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Tóm tắt hướng dẫn của Acc/Aha/Hrs 2015 cho điều chỉnh nhịp nhanh trên thất ở người lớn – P2

4. Nhịp nhanh nhĩ ổ không phải xoang và MAT

Xem hình 4 về thuật toán điều trị cấp thời nhịp nhanh nhĩ nghi ngờ ổ (AT). Hình 5 về thuật toán điều trị tiếp tục AT ổ và Tư liệu hỗ trợ trực tuyến 6, 7 và 8 cho các tư liệu hỗ trợ phần 4.

 

TS Phạm Hữu Văn

 

Hình 4 biểu thị thuật toán điều trị cấp thời nhịp nhanh nhĩ nghi ngờ ổ. Màu sắc tương ức với class khuyến cáo ở bảng 1; các thuốc được liệt kể theo abc.* Đối với nhịp tự mất đi hoặc tự tái phát, chuyển nhịp đồng bộ là không phù hợp. IV chỉ đường tĩnh mạch.

Hình 5 thể hiện thuật toán điều chỉnh tiếp tục nhanh nhĩ ổ. Các màu sắc tương ứng với Class khyến cáo ở bảng 1; các thuốc liệt kê theo abc. SHD: bệnh tim thực thế.

4.1. Nhịp nhanh nhĩ ổ

AT ổ được định nghĩa ở bảng 2. AT ổ có thể dai dẳng hoặc tạm thời. Tần số nhĩ trong quá trình AT ổ thường giữa 100 bpm và 250 bpm. [102] Sự có mặt và mức độ nặng của các triệu chứng trong quá trình AT ổ có thể thay đổi ở các bệnh nhân. AT ổ ở các quần thể người lớn thường kết hợp với tiến triển lành tính, mặc dù bệnh cơ tim qua trung gian AT đã được thông báo ở > 10% các bệnh nhân được đưa đến triệt phá do SVT liên hồi.[103,104] AT ổ tạm thời nói chung và thường không đòi hỏi điều trị.

Chẩn đoán AT ổ được nghi ngờ khi tiêu chuẩn có trên ECG (phần 2). Thuật toán đã được phát triển để xác định nguồn gốc AT ổ tử hình dạng sóng P được ghi trên 12 chuyển đạo ECG chuẩn. [105,106] Định khu chính xác AT ổ được khẳng định cuối cùng bằng lập bản đồ trong quá trình EPs khi triệt phá thành công đã đạt được.[107116] AT ổ có nguồn gốc thường hơn ở nhĩ phải so với nhĩ trái. [117,118]

Nhịp nhanh vào lại tại nút xoang là một type AT ổ ít gặp liên quan đến vòng vào lại vi thể ở khu vực nút xoang nhĩ, tạo ra hình thái sóng P giống hệt như nhịp xoang nhanh (mặc dù đây không phải nhịp xoang nhanh). Đặc điểm phân biệt vào lại nút xoang với nhịp xoang nhanh gồm khởi phát và cắt cơn đột ngột và thường khoảng RP dài hơn so với quan sát trong quá trình nhịp xoang bình thường.

4.1.1. Điều trị cấp thời: Các khuyến cáo

RCTs về điều trị thuốc để so sánh hiệu quả ở các bệnh nhân có AT ổ trong các tình huống cấp là không có khả năng. Nhiều kết quả lâm sàng đã được thông báo tử các nghiên cứu quan sát nhỏ bao gồm các bệnh nhân vị thành niên và nhi khoa.[119,120] Trong tình huống lâm sàng, nếu chẩn đoán không chắc chắn, thủ thuật cường phế vị có thể thử áp dụng để nhận biết tốt hơn cơ chế SVT. (KC 1)

Các khuyến cáo điều trị cấp thời nghi ngờ nhịp nhanh nhĩ ổ (KC 1)

COR

LOE

Các khuyến cáo

I

C-LD

1. Tiêm tĩnh mạch beta blockers, diltiazem, hoặc verapamil hữu ích cho điều trị cấp thời ở những bệnh nhân AV ổ ổn định huyết động.[107,119–121]

