Management of Arrhythmias in Heart Failure

Ilaria Spoletini, Andrew Coats


Patients with heart failure (HF) often develop ventricular and supraventricular arrhythmias, due in large part to electrical conduction abnormalities of the heart in this syndrome. Cardiac remodeling and neurohumoral activation typical of HF create a substrate that increases the risk of developing arrhythmias and/or worsening pre- existing arrhythmias. Advances in our understanding of the underlying pathophysiological mechanisms of HF have reinforced the importance of neurohumoral, mechanical and inflammatory processes as progressively more severe pump dysfunction occurs. This combination increases the likelihood of arrhythmias, both atrial and ventricular, such that ventricular arrhythmias are found in up to 80% of patients with severe HF, conferring additional risk of mortality and morbidity, in particular via an increased risk of sudden cardiac death. Arrhythmias are also responsible for an increased risk of rehospitalisation in one-third of HF patients. The high risk of arrhythmias should always be considered during the clinical management of all HF patients, due their association with worse prognosis and increased mortality. In particular, HF and atrial fibrillation mutually worsen the impact of each other. Treatment of atrial fibrillation in the setting of HF includes a variety of approaches such as drugs, devices and ablation. Restoration of sinus rhythm is not superior to optimal rate control, and the deleterious effects of antiarrhythmic drugs should be considered. Finally, cardiac function, symptoms, and quality of life may improve with catheter-based ablative therapies in appropriately selected patients with HF.


Cardiology; Heart Failure; Guidelines; Arrhythmias

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Luong, C., M. E. Barnes and T. S. Tsang (2014). Atrial fibrillation and heart failure: cause or effect? Curr Heart Fail Rep 11(4): 463–470.

Dean, J. W. and M. J. Lab (1989). Arrhythmia in heart failure: role of mechanically induced changes in electrophysiology. Lancet 1(8650): 1309–1312.

Lip, G. Y., F. R. Heinzel, F. Gaita, J. R. Juanatey, J. Y. Le Heuzey, T. Potpara, J. H. Svendsen, M. A. Vos, S. D. Anker, A. J. Coats, W. Haverkamp, A. S. Manolis, M. K. Chung, P. Sanders and B. Pieske (2015). European Heart Rhythm Association/Heart Failure Association joint consensus document on arrhythmias in heart failure, endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Eur J Heart Fail 17(9): 848–874.

Fang, J. C., G. A. Ewald, L. A. Allen, J. Butler, C. A. Westlake Canary, M. Colvin- Adams, M. G. Dickinson, P. Levy, W. G. Stough, N. K. Sweitzer, J. R. Teerlink, D. J. Whellan, N. M. Albert, R. Krishnamani, M. W. Rich, M. N. Walsh, M. R. Bonnell, P. E. Carson, M. C. Chan, D. L. Dries, A. F. Hernandez, R. E. Hershberger, S. D. Katz, S. Moore, J. E. Rodgers, J. G. Rogers, A. R. Vest, M. M. Givertz and C. Heart Failure Society of America Guidelines (2015). Advanced (stage D) heart failure: a statement from the Heart Failure Society of America Guidelines Committee. J Card Fail 21(6): 519–534.

Singh, S. N., P. E. Carson and S. G. Fisher (1997). Nonsustained ventricular tachycardia in severe heart failure. Circulation 96(10): 3794–3795.

Bardy, G. H., K. L. Lee, D. B. Mark, J. E. Poole, D. L. Packer, R. Boineau, M. Domanski, C. Troutman, J. Anderson, G. Johnson, S. E. McNulty, N. Clapp- Channing, L. D. Davidson- Ray, E. S. Fraulo, D. P. Fishbein, R. M. Luceri, J. H. Ip and I. Sudden Cardiac Death in Heart Failure Trial (2005). Amiodarone or an implantable cardioverter- defibrillator for congestive heart failure. N Engl J Med 352(3): 225–237.

