DIEN D A N Y HOC
Chuyen de trong thang
CAP NHAT VE CHAN DOAN VA DIEU TRI RUNG N H I
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Updating on Management of Atrial Fibrillation
Pham Qudc Khanh'*
Rung nhl la mdt tiong nhiing rdi loan nhjp tim thudng gap nhat trong cdng ddng va thudng gay ra nhiing bien chimg nang ne lam benh nhan (BN) cd the tu vong hoac tan phe sudt ddi. Rung nh! cd the la nguyen nhan gay ra khoang 5% eac trudng hgp dot quy mdi nam. BN suy rim ed kem theo rung nbi ri le tir vong tang bon den 34%. Ti le rung nhi tang dan theo tudi, tmng binh ti le mdi mac rung nhi khoang 0,1% mdi nam d ngudi dudi 40 mdi nhung tang len tdi 1,5 - 2% d ngudi tren 80 tudi.
I. C H A N DOAN XAC DINH RUNG NHI Dua vao dien tam do thudng quy 12 chuyen dao.
- Sdng P bien mat dupe thay the bdi nhimg sdng lan tan gpi la sdng f (fibrillation)
- Sdng fed dac diem:
+ Tan sd nhanh cham khdng deu tir 350 - dOOek/phut.
+ Cae sdng f rat khac nhau ve hinh dang, bien dp, thdi gian.
+ Thay rd sdng f d cae chuyen dao trude tim phai (VI, V3R) va eac chuyen dao dudi (D2, D3, aVF), cdn cae chuyen dao trude tim trai (Dl, aVL, V5, V6) thudng khd thdy.
- Nhip that rat khdng deu: bieu hien bang cac khoang RR dai ngan khac nhau, khdng theo quy luat nao ea. Dd la binh anh loan nhip hoan toan.
- Tan sd that nhanh hay cham phu thupc vao dan truyen cua mil nhi that.
- Hinh dang QRS ndi chung thudng hep, nhung
* lien Tim nuuh Vici .\cim
tren ciing 1 chuyen dao ed the cd khac nhau ehiit it ve bien dp, thai gian, ...
- Phan biet rung nhi vdi cudng nh! dien hinh, tan sd sdng F tir 240 den 320ek/pbiit. Ngoai ra, cdn can phan biet vdi nhip nhanh nh! da d ludn ed sdng P' di trude QRS.
II. PHAN LOAI RUNG N H I
Dua vao lam sang tien trien cua rung nhi chia eac the lam sang:
- Con rung nh! kich phat: rung nhT keo dai < 7 ngay, tu het con rung nhi.
- Rung nhl ben bi: rung nbi keo dai >7 ngay, phai dimg eac bien phap chuyen nhip can thiep mdi ed the cat dupe rung nhl.
- Rung nhl man tinh: keo dai ban 1 nam va khdng the cd gang chuyen nhip dugc bang cac bien phap can thiep.
III. LAM SANG RUNG NHI
- Thdi diem xuat hien trieu chimg dau tien (cd the la ngay khdi phat rung nbi) nhu: hdi hop danh trdng nguc, choang vang, dau nguc, ...
- Nhip tim khdng deu liic nhanh liic cham, tieng tim liic manh, liic yeu khoang each khac nhau giQa cac chu ki (loan nhip hoan toan).
- Phat hien eac trieu chimg ciia benh rim thuc tdn nhu: benh van tim, benh maeh vanh, benh tim bam sinh,...
IV. CHIEN LLTQC D I E U TRI RUNG N H I
1. Nguyen tac dieu trj
- Kiem soat tan sd that,chuyen rung nhi ve nhip xoang, du phdng huyet khdi.
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- Muc dich ciia didu tri la lam cai thien tiieu chiing, phdng chdng dot quy, giam thdi gian va sd lan dieu tri tai benh vien.
- Mpt sd nguyen nhan gay con rung nhi chi can didu tri khdi nguyen nhan ma khdng can phai dieu tri rung nhT lau dai nhu: viem eo tim,...
- BN rung nhT khdng dung nap khi da dieu tri tdi uu can dupe tu van hd trp cua cac chuyen gia ve dien sinh ly hpc tim de cd bien phap can thiep tich cue hon.
2. Kiem scat tan so that
- Kiem soat tan sd that trong mng nhT lam cai thien trieu ehiing lam sang va phdng nguy co suy tim do nhip tim qua nhanh.
- Tat ea eac BN ed chien luge chuyen ve nhip xoang eiing can dugc kiem soat tan sd that trude.
- Kiem soat nhip that trong con cudng nhT thudng khd khan hon trong rung nhT.
