TACHYCARDIA INDUCED CARDIOMYOPATHY. Case 1 ECG

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1 TACHYCARDIA INDUCED CARDIOMYOPATHY Javier E. Banchs M.D. Associate Professor of Medicine Penn State Hershey Heart & Vascular Institute Case 1 34 year old man with history of tachycardia x 6 months, nausea and vomiting Elevated liver function tests Hypotension during sedation for EGD Ejection Fraction 20% by Echo, normal coronary arteries ECG 132 ppm 1

2 On IV amiodarone 115 ppm RAO LAO I II RAA p 3 HB2 d MAPp MAPd p 6 5 CS d 200 ms 2

3 LSPV LAA MA LIPV 1 month later Case 1 follow up Discharged on beta blockers and diuretics Progressive clinical improvement Normal ejection fraction in 3 months 3

4 Case 2 37 year old woman 36 weeks pregnant with progressive dyspnea and EF 20% History of tachycardia during pregnancy follow ups ECG 4

5 Case 2 Temporary response to IV Ibutilide followed by hypotension and cardiogenic shock after 48 hours on Flecainide Urgent C Section Case 2 2 days later EP study demonstrates Permanent Junctional Reciprocating Tachycardia (PJRT) Successful ablation in the proxymal coronary sinus Discharged on heart failure therapy 5

6 Case 2 follow up EF 40% in 3 months and 55% in 6 with resolution of symptoms Case 3 62 year old woman with history of CAD and prior PCI Referred for ICD due to recent deterioration of EF to 30-35% and progressive dyspnea 6

7 Case 3 SVC RAA CS IVC Case 3 EF 6 months after ablation = 45% 7

8 Case 4 47 year old woman with hypothyroidism and 1 month of dyspnea, palpitations and chest pressure admitted with pulmonary edema and hypotension Transferred to our institutions for transplant evaluation with suspicion of viral cardiomyopathy Normal coronary arteries and EF 30% ECG 8

9 ECG after ablation Case 4 follow up Symptoms resolution EF normalized 2 months later Atrial fibrillation recurrence with heart failure symptoms 6 years later with evidence of diastolic heart failure 9

10 Heart Failure 5.7 million in USA Cause of death in more than people a year 50% of patients diagnosed with heart failure die within the first 5 years after diagnosis USA cost: 34.4 billons/year Roger VL et al. Heart disease and stroke statistics 2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2 220 Tachycardia Induced Cardiomyopathy Gossage AM, Braxton Hicks JA. On auricular fibrillation. QJM 1913; 6: Brill IC. Auricular fibrillation with congestive failure and no other evidence of organic heart disease. Am Heart J 1937; 13: Tachycardia Induced Cardiomyopathy Animal model for heart failure Atrial stimulation at 330 bpm in dogs > 3 weeks Biventricular failure, chamber dilatation, hypoperfusion, fluid retention, pulmonary congestion, neuro-hormonal activation, myocardial remodeling, apoptosis and myocardial fibrosis Partially reversible in 4 weeks off stimulation Whipple GH et al. Reversible congestive heart failure due to chronic rapid stimulation of the normal heart. Proc N Engl Cardiovasc Soc 1962; 20:

11 LOW EJECTION FRACTION DIASTOLIC DYSFUNCTION LOW CARDIAC OUTPUT ATRIAL AND VENTRICULAR DILATATION MITRAL REGURGITATION Apoptosis in dog hearts after 1,3 and 4 weeks of atrial stimulation Moe GW, Armstrong P. Pacing-induced heart failure: a model to study the mechanism of disease progression and novel therapy in heart failure. Cardiovascular Research 42 (1999)

12 Tachycardia Induced Cardiomyopathy Heart failure resulting from abnormal atrial or ventricular rate elevation without other dientifiable cause Variable progression - could depend on rate and duration of the tachycardia Tachycardia may or may not be evident at the time of presentation Reversible Tachycardia Induced Cardiomyopathy Clinical presentation: Systolic heart failure (dilated cardiomyopathy) Dyspnea, edema, low output Tachycardia Palpitations, syncope Asymptomatic Etiology Atrial fibrillation & atrial flutter Incessant atrial tachycardia Ventricular tachycardia and frequent premature ventricular complexes Permanent junctional reciprocating tachycardia (PJRT) Artificial stimulation 12

13 Treatment Treatment DIAGNOSIS Treatment DIAGNOSIS 13

14 Treatment DIAGNOSIS Treatment Rate Control Beta blockers Calcium channel blockers Digoxin Optimal heart rate? Arrhythmia suppression Ablation Antiarrhythmic drugs Management of predisposing condition Thyrotoxicosis Pheochromocytoma Case 5 24 year old man with long history of PVCs and minimal symptoms Clinical follow up for 2 years with normal echocardiogram Most recent echocardiogram shows minimal dilatation of the LV and EF 50% 14

15 ECG 15

16 Post Ablation 16

17 Case 5 follow up Symptoms resolved Normal EF Outflow Tract PVCs Yarlagadda RK. Et al. Circulation. 2005;112: Outflow Tract PVCs Yarlagadda RK. Et al. Circulation. 2005;112:

18 Outflow Tract PVCs Ablation or pharmacological suppression indicated for symptomatic ventricular tachycardia with or without syncope to (15%) PVCs in 24 hours could lead to LV dilatation and systolic dysfunction Frequent PVCs in the asymptomatic patient: monitor for symptoms & echocardiography versus pharmacological suppression or ablation The Heart Failure Patient ATRIAL FIBRILLATION DEVICE THERAPY PVCS VENTRICULAR DYSSYNCHRONY SYMPATHETIC TONE VENTRICULAR TACHYCARDIA The Heart Failure Patient ATRIAL FIBRILLATION DEVICE THERAPY PVCs VENTRICULAR DYSSYNCHRONY SYMPATHETIC TONE VENTRICULAR TACHYCARDIA 18

19 VVI 40 DDDR 70 DAVID trial Wilkoff BL. Et al. JAMA. 2002;288(24): DAVID II trial Wilkoff BL. J Am Coll Cardiol 2009;53: EF before and after PVI - 50 patients with dilated CM and EF <55% J Cardiovasc Electrophysiol Jan;18(1):

20 Meta-analysis A fib ablation in patients with heart failure. Change in EF before and after A fib ablation Dagres N. et al J Card Fail Nov;17(11): heart failure patients with frequent PVCs treated with ablation Panela D. et al. J Am Coll Cardiol Sep 24;62(13): patients withheart failure CRT and > PVCs in 24 hours treated with ablation Lakkireddy D. et al. J Am Coll Cardiol Oct 16;60(16):

21 The Heart Failure Patient Is the cardiomyopathy caused by tachycardia? How long should we treat with beta blockers and ACE-I/ARB Optimization of atrial fibrillation therapy Management of PVCs and VT Who is at risk? Relationship between stress induced and tachycardia induced cardiomyopathy Common etiology for tachycardia and cardiomyopathy Genotype and environmental factors Is atrial fibrillation a localized form of tachycardia induced cardiomyopathy? Is the cardiomyopathy really reversible? Conclusions The diagnosis of tachycardia induced cardiomyopathy should be suspected in patients with heart failure and tachycardia The clinical syndrome is reversible Aggressive management of supraventricular and ventricular tachycardia may prevent heart failure progression 21

22 Conclusions Treatment for frequent PVCs should be considered with evidence of ventricular remodeling or heart failure symptoms Further research is needed to better understand the etiology of cardiac arrhythmias and the pathophysiology of tachycardia induced cardiomyopathy 22

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