pts will frequently revert back to pts will frequently revert back to SR if AF is of recent onset SR if AF is of recent onset

ØØ If pt does not improve, already on If pt does not improve, already on anticoagulationanticoagulation , & not on , & not on an AAD, a trial of an AAD, a trial of IV amio IV amio may be helpful (may slow VR & may be helpful (may slow VR & facilitate early CVfacilitate early CV

Rate Control vs Rhythm ControlRate Control vs Rhythm Control

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ØØ If this approach fails & VR during AF remain elevated, If this approach fails & VR during AF remain elevated, ØØCVCV after a period of after a period of loading with loading with an AAD, usually an AAD, usually

amiodaroneamiodarone, is the next step, is the next stepØØWhen the patient has When the patient has not been adequately anticoagulated, not been adequately anticoagulated, ØØ a a TEETEE followed by maintained anticoagulation may facilitate followed by maintained anticoagulation may facilitate

the early CV attempt the early CV attempt ØØ If CV attempts are unsuccessful & the pt remains If CV attempts are unsuccessful & the pt remains

symptomatic with elevated VR, symptomatic with elevated VR, ØØAV junctional ablation, often with a biventricular pacing AV junctional ablation, often with a biventricular pacing

system, is an additional option that can be considered.system, is an additional option that can be considered.

Rate Control vs Rhythm ControlRate Control vs Rhythm Control

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ØØOnce Once VRVR has been at least partially has been at least partially controlledcontrolled, possible , possible benefit of a benefit of a CVCV should be considered, unless pt has known should be considered, unless pt has known long-standing pers. AFlong-standing pers. AF

ØØ Therefore, once the Therefore, once the acute HF exacerbation acute HF exacerbation has been has been correctedcorrected in such a pt in such a pt →→ a continued rate-control strategy a continued rate-control strategy

ØØ In pts with In pts with new- or recent-onset AFnew- or recent-onset AF, an , an attempt at CV & drug attempt at CV & drug Rx Rx is reasonable, with final decision on a long-term strategy is reasonable, with final decision on a long-term strategy based on Sx, drug tolerance, & frequency of recurrencesbased on Sx, drug tolerance, & frequency of recurrences

ØØAs was shown in the As was shown in the AF & HF TrialAF & HF Trial, there is no a priori , there is no a priori benefit a/w a rhythm-control strategy, but benefit a/w a rhythm-control strategy, but

ØØ Individual pt responses vary widely Individual pt responses vary widely ØØ at least 1 attempt to maintain SR at least 1 attempt to maintain SR in any pt with > mild Sx in any pt with > mild Sx ØØ In selected pts, In selected pts, RFARFA may prove effective, but experience for may prove effective, but experience for

pts in whom AF was not the primary cause for HF has been pts in whom AF was not the primary cause for HF has been limitedlimited

Rate Control vs Rhythm ControlRate Control vs Rhythm Control

Rate vs Rhythm-Control in AF: Review & Meta-AnalysisRate vs Rhythm-Control in AF: Review & Meta-Analysis

MR CVA/TIA

s. embolism rehosp

HF bleed

Chatterjee et alPACE 2012

<65 y-o

Chatterjee et al, PACE 2012

favors a rate-control strategy in pts with AF, even in thosewith HTN, HF, or VHD, and permanent AF, with a possible role of

rhythm control in younger patients with AF

Rate vs Rhythm-Control in AF: Review & Meta-AnalysisRate vs Rhythm-Control in AF: Review & Meta-Analysis

MR

success of cardioversion success of cardioversion according to according to heart failure treatment heart failure treatment

before cardioversionbefore cardioversion

Boldt et al, Am Heart J 2008;155:890-5

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Acute Acute Rate ControlRate ControlDrug Loading Dose Onset Maintenance SE

