This document discusses challenging cases of arrhythmias in acute heart failure. It notes that atrial fibrillation is a common rhythm seen in patients with acute decompensated heart failure, occurring in 20-35% of cases. The OPTIME-CHF study found that new arrhythmias during an exacerbation of heart failure identify a high-risk group with higher in-hospital morbidity and mortality as well as worse outcomes at 60 days. Atrial fibrillation can worsen the prognosis of heart failure but may also be precipitated by heart failure. The treatment of atrial fibrillation in the setting of acute decompensated heart failure depends on whether it is causing hemodynamic instability or believed to have precipitated the

1. ASM
ΕΚΠΑ
Challenging cases in acute heartChallenging cases in acute heart
failure: Arrhythmiasfailure: Arrhythmias
ØØAntonis S. Manolis, MDAntonis S. Manolis, MD
ØØ33rdrd
Department of CardiologyDepartment of Cardiology
ØØAthens University School of MedicineAthens University School of Medicine
ØØAthens, GreeceAthens, Greece
Conflict of Interest: none
HFA Meeting 2015

2. ● 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

3. Precipitants &Precipitants & causes of acutecauses of acute heart failureheart failure
ESC Guidelines for HF 2012

4. Initial assessment of patient withInitial assessment of patient with
suspected acute heart failuresuspected acute heart failure
ESC Guidelines for HF 2012

5. 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%

6. ASM
ΕΚΠΑ
AF in Heart FailureAF in Heart Failure
ØØ AFAF is theis the most common arrhythmia in HFmost common arrhythmia in HF
ØØ Its onset may lead toIts 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
ØØ PotentialPotential precipitating factorsprecipitating 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, ●● alcoholalcohol
consumption,consumption, ●● MV disease,MV disease, ●● acute ischemia,acute ischemia, ●● cardiaccardiac
surgery,surgery, ●● acute pulm. disease,acute pulm. disease, ●● infection,infection, ●●
uncontrolled HTNuncontrolled HTN
ØØ Background HF RxBackground HF Rx should be carefully re-evaluated &should be carefully re-evaluated &
optimizedoptimized

7. 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 CHF
Precautions for specific CHF-related SE (TdP) when treating AF
CHF: 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

8. ASM
ΕΚΠΑ
AF & Acute Heart FailureAF & Acute Heart Failure
ØØAF is aAF is a commoncommon rhythm in pts with acuterhythm in pts with acute
decompensated heart failure (ADHF)decompensated heart failure (ADHF)
ØØRegistry & trial data indicate thatRegistry & trial data indicate that 20% to 35%20% to 35% ofof
pts with ADHF who are admitted to the hospital willpts with ADHF who are admitted to the hospital will
be in AF at presentationbe in AF at presentation
ØØIn aboutIn about one thirdone third of these pts, the AF will be ofof these pts, the AF will be of
recent onsetrecent onset

9. ASM
ΕΚΠΑ
Acute Heart Failure: ArrhythmiasAcute Heart Failure: Arrhythmias
ØØ TheThe OPTIME-CHF (Outcomes of a Prospective Trial of IV MilrinoneOutcomes of a Prospective Trial of IV Milrinone
for Exacerbations)for Exacerbations) study:study: 949 pts949 pts with decompensated HFwith decompensated HF
ØØ 2 groups based on occurrence of a2 groups based on occurrence of a new arrhythmic eventnew arrhythmic event
ØØ 59 new arrhythmic events occurring in59 new arrhythmic events occurring in 6%6%
ØØ Of these,Of these, 49% were atrial fibrillation / flutter49% were atrial fibrillation / flutter
ØØ PPrimary endpoint:rimary endpoint: days hospitalizeddays hospitalized for CV causes within 60for CV causes within 60
d after randomization was 30.9±22.7 for those in arrhythmiad 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).
ØØ MortalityMortality 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).
ØØ Death or hospitalization at 60 d was also worse in theDeath or hospitalization at 60 d was also worse in the
arrhythmia group (35 vs 8.2%; 57 vs 34%, botharrhythmia group (35 vs 8.2%; 57 vs 34%, both PP = 0.001) = 0.001)
ØØ NNew arrhythmias: an independent risk factor for primaryew arrhythmias: an independent risk factor for primary
endpoint & death at 60 daysendpoint & death at 60 days
Benza et al, J Card Fail 2004;10(4):279-84.

