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Hà Nội 26/11/2016 RỐI LOẠN NHỊP THẤT nhồi máu tim cấp ThS.BS Hồng Việt Anh Trưởng phòng Q3B - Viện Tim mạch quốc gia Việt Nam Nhồi máu tim • Là bệnh lý tim mạch có tỷ lệ mắc ngày tăng tỷ lệ tử vong cao • Tỷ lệ mắc Hoa Kỳ: 735.000 người/năm • Yếu tố nguy cơ: Tăng huyết áp, ĐTĐ2, Rối loạn lipid máu, Béo phì, vận động thể chất, sống căng thẳng… Rối loạn nhịp biến chứng NMCT Reference to Ventricular MYOCAItDIAL to Ventricular % No Episodes- 16 Dallas, 14 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 5has 16.6 units The number of patie in with years; in the II Incidence of the Common Arrhythmias remained 10 Complete AV block 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 HE MORTALITY RATE IN ACUTE MYO- arteries little in dogs, tricular it that arrhythmia this group and fibrillation dies of ven- per rhythmias the hours Approximately the F A olume ay, ine No 51, INCIDENCE 1967 was or S used T atrial alone in 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 without myocardial tissue the terminal 15 event, to explain the Department at been University Southwestern Professor Medical generally f5*Present address Medicine of 6in intern - to widely the 20 at this In groupthe run dies of one, byfibrillation ventricular This frequency rhythm for cardiac Dilantin of the true patients continuous The fold: acute recording incidence and of the evaluation patients arrhythmiaThe cardiac the purpose are to of reportedthe describe the of the that abnormal occur (Dila becau beats were ventricular these the bi this period encountered study was in Table incidence of ous premature in is recording with incardiac the immediatearrhythmias post-infarction Stan- group variation of rhythmwas has used permitted prophylactically the study of consecutive types of the School Medicine ford University slow Resident in and Medicine rapid ectopic Part of this work was presented at the Texas Heart Association Meeting, Texarkana (February 2, 1965) and the Midwestern Section, American Federation for Clinical Research, Chicago, November, l965.’ both cardiac methods de- necropsy 50It has Medicine, of due hydantoin accepted, because of the sequence the of ligationevents of coronary agent followingin of Texas **Associate of events following HE MORTALITY three RATE hours IN TrueACUTEventricular tachycardia to MORTALITY the location of the RATE IN MYOACUTE MYOthat was present in 15 patients,little and the arteries incianterior and inferior infarction ventricular in dogs, tachycardia cardial has changed according infarction: of varied largely in threeseri- the cardiac arrhythmia, ventricular presence of ventricular to correlate tachycardia a preliminary of the disease, and the use of diphenyl- 13 known patients clinical three of ven- and features report on premature The the with ventricular tricular little arrhythmia andarteries in dogs, that thi past 30 years; it remained in the cardialin theassociatedinfarction has changed MATERIAL TheThe reported incidenceoxaloaceticof cardiac arneighborhood of 30 per cent In the maserum glutamic transwere grouped tricular arrhythmia and rhythmias varied widely This variation is (SGOT) in the pastjority 30of instances, years; death it occurred remained in the in the largely due to the frequency of recording first 48 hours Approximately in 50 per cent Patients incidence with The reported The neighborhood commonly encountered cardiac of ar- 30 the cardiac rhythm of patients with acute per cent In the maof these patients, death is sudden and unmyocardial infarction The development dence of of widely an patients are clinicallyarrhythmia well for the ventricular The slow ibrillation appeared in expected three patients These (or rhythmias varied jority of