I

C-LD

2. Chuyển nhịp đồng bộ được khuyến cáo để điều trị cấp thời AT ổ không ổn định về huyết động học.[44,122]

IIa

B-NR

1. Adenosine có thể hữi ích trong trạng thái cấp tính đối với hoặc phục hồi nhịp xoang hoặc chẩn đoán cơ chế nhịp nhanh ở các bệnh nhân nghi ngờ AT ổ.[107,121,123]

IIb

C-LD

1. Amiodarone tĩnh mạch có thể phù hợp trong trạng thái cấp tính hoặc phục hồi nhịp xoang hoặc làm chậm tần số thất ở các bệnh nhân AT ổ có huyết đông ổn định.[120,124]

IIb

C-LD

2. Ibutilide có thể phù hợp trong trạng thái cấp tính để phục hồi nhịp xoang ở các bệnh nhân AT ổ có huyết động ổn định.[1]

4.1.2. Điều chỉnh tiếp tục: Các khuyến cáo (KC 2)

Các khuyến cáo cho điều chỉnh tiếp tục nghi ngờ nhịp nhanh nhĩ ổ (KC 2)

COR

LOE

Các khuyến cáo

I

B-NR

1. Triệt phá qua catheter được khuyến cáo ở các bệnh nhân AT ổ có triệu chứng như thay thể điều trị thuốc.[104,107–112,114–116,124–126]

IIa

C-LD

1. Beta blockers, diltiazem, hoặc verapamil uống là phù hợp để điều chính tiếp tục ở các bệnh nhân AT ổ có triệu chứng.[107,119,120]

IIa

C-LD

2. Flecainide hoặc propafenone có thể hiệu quả cho điều trị tiếp tục các bệnh nhân không có bệnh tim cấu trúc hoặc bệnh cơ tim thiếu máu có AT ổ.127–131

IIb

C-LD

1. Uống sotalol hoặc amiodarone có thể phù hợp cho điều chỉnh tiếp tục các bệnh nhân có AT ổ.104,129,132–136

4.2. Nhịp nhanh nhĩ đa ổ (Multifocal Atrial Tachycardia: MAT)

MAT được định nghĩa ở Bảng 2. Cơ chế của MAT còn chưa được xác định rõ. MAT thường được kết hợp với các điều kiện nền, bao gồm bệnh phổi, tăng áp phổi, bệnh mạch vành, bệnh van tim, [137] cũng như giảm magiê máu và điều trị theophylline. [138] Việc điều trị đầu tiên là điều chỉnh trạng thái nền. Magiê tĩnh mạch cũng có thể hữu ích ở những bệnh nhân có nồng độ magiê bình thường. [139] Thuốc chống loạn nhịp nói chung không phải là hữu ích trong loại bỏ MAT. [140] Chuyển nhịp là không hữu ích trong MAT. [137]

4.2.1. Điều trị cấp thời: Khuyến cáo (KC 3)

Các khuyến cáo điều trị cấp thời nhịp nhanh nhĩ đa ổ (KC 3)

COR

LOE

Các khuyến cáo

IIa

C-LD

1. Metoprolol141hoặcverapamil142,143tĩnh mạch có thể hữu ích cho điều trị cấp thời ở bệnh nhân có MAT.

4.2.2. Điều chỉnh tiếp tục: Các khuyến cáo (KC 4)

Các khuyến cáo cho điều chỉnh tiếp tục nhịp nhanh nhĩ đa ổ (KC 4)

COR

LOE

Các khuyến cáo

IIa

B-NR

1. Verapamil (Level of Evidence: B-NR) hoặc diltiazem uống (Level of Evidence: C-LD) là phù hợp cho điều chỉnh lien tục ở bệnh nhân có MAT tái phát có triệu chứng.144,145

C-LD

IIa

C-LD

2. Metoprolol là phù hợp cho điều chỉnh tiếp tục ở các bệnh nhân MAT tái phát có triệu chứng.140,141,145

5. Nhịp nhanh vào lại nút nhĩ thất

Xem hình 6 cho thuật toán điều trị cấp thời AVNRT, hình 7 cho thuật toán điều chỉnh tiếp tục AVNRT, tư liệu Online bổ xung 9 và 10 cho tư liệu ủng hộ thêm phần 5.

Hình 6. Điều trị cấp thời AVNRT. Màu sắc tương ứng với class của Khuyến cáo trong Bảng 1; thuốc được liệt kê theo thứ tự abc. * Đối với những nhịp chấm dứt hoặc tái phát tự phát, chuyển nhịp đồng bộ là không thích hợp. AVNRT chỉ nhịp nhanh vào lại nhĩ thất; và IV: tiêm tĩnh mạch.

Hình 7. Điều trị tiếp tục AVNRT. Các màu tương ứng với Class của khuyến cáo trong bảng 1; các thuốc được liệt kê theo alphabe. AVNRT chỉ nhịp nhanh vào lại nút nhĩ thất; SHD chi bệnh tim cấu trúc (gồm bệnh tim thiếu máu cục bộ)

AVNRT là SVT phổ biến nhất và được định nghĩa ở bảng 2. Người ta thường gặp ở người trẻ không có bệnh tim thực thể hoặc bệnh tim thiếu máu cục bộ, > 60% các trường hợp gặp ở phụ nữ. [16] Tần số thất thường 180 bpm đến 200 bpm nhưng phạm vi từ 110 bpm đến >250 bpm (ở các trường hợp hiếm tần số có thể <100 bpm). [19] Nền giải phẫu của AVNRT là sinh lý nút AV hai đường (bảng 2).

5.1. . Điều trị cấp thời: Các khuyến cáo (KC 5)

Các  khuyến  cáo  cho điều  trị  cấp  thơì  AVNRT (KC 5)

COR

LOE

Các khuyến cáo

I

B-R

1. Thủ  thuật  cường  phế vị  được  khuyến cáo để điều trị cấp thời ở các bệnh nhân với AVNRT.33–35,146,147

I

B-R

2. Adenosine được khuyến cáo cho điều trị cấp thời bệnh nhân với AVNRT.37,41,43,148

I

B-NR

3. Chuyển nhịp đồng bộ nên được thực hiện cho điều trị cấp thời ở các bệnh nhân không ổn định về huyết động với AVNRT khi  adenosine và thủ thuật cường phế vị không cắt được nhịp nhanh hoặc không thểthực hiện được.44,122

I

B-NR

4. Chuyển nhịp đồng bộ nên được thực hiện cho điều trị cấp thời ở các bệnh nhân ổn định về huyết động với AVNRT khi điều trị thuốc khộng cắt được nhịp nhanh hoặc có chống chỉ định.36,45

IIa

B-R

1. Tiêm tĩnh mạch beta blockers, diltiazem, hoặc verapamil là phù hợp cho điều chỉnh cấp thời các bệnh nhân AVNRT huyết động ổn định.47,149–152

IIb

C-LD

1. Uống beta blockers, diltiazem, hoặc verapamil có thể phù hợp cho điều trị cấp thời các bệnh nhân AVNRT có huyết động ổn định.153,154

IIb

C-LD

2. Truyền tĩnh mạch amiodarone có thể được xem xét cho điều trị cấp thời các bệnh nhân AVNRT huyết động ổn định khi các điều trị khác không hiệu quả hoặc chống chỉ định.67

5.2. Điều chỉnh tiếp tục: Các khuyến cáo (KC 6)

Các khuyến cáo cho điều chỉnh tiếp tục AVNRT (KC 6)

COR

LOE

Các khuyến cáo

I

B-R

1. Uống verapamil hoặc diltiazem được khuyến cáo cho điều chỉnh tiếp tục các bệnh nhân AVNRT không phải ứng viên, hoặc ưa thích không thực hiện cho triệt phá qua catheter.49,50,155,156

I

B-NR

2. Triệt phá đường chậm qua catheter được khuyến cáo ở các bệnh nhân AVNRT.51–58,157–161

I

B-R

3. Uống beta blockers được khuyến cáo cho điều chỉnh tiếp tục các bệnh nhân AVNRT không ứng viên, hoặc không ưa thích thực hiện triệt phá qua catheter.50

IIa

B-R

1. Flecainide hoặc propafenone là phù hợp cho điều chỉnh tiếp tục các bệnh nhân không có bệnh tim cấu trúc hoặc bệnh tim thiếu máu cục bộ có AVNRT và không ứng viên, hoặc không ưa thích triệt phá qua catheter và họ không hiệu quả hoặc chống chỉ định beta blockers, diltiazem, hoặc verapamil.48,59–66,153,154,162,163

IIa

B-NR

2. Theo dõi lâm sàng không cần điều trị thuốc hoặc triệt phá là phù hợp cho điều chỉnh tiếp tục các bệnh nhân AVNRT có triệu chứng tối thiểu.156

IIb

B-R

1. Uống sotalol hoặc dofetilide có thể là phù hợp cho điều chỉnh tiếp tục các bệnh nhân AVNRT không ứng viên, hoặc không ưa thích triệt phá qua catheter.59,66

IIb

B-R

2. Uống digoxin hoặc amiodarone có thể phù hợp cho điều chỉnh tiếp tục các bệnh nhân AVNRT không ứng viên, hoặc không ưu thích thực hiện triệt phá qua catheter.50,67

IIb

C-LD

3. Các liều tự uống cấp thời (thuốc trong túi) (“pill-in-the-pocket”) beta blockers, diltiazem, hoặc verapamil có thể phù hợp cho điều chỉnh tiếp tục ở các bệnh nhân có các cơn AVNRT ít thường xuyên, chịu đựng tốt.153,154

6. Các đường phụ có biểu hiện và ẩn (Manifest and Concealed Accessory Pathways)

Các đường phụ (được xác định ở bảng 2) có thể tiến hành theo hướng xuôi (anterograde), hướng ngược (retrograde), hoặc cả hai; có thể được liên kết với một số loạn nhịp trên thất khác nhau. Một số đường xuôi có thể đặt bệnh nhân vào nguy cơ SCD.

Nhịp tim nhanh phổ biến nhất liên quan đến đường phụ là orthodromic AVRT, với vòng chu kỳ sử dụng các nút AV và hệ thống His – Purkinje theo hướng xuôi, tiếp theo dẫn truyền đến tâm thất, dẫn ngược theo đường phụ, hoàn thành vòng bằng dẫn truyền qua tâm nhĩ trở lại nút nhĩ thất. Orthodromic AVRT chiếm khoảng 90% đến 95% các cơn AVRT ở bệnh nhân có một đường phụ biểu hiện. AVRT được kích thích sớm, bao gồm antidromic AVRT, chiếm 5% trong các cơn AVRT ở bệnh nhân có một đường biểu hiện và liên quan đến việc dẫn truyền từ tâm nhĩ đến tâm thất thông qua con đường phụ, gây ra phức hợp QRS được kích thích sớm. Điều này được gọi là nhịp nhanh antidromic AVRT khi dẫn truyền vào lại trở lại biểu hiện ngược qua nút AV. Trong trường hợp hiếm của AVRT kích thích sớm, sự dẫn trở lại xảy ra thông qua một con đường AV phụ thứ hai. AF có thể xảy ra ở những bệnh nhân với các đường phụ, có thể dẫn đến dẫn truyền vô cùng nhanh đến tâm thất trên một đường biểu hiện, làm tăng nguy cơ gây rung thất và SCD.

