Management of ventricular arrhythmia in patients with chronic stablle angina LV function improvement or ablation

Harvard Medical School Management of Ventricular Arrhythmia in Patients with Chronic Stable Angina: LV Function Improvement or Ablation?. Harvard Medical What Our Our Goals of Treatmen

Harvard Medical School

Management of Ventricular Arrhythmia in Patients

with Chronic Stable Angina: LV Function

Improvement or Ablation?

Duane Pinto, MD MPH FACC FSCAI

Harvard Medical

What Our Our Goals of Treatment in

Chronic Stable Angina with Arrhythmia

and LV Dysfunction?

• In order to determine whether the ablation or

ablation is the treatment we have to define:

– Is the treatment to improve survival?

• Is the problem coronary disease and avoiding recurrent

MI, deathrevascularization, medications, ICD

– Is the treatment to improve symptoms

– Which symptoms?

» Angina- revascularizatino

» Arrhythmia- Anti-Arrhythmic Medications, Ablation

» Heart Failure- CRT, Medications

Harvard Medical School

Myocardial Ischemia:

Occurs when myocardial oxygen demand exceeds

myocardial oxygen supply

Harvard Medical

Blood Flow to the Left Ventricle

Harvard Medical School

Autoregulation

• Is the ability to maintain myocardial blood

flow at constant level in the face of changing

driving pressure

Harvard Medical

Coronary Blood Flow

• Coronary Perfusion

pressure

= Diastolic blood

pressure, minus LVEDP

• Coronary Vascular resistance

 Neural factors (esp

sympathetic nervous system)

Harvard Medical School

Effect of Stenosis in Intact Coronary Bed

Harvard Medical

The Effect of Coronary Stenosis Severity

on Stenosis Resistance

Harvard Medical School

Effect of ACE-I and BB on LV

Harvard Medical

HFSA 2010 Practice Guideline (9.7)

Device Therapy:

Biventricular Pacing

• Biventricular pacing therapy is recommended for

patients with all of the following:

– Sinus rhythm

– A widened QRS interval (≥120 ms)

– Severe LV systolic dysfunction (LVEF < 35%)

– Persistent, moderate-to-severe HF (NYHA III)

despite optimal medical therapy

Harvard Medical School

Improvement in LVEF with CRT

Harvard Medical

What Do Your Do In The Patient At Risk for

SCD When There Still Is Angina?

• Beta-Blockers are maximized

• Blood pressure controlled

• No revascularization options

• Heart failure controlled with ACE-I/ARB and

diuretics, +/- CRT?

Harvard Medical School

RANDOMIZE (1:1) Double-blind

Harvard Medical

Ranolazine in Ischemic Heart Disease

• Anti-anginal & anti-ischemic effects without clinically

significant effect on HR or BP

• Approved for treatment of chronic angina

–  exercise time,  angina in selected pts

• Novel mechanism of action

– Inhibition of late INa   Ca2+ overload   adverse

energetic, mechanical, electrical consequences

• Experimental evidence

–  LV performance during ischemia

–  recovery of LV function,  infarct size

Background

Morrow DA et al JAMA 2007; 297: 1775-83

Harvard Medical School

Ranolazine in Ischemic Heart Disease

• Ranolazine associated with an  in QTc (average ~5

msec)

• However, experimental data suggest suppression of

pro-arrhythmic markers

• Indication in chronic angina: “Because ranolazine

prolongs the QT interval, it should be reserved for

patients who have not achieved an adequate response with other anti-anginal drugs.”

Harvard Medical

Harvard Medical School

Components of Primary Endpoint

Results

CV Death or MI (%) Recurrent Ischemia (%)

Days from Randomization

Ranolazine 13.9%* (N=3,279)

Placebo 16.1%* (N=3,281)

Days from Randomization

*KM Cumulative Incidence (%) at 12 months

Morrow DA et al JAMA 2007; 297: 1775-83

Harvard Medical

Assessment of Anti-anginal Effects

RANOLAZINE (N=3,279)

Results

PLACEBO (N=3,281)

*KM Cumulative Incidence at 12 months

Antianginal Increase (%)*

20% 

P = 0.003

Harvard Medical School

Harvard Medical

What do you do when the patient continues to have symptomatic arrythmias

and LV Dysfunction?

• Are the symptoms from an atrial

tachyarrhythmia or a ventricular

tachyarrythmia?

