The potential application of electrophysiology diagnostics and therapeutics in acute heart failure syndromes

A major conundrum in the management of acute heart failure syndromes is the observation that patients are generally treated successfully during the in-hospital phase, but have a markedly high post-discharge event rate [1, 2]. The 30-day readmission rate has remained fairly constant or increased over the last decade at approximately 25% [3, 4]. Over one-third of patients hospitalized for acute heart failure syndromes are dead 1 year after discharge [3]. Despite fairly successful implementation of heart failure performance metrics in recent years, there has been no significant improvement in these outcomes [5]. It has become clear that our current state-of-the-art care of patients with heart failure exacerbation is not sufficient. Many patients with heart failure have co-existing heart rhythm disorders. Few systematic evaluations of electrophysiology diagnostics and therapeutics have been performed in patients in the acute heart failure setting. As arrhythmias can be precipitants of heart failure exacerbations or contribute directly to mortality, optimizing management may provide a significant opportunity to improve outcomes. This issue of Heart Failure Reviews contains seven articles that focus on select topics dealing with how tools available in the management of heart rhythm disorders may potentially be applied to patients hospitalized for or recently discharged from a hospitalization for heart failure. Many patients who present with worsening heart failure already have an implanted device with pacing functionality. Marc Lahiri, Justin Mao, and Claudio Schuger discuss pacemaker parameters that may interact with heart failure status. They specifically focus on the issues of right ventricular pacing burden, atrioventricular timing, and interventricular timing. Theoretically, adjusting these parameters in the decompensated patient may be of benefit. They propose two algorithms to assess pacing parameters in patients who present with heart failure, with and without atrial fibrillation. Many patients with heart failure and reduced left ventricular ejection fraction (LVEF) have an implantable cardioverter-defibrillator (ICD). Arrhythmias that often accompany heart failure deterioration may lead to appropriate and/or inappropriate ICD shocks. Although potentially life-saving in cases of ventricular arrhythmias, these shocks are often extremely painful. Jason Bradfield, Roderick Tung, Noel Boyle, and Kalyanam Shivkumar explore the management of ICD shocks with an emphasis on medical therapy, ICD programming, and catheter ablation. Despite the prevalence of atrial fibrillation and heart failure, there are little data to direct the management of patients who present with both conditions [6, 7]. Pacemaker implantation with catheter ablation of the atrioventricular junction represents the ultimate treatment for patients with medically refractory rapid ventricular rates. It is highly effective, but is both invasive and permanent. Jason Rubenstein and James Roth provide an in-depth discussion of the potential benefits and risks of this therapy in acute heart failure patients. N. C. Wang Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA