Rối loạn nhịp thất trong nhồi máu cơ tim cấp - Hoàng Việt Anh

served
ejection fraction
Modern revascularization and secondary prevention therapy allows
preservation of LVEF in most patients presenting early with an acute
myocardial infarction. Although the risk for SCD in these patients is
substantially lower compared with patients with severely
impaired LVEF, the absolute number of SCD victims with preserved
LVEF is high. Improved SCD risk-detection strategies in the
intermediate-risk population are needed.
5.3.1 Risk stratification
Risk stratification in patients with stable coronary
artery disease after myocardial infarction with
preserved ejection fraction
Recommendations Classa Levelb Ref.c
PVS should be considered in survivors of
a myocardial infarction with preserved
LV function and otherwise unexplained
syncope.
IIa C
280–
282
LV ¼ left ventricular; PVS ¼ programmed ventricular stimulation.
aClass of recommendation.
bLevel of evidence.
cReference(s) supporting recommendations.
Most studies that have evaluated the usefulness of non-invasive risk
stratification have been performed in patients with severely im-
paired LVEF (,40%) or in mixed populations. In these studies, ei-
ther the outcome in the subgroup of patients with LVEF .40%
has not been reported or the subgroups were too small to allow
analysis and interpretation of the data. To date, in patients with re-
mote myocardial infarction and preserved LVEF, no non-invasive
risk stratification technique has demonstrated sufficient specificity
and sensitivity.
There is limited evidence from subgroups of large-scale studies
that programmed ventricular stimulation is helpful for risk stratifica-
tion in patients after myocardial infarction with intermediate LVEF
values or with an LVEF .40%.280 – 282 This question is currently
being addressed in the ongoing Risk Stratification in Patients
With Preserved Ejection Fraction (PRESERVE-EF) trial
(NCT02124018).
5.3.2 Recommendations for optimal strategy
Revascularization in patients with stable coronary
artery disease after myocardial infarction with
preserved ejection fraction
Recommendations Classa Levelb Ref.c
Coronary revascularization is
recommended to reduce the risk of
SCD in patients with VF when acute
myocardial ischaemia precedes the
onset of VF.
I B
289,
290
SCD ¼ sudden cardiac death; VF ¼ ventricular fibrillation.
aClass of recommendation.
bLevel of evidence.
cReference(s) supporting recommendations.
Guidelines for coronary revascularization have been published re-
cently.13 They provide clear management information and the read-
er is referred to the source documents for details.
In patients with CAD and VAs, assessment of obstructive coronary
disease and ischaemia is essential. Surgical revascularization may in-
crease survival and prevent SCD. Implantation of an epicardial ICD
lead at the time of coronary artery bypass grafting is not associated
with an overall mortality benefit. Percutaneous coronary intervention
is also associated with a marked decline in cardiac mortality driven by
fewer deaths from myocardial infarction or sudden death.
Revascularization may be associated with an increase in LVEF of
≥5–6% in 15–65% of stable patients. This is particularly true for
those with evidence of ischaemic or hibernating myocardium on
preoperative imaging studies.291,292 The majority of patients with se-
verely depressed LVEF immediately after STEMI show significantly
improved systolic function after 3 months.286 LVEF should be re-
evaluated 6–12 weeks after coronary revascularization to assess
potential indications for primary prevention ICD implantation.
In patients who survive SCD, revascularization can reduce the re-
currence of life-threatening arrhythmias and SCD and also improve
patient outcomes, particularly if there is evidence of ischaemia pre-
ceding SCD. Sustained monomorphic VT in patients with previous
myocardial infarction is less likely to be affected by revascularization.
Myocardial revascularization is unlikely to prevent recurrent SCD in
patients with extensive myocardial scarring and markedly depressed
LVEF.
5.3.3 Use of anti-arrhythmic drugs
Use of anti-arrhythmic drugs
Recommendations Classa Levelb Ref.c
Amiodarone may be considered for
relief of symptoms from VAs in survivors
of a myocardial infarction but it has no
effect on mortality.
IIb B
293,
294
ESC GuidelinesPage 28 of 87
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LVEF should be assessed 6–12 weeks after myocardial infarction
in stable patients and in those on optimized HF medication to assess
a potential indication for a primary preventive defibrillator implant-
ation. This evaluation should be structured and offered to all
patients.271,286–288
5.3 Stable coronary artery disease after
myocardial infarction with preserved
ejection fraction
Modern revascularization and secondary prevention therapy allows
preservation of LVEF in most patients presenting early with an acute
myocardial infarction. Although the risk for SCD in these patients is
substantially lower compared with patients with severely
impaired LVEF, the absolute number of SCD victims with preserved
LVEF is high. Improved SCD risk-detection strategies in the
intermediate-risk population are needed.