10. Kaplan-Meier estimatesKaplan-Meier estimates of survivalof survival in the first 60 days afterin the first 60 days after
the indexthe index hospitalization forhospitalization for both groups of patients. Anboth groups of patients. An
early risk of death withinearly risk of death within 30 days30 days is clearly depictedis clearly depicted forfor
thosethose patients with apatients 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

11. ASM
ΕΚΠΑ
OPTIME-CHFOPTIME-CHF
ØØNew arrhythmia during an exacerbation ofNew arrhythmia during an exacerbation of
HFHF identifies aidentifies a high-risk grouphigh-risk group with higherwith higher
intrahospital & 60-day morbidity & mortalityintrahospital & 60-day morbidity & mortality

12. Impact of AF onImpact of AF on mortalitymortality && readmissionreadmission inin
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).

13. ASM
ΕΚΠΑ
AF & Acute Heart FailureAF & Acute Heart Failure
ØØAF & worsening HFAF & worsening HF interactinteract in a dangerous patternin a dangerous pattern
ØØAdverse effects of AFAdverse effects of AF in pts with HF may includein pts with HF may include
●● loss of atrial transport,loss of atrial transport, ●● rapidrapid & irregular& irregular VRVRs, &s, &
●● toxic effects oftoxic 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 sympatheticheightened sympathetic
tonetone // Acute HF can precipitate AF
ØØThese latter changes make theThese latter changes make the AF more resistantAF more resistant toto
treatment using either a rate-control or a rhythm-treatment using either a rate-control or a rhythm-
controlcontrol strategystrategy
● AF may be chronic and not directly related to
the acute HF decompensation

14. (1) Dx to be confirmed by(1) Dx to be confirmed by ECGECG
CheckCheck electrolyteselectrolytes & review& review CXRCXR
Attempt to establish the etiologyAttempt to establish the etiology
of acuteof acute hemodynamic instabilityhemodynamic instability
(2) initiation of(2) initiation of anticoagulationanticoagulation
should not delay any emergencyshould not delay any emergency
interventionintervention
(3) Urgent(3) Urgent rate controlrate control c IV Rxc IV Rx
should be with (a) b-blockers,should be with (a) b-blockers, DigDig
oror rate-limiting Ca++ antagonists,rate-limiting Ca++ antagonists,
(b) amiodarone, where b-blockers(b) amiodarone, where b-blockers
or Ca++ antagonists areor Ca++ antagonists are
contraindicated or ineffective.contraindicated or ineffective.
(4)Where there is a delay in(4)Where there is a delay in
organisingorganising electrical CVelectrical CV,, IVIV
amiodaroneamiodarone should be usedshould be used
Hemodynamically unstable
AF Rx algorithm
Mann et al, Heart 2007;93:45–47

15. ASM
ΕΚΠΑ
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.
ØIn some pts c AF & ADHF, effective treatment of pulmonary
edema results in slowing of the ventricular rate or
spontaneous reversion of the arrhythmia.
ØIf AF persists, it is treated in the same fashion as AF in
other situations

16. ASM
ΕΚΠΑ
AF /AF / Rate ControlRate Control
Ø 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 decompensation
ØHowever, 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.
ØIn 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

17. ASM
ΕΚΠΑ
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

18. ASM
ΕΚΠΑ
Initial AssessmentInitial Assessment
ØØTheThe clinical historyclinical history provides critical informationprovides critical information
that should be used to guide Rxthat should be used to guide Rx
ØØ5 key questions5 key questions should be asked before startingshould be asked before starting
RxRx
●● Does the pt have anDoes the pt have an ICD or pacemakerICD or pacemaker in place?in place?
●● Does the pt have preserved or reducedDoes the pt have preserved or reduced systolicsystolic
functionfunction at the baseline?at the baseline?
●● What is theWhat is the durationduration of the AF episode?of the AF episode?
●● Is the pt already onIs the pt already on drugsdrugs for rhythm or ratefor rhythm or rate
control & anticoagulation?control & anticoagulation?
●● WhatWhat concomitant disordersconcomitant disorders are present?are present?

