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

Hà Nội 26/11/2016<br /> <br /> RỐI LOẠN NHỊP THẤT<br /> trong nhồi máu cơ tim cấp<br /> ThS.BS Hoàng Việt Anh<br /> Trưởng phòng Q3B - Viện Tim mạch quốc gia Việt Nam<br /> <br /> Nhồi máu cơ tim<br /> <br /> •  Là bệnh lý tim mạch có tỷ lệ mắc ngày càng tăng và tỷ lệ tử vong cao<br /> •  Tỷ lệ mới mắc tại Hoa Kỳ: 735.000 người/năm<br /> •  Yếu tố nguy cơ: Tăng huyết áp, ĐTĐ2, Rối loạn lipid máu, Béo phì, ít vận<br /> động thể chất, cuộc sống căng thẳng….<br /> <br /> Rối loạn nhịp là một biến chứng của NMCT<br /> <br /> Reference<br /> <br /> to Ventricular<br /> MYOCAItDIAL<br /> <br /> to Ventricular<br /> <br /> %<br /> <br /> No.<br /> Episodes-<br /> <br /> 16<br /> <br /> Dallas,<br /> <br /> 14<br /> 2 INTRODUCTION3<br /> <br /> Tachycardia*<br /> <br /> mean<br /> E. with<br /> JONES,<br /> <br /> Total F.C.C,P,,**<br /> M.D.,<br /> <br /> F. A. BASHOUR,<br /> Inferior<br /> <br /> Anterior<br /> <br /> Tachycardia*<br /> <br /> Reference<br /> <br /> LESION<br /> <br /> 10<br /> <br /> SGOT<br /> of 213 units per ml,<br /> M.D.f<br /> M.D.<br /> true AND R. EDMONSON, tachycardia<br /> ventricular<br /> <br /> Texas<br /> <br /> per<br /> <br /> ml.<br /> <br /> In<br /> <br /> the<br /> <br /> absence<br /> <br /> of ventricular<br /> <br /> cardia,<br /> the accepted,<br /> mean because of the sequence<br /> SGOT<br /> rise<br /> generally<br /> the<br /> of coronary<br /> with of events following<br /> acute<br /> myocardial ligation infarction<br /> <br /> i<br /> <br /> Cardiac<br /> Arrhythmias<br /> in Acute<br /> Myocardial<br /> T Infarction M.D.f<br /> BASHOUR,<br /> M.D.,<br /> F.C.C,P,,** Supraventricular E. JONES, infarction 5has changed<br /> AND ml. R. EDMONSO<br /> cardial<br /> tachycardia<br /> 4<br /> 1<br /> 16.6<br /> per<br /> the past<br /> years;<br /> II. Incidence<br /> of the Common<br /> Arrhythmias block in0with 303 Specialremained 10 in the units The reported The number cardiac of patie<br /> 3<br /> Complete<br /> AV<br /> incidence<br /> of<br /> arshock<br /> or heart<br /> failure<br /> on admission<br /> neighborhood<br /> of 30<br /> cent.<br /> In the maMultifocal<br /> PVC’s<br /> 16<br /> 14<br /> 30<br /> 100<br /> of instances,<br /> Reference<br /> to Ventricular<br /> Tachycardia* jority Texas death occurred in Voiume<br /> to demonstrate<br /> a close relationship<br /> Si, No. S<br /> Ectopic Dallas,<br /> ventricular<br /> first 48<br /> 50 per cent<br /> rhythms:<br /> clinical<br /> and<br /> of these patients,<br /> death<br /> is sudden<br /> and un- these<br /> May,myocardial 1967 features The developmentthe ofa<br /> infarction.<br /> a) True<br /> ventricular<br /> expected.<br /> These<br /> patients<br /> are clinically<br /> well of ectopic<br /> ventricular<br /> rhythms.<br /> Atrial<br /> <br /> F. A.<br /> <br /> fibrillation<br /> <br /> 1<br /> <br /> HE<br /> <br /> MORTALITY<br /> <br /> RATE<br /> <br /> IN<br /> <br /> ACUTE<br /> <br /> MYO-<br /> <br /> arteries<br /> <br /> little<br /> <br /> in dogs,<br /> <br /> tricular<br /> <br /> it<br /> <br /> that<br /> <br /> this<br /> <br /> group<br /> <br /> and<br /> <br /> arrhythmia<br /> <br /> fibrillation.<br /> <br /> dies<br /> <br /> of ven-<br /> <br /> per<br /> <br /> rhythmias<br /> <br /> the<br /> <br /> hours.<br /> <br /> Approximately<br /> <br /> the<br /> <br /> F. A.<br /> <br /> olume<br /> <br /> ay,<br /> <br /> ine<br /> <br /> No.<br /> <br /> 51,<br /> <br /> INCIDENCE<br /> <br /> 1967<br /> <br /> was<br /> <br /> or<br /> <br /> S<br /> <br /> used<br /> <br /> T<br /> atrial<br /> <br /> alone<br /> <br /> in<br /> <br /> arrhythmia.