dgu voi phurc

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Khao sat dac diem lam sang cua benh nhan co nhip nhanh dgu voi phurc bo QRS rong

To Survey the Clinical Features of tlie Regular Wide QRS Complex Tachycardia

Le Ngoc Long*, Benh vien Ddu Tiing Pham Nguyen Sffn** y^^^ f/^ ^^^^ - Benh vien Tl/QD 108

Tom t a t :

IViuc dich nghien cdu: khcio sat dac diem lam sang cCia nhjp nhanh deu phCrc bg QRS rpng. Doi tUOng va phuong phap nghien cu'u. nghien ctru 81 benh nhan co nhip nhanh deu phurc bp QRS rong tuoi tir 13 den 70 (trung binh 37,8 ± 15,3) trong do nam: 49, nQ: 32, di/oc tham do dien smh ly tai Benh vien Tam DOrc, Benh vien Thong Nhat, Benh vien Dai hpc Y Duac - Thanh pho Ho Chi Mmh {\is thang 3 nam 2007 den thang 8 nam 2010), Ket qud; Co 61 benh nhan nhjp nhanh that, 10 benh nhan nhip nhanh tren that dan truyen lac hucfng, 10 b^nh nhan nhip nhanh v6ng vao lai nhi that nguoc chieu, Tuoi trung binh cua nhip nhanh that {36,2 + 15,2}, nhjp nhanh tren th^t dan truyen lac hudng (38,3 + 7,7), nhjp nhanh vong vao lai nhi that ngUoc chieu {45,4 ± 18,6), Gidi tinh: nhip nhanh that (nam: 57%), nhip nhanh tren that dan truyen lac hu6ng (nam: 70%), nhip nhanh vong vao lai nhi that ngUOc chieu nam gi6i chiem ty le (nam: 80%), Trieu chirng lam sang: hoi hop 86,5%, dau nguc 47%, kho t h d 33%, ngat 11 % va tut HA 11 %.

Ket ludn: Chung ta khong the sd dung tuoi, gidi tinh, lam sang, tien sir benh tim mach de chan doan phan biet benh nhan co nhip nhanh deu phCrc bo QRS rong.

Ti^l<h6a: Nhip nhanh deu phiic bo QRS rpng.

Summary:

Objective: To survey the clinical features of the regular wide QRS complex tachycardia. Patients and methods: To study 81 patients with regular wide QRS complex tachycardia, from 13 to 70 years old (at the mean age of 37.8 ± 15.3), having enrolled m this study, of which 49 patients were men and 32 patients were women, who were performed electrophysiologic study at Tam Due Hospital, Thong Nhat Hospital, and the Hospital of University of Medicine and Pharmacy - Ho Chi Mmh City {from March 2007 to August 20101, Results: 61 were with ventricular tachycardias, 10 with supraventricular tachycardias with aberrancy and 10 with antidromic conduction. The average age of those with ventricular tachycardia was 36.2+15.2, of those with supraventricular tachycardia with aberrant intraventricular conduction was 38.3±7.7 and with antidromic conduction from 45,4+18 6 As for gender, 57% of those with entricular tachycardia were male; that of those with supraventricular tachycardia with aberrant intraventricular conduction was 70%, and antidromic conduction 80%, As for clinical symptoms, those

Ph4n bifn khoa h9c: PGS.TS VU DIEN BIEN

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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol9-N°2/2014

With palpitation took up 86.5%; chest pain 47%; dyspnea 33%; syncope 1 1 % ; and hypotension 1 1 % . Conclusion: We cannot use the age, gender, clinical manifestations and t h e history of cardiovascular disease for the differential diagnosis in the patients with regular wide QRS complex tachycardia.

Keywords: Regular wide QRS complex tachycardia.

1 . D a t van d e

Nhip nhanh deu phufc bo QRS rong la m p t cap cCru noi khoa hang dau t r o n g t h i i c hanh lam sang, d i f n g trade benh nhan nhip nhanh 6eu phisc bp QRS rpng la lam sao chan doan phan biet dupc nhip nhanh t h a t (NNT), nhip nhanh tren that dan truyen lac h u d n g (NNTTDTLH) hoac co QRS bat t h u d n g Xii trudc va nhjp nhanh v o n g vao lai nhi that ngUdc chieu (NNVLNTNC).

