Congestive Heart Failure
Jahangir Moini, Matthew Adams, Anthony LoGalbo in Complications of Diabetes Mellitus, 2022
Additional treatments are based on the cause of pulmonary edema. If there is rapid atrial fibrillation, cardioversion is done. Intravenous beta-blockers, digoxin, or careful use of calcium channel blockers can slow the ventricular rate. Intravenous vasodilators are used for severe hypertension. For acute MI or another acute coronary syndrome, treatments include thrombolysis or direct percutaneous coronary angioplasty, with or without stenting. The fluid status is usually normal before pulmonary edema develops. Therefore, diuretics may be not useful when patients have acute decompensation of chronic HF, and can precipitate hypotension. When systolic BP is lower than 100 mg Hg or there is shock, IV dobutamine and counterpulsation with an intra-aortic balloon pump may be needed. Direct-current cardioversion is used for ventricular or supraventricular tachycardia. Newer drugs are available but do not improve outcomes greatly, and can even be implicated in the death of the patient. These include intravenous BNP (nesiritide), ibopamine, levosimendan, pimobendane, and vesnarinone. Once the patient is stabilized, long-term treatment for HF is started.
Arrhythmias in Hypertrophic Cardiomyopathy and Their Management
Srilakshmi M. Adhyapak, V. Rao Parachuri in Hypertrophic Cardiomyopathy, 2020
Anti-arrhythmias like amiodarone can be considered for pharmacological rhythm control for acute AF especially with associated heart failure; however, if the patient is hemodynamically unstable, direct current cardioversion is preferred [2]. Electrical cardioversion can also be considered after at least three weeks of anticoagulation or with transesophageal echocardiography, which rules out intracardiac thrombus for rate-controlled AF. Pharmacological rhythm control strategies for other atrial tachyarrhythmias should follow contemporary guidelines [44]. Amiodarone and sotalol appear to suppress AF and supraventricular arrhythmias in observational studies long term, although there are no randomized trials [45, 46]. There is no data for dronerdarone and disopyramide (also used for LVOT obstruction) to suppress AF. Nevertheless amiodarone is often recommended for rhythm control long term, following AF cardioversion to sinus rhythm [2]. Both amiodarone and disopyramide have not reduced SCD in recent observational studies, although amiodarone is still sometimes used to suppress ventricular tachyarrhythmias if it is recurrent [47, 48].
The electrophysiology laboratory
John Edward Boland, David W. M. Muller in Interventional Cardiology and Cardiac Catheterisation, 2019
Presence of symptoms remains the most common indication for pacemaker treatment. Symptomatic bradycardia is the term used to identify clinical manifestations associated with a heart rate that does not allow cardiac output to meet physiologic demands. The aim of the procedure is to ensure optimal heart rate in a heart with a conduction deficit. Duration of the implant procedure is 1–2 hours depending on the number of leads and difficulty of access. Local anaesthetic (usually Marcain 0.4%) is administered at the site. It is an aseptic procedure, in which the medical practitioner scrubs, gowns and gloves. Cutdown cannulation of the cephalic vein and/or percutaneous cannulation of the sub-clavian vein provides access to the right atrium and ventricle. Pacing leads are then inserted into the heart via this access and the lead parameters measured via alligator leads and the pacing system analyser (PSA). The pacing device is then connected to the lead(s), inserted into a pre-pectoral pocket, and the wound closed. A drain may be required, particularly if the patient has been anticoagulated. Antibiotic prophylaxis, usually a cephalosporin, is given routinely, and occasionally with gentamicin cover. If penicillin allergy is suspected a skin test for drug reaction is performed with the cephalosporin. Cardioversion may (rarely) be required to continue the procedure (e.g. in the event of VF or VT). Recent developments to reduce infection and bleeding risk include an antibiotic sleeve (Tyrx, Medtronic) that encapsulates the generator, and a fibrinogenic implant (Tachosil, Medtronic), respectively.
