Xử trí rung nhĩ ở bệnh nhân suy tim - Nguyễn Thị Thu Hoài

s 
Average 24-hr rate on ambulatory 
monitor (£80/min) 
Treadmill 
6-minute walk 
Beta 
blockers 
Verapamil/ 
Diltiazem 
Amiodarone AVN ablation 
+ PPM 
• Therapy 
Digoxin alone is ineffective unless 
preexisting conduction disease 
Rate Control in Atrial Fibrillation 
CP942632-82 
Principles 
Do not rely on resting heart rate 
• Assess 
Average 24-hr rate on ambulatory 
monitor (£80/min) 
Treadmill 
6-minute walk 
Beta 
blockers 
Verapamil/ 
Diltiazem 
Amiodarone AVN ablation 
+ PPM 
• Therapy 
Digoxin alone is ineffective unless 
pre i ti g conduction di ase 
Rate Control in Atrial Fibrillation 
CP942632-82 
Principles 
Do not rely on resting heart rate 
• Assess 
Average 24-hr rate on mbulatory 
monitor (£80/min) 
Treadmill 
6-minute walk 
blockers 
Verapa il/ 
iltiaze 
A iodarone AVN ablation 
+ 
• Therapy 
Digoxin alone is ineffective unless 
preexisting conduction disease 
Rate Control in Atrial Fibrillation 
Principles 
Do not rely on resting heart rate 
• Assess 
Average 24-hr rate on a bulatory 
onitor (£80/ in) 
Tread ill 
6- inute alk 
• Therapy 
igoxin alone is ineffective unless 
reexistin c cti isease 
t tr l i tri l i rill ti 
- 
rinciples 
 t r l r ti rt r t 
• 
r - r r t l t r 
it r ( / i ) 
r ill 
- i t l 
t il/ i l ti 
Beta blockers 
 US Carvedilol Heart Failure Trials Program: 
- Retrospective analysis 
- 136 patients with concomitant CHF and AF 
- EF improved in patients treated with carvedilol (from 23 to 33% 
with carvedilol and from 24 to 27% with placebo, p < 0.001). 
- A reduction in the combined end point of death or CHF 
hospitalization: 19% in patients treated with placebo and 7% in 
patients on carvedilol, p < 0.05. 
 The MERIT-HF study: 
3991 patients with CHF NYHA classes II–IV and EF< 40%. 
Metoprolol significantly reduced the risk of death or heart 
transplantation by 32% compared with placebo. 
Non-dihydropyridine calcium channel 
antagonists 
(Verapamil/Diltiazem) 
Because of their negative inotropic effects, calcium 
channel antagonists are in general regarded as 
inappropriate in CHF patients. 
DIGITALIS 
 Digoxin to control heart rate during rest in CHF and AF: 
recommended by the ACC/AHA/ESC guidelines for the 
management of AF and the CHF. 
 Enhances vagal tone ->less effective at controlling the 
ventricular rate in exercise or increased sympathetic 
activity. 
 In patients with CHF and AF, digoxin + beta-blocker 
(carvedilol)  symptoms,  ventricular function -> better 
ventricular rate control than either agent alone (Khan 2003) 
 Adequate rate control at rest and exertion (AFFIRM trial) was 
achieved with digoxin alone in 54% at 1 year vs. 81% with a 
beta-blocker (with or w/o digoxin) in patients with CHF 
symptoms or EF <40%. 
 Beta-blocker + digoxin: allow  the dose of each drug. This 
may be advantageous with respect to their possible adverse 
effects. 
DIGITALIS 
Amiodarone 
 The use of amiodarone in CHF patients to control heart 
rate during AF is regarded a second-line treatment 
according to the guidelines. 
 Singh SN (1995): Rate of sudden death and mortality with 
amiodarone: not increased in 674 patients with CHF and an 
EF < 40%. 
 Because of its possible adverse effects, it is recommended 
only when other measures are unsuccessful or 
contraindicated. 
AVN ablation and ventricular pacing 
 Atrioventricular (AV) nodal ablation and 
ventricular pacing is a very efficient way to 
control heart rate. 
 Patients with symptoms due to tachyarrhythmia 
or with tachycardiomyopathy most likely benefit 
from this therapeutic option. 
AVN ablation and ventricular pacing 
1181 patients with sympomatic, medically refractory AF who underwent AV node 
ablation and pacing. Effects on left ventricular function, healthcare use, and NYHA 
functional classification p <0,0.001. From Wood et al, Circulation 2000 
0 10 20 30 40 50
0 20 40 60 80 100
Blitzer et al: PACE 21:590, 1998 
Pharmacologic Therapy for Maintaining Sinus Rhythm 
Can We Achieve Efficacy Without Toxicity? 
Proportion free of events (%) 
Efficacy 
Withdrawn 
because of AEs 
 Studies No. 
Quinidine 11 638 
Flecainide 3 215 
Propafenone 5 1,253 
Sotalol 3 275 
Amiodarone 4 163 
Dofetilide 3 
 Studies No. 
Quinidine 3 182 
Flecainide 5 428 
Dofetilide 3 
Propafenone 5 1,253 
Sotalol 4 438 
Amiodarone 4 1,671 
CP1192728-9 
Pharmacologic therapies for maintaining sinus rhythm 
Can we achieve efficacy without toxicity 
Blitzer et al: PACE 21:590,1998 
Proportion free of events (%) 
 Treating HF with beta blockers: reduce atrial load, facilitate 
reversed atrial remodelling. 