instances, death occurred in the methods for continuous recording of the at the time ofre- death without sufficient de10 per cent), with a rapid ventricular cardiac rhythm has permitted the study were of struction of myocardial tissue at necropsy largely due to studied the frequ first 48 hours Approximately in 50 per cent the true incidence and the evaluation of the to explain the terminal event, It has been 1:arrhythmia Avionics’ that monitoring system The unit, of the FIGURE cardiac occur 30 portable episodes of the cardiac rhythm ner The recorder is the small unit in of the of these patients, death is sudden pertypes and unin minthe immediate post-infarction period cardiocharter Medicine (referred The purpose of this myocardial study was threewhom had anterior and one inferior myoinfarction to be fThese Stanexpected patients are clinically well cardial infarction fold:pre- to describe the incidence of the seritored for a pe ous cardiac arrhythmia, methods to correlate the for continuous at the time of death withoutat sufficient depresenceof of ventricular tachycardia with stances, m cardiac rhythm hasthe perm known clinical features of the disease, and struction of myocardial tissue at necropsy a preliminary report on the use of diphenylthe true incidence and in the anterior to explain the terminal event, It has been types of of the thecardiacheart arrh *From the Department of Medicine, University Downloaded From: http://journal.publications.chestnet.org/ on 11/15/2016 in the immediate diaphragmatic post-inf of Texas Southwestern Medical School (or posterior) nvolvement Arrhythmias of the lateral with either dence with myocardial previous terior wall cardia are reported in Table more ectopic ponse in two patients Wandering maker was observed in 11 patients ure atrial beats were frequent in **Associate Present observed pacePremafour pathe tachyDepartment *From supraventricular of Texas four Southwestern in five patients, of Paroxysmal occurred Multifocal ventricular were seen in all patients was or Atrial beats in three Professor address - six and per ranged minute ventricular ventricular PVC’s infarction fibrillation tachyaminase one and 70 The in 27 between 100 and blood In five patients, two foci were was (Fig followed 4) rhythm patients, five of whom one inferior myocardial ute In one patient, both types intern in Medicine at rhythm were present Runs multifocal, number Atrial cardia levels patients levels The was peak correlated were determined rise of with SGOT the ap- were were tient respectively was observed had ventricular quite r and nod fibrillation noted in two and Ventricular in four i t patients, ach two fibrillation on responsible was present in had anterior infarction The attacks numbered between one and a singleof Medicine, patient and University the ventricular ranged Medical between School 72 and 90 beats of three an- of ventricular between rate between myocardial of attacks varied ventricular distributed inferior number 220 rhythmias equally and The location depending on whether the anterior or the nferior wall was predominantly involved ients cardia was though ten in rate FIGURE 1: Avionics’ ner The recorder is monitoring the small system The unit, portable unit in the of ventricular of three ford University premature beats Medicine mature ventricular beats interrupted Resident in normally conducted beats Texas were seen in R/TPart phenomenon of this work was presented the Meeting, Texarkana (Febru(twoHeart had Association anterior patients; 12 of these patients had runs ary 2, 1965) and the Midwestern Section, American Federation for Clinical Research, Chicago, November, l965.’ on center cardiocharter 520 by 16 Downloaded From: http://journal.publications.chestnet.org/ on 11/15/2016 V.W (PMH 283525) 1-28-65 the right of the side picture of the On picture, the represents left side the is the scan- eLectro- Table Occurrence of arrhythmias in STEMI patients during and Tỷ lệ mắc rối loạn nhịp thất ACS immediately after primary PCI.71 Accelerated idioventricular rhythm (50-120 b.p.m.) 15-42% Sinus bradycardia (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 rối loạn nhịp thất theo vùng NMCT International Journal of Contemporary Medical Research Volume | Issue | May 2016 | ICV: 50.43 | Sinh lý bệnh rối loạn nhịp thất 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 More patient Các YTNC rối loạn nhịp thất bền bỉ NMCT cấp • Sốc tim hay tổn thương cấp động mạch vành lớn (VD: thân chung ĐMV trái) • Chậm trễ tái thơng ĐMV • Tái thơng khơng hay khơng hồn tồn ĐMV thủ phạm vấn đề kỹ thuật hay giải phẫu khó khăn • Có suy chức thất trái hay sẹo tim NMCT cũ hay ST bệnh tim trước • Bệnh tim rối loạn nhịp 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 STEMI so với NSTEMI (gấp lần) • STEMI: 90% xảy 48 đầu • NSTEMI: 60% xảy sau 48 • Tỷ lệ xuất hiện: NNT không bền bỉ (13%), NNT bền bỉ (3%) rung thất (3%) • Một nghiên cứu khác: 6% • Tại viện Tim mạch Việt Nam: 13% NNT, 48% NTT thất 24h sau can thiệp STEMI Willich and Goette Int J Crit Care Emerg Med 2015, 1:2 Chỉ định ICD phòng ngừa nhịp nhanh thất / rung thất đột tử sau NMCT Máy phá rung tự động buồng tim Máy phá rung tự động cấy da Máy phá rung tự động cấy da Máy phá rung tự động dạng áo Máy phá rung tự động dạng áo Phòng ngừa xử trí đột tử hội chứng vành cấp viện: Máy tạo nhịp/ phá rung tự động Phòng ngừa xử trí đột tử hội chứng vành cấp viện: Máy tạo nhịp/ phá rung tự động Phân tầng sớm nguy đột tử sau NMCT (trong vòng 10 ngày) Đánh giá chức thất trái xét ICD Khuyến cáo ICD sau NMCT EHRA/HRS/APHRS Expert Consensus on Ventricular Arrhythmias Heart Rhythm, Vol 11, No 10, October 2014 preserved ejection fraction Phân tầng tái thông ĐMV 3.2 Recommendations for optimal strategy bệnh ĐMV ổn định sau NMCT có CNTT bảo tồn a b c Recommendations Class Level Ref Revascularization in patients with stable coronary PVS should be considered in survivors of infarction with artery disease after myocardial a myocardial ejection infarction with preserved 280– preserved fraction IIa C LV function and otherwise unexplained 282 syncope Recommendations Classa Levelb LV ¼ left ventricular; PVS ¼ programmed ventricular stimulation Coronary revascularization is a Class of recommendation brecommended to reduce the risk of Level of evidence I B cSCD in patients with VF when acute Reference(s) supporting recommendations myocardial ischaemia precedes the onset of VF Ref.c 289, 290 Thuốc chống loạn nhịp điều trị bệnh ĐMV ổn định sau NMCT có CNTT bảo tồn Rối loạn nhịp thất NMCT cấp • Bao gồm: ngoại tâm thu thất, nhịp nhanh thất, rung thất biến chứng hay gặp • Hay xảy ra: STEMI 48 đầu, NSTEMI sau 48 • Nếu xảy giai đoạn sớm (trong vòng 48 giờ) làm tỷ lệ tử vong tăng 4-5 lần • Tái thơng mạch vành sớm biện pháp giúp làm giảm rối loạn nhịp thất, giảm tử vong • Các biện pháp điều trị quan trọng: điều chỉnh điện giải, thuốc chẹn bêta, amiodarone, máy phá rung tự động… XIN CHÂN THÀNH CẢM ƠN !!! ... chức thất trái hay sẹo tim NMCT cũ hay ST bệnh tim trước • Bệnh tim rối loạn nhịp di truyền Willich and Goette Int J Crit Care Emerg Med 2015, 1:2 Rối loạn nhịp thất sau NMCT cấp • RL nhịp thất. .. vành cấp viện: Điều trị rối loạn nhịp Phòng ngừa tử chứng vành viện: Điều trị rối nhịp đột hội cấp loạn EuroIntervention 2014;10-online publish-ahead-of-print August 2014 Chỉ định điều trị RF rối. .. mắc rối loạn nhịp thất theo vùng NMCT International Journal of Contemporary Medical Research Volume | Issue | May 2016 | ICV: 50.43 | Sinh lý bệnh rối loạn nhịp thất NMCT cấp Piccini et al Rối loạn