Lane, R. E., M. R. Cowie and A. W. Chow (2005). Prediction and prevention of sudden cardiac death in heart failure. Heart 91(5): 674–680.

Ramineni, R., M. K. Bheemarasetti, A. Baranchuk, T. Mandalapu, V. K. Mukku, K. Fujise and A. Barbagelata (2012). Management of arrhythmias in heart failure. What a practicing physician should know in the current times. Cardiol J 19(6): 567–577.

Nieminen, M. S., D. Brutsaert, K. Dickstein, H. Drexler, F. Follath, V. P. Harjola, M. Hochadel, M. Komajda, J. Lassus, J. L. Lopez- Sendon, P. Ponikowski, L. Tavazzi, I. EuroHeart Survey and E. S. o. C. Heart Failure Association (2006). EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population. Eur Heart J 27(22): 2725–2736.

Fuster, V., L. E. Ryden, D. S. Cannom, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace 8(9): 651–745.

Corell, P., F. Gustafsson, M. Schou, J. Markenvard, T. Nielsen and P. Hildebrandt (2007). Prevalence and prognostic significance of atrial fibrillation in outpatients with heart failure due to left ventricular systolic dysfunction. Eur J Heart Fail 9(3): 258–265.

Maggioni, A. P., U. Dahlstrom, G. Filippatos, O. Chioncel, M. Crespo Leiro, J. Drozdz, F. Fruhwald, L. Gullestad, D. Logeart, G. Fabbri, R. Urso, M. Metra, J. Parissis, H. Persson, P. Ponikowski, M. Rauchhaus, A. A. Voors, O. W. Nielsen, F. Zannad, L. Tavazzi and C. Heart Failure Association of the European Society of (2013). EURObservational Research Programme: regional differences and 1- year follow- up results of the Heart Failure Pilot Survey (ESC- HF Pilot). Eur J Heart Fail 15(7): 808–817.

Ambrosy, A. P., G. C. Fonarow, J. Butler, O. Chioncel, S. J. Greene, M. Vaduganathan, S. Nodari, C. S. Lam, N. Sato, A. N. Shah and M. Gheorghiade (2014). The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. J Am Coll Cardiol 63(12): 1123–1133.

The SOLVD Investigators. (1992). Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 327(10): 685–691.

The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 316(23): 1429–1435.

Schnabel, R. B., L. M. Sullivan, D. Levy, M. J. Pencina, J. M. Massaro, R. B. D’Agostino, Sr., C. Newton- Cheh, J. F. Yamamoto, J. W. Magnani, T. M. Tadros, W. B. Kannel, T. J. Wang, P. T. Ellinor, P. A. Wolf, R. S. Vasan and E. J. Benjamin (2009). Development of a risk score for atrial fibrillation (Framingham Heart Study): a community- based cohort study. Lancet 373(9665): 739–745.

Wang, T. J., M. G. Larson, D. Levy, R. S. Vasan, E. P. Leip, P. A. Wolf, R. B. D’Agostino, J. M. Murabito, W. B. Kannel and E. J. Benjamin (2003). Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 107(23): 2920–2925.

Kotecha, D., R. Chudasama, D. A. Lane, P. Kirchhof and G. Y. Lip (2016). Atrial fibrillation and heart failure due to reduced versus preserved ejection fraction: A systematic review and meta- analysis of death and adverse outcomes. Int J Cardiol 203: 660–666.

Zakeri, R., B. A. Borlaug, S. E. McNulty, S. F. Mohammed, G. D. Lewis, M. J. Semigran, A. Deswal, M. LeWinter, A. F. Hernandez, E. Braunwald and M. M. Redfield (2014). Impact of atrial fibrillation on exercise capacity in heart failure with preserved ejection fraction: a RELAX trial ancillary study. Circ Heart Fail 7(1): 123–130.

