Rung nhĩ trong suy tim có gì khác với nhịp xoang

Priorities of management with HF and AF HF priorities AF priorities Prevent stroke Control heart rate Restore sinus Prevent and treat HF Manage bleeding Achive euvolaemia Amel

Điều trị suy tim khi nhịp xoang và khi

rung nhĩ: Có gì khác biệt?

TS BS Ph¹m Nh Hïng FACC, FHRS, FSCAI, FAsCC

Consultant of Cardiology and Electrophysiology

Director of Cath Lab and EP Lab

Hanoi Heart Hospital

VNCC 2016

Epidemics of Heart Failure

Tû lÖ m¾c hµng năm

Tæng sè bÖnh nh©n suy tim

Tû lÖ tö vong hµng năm

Mü

Ch©u ©u

Congestive heart failure worldwide markets, clinical status and product development opportunities New Medicine, Inc 1997:1-40

Wilkerson Group Survey, 1998

V-HeFT CHF-STAT DIAMOND

Rung nhĩ gây suy tim và suy tim gây rung nhĩ: một số cơ chế góp phần gây nên và duy tri giữa rung nhĩ và suy tim

Tạo ra sự không đồng nhất đờng dẫn truyền

Mất đồng bộ nhĩ thất

Dáp ứng thất nhanh

Tác dụng phụ của thuốc (Vd: thuốc chống loạn nhịp)

Biến đổi khoảng R-R

RN

ST

AmJ Cardio2003:91(suppl);2D – 8D

Priorities of management with HF and

AF

HF

priorities

AF priorities

Prevent stroke

Control heart rate

Restore sinus Prevent

and treat

HF

Manage bleeding

Achive

euvolaemia

Ameliorate RAAS disturbance

Heart rate control

ICD

&CRT

Transplant

Rate vs Rhymth control of Afib

Roy D et al N Engl J Med 2008: 358;25

AFFIRM trial

Rate vs Rhymth control of Afib

Roy D et al N Engl J Med 2008: 358;25

AF-CHF trial

Ph©n tÝch gép: Khi theo dâi thêi

gian kÐo dµi

JAMA 2012;172(13):997-1004

Rhymth control Strategy

Eur Heart J 2007;28:1351–1357

Cardioversion

Rhymth control Strategy

Eur Heart J 2007;28:1351–1357

Antiarrhythmic drugs

Rhymth control Strategy

M I Amin et al / World Journal of Cardiovascular Diseases 3 (2013) 49-57

AF ablation

Beta Blocker in HF

Kotecha D et al Lancet 2014;384:2235–2243

Different effects of beta-blockers between

HF patients with AF and sinus rhythm

 Comparable dosages of beta-blockers: achieved heart rate was not available and may have been different in AF and sinus rhythm

 For patients with permanent AF, it was recently demonstrated that stricter rate control was not superior to a lenient rate control

 Loss of the atrial kick and irregularity in ventricular response during

AF, patients with AF may need a higher heart rate to maintain a

similar cardiac output

 low heart rate in patients with AF may be an expression of an

underlying conduction disorder, which may be associated with

impaired outcome itself

 AF in patients with HF may be a marker of a poorer clinical condition leading to a worse outcome

Digoxin

NEJM 1997; 336: 525

Digoxin

NEJM 1997; 336: 525

Heart rate targets for sinus Rhythm

Lancet 2010;376:886-894

Heart rate targets for atrial fibrillation

Heart rate targets for atrial fibrillation in

heart failure

N Engl J Med 2010;362:1363–1373

RACE II trial

Anticoagulation in Sinus Rhythm

[1] Lancet 2014;383: 955–962; [2] N Engl J Med 2013; 369:2093–2104

Anticoagulation in Sinus Rhythm

[1] Lancet 2014;383: 955–962; [2] N Engl J Med 2013; 369:2093–2104

Anticoagulation in Afib

 Anticoagulation with vitamin K antagonists (VKA; e.g warfarin) or

non-VKA anticoagulants (NOACs) prevent 2/3 of ischaemic strokes in

AF patients [1]

 Although no trials have investigated this specific population, indirect sub-group data from the NOAC RCTs suggest the effect of

anticoagulation for AF is similar in patients with concomitant HF [2]

 With the combination of higher stroke risk and effective therapy,

anticoagulation is essential in all patients with HF and AF that do not have an absolute contraindication,

 The NOACs are particularly attractive due to lower rates of

intracranial haemorrhage compared to VKA therapy

[1] Lancet 2014;383: 955–962; [2] N Engl J Med 2013; 369:2093–2104

673 bn CRT

162 cã rung nhÜ m¹n tÝnh T¹o nhÞp BiV <85% AVN

JACC 2013;500:7

Conclusion

 AF is high risk for patients with HF

 We need the advance therapy for HF with AF

 Due to the poor outcomes observed in patients with HF and

AF, perhaps the best treatment strategy is to prevent AF from occurring in the first place