Esmolol 500 μg/kg IV over 1 min

5 min 60-200 μg/kg/min ↓BP, HB, ↓HR, asthma, HF

Diltiazem 0.25 mg/kg IV over 2 min

2-7 min 5-15 mg/h ↓BP, HB, HF

Verapamil 5-10 mg IV given slowly as 1 mg increments at a time (0.075-0.15 mg/kg over 2-5 min)

3-5 min NA ↓BP, HB, HF

Propranolol 0.15 mg/kg IV 5 min NA ↓BP, HB, ↓HR, asthma, HF

Metoprolol 2.5 to 5 mg IV bolus over 2 min; up to 3 doses

5 min NA ↓BP, HB, ↓HR, asthma, HF

Digoxin 0.25 mg IV each 2 h, up to 1.5 mg

> 60 min 0.125 to 0.375 mg daily IV or orally

Digitalis toxicity, HB, ↓HR

Amiodarone 150 mg IV over 10 min (or 5 mg/kg over 30-60 min )

Hours/Days 0.5 to 1 mg/min IV (up to 1800 mg/24 h)

↓BP, HB, SB, pulm. /liver toxicity, hypo/hyper-thyroidism,warfarin interaction

Rate control Rate control during AF with HFduring AF with HF

Indications for electrical & pharmacological CV, & choice of Indications for electrical & pharmacological CV, & choice of antiarrhythmic drugs for antiarrhythmic drugs for pharmacological CVpharmacological CV

in pts with in pts with recent-onset AFrecent-onset AF

ESC AF Guidelines

2012

Choice of AAD according to underlying pathology

ESC AF Guidelines

2012

Antiarrhythmic Antiarrhythmic drugs and/or drugs and/or

LA ablation for LA ablation for rhythm control rhythm control

in AFin AF

ESC AF Guidelines

2012

2011 ACCF/AHA/HRS Focused Update 2011 ACCF/AHA/HRS Focused Update on on the Management the Management of of Pts Pts With With AF AF

CCS AF Guidelines 2012CCS AF Guidelines 2012

Recommendations for the treatment Recommendations for the treatment of patients with of patients with acute heart failureacute heart failure

ESC (2012) HF Guideliness

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IV diltiazem IV diltiazem is rapid, safe, & effective in acutely lowering a is rapid, safe, & effective in acutely lowering a rapid VR in pts with AF or flutter & moderate to severe CHFrapid VR in pts with AF or flutter & moderate to severe CHF

ØØ 37 pts 37 pts c rapid (VR,142 ± 17 bpm) AF or Aflu & moderate to severe c rapid (VR,142 ± 17 bpm) AF or Aflu & moderate to severe CHF (EF, 36 ± 14%; CHF (EF, 36 ± 14%; NYHA class III NYHA class III [23 pts], [23 pts], class IV class IV [14 pts]) [14 pts])

ØØ IV diltiazem, 0.25 mg/kg over 2 min, or placebo followed 15 min IV diltiazem, 0.25 mg/kg over 2 min, or placebo followed 15 min later by diltiazem or placebo, 0.35 mg/kg over 2 minlater by diltiazem or placebo, 0.35 mg/kg over 2 min

ØØ Placebo nonresponders: open-label IV diltiazem (all 15 responded) Placebo nonresponders: open-label IV diltiazem (all 15 responded) ØØ 21 pts (95%) responded to diltiazem21 pts (95%) responded to diltiazem, & 0% to placebo (p< 0.001) , & 0% to placebo (p< 0.001)

/Overall, 36 of 37 pts (97%)//Overall, 36 of 37 pts (97%)/median time to response ~ 5 minmedian time to response ~ 5 min ØØHypotensionHypotension was the most common adverse event occurring in 4 of was the most common adverse event occurring in 4 of

37 pts (37 pts (11%11%). ). No patient had an exacerbation of CHFNo patient had an exacerbation of CHF due to due to diltiazemdiltiazem