Mac d u CO nhieu ghi nhan cua cac tac gia {Wellens 1978, Wellens 1988, Brugada 1991, Verckei 2006, Ton That Minh...) cho thay tan suat mac benh thay doi theo tC/ng ICfa tuoi, gidi, tien can mac benh t i m mach cd the gap trirdc do (tang huyet ap, nhoi mau CO t i m , benh ly c o t i m gian nd...) cung nhOcac trieu chirng lam sang t h u d n g gap t r o n g nhjp nhanh that, nhjp nhanh v d n g vao lai nhi that ngUdc chieu, nhip nhanh tren that dan truyen lech h u d n g (Hoi hop, dau nguc, khd t h d , ngat, t u t HA...)[3,6,7] Nham t i m hieu cau hdi dac diem dac dan so hoc va dac d i e m lam sang lam sang cd phai la p h u o n g phap chan doan phan biet sdm nhip nhanh phUc bp QRS rdng, chung toi tien hanh khao sat benh nhan cd con nhjp nhanh deu phUc bp QRS rpng.

C h u n g t d i t i e n hanh n g h i e n cUu vdi muc t i e u sau: Khao sat dac d i e m dan so hoc va dac d i e m lam sang cua tUng loai n h i p nhanh d e u phtfc bp QRS r p n g .

2 . f ) 6 i t i / a n g , phUorng phap nghien cufu

2.1. Doi titang: 81 benh nhan nhip nhanh deu phUc bd QRS rdng da khao sat dien sinh ly tai Benh vien Tam OUc - Benh vien Thong Nhat - Benh vien Dai hpc Y dUdc Thanh pho Ho Chi Minh tU thang 3 nam 2007 den thang 8 nam 2010.

r/euchf/op/rrLT/c/id/mdu: N g u d i d a n g s U d y n g t h u o c c h o n g loan n h j p n h d m IC, n h d m III, b e n h

n h a n roi loan d i e n g i ^ i , b e n h an k h d n g day diJ dO lieu, n h o i m a u co t i m trUdc v a c h , t a o n h j p t h a t .

2.2. PhUffng phap nghien cdu

2.2.1. Thiet ke nghien cdu: Hoi CLfu, tien cufu, md ta cat ngang.

2.2.2. Cac tieu chuan sU dung trong nghien cuu - Nhip nhanh deu cd phUc b d QRS rdng: la nhjp nhanh co tan sd >lQ0lan/phLit, khoang RR deu va p h U c b p Q R S > 1 2 0 m s [ 1 ] [ 2 ] .

- Benh nhan thoa man dieu kien: Nhjp nhanh that, nhjp nhanh tren t h a t dan truyen lac hUdng hoac cd QRS bat t h u d n g tii trUdc, n h j p nhanh vdng vao lai n h l t h a t n g U p c chieu.

2.2.3. Cdc budc tien hanh Lap ho so nghien cUu

M o i b e n h n h a n t r o n g n g h i e n cUu deu dUdc ghi n h a n : Hp t e n - T u o i - Gidi - Sd b e n h an - Ngay can t h i e p .

Tien sCf b e n h : T a n g h u y e t a p , n h o i mau cd t i m , b e n h c d t i m gian n d , sCr d u n g t h u d c chong roi loan n h j p .

Trieu chUng c d nang t r o n g c d n n h j p nhanh: Hoi hop, khd t h d , dau nguc, ngat, t u t huyet ap.

Ket qua dien sinh ly: Nhjp nhanh that, nhip nhanh tren t h a t darl truyen lac h u d n g , nhjp nhanh v d n g vao lai nhi t h a t ngUdc chieu.

Ghi dien torn do: May ghi dien t i m Cardiolab v 6.5 cua GE Medical Systems t r o n g p h d n g tham do dien sinh ly cho p h e p ghi c u n g luc 12 chuyen dao be mat chay d toe d d 2 5 m m / s , bien d p l O m m / m V .

- Ghi dien t a m d o 12 dao t r i n h trudc t h a m dd dien sinh ly de xem h i n h dang cac sdng co ban.

- Ghi dien tam do 12 dao t r i n h t r o n g cdn nhjp nhanh de do dac cac bien sd nghien cUu.

- Ghi dien t a m d o qua cac dien cue t r o n g budng t i m t r o n g con nhip nhanh de lam bang chUng trong viec xac d j n h vj t r i loan nhip.

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Tap 9 - se 2 /2014

Dao ddc nghien cdu: Benh nhan dUOc giai thich tien t r i n h thUc hien t h u thuat, hieu qua va loi ich cua p h u o n g p h a p c u n g n h u cac yeu t d nguy co va bien chUng cd t h e gap t r o n g qua trinh thuc hien t h u thuat. Benh nhan ky giay cam ket d o n g y thuc hien tham d d va can thiep.