Dẫn truyền xuôi nhanh qua đường phụtrong AF có thể dẫn đến SCD ở bệnh nhân có một đường phụ biểu hiện, với phạm vi nguy cơ 10 năm dao động từ 0,15% đến 0,24%. [164.165] Thật không may, SCD có thể được biểu hiện đầu tiên của bệnh nhân với chẩn đoán WPW. Gia tăng nguy cơ SCD được liên kết với bệnh sử có nhịp tim nhanh triệu chứng, nhiều đường phụ, khoảng R-R kích thích sớm ngắn nhất <250 ms trong AF. Nguy cơ SCD kết hợp với WPW xuất hiện cao nhất trong 2 thập kỷ đầu tiên của đời sống. [165-169]

6.1. Điều chỉnh các bệnh nhân có các đường phụ biểu hiện hoặc ẩn

Xem hình 8 cho thuật toán điều trị cấp thời orthodromic AVRT, hình 9 cho thuật toán điều chỉnh tiếp tục orthodromic AVRT và các tư liệu hỗ trợ online 11 đến 15 có tử liệu bổ xung hỗ trợ cho chương 6.

Hình 8, chỉ thuật toán điều chỉnh orthodromic AVRT. Màu sắc tương ứng với Class khuyến cáo ở bảng 1; các thuốc được liệt kê theo alphabê. * Đối với những nhịp được ngừng hoặc tái phát một cách tự nhiên, chuyển nhịp đồng bộ là không phù hợp. AVRT chỉ nhịp nhanh vào lại nhĩ thất; ECG chỉ điện tâm đồ, IV chỉ tiêm truyền tĩnh mạch.

Hình 9 thuật toán điều chỉnh tiếp tục orthodromic AVRT. Màu sắc tương ưng Class khuyến cáo ở bảng 1; các thuốc liệt kê theo alphabe. AVRT chỉ nhịp nhanh vào lại nhĩ  thất; ECG, điện tâm đồ; BN, bệnh nhân, SHD, bệnh tim cấu trúc (gồm bệnh tim thiếu máu cục bộ).

6.1.1. Điều trị cấp thời: Các khuyến cáo (KC 7)

Các khuyến cáo cho điều trị cấp thời Orthodromic AVRT (KC 7)

COR

LOE

Các khuyến cáo

I

B-R

1. Phương pháp cường phế vị được khuyến cáo điều trị cấp thời các bệnh nhân orthodromic AVRT.43,147,170,171

I

B-R

2. Adenosine lợi cho điều trị cấp thời các bệnh nhân orthodromic AVRT.43,172,173

I

B-NR

3. Chuyển nhịp đồng bộ cần được thực hiện để điều trị cấp thời các bệnh nhân AVRT không ổn định huyết động nếu các phương pháp cường phế vị hoặc adenosine không hiệu quả hoặc không khả thi.170,174,175

I

B-NR

4. Chuyển nhịp đồng bộ được khuyến cáo để điều trị cấp thời các bệnh nhân AVRT ổn định huyết học khi điều trị thuốc không hiệu quả hoặc chống chỉ định.36,45

I

B-NR

5. Chuyền nhịp đồng bộ nên thực hiện để điều trị cấp thời các bệnh nhân AF kích thích sớm không ổn định huyết động.44,170

I

C-LD

6. Ibutilide176 hoặc procainamide tĩnh mạch177 có lợi để điều trị cấp thời ở các bệnh nhân AF kích thích sớm có huyết động ổn định.

IIa

B-R

1.  Tiêm tĩnh mạch diltiazem, verapamil43,172,178,179 (Level of Evidence: B-R) hoặc beta blockers180 (Level of Evidence: C-LD) có thể hiệu quả để điều trị cấp thời các bệnh nhân orthodromic AVRT không có kích thích sớm trên ECG lúc nghỉ trong lúc nhịp xoang.

