Hng dn u tin ca hi tim mch Chu u v x tr rung nh

Cch y 4 nm, Hi Tim mch chu u phi hp vi Trng mn Tim mch Hoa K v Hip hi Tim
Hoa K a ra mt hng dn chung v x tr bnh nhn rung nh 1. Hng dn ny cp mt cch chi
tit n nh ngha, phn loi, dch t hc v d hu, cc c ch sinh l bnh, cc nguyn nhn, bnh l kt
hp, cc biu hin lm sng, cht lng sng, cch nh gi lm sng v iu tr bnh nhn rung nh.
Hng dn chung ny rt hu ch i vi cc bc s thc hnh c 2 b i Ty Dng. Tuy nhin trong
cc hi ngh khoa hc thng nin gn y ca Hi tim mch chu u, nhiu chuyn gia tim mch chu
lc ny nu kin cn phi c mt hng dn ring v x tr rung nh cho chu u. kin ny xut pht
t mt thc t l c 2 khc bit ln gia chu u v Hoa K trong thc hnh thng ngy. Khc bit th
nht l vic cp php lu hnh thuc Hoa K l do FDA (Food and Drug Administration) thc hin, cn
chu u l do EMA (European Medicines Agency) thc hin. Danh mc v cc ch nh c th ca cc
thuc c cp php bi 2 c quan ny khng phi lc no cng ging nhau. Khc bit th hai l Hoa K
s lng bc s chuyn khoa tim mch v bc s chuyn v in sinh l tim nhiu hn so vi chu u, do
vy chu u cn c mt hng dn khng ch dnh cho bc s chuyn khoa m cn phi nhm n cc bc
s a khoa 2.
Thng 10 va qua Hi Tim mch chu u cng b hng dn ring u tin ca Hi v x tr rung nh 3.
Theo GS John Camm (i hc St George, London) l trng ban bin son, hng dn 2010 ca Hi Tim
mch chu u c mt s im mi v mt phn tng nguy c v iu tr 2. Bi vit di y tm tt mt s
im mi chnh c GS John Camm cp.
PHN TNG NGUY C BNH NHN RUNG NH
Trong s cc phng php phn tng nguy c dnh cho bnh nhn rung nh khng do bnh van tim, thang
im CHADS2 (CHADS2 score) thng c dng nht v c gi tr c kim chng. Trong 5 ch ci
C, H, A, D v S, ch C l vit tt ca Congestive heart failure (bnh nhn c suy tim hoc phn sut tng
mu tht tri 40%), H l vit tt ca Hypertension (tng huyt p), A l vit tt ca Age (tui cao > 75), D
l vit tt ca Diabetes (i tho ng) v S l vit tt ca Stroke (tin s t qu hoc cn thiu mu no
thong qua). S 2 sau ch S (S2) nhm nhn mnh l yu t nguy c ny c tm quan trng gp i cc
yu t cn li. Cch tnh im da vo thang im CHADS2 nh sau: ng vi tng thnh phn C, H, A
hoc D l 1 im, cn ng vi S2 l 2 im. Phn tng nguy c da vo thang im CHADS2 c ly lm
c s cho ch nh iu tr chng ng di hn: Nu bnh nhn c im l 0 th khng cn iu tr chng
ng, cn nu bnh nhn c tng s im 2 th c ch nh dng thuc chng ng di hn. im bng 1
l mt "vng xm": Trong trng hp ny cc tc gi khng thng nht vi nhau v hng x tr, mt s
ngh dng thuc chng ng, mt s khc th ngh dng aspirin liu thp.
Hng dn 2010 a ra mt thang im mi l thang im CHA2DS2-VASc, theo vic phn tng nguy
c cng nh ch nh iu tr chng ng cho nhng trng hp trong "vng xm" c nu ln mt cch
chi tit hn. Trong thang im ny c 2 yu t nguy c chnh (major risk factor) l A2 v S2. A2 (Age 75)
l tui 75 v S2 (Stroke / TIA / Systemic embolism) l tin s t qu, cn thiu mu no thong qua hoc
thuyn tc mch h thng. ng vi mi yu t nguy c chnh l 2 im. C 6 yu t nguy c quan trng v
mt lm sng (clinically relevant risk factor) l: C (Congestive heart failure / LV systolic dysfunction - suy tim