<br /> <br /> Cardiac<br /> <br /> wo groups<br /> myocardial<br /> <br /> one<br /> <br /> other<br /> <br /> T<br /> <br /> arrhythmias<br /> <br /> were<br /> <br /> OF<br /> <br /> BASHOUR,<br /> <br /> M.D.,<br /> <br /> COMMON<br /> <br /> and<br /> <br /> patient<br /> <br /> one<br /> <br /> inferior<br /> <br /> into<br /> <br /> Texas<br /> <br /> myocardial<br /> <br /> infarction)<br /> <br /> bigeminy<br /> in<br /> the bigeminal<br /> <br /> INTRODUCTION<br /> one of these,<br /> <br /> R.<br /> <br /> JONES,<br /> <br /> Dallas,<br /> <br /> INTRODUCTION<br /> and ventricular<br /> <br /> divided<br /> <br /> E.<br /> <br /> F.C.C,P,,**<br /> <br /> ARRHYTHMIAS<br /> <br /> M.D.f<br /> tachycardia AND (rate<br /> than<br /> 523 greater<br /> than<br /> 100/mm)<br /> b) Slow ventricular<br /> rhythm<br /> (rate<br /> from<br /> 70-100/mm)<br /> <br /> 11 patients.<br /> In<br /> *One<br /> had<br /> generally patient accepted,<br /> rhythm<br /> lastedventricular<br /> rhythms.<br /> <br /> atEDMONSON, death<br /> the time of<br /> <br /> struction<br /> *From<br /> <br /> HE<br /> <br /> M.D. sufficient<br /> without<br /> <br /> myocardial<br /> <br /> tissue<br /> <br /> the 7 terminal 15 event,<br /> <br /> to 8 explain<br /> the<br /> <br /> Department<br /> <br /> at<br /> <br /> been<br /> <br /> University<br /> <br /> Southwestern<br /> Professor<br /> <br /> Medical<br /> <br /> generally<br /> <br /> f5*<br /> Present<br /> <br /> address<br /> <br /> 1<br /> <br /> Medicine.<br /> <br /> of<br /> <br /> 6in<br /> <br /> intern<br /> <br /> -<br /> <br /> to<br /> <br /> widely.<br /> <br /> the<br /> <br /> 20<br /> <br /> at<br /> <br /> this<br /> In<br /> <br /> group<br /> dies<br /> one, the run of<br /> by ventricular<br /> fibrillation.<br /> <br /> This<br /> <br /> frequency<br /> <br /> rhythm<br /> <br /> for<br /> <br /> cardiac<br /> Dilantin<br /> <br /> of<br /> <br /> the true<br /> <br /> patients<br /> <br /> continuous<br /> <br /> The<br /> <br /> fold:<br /> <br /> is<br /> <br /> recording<br /> <br /> with<br /> <br /> acute<br /> <br /> recording<br /> <br /> incidence<br /> <br /> and<br /> <br /> of<br /> <br /> the evaluation<br /> <br /> patients. arrhythmiaThe<br /> cardiac<br /> <br /> the<br /> <br /> the<br /> <br /> purpose<br /> <br /> are<br /> to<br /> <br /> of<br /> <br /> reportedthe<br /> describe<br /> <br /> of the<br /> <br /> that abnormal<br /> occur<br /> <br /> (Dila<br /> becau<br /> 3.<br /> beats<br /> were<br /> ventricular<br /> these bi<br /> the<br /> <br /> in the immediate<br /> post-infarction<br /> cardiac<br /> arrhythmias<br /> <br /> Stan- group<br /> <br /> variation<br /> <br /> of<br /> <br /> rhythmwas has used<br /> permitted prophylactically of<br /> the study<br /> <br /> consecutive of<br /> types<br /> the<br /> <br /> School.<br /> <br /> Medicine<br /> <br /> ford<br /> University.<br /> slow<br /> Resident<br /> in and<br /> Medicine. rapid<br /> ectopic<br /> Part<br /> of<br /> this<br /> work<br /> was<br /> presented<br /> at the Texas<br /> Heart<br /> Association<br /> Meeting,<br /> Texarkana<br /> (February 2, 1965)<br /> and<br /> the Midwestern<br /> Section,<br /> American<br /> Federation<br /> for Clinical<br /> Research,<br /> Chicago,<br /> November,<br /> l965.’