Treatment of arrhythmias in patients with congestive heart failure

  • Robert M. Lobel
  • Daniel L. Lustgarten


Both ventricular and atrial arrhythmias are commonly encountered in patients with ventricular dysfunction. In fact, roughly half of the deaths occurring in patients with ventricular dysfunction are caused by ventricular arrhythmias. Atrial arrhythmias in this patient population compromise left ventricular filling and if uncontrolled can exacerbate (and in some cases cause) the underlying myopathic process. Consequently, the diagnosis and treatment of these complex, and often life-threatening, arrhythmias is a critical component in the management of congestive heart failure (CHF). As the complexity of pharmacologic and nonpharmacologic antiarrhythmic therapy evolves, it has become increasingly important to understand the potential benefits and limitations of the various treatment modalities in the setting of patients with CHF. The management of arrhythmias in patients with CHF includes conventional drug therapies, as well as therapies directed specifically at treating the arrhythmias that are encountered. The treatment of atrial arrhythmias may include anticoagulation, drugs for rate control, rhythm control, or radiofrequency ablation. The treatment of ventricular arrhythmias, conversely, uses the implantable cardioverter-defibrillator to prevent sudden death, with adjuvant drug therapy or ablation for refractory ventricular tachycardia. This article provides an overview of the current state-of-the-art arrhythmia management in patients with CHF.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Graves EG, Gillum BS: 1994 Summary: National Hospital Discharge Survey: Advance Data. Hyattsville, MD: National Center for Health Statistics; 1996:278(1).Google Scholar
  2. 2.
    Engelstein ED, Zipes DP: Sudden cardiac death. In Hurst’s The Heart, edn 9. Edited by Alexander RW, et al. New York, NY: McGraw Hill; 1998:1081–1112.Google Scholar
  3. 3.
    Brophy JM, Joseph L, Rouleau JL: Beta-blockers in congestive heart failure. A Bayesian meta-analysis. Ann Intern Med 2001, 134:550–560.PubMedGoogle Scholar
  4. 4.
    Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) [no authors listed]. Lancet 1999, 353:2001–2007.Google Scholar
  5. 5.
    Packer M, Bristow MR, Cohn JN, et al.: The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996, 334:1349–1355.PubMedCrossRefGoogle Scholar
  6. 6.
    Fletcher RD, Cintron GB, Johnson G, et al.: Enalapril decreases ventricular tachycardia in heart failure: V-HeFT II. Circulation 1993, 87:VI49-VI55.PubMedGoogle Scholar
  7. 7.
    Cohn JN, Johnson G, Ziesche S, et al.: A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991, 325:303–310.PubMedCrossRefGoogle Scholar
  8. 8.
    Pitt B, Poole-Wilson PA, Segal R, et al.: Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITE II. Lancet 2000, 355:1582–1587.PubMedCrossRefGoogle Scholar
  9. 9.
    Pfeffer MA, Swedberg K, Granger CB, et al.: Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. Lancet 2003, 362:759–766.PubMedCrossRefGoogle Scholar
  10. 10.
    Pederson OD, Bagger H, Kober L, Torp-Pedersen C: Trandolapril reduces the incidence of atrial fibrillation after acute myocardial infarction in patients with left ventricular dysfunction. Circulation 1999, 100:376–380.Google Scholar
  11. 11.
    Pitt B, Zannad F, Remme WJ, et al.: The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999, 341:709–717.PubMedCrossRefGoogle Scholar
  12. 12.
    Shinbane JS, Wood MA, Jensen DN: Tachycardiainduced cardiomyopathy: a review of animal models and clinical studies. J Am Coll Cardiol 1997, 29:709–715.PubMedCrossRefGoogle Scholar
  13. 13.
    Spinale FG, Hendrick DA, Crawford FA, et al.: Chronic supraventricular tachycardia causes ventricular dysfunction and subendocardial injury in swine.Am J Physiol 1990, 259(1Pt 2):H218-H229.PubMedGoogle Scholar
  14. 14.
    Wang TJ, Larson MG, Levy D, et al.: Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 2003, 107:2920–2925.PubMedCrossRefGoogle Scholar
  15. 15.
    Dries DL, Exner DV, Gersh BJ, et al.: Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction. J Am Coll Cardiol 1998, 32:695–703.PubMedCrossRefGoogle Scholar
  16. 16.
    Naccarelli GV, Hynes JB, Wolbrette DL, et al.: Atrial fibrillation in heart failure: prognostic significance and management. J Cardiovasc Electrophysiol 2003, 14(suppl):S281-S286.PubMedCrossRefGoogle Scholar
  17. 17.