Goldenberg et al, AJC 1994; 74 (9) : 884–889

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AF in HF / AF in HF / 2013 ACCF/AHA 2013 ACCF/AHA HF GuidelineHF GuidelineØØPt c Pt c newly detected HF in the presence of AF newly detected HF in the presence of AF with a with a rapid rapid VR VR

should be should be presumedpresumed to have a to have a rate-related CM rate-related CM / 2 strategies: / 2 strategies: ØØ 11) ) rate control rate control of the of the patient’s AF patient’s AF and see if HF and EF improve. and see if HF and EF improve. ØØ 2) try 2) try to to restore & restore & maintain maintain SRSR. Initiate . Initiate amiodaroneamiodarone & & then then

arrange for arrange for CV 1 CV 1 month month laterlaterØØ beta-blockersbeta-blockers are the preferred are the preferred agents for agents for achieving rate control achieving rate control

unless otherwise unless otherwise contraindicatedcontraindicatedØØDigoxinDigoxin may be an effective adjunct to a beta may be an effective adjunct to a beta blockerblockerØØDDiltiazemiltiazem, , should be should be used with caution in those with used with caution in those with depressed depressed

EFEF because because of its of its negative inotropic negative inotropic effect effect ØØHFHFppEFEF:: diltiazemdiltiazem can be effective for can be effective for achieving rate achieving rate control but control but

may be more effective when used in may be more effective when used in combination with combination with digoxindigoxin..ØØ For those for whom a rate-control For those for whom a rate-control strategy is strategy is chosen, when rate chosen, when rate

control cannot be achieved either control cannot be achieved either because of because of drug inefficacy or drug inefficacy or intolerance, intolerance, AVN ablation & AVN ablation & CRT CRT device placement can be device placement can be usefuluseful

New onset of AF or flutter in pts New onset of AF or flutter in pts without AF or flutter at baselinewithout AF or flutter at baseline

JACC 2012;59:1598

New onset AFF was significantly ↓ by eplerenone: 25 of 911 (2.7%) vs 40 of 883 (4.5%) in the placebogp (hazard ratio [HR]: 0.58; p = 0.034)

Mineralocorticoid Receptor Mineralocorticoid Receptor Antagonists & CV Mortality in Pts With Antagonists & CV Mortality in Pts With

AF and Left Ventricular DysfunctionAF and Left Ventricular Dysfunction

Circ Heart Fail. 2012;5:586-593

N.B. c Spironolactone !

SVTSVT

AF / AFluAF / AFluDigoxin IV: 0.5 mg (→1.5 mg) (0.125-.375/d) Diltiazem IV:dose 0.25 mg/kg over 2 min, 2nd @ 15 min 0.35 mg/kg over 2 min, infusion @ 5-15 mg/hAmiodarone IV: 150 mg/10 min or 5mg/kg /30-60 min(0.5-1 mg/min)

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Atrial FlutterAtrial Flutter

ØØAcute Rx: depends on clinical presentationAcute Rx: depends on clinical presentationØØRate control Rate control

ØØAFlu can be successfully cardioverted to SR AFlu can be successfully cardioverted to SR cc DCDC-energies -energies <<50-100 j (vs 100-200 J for AF)50-100 j (vs 100-200 J for AF)

ØØIbutilideIbutilide ( (1 mg IV over 10 min1 mg IV over 10 min) : efficacy rates ) : efficacy rates of of 38-76%38-76% for CV of AFlu (c/w 5-13% with IV for CV of AFlu (c/w 5-13% with IV flecainide, propafenone or verapamil)flecainide, propafenone or verapamil)

ØØContinuous cardiac monitoring for > 4h (Continuous cardiac monitoring for > 4h (TdPTdP))

ØØ Atrial pacing Atrial pacing (TV /TE)(TV /TE)

Preexcited AFPreexcited AF

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12-Lead ECG in ER12-Lead ECG in ER

VFlu / VFVFlu / VF

amiodarone 300 mg IV over 20—60 minfollowed by an infusion of 900 mg over 24 h

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VTAs in Acute HF / VTAs in Acute HF / MManagementanagement

Ø VT during pulmonary edema is usually life-threatening.

