Bài giảng Rối loạn nhịp thất trong nhồi máu cơ tim cấp - ThS. Hoàng Việt Anh

Hà Nội 26/11/2016

RỐI LOẠN NHỊP THẤT
trong nhồi máu cơ tim cấp
ThS.BS Hoàng Việt Anh
Trưởng phòng Q3B - Viện Tim mạch quốc gia Việt Nam


Nhồi máu cơ tim

•  Là bệnh lý tim mạch có tỷ lệ mắc ngày càng tăng và tỷ lệ tử vong cao
•  Tỷ lệ mới mắc tại Hoa Kỳ: 735.000 người/năm
•  Yếu tố nguy cơ: Tăng huyết áp, ĐTĐ2, Rối loạn lipid máu, Béo phì, ít vận
động thể chất, cuộc sống căng thẳng….


Rối loạn nhịp là một biến chứng của NMCT


Reference

to Ventricular
MYOCAItDIAL

to Ventricular

%

No.
Episodes-

16

Dallas,

14
2 INTRODUCTION3

Tachycardia*

mean
E. with
JONES,

Total F.C.C,P,,**
M.D.,

F.Inferior
A. BASHOUR,

Anterior

Tachycardia*

Reference

LESION

10

SGOT

of 213 units per ml,
M.D.f
AND
R. EDMONSON, tachycardia
M.D.
true
ventricular

Texas

per

ml.

In

the

absence

of ventricular

cardia,generally the accepted,
mean becauseSGOTof the sequence
rise
the ligation
of coronary
with of events
acute following
myocardial

infarction

i

Cardiac
Arrhythmias
in Acute
Myocardial
T Infarction
BASHOUR,
M.D.,
F.C.C,P,,** Supraventricular
E.
JONES,
M.D.f
ANDper ml. R.
EDMONSO
cardial
infarction
changed
tachycardia
4
1
5has
16.6
units
The
number
of patie
in with

years;
in the
II. Incidence
of the Common
Arrhythmias
3 remained 10
Complete
AV block
0 the past 303 Special
The
reported
incidence
of
cardiac
arshock
or
heart
failure
on
admission
neighborhood
of 30
cent.
In the maMultifocal
PVC’s
16
14
30
100
jority

of instances,
death
occurred
in
Reference
to Ventricular
Tachycardia*
to
demonstrate
a
close
relationship
Voiume
Si, No. S
Ectopic Dallas,
ventricular
first 48Texas
50 per cent
rhythms:
clinical
features
and
the a
of these patients,
death
is sudden
and un- these
May,
1967
myocardial

infarction.
The development
of
a) True
ventricular
expected.
These
patients
are clinically
well of ectopic
ventricular
rhythms.
Atrial

F. A.

fibrillation

1

HE

MORTALITY

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hours.

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F. A.

olume

ay,

ine

No.

51,

INCIDENCE

1967

was

or

S

used

T
atrial

alone

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arrhythmia.

Cardiac

wo groups
myocardial

one

other

T

arrhythmias

were

OF

BASHOUR,

M.D.,

COMMON

and

patient

one

inferior

into

Texas

myocardial

infarction)

bigeminy
in
the bigeminal

INTRODUCTION
one of these,

R.

JONES,

Dallas,

INTRODUCTION
and ventricular

divided

E.

F.C.C,P,,**

ARRHYTHMIAS

M.D.f
tachycardia AND (rate
than
523 greater
than
100/mm)
b) Slow ventricular
rhythm
(rate
from
70-100/mm)

11 patients.
In

*One
patient accepted,
had
generally
rhythm
lastedventricular
rhythms.

atEDMONSON,
the time of death

struction
*From

HE

M.D. sufficient
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myocardial

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the 7 terminal 15 event,

to 8 explain
the

Department

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been

University

Southwestern
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f5*Present

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Medicine.

of

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-

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at

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In

groupthe run
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ventricular

This

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Dilantin

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patients

continuous

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fold:

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of

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the

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are
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reportedthe
describe

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of the

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occur

(Dila
becau
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beats
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this

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encountered

study

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in Table
incidence
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ous
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is

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the

School.