19. ASM
ΕΚΠΑ
ØØMany pts who present with ADHF will have ICDsMany pts who present with ADHF will have ICDs
ØØInappropriate ICD therapyInappropriate ICD therapy during AF episodes isduring AF episodes is
both undesirable & dangerousboth undesirable & dangerous
ØØIf pt has an ICD,If pt has an ICD, interrogation & reprogramminginterrogation & reprogramming ofof
ICD toICD to minimizeminimize risk forrisk for inappropriate therapyinappropriate therapy
should be performed as soon as possibleshould be performed as soon as possible
ØØUsually, rate & duration of arrhythmia that triggersUsually, rate & duration of arrhythmia that triggers
VT or VF detectionVT or VF detection should be ↑, & SVTAshould be ↑, & SVTA
discriminators should be activated if availablediscriminators should be activated if available
ØØWithWith dual-chamber or biventricular devicesdual-chamber or biventricular devices, the, the
atrial tachyarrhythmia pacing response should beatrial tachyarrhythmia pacing response should be
set to eliminate inappropriateset to eliminate inappropriate high-rate atrialhigh-rate atrial
trackingtracking
Initial AssessmentInitial Assessment

20. ASM
ΕΚΠΑ
Rate Control vsRate Control vs Rhythm ControlRhythm Control
ØØAF episodeAF episode durationduration will affect decisions aboutwill affect decisions about
advisability & potential foradvisability & potential for CVCV & selection of agents for& selection of agents for
rhythm or rate controlrhythm or rate control
ØØ3 scenarios are commonly encountered3 scenarios are commonly encountered
ØØSomeSome pts will present shortly after the onset of AFpts will present shortly after the onset of AF
ØØEither the AF episode itself has rapidly precipitated HFEither the AF episode itself has rapidly precipitated HF
in a previously stable pt or worsening HF has triggeredin a previously stable pt or worsening HF has triggered
an acute episode of AFan acute episode of AF
ØØIn these pts,In these pts, potentialpotential for successfulfor successful early restoration ofearly restoration of
SRSR is high if the HF Sx can beis high if the HF Sx can be controlledcontrolled
ØØA secondA second pattern:pattern: onset ofonset of AFAF unknown or >48 hunknown or >48 h
ØØ candidates for acandidates for a later CVlater CV attemptattempt vsvs rate controlrate control

21. ASM
ΕΚΠΑ
ØØ Optimal restOptimal rest VR<100 bpmVR<100 bpm desirable/ may not be achievabledesirable/ may not be achievable
until volume overload & hypoxia corrected / More realisticuntil volume overload & hypoxia corrected / More realistic
targettarget <120 bpm<120 bpm @ first hrs of Rx@ first hrs of Rx
ØØ DigoxinDigoxin should be first rate-control agent considered, but inshould 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 dangerousIf 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
ØØ CautiousCautious addition ofaddition of IV -blockerIV -blocker, e.g. esmolol (, e.g. esmolol (500500 μμg/kg/g/kg/
1min1min),or, if systolic function preserved,),or, if systolic function preserved, diltiazemdiltiazem
ØØ IfIf rate control along with relief of volume overload &rate control along with relief of volume overload &
dyspneadyspnea can be achieved,can be achieved, pts will frequently revert back topts will frequently revert back to
SR if AF is of recent onsetSR if AF is of recent onset
ØØ If pt does not improve, already onIf pt does not improve, already on anticoagulationanticoagulation , & not on, & not on
an AAD, a trial ofan AAD, a trial of IV amioIV 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

22. ASM
ΕΚΠΑ
ØØ If this approach fails & VR during AF remain elevated,If this approach fails & VR during AF remain elevated,
ØØ CVCV after a period ofafter a period of loading withloading with an AAD, usuallyan AAD, usually
amiodaroneamiodarone, is the next step, is the next step
ØØ When the patient hasWhen the patient has not been adequately anticoagulated,not been adequately anticoagulated,
ØØ aa TEETEE followed by maintained anticoagulation may facilitatefollowed by maintained anticoagulation may facilitate
the early CV attemptthe early CV attempt
ØØ If CV attempts are unsuccessful & the pt remainsIf CV attempts are unsuccessful & the pt remains
symptomatic with elevated VR,symptomatic with elevated VR,
ØØ AV junctional ablation, often with a biventricular pacingAV 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