ØAs a result, prompt electrical cardioversion or defibrillation is required.

ØIf the arrhythmia recurs after reversion, antiarrhythmic therapy, particularly with amiodarone, may be effective

ØThe development of VF mandates prompt resuscitation (CPR/CPR/BLSBLS), ), earlyearly DFDF & & ACLSACLS / PAD / / PAD / AED)AED)

Torsade des PointesTorsade des Pointes

TdP degenerating into VF in an 83-yr-old female hospitalized in the ICU for pneumonia; started on IV erythromycin several hrs earlier

QT Prolonging DrugsQT Prolonging Drugs

www.longqt.org

www.sads.org

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Management of Drug-Induced QTManagement of Drug-Induced QTProlongation & Prolongation & TdPTdP in Hospital Settings in Hospital Settings

ØØ removal of the offending agent removal of the offending agent in pts with drug-induced in pts with drug-induced LQTS (Class I, LoE: A); however, ? what QTc valueLQTS (Class I, LoE: A); however, ? what QTc value

ØØContinuous QTc monitoring Continuous QTc monitoring appropriate for drugs deemed appropriate for drugs deemed most at risk to cause QT prolongation /TdPmost at risk to cause QT prolongation /TdP

ØØAt-risk drug: if QTc > At-risk drug: if QTc > 500 ms 500 ms or there has been an ↑ or there has been an ↑ >>60 ms 60 ms c/w the predrug baseline value, esp. when accompanied by c/w the predrug baseline value, esp. when accompanied by other ECG signs of impending TdP: prompt action other ECG signs of impending TdP: prompt action

ØØActions: Actions: ●● alternative drug Rx; alternative drug Rx; ●●assessment of potentially assessment of potentially aggravating aggravating ● ● drug-drug interactions, drug-drug interactions, ● ● bradyarrhythmias, bradyarrhythmias, or or ● ● electrolyte abn.; & electrolyte abn.; & ● ● availability of an ext. defibrillator availability of an ext. defibrillator

ØØPts should Pts should not be transported from the unit not be transported from the unit for diagnostic for diagnostic or therapeutic procedures, and they should be in a unit with or therapeutic procedures, and they should be in a unit with the the highest possible ECG monitoring highest possible ECG monitoring surveillancesurveillance

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Management of Drug-Induced QTManagement of Drug-Induced QTProlongation & Prolongation & TdPTdP in Hospital Settings in Hospital Settings

ØØ For pts with TdP that does not terminate spontaneously or For pts with TdP that does not terminate spontaneously or degenerates into VFdegenerates into VF, , immediate DC CV immediate DC CV should be performed should be performed

ØØ IV MgIV Mg++++ sulfate sulfate is reasonable for pts taking QT-prolonging is reasonable for pts taking QT-prolonging drugs who present c episodes of TdP & a ↑QT interval (Class drugs who present c episodes of TdP & a ↑QT interval (Class IIa, LoE: B) IIa, LoE: B)

ØØMgMg++++ sulfate 2 g can be infused IV sulfate 2 g can be infused IV as a first-line agent to as a first-line agent to terminate TdP irrespective of the serum Mgterminate TdP irrespective of the serum Mg++++ level level

ØØ If episodes of TdP persist, it may be necessary to repeat If episodes of TdP persist, it may be necessary to repeat infusions of Mginfusions of Mg++++ sulfate 2 g. Mechanism underlying sulfate 2 g. Mechanism underlying protective effect of Mgprotective effect of Mg++++ is unknown is unknown

ØØ ↑ in HR to prevent pauses triggering TdP may be attempted c ↑ in HR to prevent pauses triggering TdP may be attempted c temp. TV atrial or ventricular pacing temp. TV atrial or ventricular pacing at at 90-110 bpm 90-110 bpm