hoc phn sut tng mu tht tri 40%), H (Hypertension - tng huyt p), D (Diabetes - i tho ng),
V (Vascular disease - bnh mch mu, gm tin s nhi mu c tim, bnh ng mch ngoi vi hoc s
hin din mng x va phc tp trong ng mch ch), A (Age - tui 65-74) v Sc (Sex category - gii n).
ng vi mi yu t nguy c quan trng v mt lm sng l 1 im. Trn bng 1 l cch tnh im theo
thang im CHA2DS2-VASc v nguy c t qu ty theo tng s im.
Bng 1: Cch tnh im theo thang im CHA2DS2-VASc v nguy c t qu ty theo tng s im.
Yu t nguy c

im

C: Suy tim / phn sut tng mu 40%

H: Tng huyt p

A2: Tui 75

D: i tho ng

S2: t qu / cn thiu mu no thong qua / thuyn tc mch h thng

V: Bnh mch mu (tin s nhi mu c tim / bnh ng mch ngoi vi / mng x va ng

mch ch)

A: Tui 65-74

Sc: Gii n

im ti a

IM

TN SUT T QU (%/NM)

IM

TN SUT T QU (%/NM)

6,7

1,3

9,8

2,2

9,6

3,2

6,7

4,0

15,2

Phn tng nguy c theo thang im CHA 2DS2-VASc c ly lm c s cho vic ch nh iu tr chng
ng. Bng 2 tm tt tip cn phng nga huyt khi thuyn tc cho bnh nhn rung nh da vo im
CHA2DS2-VASc.
Bng 2: Phng nga huyt khi thuyn tc cho bnh nhn rung nh.
Yu t nguy c

im CHA2DS2-VASc

iu tr c khuyn co

Mt yu t nguy c chnh hoc 2 yu

t nguy c quan trng v mt lm sng

Thuc chng ng ung*

Thuc chng ng ung* hoc aspirin

Mt yu t nguy c quan trng v mt
lm sng

75-325 mg/ngy.
Thuc chng ng ung c a
chung hn aspirin.
Aspirin 75-325 mg/ngy hoc khng

Khng c yu t nguy c no

dng thuc g c.
Khng dng thuc g c c a
chung hn aspirin.

*Thuc chng ng ung: thuc khng vitamin K, dng vi liu t INR trong khong 2-3. C th
dng nhng thuc chng ng ung mi c cng nhn, v d dabigatran.
IU TR BNG THUC
Trong hng dn 2010 c mt thuc chng lon nhp mi c cp l dronedarone. Dronedarone l mt
ng dng ca amiodarone, c tc dng gim tn s p ng tht (c khi ngh ln khi gng sc) v duy tr
nhp xoang sau chuyn nhp. Dronedarone t c tnh hn amiodarone nhng hiu qu duy tr nhp xoang
cng km hn so vi amiodarone. Theo hng dn 2010, dronedarone c khuyn co dng vi liu 400
mg x 2/ngy ( ngi ln), cho c ngi khng c hoc c bnh tim thc th nh ln cho ngi c bnh
tim thc th ng k (tng huyt p km ph i tht tri, bnh mch vnh, suy tim NYHA I-II). Dronedarone
chng ch nh ngi suy tim NYHA III-IV.
Hng dn 2010 cng cp nht nhng thng tin mi v li ch ca thuc c ch men chuyn, thuc chn
th th angiotensin v thuc nhm statin trong iu tr rung nh. Cc nhm thuc ny c xp chung trong
liu php "thng ngun" (upstream therapy) tc l liu php hng n vic ngn nga hoc lm chm
qu trnh ti cu trc c tim lin quan vi tng huyt p, suy tim hoc vim (v d sau phu thut tim). Qua
vic chng ti cu trc c tim, liu php "thng ngun" c th ngn s xut hin rung nh (phng nga
tin pht) hoc mt khi rung nh xut hin, ngn rung nh ti pht hoc tin trin thnh rung nh thng
trc (phng nga th pht). Bng 3 v 4 tm tt ch nh ca liu php "thng ngun" trong phng nga
tin pht v th pht rung nh.
Bng 3: Phng nga tin pht rung nh vi liu php "thng ngun".
Khuyn co

Loi

Nn xem xt dng thuc c ch men chuyn v chn th th angiotensin nhm IIa

Mc chng c
A

phng nga rung nh mi xut hin bnh nhn c suy tim v phn sut tng
mu thp.