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ford
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ectopic
Part
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Heart
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Meeting,
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(February 2, 1965)
and
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Chicago,
November,
l965.’

both

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accepted,
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of Texas
**Associate

of events
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HE
MORTALITY
three RATE
hours. IN TrueACUTEventricular
tachycardia
to MORTALITY
the location
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RATE
IN MYOACUTE
MYOthat
was present
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the arteries
incianterior

and inferior infarction
ventricular in dogs,
tachycardia.
cardial
has changed

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infarction:

of

varied

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presence
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with

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past 30 years;
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MATERIAL
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arneighborhood
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The slow
ibrillation
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jority
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to explain
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ner.
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The
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ous cardiac
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a preliminary
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types
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nvolvement

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ure
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ients.

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FIGURE
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ford
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Meeting,
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ary 2, 1965)
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eLectro-


Table 1. Occurrence of arrhythmias in STEMI patients during and
Tỷ lệ mắc các rối loạn nhịp thất trong ACS
immediately after primary PCI.71
Accelerated idioventricular rhythm (50-120 b.p.m.)

15-42%

Sinus bradycardia (<50 b.p.m.)

28%

Non-sustained VT

26%

Sinus tachycardia (>100 b.p.m.)

22%

Atrial fibrillation
High-degree AV block

9%
5-10%

Sustained VT

2-4%

VF

2-5%

AV: atrioventricular; b.p.m.: beats per minute; PCI: percutaneous
coronary intervention; STEMI: ST-elevation myocardial infarction;
VF: ventricular fibrillation; VT: ventricular tachycardia


Tỷ lệ mắc các rối loạn nhịp thất theo vùng NMCT

International Journal of Contemporary Medical Research Volume 3 | Issue 5 | May 2016 | ICV: 50.43 |


Sinh lý bệnh
của rối loạn
nhịp thất trong
NMCT cấp

Piccini et al
Rối loạn nhịp thất sau NSTEMI

Sustaine

EARLY ACS trial

Fi
ta
fib
w
de

Piccini et al Sustained VT/VF After NSTE ACS.

Circulation July 3, 2012

These variables included the same covariates as in the 30-day

Table 1. More patient


Các YTNC của rối loạn nhịp thất bền bỉ trong NMCT cấp
•  Sốc tim hay tổn thương cấp động mạch vành lớn (VD:
thân chung ĐMV trái)
•  Chậm trễ trong tái thông ĐMV
•  Tái thông không được hay không hoàn toàn ĐMV thủ
phạm do vấn đề kỹ thuật hay giải phẫu khó khăn

•  Có suy chức năng thất trái hay sẹo cơ tim do NMCT cũ
hay ST do bệnh cơ tim trước đó
•  Bệnh cơ tim rối loạn nhịp do di truyền

Willich and Goette. Int J Crit Care Emerg Med 2015, 1:2


Rối loạn nhịp thất sau NMCT cấp
•  RL nhịp thất hay gặp hơn trong STEMI so với NSTEMI
(gấp 4 lần)
•  STEMI: 90% xảy ra trong 48 giờ đầu
•  NSTEMI: 60% xảy ra sau 48 giờ
•  Tỷ lệ xuất hiện: NNT không bền bỉ (13%), NNT bền bỉ
(3%) và rung thất (3%)
•  Một nghiên cứu khác: 6%
•  Tại viện Tim mạch Việt Nam: 13% NNT, 48% NTT thất
trong 24h sau can thiệp STEMI.
Willich and Goette. Int J Crit Care Emerg Med 2015, 1:2


Tiên lượng của NMCT có rối loạn nhịp thất

•  Tổng hợp 4 nghiên cứu lớn: GUSTO, PURSUIT,
PARAGON A, PARAGON B
•  Tổng cộng 26.416 bệnh nhân NSTEMI
•  Có 552 bệnh nhân có rối loạn nhịp thất trong thời gian
nằm viện (nhịp nhanh thất và/hoặc rung thất): 2.1%
•  Tỷ lệ tử vong sau 30 ngày và sau 6 tháng đều tăng ở
nhóm có rối loạn nhịp thất.
Sustained Ventricular Arrhythmias Among Patients With Acute Coronary Syndromes With No ST-Segment Elevation – Al Khatib et

al – Circulation July16,2002


tions was unavailable, we could not explore their relationships with outcomes.

Tiên lượng của NMCT có rối loạn nhịp thất

Sustained Ventricular Arrhythmias Among Patients With Acute Coronary Syndromes With No ST-Segment Elevation – Al Khatib et
al – Circulation July16,2002

Kaplan-Meier curves of mortality by ventricular arrhythmia.