Inotersen therapy of transthyretin amyloid cardiomyopathy
Published in Amyloid, 2020
Noel R. Dasgupta, Stacy M. Rissing, Jessica Smith, Jeesun Jung, Merrill D. Benson
Supportive treatments of the consequences of ATTR cardiomyopathy are in 2 main categories which certainly prolong life beyond the recognised 2.5 to 4.5 year mean survival after diagnosis of ATTR cardiomyopathy [3,4]. (1) Maintenance of a normal or controlled ventricular rate and rhythm to allow optimal diastolic filling of the left ventricle favours maintaining cardiac output and therefore tissue perfusion. Cardioversion for atrial fibrillation is usually effective in the early stages of ATTR cardiomyopathy but often fails with advanced atrial enlargement. Ventricular pacemakers may be needed for conduction system failure but mechanical defibrillators are usually not optimally effective in cardiac amyloidosis. (2) Medical control of the systemic manifestations of cardiovascular amyloidosis is imperative in the care of patients with ATTR congestive heart failure. Retention of electrolytes and water as a response to the failing heart usually reaches a point where cardiac function suffers more than it is helped. Any medication given to ease the load on the heart may lead to fluid retention and decline in effective tissue perfusion. Diuretic medications to reverse the negative response of the kidney are the mainstay of alleviating the effects of congestive heart failure. While life can certainly be prolonged by these non-specific therapeutic measures they do not affect the progressive ingravescent course of transthyretin cardiomyopathy. Therapy to slow or stop the progression of cardiac amyloid burden is needed and may be achievable.
Management of atrial fibrillation-flutter: uptodate guideline paper on the current evidence
Published in Journal of Community Hospital Internal Medicine Perspectives, 2018
Syed Raza Shah, Sue-Wei Luu, Matthew Calestino, John David, Christopher Bray
Rhythm control could be achieved with medications or via synchronized cardioversion in both AFIB and AFLUT [45]. Synchronized current cardioversion depolarizes the cardiomyocytes simultaneously in an attempt to restore normal sinus rhythm. During the early onset of AFIB, cardioversion is generally avoided unless the patient has other heart conditions like preexcitation [43]. More commonly, cardioversion is attempted if the AFIB is persistent (lasted longer than 7 days), as the probability of it spontaneously converting to normal sinus rhythm after then is very low. In many cases, electrical cardioversion is coupled with the administration of an anti-arrhythmic drug, usually a potassium-channel blocker like ibutilide. Studies suggest that the combination of electrical shock with an intravenous drug (like a potassium-channel blocker) increases the chances of restoring the normal sinus rhythm [43].
Sedation in cardiac arrhythmias management
Published in Expert Review of Cardiovascular Therapy, 2018
Federico Guerra, Giulia Stronati, Alessandro Capucci
Sedative and anesthetic drugs are commonly used both in the electrophysiology lab and in the emergency setting for arrhythmia-related issues.Electrical cardioversion is a common procedure requiring deep sedation in order to avoid pain and discomfort related to shock discharge. While anesthesiology support is traditionally recommended, many different approaches are possible in order to reach the same level of safety while cutting time-related issues and healthcare costs.Many procedures currently performed in an electrophysiology lab only require local anesthesia. However, deep sedation or even general anesthesia can become a requirement in many cases, such as complex substrate or pace-mapping ablation, subcutaneous device positioning, and unconventional cardiac anatomies. In these cases, the line between a safe cardiologist-directed sedation and the need for anesthesiology support is often quite thin, and many controversies exist related to the pros and cons of both strategies.Sedative drugs present anti-arrhythmic properties and can be administered to stop supraventricular and ventricular arrhythmias, atrial fibrillation, and electrical storm. On the other hand, some sedatives such as propofol could potentially prevent arrhythmia inducibility, making the ablation procedure unfeasible.
Related Knowledge Centers
- Arrhythmia
- Cardiac Arrest
- Cardiac Cycle
- Heart Rate
- Tachycardia
- Sinus Rhythm
- Heart
- Medical Procedure
- Medication
- Cardiac Conduction System