ØØRepletion of KRepletion of K++ to supratherapeutic levels of 4.5 to 5 mmol/L to supratherapeutic levels of 4.5 to 5 mmol/L may also be considered, although there is little evidence to may also be considered, although there is little evidence to support this practice (Class IIb, LoE: C)support this practice (Class IIb, LoE: C)

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Recommendations for Recommendations for management of management of ventricular arrhythmias in heart failureventricular arrhythmias in heart failure

ØØPPotential otential aggravating/precipitating factors aggravating/precipitating factors (e.g. electrolyte (e.g. electrolyte disorders, use of disorders, use of proarrhythmicproarrhythmic drugsdrugs, myocardial , myocardial ischemiaischemia) ) should be sought and corrected should be sought and corrected / / I CI C

ØØRx c Rx c an an ACEI ACEI (or ARB), (or ARB), ββ-blocker-blocker, &, & MRA MRA should be should be optimizedoptimizedØØ coronary coronary revascularizationrevascularization be considered be considered in in pts pts with with VAs & CADVAs & CADØØ ICDICD be be implanted in a implanted in a pt pt with symptomatic or sustained with symptomatic or sustained VTAVTA (VT (VT

or or VF), VF), reasonable functional status, and in whom a goal of reasonable functional status, and in whom a goal of treatment is treatment is to improve survivalto improve survival

ØØAmiodaroneAmiodarone for pts with an ICD, who continue to have Sxic VAs for pts with an ICD, who continue to have Sxic VAs or recurrent shocks despite optimal Rx & device re-programmingor recurrent shocks despite optimal Rx & device re-programming

ØØCatheter ablation Catheter ablation is recommended in is recommended in pts pts with an ICD who with an ICD who continue to have continue to have VAs causing VAs causing recurrent recurrent shocks shocks not preventable not preventable by optimal by optimal treatment, treatment, device re-programming &device re-programming & amiodarone amiodarone

ESC (2012) HF Guideliness

Recommendations for the use of Recommendations for the use of ICDs ICDs in in pts pts with with HFHF

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12-Lead ECG in ER12-Lead ECG in ER

ICD ICD

ØØ Electrical cardioversion Electrical cardioversion is recommended if is recommended if an an ventricular ventricular arrhythmia is arrhythmia is contributing contributing to to the patient’s hemodynamic the patient’s hemodynamic compromise in compromise in order to restore order to restore SR SR and improve the patient’s and improve the patient’s clinical clinical condition. condition. I I CC

Pts with hypotension, hypoperfusion or shockPts with hypotension, hypoperfusion or shock

Initial assessment of Initial assessment of pt pt with suspected acute with suspected acute HF HF

Brady- Brady-arrhythmiasarrhythmias

CHBCHB

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Patients with severe Patients with severe bradycardia or heart blockbradycardia or heart block

ØØ PacingPacing is recommended in patients is recommended in patients hemodynamically hemodynamically compromised by severe compromised by severe bradycardia or heart block to bradycardia or heart block to improve the improve the patient’s clinical patient’s clinical condition / condition / I I CC

Bradycardia AlgorithmBradycardia Algorithm

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Electrical Storm (ES)Electrical Storm (ES)

ØØClinical syndromes of electrical storm:Clinical syndromes of electrical storm:●● ES in ES in acute MI or ischemiaacute MI or ischemia / / QT prolonging drugs/ QT prolonging drugs/

electrolyte abnelectrolyte abn● ● In pts with In pts with genetic arrhythmia syndromes genetic arrhythmia syndromes ● ● InIn pts with pts with ICDsICDs

ØØEvaluation & management should focus on Evaluation & management should focus on ● ● immediate suppression immediate suppression of the arrhythmia, of the arrhythmia, ● ● a search for possible reversible a search for possible reversible causescauses, and , and ● ● attempts to attempts to prevent recurrencesprevent recurrences

ES is defined as recurrent, hemodynamically destabilizing VT or VF occurring >3 times in a 24 h period, and usually requiring electrical CV or DF

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Arrhythmias with delayed Arrhythmias with delayed repolarization (QT-U prolongation)repolarization (QT-U prolongation)