Nn xem xt dng thuc c ch men chuyn v chn th th angiotensin nhm IIa

phng nga rung nh mi xut hin bnh nhn tng huyt p, nht l nu c
ph i tht tri.
Nn xem xt dng thuc nhm statin nhm phng nga rung nh mi xut hin IIa

sau phu thut bc cu ni ng mch vnh (bc cu n thun hoc kt hp

vi phu thut van tim).
C th xem xt dng thuc nhm statin nhm phng nga rung nh mi xut

IIb

III

Khuyn co

Loi

Mc chng c

C th xem xt vic iu tr trc vi thuc c ch men chuyn v chn th

IIb

IIb

hin ngi c bnh tim, nht l nu c suy tim.

Liu php "thng ngun" vi thuc c ch men chuyn, chn th th
angiotensin v statin khng c khuyn co nhm phng nga tin pht rung
nh cho ngi khng c bnh tim mch.

Bng 4: Phng nga th pht rung nh vi liu php "thng ngun".

th angiotensin cho bnh nhn c rung nh ti din v ang dng thuc chng
lon nhp.
Thuc chn th th angiotensin hoc c ch men chuyn c th hu ch trong
phng nga cn rung nh ti din hoc i vi bnh nhn c rung nh dai dng
c sc in chuyn nhp v khng c bnh tim thc th nng, nu cc thuc
ny c ch nh v nhng nguyn nhn khc (v d tng huyt p).

IU TR CHNG HUYT KHI SAU T STENT NG MCH VNH BNH NHN RUNG NH
Sau t stent ng mch vnh, bnh nhn cn c iu tr vi phi hp 2 thuc chng tiu cu l aspirin
v clopidogrel. bnh nhn rung nh ang dng thuc khng vitamin K, iu tr chng huyt khi sau t
stent ng mch vnh phi bao gm 3 thuc l khng vitamin K, aspirin v clopidogrel. Nguy c chy mu
nng khi dng ng thi 3 thuc mc chp nhn c nu thi gian iu tr ngn, tuy nhin thi gian iu
tr cng di th nguy c ny cng ln.
Hng dn 2010 a ra thang im HAS-BLED nh gi nguy c chy mu. HAS-BLED l ch vit tt,
trong H l Hypertension (tng huyt p, c nh ngha l huyt p tm thu > 160 mm Hg), A l
Abnormal renal/liver function (bt thng chc nng thn/gan, trong bt thng chc nng thn l thn
nhn to nh k, ghp thn hoc creatinin huyt thanh 200 mmol/l, bt thng chc nng gan l bnh
gan mn nh x gan hoc bt thng sinh ha r rt, v d bilirubin > 2 gii hn trn km AST, ALT,

alkaline phosphatase > 3 gii hn trn), S l Stroke (tin s t qu), B l Bleeding (chy mu, gm tin s
chy mu v/hoc tng chy mu), L l Labile INRs (INR dao ng, l INR khng n nh hoc t l thi
gian INR trong khong tr liu < 60%), E l Elderly (ln tui, nh ngha l tui > 65), v D l Drugs/alcohol
(c dng ng thi thuc tng nguy c chy mu nh thuc chng tiu cu hoc khng vim khng steroid
hoc nghin ru). Trn bng 5 l cch tnh im theo thang im HAS-BLED. im HAS-BLED 3 tng
ng vi nguy c chy mu cao.
Bng 5: Cch tnh im theo thang im HAS-BLED.
Ch ci

c im lm sng

im

Tng huyt p

Bt thng chc nng thn/gan (1 im cho mi yu t)

1 hoc 2

t qu

Chy mu

INR dao ng

Tui > 65

Dng ng thi thuc tng nguy c chy mu hoc nghin ru (1 im cho 1 hoc 2
mi yu t)
Ti a 9 im