2.2.4. Xd ly so lieu nghien cdu

Nhap sd lieu bang phan m e m Excel 2007 t h d n g qua b^ng t h u thap sd lieu, phan tich sd lieu bSng phan m e m STATA10.0, m d ta bien dinh t i n h bang ty le %, m d tci bien d i n h lupng bang t r u n g binh ± d d lech chuan, kiem dinh m d i lien quan giUa cac bien dinh tfnh bang phep kiem Chi-Square (cd hieu chinh

theo Exact Fisher), so sanh bien dinh luong giUa 2 n h d m bang t test, su khac biet cd y nghia t h d n g ke khi p < 0,05.

3. Ket qua va ban luan

Nghien cUu 81 t r u d n g hdp nhjp nhanh deu phCfc bd QRS rpng (61 trUdng hgp nhanh that, 10 trUdng h o p nhip nhanh tren that dan truyen lac hudng, 10 t r u d n g hop nhip nhanh vao lai nhT that ngUdc chieu).

Dac diem chung (nhan trSc) cua nhdm nghien cUu

Bang 3 . 1 . Tuoi trung binh cua nhom nghien cu^u

Chan doan

Tudi trung binh (*)

Nhip nhanh tren that 41,85 ±14,36 Nhip nhanh tren that dan truyen lac hudng

38,3 + 7,7

Nhip nhanh vong vao lai nhi that

ngupc chieu 45,4+18,6

Nhip nhanh that

36,14± 15,21

Tuoi trung binh cua nhom nghien cUu

37,8 ±15,3 (*) Bien dupc trinh bay dUdi dgng trung binh va do lech chuan.

Tudi t r u n g binh cua n h d m nhip nhanh tren that Tudi trung binh cua n h d m nhip nhanh v d n g vao cao hdn n h d m nhip nhanh that khong cd su khac lai nhi that ngUOc chieu cao hon nhdm nhjp nhanh b i e t c d y nghia t h d n g ke (p = 0,13). tren that DTLH khdng cd sU khac biet cd y nghia

t h d n g ke{p=0,28).

Bang 3.2. So sanh t u o i t r u n g b i n h v d i cac n g h i e n ciifu khac

Tac gia va cong su

Isenhour (n=157) Chung toi {n-81)

Marrtin Eisenberger (n-238) Vereckel2008 (n=483) Vereckei2006 (n=453)

NHIP NHANH THAT

6 1 , 6 ± 1 2 36,2 ±15,2

57 ± 1 7 58 ± 1 8

NHIP NHANH TREN THAT NNTTDTLH NNWLNTNC

51 ±21,7 41,85 ± 14,36 38,3 ± 7,7

45 ± 2 0 44 ± 2 0

45,4 ±18,6 37 ± 16 3 6 ± 17 3 5 ± 17

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Trong nghien cUu cua chung tdi t u d i t r u n g b i n h cua NNT la 36,2 ± 15,2, nhd t u d i nhat la 13, Idn t u o i nhat la 70, t h e o n g h i e n cUu cua Vereckei 2008 cho thay t u d i t r u n g binh cua NNT la 57±17 va Vereckei 2006 la 58+18, t h e o Isenhour t u o i t r u n g b i n h cua NNT la 61,6 ± 12 [5], [6], [7], [8]). NhU vay, t u d i t r u n g binh cua NNT t r o n g nghien cUu chung tdi so v d i cac nghien cUu khac thap hdn. Oieu nay cd t h e giai t h i c h

dUdc vi m l u n g h i e n cUu cua c h u n g t d i n h d , co cau benh co t h e k h o n g g i d n g vdi cac n g h i e n cufu khac.

Phan b d d p t u d i b e n h n h a n t h e o n h j p nhanh that, n h j p nhanh tren t h a t dan t r u y e n lac hudng, n h i p nhanh v d n g vao lai nhi t h a t ngUdc chieu.

T r o n g n h d m nhjp n h a n h that: t u o i tU 20-29 chiem t i le cao nhat 26%.

Trong n h d m nhjp nhanh tren that: t u d i tii 30 39 chiem t i l e 4 0 % .

< 20 20-: 5CW9 6 0 ^ 9 5 70 fi6tu(3i

Bieu do 3.1. Phan bo dp tuoi benh nhan theo nhjp nhanh thdt-nhjp nhanh tren thdt dan truyen lgc hUdng - nhip nhanh vong vao Igi nhi thdt ngiJcfc chieu

Tffeo khuyen cao cua ACC/AHA benh cd t h e gap d tre so sinh va hdn 90 t u d i , n h u vay nghien cUu ciJa chung tdi cung tUdng t u n h u t r o n g khuyen cao.

