Điều trị suy tim nhịp xoang rung nhĩ: Có khác biệt? VNCC 2016 TS BS Ph¹m Nh Hïng FACC, FHRS, FSCAI, FAsCC Consultant of Cardiology and Electrophysiology Director of Cath Lab and EP Lab Hanoi Heart Hospital Epidemics of Heart Failure Tỷ lệ mắc hàng nm Tỉng sè bƯnh nh©n suy tim Tû lƯ tư vong hàng nm 400,000 5.0 triệu 250,000 Châu âu 580,000 6.5 triÖu 300,000 Mü Congestive heart failure worldwide markets, clinical status and product development opportunities New Medicine, Inc 1997:1-40 Wilkerson Group Survey, 1998 Sè bƯnh nh©n rung nhÜ TriƯu Epidemics of Afib Tỷ lệ dự báo rung nhĩ Hoa kú 18 16 14 12 10 Dùa trªn tû lệ dự báo Dựa tỷ lệ Năm Miyakasa et al Cir 2006:114:119-125 Tỷ lƯ bn RN trªn ST 0.4 0.4 Cumulative incidence of AF Cumulative incidence of CHF Tû lÖ bn suy tim trªn RN 33/1000 a year 0.3 0.2 0.1 0 10 54/1000 a year 0.3 0.2 0.1 0 Years No at risk 683 454 360 250 171 120 No at risk 708 10 146 92 62 Years 323 230 Tû lÖ rung nhÜ mét sè nghiªn cøu suy tim lín I PHân độ NYHA II III III IV IV Prevalence of AF(%) 60 49.8 50 40 28.9 30 25.8 20 14.4 15.4 V-HeFT CHF-STAT 10.1 10 4.2 SOLVD prevention SOLVD Treatment DIAMOND CHF GESICA CONSESUS Adapted from Lancet, JACC, NEJM and Circulation Rung nhÜ g©y suy tim suy tim gây rung nhĩ: số chế góp phần gây nên tri gia rung nhĩ suy tim Tạo không đồng đờng dÉn trun MÊt ®ång bé nhÜ thÊt RN Thay ®ỉi đặc tính trở nhĩ Xơ hoá khoảng kẽ Quá tải thể tích áp lực ST Dáp ứng thất nhanh Biến đổi khoảng R-R Tác dụng phụ thuốc (Vd: thuốc chống loạn nhịp) AmJ Cardio2003:91(suppl);2D 8D Priorities of management with HF and AF Transplant Heart rate control ICD &CRT Ameliorate RAAS disturbance AF priorities Prevent stroke Achive euvolaemia Control heart rate HF priorities Manage bleeding Prevent and treat HF Restore sinus Rate vs Rhymth control of Afib AFFIRM trial Roy D et al N Engl J Med 2008: 358;25 Rate vs Rhymth control of Afib AF-CHF trial Roy D et al N Engl J Med 2008: 358;25 Phân tích gộp: Khi theo dõi thời gian kéo dài JAMA 2012;172(13):997-1004 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 in heart failure Rung nhÜ mạn tính >80 c/phút Vừa phải Tần số tim