23. ASM
ΕΚΠΑ
ØØ OnceOnce VRVR has been at least partiallyhas been at least partially controlledcontrolled, possible, possible
benefit of abenefit of a CVCV should be considered, unless pt has knownshould be considered, unless pt has known
long-standing pers. AFlong-standing pers. AF
ØØ Therefore, once theTherefore, once the acute HF exacerbationacute HF exacerbation has beenhas been
correctedcorrected in such a ptin such a pt →→ a continued rate-control strategya continued rate-control strategy
ØØ In pts withIn pts with new- or recent-onset AFnew- or recent-onset AF, an, an attempt at CV & drugattempt at CV & drug
RxRx is reasonable, with final decision on a long-term strategyis reasonable, with final decision on a long-term strategy
based on Sx, drug tolerance, & frequency of recurrencesbased on Sx, drug tolerance, & frequency of recurrences
ØØ As was shown in theAs 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, butbenefit a/w a rhythm-control strategy, but
ØØ Individual pt responses vary widelyIndividual pt responses vary widely
ØØ at least 1 attempt to maintain SRat least 1 attempt to maintain SR in any pt with > mild Sxin any pt with > mild Sx
ØØ In selected pts,In selected pts, RFARFA may prove effective, but experience formay prove effective, but experience for
pts in whom AF was not the primary cause for HF has beenpts in whom AF was not the primary cause for HF has been
limitedlimited
Rate Control vs Rhythm ControlRate Control vs Rhythm Control

24. 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 al
PACE 2012

25. <65 y-o
Chatterjee et al, PACE 2012
favors a rate-control strategy in pts with AF, even in those
with 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

26. success of cardioversionsuccess of cardioversion
according toaccording to heart failure treatmentheart failure treatment
before cardioversionbefore cardioversion
Boldt et al, Am Heart J 2008;155:890-5

27. ASM
ΕΚΠΑ
AcuteAcute Rate ControlRate Control
Drug 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

28. Rate controlRate control during AF with HFduring AF with HF

29. Indications for electrical & pharmacological CV, & choice ofIndications for electrical & pharmacological CV, & choice of
antiarrhythmic drugs forantiarrhythmic drugs for pharmacological CVpharmacological CV
in pts within pts with recent-onset AFrecent-onset AF
ESC AF
Guidelines
2012

30. Choice of AAD
according to
underlying
pathology
ESC AF
Guidelines
2012

31. AntiarrhythmicAntiarrhythmic
drugs and/ordrugs and/or
LA ablation forLA ablation for
rhythm controlrhythm control
in AFin AF
ESC AF
Guidelines
2012

32. 2011 ACCF/AHA/HRS Focused Update2011 ACCF/AHA/HRS Focused Update
onon the Managementthe Management ofof PtsPts WithWith AFAF

33. CCS AF Guidelines 2012CCS AF Guidelines 2012

34. Recommendations for the treatmentRecommendations for the treatment
of patients withof patients with acute heart failureacute heart failure
ESC (2012) HF Guideliness

35. ASM
ΕΚΠΑ
IV diltiazemIV diltiazem is rapid, safe, & effective in acutely lowering ais 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 pts37 pts c rapid (VR,142 ± 17 bpm) AF or Aflu & moderate to severec rapid (VR,142 ± 17 bpm) AF or Aflu & moderate to severe
CHF (EF, 36 ± 14%;CHF (EF, 36 ± 14%; NYHA class IIINYHA class III [23 pts],[23 pts], class IVclass IV [14 pts])[14 pts])
ØØ IV diltiazem, 0.25 mg/kg over 2 min, or placebo followed 15 minIV 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
ØØ HypotensionHypotension was the most common adverse event occurring in 4 ofwas 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 todue to
diltiazemdiltiazem
Goldenberg et al, AJC 1994; 74 (9) : 884–
889