Benh nhan NNTTDTLH t r o n g nghien cUu cua chung tdi t h a p hdn cac nghien cUu cua cac tac gia khac, t u o i nhd nhat la 18, cao nhat la 5 1 , n h d m t u d i 30-39 chiem ty le cao nhat, t r o n g n h o m nhjp nhanh v d n g vao lai nhi*that ngugc chieu t u d i t r o n g nghien cUu chung tdi cao hdn t r o n g cac nghien cUu khac, tudi thap nhat la 16, cao nhat la 84, dieu nay giai thich la do mau cua chung tdi nhd, dp tudi chenh lech cao nen

tudi trung binh se cao. Mat khac do Viet Nam ife nUdc dang phat trien, phuong phap can thiep dien sinh ly la ky thuat cao, tuong ddi mdi d nUdc ta, chUa dugc ap dung rdng rai nen viec benh nhan lua chpn phUdng phap dieu tn nay phu thudc vao kha nang kinh te, sif hieu biet cua ngudi benh cijng n h u dieu kien cd sd vat chat, nhan luc cua benh vien ndi dd nen bien sd nay khdng gidng vdi cac nghien cUu cua cac tac gia khacvay tuoi tac khdng the la ggi y phan biet cac nhdm nhip nhanh that-nhip nhanh tren that dan truyen lac hudng- nhip nhanh vdng vao lai nhlthcit ngugc chieu.

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T i p 9 - S6 2 /2014

BSng 3,3. Phan bo nhip nhanh deu phuTc bo QRS rong t h e o g i d i Chan floan

Gidi Nam NCf Tong

NNT

34 (55,7%) 27 (44,3%) 61 (100%)

NNTT NNTTDTLH

7 (70,0%) 3 (30%) 10(100%)

NNWLNTNC 8 (80%) 2 (20%) 10(100%)

Trong mau NC ciiung, nam gi6i chiem uu t h e hon niJ gidi (60,5%), su khac biet khong co y nghia t h o n g k e ( p = 0,101).

Rieng n h o m nhjp nhanh that nam gidi chiem Uu the va t! le nO/nam = 0,8/1, sU khac biet khong co y nghia t h o n g ke.

Rieng n h d m nhjp nhanh tren that nam gidi chiem uu t h e va t i le nQ/nam = 0,33/1.

Bang 3,4, So sanh gidi vdi cac nghien c d u khac

Tac g i ^ va cpng su Isenhour (n=157) Chung toi (n=81) Vereckei 2008 (n=483) Vereckei 2006 (n=453) IVIartin Eisenberger (n=283)

NNT (Nam/Na%)

80/20 57/43 16/84 17/83

NNTT

NNTTDTLH (Nam/NU%) NNWLNTNC (Nam/NLr%) 76/24

75/25 70/30

44/56 44/56

80/20 35/65 31/69 79/21

Trong nghien cUu cCia chung t d i , ty le nam gidi cao hon nU gidi. Trong khi cac nghien cUu cua Vereckei cho thay nCf gidi gap cao hon nam gidi trong c i nhjp nhanh that - nhip nhanh tren that dan truyen lac hUdng - nhjp nhanh vao lai nhi that

nguoc chieu [6,7]. Theo tac gia Martin Eisenberger va cong su ty le nam/nCr la 1,08. Theo Isenhour ty le nam gidi cao han n d gidi t r o n g ca nhip nhanh tren t h a t lan nhjp nhanh t h a t [6].

3.3. Cac benh tim mach di kem

Bang 3.5. Cac b e n h t i m di k e m

Tien can

Tang huyet ap Nhoi mau CO tim Benh c o t i m gian n d Sddung thudc chdng rdi loan nhjp

Nh|p nhanh that

11(18%) 1(3,2%) 2(3,2%) 42(69%)

Nhip nhanh tren that NNWL NTNC

1 0 0 4(40%)

NNTTDTLH 1 0 0 4(40%)

Tdng

13 1 2 50

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Bang 3.6. So sanh tien can t i m mach cua nghien cuTu chung t o i vdi cac nghien cuTu khac Tacg