Tiên lượng của NMCT có rối loạn nhịp thất

•  Rung thất sớm trong vòng 48 giờ sau NMCT: tử vong
tăng 5 lần so với NMCT không có rung thất
•  Trên những bệnh nhân NMCT sau can thiệp ĐMV, nếu
có NNT/RT: tỷ lệ tử vong tăng 4 lần, biến cố tim mạch
tăng 3 lần, thời gian nằm viện tăng 50%.

Sustained Ventricular Arrhythmias Among Patients With Acute Coronary Syndromes With No ST-Segment
Elevation – Al Khatib et al – Circulation July16,2002
The American Journal of Medicine, Vol 121, No 9, September 2008


Tử vong tăng khi có rung thất

120

FAST-AMI 2005
A

B 60

60

50

In-hospital mortality, %

50

In-hospital mortality, %

W. Bougouin et al.

40
30
20

40
30
20

10

10

0

0
Patients without VF

Patients with VF

No VF

Early VF

Late VF

Figure 1 In-hospital mortality according to occurrence of ventricular fibrillation.

Table 3 Cause-specific death during hospitalization
European
 H
Journal
 (2014)
 
35,
 116–122
 
according
toeart
 
occurrence
of VF

Table 4 Treatments at hospital discharge among

survivors by occurrence of VF


Các yếu tố dự báo NNT bền bỉ sau NMCT cấp

The American Journal of Medicine 2008 121, 797-804DOI: (10.1016/j.amjmed.2008.04.024)
Copyright © 2008 Elsevier Inc. Terms and Conditions


Tử vong và RLNT tăng theo số yếu tố nguy cơ

The American Journal of Medicine 2008 121, 797-804DOI: (10.1016/j.amjmed.2008.04.024)
Copyright © 2008 Elsevier Inc. Terms and Conditions


Tử vong tăng ở nhóm can thiệp thất bại

The American Journal of Medicine 2008 121, 797-804DOI: (10.1016/j.amjmed.2008.04.024)
Copyright © 2008 Elsevier Inc. Terms and Conditions


Làm thế nào phòng ngừa và điều trị
rối loạn nhịp thất à giảm tử vong
trong NMCT cấp ???


nal of the American College of Cardiology
013 by the American College of Cardiology Foundation, the American Heart Association, Inc.,
the Heart Rhythm Society
ished by Elsevier Inc.

V
ISSN
/>
PRACTICE GUIDELINE

2012 ACCF/AHA/HRS Focused Update Incorporated
Into the ACCF/AHA/HRS 2008 Guidelines for
Device-Based Therapy of Cardiac Rhythm Abnormalities
A Report of the American College of Cardiology Foundation/American Heart Association


Phòng ngừa và điều trị
đột tử trong hội chứng
vành cấp ngoại viện


may reveal disease-specific findings are detailed in Web Table 4.

of these conditions must be avoided. Co-morbidities that may

Phác đồ xử trí RL nhịp thất theo nguyên nhân
Clinical History
• Angina pectoris or shortness of breath
• Family history of premature SCD (age <40 years) or ealy-onset heart disease
• ECG during tachycardia

Acute ischemia
(STEMI, NSTEMI)

ECG
Echocardiogram
History and
Family history a

Urgent angiogram
and
revascularisation
Reverse
transient cause

Evaluate for
cardiovascular
diseases
• ECG
• Echocardiogram / CMR
• History
• Other tests

Evaluate for
complete
reversal of
cause

Secondary
prevention for
SCD (ACEi,
beta-blockers, statin,
antiplatelets)
Re-evaluate

LVEF
6–10 weeks
after event

Consider ICD
according to
secondary
prevention

Structural heart disease
and congenital heart
diseases
suspected (e.g. Stable CAD,
sarcoidosis, aortic valve
disease, DCM)

Sudden death victims
• Autopsy in collaboration with pathologists
• Obtain blood and tissue samples
• Molecular autopsy after autopsy
• Offer family councelling and support
• Refer family for cardiology / SCD workup

No detectable
heart disease

Inherited
arrhythmogenic
disease or
cardiomyopathy

suspected

Further patient assessment, e.g.b
• Stress test, Holter 48 hours,
• Consider coronary angiogram
• Refer patients to experienced centers for risk evaluation,
catheter ablation, drugs and ICD
• Drug challenges, EPS
• CMR, CT, myocardial biopsy
• Signal averaged ECG, TOE based on suspected disease

• Treatment of underlying
heart disease (e.g. valve
repair, medication)
• Assess risk for SCD

Specific treatment
• Genetic testing
• Family screening
• Assess risk for SCD

Consider to
obtain second opinion
on cause of
VT/VF

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Other transient
cause e.g.

