Congestive heart failure antiarrhythmic drugs

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Summary
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Chronic Pharmacotherapy in HFrEF
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Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
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Congestive heart failure end-of-life considerations

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Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Antiarrhythmic therapy can be considered as part of a therapeutic strategy to prevent sudden cardiac death. Over 50% of heart failure patients will have asymptomatic non-sustained ventricular tachycardia (NSVT) and it is generally not recommended that NSVT be treated.

Antiarrhythmic Drugs

There are multiple causes of sudden cardiac death in the patient with congestive heart failure which include not only arrhythmic causes, but also thrombotic and other causes:

Metabolism of Antiarrhythmics in the setting of Congestive Heart Failure

The metabolism of following anti-arrhythmic drugs are significantly affected in patients with congestive heart failure and care should be taken regarding their administration:

  1. Quinidine
  2. Procainamide
  3. Disopyramide: Contraindicated in patients with heart failure.
  4. Moricizine
  5. Lidocaine
  6. Mexiletine
  7. Tocainide
  8. Flecainide
  9. Propafenone
  10. Amiodarone

Patients with congestive heart failure should not be treated with dronedarone.

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (DO NOT EDIT) [1][2][3]

Antiarrhythmics in Patients Presenting With Heart Failure (DO NOT EDIT) [4][2]

Class I
"1. Drugs known to adversely affect the clinical status of patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF) should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs.[5][6][7][8][9][10][11] (Level of Evidence: B) "
Class IIa

1. Ivabradine can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤ 35%) who are receiving GDEM, including a beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 bpm or greater at rest. (Class IIa, Level of Evidence: B-R)

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References

  1. Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  2. 2.0 2.1 2.2 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID:19324967
  3. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Colvin MM; et al. (2017). "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America". J Am Coll Cardiol. 70 (6): 776–803. doi:10.1016/j.jacc.2017.04.025. PMID 28461007.
  4. 4.0 4.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
  5. Heerdink ER, Leufkens HG, Herings RM, Ottervanger JP, Stricker BH, Bakker A (1998). "NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics". Archives of Internal Medicine. 158 (10): 1108–12. PMID 9605782. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  6. Herchuelz A, Derenne F, Deger F, Juvent M, Van Ganse E, Staroukine M, Verniory A, Boeynaems JM, Douchamps J (1989). "Interaction between nonsteroidal anti-inflammatory drugs and loop diuretics: modulation by sodium balance". The Journal of Pharmacology and Experimental Therapeutics. 248 (3): 1175–81. PMID 2703968. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  7. Gottlieb SS, Robinson S, Krichten CM, Fisher ML (1992). "Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy". The American Journal of Cardiology. 70 (9): 890–3. PMID 1529943. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  8. Bank AJ, Kubo SH, Rector TS, Heifetz SM, Williams RE (1991). "Local forearm vasodilation with intra-arterial administration of enalaprilat in humans". Clinical Pharmacology and Therapeutics. 50 (3): 314–21. PMID 1655327. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  9. "Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators". The New England Journal of Medicine. 321 (6): 406–12. 1989. doi:10.1056/NEJM198908103210629. PMID 2473403. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  10. "Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. The Cardiac Arrhythmia Suppression Trial II Investigators". The New England Journal of Medicine. 327 (4): 227–33. 1992. doi:10.1056/NEJM199207233270403. PMID 1377359. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  11. Pratt CM, Eaton T, Francis M, Woolbert S, Mahmarian J, Roberts R, Young JB (1989). "The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-benefit ratio". American Heart Journal. 118 (3): 433–40. PMID 2476016. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)

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