Management of Ventricular Arrhythmia in Patients with Chronic Stable Angina: LV Function Improvement or Ablation? Duane Pinto, MD MPH FACC FSCAI Harvard Medical School 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 School Blood Flow to the Left Ventricle Predominates in Diastole Aortic Pressure (mmHg) Left Ventricular Pressure (mmHg) Circumflex Coronary Flow (ml/min) sec Harvard Medical School Autoregulation • Is the ability to maintain myocardial blood flow at constant level in the face of changing driving pressure Harvard Medical School Coronary Blood Flow • Coronary Perfusion pressure = Diastolic blood pressure, minus LVEDP • Coronary Vascular resistance  external compression  intrinsic regulation  Local metabolites  Autoregulation  Endothelial factors  Neural factors (esp sympathetic nervous system) Harvard Medical School Effect of Stenosis in Intact Coronary Bed Maximal Flow Basal Flow 20 40 60 Diameter Stenosis 80 100 Harvard Medical School The Effect of Coronary Stenosis Severity on Stenosis Resistance Harvard Medical School Effect of ACE-I and BB on LV Harvard Medical School 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 Strength of Evidence = A Harvard Medical School Therapies for VA • 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 Harvard Medical School VA & SCD Related to Specific Pathology LV Dysfunction Due to Prior MI I IIa IIb III 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 year I IIa IIb III 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 I IIa IIb III Sotalol is reasonable therapy to reduce symptoms resulting from VT for patients with LV dysfunction due to prior MI unresponsive to beta-blocking agents Harvard Medical School Therapies for VA Ablation I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III 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 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 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 Harvard Medical School Therapies for VA Ablation I IIa IIb III 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 not wish long-term drug therapy I IIa IIb III 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 not wish long-term drug therapy I IIa IIb III Ablation can be useful in symptomatic patients with WPW syndrome who have accessory pathways with refractory periods less than 240 ms in duration Harvard Medical School Therapies for VA Ablation I IIa IIb III I IIa IIb III I IIa IIb III 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 tachycardiainduced cardiomyopathy Ablation of asymptomatic relatively infrequent PVCs is not indicated Harvard Medical School Nonsustained Monomorphic VT Harvard Medical School Nonsustained LV VT Harvard Medical School Sustained Monomorphic VT 72-year-old woman with CHD Harvard Medical School Nonsustained Polymorphic VT Harvard Medical School Sustained Polymorphic VT Exercise induced in patient with no structural heart disease Harvard Medical School Bundle Branch Reentrant VT Harvard Medical School Ventricular Flutter Spontaneous conversion to NSR (12-lead ECG) Harvard Medical School 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 School 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- Ablation » Heart Failure- CRT, Medications Harvard Medical School