Xử trí rung nhĩ trên 48 giờ

• Rung nhĩ gây rối loạn huyết động • Khó kiểm soát tần số thất • Trẻ tuổi • Bệnh cơ tim do nhịp nhanh • Cơn rung nhĩ đầu tiên • Rung nhĩ do 1 bệnh lý cấp tính thúc đẩy • Chọn lựa c

XỬ TRÍ RUNG NHĨ TRÊN 48 GiỜ:

AI NÊN CHUYỂN NHỊP?

KHI NÀO? NHƯ THẾ NÀO?

BS BÙI THẾ DŨNG

BV ĐẠI HỌC Y DƯỢC TP HCM

PHÂN LOẠI RUNG NHĨ

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

ĐIỀU TRỊ RUNG NHĨ

KIỂM SOÁT TẦN SỐ

KIỂM SOÁT NHỊP

NGỪA HUYẾT KHỐI

ĐIỀU TRỊ BỆNH LIÊN QUAN

Rate vs Rhythm Control Trials for AF

Heist et al Rate Control in Atrial Fibrillation: Targets, Methods, Resynchronization Considerations Circulation 2011;124:2746-2755

CHUYỂN NHỊP RUNG NHĨ > 48H

1 Tại sao cần kiểm soát nhịp

2 Đối tượng cần kiểm soát nhịp

3 Chuẩn bị bệnh nhân cần chuyển nhịp

4 Các phương thức kiểm soát nhịp

• Shock điện

• Thuốc

• Cắt đốt qua catheter

LỢI ÍCH CHUYỂN NHỊP RUNG NHĨ

• Cải thiện triệu chứng, tăng khả năng gắng sức

• Cải thiện chất lượng sống

• Giảm nguy cơ đột quỵ

• Tránh tai biến do dùng thuốc kháng đông kéo dài

European Heart Journal (2010) 31, 2369-2429

AI CẦN CHUYỂN NHỊP?

• Rung nhĩ gây rối loạn huyết động

• Khó kiểm soát tần số thất

• Trẻ tuổi

• Bệnh cơ tim do nhịp nhanh

• Cơn rung nhĩ đầu tiên

• Rung nhĩ do 1 bệnh lý cấp tính thúc đẩy

• Chọn lựa của bệnh nhân

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

Canadian Journal of Cardiology 2014 30, 1114-1130

→ Đối với rung nhĩ ≥ 48h hoặc không rõ thời gian

khởi phát, cần dùng kháng đông uống (warfarin/ NOACs) trước chuyển nhịp ≥ 3 tuần [4]

1 Boston Area Anticoagulation Trial for AF Investigators The effect of low dose warfarin on the risk of

stroke in patients with nonrheumatic AF N Engl J Med 1990;323:1505–11

2 Bjerkelund C The efficacy of anticoagulant therapy in preventing embolism related to DC electrical

cardioversion of atrial fibrillation Am J Cardiol 1969;23:208–16

3 Weigner WJ Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with AFlasting less than 48 hours Ann Intern Med 1997;126:615–20

4 2014 AHA/ACC/HRS Atrial Fibrillation Guideline

DỰ PHÒNG HUYẾT KHỐI LẤP MẠCH

• TEE có thể thay thế cho việc dùng kháng đông

3 tuần trước chuyển nhịp

• Kháng đông nên được dùng càng sớm càng tốt nếu cần chuyển nhịp cấp cứu

• Dùng kháng đông đường uống ≥ 4 tuần sau

chuyển nhịp, bất kể điểm CHADS-VAS

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

Prevention of Thromboembolism

Recommendations COR LOE

For patients with AF or atrial flutter of 48 hours’ duration or longer, or

when the duration of AF is unknown, anticoagulation with warfarin (INR

2.0 to 3.0) is recommended for at least 3 weeks before and 4 weeks after

cardioversion, regardless of the CHA2DS2-VASc score and the method

(electrical or pharmacological) used to restore sinus rhythm

I B

For patients with AF or atrial flutter of more than 48 hours’ duration or

unknown duration that requires immediate cardioversion for

hemodynamic instability, anticoagulation should be initiated as soon as

possible and continued for at least 4 weeks after cardioversion unless

contraindicated

I C

For patients with AF or atrial flutter of less than 48 hours’ duration and

with high risk of stroke, intravenous heparin or LMWH, or

administration of a factor Xa or direct thrombin inhibitor, is

recommended as soon as possible before or immediately after

cardioversion, followed by long-term anticoagulation therapy

I C

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

Prevention of Thromboembolism (cont’d)