<br /> <br /> both<br /> <br /> cardiac<br /> <br /> methods<br /> <br /> de-<br /> <br /> necropsy<br /> <br /> 50 has<br /> It<br /> <br /> Medicine,<br /> <br /> of<br /> <br /> due<br /> <br /> hydantoin<br /> accepted,<br /> because<br /> of the sequence<br /> the of<br /> ligationeventscoronary followingin<br /> of<br /> agent<br /> <br /> of Texas<br /> **Associate<br /> <br /> HE<br /> MORTALITY<br /> three RATE<br /> hours.<br /> ventricular<br /> to MORTALITY the<br /> the location<br /> of<br /> RATEIN TrueACUTE MYO- tachycardia events following<br /> IN ACUTE of<br /> MYOthat<br /> was present<br /> in 15 patients,<br /> incianterior<br /> and inferior infarction<br /> ventricular in dogs,<br /> tachycardia.<br /> cardial<br /> has changed<br /> little and the arteries<br /> <br /> according<br /> infarction:<br /> <br /> of<br /> <br /> varied<br /> <br /> largely<br /> <br /> in<br /> <br /> this<br /> <br /> period.<br /> encountered<br /> <br /> study<br /> <br /> was<br /> <br /> in<br /> incidence Table<br /> of<br /> <br /> ous<br /> premature<br /> <br /> threeseri-<br /> <br /> the<br /> <br /> cardiac<br /> arrhythmia,<br /> ventricular<br /> presence<br /> of ventricular<br /> <br /> in<br /> <br /> to correlate<br /> tachycardia<br /> <br /> a preliminary<br /> <br /> of the disease,<br /> and<br /> the use of diphenyl-<br /> <br /> 13 patients<br /> known<br /> clinical<br /> <br /> three.<br /> of ven-<br /> <br /> and<br /> features<br /> <br /> report<br /> prematureon<br /> <br /> The<br /> <br /> the<br /> with<br /> <br /> ventricular<br /> <br /> associated<br /> arrhythmia<br /> andarteries<br /> in dogs, that thi<br /> past 30 years;<br /> in the<br /> cardialin the infarction it remained changed tricular little<br /> has<br /> MATERIAL<br /> TheThe reported glutamic<br /> incidence<br /> of cardiac<br /> arneighborhood<br /> of 30 per cent.<br /> In the maserum<br /> oxaloacetic<br /> transwere grouped<br /> and<br /> rhythmias<br /> varied<br /> widely. tricular variation arrhythmia<br /> This<br /> is<br /> (SGOT)<br /> in the pastjority 30 instances, death it occurred in the<br /> years;<br /> remained<br /> in the<br /> of<br /> largely<br /> due to the frequency<br /> of recording<br /> first 48 hours.<br /> Approximately<br /> in 50 per cent<br /> Patients incidence<br /> with<br /> The with reported<br /> The neighborhood<br /> commonly<br /> encountered<br /> cardiac of ar- 30<br /> acute<br /> per sudden and un-In the cardiacma-rhythm of patients<br /> cent.<br /> the<br /> of these patients,<br /> death<br /> is<br /> myocardial<br /> infarction.<br /> The development dence<br /> of<br /> of widely.<br /> an<br /> expected.<br /> These<br /> patientsthe ventricular<br /> are clinically<br /> well<br /> arrhythmia.<br /> slow<br /> ibrillation<br /> jority appeared ofa inrapidthree the patients of deathfor death sufficient de- The methods the continuous rhythmias of the varied<br /> instances, (or<br /> occurred<br /> in for<br /> recording<br /> at ventricular<br /> time<br /> without<br /> 10 per cent),<br /> with<br /> recardiac<br /> rhythm<br /> has permitted<br /> the study were<br /> of<br /> struction<br /> of myocardial<br /> tissue<br /> necropsy<br /> duethe to studied. frequ<br /> the<br /> first 48 hours.explain Approximatelyevent, at has in 50 the true cent<br /> per incidence and largely<br /> the evaluation<br /> of<br /> to<br /> the terminal<br /> It<br /> been<br /> FIGURE<br /> 1:arrhythmia<br /> Avionics’ that monitoring<br /> system.<br /> 30 episodes The unit,<br /> of<br /> the<br /> rhythm<br /> recorder<br /> is the small<br /> the<br /> of these patients,<br /> death<br /> is sudden pertypesthe of immediatecardiacThepost-infarction cardiacoccur portable unit in of<br /> and the ner.