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HUẤN LUYỆN NÂNG CAO VÀ CHUYÊN SÂU

TS. PHẠM HỮU VĂN

 

4.2.4.2 Theo dõi Holter

            Đã lâu, ở hầu hết các bệnh nhân, các triệu chứng không tái phát trong quá trình theo dõi, hiệu suất thực sự của việc theo dõi Holter trong ngất có thể thấp tới 1–2% trong một quần thể không được chọn. Ở 15% bệnh nhân, các triệu chứng không liên quan đến rối loạn nhịp tim. [161] Do đó, ở những bệnh nhân này, rối loạn nhịp có thể bị loại trừ như một nguyên nhân gây ra ngất. Theo dõi Holter trong ngất không tốn kém về chi phí thiết lập, nhưng tốn kém về chi phí cho mỗi chẩn đoán. [162] Theo dõi Holter trong ngất có thể có giá trị hơn nếu các triệu chứng thường xuyên. Một hoặc nhiều cơn hàng ngày của LOC có thể làm tăng khả năng tương quan triệu chứng ECG.

4.2.4.3 Ghi sự kiện ngoài định trước

Máy ghi sự kiện là thiết bị bên ngoài được bệnh nhân áp dụng khi các triệu chứng xuất hiện. Trong khi những máy ghi này có thể hữu ích trong việc điều tra đánh trống ngực, [163] chúng có vai trò cận biên trong việc đánh giá ngất.

4.2.4.4 Ứng dụng điện thoại thông minh

Vi cho đến nay các ứng dụng điện thoại thông minh đã ghi lại ECG thời gian thực, vai trò hiện tại của chúng trong ngất bị giới hạn vì lý do tương tự như đối với máy ghi sự kiện tương lai [164,165] Tuy nhiên, các bản ghi video gia đình rất hữu ích trong tất cả các dạng TLOC (xem phần 4.2 .5.2).

4.2.4.5 Ghi vòng lặp bên ngoài

Nói chung, máy ghi vòng lặp bên ngoài có hiệu suất chẩn đoán cao hơn so với theo dõi Holter. [162] Các máy ghi vòng lặp bên ngoài có thể hữu ích ở những bệnh nhân có các cơ ngất tương đối thường xuyên. [166–168] Trong một đăng ký quốc tế đa trung tâm gần đây, hiệu suất chẩn đoán ngất là 24,5%, với phát hiện phổ biến nhất là loạn nhịp tim; dự đoán mạnh mẽ hơn cho những phát hiện chẩn đoán đã được theo dõi sớm sau sự kiện chỉ điểm. [166]

4.2.4.6 Điều khiển (tại nhà) từ xa

            Gần đây nhất, các hệ thống thiết bị ngoài và cấy được phát triển cung cấp việc ghi ECG liên tục hoặc bộ nhớ vi mạch 24 giờ với truyền không dây (thời gian thực) đến một trung tâm dịch vụ. Một số nghiên cứu gần đây đã chỉ ra việc thực hiện theo dõi từ xa làm tăng hiệu suất chẩn đoán và đạt được chẩn đoán sớm hơn là không theo dõi từ xa. [169–171]

4.2.4.7 Ghi vòng lặp có thể cấy (Implantable loop recorders)

Trong phân tích gộp 5 nghiên cứu ngẫu nhiên có đối chứng (RCT), [172–176] 660 bệnh nhân ngất không giải thích được ngẫu nhiên với chiến lược thông thường gồm máy ghi ngoài, test độ nghiêng và nghiên cứu điện sinh lý (EPS), hoặc theo dõi kéo dài bằng ILR. Kết quả cho thấy việc cấy ILR khởi đầu trong khám và chẩn đoánđãcung cấp 3,7 [CL 95%: 2,7–5,0] tăng xác suất tương đối của chẩn đoán so với chiến lược thông thường (xem Tư liệu Hỗ trợ Bảng 5). ILR đã có hiệu quả - chi phí hơn so với chiến lược kinh điển. [172,173,177,178] Trong dữ liệu tổng hợp từ 9 nghiên cứu [179] được thực hiện ở 506 bệnh nhân với ngất không giải thích được khi kết thúc việc khám và chẩn đoán hoàn toàn âm tính, tương quan giữa ngất và ECG được xác định ở 176 bệnh nhân (35%); trong số này, 56% có vô tâm thu (hoặc nhịp tim chậm trong một số trường hợp) tại thời điểm sự kiện được ghi nhận, 11% có nhịp tim nhanh, và 33% không có rối loạn nhịp tim. Tiền ngất ít có khả năng liên quan đến loạn nhịp tim hơn là ngất. Những phát hiện tương tự sau đó được quan sát thấy với việc sử dụng ILR được mở rộng trong giai đoạn đánh giá sớm ở những bệnh nhân có ngất tái phát có nguồn gốc không chắc chắn, trong trường hợp không có các tiêu chí nguy cơ cao và bệnh tim cấu trúc, [176,180–183] và trong ngất phản xạ được nghi ngờ. [184 –186] Đặc biệt, vô tâm thu hiện diện trong quá trình ngât ở khoảng 50% các bệnh nhân này.

