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 ĐIỀU TRỊ BỆNH LIÊN QUAN NGỪA HUYẾT KHỐI 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 • • • Tại cần kiểm soát nhịp Đối tượng cần kiểm soát nhịp Chuẩn bị bệnh nhân cần chuyển nhịp 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 gắng sức Cải thiện chất lượng sống Giảm nguy đột quỵ Tránh tai biến 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 tim nhịp nhanh Cơn rung nhĩ Rung nhĩ bệnh lý cấp tính thúc đẩy Chọn lựa bệnh nhân 2014 AHA/ACC/HRS Atrial Fibrillation Guideline Canadian Journal of Cardiology 2014 30, 1114-1130 DỰ PHÒNG HUYẾT KHỐI LẤP MẠCH • Sau chuyển nhịp, tỷ lệ lấp mạch BN không dùng warfarin 5.3%, có dùng warfarin 0.8% [1,2] • Tỷ lệ lấp mạch sau chuyển nhịp rung nhĩ xuất < 48h 1% [3] → Đối với rung nhĩ ≥ 48h không rõ thời gian khởi phát, cần dùng kháng đông uống (warfarin/ NOACs) trước chuyển nhịp ≥ tuần [4] 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 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 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 2014 AHA/ACC/HRS Atrial Fibrillation Guideline DỰ PHÒNG HUYẾT KHỐI LẤP MẠCH • TEE thay cho việc dùng kháng đông tuần trước chuyển nhịp • Kháng đông nên dùng sớm tốt cần chuyển nhịp cấp cứu • Dùng kháng đông đường uống ≥ tuần sau chuyển nhịp, điểm CHADS-VAS 2014 AHA/ACC/HRS Atrial Fibrillation Guideline Prevention of Thromboembolism Recommendations 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 weeks before and weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method (electrical or pharmacological) used to restore sinus rhythm COR LOE 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 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) Recommendations Following cardioversion for AF of any duration, the decision about long-term anticoagulation therapy should be based on the thromboembolic risk profile 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 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 weeks 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 weeks before and weeks after cardioversion COR LOE I C IIa B 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 Recommendations COR 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 I adjusting the location of the electrodes, applying pressure over the electrodes or following administration of an antiarrhythmic medication Cardioversion is recommended when a rapid ventricular response to AF or atrial flutter does not respond promptly to I pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or HF Cardioversion is recommended for patients with AF or atrial flutter and pre-excitation when tachycardia is associated with I hemodynamic instability 2014 AHA/ACC/HRS Atrial Fibrillation Guideline LOE B C C Pharmacological Cardioversion Recommendations Flecainide, dofetilide, propafenone, and intravenous ibutilide are useful for pharmacological cardioversion of AF or atrial flutter, provided contraindications to the selected drug are absent Administration of oral amiodarone is a reasonable option for pharmacological cardioversion of AF 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 Dofetilide therapy should not be initiated out of hospital because of the risk of excessive QT prolongation that can cause torsades de pointes COR LOE I A IIa A IIa B III: Harm B 2014 AHA/ACC/HRS Atrial Fibrillation Guideline Antiarrhythmic Drugs to Maintain Sinus Rhythm Recommendations Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm, depending on underlying heart disease and comorbidities: a Amiodarone b Dofetilide c Dronedarone d Flecainide e Propafenone f Sotalol The risks of the antiarrhythmic drug, including proarrhythmia, should be considered before initiating therapy with each drug COR LOE I C I A I C 2014 AHA/ACC/HRS Atrial Fibrillation Guideline Antiarrhythmic Drugs to Maintain Sinus Rhythm (cont’d) Recommendations