C-LD

IIb

B-R

1. Tiêm tĩnh mạch beta blockers, diltiazem, hoặc verapamil có thể được xem xét để điều trị cấp thời các bệnh nhân orthodromic AVRT có kích thích sớm trên ECG lúc nghỉ của bệnh nhân và không đáp ứng với các điều trị khác.43,178,179,181

III: Harm

C-LD

1. Truyền tĩnh mạch amiodarone, tiêm tĩnh mạch hoặc uống beta blockers, diltiazem, và verapamil có hại một cách tiềm tàng để điều trị cấp thời các bệnh nhân có AF kích thích sớm.1

6.1.2. Điều chỉnh tiếp tục: Các khuyến cáo (KC 8)

Các khuyến cáo cho điều chỉnh tiếp tục Orthodromic AVRT (KC 8)

COR

LOE

Các khuyến cáo

I

B-NR

1. Triệt phá qua catheter đường phụ được khuyến cáo ở các bệnh nhân có AVRT và hoặc AF kích thích sớm.55,165,187–193

I

C-LD

2. Uống beta blockers, diltiazem, hoặc verapamil được chỉ định để điều chỉnh tiếp tục các bệnh nhân AVRT không có kích thích sớm trên ECG lúc nghỉ.48,194

IIa

B-R

1. Uống flecainide hoặc propafenone là phù hợp để điều chỉnh tiếp tục các bệnh nhân không có bệnh tim cấu trúc hoặc bệnh tim thiếu máu cục bộ có AVRT và hoặc AF kích thích sớm và không phải ứng viên cho, hoặc không thích triệt phá qua catheter.60,61,64,65,195

IIb

B-R

1. Uống dofetilide hoặc sotalol có thể phù hợp để điều chỉnh tiếp tục các bệnh nhân AVRT và hoặc AF kích thích sớm không phải ứng viên cho, hoặc không thích thực hiện triệt phá qua catheter.99,106

IIb

C-LD

2. Uống amiodarone có thể được xem xét để điều trị tiếp tục ở các bệnh nhân AVRT và hoặc AF kích thích sớm không phải ứng viên cho, hoặc không thích thực hiện triệt phá qua catheter và ở họ beta blockers, diltiazem, flecainide, propafenone, và verapamil không hiệu quả hoặc chống chỉ định.196,197

IIb

C-LD

3. Uống beta blockers, diltiazem, hoặc verapamil có thể phù hợp cho điều chỉnh tiếp tục các bệnh nhân orthodromic AVRT có kích thích sớm trên ECG của bệnh nhân lúc nghỉ không phải ứng viên cho, hoặc không thích thực hiện triệt phá qua catheter.48,194

IIb

C-LD

4. Uống digoxin có thể phù hợp để điều chính tiếp tục orthodromic AVRT không có kích thích sớm trên ECG của họ lúc nghỉ không phải ứng viên cho, hoặc không thích thực iện triệt phá qua catheter.198

III: Harm

C-LD

1. Uống digoxin có hại một cách tiềm tàng cho điều chỉnh tiếp tục các bệnh nhân AVRT hoặc AF và kích thích sớm trên ECG của họ lúc nghỉ.182

6.2. Điều chỉnh kích thích sớm không triệu chứng

6.2.1. Các cầu hỏi PICOTS quan trọng

Xem báo cáo ERC tổng quan hệ thống, “Phân tầng nguy cơ đối với biến cố loạn nhịp tim ở bệnh nhân có kích thích sớm không triệu chứng” cho việc xem xét các bằng chứng đầy đủ về việc điều chỉnh kích thích sớm không triệu chứng, 10 và xem dữ liệu trực tuyến bổ sung 13, 14, và 15 cho dữ liệu bổ sung trong kích thích sớm không triệu chứng, được sao chép trực tiếp từ tổng quan hệ thống của ERC. Những khuyến cáo này đã được thiết kế với SR ký hiệu để nhấn mạnh sự chặt chẽ của các hỗ trợ từ tổng quan hệ thống của ERC. Câu hỏi PICOTS 1 đã không cung cấp đủ dữ liệu cho khuyến cáo; các câu hỏi PICOTS 3 khác được đề cập trong các khuyến cáo ở Mục 6.2.2.

Tiếp theo 4 câu hỏi được ERC xem xét:

1.     Độ chính xác của nghiên cứu điện sinh lý (EPs) xâm lấn dự báo tương đối (không triệt phá qua catheter đường phụ) đối lại với không test cho dự báo biến cố rối loạn nhịp (gồm SCD) ở các bệnh nhân kích thích sớm không triệu chứng là gì ?