- Kiem soat nhip that can dn djnh trong khi nghi ngoi va ca khi gang sire.
- Khdng cd cdng thirc tieu chuan cho viec dung thude kiem soat tan sd that ma phu thude vao tinh trang lam sang eiia BN.
- Kiem soat tan sd that ciing phu thupc vao tudi BN, nhung thdng thudng dam bao khoang 60 - 80ck/p khi nghi ngoi va 90 - 115ck/p khi gang sue.
- Tat ca cac thude tac ddng lam giam kha nang dan truyen qua niit nhT that dugc su dung de kiem soat tan sd that:
+ Chen Beta giao cam, cben kenh canxi (nondihydropyridine), Digoxin.
+ Chen Beta giao cam la thude cd hieu qua nhit trong kiem soat tan sd that.
+ Digoxin cd the uu tien dung cho BN ed suy tim.
+ Cd the phdi hgp thude: eben Beta giao cam vdi ehen kenh canxi hoac digoxin khi eSn thidt trong kiem soat tan sd that.
+ Tuy thude tinh trang lam sang de lua chpn
thude va lidu lugng thich hgp tianh gay nhip that dap ling qua cham.
+ BN suy tim cd phan sd tdng mau <35%. Cdn phai bet sire than trpng khi diing ehen Beta giao cam va cben kenh canxi.
+ Mot sd thude khae sir dung de duy tii nhjp xoang nhu sotalol, dronedarone, amiodarone, ed thd diing trong mot sd trudng hgp kiem soat dap irng tan sd that.
+ Rung nhT tren BN ed hdi chiing Wolif- Parkinson-White chdng chi djnh diing Digoxin va cben kenh canxi de kiem soat nhjp that.
- Triet dot nut nhT that:
+ Triet ddt nut nhT that va cay may tao nhjp tim vTnb vien ebo nhimg BN cd nhip that dap ling qua nhanh, mac dii da dieu tn bang thude tdi uu.
+ Tao nhjp ddng bd co rim CRT (Cardiac resynebronization therapy) cd hieu qua cai thien huyet ddng d benh nhan rung nhT da duge triet ddt niit nhT that.
3. Chuyen rung nhi ve nhjp xoang - Nguyen tac chuyen nhip:
+ Cd the chuyen nhjp bang thude hay sde dien.
+ Soc dien ddng bd true tiep cd hieu qua ban chuyen nhjp bang thude don thuan.
+ Han ehe eiia sde dien ddng bd la can phai cd gay me.
+ Han che ldn nhat khi ehuyen nhip bang thude la ed nguy co bj xoan dinh do tac dung phu cua cac thude chdng loan nhjp.
+ Nguy CO huyet khdi khdng cd sir khac nhau giira ehuyen nhip bang thude va bang sde dien.
- Sde dien chuyen nhip true tiep:
+ Sde dien ddng bp nhan cam sdng R.
+ Nen sir dung may soc dien 2 pha (biphasic).
+ Sde dien cap ciiu trong trudng hgp nhjp that dap ling qua nhanh khdng kiem soat dugc bang thude, buydt ddng khdng dn dinh, benh tim thieu mau cue bp, riit huydt ap, suy rim, rung nhT d BN cd hdi chimg Wolf-Parkinson-White.
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+ Trong trudng hgp rung nhT tai phat ngay sau sde dien, ed thd sde dien lin tidp theo ngay ket hgp diing thuoc chdng rdi loan nhip.
+ Lidu sde dien didu tri rung nhT nen bat dau tir 150J.
-I- Chdng chi dinh sde dien tren BN mng nhT cd ngd ddc Digoxin, hoac giam Kali mau hoac benh nhan cd hdi chimg nhip nhanh, nhip cham (hpi chimg suy niit xoang).
- Chuyen nhip bang thude:
+ Ibutilide, Flecainide, Dofetilide, Propafenone la cae thude duge lua chpn bang dau ed hieu qua cao trong chuyen rung nhT ve nhip xoang.
+ Amiodarone truyen tinh mach cd the sir dung de chuyen rung nhT ve nhip xoang tuy nhien ti le thanh cdng khdng cao.
+ Cd hieu qua ehuyen nhip tdt hon d BN cudng nhT so vdi rung nhT.
+ Cd the su dung de ket hgp vdi soc dien chuyen nhjp tang ti le thanh cdng.
+ Cd the ket hgp Magne tinh mach trude khi diing thude chdng rdi loan nhip de ban che nguy co xoan dinh.
+ Theo ddi dien tam do lien tuc it nhat 4 gid sau khi chuyen nhip.