Agostoni, P., M. Emdin, U. Corra, F. Veglia, D. Magri, C. C. Tedesco, E. Berton, C. Passino, E. Bertella, F. Re, A. Mezzani, R. Belardinelli, C. Colombo, R. La Gioia, M. Vicenzi, A. Giannoni, D. Scrutinio, P. Giannuzzi, C. Tondo, A. Di Lenarda, G. Sinagra, M. F. Piepoli and M. Guazzi (2008). Permanent atrial fibrillation affects exercise capacity in chronic heart failure patients. Eur Heart J 29(19): 2367–2372.

Rivero- Ayerza, M., W. Scholte Op Reimer, M. Lenzen, D. A. Theuns, L. Jordaens, M. Komajda, F. Follath, K. Swedberg and J. G. Cleland (2008). New- onset atrial fibrillation is an independent predictor of in- hospital mortality in hospitalized heart failure patients: results of the EuroHeart Failure Survey. Eur Heart J 29(13): 1618–1624.

Santini, M., M. Gasparini, M. Landolina, M. Lunati, A. Proclemer, L. Padeletti, D. Catanzariti, G. Molon, G. L. Botto, L. La Rocca, A. Grammatico, G. Boriani and P. cardiological centers participating in ClinicalService (2011). Device- detected atrial tachyarrhythmias predict adverse outcome in real- world patients with implantable biventricular defibrillators. J Am Coll Cardiol 57(2): 167–172.

Lam, C. S., P. E. Carson, I. S. Anand, T. S. Rector, M. Kuskowski, M. Komajda, R. S. McKelvie, J. J. McMurray, M. R. Zile, B. M. Massie and D. W. Kitzman (2012). Sex differences in clinical characteristics and outcomes in elderly patients with heart failure and preserved ejection fraction: the Irbesartan in Heart Failure with Preserved Ejection Fraction (I- PRESERVE) trial. Circ Heart Fail 5(5): 571–578.

Mentz, R. J., M. J. Chung, M. Gheorghiade, P. S. Pang, M. J. Kwasny, A. P. Ambrosy, M. Vaduganathan, C. M. O’Connor, K. Swedberg, F. Zannad, M. A. Konstam and A. P. Maggioni (2012). Atrial fibrillation or flutter on initial electrocardiogram is associated with worse outcomes in patients admitted for worsening heart failure with reduced ejection fraction: findings from the EVEREST Trial. Am Heart J 164(6): 884–892 e882.

Nanayakkara, S. and D. M. Kaye (2015). Management of heart failure with preserved ejection fraction: a review. Clin Ther 37(10): 2186–2198.

Linssen, G. C., M. Rienstra, T. Jaarsma, A. A. Voors, I. C. van Gelder, H. L. Hillege and D. J. van Veldhuisen (2011). Clinical and prognostic effects of atrial fibrillation in heart failure patients with reduced and preserved left ventricular ejection fraction. Eur J Heart Fail 13(10): 1111–1120.

Taillandier, S., A. Brunet Bernard, B. Lallemand, E. Simeon, L. Pericart, N. Clementy, D. Babuty and L. Fauchier (2014). Prognosis in patients hospitalized with permanent and nonpermanent atrial fibrillation in heart failure. Am J Cardiol 113(7): 1189–1195.

Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González- Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P; Authors/Task Force Members; Document Reviewers. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016 May 20. pii: ehw128. PMID: 27206819.

Martin, R. I., O. Pogoryelova, M. S. Koref, J. P. Bourke, M. D. Teare and B. D. Keavney (2014). Atrial fibrillation associated with ivabradine treatment: meta- analysis of randomised controlled trials. Heart 100(19): 1506–1510.

Khand, A. U., A. C. Rankin, W. Martin, J. Taylor, I. Gemmell and J. G. Cleland (2003). Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure? J Am Coll Cardiol 42(11): 1944–1951.