2.      Tính hữu ích của nghiên cứu EP xâm lấn là gì (không triệt phá qua catheter đường phụ) đối lại với không test để dự báo biến cố rối loạn nhịp (gồm SCD) ở bệnh nhân kích thích sớm không triệu chứng là gì ?

3. Tính hữu ích của nghiên cứu EP xâm lấn (không triệt phá đường phụ qua catheter) hoặc nghiên cứu EP không xâm lấn để dự đoán các biến cố rối loạn nhịp tim (bao gồm SCD) ở bệnh nhân kích thích sớm không triệu chứng là gì ?

4. Hiệu quả và hiệu lực của các nghiên cứu EP xâm lấn với triệt phá qua catheter đường phụ phù hợp so với các test không xâm lấn với điều trị (bao gồm theo dõi) hoặc không có test / triệt phá cho phù hợp để ngăn ngừa các biến cố rối loạn nhịp tim (bao gồm SCD) và cải thiện kết quả ở bệnh nhân kích thích sớm không triệu chứng là gì ?

6.2.2. Các bệnh nhân kích thích sớm không triệu chứng: Các khuyến cáo (KC 9)

Các khuyến cáo cho điều chỉnh các bệnh nhân kích thích sớm không triệu chứng (KC 9 )

COR

LOE

Các khuyến cáo

I

B-NRSR

1. Ở những bệnh nhân kích thích sớm không triệu chứng, các biểu hiện của mất đột ngột dẫn truyền qua đường phụ biểu hiện trong quá trình test gắng sức ở nhịp xoang199-202 (Mức chứng cứ: B-NR) SR hoặc mất kích thích sớm từng lúc trong quá trình ECG hoặc theo dõi lưu động 202 ( Cấp chứng cứ: C-LD) SR là hữu ích để xác định bệnh nhân có nguy cơ thấp của dẫn truyền nhanh qua đường phụ.

C-LDSR

IIa

B-NRSR

1. Nghiên cứu EP là phù hợp ở các bệnh nhân kích thích sớm không triệu chứng để phân tầng nguy cơ cho các biến cố loạn nhịp.165,167,203–206

IIa

B-NRSR

2. Triệt phá đường phụ qua catheter là phù hợp ở các bệnh nhân kích thích sớm không triệu chứng nếu nghiên cứu EP nhận biết nguy cơ cao biến cố rối loạn nhịp, gồm AF kích thích sớm dẫn truyền nhanh.165,207,208

IIa

B-NRSR

3. Triệt phá đường phụ qua catheter đường phụ là phù hợp ở các bệnh nhân không triệu chứng nếu hiện diện kích thích sớm ngăn cản công việc đặc biệt (như với các phi công).55,165,187–193,207–209

IIa

B-NRSR

4. Theo dõi, không đánh giá tiếp theo hoặc điều trị, là phù hợp với các bệnh nhân kích thích sớm không triệu chứng.206,210–213

6.3. Phân tầng nguy cơ các bệnh nhân có các đường phụ biểu hiện có triệu chứng: Các khuyến cáo (KC 10)

Các khuyến cáo điều chỉnh các bệnh nhân có đường phụ biểu hiện có triệu chứng (KC 10)

COR

LOE

Các khuyến cáo

I

B-NR

1. Ở các bệnh nhân kích thích sớm có triệu chứng, các biểu hiện mất đột ngột dẫn truyền qua đường phụ trong quá trình test gắng sức ở nhịp xoang199–202 (Mức chứng cứ: B-NR) hoặc mất từng lúc kích thích sớm trong quá trình ECG hoặc theo dõi lưu động202 (Mức chứng cứ: C-LD) là hữu ích cho nhận biết bệnh nhân có nguy cơ thấp phát triển dẫn nhanh qua đường dẫn.

C-LD

I

B-NR

2. Nghiên cứu EP là hữu ích ở các bệnh nhân kích thích sớm có triệu chứng để phân tầng nguy cơ các biến cố rối loạn nhịp nguy hiểm.165,167,203–205

(Còn nữa)

 

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