Ty theo im HAS-BLED v bi cnh lm sng, phc iu tr chng huyt khi sau t stent ng mch
vnh c mt s im khc nhau. Ni chung, stent ph thuc khng c khuyn khch, nht l nhng
bnh nhn c nguy c chy mu cao. Trong thi gian dng thuc chng ng ung phi hp aspirin, nn
xem xt dng thm mt thuc c ch bm proton hoc khng th th H2 nga xut huyt tiu ha. Trn
bng 6 l phc iu tr chng huyt khi sau t stent ng mch vnh cho bnh nhn rung nh c ch
nh dng thuc chng ng ung di hn.
Nhiu bnh nhn rung nh c bnh mch vnh mn n nh (khng c bin c cp, khng c t stent trong
1 nm trc ). nhng ngi ny, ch cn dng thuc chng ng ung l . Nhiu nghin cu cho
thy ngi bnh mch vnh mn n nh, thuc chng ng ung c hiu qu nga nhi mu c tim/t
qu tng ng aspirin v phi hp thuc chng ng ung vi aspirin khng tng hiu qu ny m ch
tng nguy c chy mu.
Bng 6: Phc iu tr chng huyt khi sau t stent ng mch vnh cho bnh nhn rung nh c ch
nh dng thuc chng ng ung.
Nguy c chy mu

Bi cnh lm sng

Loi stent

Ch iu tr

Thp hoc trung

t stent chng

gian (im HAS-

trnh

Thng

1 thng: KVK (INR 2,0-2,5) + ASA 100 mg/ngy +

clopidogrel 75 mg/ngy

BLED 0-2)

Cho n thng th 12: KVK (INR 2,0-2,5) +

clopidogrel 75 mg/ngy (hoc ASA 100 mg/ngy)
Sut i: KVK n thun (INR 2,0-3,0)
t stent chng

Ph thuc

trnh

3 thng (nhm -olimus) n 6 thng (paclitaxel):

KVK (INR 2,0-2,5) + ASA 100 mg/ngy +
clopidogrel 75 mg/ngy
Cho n thng th 12: KVK (INR 2,0-2,5) +
clopidogrel 75 mg/ngy (hoc ASA 100 mg/ngy)
Sut i: KVK n thun (INR 2,0-3,0)

Hi chng mch

Thng /ph 6 thng: KVK (INR 2,0-2,5) + ASA 100 mg/ngy +

vnh cp

thuc

clopidogrel 75 mg/ngy
Cho n thng th 12: KVK (INR 2,0-2,5) +
clopidogrel 75 mg/ngy (hoc ASA 100 mg/ngy)
Sut i: KVK n thun (INR 2,0-3,0)

Cao (im HAS-

t stent chng

BLED 3)

trnh

Thng

2-4 tun: KVK (INR 2,0-2,5) + ASA 100 mg/ngy

+ clopidogrel 75 mg/ngy
Sut i: KVK n thun (INR 2,0-3,0)

Hi chng mch
vnh cp

Thng

4 tun: KVK (INR 2,0-2,5) + ASA 100 mg/ngy +

clopidogrel 75 mg/ngy
Cho n thng th 12: KVK (INR 2,0-2,5) +
clopidogrel 75 mg/ngy (hoc ASA 100 mg/ngy)
Sut i: KVK n thun (INR 2,0-3,0)

KVK: thuc khng vitamin K; ASA: aspirin; Nhm -olimus: gm sirolimus,

everolimus v tacrolimus.
Ghi ch:

KIM SOT TN S THT: CHT CH HAY VA PHI ?

Trong cc hng dn iu tr rung nh trc y, tn s tht c khuyn co gi mc 60-80/pht lc
ngh v 90-115/pht khi gng sc. Khuyn co ny da vo chin lc iu tr c p dng trong nghin
cu AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) 4. Kt qu ca nghin cu
RACE II (Rate Control Efficacy in permanent atrial fibrillation: a comparison between lenient versus strict
rate control II) c cng b mi y lm thay i quan nim ny 5. Trong RACE II, 614 bnh nhn rung
nh thng trc c phn ngu nhin vo mt trong 2 nhm, nhm kim sot tn s tht va phi (tn s
tht lc ngh < 110/pht) v nhm kim sot tn s tht cht ch (tn s tht lc ngh < 80/pht). Tiu ch

