RỐI LOẠN NHỊP TIM CHẬM GS.TS HUỲNH VĂN MINH, FACC P Chủ tịch Phân Hội Rối loạn nhịp tim Việt nam P Chủ tịch Hội Tim mạch Việt nam GS Huỳnh văn MInh, ĐHYD Huế, 2017 NHỊP XOANG BÌNH THƯỜNG • TS : 60-90 bpm – PR: 120-200 ms (.12-.20 seconds) – QRS: 60-100 ms (.06-.10 seconds) GS Huỳnh văn MInh, ĐHYD Huế, 2017 Nguyên nhân nhịp chậm ➢ Blốc nhĩ thất: Người lớn ➢ Blốc nhánh phân nhánh bó His ➢ Hội chứng suy nút xoang ➢ Ngất qua trung gian thần kinh ➢ Hội chứng xoang cảnh nhạy cảm GS Huỳnh văn MInh, ĐHYD Huế, 2017 Nguyên nhân Hội chứng nút xoang bệnh lý • Nguyên nhân tiên phát - Biến đổi thối hóa • Ngun nhân thứ phát yếu tố làm nặng - Nguyên nhân nội khoa • Suy giáp, bệnh tẩm nhuận (Amyloidosis, etc), viêm (viêm màng ngồi tim, rối loạn mơ liên kết), BMV, bệnh ác tính, suy gan thận - Nguyên nhân thuốc • B-blockers, chẹn calci, digitalis, thuốc chống loạn nhịp (e.g amiodarone, etc), chống trầm cảm, lithium GS Huỳnh văn MInh, ĐHYD Huế, 2017 Các thuốc có tác dụng gây làm nặng thêm nhịp chậm rối loạn dẫn truyền Antihypertensive • • • • • Beta-adrenergic receptor blockers (including betaadrenergic blocking eye drops used for glaucoma) Clonidine Methyldopa Non-dihydropyridine calcium channel blockers Reserpine Antiarrhythmic • • • • • • • • Adenosine Amiodarone Dronedarone Flecainide Procainamide Propafenone Quinidine Sotalol Psychoactive • • • • • • • Donepezil Lithium Opioid analgesics Phenothiazine antiemetics and antipsychotics Phenytoin Selective serotonin reuptake inhibitors Tricyclic antidepressants GS Huỳnh văn MInh, ĐHYD Huế, 2017 Other • • • • • Anesthetic drugs (propofol) Cannabis Digoxin Ivabradine Muscle relaxants (e.g., succinylcholine) Nguyên nhân bệnh lý phối hợp Nhịp chậm Rối loạn dẫn truyền Intrinsic Cardiomyopathy (ischemic or nonischemic) Congenital heart disease Degenerative fibrosis Infection/inflammation • Chagas disease • Diphtheria • Infectious endocarditis • Lyme disease • Myocarditis • Sarcoidosis • Toxoplasmosis Infiltrative disorders • Amyloidosis • Hemochromatosis • Lymphoma Ischemia/infarction Rheumatological conditions • Rheumatoid arthritis • Scleroderma • Systemic lupus erythematosus Surgical or procedural trauma • Cardiac procedures such as ablation or cardiac catheterization • Congenital heart disease surgery • Septal myomectomy for hypertrophic obstructive cardiomyopathy • Valve surgery (including percutaneous valve replacement) Extrinsic Autonomic perturbation • Carotid sinus hypersensitivity • Neurally-mediated syncope/presyncope • Physical conditioning • Situational syncope o Cough o Defecation o Glottic stimulation o Medical procedures o Micturition o Vomiting • Sleep (with or without sleep apnea) Metabolic • Acidosis • Hyperkalemia • Hypokalemia • Hypothermia • Hypothyroidism • Hypoxia GS Huỳnh văn MInh, ĐHYD Huế, 2017 Nguyên thường gặp có khả hồi phục điều trị Bệnh lý Suy nút xoang Acute myocardial ischemia or infarction Athletic training Atrial fibrillation Cardiac surgery • Valve replacement, maze procedure, coronary artery bypass graft Drugs or toxins* • Toluene, organophosphates, tetrodotoxin, cocaine Electrolyte abnormality • Hyperkalemia, hypokalemia, hypoglycemia Heart transplant : Acute rejection, chronic rejection, remodeling Hypervagotonia Hypothermia • Therapeutic (post-cardiac arrest cooling) or environmental exposure Hypothyroidism Hypovolemic shock Hypoxemia, hypercarbia, acidosis • Sleep apnea, respiratory insufficiency (suffocation, drowning, stroke, drug overdose) Infection • Lyme disease, legionella, psittacosis, typhoid fever, typhus, listeria, malaria, leptospirosis, Dengue fever, viral hemorrhagic fevers, Guillain-Barre Medications* • Beta blockers, non-dihydropyridine blockers, digoxin, drugs, lithium, methyldopa, GS.calcium Huỳnhchannel văn MInh, ĐHYD Huế,antiarrhythmic 2017 risperidone, cisplatin, interferon Nguyên nhân Bloc Nhĩ thất Congenital/genetic Vagotonic-associated