    Wyse DG, Waldo AL, DiMarco JP, et al.: A comparison of rate control and rhythm control in patients with atrial fibrillation. The atrial fibrillation follow-up investigation of rhythm management (AFFIRM) investigators. N Engl J Med 2002, 347:1825–1833. This is the largest prospective trial to date comparing rate and rhythm control in patients with AF. Although important, critical limitations of the study design require careful application of trial findings to specific patient subpopulations.PubMedCrossRefGoogle Scholar
  18. 18.
    Rationale and design of a study assessing treatment strategies of atrial fibrillation in patients with heart failure: the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial [no authors listed]. Am Heart J 2002, 144:597–607.Google Scholar
  19. 19.
    Klein AL, Grimm RA, Murray D, et al.: Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001, 344:1411–1420.PubMedCrossRefGoogle Scholar
  20. 20.
    Fuster V, Ryden LE, Asinger RW, et al.: ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive summary. 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 and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation). Developed in collaboration with the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 2001, 104:2118–2150.Google Scholar
  21. 21.
    Kochiadakis GE, Igoumenidis NE, Marketou ME, Kaleboubas MD: Low dose amiodarone and sotalol in the treatment of recurrent, symptomatic atrial fibrillation: a comparative, placebo controlled study. Heart 2000, 84:251–257.PubMedCrossRefGoogle Scholar
  22. 22.
    Deedwania PC, Singh BN, Ellenbogen K, et al.: Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation. Observations from the Veterans Affairs Congestive Heart Failure Survival Trial of Antiarrhythmic Therapy (CHF-STAT). Circulation 1998, 98:2574–2579.PubMedGoogle Scholar
  23. 23.
    Pedersen OD, Bagger H, Keller N, et al.: Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function: a Danish investigations of arrhythmia and mortality on dofetilide (Diamond) substudy. Circulation 2001, 104:292–296.PubMedGoogle Scholar
  24. 24.
    Roy D, Talajic M, Dorian P, et al.: Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. N Engl J Med 2000, 342:913–920.PubMedCrossRefGoogle Scholar
  25. 25.
    Benditt DG, Williams JH, Jin J, et al.: Maintenance of sinus rhythm with oral d,l-sotalol therapy in patients with symptomatic atrial fibrillation and/or atrial flutter. d,l-Sotalol Atrial Fibrillation/Flutter Study Group. Am J Cardiol 1999, 84:270–277.PubMedCrossRefGoogle Scholar
  26. 26.
    Singh S, Zoble RG, Yellen L, et al.: Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or flutter. The Symptomatic Atrial Fibrillation Investigative Research on Dofetilide (SAFIRE-D) study. Circulation 2000, 102:2385–2390.PubMedGoogle Scholar
  27. 27.
    Echt DS, Liebson PR, Mitchell LB, et al.: Mortality and morbidity in patients receiving encainide, flecainide or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991, 324:781–788.PubMedCrossRefGoogle Scholar
  28. 28.
    Wilkoff BL, Cook JR, Epstein AE, et al.: Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA 2002, 288:3115–3123.PubMedCrossRefGoogle Scholar
  29. 29.
    Chen MS, Marrouche NF, Natale A, et al.: Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. J Am Coll Cardiol 2004, 43:1004–1009.PubMedCrossRefGoogle Scholar
  30. 30.
    Hsu LF, Jais P, Sanders P: Cardiac function improves following catheter ablation of atrial fibrillation associated with heart failure. Presented at the North American Society of Pacing and Electrophysiology abstract session. San Francisco, CA; May 19–22, 2004.Google Scholar
  31. 31.
    Wellens HJ: Contemporary management of atrial flutter. Circulation 2002, 106:649–652.PubMedCrossRefGoogle Scholar
  32. 32.
    Engelstein ED: Prevention and management of chronic heart failure with electrical therapy. Am J Cardiol 2003, 19(suppl):62F-73F.CrossRefGoogle Scholar
  33. 33.
    Koilpillai C, Quinones MA, Greenberg B, et al.: Relation of ventricular size and function to heart failure status and ventricular dysrhythmia in patients with severe left ventricular dysfunction. Am J Cardiol 1996, 77:606–611.PubMedCrossRefGoogle Scholar
  34. 34.
    Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: 7D: the tachycardia algorithms. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation [no authors listed]. Circulation 2000, 102:I158–I165.Google Scholar
  35. 35.
    Connolly SJ, Gent M, Roberts RS, et al.: Canadian Implantable Defibrillator Study (CIDS): a randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation 2000, 101:1297–1302.PubMedGoogle Scholar
  36. 36.
    A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators [no authors listed]. N Engl J Med 1997, 337:1576–1583.Google Scholar
  37. 37.
