Heart failure combined with arrhythmias: 2015 European consensus recommends that patients with heart failure can have an increased incidence of arrhythmias or exacerbation of arrhythmic conditions due to the presence of cardiac remodeling and neurohumoral activation.In August 2015, the European Heart Rhythm Society (EHR)/European Heart Failure Association (HFA) jointly published a consensus document on heart failure combined with arrhythmias, which was supported by the American Heart Rhythm Society (HRS) and the Asian Pacific Heart Rhythm Society (APHRS).
1. General Interventions
(1) Despite the high prevalence of arrhythmias in patients with heart failure, screening for ventricular arrhythmias (VA) in asymptomatic heart failure patients is not recommended. However, routine electrocardiography or at least periodic pulse measurements should be performed and patients with asymptomatic atrial fibrillation should be managed in high-risk groups.
(2) Treatment should be given for persistent VA with or without symptoms.
2. Atrial fibrillation
(1) Most patients with heart failure (reduced or preserved EF) and AF should be treated with oral anticoagulants (VKA or NOAC) according to the CHAsDSs-VASC score, taking into account their bleeding risk (HAS-BLED score). The SAMe-TT2R2 score can be applied to help decision-making for VKA or NOAC therapy.
(2) Heart rate control is not superior to rhythm control in patients with heart failure combined with atrial fibrillation, but rhythm control should be attempted in patients with symptomatic atrial fibrillation episodes.
(3) Amiodarone is the drug of choice for rhythm control, and beta-blockers, digoxin, or a combination is recommended for ventricular rate control. Regular screening for side effects is required.
(4) Heart rate control appears to be the treatment strategy of choice for patients with acute heart failure. The indications for rhythm control should be reassessed after the acute phase of heart failure.
(5) Beta-blockers should not be used solely for the purpose of improving the prognosis of patients with heart failure combined with atrial fibrillation. Catheter ablation may be considered in patients with symptomatic atrial fibrillation who have failed drug therapy and in patients with good atrial structure. Atrioventricular node ablation (pacing and cautery) after implantation of a biventricular pacemaker should be considered for the treatment of patients with symptomatic or uncontrolled heart rate refractory atrial fibrillation. Atrioventricular node ablation is also necessary in patients with cardiac resynchronization therapy (CRT) heart failure who have persistent atrial fibrillation and ineffective biventricular pacing (fusion pacing).
3. Bradycardia
(1) Patients with irreversible and symptomatic bradycardia should be considered for implantation of a CRT device according to the pacing guidelines for patients with heart failure (NYHA class I-III), avoiding right ventricular pacing only.
(2) Patients with heart failure with reduced ejection fraction with AV block may benefit from CRT pacing, but further evidence comparing standard (RV) pacing with implantation of a CRT device is needed to make a recommendation.
4. Ventricular arrhythmias
(1) Patients with persistent VA require ICD therapy in most patients after excluding potentially reversible factors, such as significant electrolyte disturbances or acute myocardial ischemia. In addition, gradual dosing with beta-blockers and amiodarone may help to reduce the incidence of arrhythmias.
(2) ICD or ICD-CRT is generally recommended as primary prevention in patients with severely reduced ejection fraction, unless the patient has severe heart failure symptoms (resting state) and no improvement is expected likely or life expectancy is less than 1 year.
(3) After acute infarction, early application of optimal drug therapy including beta-blockers is required to reduce the risk of arrhythmia.
(4) High-risk patients (low EF) should be re-evaluated for optimal drug therapy after 4-6 weeks (or 3 months after hemodynamic reconstruction) before considering ICD as primary prevention.
(5) The option of wearable defibrillator therapy can be evaluated during the bridging period at this time.
5. Post-infarction heart failure and arrhythmias
(1) Left ventricular systolic insufficiency and heart failure are still common complications of acute myocardial infarction.
(2) Patients with STEMI should receive reperfusion therapy as soon as possible, preferably direct PCI or immediate post-thrombolytic PCI. patients who experience a single infarction have an increased risk of death and reinfarction in the subsequent year, with most events occurring weeks after discharge from the hospital.
(3) All patients should receive optimized drug therapy to survive the initial 4 to 6 weeks until reevaluation. Patients with reduced ejection fraction (35%) and NYHA class II-III, ICD combined with or without CRT therapy should be considered as appropriate.
(4) Post-infarction patients with angina pectoris, heart failure, or VA are at extremely high risk and require immediate reevaluation. Hemodialysis should be considered to prevent recurrent ischemia and/or early implantation of an ICD or application of a wearable defibrillator.
(5) Unless specifically contraindicated, all post-infarction patients should be treated with beta-blockers.
(6) In addition, patients with significant left ventricular insufficiency should be treated with ACEI or ARB and MRA.
(7) Patients with large anterior wall infarction are at risk for thromboembolism, VA and heart failure and should be treated accordingly.
6. Cardiac resynchronization therapy and patients with heart failure
(1) Patients with the strongest evidence of CRT benefit include: sinus rhythm QRS interval >130ms, QRS wave with LBBB pattern (I, A), or QRS interval >150ms, QRS wave without LBBB (IIa, A), as well as LVEF <30%, good functional status of the organism, and expected survival time more than 1 year. Recently, based on the latest studies, the indications have been expanded to include patients with class II cardiac function.
(2) Patients with persistent AF, NYHA class III-IV, with QRS interval >120ms and LVEF <35%, with good functional status and expected survival time more than 1 year may be considered for CRT or CRTD to reduce the risk of HF deterioration if.
– the patient requires pacing therapy due to his own slow ventricular rate
– the patient is pacemaker dependent due to atrioventricular node ablation
– the patient has a resting heart rate <60 beats/min and an exercise heart rate <90 beats/min.
(3) Patients who meet the indications for conventional pacing, anticipate high-frequency ventricular pacing, have no other indications for CRT, are in good functional status, and are expected to survive longer than 1 year, may be considered for implantation of a CRT device if they meet the following conditions.
– NYHA class III-IV with LVEF <35%, regardless of QRS interval length, to reduce the risk of HF deterioration
– NYHA class II with LVEF <35%, regardless of QRS interval length, to reduce the risk of HF progression.
In conclusion, clinical management of heart failure needs to take into account the high risk of arrhythmias in these patients. Underlying structural heart disease limits the use of antiarrhythmic drugs in symptomatic patients. Buried resuscitation defibrillator therapy is effective in reducing LVEF severely reducing mortality in patients. Only a small proportion of implant recipients will experience clinically relevant VA, and improvements in primary prevention risk assessment warrant further study, including risk stratification for HFpEF.