with increased vagal tone • • • • • • Congenital AV block (associated with maternal systemic lupus erythematosus) Congenital heart defects (e.g., L-TGA) Genetic (e.g., SCN5A mutations) Sleep, obstructive sleep apnea High-level athletic conditioning Neurocardiogenic Infectious Metabolic/endocrine • • • • • • • Lyme carditis Bacterial endocarditis with perivalvar abscess Acute rheumatic fever Chagas disease Toxoplasmosis Inflammatory/infiltrative • • • • • Other diseases Myocarditis • Amyloidosis Cardiac sarcoidosis • Rheumatologic disease: Systemic sclerosis, SLE, RA, reactive arthritis (Reiter’s syndrome) Other cardiomyopathy-idiopathic, valvular Ischemic • • • • Acid-base disorders Poisoning/overdose (e.g., mercury, cyanide, carbon monoxide, mad honey) Thyroid disease (both hypothyroidism and hyperthyroidism) Adrenal disease (e.g., pheochromocytoma, hypoaldosteronism) Neuromuscular diseases (e.g., myotonic dystrophy, KearnsSayre syndrome, Erb’s dystrophy) Lymphoma Iatrogenic Acute MI • Medication related Coronary ischemia without infarction—unstable angina, variant o Beta blockers, verapamil, diltiazem, digoxin angina o Antiarrhythmic drugs • Chronic ischemic cardiomyopathy o Neutraceuticals • Catheter ablation Degenerative • Cardiac surgery, especially valve surgery GS Huỳnh văn MInh, ĐHYD Huế, 2017 • TAVR, alcohol septal ablation • Lev’s and Lenegre’s diseases Hình ảnh điện tâm đồ GS Huỳnh văn MInh, ĐHYD Huế, 2017 Rối loạn nhịp xoang GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo Tạo nhịp chậm? GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo tạo nhịp / nhịp chậm Recommendations Cardiac pacing for bradycardia and conduction system disease Class Level Pacing is indicated in symptomatic patients with the bradycardia-tachycardia form of SND to correct bradyarrhythmias and enable pharmacological treatment, unless ablation of the tachyarrhythmia is preferred I B Pacing is indicated in patients with atrial arrhythmia (mainly AF) and permanent or paroxysmal third- or high-degree AVB irrespective of symptoms I C In patients with SND and DDD PM, minimization of unnecessary ventricular pacing through programming is recommended I A AF = atrial fibrillation; AVB = atrioventricular block; DDD = dual-chamber, atrioventricular pacing; PM = pacemaker; SND = sinus node dysfunction GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo tạo nhịp / nhịp chậm & bệnh lý dẫn truyền New recommendations in 2021 (9) Recommendations Class Level Cardiac pacing for bradycardia and conduction system disease (continued) Dual chamber cardiac pacing is indicated to reduce recurrent syncope in patients aged >40 years with severe, unpredictable, recurrent syncope who have: • spontaneous documented symptomatic asystolic pause/s >3 s or asymptomatic pause/s >6 s due to sinus arrest or AVB; or • cardioinhibitory carotid sinus syndrome; or • asystolic syncope during tilt testing In patients with recurrent unexplained falls, the same assessment as for unexplained syncope should be considered I A IIa C ©ESC AVB = atrioventricular block www.escardio.org/guidelines 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab364) GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo tạo nhịp / nhịp chậm & bệnh lý dẫn truyền New recommendations in 2021 (10) Recommendations Class Level Cardiac pacing for bradycardia and conduction system disease (continued) AF ablation should be considered as a strategy to avoid pacemaker implantation in patients with AF-related bradycardia or symptomatic preautomaticity pauses, after AF conversion, taking into account the clinical situation IIa C In patients with the bradycardia-tachycardia variant of SND, programming of atrial ATP may be considered IIb B Dual-chamber cardiac pacing may be considered to reduce syncope recurrences in patients with the clinical features of adenosine-sensitive syncope IIb B ©ESC AF = atrial fibrillation; ATP = antitachycardia pacing; SND = sinus node dysfunction www.escardio.org/guidelines 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab364) GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo tạo nhịp bệnh nhân RLCNNX Recommendations for pacing in sinus node dysfunction (1) Recommendations Class Level In patients with SND and a DDD pacemaker, minimization of unnecessary ventricular pacing through programming is recommended I A Pacing is indicated in SND when symptoms can clearly be attributed to bradyarrhythmias I B Pacing is indicated in symptomatic patients with the bradycardia-tachycardia form of SND in order to correct bradyarrhythmias and enable pharmacological treatment, unless ablation of the tachyarrhythmia is preferred I B ©ESC ATP = antitachycardia pacing; DDD = dual-chamber, atrioventricular pacing; SND = sinus node dysfunction www.escardio.org/guidelines 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab364) GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo tạo nhịp bệnh nhân RLCNNX Recommendations for pacing in sinus node dysfunction (3) Recommendations Class Level In patients with syncope, cardiac pacing may be considered to reduce recurrent syncope when asymptomatic pause(s) >6 s due to sinus arrest is documented IIb C Pacing may be considered in SND when symptoms are likely to be due to bradyarrhythmias, when the evidence is not conclusive IIb C Pacing is not recommended in patients with bradyarrhythmias related to SND that are asymptomatic or due to transient causes that can be corrected and prevented III C ©ESC ATP = antitachycardia pacing; DDD = dual-chamber, atrioventricular pacing; SND = sinus node dysfunction www.escardio.org/guidelines 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab364) GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo tạo nhịp bệnh nhân Bloc nhĩ thất Recommendations for pacing for atrioventricular block (1) Class Level Pacing is indicated in patients in SR with permanent or paroxysmal third- or second-degree type 2, infranodal 2:1 or high-degree AVB, irrespective of symptoms.a I C Pacing is indicated in patients with atrial arrhythmia (mainly AF) and permanent or paroxysmal third- or high-degree AVB irrespective of symptoms I C In patients with permanent AF in need of a pacemaker, ventricular pacing with rate-response function is recommended I C IIa C Pacing should be considered in patients with second-degree type AV block that causes symptoms or is found to be located at intra- or infra-His levels at EPS AF = atrial fibrillation; AV = atrioventricular; AVB = atrioventricular block; DDD = dual-chamber, atrioventricular pacing; EPS = electrophysiology study; SR = sinus rhythm aIn asymptomatic narrow QRS-complex and 2:1 AVB, pacing may be avoided if supra-Hisian block is clinically suspected (concomitant Wenckebach is observed and block disappears with exercise) or demonstrated at EPS www.escardio.org/guidelines 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab364) GS Huỳnh văn MInh, ĐHYD Huế, 2017 ©ESC Recommendations GS Huỳnh văn MInh, ĐHYD Huế, 2017 Fred M Kusumoto Circulation 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College GS Huỳnh văn MInh, ĐHYD Huế, 2017 of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society, Volume: 140, Issue: 8, Pages: e382-e482, DOI: (10.1161/CIR.0000000000000628) Fred M Kusumoto Circulation 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College GS Huỳnh văn MInh, ĐHYD Huế, 2017 of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society, Volume: 140, Issue: 8, Pages: e382-e482, DOI: (10.1161/CIR.0000000000000628) Fred M Kusumoto Circulation 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American Huỳnh văn MInh,and ĐHYD Huế, 2017Society, Volume: 140, Issue: 8, Pages: e382-e482, DOI: College of Cardiology/American Heart Association Task Force on GS Clinical