Ventricular arrhythmias in acute heart failure: a clinical consensus statement of the Association for Acute CardioVascular Care, the European Heart Rhythm Association, and the Heart Failure Association of the European Society of Cardiology

Abstract

Patients presenting with or alerting emergency networks due to acute heart failure (AHF) form a diverse group with a plethora of symptoms, risks, comorbidities, and aetiologies. During AHF, there is an increased risk of destabilizing the functional substrate and modulatory adding to the risk of ventricular arrhythmias (VAs) already created by the structural substrate. New VAs during AHF have previously identified patients with higher intra-hospital and 60-day morbidity and mortality. Risk stratification and criteria/best time point for coronary intervention and implantable cardioverter defibrillator implantation, however, are still controversial topics in this difficult clinical setting. The characteristics and logistics of pre-hospital emergency medicine, as well as the density of centres capable of treating AHF and VAs, differ massively throughout Europe. Scientific guidelines provide clear recommendations for the management of arrhythmias in patients with chronic heart failure. However, the incidence, significance, and management of arrhythmias in patients with AHF have been less studied. This consensus paper aimed to address the identification and treatment of VAs that complicate the course of patients who have AHF, including cardiogenic shock.

Keywords: Acute heart failure; Ventricular arrhythmias.

Figure 1

Need for advanced therapies and risk of poor outcome. HF, heart failure; NONSTE-ACS, non-ST elevation acute coronary syndrome; SBP, systolic blood pressure; STEMI, ST elevation myocardial infarction; VA, ventricular arrhythmia.

Figure 2

Initial approach to ventricular arrhythmias in acute heart failure. ACLS, advanced cardiac life support; BP, blood pressure; CS, cardiogenic shock; ECG, electrocardiogram; HR, heart rate; ICCU, intensive cardiac care unit; ICD, implantable cardioverter defibrillator; RAAS, renin–angiotensin–aldosterone system; RR, respiratory rate; SpO₂, pulse oximetry.

Figure 3

Mechanisms leading to sudden cardiac death. CV, cardiovascular; SCD, sudden cardiac death.

Figure 4

Complex cycle of deterioration during myocardial ischaemia.

Figure 5

Management of ventricular arrhythmias in acute heart failure. ^a/^bBeta-blocker if not contraindicated, i.v. non-selective or short acting beta-blocker preferred. ^cLidocaine in cases with acute ischaemia. ^dOverdrive pacing in polymorphic ventricular arrhythmia with bradycardia or slow incessant ventricular arrhythmia. ^eCatheter ablation in sustained monomorphic ventricular tachycardia or polymorphic ventricular arrhythmia induced by similar premature ventricular contraction. ^fMechanical circulatory support in cases with cardiogenic shock despite optimal medical therapy and to facilitate catheter ablation if indicated. ICD, implantable cardioverter defibrillator; MCS, mechanical circulatory support; NONSTE-ACS, non-ST elevation acute coronary syndrome; PMVAs, polymorphic ventricular arrhythmias; SMVT, sustained monomorphic ventricular tachycardia; STEMI, ST elevation myocardial infarction; VA, ventricular arrhythmia; VF, ventricular fibrillation; VT, ventricular tachycardia.

Figure 6

Summary of management of ventricular arrhythmias in acute heart failure. AAD, anti-arrhythmic drug; ACLS, advanced cardiac life support; AHF, acute heart failure; HD, haemodynamic; MCS, mechanical circulatory support; VA, ventricular arrhythmia.