    Lee DS, Green LD, Liu PP, et al.: Effectiveness of implantable defibrillators for preventing arrhythmic events and death: a meta-analysis. J Am Coll Cardiol 2003, 41:1573–1583.PubMedCrossRefGoogle Scholar
  38. 38.
    Moss AJ, Hall WJ, Cannom DS, et al.: Improved survival with an implanted defibrillator in patients with coronary disase at high risk for ventricular arrhythmia. N Engl J Med 1996, 335:1933–1940.PubMedCrossRefGoogle Scholar
  39. 39.
    Buxton AE, Lee KL, Fisher JD, et al.: A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med 1999, 342:1300.Google Scholar
  40. 40.
    Moss AJ, Zareba W, Hall WJ, et al.: Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002, 346:877–883. This large randomized trial of patients with ischemic cardiomyopathy demonstrated the mortality benefit of the ICD as primary prevention of sudden cardiac death.PubMedCrossRefGoogle Scholar
  41. 41.
    Doval HC, Nul DR, Grancelli HO, et al.: Randomised trial of low dose amiodarone in severe congestive heart failure. Grupo de Estudio de la Sobrevida en la In suficiencia Cardiaca en Argentina (GESICA). Lancet 1994, 344:493–498.PubMedCrossRefGoogle Scholar
  42. 42.
    Bansch D, Antz M, Boczor S, et al.: Primary prevention of sudden cardiac death in idiopathic dilated cardiomyopathy: the Cardiomyopathy Trial (CAT). Circulation 2002, 105:1453–1458.PubMedCrossRefGoogle Scholar
  43. 43.
    Strickberger SA, Hummel JD, Bartlett TG, et al.: Amiodarone versus implantable cardioverterdefibrillator: randomized trial in patients with nonischemic dilated cardiomyopathy and asymptomatic nonsustained ventricular tachycardia—AMIOVIRT. J Am Coll Cardiol 2003, 41:1707–1712.PubMedCrossRefGoogle Scholar
  44. 44.
    Kadish A, Dyer A, Daubet JP, et al.: Prophylactic Defibrillator Implantation in Patients with Nonischemic Cardiomyopathy (DEFINITE trial). N Engl J Med 2004, 350:2151–2158.PubMedCrossRefGoogle Scholar
  45. 45.
    Bardy GH: SCD HEFT Trial. Presented at the 2004 Scientific Sessions of the American College of Cardiology. New Orleans, LA: March 7–10, 2004.Google Scholar
  46. 46.
    Bristow MR, Saxon LA, Boehmer J: Cardiac-Resynchronization Therapy with or without an Implantable Defibrillator in Advanced Chronic Heart Failure (COMPANION). N Engl J Med 2004, 350:2140–2150. This recently released clinical trial demonstrates the mortality benefit of the ICD in patients with nonischemic cardiomyopathy. The trial also demonstrates the benefits of biventricular pacing on all-cause mortality in patients with heart failure.PubMedCrossRefGoogle Scholar
  47. 47.
    Kuck KH, Cappato R, Siebels J, et al.: Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest. The Cardiac Arrest Study Hamburg (CASH). Circulation 2000, 102:748–754.PubMedGoogle Scholar
  48. 48.
    Grimm W, Hoffmann J, Muller HH, Maisch B: Implantable defibrillator event rates in patients with idiopathic dilated cardiomyopathy, nonsustained ventricular tachycardia on Holter and a left ventricular ejection fraction below 30%. J Am Coll Cardiol 2002, 39:780–787.PubMedCrossRefGoogle Scholar
  49. 49.
    Fonarow GC, Feliciano Z, Boyle NG, et al.: Improved survival in patients with nonischemic advanced heart failure and syncope treated with an implantable cardioverter-defibrillator. Am J Cardiol 2000, 85:981–985.PubMedCrossRefGoogle Scholar
  50. 50.
    Middlekauff HR, Stevenson WG, Stevenson LW, et al.: Syncope in advanced heart failure: high risk of sudden death regardless of the origin of syncope. J Am Coll Cardiol 1993, 21:110–116.PubMedCrossRefGoogle Scholar
  51. 51.
    Stevenson WG, Friedman PL, Kocovic D, et al.: Radiofrequency catheter ablation of ventricular tachycardia after myocardial infarction. Circulation 1998, 98:308–314.PubMedGoogle Scholar
  52. 52.
    Stevenson WG: Catheter mapping of ventricular tachycardia. In Cardiac Electrophysiology: From Cell to Bedside, edn 2. Edited by ZipesDP, JalifeJ. Philadelphia, PA: WB Saunders; 1995:1093–1112.Google Scholar
  53. 53.
    Cohen TJ, Chien WW, Lurie KG, et al.: Radiofrequency catheter ablation for treatment of bundle branch reentrant ventricular tachycardia: results and longterm follow-up. J Am Coll Cardiol 1991, 18:1767–1773.PubMedCrossRefGoogle Scholar
  54. 54.
    Bayes de Luna A, Coumel P, Leclercq JF: Ambulatory sudden cardiac death: mechanisms of production of fatal arrhythmia on the basis of data from 157 cases. Am Heart J 1989, 117:151–159.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc. 2004

Authors and Affiliations

  • Robert M. Lobel
    • 1
  • Daniel L. Lustgarten
    • 1
  1. 1.Department of CardiologyMcClure Building, Fletcher Allen Health CareBurlingtonUSA

Personalised recommendations