Practice Guidelines the Heart Rhythm (10.1161/CIR.0000000000000628) Fred M Kusumoto Circulation 2018 ACC/AHA/HRS Guideline on the of Patients Bradycardia and Cardiac Conduction Delay: A Report of the American GS.Evaluation Huỳnh and vănManagement MInh, ĐHYD Huế,With 2017 College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society, Volume: 140, Issue: 8, Pages: e382-e482, DOI: (10.1161/CIR.0000000000000628) Figure Evaluation of Bradycardia and Conduction Disease Algorithm Patient with symptoms suggestive of or consistent with bradycardia or conduction disorder SND* SND Diagnostic algorithm Comprehensive history and physical examination (Class I) Sleep apnea? ECG (Class I) Directed blood testing (Class IIa) AV Block AV Block Diagnostic algorithm Conduction disorder with 1:1 AV conduction Nondiagnostic Conduction disorder Diagnostic algorithm§ Echocardiography if structural heart disease suspected Exercise-related symptoms Yes No Exercise ECG testing (Class IIa) Abnormal Infrequent Symptoms (>30 days) ICM (Class IIa) Normal Ambulatory ECG monitoring (Class I) Significant arrythmias No significant arrhythmias SND AV Block Conduction disorder with 1:1 AV conduction SND Diagnostic algorithm AV Block Diagnostic algorithm Conduction disorder Diagnostic algorithm§ GS Huỳnh văn MInh, ĐHYD Huế, 2017 Observation Continued concern for bradycardia? Figure Initial Evaluation of Suspected or Documented SND Algorithm Evidence for sinus node dysfunction* Can we fix this arrow? Reversible or physiologic cause Treat underlying cause as needed, (e.g., sleep apnea (Class I) Yes Can we make these lines even? No Treatment effective or unnecessary Yes Suspicion for structural heart disease No Observe Yes Transthoracic echocardiography (Class IIa) No Suspicion for infitrative CM, endocarditis, ACHD Yes Advanced imaging (Class IIa) No Treat identified abnormalities Symptoms Yes No Observe Exercise related Yes No If not already performed: Exercise ECG testing (Class IIa) Diagnostic No Yes If not already performed: Ambulatory ECG monitoring (Class I) Electrophysiology study (if performed for other reasons) (Class IIb) Sinus node dysfunction treatment algorithm GS Huỳnh văn MInh, ĐHYD Huế, 2017 Figure Initial Evaluation of Suspected Atrioventricular Block Algorithm Evidence for AV Block Reversible or Physiologic cause No Yes Treat underlying cause as needed, e.g., sleep apnea (Class I) Treatment effective or not necessary Mobitz type II 2° AV Block, Advanced AV Block, complete heart block No Yes Observe Yes No Transthoracic echocardiography (Class I) Suspicion for structural heart disease Suspicion for infiltrative CM, endocarditis, ACHD, etc Yes Suspicion for infiltrative CM, endocarditis, ACHD, etc Yes Advanced imaging* (Class IIa) No AV block treatment algorithm Yes Advanced imaging (Class IIa) No No Transthoracic echocardiography (Class IIa) Treat identified abnormalities Infranodal AV node (Mobitz Type I) Unclear e.g 2:1 AV Block Symptoms Symptoms Yes AV block treatment algorithm AV block treatment algorithm No Exercise testing (Class IIa) Infranodal Electrophysiology study (Class IIb) Infranodal Yes No AV block AV block 2017 GS Huỳnh văn MInh,treatment ĐHYD Huế, treatment AV node Observe algorithm algorithm Observe Determine site of AV Block ... tạo nhịp hai buồng dùng cần lập trình để khơng tạo -nhịp thất - Tạo nhịp buồng VVI chấp thuận cho người già khơng có rối loạn chức thất trái GS Huỳnh văn MInh, ĐHYD Huế, 2017 TẠO NHỊP TIM Tạo nhịp. .. PHƯƠNG PHÁP TẠO NHỊP VĨNH VIỄN -Vị trí gắn dây điện cực GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo Tạo nhịp chậm? GS Huỳnh văn MInh, ĐHYD Huế, 2017 Khuyến cáo tạo nhịp / nhịp chậm Recommendations... xoang nhĩ GS Huỳnh văn MInh, ĐHYD Huế, 2017 HỘI CHỨNG NHỊP NHANH -NHỊP CHẬM GS Huỳnh văn MInh, ĐHYD Huế, 2017 Hội chứng nhịp nhanh nhịp chậm Atrial Flutter Atrial Flutter terminates Sinus arrest