36. ASM
ΕΚΠΑ
AF in HF /AF in HF / 2013 ACCF/AHA2013 ACCF/AHA HF GuidelineHF Guideline
ØØ Pt cPt c newly detected HF in the presence of AFnewly detected HF in the presence of AF with awith a rapidrapid VRVR
should beshould be presumedpresumed to have ato have a rate-related CMrate-related CM / 2 strategies:/ 2 strategies:
ØØ 11)) rate controlrate control of theof the patient’s AFpatient’s AF and see if HF and EF improve.and see if HF and EF improve.
ØØ 2) try2) try toto restore &restore & maintainmaintain SRSR. Initiate. Initiate amiodaroneamiodarone && thenthen
arrange forarrange for CV 1CV 1 monthmonth laterlater
ØØ beta-blockersbeta-blockers are the preferredare the preferred agents foragents for achieving rate controlachieving rate control
unless otherwiseunless otherwise contraindicatedcontraindicated
ØØ DigoxinDigoxin may be an effective adjunct to a betamay be an effective adjunct to a beta blockerblocker
ØØ DDiltiazemiltiazem,, should beshould be used with caution in those withused with caution in those with depresseddepressed
EFEF becausebecause of itsof its negative inotropicnegative inotropic effecteffect
ØØ HFHFppEFEF:: diltiazemdiltiazem can be effective forcan be effective for achieving rateachieving rate control butcontrol but
may be more effective when used inmay be more effective when used in combination withcombination with digoxindigoxin..
ØØ For those for whom a rate-controlFor those for whom a rate-control strategy isstrategy is chosen, when ratechosen, when rate
control cannot be achieved eithercontrol cannot be achieved either because ofbecause of drug inefficacy ordrug inefficacy or
intolerance,intolerance, AVN ablation &AVN ablation & CRTCRT device placement can bedevice placement can be

37. New onset of AF or flutter in ptsNew 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 placebo
gp (hazard ratio [HR]:
0.58; p = 0.034)

38. Mineralocorticoid ReceptorMineralocorticoid Receptor
Antagonists & CV Mortality in Pts WithAntagonists & 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 !

39. SVTSVT

40. AF / AFluAF / AFlu
Digoxin 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/h
Amiodarone IV: 150 mg/10 min or 5mg/kg /30-60 min
(0.5-1 mg/min)

41. ASM
ΕΚΠΑ
Atrial FlutterAtrial Flutter
ØØAcute Rx: depends on clinical presentationAcute Rx: depends on clinical presentation
ØØRate controlRate control
ØØAFlu can be successfully cardioverted to SRAFlu 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
ofof 38-76%38-76% for CV of AFlu (c/w 5-13% with IVfor 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 pacingAtrial pacing (TV /TE)(TV /TE)

42. Preexcited AFPreexcited AF

43. ASM
ΕΚΠΑ
12-Lead ECG in ER12-Lead ECG in ER

44. VFlu / VFVFlu / VF

45. amiodarone 300 mg IV over 20—60 min
followed by an infusion of 900 mg over 24 h

46. ASM
ΕΚΠΑ
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)

47. 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

48. QT Prolonging DrugsQT Prolonging Drugs
www.longqt.org
www.sads.org

49. ASM
ΕΚΠΑ
Management of Drug-Induced QTManagement of Drug-Induced QT
Prolongation &Prolongation & TdPTdP in Hospital Settingsin Hospital Settings
ØØ removal of the offending agentremoval of the offending agent in pts with drug-inducedin pts with drug-induced
LQTS (Class I, LoE: A); however, ? what QTc valueLQTS (Class I, LoE: A); however, ? what QTc value
ØØ Continuous QTc monitoringContinuous QTc monitoring appropriate for drugs deemedappropriate for drugs deemed
most at risk to cause QT prolongation /TdPmost at risk to cause QT prolongation /TdP
ØØ At-risk drug: if QTc >At-risk drug: if QTc > 500 ms500 ms or there has been an ↑or there has been an ↑ >>60 ms60 ms
c/w the predrug baseline value, esp. when accompanied byc/w the predrug baseline value, esp. when accompanied by
other ECG signs of impending TdP: prompt actionother ECG signs of impending TdP: prompt action
ØØ Actions:Actions: ●● alternative drug Rx;alternative drug Rx; ●●assessment of potentiallyassessment of potentially
aggravatingaggravating ●● drug-drug interactions,drug-drug interactions, ●● bradyarrhythmias,bradyarrhythmias,
oror ●● electrolyte abn.; &electrolyte abn.; & ●● availability of an ext. defibrillatoravailability of an ext. defibrillator
ØØ Pts shouldPts should not be transported from the unitnot be transported from the unit for diagnosticfor diagnostic
or therapeutic procedures, and they should be in a unit withor therapeutic procedures, and they should be in a unit with
thethe highest possible ECG monitoringhighest possible ECG monitoring surveillancesurveillance

