[Management of arrhythmias in patients with heart failure]

Cardiac failure is a common cause of arrhythmia. Many factors predispose to the genesis of arrhythmias in these patients. A number of non-invasive methods allow stratification of the risk of arrhythmia in cardiac failure. Approximately half the deaths of these patients are due to arrhythmia. Unfortunately, most of the investigations for risk evaluation have a high negative predictive value but a lower positive predictive value. The treatment of supraventricular arrhythmias, mainly atrial fibrillation, is complex in cardiac failure. Class I antiarrhythmics are contraindicated. The only remaining options are Class II, especially Sotalol, and Class III drugs, especially Amiodarone. In some cases, non-pharmacological methods such as ablation, pacing or an implantable atrial defibrillator must be considered. The treatment of ventricular arrhythmias is also difficult. In this indication, Class I antiarrhythmic agents must also be avoided. Non-sustained ventricular tachycardia may be treated by betablockers or amiodarone. The use of an implantable defibrillator is increasingly recommended after the results of several controlled large scale trials. The indication is obvious in patients resuscitated from sudden death and these devices are also beneficial in sustained ventricular tachycardia in patients with cardiac failure. Many studies are currently under way to determine the value of this therapeutic modality in indications now considered to be "prophylactic".