Roy, D., M. Talajic, S. Nattel, D. G. Wyse, P. Dorian, K. L. Lee, M. G. Bourassa, J. M. Arnold, A. E. Buxton, A. J. Camm, S. J. Connolly, M. Dubuc, A. Ducharme, P. G. Guerra, S. H. Hohnloser, J. Lambert, J. Y. Le Heuzey, G. O’Hara, O. D. Pedersen, J. L. Rouleau, B. N. Singh, L. W. Stevenson, W. G. Stevenson, B. Thibault, A. L. Waldo, F. Atrial and I. Congestive Heart Failure (2008). Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 358(25): 2667–2677.

Gupta, S. and V. M. Figueredo (2014). Tachycardia mediated cardiomyopathy: pathophysiology, mechanisms, clinical features and management. Int J Cardiol 172(1): 40–46.

Torp- Pedersen, C., M. Metra, P. Spark, M. A. Lukas, C. Moullet, A. Scherhag, M. Komajda, J. G. Cleland, W. Remme, A. Di Lenarda, K. Swedberg, P. A. Poole- Wilson and C. Investigators (2007). The safety of amiodarone in patients with heart failure. J Card Fail 13(5): 340–345.

Kober, L., C. Torp- Pedersen, J. J. McMurray, O. Gotzsche, S. Levy, H. Crijns, J. Amlie, J. Carlsen and G. Dronedarone Study (2008). Increased mortality after dronedarone therapy for severe heart failure. N Engl J Med 358(25): 2678–2687.

Cintra, F. D., R. P. Leite, L. J. Storti, L. A. Bittencourt, D. Poyares, L. D. Castro, S. Tufik and A. D. Paola (2014). Sleep Apnea and Nocturnal Cardiac Arrhythmia: A Populational Study. Arq Bras Cardiol 103(5): 368–374.

Gilat, H., S. Vinker, I. Buda, E. Soudry, M. Shani and G. Bachar (2014). Obstructive sleep apnea and cardiovascular comorbidities: a large epidemiologic study. Medicine (Baltimore) 93(9): e45.

Vizzardi, E., E. Sciatti, I. Bonadei, A. D’Aloia, A. Curnis and M. Metra (2014). Obstructive sleep apnoea- hypopnoea and arrhythmias: new updates. J Cardiovasc Med (Hagerstown). DOI: 10.2459/JCM.0000000000000043

Bloch Thomsen, P. E., C. Jons, M. J. Raatikainen, R. Moerch Joergensen, J. Hartikainen, V. Virtanen, J. Boland, O. Anttonen, U. J. Gang, N. Hoest, L. V. Boersma, E. S. Platou, D. Becker, M. D. Messier, H. V. Huikuri, A. Cardiac and G. Risk Stratification After Acute Myocardial Infarction Study (2010). Long- term recording of cardiac arrhythmias with an implantable cardiac monitor in patients with reduced ejection fraction after acute myocardial infarction: the Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction (CARISMA) study. Circulation 122(13): 1258–1264.

Faggiano, P., A. d’Aloia, A. Gualeni, A. Gardini and A. Giordano (2001). Mechanisms and immediate outcome of in- hospital cardiac arrest in patients with advanced heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 87(5): 655–657, A610–651.

Brignole, M., A. Auricchio, G. Baron- Esquivias, et al. (2013). 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 34(29): 2281-2329.

Priori, S. G., C. Blomstrom- Lundqvist, A. Mazzanti, N. Blom, M. Borggrefe, J. Camm, P. M. Elliott, D. Fitzsimons, R. Hatala, G. Hindricks, P. Kirchhof, K. Kjeldsen, K. H. Kuck, A. Hernandez- Madrid, N. Nikolaou, T. M. Norekval, C. Spaulding and D. J. Van Veldhuisen (2015). 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 36(41): 2793–2867.

Anter, E., M. Jessup and D. J. Callans (2009). Atrial fibrillation and heart failure: treatment considerations for a dual epidemic. Circulation 119(18): 2516–2525.

Shewan LG, Coats AJS, Henein M. Requirements for ethical publishing in biomedical journals. International Cardiovascular Forum Journal 2015;2:2, DOI: 10.17987/icfj.v2i1.4.


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