Current pharmacotherapeutic strategies for cardiac arrhythmias in heart failure

ABSTRACT

Introduction: Heart failure (HF) affects over 6 million Americans and is the most common cause of hospital readmissions in the United States. Cardiac arrhythmias are common comorbidities seen in patients with HF and are associated with an increase in morbidity and mortality. Pharmacotherapeutic agents along with device and ablation therapies are the mainstays of treatment for cardiac arrhythmias in HF.

Areas covered: An extensive literature review of articles and clinical trials on PUBMED on the topic of pharmacotherapy for cardiac arrhythmias in heart failure was conducted. This review article summarizes the above literature to describe the prevalence of the various types of arrhythmias in HF, the recommended pharmacotherapies for the treatment of these arrhythmias in HF and the evidence that supports these recommendations.

Expert opinion: Cardiac arrhythmias are common in HF and are the leading cause of death in this patient population. The management of cardiac arrhythmias in HF is challenging. Pharmacotherapy is the primary though increasingly adjunctive therapy for most cardiac arrhythmias. Further, antiarrhythmic drugs must be used with caution in this patient population due to their potential adverse effects.

KEYWORDS:

• Congestive heart failure
• cardiac arrhythmias
• antiarrhythmic drugs
• atrial fibrillation
• ventricular tachycardia

Article highlights

• A variety of arrhythmias are seen in heart failure, including atrial fibrillation, atrial flutter, premature ventricular contractions, non-sustained and sustained ventricular tachycardias, and ventricular fibrillation.

• Sudden cardiac death is the most common mechanism of death in heart failure. While a majority of these are due to malignant ventricular arrhythmias, it is now being recognized that many instances of sudden death are due to bradyarrhythmias and electromechanical dissociation.

• While trials have not shown any difference in mortality benefit between rate-control and rhythm-control strategies in atrial fibrillation, rhythm control – primarily the maintenance of sinus rhythm – may be beneficial in patients with heart failure due to improved hemodynamics. Recent trial evidence has shown that catheter ablation is superior to medical therapy (either rate or rhythm control).

• Implantable cardioverter-defibrillators are the mainstay for the primary and secondary prevention of sudden cardiac death (by malignant ventricular arrhythmias). However, anti-arrhythmics may be needed to supplement therapy (especially to reduce the frequency of shocks).

• While there have been improvements in catheter ablation techniques in recent years, anti-arrhythmics are falling out of favor due to their pro-arrhythmic and toxic side-effects. There have been few recent advances in anti-arrhythmic pharmacology, and this remains a potential area of discovery in the coming years.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.