• Drugs
• Electrolytes
• Chest trauma


ment of sustained VA.

014

e drugs
n of the
nts after
ompared
largely
in ACS.
ong carcacy on
did not
ejection
f dronemortality
treated
interval
none of
eatment
for this

Phác đồ điều trị rối loạn nhịp thất trong ACS

tructure

Recurrent VT/VF and Electrical Storm in ACS

Cardioversion/defibrillation
Overdrive pacing
Attempt complete revascularization
Treat ischaemia
Correct electrolyte imbalance
β-blocker therapy
Deep sedation
Recurrent VT/VF

Electrical Storm

Amiodarone
Lidocaine
Consider catheter ablation

Amiodarone
Consider ICD reprogramming
Consider catheter ablation
Consider LVAD implantation

EuroIntervention
2014;10-online
publish-ahead-of-print
August 2014


Phòng ngừa đột tử
trong hội chứng vành
cấp trong viện:

Tái thông ĐMV


Phòng ngừa đột tử
trong hội chứng
vành cấp trong viện:
Tái thông ĐMV


ment

C

Điều trị rối loạn nhịp thất và mục tiêu

FIGURE 52-29 Cardiac rupture syndromes complicating STEMI. A, Anterior myocardial rupture in an acute infarct. B, Rupture of the ventricular septum. C, Complete
rupture of a necrotic papillary muscle. (From Schoen FJ: The heart. In Kumar V, Abbas AK, Fausto N [eds]: Robbins & Cotran Pathologic Basis of Disease. 7th ed. Philadelphia,
WB Saunders, 2005.)

TABLE 52-12 Cardiac Arrhythmias and Their Management During Acute Myocardial Infarction
CATEGORY
1. Electrical
instability

ARRHYTHMIA

OBJECTIVE OF TREATMENT

THERAPEUTIC OPTIONS

Correction of electrolyte deficits and
increased sympathetic tone
Prophylaxis against ventricular fibrillation,
restoration of hemodynamic stability
Urgent reversion to sinus rhythm
Observation unless hemodynamic function
is compromised
Search for precipitating cause (e.g., digitalis
intoxication); suppress arrhythmia only if
hemodynamic function is compromised

Potassium and magnesium solutions,
beta blocker
Antiarrhythmic agents, beta blocker;
cardioversion/defibrillation
Defibrillation; amiodarone, lidocaine
Increase sinus rate (atropine, atrial pacing);
antiarrhythmic agents
Atrial overdrive pacing; antiarrhythmic agents;
cardioversion relatively contraindicated if
digitalis intoxication present

Sinus tachycardia

Reduce heart rate to diminish myocardial
oxygen demands

Atrial fibrillation and/or
atrial flutter
Paroxysmal

supraventricular
tachycardia

Reduce ventricular rate; restore sinus
rhythm
Reduce ventricular rate; restore sinus
rhythm

Antipyretics; analgesics; consider betablocking agent unless congestive heart
failure present
Verapamil, digitalis glycosides; amiodarone;
treat heart failure; cardioversion
Vagal maneuvers; verapamil, cardiac
glycosides, beta-adrenergic blocking
agents; cardioversion

Sinus bradycardia

Acceleration of the heart rate only if
hemodynamic function is compromised
Acceleration of the sinus rate only if loss of
atrial “kick” causes hemodynamic
compromise

Ventricular premature
beats
Ventricular tachycardia
Ventricular fibrillation
Accelerated idioventricular
rhythm

Nonparoxysmal AV
junctional tachycardia

2. Pump failure/
excessive
sympathetic
stimulation

3. Bradyarrhythmias
and conduction
disturbances

Junctional escape rhythm
AV block and
intraventricular block

Atropine; atrial pacing
Atropine; atrial pacing
Insertion of a pacemaker

Modified from Antman EM, Rutherford JD (eds): Coronary Care Medicine: A Practical Approach. Boston, Martinus Nijhoff, 1986, p 78.

imaging (Fig. 52-30) or by insertion of a pulmonary artery balloon

Rupture of a Papillary Muscle