Xử trí rung nhĩ trên 48 giờ: Ai nên chuyển nhịp? Khi nào? Như thế nào? - Bùi Thế Dũng

ted with conversion to sinus rhythm in patients 
with AFlasting less than 48 hours. Ann Intern Med. 1997;126:615–20 
4. 2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
DỰ PHÒNG HUYẾT KHỐI LẤP MẠCH 
• TEE có thể thay thế cho việc dùng kháng đông 
3 tuần trước chuyển nhịp 
• Kháng đông nên được dùng càng sớm càng tốt 
nếu cần chuyển nhịp cấp cứu 
• Dùng kháng đông đường uống ≥ 4 tuần sau 
chuyển nhịp, bất kể điểm CHADS-VAS 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Prevention of Thromboembolism 
Recommendations COR LOE 
For patients with AF or atrial flutter of 48 hours’ duration or longer, or 
when the duration of AF is unknown, anticoagulation with warfarin (INR 
2.0 to 3.0) is recommended for at least 3 weeks before and 4 weeks after 
cardioversion, regardless of the CHA2DS2-VASc score and the method 
(electrical or pharmacological) used to restore sinus rhythm. 
I B 
For patients with AF or atrial flutter of more than 48 hours’ duration or 
unknown duration that requires immediate cardioversion for 
hemodynamic instability, anticoagulation should be initiated as soon as 
possible and continued for at least 4 weeks after cardioversion unless 
contraindicated. 
I C 
For patients with AF or atrial flutter of less than 48 hours’ duration and 
with high risk of stroke, intravenous heparin or LMWH, or 
administration of a factor Xa or direct thrombin inhibitor, is 
recommended as soon as possible before or immediately after 
cardioversion, followed by long-term anticoagulation therapy. 
I C 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Prevention of Thromboembolism (cont’d) 
Recommendations COR LOE 
Following cardioversion for AF of any duration, the decision 
about long-term anticoagulation therapy should be based on the 
thromboembolic risk profile. 
I C 
For patients with AF or atrial flutter of 48 hours’ duration or 
longer or of unknown duration who have not been anticoagulated 
for the preceding 3 weeks, it is reasonable to perform TEE before 
cardioversion and proceed with cardioversion if no LA thrombus 
is identified, including in the LAA, provided that anticoagulation 
is achieved before TEE and maintained after cardioversion for at 
least 4 weeks. 
IIa B 
For patients with AF or atrial flutter of 48 hours’ duration or 
longer or when duration of AF is unknown, anticoagulation with 
dabigatran, rivaroxaban, or apixaban is reasonable for at least 3 
weeks before and 4 weeks after cardioversion. 
IIa C 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Kháng đông trước – sau chuyển nhịp 
Canadian Journal of Cardiology 2014 30, 1114-1130 
Direct-Current Cardioversion 
Recommendations COR LOE 
In pursuing a rhythm-control strategy, cardioversion is 
recommended for patients with AF or atrial flutter as a method to 
restore sinus rhythm. If cardioversion is unsuccessful, repeated 
attempts at direct-current cardioversion may be made after 
adjusting the location of the electrodes, applying pressure over the 
electrodes or following administration of an antiarrhythmic 
medication. 
I B 
Cardioversion is recommended when a rapid ventricular response 
to AF or atrial flutter does not respond promptly to 
pharmacological therapies and contributes to ongoing myocardial 
ischemia, hypotension, or HF. 
I C 
Cardioversion is recommended for patients with AF or atrial 
flutter and pre-excitation when tachycardia is associated with 
hemodynamic instability. 
I C 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Pharmacological Cardioversion 
Recommendations COR LOE 
Flecainide, dofetilide, propafenone, and intravenous ibutilide are 
useful for pharmacological cardioversion of AF or atrial flutter, 
provided contraindications to the selected drug are absent. 
I A 
Administration of oral amiodarone is a reasonable option for 
pharmacological cardioversion of AF. 
IIa A 
Propafenone or flecainide (“pill-in-the-pocket”) in addition to a 
beta blocker or nondihydropyridine calcium channel antagonist is 
reasonable to terminate AF outside the hospital once this 
treatment has been observed to be safe in a monitored setting for 
selected patients. 
IIa B 
Dofetilide therapy should not be initiated out of hospital because 
of the risk of excessive QT prolongation that can cause torsades 
de pointes. 
III: 
Harm 
B 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Antiarrhythmic Drugs to Maintain Sinus Rhythm 
Recommendations COR LOE 
Before initiating antiarrhythmic drug therapy, treatment of 
precipitating or reversible causes of AF is recommended. 
I C 
The following antiarrhythmic drugs are recommended in patients 
with AF to maintain sinus rhythm, depending on underlying heart 
disease and comorbidities: 
a. Amiodarone 
b. Dofetilide 
c. Dronedarone 
d. Flecainide 
e. Propafenone 
f. Sotalol 
I A 
The risks of the antiarrhythmic drug, including proarrhythmia, 
should be considered before initiating therapy with each drug. I C 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Antiarrhythmic Drugs to Maintain Sinus Rhythm 
(cont’d) 
Recommendations COR LOE 
Because of its potential toxicities, amiodarone should only be 
used after consideration of risks and when other agents have failed 
or are contraindicated. 
I C 
A rhythm-control strategy with pharmacological therapy can be 
useful in patients with AF for the treatment of tachycardia-
induced cardiomyopathy. 