Có một số lĩnh vực quan tâm khác với ngất không giải thích được, trong đó ILR đã được nghiên cứu:

• Các bệnh nhân block nhánh bó (BBB) ở người có block AV kịch phát có nhiều khả năng mặc dù Eps âm tính: rối loạn nhịp được quan sát ở 41% những bệnh nhân này (đang block AV kịch phát ở 70%) dưới sự quan sát của ILR, trên cơ sở tư liệu tổng hợp từ  3 nghiên cứu [174,187,188] (xem Tư liệu Hỗ trợ Bảng 6).

• Các bệnh nhân ở người động kinh được nghi ngờ nhưng điều trị đã được chứng minh không hiệu quả: trong tư liệu tổng hợp, sự tấn công có thể được chứng minh bằng tư liệu tử ILR ở 62% các bệnh nhân, với nguyên nhân rối loạn nhịp đang có thể chịu trách nhiệm ở 26% [137,189 191] (xem Tư liệu Hỗ trợ ở Bảng 7).

• Các bệnh nhân có ngã không giải thích được, trong tổng hợp các tài liệu, sự tần công có thể đã được chứng minh bằng ILR ở 70%  các bệnh nhân, với nguyên nhân rối loạn nhịp đang có thể chịu trách nhiệm ở 14% [191–194] (xem Tư liệu Hỗ trợ Bảng 8).

• Các bệnh nhân bị HCM, bệnh cơ tim thất phải gây rối loạn nhịp (ARVC), hoặc các bệnh điện học tiên phát (xem phần 5.4).

4.2.4.8 Tiêu chuẩn chẩn đoán

Tiêu chuẩn vàng để chẩn đoán ngất do rối loạn nhịp khi có tương quan giữa triệu chứng và ghi ECG. [195,196] Sự hiện diện của loạn nhịp có ý nghĩa không triệu chứng - được định nghĩa như vô tâm thu kéo dài (> _3 s), nhịp tim nhanh trên thất nhanh (SVTs) ( tức l> 160 bpm cho > 32 nhắt bóp), hoặc nhịp nhanh thất (VT) - đã được nhiều tác giả xem là nhận định chẩn đoán. [185,188,197–199] Mặt khác, mặc dù không có tài liệu về chứng rối loạn nhịp tim trong quá trình cơn ngất không thể được xem xét là chẩn đoán chuyên biệt, nó cho phép loại trừ rối loạn nhịp như là cơ chế ngất. Hầu hết bằng chứng ủng hộ các tiêu chí chẩn đoán trên là gián tiếp dựa trên lợi ích của các liệu pháp cụ thể được hướng dẫn bằng việc theo dõi ECG trong việc ngăn ngừa tái phát ngất. [172,184–186,188,200]

Nếu như chất lượng bằng chứng là vừa phải, có sự đồng thuận mạnh mẽ dựa trên bằng chứng từ một số nghiên cứu có đối chứng có sự tương quan giữa các triệu chứng và rối loạn nhịp tim, hoặc sự hiện diện của một số rối loạn nhịp tim không triệu chứng (được xác định ở trên)thìchẩn đoán nguyên nhân của ngất và điều trị cụ thể phải được quy định.

Giới hạn chính của bất kỳ thiết bị theo dõi ECG nào là không có khả năng ghi lại BP cùng với ECG. Trong ngất phản xạ, các tài liệu về nhịp tim chậm / vô tâm thu trong một cơn ngất không loại trừ khả năng phản xạ hạ huyết áp ẩn là nguyên nhân chính của ngất, và nhịp tim chậm / vô tâm thu là biến cố trễ thứ phát. Vấn đề này có ý nghĩa quan trọng đối với điều trị (xem phần 5). Việc phân loại các bản ghi ECG bằng sinh lý bệnh có liên quan có thể xảy ra của chúng có sẵn trong phần Bảng 6 và Hướng dẫn Thực hành trên trang Web 8.

 

Còn nữa...

 

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