ØØThis type of electrical storm has specific This type of electrical storm has specific treatment, which should start with treatment, which should start with correction of the underlying causecorrection of the underlying cause (D/C (D/C offending agent)offending agent)

ØØIV IV magnesiummagnesium (1 to 2 g over 1 or 2 minutes), (1 to 2 g over 1 or 2 minutes), or increasing heart rate via or increasing heart rate via temporarytemporary tv tv overdrive pacing overdrive pacing (90-110 bpm)(90-110 bpm)

ØØThe prognosis is excellent, if the cause is The prognosis is excellent, if the cause is quickly corrected quickly corrected

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Arrhythmia StormArrhythmia StormØØ Rx HF / r/o Ischemia / Correct electrolyte abn / Eliminate Rx HF / r/o Ischemia / Correct electrolyte abn / Eliminate

precipitating factors precipitating factors ØØIV IV Amiodarone

ØBeta-blockers have proven their usefulness, & careful titration in pts c HF is necessary / influence of SNS is often underestimated

Ø Adequate sedation and in extremely refractory cases even general anesthesia may prove to be life-saving

ØCatheter ablation for monomorphic arrhythmias / promising for VF

Ø If all else fails, hemodynamic support or even

Øheart transplantation may be an option

ØMost pts are not suitable candidates for the latter (age or comorbidity) & the limited supply of donor organs severely limits this option

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Electrical storm in acute HFElectrical storm in acute HF

ØØMonomorphic / polymorphic VT Monomorphic / polymorphic VT or or VFVF arising from s-tach, arising from s-tach, with a short coupling interval of the first beat (the PVC) to with a short coupling interval of the first beat (the PVC) to the last normal beat (~250 - 350 ms)the last normal beat (~250 - 350 ms)

ØØ Focus of Rx should be anti-congestive or anti-adrenergicFocus of Rx should be anti-congestive or anti-adrenergic interventions, rather than simply AADsinterventions, rather than simply AADs

ØØ CVCV

ØØ AmiodaroneAmiodarone remains the AAD of choice remains the AAD of choice

ØØ IV beta-blocking agentsIV beta-blocking agents useful but great cautionuseful but great caution

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Recurrent dilated cardiomyopathyRecurrent dilated cardiomyopathyreversed with conversion of AFreversed with conversion of AF

ØØAF can be the critical and AF can be the critical and reversible etiologic factor reversible etiologic factor in some patients with in some patients with dilated cardiomyopathy.dilated cardiomyopathy.

Kessler et al, AHJ March 1997

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Conclusion: Arrhythmias in Acute HFConclusion: Arrhythmias in Acute HFØØHF & AF often HF & AF often coexistcoexist, c deleterious effects on each other, c deleterious effects on each otherØØRate vs Rhythm controlRate vs Rhythm control? ? ØØSuccessful Successful restoration of SR restoration of SR may be achieved c CV or AAD; may be achieved c CV or AAD;

/ ?/ ?long-term efficacy & safety long-term efficacy & safety ØØRestoring SR: Restoring SR: ●● in pts with in pts with hemodynamic compromisehemodynamic compromise● ● likely to be preferable where the onset of AF is a/w likely to be preferable where the onset of AF is a/w

increasing symptoms or deterioration in LV functionincreasing symptoms or deterioration in LV functionØØ Irrespective of strategy, Irrespective of strategy, anticoagulationanticoagulation is paramount is paramountØØCatheter Catheter ablationablation : improvements in QOL & LV : improvements in QOL & LV functionfunction__________________________________________________________________________________________________

ØØ Life-threatening Ventr. arrhythmiasLife-threatening Ventr. arrhythmias: CV / Amio / ICD / RFA: CV / Amio / ICD / RFAØØBrady-arrhythmiasBrady-arrhythmias: pacing: pacing

ØØCComplex omplex interplay of HF & interplay of HF & Arrhythmias Arrhythmias