Because of its potential toxicities, amiodarone should only be used after consideration of risks and when other agents have failed or are contraindicated A rhythm-control strategy with pharmacological therapy can be useful in patients with AF for the treatment of tachycardiainduced cardiomyopathy 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 Antiarrhythmic drugs for rhythm control should not be continued when AF becomes permanent,… …including dronedarone COR LOE I C IIa C IIb C III: Harm 2014 AHA/ACC/HRS Atrial Fibrillation Guideline C B Upstream Therapy Recommendations An ACE inhibitor or angiotensin-receptor blocker is reasonable for primary prevention of new-onset AF in patients with HF with reduced LVEF Therapy with an ACE inhibitor or ARB may be considered for primary prevention of new-onset AF in the setting of hypertension Statin therapy may be reasonable for primary prevention of newonset AF after coronary artery surgery Therapy with an ACE inhibitor, ARB, or statin is not beneficial for primary prevention of AF in patients without cardiovascular disease COR LOE IIa B IIb B IIb A III: No Benefit B 2014 AHA/ACC/HRS Atrial Fibrillation Guideline Cắt đốt qua catheter: phân tích gộp Ablation method Patients Paroxysmal AF SHD 6-month cure 6-months OK Linear 443 75% 26% 33% 55% Focal 508 81% 35% 54% 71% Isolation 2,187 83% 36% 62% 75% Circumferential (all) 15,455 68% 37% 64% 74% Circumferential (LACA, WACA) 2,449 65% 37% 59% 72% Circumferential (PVAI) 11,132 68% 42% 67% 76% 559 51% 49% 75% 87% 23,626 61% 55% 63% 75% Substrate ablation (CFAE) TOTAL Cure (by each author’s criteria) means no further AFib 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 Fisher JD, et al PACE 2006;29: 523 19 Bệnh nhân không rung nhĩ sau cắt đốt so với thuốc Khả sống không rung nhĩ (%) 100 84% 79% 80 78% 61% P < 0,001 60 47% Nhóm cắt đốt (n=589) 37% 40 Nhóm thuốc (n=582) 20 0 12 18 24 30 36 Theo dõi (tháng) Pappone C, et al J Am Coll Cardiol 2003 Jul 16;42(2):185-97 20 Cải thiện sống cắt đốt so với thuốc  589 BN rung nhĩ có triệu chứng cắt đốt so với 582 điều trị thuốc Nhóm cắt đốt Nhóm điều trị thuốc Khả sống (%) 100 90 Chờ đợi Quan sát 80 70 60 One-sample log-rank test Obs=36, Exp=31, Z=0.597, p=0.55 One-sample log-rank test Obs=79, Exp=341, Z=7.07, p[...]... PACE 2006;29: 523 19 Bệnh nhân không còn rung nhĩ sau cắt đốt so với thuốc Khả năng sống còn không còn rung nhĩ (%) 100 84% 79% 80 78% 61% P < 0,001 60 47% Nhóm cắt đốt (n=589) 37% 40 Nhóm thuốc (n=582) 20 0 0 6 12 18 24 30 36 Theo dõi (tháng) Pappone C, et al J Am Coll Cardiol 2003 Jul 16;42(2):185-97 20 Cải thiện sống còn bằng cắt đốt so với thuốc  589 BN rung nhĩ có triệu chứng được cắt đốt so với... 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 COR LOE I B For patients with AF or atrial flutter of more than 48 hours’ duration... antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy COR LOE I A I C IIa A IIa B 2014 AHA/ACC/HRS Atrial Fibrillation Guideline Chiến lược kiểm soát nhịp trong rung nhĩ kịch phát và dai dẳng Không có bệnh tim cấu trúc Có bệnh tim cấu trúc Bệnh mạch vành Dofetilide Dronedatone Flecaine Propafenone Sotalol Amidarone Cắt đốt Dofetilide Dronedarone Sotalol Cắt đốt... Dofetilide Amidarone January, CT et al 2014 AHA/ACC/HRS Atrial Fibrillation Guideline 24 KẾT LUẬN • Chuyển nhịp RN giúp cải thiện triệu chứng, và nên thực hiện ở một số đối tượng thích hợp • RN xuất hiện trên 48h: cần kháng đông trước chuyển nhịp 3 tuần và sau chuyển nhịp 4 tuần 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... 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... Recommendations Following cardioversion for AF of any duration, the decision about long-term anticoagulation therapy should be based on the thromboembolic risk profile 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 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 COR LOE