50. ASM
ΕΚΠΑ
Management of Drug-Induced QTManagement of Drug-Induced QT
Prolongation &Prolongation & TdPTdP in Hospital Settingsin Hospital Settings
ØØ For pts with TdP that does not terminate spontaneously orFor pts with TdP that does not terminate spontaneously or
degenerates into VFdegenerates into VF,, immediate DC CVimmediate DC CV should be performedshould be performed
ØØ IV MgIV Mg++++
sulfatesulfate is reasonable for pts taking QT-prolongingis reasonable for pts taking QT-prolonging
drugs who present c episodes of TdP & a ↑QT interval (Classdrugs who present c episodes of TdP & a ↑QT interval (Class
IIa, LoE: B)IIa, LoE: B)
ØØ MgMg++++
sulfate 2 g can be infused IVsulfate 2 g can be infused IV as a first-line agent toas a first-line agent to
terminate TdP irrespective of the serum Mgterminate TdP irrespective of the serum Mg++++
levellevel
ØØ If episodes of TdP persist, it may be necessary to repeatIf episodes of TdP persist, it may be necessary to repeat
infusions of Mginfusions of Mg++++
sulfate 2 g. Mechanism underlyingsulfate 2 g. Mechanism underlying
protective effect of Mgprotective effect of Mg++++
is unknownis 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 pacingtemp. TV atrial or ventricular pacing atat 90-110 bpm90-110 bpm
ØØ Repletion of KRepletion of K++
to supratherapeutic levels of 4.5 to 5 mmol/Lto supratherapeutic levels of 4.5 to 5 mmol/L
may also be considered, although there is little evidence tomay also be considered, although there is little evidence to
support this practice (Class IIb, LoE: C)support this practice (Class IIb, LoE: C)

51. ASM
ΕΚΠΑ
Recommendations forRecommendations for management ofmanagement of
ventricular arrhythmias in heart failureventricular arrhythmias in heart failure
ØØ PPotentialotential aggravating/precipitating factorsaggravating/precipitating factors (e.g. electrolyte(e.g. electrolyte
disorders, use ofdisorders, use of proarrhythmicproarrhythmic drugsdrugs, myocardial, myocardial ischemiaischemia))
should be sought and correctedshould be sought and corrected // I CI C
ØØ Rx cRx c anan ACEIACEI (or ARB),(or ARB), ββ-blocker-blocker, &, & MRAMRA should beshould be optimizedoptimized
ØØ coronarycoronary revascularizationrevascularization be consideredbe considered inin ptspts withwith VAs & CADVAs & CAD
ØØ ICDICD bebe implanted in aimplanted in a ptpt with symptomatic or sustainedwith symptomatic or sustained VTAVTA (VT(VT
oror VF),VF), reasonable functional status, and in whom a goal ofreasonable functional status, and in whom a goal of
treatment istreatment is to improve survivalto improve survival
ØØ AmiodaroneAmiodarone for pts with an ICD, who continue to have Sxic VAsfor 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
ØØ Catheter ablationCatheter ablation is recommended inis recommended in ptspts with an ICD whowith an ICD who
continue to havecontinue to have VAs causingVAs causing recurrentrecurrent shocksshocks not preventablenot preventable
by optimalby optimal treatment,treatment, device re-programming &device re-programming & amiodaroneamiodarone
ESC (2012) HF Guideliness

52. Recommendations for the use ofRecommendations for the use of ICDsICDs inin ptspts withwith HFHF

53. ASM
ΕΚΠΑ
12-Lead ECG in ER12-Lead ECG in ER
ICDICD
ØØ Electrical cardioversionElectrical cardioversion is recommended ifis recommended if
anan ventricularventricular arrhythmia isarrhythmia is contributingcontributing toto
the patient’s hemodynamicthe patient’s hemodynamic compromise incompromise in
order to restoreorder to restore SRSR and improve the patient’sand improve the patient’s
clinicalclinical condition.condition. II CC
Pts with hypotension, hypoperfusion or shockPts with hypotension, hypoperfusion or shock

54. Initial assessment ofInitial assessment of ptpt with suspected acutewith suspected acute HFHF

55. Brady-Brady-
arrhythmiasarrhythmias
CHBCHB

56. ASM
ΕΚΠΑ
Patients with severePatients with severe
bradycardia or heart blockbradycardia or heart block
ØØ PacingPacing is recommended in patientsis recommended in patients
hemodynamicallyhemodynamically compromised by severecompromised by severe
bradycardia or heart block tobradycardia or heart block to improve theimprove the
patient’s clinicalpatient’s clinical condition /condition / II CC