Harvard Medical School

Transient Arrhythmias of Reversible Cause

Myocardial revascularization should be performed, when appropriate, to reduce the risk of SCD in patients

experiencing cardiac arrest due to VF or polymorphic VT in the setting of acute ischemia or MI

II IIa IIb III

II IIa IIb III

II IIa IIa IIb IIb III III

VA & SCD Related to Specific Pathology

Harvard Medical

• Antiarrhythmic Drugs

• ♥ Beta Blockers: Effectively suppress ventricular ectopic beats &

arrhythmias; reduce incidence of SCD

• ♥ Amiodarone: No definite survival benefit; some studies have shown reduction in SCD in patients with LV dysfunction especially when given

in conjunction with BB Has complex drug interactions and many

adverse side effects (pulmonary, hepatic, thyroid, cutaneous)

• ♥ Sotalol: Suppresses ventricular arrhythmias; is more pro-arrhythmic than amiodarone, no survival benefit clearly shown

• ♥ Conclusions: Antiarrhythmic drugs (except for BB) should not be used

as primary therapy of VA and the prevention of SCD

Therapies for VA

Harvard Medical School

LV Dysfunction Due to Prior MI

Implantation of an ICD is reasonable in patients with

LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF of less than or equal to 30% to 35%, are NYHA functional class I on chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year

Amiodarone, often in combination with beta blockers, can be useful for patients with LV dysfunction due to prior MI and symptoms due to VT unresponsive to beta-adrenergic–

blocking agents

Sotalol is reasonable therapy to reduce symptoms resulting from VT for patients with LV dysfunction due to prior MI unresponsive to beta-blocking agents

I

I

I I I IIa IIa IIa IIb IIb IIb III III III

I I I IIa IIa IIa IIb IIb IIb III III III

I IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb III III III III III III

I

I

I I I IIa IIa IIa IIb IIb IIb III III III

I I I IIa IIa IIa IIb IIb IIb III III III

I IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb III III III III III III

I

I

I I I IIa IIa IIa IIb IIb IIb III III III

I I I IIa IIa IIa IIb IIb IIb III III III

I IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb III III III III III III

VA & SCD Related to Specific Pathology

Harvard Medical

Therapies for VA

Ablation

Ablation is indicated in patients who are otherwise at low risk for SCD and have sustained predominantly monomorphic VT that is drug resistant, who are drug intolerant, or who do not

wish long-term drug therapy

Ablation is indicated in patients with bundle-branch reentrant

VT

Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of sustained

VT that is not manageable by reprogramming or changing drug

therapy or who do not wish long-term drug therapy

Ablation is indicated in patients with WPW syndrome resuscitated from sudden cardiac arrest due to AF and rapid conduction over the accessory pathway

causing VF

I

I

I I I IIa IIa IIa IIb IIb IIb III III III

I I I IIa IIa IIa IIb IIb IIb III III III

I IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb III III III III III III

II IIa IIa IIb IIb III III

II IIa IIa IIb IIb III III

II IIa IIa IIb IIb III III

Harvard Medical School

Therapies for VA

Ablation

Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have symptomatic nonsustained monomorphic VT that is drug resistant, who are drug intolerant or who do not wish long-term drug therapy

Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have frequent symptomatic predominantly monomorphic PVCs that are drug resistant or who are drug intolerant or who do not wish long-term drug therapy

Ablation can be useful in symptomatic patients with WPW syndrome who have accessory

pathways with refractory periods less than

240 ms in duration

I

I

I I I IIa IIa IIa IIb IIb IIb III III III

I I I IIa IIa IIa IIb IIb IIb III III III

I IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb III III III III III III

I

I

I I I IIa IIa IIa IIb IIb IIb III III III

I I I IIa IIa IIa IIb IIb IIb III III III

I IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb III III III III III III

I

I

I I I IIa IIa IIa IIb IIb IIb III III III

I I I IIa IIa IIa IIb IIb IIb III III III

I IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb III III III III III III

Harvard Medical

Therapies for VA Ablation

Ablation of Purkinje fiber potentials may be considered

in patients with ventricular arrhythmia storm consistently provoked by PVCs of similar morphology

Ablation of asymptomatic PVCs may be considered when the PVCs are very frequent to avoid or treat tachycardia-

induced cardiomyopathy

Ablation of asymptomatic relatively infrequent PVCs is not indicated

II IIa IIb III

II IIa IIb III

II IIa IIa IIb IIb III III

II IIa IIb III

II IIa IIb III

II IIa IIa IIb IIb III III

II IIa IIb III

II IIa IIb III

II IIa IIa IIb IIb III III

Harvard Medical School

Nonsustained Monomorphic VT

Harvard Medical

Nonsustained LV VT

Harvard Medical School

Sustained Monomorphic VT

72-year-old woman with CHD

Harvard Medical

Nonsustained Polymorphic VT

Harvard Medical School Sustained Polymorphic VT

Exercise induced in patient with no structural heart disease

Harvard Medical

Bundle Branch Reentrant VT

Harvard Medical School

Ventricular Flutter

Spontaneous conversion to NSR (12-lead ECG)

Harvard Medical

VF with Defibrillation (12-lead ECG)

Harvard Medical School

Wide QRS Irregular Tachycardia:

Atrial Fibrillation with antidromic conduction in patient with accessory

pathway – Not VT

Harvard Medical

What Our Our Goals of Treatment in

Chronic Stable Angina with Arrhythmia

and LV Dysfunction?

• In order to determine whether the ablation or

ablation is the treatment we have to define:

– Is the treatment to improve survival?

• Is the problem coronary disease and avoiding recurrent

MI, deathrevascularization, medications, ICD

– Is the treatment to improve symptoms