 Chronic treatment with a beta-blocker is associated with a 
prolongation of the atrial action potential ->increase atrial 
wavelength -> exert anti-fibrillatory effects. 
 Beta blocker reduces new onset of AF. 
 COPERNICUS, CAPRICORN, MERIT-HF: carvedilol, 
metoprolol 
 Plewan A et al (2001): bisoprolol, sotalol 
Maintenance of sinus rhythm after cardioversion 
of AF in patients with chronic HF 
Beta blocker 
Maintenance of sinus rhythm after cardioversion 
of AF in patients with chronic HF 
Beta blocker 
Newly diagnosed AF with metoprolol 
Maintenance of sinus rhythm after cardioversion 
of AF in patients with chronic HF 
Amiodarone and dofetilide 
 CHF:  risk of ventricular arrhythmias and sudden death. 
 Amiodarone and dofetilide: the only anti-arrhythmic agents 
recommended by the current guidelines for maintenance of sinus 
rhythm in patients with AF and CHF. 
 DIAMOND study: Dofetilide was effective in converting to and 
maintaining sinus rhythm, safe, did negative inotropic effects, did not 
affect mortality. 
 However: dofetilide has its narrow therapeutic window, torsade de 
pointes occurred in 4.8%. 
 CHF-STAT trial: Amiodarone was effective in converting to and 
stabilizing sinus rhythm, safe. 
 Side effect of amiodarone: marked bradycardia-> limits long-term use 
Maintenance of sinus rhythm after cardioversion 
of AF in patients with chronic HF 
Sotalol 
 SWORD trial: the class III effect (as exerted by d-
sotalol) was associated with  mortality in patients 
with EF < 40% after myocardial infarction. 
 Retrospective analysis (22 clinical trials): 3135 
patients received oral D, L-sotalol, CHF was a 
predictor of torsade de pointes ventricular 
tachyarrhythmia. 
 D, L-sotalol should be avoided in patients with CHF. 
Non-pharmacological options 
 Catheter ablation: 
 Reasonable alternative to pharmacological 
therapy in symptomatic patients with little or no LA 
enlargement. 
 However: limited data, complex procedure. 
 Not generally recommended in AF with CHF. 
Surgery (Cox-Maze procedure): 
 Restoration of sinus rhythm during long-term 
follow-up (3 months to 8 years): achieved in more 
than 90% without anti-arrhythmic medication. 
 Restoring atrial contraction: 21% to 100% 
 In patients with CHF: no prospective data 
 Should be indicated individually for patients with 
valvular or CABG surgery. 
Non-pharmacological options 
 In symptomatic AF, electrical cardioversion can be performed 
and sinus rhythm may be stabilized with beta-blockers. 
 BB drugs can reduce the occurrence of AF in patients with CHF. 
Adequate HF (with RAAS blockers)  the chance to maintain 
sinus rhythm and should be optimized before cardioversion. 
 Amiodarone is safe and effective, if loaded before electrical 
cardioversion. 
 In severe HF and hemodynamic deterioration associated with AF, 
intravenous amiodarone and immediate electrical cardioversion 
may stabilize the patient. 
Electrical Cardioversion 
Heart Failure Therapy In Patient with AF 
 Renin - Angiotensin - Aldosterone system blocker. 
 Diuretic and salt restriction. 
 Biventricular pacing. 
Beta-blocker in AF and HF 
 Evidence suggests that BB can reduce the 
incidence of AF in HF patients. 
 Do not seem to be as effective in preventing 
major adverse CV outcomes in AF patients with 
chronic HFrEF. 
Stroke Prevention in AF and HF 
Why is stroke an issue in heart failure? 
HF is a prothrombotic state: 
 Stasis 
 Abnormalities in endothelial integrity 
 Abnormalities in clotting and platelet 
indices, inflammation. 
Assessing Risk 
Pivotal Wafarin- Controlled trials 
Stroke Prevention in AF 
ALL NOACS: Stroke or SEE 
ALL NOACS: Major bleeding 
ENGAGE-AF TIMI 48 
Stroke/SEE in HF patients 
SUMMARY 
 Concomitant AF and HF: poor prognosis,  hospitalization, 
adversely affect mortality. HF can cause AF, and vice versa. 
 Restoration of sinus rhythm with anti-arrhythmic drugs can be 
effective in alleviating symptoms, but has failed to show a 
mortality benefit over rate control. 
 For rate control, beta-blockers and digoxin can be used safely, 
and amiodarone is second choice. 
 So far, with beta-blockers, a reduction in mortality has not been 
shown in patients with AF and CHF, prospective trials are needed. 
 If these measures are ineffective, AVN ablation and ventricular pacing 
is an effective way to control heart rate. Biventricular pacing is 
superior to right ventricular pacing. 
SUMMARY 
 The existence of symptoms when the patient is in AF is the 
primary indication for rhythm restoration over rate control. 
 Current anti-arrhythmic drugs continue to have limited efficacy in 
sinus rhythm promotion, and catheter-based AF ablation has 
been shown to be superior to anti-arrhythmic drugs in 
maintaining sinus rhythm. 
 In patients scheduled for open-heart surgery for other reasons, a 
Cox-Maze procedure may be considered. 
 Novel risk characterization schemes and OACs are now 
accessible, and knowledge of their utility and limitations is 
necessary to optimize the care for patients with both AF and HF. 
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