4. Duy tri nhjp xoang
- Nguyen tac diing thuoc chdng rdi loan nhip:
-I- Chi djnh cho BN ed trieu chimg lien quan den con rung nhT hoac rung nhT ben bi tai phat sau chuyen nhip cdn dung nap tdt vdi thuoc chdng rdi loan nhip va duy tri dupe nhip xoang.
+ Lira chpn thude phu thupc vao benh tim thuc tdn, miie dp suy tim va can nhac tac dung phii cua thude.
-I- Lira chpn thude ciing edn phu thupc vao chirc nang gan, than.
+ Thuoc duy tri nhip xoang lam ban che tan suat, thdi gian rung nhT, cai thien trieu chimg. Do vay, ndu rung nhT tai phat trong khi dang dimg thude
rdi loan nhip thi eiing chua phai dieu tri that bai va khdng can phai thay ddi thude chdng rdi loan nhip.
+ Khdng diing thude neu khdng cai thien duge trieu chimg hoac ed nhieu tac dung phu.
+ Bdi phu du tinh tiang dien giai dd va thuoc chdng ddng (theo thang diem CHADS2) trude khi diing thude chdng rdi loan nhip.
+ Khdng dimg thude khi cd Bloc nhT that, suy niit xoang benh li.
+ Nen khdi dau bang lieu thap va cd the tang dan lieu theo danh gia hieu qua cua thude.
- Thude chdng rdi loan nhip thudng dung duy tri nhip xoang:
-H Flecainide/Propafenone: nhdm IC cd tac dung lam giam van toe dan tmyen do ire che kenh natri.
Chdng ehi dinh d BN thieu mau eo tim, suy tim nang.
- Sotalol: thude ehen beta khdng chpn Ipc thude nhdm 111 ed tac dung keo dai thdi gian tai cue. Khdng ed tac dung chuyen rung nhT ve nhjp xoang nhung dupe sir dung du phdng rung nhT tai phat. Chdng chi dinh d BN COPD (Chronic Obstructive Pulmonary Disease) ben phe quan, suy tim nang, suy than hoac QT keo dai.
- Dofetilide. la thude thupc nhdm 111, cd tac dung keo dai thdi gian tai cue do iic che nhanh kenh Kali. Cd hieu qua duy tri nhip xoang, ban che nguy CO xoan dinh. Can than trpng khi su dung Dofetilide d BN suy than, cd QT keo dai.
- Amiodarone. la thuoc ed hieu qua nhat trong duy tri nhip xoang, tuy nhien cd nhieu tac dung phu ciing nhu dpc tinh nen chi la lua chpn thir hai hoac lua chpn sau eiing khi cac thude khac khdng cd tac dung.
Amiodarone thich hgp diing trong cac trudng hgp cd day that trai, suy tim, hay benh ddng mach vanh. BN sir dung amiodarone can dugc theo ddi dinh ky chirc nang tuyen giap, chire nang gan va ehire nang hd hap.
Sir dung lieu thap (< 200mg/ngay) cd it tac dung phu va dpc tinh hon khi dimg lieu cao.
- Dronedarone. tuong tu nhu amiodarone nhung khdng gay dpc vdi gan, than. Dronedarone dugc chi
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Chuyen de trong thang
djnh de giam nguy co nhap vien cho BN cd eon mng nhT hoac mng nhT ben bi, BN cd nhieu yeu td nguy ca tim mach, hoac diing chuyen nhip cho BN. Chdng chi dinh trong tmdng hgp: Suy tim nang, NYHAIV.
5. Dieu trj rung nhT bang triet ddt qua catheter - Dua vao co che tinh maeh phdi la vi tri quan trpng khdi phat va tao rat nhieu vdng vao lai nhd d BN mng nhT.
- Cd lap dien hpc giira tTnh mach phdi va nhT trai bang nang lugng sdng radio loai trir dugc rung nhT d mdt sd BN.
- Triet ddt bang catheter la phuong phap cd hieu qua va la lua chpn cho BN mng nhT cd tiieu chimg dieu tri ndi khoa that bai.
- Dac biet d BN tre mdi triet ddt bang catheter ed igi ieh hon la dieu tri bang thude keo dai nhieu nam.
- Ti le thanh cdng tir 40 - 90% vdi ehi 1 lan tiiet ddt, neu BN tai phat rung nhT cd the tiep tue tien hanh triet ddt nhieu lan tiep theo.
- BN cd con mng nhT \ di chirc nang tim edn tdt ed ti le thanh cdng cao hem rd ret so vdi BN rung nhT ben bi, man tinh vdi nhT Uai gian to.