Tang HA

NMCT

Benh catim gian nd

a va cong su NNT%

NNTTDTLH % NNWLNTNC % NNT%

NNTTDTLH % NNWLNTNC %

Chung tdl 18 10 10 1.6

3,2

Vereckei 2008

61 4

15 1 0 Trong nghien cUu cua chung tdi cho thay t y le

benh nhan cd tien can t a n g HA t r o n g NNT chiem ty l e c a o n h a t 18%, cdn NMCT, benh CO t i m gian n d c h ; gap d benh nhan NNT t h a p hon nhieu so vdi cac

3.4, Cac trieu chdng lam sang di kem

nghien cUu khac. Dieu nay giai thich dUdc la do d TP.HCM chua trien khai t h a m d d cat d d t dien sinh ly cho nhQng benh nhan NNT do NMCT- Benh co tim gian n d .

Bieu do 3.2. Phan bo trieu chdng lam sang di kem NNT - NNTT

Hdi hop la trieu chUng t h u d n g gap nhat t r o n g ca nhip nhanh that va nhip nhanh tren that.

Trong 81 benh nhan nghien cUu, chung tdi nhan thay 81 benh nhan cd trieu chUng lam sang di kem chiem ty le 100%. Tneu chUng lam sang noi bat hau het benh nhan cd luc len cdn nhip nhanh la hdi h d p (86,5%) g i d n g n h u cac benh nhan cua cac tac gia Tdn That M i n h [ l ] , ngoai ra trieu chUng kha phd bien la dau ngUc (47%), khd t h d (33%). Hai trieu

chUng dang quan t a m nhat la ngat {11%) va t u t HA {11%). Trieu chUng ngat, t u t HA t h u d n g gap trong NNT, ket qua nay la p h u h o p vdi ghi nhan cua nhieu tac gia [3], [6], [7].

4. Ket luan

Tuoi t r u n g binh cua nhjp nhanh that-nhjp nhanh tren that dan truyen lac h u d n g - n h j p hhanh

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Tap 9 - S 6 2/2014

v d n g vao lai nhT that ngupc chieu lan luot la 36,2 ± 15,2; 38,3 ± 7,7; 45,4 ±18,6. Ve gidi t i n h : t r o n g nhjp nhanh t h a t - n h i p nhanh tren that dan truyen lac h u d n g - n h j p nhanh v d n g vao lai nhi that ngugc chieu thi nam gidi deu chieu Uu the theo t h U t u la 57%, 70%, 80%; ve trieu chUng lam sang hdi hop 86,5%, dau nguc 47%, khd t h d 33%, ngat 1 1 % va t u t HA 1 1 % . Cac benh ly di kem: tang HA la t h u d n g gap nhat.

Tai lieu t h a m khao

1, Tdn That Minh {2004). Khao sat dien sinh ly va cat dot bang nang lupng cd tan sd radio qua catheter de dieu tri nhjp nhanh kich phat tren that. NXB Dai Hoc Y duoc TP Hd Chi Minh.

2, Tran D6Trinh{1972).Dien tam do trong lam sang.

Nha xuat ban Y hpc Ha Noi.

3, Antunes, E., Brugada, J,, Steurer, G., Andries, E. &

Brugada, P (1994). The dilTerential diagnosis of a regular, tachycardia with a wide QRS complex on the 12-lead ECG: ventricular tachycardia, supraventricular tachycardia with aberrant intraventricular conduction, and supraventricular tachycardia with anterograde conduction over an accessory pathway. Pacing Clin Electrophysiol,

17(9), 1515-1524. tachycardia, Zhonghua Xin Xue Guan Bing Za Zhi, 39(1), 69-72.

Brugada, P., Brugada, J., Mont, L., Smeets, J. &

Andries, E.W {1991). A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation, 83{5), 1649-1659.

Lin, T„ Ma, Y.T., Muhu, Y., Tang, B.P., Hou, Y. M. &

Zhang, Y.Y. [Value of aVR lead four steps algorithm on differential diagnosis of wide QRS complex tachycardia. Zhonghua Xin Xue Guan Bing Za Zhi, 39(1), 69-72.

Isenhour, J, L„ Craig, S,, Gibbs, M , Littmann, L, Rose, G. & Risch, R {2000). Wide-compiex tachycardia: continued evaluation of diagnostic criteria. Acad Emerg Med, 7(7), 769-773, Vereckei, A., Duray, G., Szenasi, G., Altemose, G.T. &

Miller, J.M (2007). Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J, 28{5), 589-600.

Vereckei, A., Duray, G., Szenasi, G., Altemose, G.T. &

Miller, J.M (2008). New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm, 5(1), 89-98.