IIa C 
It may be reasonable to continue current antiarrhythmic drug 
therapy in the setting of infrequent, well-tolerated recurrences of 
AF when the drug has reduced the frequency or symptoms of AF. 
IIb C 
Antiarrhythmic drugs for rhythm control should not be continued 
when AF becomes permanent, III: 
Harm 
C 
including dronedarone. 
B 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Upstream Therapy 
Recommendations COR LOE 
An ACE inhibitor or angiotensin-receptor blocker is reasonable 
for primary prevention of new-onset AF in patients with HF with 
reduced LVEF. 
IIa B 
Therapy with an ACE inhibitor or ARB may be considered for 
primary prevention of new-onset AF in the setting of 
hypertension. 
IIb B 
Statin therapy may be reasonable for primary prevention of new-
onset AF after coronary artery surgery. 
IIb A 
Therapy with an ACE inhibitor, ARB, or statin is not beneficial 
for primary prevention of AF in patients without cardiovascular 
disease. 
III: No 
Benefit 
B 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Linear 443 75% 26% 33% 55% 
Focal 508 81% 35% 54% 71% 
Isolation 2,187 83% 36% 62% 75% 
Circumferential (all) 15,455 68% 37% 64% 74% 
Circumferential 
(LACA, WACA) 
2,449 65% 37% 59% 72% 
Circumferential 
(PVAI) 
11,132 68% 42% 67% 76% 
Substrate ablation 
(CFAE) 
559 51% 49% 75% 87% 
TOTAL 23,626 61% 55% 63% 75% 
Patients Paroxysmal AF 6-month cure 6-months OK Ablation method SHD 
 Fisher JD, et al. PACE 2006;29: 523 
Cắt đốt qua catheter: phân tích gộp 
Cure (by each author’s criteria) means no further AFib 6 months after the procedure in the absence of 
AAD. 
OK means improvement (fewer episodes, no episodes with previously ineffective AAD). 
SHD indicates structural heart disease. 
19 
Bệnh nhân không còn rung nhĩ sau cắt 
đốt so với thuốc 
Pappone C, et al. J Am Coll Cardiol 2003 Jul 16;42(2):185-97 
K
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 n
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 s
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n
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 c
ò
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 k
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ô
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c
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 r
u
n
g
 n
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ĩ 
(%
) 
Theo dõi (tháng) 
0 
100 
80 
60 
40 
20 
Nhóm cắt đốt (n=589) 
Nhóm thuốc (n=582) 
0 12 6 24 18 36 30 
84% 
79% 78% 
61% 
47% 
37% 
P < 0,001 
20 
Cải thiện sống còn bằng cắt đốt so với thuốc 
Pappone C, et al. J Am Coll Cardiol 2003 Jul 16;42(2):185-97 
Ngày theo dõi Ngày theo dõi 
100 
0 
80 
60 
1080 
Nhóm cắt đốt Nhóm điều trị thuốc 
90 
70 
0 180 360 540 900 720 
One-sample log-rank test 
Obs=36, Exp=31, Z=0.597, p=0.55 
1080 0 180 360 540 900 720 
One-sample log-rank test 
Obs=79, Exp=341, Z=7.07, p<0.001 
K
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 n
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n
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 (
%
) 
Chờ đợi 
Quan sát 
 589 BN rung nhĩ có triệu chứng được cắt đốt so với 
582 điều trị thuốc 
21 
Cân nhắc Lợi ích-Nguy cơ cắt đốt 
Canadian Journal of Cardiology 2014 30, 1114-1130 
AF Catheter Ablation to Maintain Sinus Rhythm 
Recommendations COR LOE 
AF catheter ablation is useful for symptomatic paroxysmal AF 
refractory or intolerant to at least 1 class I or III antiarrhythmic 
medication when a rhythm-control strategy is desired. 
I A 
Before consideration of AF catheter ablation, assessment of the 
procedural risks and outcomes relevant to the individual patient is 
recommended. 
I C 
AF catheter ablation is reasonable for some patients with 
symptomatic persistent AF refractory or intolerant to at least 1 
class I or III antiarrhythmic medication. 
IIa A 
In patients with recurrent symptomatic paroxysmal AF, catheter 
ablation is a reasonable initial rhythm-control strategy before 
therapeutic trials of antiarrhythmic drug therapy, after weighing 
the risks and outcomes of drug and ablation therapy. 
IIa B 
2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Chiến lược kiểm soát nhịp trong rung nhĩ 
kịch phát và dai dẳng 
January, CT et al. 2014 AHA/ACC/HRS Atrial Fibrillation Guideline 
Không có bệnh tim 
cấu trúc 
Có bệnh tim cấu trúc 
Bệnh mạch vành Suy tim 
Amidarone 
Dofetilide Cắt đốt 
Dofetilide 
Dronedarone 
Sotalol 
Amidarone 
Cắt đốt 
Dofetilide 
Dronedatone 
Flecaine 
Propafenone 
Sotalol 
Amidarone 
24 
KẾT LUẬN 
• Chuyển nhịp RN giúp cải thiện triệu chứng, và 
nên thực hiện ở một số đối tượng thích hợp 
• RN xuất hiện trên 48h: cần kháng đông trước 
chuyển nhịp 3 tuần và sau chuyển nhịp 4 tuần 
để giảm thiểu biến cố lấp mạch 
• Shock điện là phương tiện chuyển nhịp tức 
thời hiệu quả nhất 
• Cắt đốt so với thuốc: hiệu quả tức thời và lâu 
dài cao hơn, cải thiện tỷ lệ sống còn tốt hơn