What is the treatment for heart failure with tachyarrhythmia?

From the Guidelines

Treatment of heart failure with tachyarrhythmia should prioritize optimization of heart failure therapy with an ACE inhibitor, beta-blocker, and mineralocorticoid receptor antagonist, alongside consideration of an implantable cardioverter-defibrillator (ICD) for patients with symptomatic or sustained ventricular arrhythmias. This approach is supported by the European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 1. The guidelines recommend that potential aggravating or precipitating factors for ventricular arrhythmias should be sought and corrected, and that treatment with an ACE inhibitor, beta-blocker, and mineralocorticoid receptor antagonist should be optimized in patients with ventricular arrhythmias.

Key considerations in the management of heart failure with tachyarrhythmia include:

• Optimization of heart failure therapy to reduce morbidity and mortality
• Use of beta-blockers to control heart rate and reduce the risk of sudden death 1
• Consideration of an ICD for patients with symptomatic or sustained ventricular arrhythmias, as recommended by the European Society of Cardiology guidelines 1
• Avoidance of antiarrhythmic drugs that may worsen heart failure or increase the risk of proarrhythmia, such as class IC agents and dronedarone 1

In terms of specific medications, the following may be considered:

• ACE inhibitors, such as lisinopril (5-40 mg daily) or enalapril (2.5-20 mg daily)
• Beta-blockers, such as metoprolol succinate (25-200 mg daily) or carvedilol (3.125-25 mg twice daily)
• Mineralocorticoid receptor antagonists, such as spironolactone (25-50 mg daily)
• Amiodarone (200 mg daily after loading) may be considered for patients with symptomatic or sustained ventricular arrhythmias, although it requires careful monitoring for toxicity 1

Overall, the goal of treatment is to improve cardiac output, reduce symptoms, and minimize the risk of morbidity and mortality associated with heart failure and tachyarrhythmia. Optimization of heart failure therapy and consideration of an ICD for patients with symptomatic or sustained ventricular arrhythmias are key components of this approach.

From the FDA Drug Label

Amiodarone HCl injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy The answer is: Amiodarone can be used to treat heart failure with tachyarrhythmia, specifically for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy 2.

• Key points:
  • Amiodarone is indicated for patients with VT/VF who are unable to take oral medication
  • The drug can be used to treat patients with VT/VF for whom oral amiodarone is indicated
  • Amiodarone therapy must be weighed against its benefits in patients whose lives are threatened by cardiac arrhythmias 2

From the Research

Treatment Options for Heart Failure with Tachyarrhythmia

• Implantable cardioverter-defibrillators (ICDs) can prevent sudden cardiac death associated with ventricular fibrillation and ventricular tachycardia, but recurrent ICD shocks remain a clinical management challenge 3.
• Drug therapy, radiofrequency catheter ablation (RFCA), and recent RFCA advances are management strategies for ventricular tachycardia in congestive heart failure 3.
• Beta-blockers are effective in reducing mortality and sudden cardiac death in patients with heart failure 4.
• Angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) has been shown to reduce cardiovascular mortality, specifically by reducing sudden cardiac death, as well as death due to worsening heart failure in patients with heart failure with reduced ejection fraction 4.

Management of Atrial Fibrillation in Heart Failure

• Atrial fibrillation can precipitate and be a consequence of heart failure with reduced ejection fraction and cardiomyopathy 5.
• Catheter ablation for atrial fibrillation in patients with heart failure and reduced ejection fraction has shown superiority in improving survival, quality of life, and ventricular function and reducing heart failure hospitalizations compared with antiarrhythmic drugs and rate control therapies 5.
• Medical management for rate and rhythm control of atrial fibrillation in heart failure remains hampered by variable success, intolerance, and adverse effects 5.

Advances in Treatment of Ventricular and Atrial Tachyarrhythmias

• Optimal treatment of ventricular arrhythmias is variable and depends on the medical condition associated with the rhythm disorder 6.
• Implantable cardioverter-defibrillator is often indicated in secondary prevention of ventricular arrhythmias 6.
• Newest advancements in techniques and management of ventricular and atrial tachyarrhythmias, along with pharmacological therapy, have been highlighted in recent reviews 6.

Initial Therapy for Congestive Heart Failure

• Initial pharmacotherapy for systolic heart failure should consist of maximal tolerated dosages of ACE inhibitors, ARBs if ACE inhibitors are not tolerated, adequate dosages of hydralazine and isosorbide dinitrate if ACE inhibitors or ARBs are not tolerated, relatively low dosages of digoxin, and diuretics to relieve congestive symptoms 7.
• Addition of spironolactone to ACE inhibitors can result in a significant reduction in the risk of sudden death in patients with symptomatic severe heart failure 7.