Introduction to arrhythmias in heart failure

Occasionally, arrhythmias are the primary cause of heart failure in a patient with an otherwise healthy heart. The clearest example is atrial fibrillation or atrial flutter persisting for several weeks to months. Heart failure results from a combination of the arrhythmia and secondary left ventricular dysfunction.

Arrhythmia-induced cardiomyopathy can be caused byHuizar, 2019:

• tachycardia
• atrial fibrillation
• premature ventricular contractions.

Control of the arrhythmia in such cases can completely reverse the left ventricular dysfunction and heart failure.

More commonly, arrhythmias are secondary to heart disease and are an important contributing cause of worsening heart failure. Examples are major bradyarrhythmias (eg complete heart block) and tachyarrhythmias (eg atrial flutter or atrial fibrillation with rapid ventricular response). In such cases, treatment of heart failure must include treatment of the arrhythmia. Often it is not possible to determine how much the arrhythmia is contributing to the heart failure until the arrhythmia has been controlled for some time.

All arrhythmias occur more frequently in patients with heart failure. In general, the more severe the heart disease and heart failure, the more severe and frequent the arrhythmias. If using diuretic therapy, avoid potassium or magnesium depletion; this can increase the risk of arrhythmias. In patients with recurrent atrial fibrillation associated with heart failure with reduced ejection fraction (HFrEF), rhythm control (including catheter ablation) may be superior to rate controlKirchhof, 2020Rillig, 2021. Consider referral for patients with recent-onset HFrEF and concurrent atrial fibrillation.