nh gi chnh l phi hp cc bin c cht do nguyn nhn tim mch, nhp vin v suy tim, t qu, thuyn
tc mch h thng, chy mu v ri lon nhp nng (gm ngt, nhp nhanh tht ko di, ngng tim, tc dng
ph gy nguy him n tnh mng ca thuc dng kim sot tn s tht v phi t my to nhp hoc
my ph rung-chuyn nhp). Kt qu RACE II cho thy tn sut cc bin c thuc tiu ch nh gi chnh
ca 2 nhm khng khc bit 5.
Xut pht t kt qu ca RACE II, hng dn 2010 khng cn khuyn co kim sot tn s tht mt cch
cht ch cho mi bnh nhn rung nh. Vic kim sot tn s tht mt cch cht ch (lc ngh < 80/pht v
khi gng sc nh < 110/pht) ch c ngh cho nhng bnh nhn vn cn triu chng trong khi ang
c kim sot tn s tht mt cch va phi. Sau khi t mc tiu kim sot cht ch tn s tht nn cho
bnh nhn lm Holter ECG 24 gi nh gi s an ton ca tip cn iu tr ny (xem c nhp chm qu
mc hay khng).
X TR RUNG NH VN NG VIN
Hng dn 2010 dnh mt phn ring vit v x tr rung nh vn ng vin. Vic ny c 2 l do. L do th
nht l vn ng vin, tn sut rung nh cao gp 2-10 ln so vi trong dn s chung. iu ny c lin
quan vi nhng thay i c v chc nng (tng trng lc giao cm, tng ti th tch khi gng sc, tng
trng lc thn kinh X khi ngh) ln v cu trc (ph i v dn nh). L do th hai l vn ng vin kim
sot tn s tht thng kh t mc tiu hn: Thuc chn bta c dung np km (v thm ch b cm
dng khi thi u mt s mn th thao), digoxin v cc thuc chn canxi khng dihydropyridine th c hiu
qu km trong kim sot tn s tht khi gng sc.
Theo hng dn 2010, nu khi hot ng th lc mc ti a m tn s tht trong khi rung nh mc
chp nhn c v khng c du hiu ri lon huyt ng (chong vng, ngt, mt t ngt) th ngi vn
ng vin c th tham gia thi u.
Trong iu tr rung nh kch pht c mt cch tip cn c chp nhn gn y l tip cn "vin thuc trong
ti" ("pill-in-the-pocket" approach), tc l dng cc thuc chng lon nhp nhm I (propafenone, flecainide)
ung ngoi tr chuyn rung nh v nhp xoang. Cn lu l dng cc thuc ny n c c th dn n
mt bin c nguy him l cung nh chm vi dn truyn nh tht 1:1. Theo hng dn 2010, vn ng vin
c nhng cn rung nh kch pht c th dng propafenone hoc flecainide theo kiu "vin thuc trong ti"
chuyn nhp xoang, tuy nhin ngi vn ng vin phi ngng tp luyn v thi u khi rung nh vn cn v
cho n khi ht 1-2 bn thi gian loi thi ca thuc chng lon nhp (khuyn co loi IIa). Nn xem xt lm
th thut hy vng eo (isthmus ablation) cho nhng vn ng vin c xc nh c cung nh, nht l nu
nh dng cc thuc propafenone hoc flecainide (khuyn co loi IIa).
C 2 tnh hung m ngi vn ng vin khng nn tip tc tp luyn-thi u l: (1) c mt nguyn nhn
c hiu ca rung nh (v d cng gip) c xc nh nhng cha c gii quyt; (2) c triu chng
do ri lon huyt ng (v d chong vng).
iu tr chng ng c th cn thit ty theo s hin din ca cc yu t nguy c (thang im CHA2DS2VASc). Tuy nhin khng c iu tr chng ng cho ngi chi cc mn th thao c kh nng va chm
c th (gy chn thng).
TI LIU THAM KHO

1) ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: A report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
European Society of Cardiology Committee for Practice Guidelines (Writing committee to revise the 2001
guidelines for the management of patients with atrial fibrillation): Developed in collaboration with the
European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006;114:e257-e354.
2) Camm J. This year the first European Society of Cardiology guidelines for the management of patients
with atrial fibrillation will be published. Eur Heart J 2010;31:2311-2319.
3) Guidelines for the management of atrial fibrillation. The Task Force for the management of atrial
fibrillation of the European Society of Cardiology (ESC): Developed with the special contribution of the
European Heart Rhythm Association (EHRA). Eur Heart J 2010;31:2369-2429.
4) AFFIRM Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N
Engl J Med 2002;347:1825-1833.
5) Van Gelder IC, Groenveld HF, Crijns HJGM, et al, for the RACE II Investigators. Lenient versus strict rate
control in patients with atrial fibrillation. N Engl J Med 2010;362:1363-1373