<br /> unin minperiod.<br /> cardiocharter.<br /> Medicine.<br /> to be<br /> purpose<br /> study<br /> was<br /> whom<br /> had anterior<br /> myocardial (referred<br /> fThese<br /> Stanexpected. and one inferior myo- patients<br /> are clinically The to well ofthe thisincidence of the three- infarction.<br /> cardial<br /> infarction.<br /> fold:predescribe<br /> serifor a<br /> ous<br /> to<br /> the<br /> for<br /> at the time of death<br /> withoutat<br /> sufficient cardiac of ventricular methods<br /> de- arrhythmia, tachycardiacorrelate tored continuous pe<br /> presence<br /> with<br /> of<br /> stances, has perm<br /> the m<br /> cardiac disease, rhythm<br /> known<br /> clinical<br /> features<br /> of the<br /> and<br /> struction<br /> of myocardial<br /> tissue<br /> at necropsy<br /> a preliminary<br /> report<br /> on the use of diphenylthe true incidence anterior<br /> and<br /> in the<br /> to explain<br /> the terminal<br /> event,<br /> It has been<br /> types<br /> of of the heart arrh<br /> the cardiac<br /> *From<br /> the Department<br /> of<br /> Medicine,<br /> University<br /> Downloaded From: http://journal.publications.chestnet.org/ on 11/15/2016<br /> in the immediate<br /> diaphragmatic post-inf<br /> of Texas<br /> Southwestern<br /> Medical<br /> School.<br /> <br /> (or posterior).<br /> <br /> nvolvement<br /> <br /> Arrhythmias<br /> <br /> of the<br /> <br /> lateral<br /> <br /> with<br /> <br /> dence<br /> <br /> with<br /> <br /> either<br /> <br /> myocardial<br /> <br /> previous<br /> <br /> terior<br /> <br /> wall<br /> <br /> cardia<br /> <br /> are reported<br /> <br /> in<br /> <br /> Table<br /> <br /> more<br /> <br /> ectopic<br /> <br /> ponse<br /> in two<br /> patients.<br /> Wandering<br /> maker<br /> was observed<br /> in 11 patients.<br /> ure<br /> atrial<br /> beats<br /> were<br /> frequent<br /> in<br /> <br /> **Associate<br /> <br /> Present<br /> <br /> observed<br /> <br /> pacePremafour pathe tachyDepartment<br /> <br /> *From<br /> supraventricular<br /> of<br /> in five patients, Texas four Southwestern<br /> of<br /> <br /> Paroxysmal<br /> occurred<br /> <br /> Multifocal<br /> ventricular<br /> were seen in all patients.<br /> <br /> was<br /> <br /> or<br /> <br /> 1. Atrial<br /> <br /> beats<br /> <br /> in<br /> <br /> three<br /> <br /> Professor<br /> <br /> address<br /> <br /> -<br /> <br /> six<br /> and<br /> <br /> per<br /> <br /> ranged<br /> <br /> minute.<br /> <br /> ventricular<br /> <br /> ventricular<br /> <br /> PVC’s<br /> <br /> infarction. fibrillation<br /> <br /> tachyaminase<br /> one<br /> and<br /> 70. The<br /> in<br /> between<br /> 100 and 27<br /> blood<br /> In five patients,<br /> two<br /> <br /> foci<br /> <br /> were<br /> <br /> was<br /> <br /> (Fig.<br /> <br /> followed<br /> <br /> 4).<br /> <br /> rhythm<br /> <br /> patients,<br /> five of whom<br /> one inferior<br /> myocardial<br /> <br /> ute. In one patient,<br /> both types<br /> intern<br /> in Medicine<br /> at<br /> rhythm<br /> were<br /> present.<br /> Runs<br /> <br /> multifocal,<br /> <br /> number.<br /> <br /> Atrial<br /> <br /> cardia<br /> <br /> levels<br /> <br /> patients.<br /> <br /> levels<br /> <br /> The<br /> <br /> was<br /> <br /> peak<br /> <br /> correlated<br /> <br /> were<br /> <br /> of<br /> <br /> with<br /> <br /> SGOT<br /> <br /> the<br /> <br /> were<br /> <br /> tient<br /> <br /> determined<br /> <br /> rise<br /> <br /> ap-<br /> <br /> were<br /> <br /> observed<br /> <br /> had<br /> <br /> noted<br /> <br /> respectively.