57. Bradycardia AlgorithmBradycardia Algorithm

58. ASM
ΕΚΠΑ
Electrical Storm (ES)Electrical Storm (ES)
ØØClinical syndromes of electrical storm:Clinical syndromes of electrical storm:
●● ES inES in acute MI or ischemiaacute MI or ischemia // QT prolonging drugs/QT prolonging drugs/
electrolyte abnelectrolyte abn
●● In pts withIn pts with genetic arrhythmia syndromesgenetic arrhythmia syndromes
●● InIn pts withpts with ICDsICDs
ØØEvaluation & management should focus onEvaluation & management should focus on
●● immediate suppressionimmediate suppression of the arrhythmia,of the arrhythmia,
●● a search for possible reversiblea search for possible reversible causescauses, and, and
●● attempts toattempts 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

59. ASM
ΕΚΠΑ
Arrhythmias with delayedArrhythmias with delayed
repolarization (QT-U prolongation)repolarization (QT-U prolongation)
ØØThis type of electrical storm has specificThis type of electrical storm has specific
treatment, which should start withtreatment, which should start with
correction of the underlying causecorrection of the underlying cause (D/C(D/C
offending agent)offending agent)
ØØIVIV magnesiummagnesium (1 to 2 g over 1 or 2 minutes),(1 to 2 g over 1 or 2 minutes),
or increasing heart rate viaor increasing heart rate via temporarytemporary tvtv
overdrive pacingoverdrive pacing (90-110 bpm)(90-110 bpm)
ØØThe prognosis is excellent, if the cause isThe prognosis is excellent, if the cause is
quickly correctedquickly corrected

60. ASM
ΕΚΠΑ
Arrhythmia StormArrhythmia Storm
ØØ Rx HF / r/o Ischemia / Correct electrolyte abn / EliminateRx HF / r/o Ischemia / Correct electrolyte abn / Eliminate
precipitating factorsprecipitating factors
ØØIVIV Amiodarone
ØBeta-blockers have proven their usefulness, & careful titration in pts c H
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
ØIf 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

61. ASM
ΕΚΠΑ
Electrical storm in acute HFElectrical storm in acute HF
ØØ Monomorphic / polymorphic VTMonomorphic / polymorphic VT oror VFVF arising from s-tach,arising from s-tach,
with a short coupling interval of the first beat (the PVC) towith 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 choiceremains the AAD of choice
ØØ IV beta-blocking agentsIV beta-blocking agents useful but great cautionuseful but great caution

62. ASM
ΕΚΠΑ
Recurrent dilated cardiomyopathyRecurrent dilated cardiomyopathy
reversed with conversion of AFreversed with conversion of AF
ØØ AF can be the critical andAF can be the critical and
reversible etiologic factorreversible etiologic factor
in some patients within some patients with
dilated cardiomyopathy.dilated cardiomyopathy.
Kessler et al, AHJ March 1997

66. ASM
ΕΚΠΑ
Conclusion: Arrhythmias in Acute HFConclusion: Arrhythmias in Acute HF
ØØ HF & AF oftenHF & AF often coexistcoexist, c deleterious effects on each other, c deleterious effects on each other
ØØ Rate vs Rhythm controlRate vs Rhythm control??
ØØ SuccessfulSuccessful restoration of SRrestoration of SR may be achieved c CV or AAD;may be achieved c CV or AAD;
/ ?/ ?long-term efficacy & safetylong-term efficacy & safety
ØØ Restoring SR:Restoring SR: ●● in pts within pts with hemodynamic compromisehemodynamic compromise
●● likely to be preferable where the onset of AF is a/wlikely to be preferable where the onset of AF is a/w
increasing symptoms or deterioration in LV functionincreasing symptoms or deterioration in LV function
ØØ Irrespective of strategy,Irrespective of strategy, anticoagulationanticoagulation is paramountis paramount
ØØ CatheterCatheter 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 / RFA
ØØ Brady-arrhythmiasBrady-arrhythmias: pacing: pacing
ØØ CComplexomplex interplay of HF &interplay of HF & ArrhythmiasArrhythmias