- Ti le bien chung cua phuong phap nay la 2-12%. Nhirng bien chimg bao gdm: tran dich mang tim, ep tim cap, bien chimg mach mau, hep tinh mach phdi, dot quy, dd nhT trai thuc quan, tdn thuong than kinh hoanh, tdn thuong \ an hai la.
- Tl le nr vong thdp < 0.1%.
- Nhip nhanh nhT cd the xuat hien sdm trong 2 thang dau tien sau khi cd lap tinh mach phdi. Cd the su dung thude dieu tri rdi loan nhip hoac triet ddt bang catheter neu nhjp nhanh nhT ben bi.
- BN dugc chi dinh diing thude khang Vitamin K nhu sintroni, wafarin it nhat 2 thang sau khi triet ddt. Dieu tii thude chdng ddng keo dai trong tmdng hgp BN ed didm CHADS2 > 1.
- Huyet khdi trong nhT trai la chdng chi djnh dime catheter triet ddt.
- Triet dot bang catheter viing eo \ dng van ba la la lira chpn bang diu trong didu tri cudng nhi dien hinh.
6. Phau thuat dieu trj rung nhT
- Phau thuat cd lap nhT trai (Maze) thudng dupe ehi djnh ket hgp vdi cac phau thuat tim khac nhu md bac cau chu vanh, thay van tim, md sira chOra Uong benh tim bam sinh.... Phau thuat se tao cac dudng cat cd lap timg viing ca nhT, tieu nhT va cac tinh mach phdi nhung van bao tdn dugc chirc nang dan truyen Uong nhT, nhd vay ngan chan dugc su hinh thanh cae vdng vao lai gay mng nhT.
7. Dy phong huyet khdi phdng chong dot quy - Thude chdng ddng du phdng huyet khdi dugc ehl dinh diing cho tat ca BN rung nhT trir duy nhat trudng hgp rung nhT don ddc d BN dudi 60 tudi (khdng cd benh ly tim mach thirc the kem theo) hoac cd chdng ehi dinh dimg thude chdng ddng mau.
- Aspirin va elopidogrel khdng thay the dugc cho thude khang Vitamin K nhu: warfarin, sintrom.
Aspirin phdi hgp vdi elopidogrel cd hieu qua hon la diing aspirin don ddc phdng chdng dot quy d BN cd nguy eo cao kem theo chdng chi dinh diing thude khang Vitamin K nhung nguy co chay mau ciing tang cao hon so vdi diing aspirin don ddc.
- BN mng nhT khdng cd van co hpc cd the dimg thude chdng ddng 1 man tmdc phau thuat ldn cd nguy CO chay mau ma khdng can thay the bang Heparin.
- BN mng nhT cd benh co tim phi dai, hep van hai la hoac van co bpc phai duge dieu tri bang thude khang Vitamin K nhu: warfarin hoac sintrom.
- Thang diem CHADS2 dugc diing de danh gia tien lugng dot quy d BN rung nhT khdng cd benh van tim. Vdi diem CHADS2 la 0 thi nguy co dot quy la 1.9%. Ndu diem la 6 thi nguy co dot quy la 18,2%.
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8. Dieu trj thude chdng dong khi chuyen nhjp - Tdt ca BN mng nhT > 48 gid hoac khdng biet mng nhT tir khi nao phai didu tri warfarin 3 tuan vdi INR > 2,0 tmdc khi ehuydn nhip.
- Sieu am tim qua thuc quan danh gia huyet khdi nhT trai ed the thay thd cho 3 tuan dieu tri warfarin nhung BN van phai tidp tue dupe dieu tri warfarin hoac heparin trong thdi gian chuyen nhip.
- Trong trudng hgp chuyen nhip cap cim phai diing Heparin dudng tinh maeh duy tri aPTT tu 1,5 den 2 lan nhdm chiing va dieu tii tiep theo bang thude khang Vitamin K.
- Warfarin hoac sintrom dugc tiep tuc dieu trj sau chuyen nhip it nhat 4 tuan. Sau dd dua vao tbang diem CHADS2 de quyet dinh tiep tuc diing warfarin hay khdng.
TAI LIEU THAM KHAO
/, ACC/AHA/ESC guidelines for the Management of Patients with Atrial Fibrillation.
A report of the American College of Cardiology/
American Heart Association Task force on practice guidelines and the European Society of Cardiology Committee for Practice guidelines (Writing Committee to revise the 2001 Guidelines for the
Management of Patients with Atrial fibrillation).
Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
2. Practical Rate and Rhythm Management of Atrial Fibrillation update Januaiy 2010 (adapted from ACC/AHA/ESC 2006 guidelines for Management of Patients with Atrial Fibrillation).
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