Following cardioversion for AF of any duration, the decision

about long-term anticoagulation therapy should be based on the

thromboembolic risk profile

I C

For patients with AF or atrial flutter of 48 hours’ duration or

longer or of unknown duration who have not been anticoagulated

for the preceding 3 weeks, it is reasonable to perform TEE before

cardioversion and proceed with cardioversion if no LA thrombus

is identified, including in the LAA, provided that anticoagulation

is achieved before TEE and maintained after cardioversion for at

least 4 weeks

IIa B

For patients with AF or atrial flutter of 48 hours’ duration or

longer or when duration of AF is unknown, anticoagulation with

dabigatran, rivaroxaban, or apixaban is reasonable for at least 3

weeks before and 4 weeks after cardioversion

IIa C

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

Kháng đông trước – sau chuyển nhịp

Canadian Journal of Cardiology 2014 30, 1114-1130

Direct-Current Cardioversion

In pursuing a rhythm-control strategy, cardioversion is

recommended for patients with AF or atrial flutter as a method to

restore sinus rhythm If cardioversion is unsuccessful, repeated

attempts at direct-current cardioversion may be made after

adjusting the location of the electrodes, applying pressure over the

electrodes or following administration of an antiarrhythmic

medication

I B

Cardioversion is recommended when a rapid ventricular response

to AF or atrial flutter does not respond promptly to

pharmacological therapies and contributes to ongoing myocardial

ischemia, hypotension, or HF

I C

Cardioversion is recommended for patients with AF or atrial

flutter and pre-excitation when tachycardia is associated with

hemodynamic instability

I C

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

Pharmacological Cardioversion

Flecainide, dofetilide, propafenone, and intravenous ibutilide are

useful for pharmacological cardioversion of AF or atrial flutter,

provided contraindications to the selected drug are absent I A

Administration of oral amiodarone is a reasonable option for

pharmacological cardioversion of AF IIa A Propafenone or flecainide (“pill-in-the-pocket”) in addition to a

beta blocker or nondihydropyridine calcium channel antagonist is

reasonable to terminate AF outside the hospital once this

treatment has been observed to be safe in a monitored setting for

selected patients

IIa B

Dofetilide therapy should not be initiated out of hospital because

of the risk of excessive QT prolongation that can cause torsades

Antiarrhythmic Drugs to Maintain Sinus Rhythm

Before initiating antiarrhythmic drug therapy, treatment of

precipitating or reversible causes of AF is recommended I C The following antiarrhythmic drugs are recommended in patients

with AF to maintain sinus rhythm, depending on underlying heart

disease and comorbidities:

The risks of the antiarrhythmic drug, including proarrhythmia,

should be considered before initiating therapy with each drug I C

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

Antiarrhythmic Drugs to Maintain Sinus Rhythm

(cont’d)

Because of its potential toxicities, amiodarone should only be

used after consideration of risks and when other agents have failed

or are contraindicated

I C

A rhythm-control strategy with pharmacological therapy can be

useful in patients with AF for the treatment of

tachycardia-induced cardiomyopathy

IIa C

It may be reasonable to continue current antiarrhythmic drug

therapy in the setting of infrequent, well-tolerated recurrences of

AF when the drug has reduced the frequency or symptoms of AF IIb C

Antiarrhythmic drugs for rhythm control should not be continued

when AF becomes permanent,… III:

Upstream Therapy

An ACE inhibitor or angiotensin-receptor blocker is reasonable

for primary prevention of new-onset AF in patients with HF with

reduced LVEF

IIa B

Therapy with an ACE inhibitor or ARB may be considered for

primary prevention of new-onset AF in the setting of

hypertension

IIb B

Statin therapy may be reasonable for primary prevention of

new-onset AF after coronary artery surgery IIb A Therapy with an ACE inhibitor, ARB, or statin is not beneficial

for primary prevention of AF in patients without cardiovascular

disease

III: No Benefit B

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

Fisher JD, et al PACE 2006;29: 523

Cắt đốt qua catheter: phân tích gộp

Cure (by each author’s criteria) means no further AFib 6 months after the procedure in the absence of

AAD

OK means improvement (fewer episodes, no episodes with previously ineffective AAD)

SHD indicates structural heart disease

19

Bệnh nhân không còn rung nhĩ sau cắt

84%

79% 78% 61%

47%

37%

P < 0,001

20

Cải thiện sống còn bằng cắt đốt so với thuốc

Pappone C, et al J Am Coll Cardiol 2003 Jul 16;42(2):185-97

Ngày theo dõi Ngày theo dõi

582 điều trị thuốc

21

Cân nhắc Lợi ích-Nguy cơ cắt đốt

Canadian Journal of Cardiology 2014 30, 1114-1130

AF Catheter Ablation to Maintain Sinus Rhythm

AF catheter ablation is useful for symptomatic paroxysmal AF

refractory or intolerant to at least 1 class I or III antiarrhythmic

medication when a rhythm-control strategy is desired I A

Before consideration of AF catheter ablation, assessment of the

procedural risks and outcomes relevant to the individual patient is

recommended

I C

AF catheter ablation is reasonable for some patients with

symptomatic persistent AF refractory or intolerant to at least 1

class I or III antiarrhythmic medication

IIa A

In patients with recurrent symptomatic paroxysmal AF, catheter

ablation is a reasonable initial rhythm-control strategy before

therapeutic trials of antiarrhythmic drug therapy, after weighing

the risks and outcomes of drug and ablation therapy

IIa B

2014 AHA/ACC/HRS Atrial Fibrillation Guideline

Chiến lược kiểm soát nhịp trong rung nhĩ

Dofetilide Dronedarone Sotalol

để giảm thiểu biến cố lấp mạch

• Shock điện là phương tiện chuyển nhịp tức thời hiệu quả nhất

• Cắt đốt so với thuốc: hiệu quả tức thời và lâu dài cao hơn, cải thiện tỷ lệ sống còn tốt hơn