5.3.1 Risk stratification
Risk stratification in patients with stable coronary
artery disease after myocardial infarction with
preserved ejection fraction
Recommendations Classa Levelb Ref.c
PVS should be considered in survivors of
a myocardial infarction with preserved
LV function and otherwise unexplained
syncope.
IIa C
280–
282
LV ¼ left ventricular; PVS ¼ programmed ventricular stimulation.
aClass of recommendation.
bLevel of evidence.
cReference(s) supporting recommendations.
Most studies that have evaluated the usefulness of non-invasive risk
stratification have been performed in patients with severely im-
paired LVEF (,40%) or in mixed populations. In these studies, ei-
ther the outcome in the subgroup of patients with LVEF .40%
has not been reported or the subgroups were too small to allow
analysis and interpretation of the data. To date, in patients with re-
mote myocardial infarction and preserved LVEF, no non-invasive
risk stratification technique has demonstrated sufficient specificity
and sensitivity.
There is limited evidence from subgroups of large-scale studies
that programmed ventricular stimulation is helpful for risk stratifica-
tion in patients after myocardial infarction with intermediate LVEF
values or with an LVEF .40%.280 – 282 This question is currently
being addressed in the ongoing Risk Stratification in Patients
With Preserved Ejection Fraction (PRESERVE-EF) trial
(NCT02124018).
5.3.2 Recommendations for optimal strategy
Revascularization in patients with stable coronary
artery disease aft r myocardial infarction with
preserved ejection fraction
Recommendations Classa Levelb Ref.c
Coronary revascularization is
recommended to reduce the risk of
SCD in patients with VF when acute
myocardial ischaemia precedes the
onset of VF.
I B
289,
290
SCD ¼ sudden cardiac death; VF ¼ ventricular fibrillation.
aClass of r commendation.
bLevel of evidence.
cReference(s) supporting recommendations.
Guidelines for coronary revascularization have been published re-
cently.13 They provide clear management information and the read-
er is referred to the source documents for details.
In patients with CAD and VAs, assessment of obstructive coronary
disease and ischaemia is essential. Surgical revascularization may in-
crease survival and prevent SCD. Implantation of an epicardial ICD
lead at the time of coronary artery bypass grafting is not associated
with an overall mortality benefit. Percutaneous coronary intervention
is also associated with a marked decline in cardiac mortality driven by
fewer deaths from myocardial infarction or sudden death.
Revascularization may be associated with an increase in LVEF of
≥5–6% in 15–65% of stable patients. This is particularly true for
those with evidence of ischaemic or hibernating myocardium on
preoperative imaging studies.291,292 The majority of patients with se-
verely depressed LVEF immediately after STEMI show significantly
improved systolic function after 3 months.286 LVEF should be re-
evaluated 6–12 weeks after coronary revascularization to assess
potential indications for primary prevention ICD implantation.
In patients who survive SCD, revascularization can reduce the re-
currence of life-threatening arrhythmias and SCD and also improve
patient outcomes, particularly if there is evidence of ischaemia pre-
ceding SCD. Sustained monomorphic VT in patients with previous
myocardial infarction is less likely to be affected by revascularization.
Myocardial revascularization is unlikely to prevent recurrent SCD in
patients with extensive myocardial scarring and markedly depressed
LVEF.
5.3.3 Use of anti-arrhythmic drugs
Use of anti-arrhythmic drugs
Recommendations Classa Levelb Ref.c
Amiodarone may be considered for
relief of symptoms from VAs in survivors
of a myocardial infarction but it has no
effect on mortality.
IIb B
293,
294
ESC GuidelinesPage 28 of 87
 by guest on November 21, 2016
Downloaded from 
Phân tầng và tái thông ĐMV ở 
bệnh ĐMV ổn định sau NMCT có CNTT bảo tồn 
Thuốc chống loạn nhịp điều trị 
bệnh ĐMV ổn định sau NMCT có CNTT bảo tồn 
Rối loạn nhịp thất trong NMCT cấp 
•  Bao gồm: ngoại tâm thu thất, nhịp nhanh thất, rung thất là 
một biến chứng hay gặp 
•  Hay xảy ra: STEMI trong 48 giờ đầu, NSTEMI sau 48 giờ 
•  Nếu xảy ra trong giai đoạn sớm (trong vòng 48 giờ) sẽ làm 
tỷ lệ tử vong tăng 4-5 lần 
•  Tái thông mạch vành sớm là một trong các biện pháp đầu 
tiên 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 !!!