<br /> <br /> was<br /> <br /> quite<br /> <br /> r<br /> <br /> and<br /> <br /> nod<br /> <br /> fibrillation<br /> in<br /> <br /> ventricular<br /> <br /> two<br /> <br /> and<br /> <br /> Ventricular<br /> <br /> in four<br /> <br /> i<br /> <br /> t<br /> <br /> patients,<br /> <br /> ach<br /> <br /> two<br /> <br /> fibrillation<br /> <br /> on<br /> <br /> responsible<br /> <br /> was<br /> <br /> present<br /> <br /> in<br /> <br /> had<br /> anterior<br /> infarction.<br /> The<br /> <br /> attacks<br /> numbered<br /> between<br /> one and<br /> of<br /> Medicine, and University ventricular<br /> a single<br /> patient<br /> the<br /> ranged Medical<br /> between School. and<br /> 72<br /> 90 beats<br /> of<br /> <br /> three<br /> an-<br /> <br /> of ventricular<br /> <br /> between<br /> <br /> rate<br /> <br /> between<br /> <br /> myocardial<br /> <br /> of attacks<br /> <br /> varied<br /> <br /> ventricular<br /> <br /> distributed<br /> <br /> inferior<br /> <br /> number<br /> <br /> 220<br /> <br /> rhythmias<br /> <br /> equally<br /> <br /> and<br /> <br /> The<br /> <br /> location<br /> <br /> depending<br /> on whether<br /> the anterior or the<br /> nferior<br /> wall<br /> was predominantly<br /> involved.<br /> <br /> ients.<br /> cardia<br /> <br /> was<br /> <br /> though<br /> <br /> ten<br /> <br /> in<br /> rate<br /> <br /> FIGURE<br /> 1:<br /> Avionics’<br /> ner.<br /> The recorder<br /> is<br /> <br /> monitoring<br /> the small<br /> <br /> system.<br /> The<br /> unit,<br /> portable<br /> unit<br /> in the<br /> <br /> of ventricular<br /> of three<br /> <br /> ford<br /> University.<br /> premature<br /> beats<br /> ventricular<br /> beats<br /> interrupted<br /> Resident<br /> in Medicine. mature<br /> normally presented<br /> conducted<br /> beats<br /> were<br /> seen in<br /> R/TPart phenomenon<br /> of<br /> this<br /> work<br /> was<br /> the Texas<br /> Meeting,<br /> Texarkana<br /> (Febru(twoHeart had Association<br /> anterior<br /> patients;<br /> 12 of these<br /> patients<br /> had<br /> runs<br /> ary 2, 1965)<br /> and<br /> the Midwestern<br /> Section,<br /> American<br /> Federation<br /> for Clinical<br /> Research,<br /> Chicago,<br /> November,<br /> l965.’<br /> <br /> on<br /> <br /> center<br /> <br /> cardiocharter.<br /> <br /> 520<br /> <br /> by<br /> 16<br /> <br /> Downloaded From: http://journal.publications.chestnet.org/ on 11/15/2016<br /> <br /> V.W.<br /> <br /> (PMH<br /> <br /> 283525)<br /> <br /> 1-28-65<br /> <br /> the<br /> <br /> right<br /> <br /> of<br /> <br /> the<br /> <br /> side<br /> <br /> picture.<br /> <br /> of<br /> <br /> the<br /> <br /> On<br /> <br /> picture,<br /> the<br /> <br /> represents<br /> <br /> left<br /> <br /> side<br /> <br /> the<br /> <br /> is<br /> <br /> the<br /> <br /> scan-<br /> <br /> eLectro-<br /> <br /> Table 1. Occurrence of arrhythmias in STEMI patients during and<br /> Tỷ lệ mắc các rối loạn nhịp thất trong ACS<br /> immediately after primary PCI.71<br /> Accelerated idioventricular rhythm (50-120 b.p.m.)<br /> <br /> 15-42%<br /> <br /> Sinus bradycardia (100 b.p.m.)<br /> <br /> 22%<br /> <br /> Atrial fibrillation<br /> High-degree AV block<br /> <br /> 9%<br /> 5-10%<br /> <br /> Sustained VT<br /> <br /> 2-4%<br /> <br /> VF<br /> <br /> 2-5%<br /> <br /> AV: atrioventricular; b.p.m.: beats per minute; PCI: percutaneous<br /> coronary intervention; STEMI: ST-elevation myocardial infarction;<br /> VF: ventricular fibrillation; VT: ventricular tachycardia<br /> <br />