Khuyến cáo của Hội tim mạch học Việt Nam về chẩn đoán và điều trị bệnh cơ tim phì đại (2022) – P5

Trưởng ban: PGS.TS PHẠM NGUYỄN VINH

Đồng trưởng ban: TS.BS NGUYỄN THỊ THU HOÀI

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6.3 Điều trị bệnh nhân BCTPĐ có rung nhĩ

Rung nhĩ thường xảy ra ở bệnh nhân BCTPĐ, làm giảm cung lượng tim, giảm chất lượng cuộc sống và làm tăng nguy cơ đột quỵ. Điều trị bao gồm phòng ngừa thuyên tắc do huyết khối và kiểm soát triệu chứng. Điểm số nguy cơ đột quỵ truyền thống được sử dụng trong dân số chung không dự báo nguy cơ đột quỵ ở bệnh nhân BCTPĐ có rung nhĩ. Rung nhĩ được phát hiện qua những dụng cụ đặt trong tim hoặc theo dõi bằng màn hình ở những bệnh nhân không triệu chứng cũng làm gia tăng khả năng đột quỵ. Vì vậy, kháng đông cần được cân nhắc ở những bệnh nhân này. Kháng vitamin K và thuốc kháng đông uống tác dụng trực tiếp (DOAC) đều có hiệu quả phòng ngừa đột quỵ ở những bệnh nhân BCTPĐ có rung nhĩ. Trong trường hợp cần kiểm soát nhịp, một số thuốc chống loạn nhịp cho thấy có hiệu quả và an toàn; việc chọn lựa thuốc nên được cá nhân hóa. Một số biện pháp can thiệp như triệt đốt qua đường ống thông, giảm dầy tiểu nhĩ trái, phẫu thuật Maze được sử dụng. Cắt đốt qua ống thông ít hiệu quả hơn trong dân số chung và có thể cần lặp lại nhiều lần và cần phối hợp với thuốc chống loạn nhịp. Giảm dầy tiểu nhĩ trái là một chọn lựa điều trị nhịp ở bệnh nhân phẫu thuật cắt vách. Phẫu thuật Maze ít khi được thực hiện đơn độc. Các loạn nhịp trên thất khác và cuồng nhĩ xảy ra không nhiều hơn và điều trị thường tương tự như người không mắc BCTPĐ.

Nguy cơ thuyên tắc hệ thống được ghi nhận trong một phân tích tổng hợp với 7381 bệnh nhân rung nhĩ là 27,09%⁽¹⁷⁵⁾. Trong phân tích tổng hợp (meta-analysis) được đề cập, 25,7% bệnh nhân đột quỵ có chỉ số CHA₂DS₂-VAS_C bằng 0; từ đó gợi ý nguy cơ đột quỵ độc lập với chỉ số này ở bệnh nhân BCTPĐ. Warfarin có khả năng làm giảm nguy cơ đột quỵ ở người BCTPĐ có rung nhĩ, đặc biệt với INR 2 – 3. Trong những năm gần đây, nhiều nghiên cứu đã chứng minh hiệu quả không thua kém của DOAC so với warfarin bên cạnh nhiều lợi ích cộng thêm của DOAC như sự thuận tiện khi dùng thuốc, kết cục lâu dài^(176–178). Khuyến cáo dùng kháng đông ở bệnh nhân cuồng nhĩ tương tự như ở bệnh nhân rung nhĩ⁽¹⁷⁹⁾.

Tương tự như ở người không mắc BCTPĐ, rung nhĩ dưới lâm sàng ở bệnh nhân BCTPĐ không triệu chứng có thể được phát hiện qua dụng cụ gắn ở tim và tỷ lệ này được báo cáo là 53% sau thời gian theo dõi 595 ngày⁽¹⁸⁰⁾. Ở người không mắc BCTPĐ, rung nhĩ dưới lâm sàng làm gia tăng nguy cơ thuyên tắc do huyết khối, nhưng thấp hơn so với rung nhĩ lâm sàng⁽¹⁸¹⁾. Ngưỡng thời gian rung nhĩ để bắt đầu kháng đông trong rung nhĩ dưới lâm sàng thay đổi đáng kể giữa các nghiên cứu. Tuy nhiên, nhiều dữ liệu cho thấy cơn rung nhĩ càng kéo dài, hoặc kết hợp các yếu tố nguy cơ khác (tuổi cao, tiền căn thuyên tắc, phân độ NYHA, đường kính nhĩ trái, bệnh lý mạch máu, bề dầy thành thất trái tối đa) thì nguy cơ càng cao. Dữ liệu từ nghiên cứu ASSERT (Atrial Fibrillation Reduction Atrial Pacing Trial) cho thấy cơn rung nhĩ kéo dài trên 24 giờ làm tăng nguy cơ. Trong khi đó, những cơn rung nhĩ rất ngắn kéo dài một vài giây không làm tăng nguy cơ.

Vì khả năng dung nạp rung nhĩ kém nên chiến lược kiểm soát nhịp được ưa chuộng ở người BCTPĐ ⁽¹⁸²⁾. Thuốc được dùng để chuyển nhịp bao gồm amiodarone, disopyramide được cho thấy an toàn và hiệu quả. Thuốc chống loạn nhịp khuyến cáo loại 1c được dùng an toàn nhất khi bệnh nhân được đặt ICD⁽¹⁸²⁾. Thuốc khuyến cáo loại 3 cũng có thể được chỉ định. Sotalol an toàn và thường được dùng cho trẻ em cả đường uống và đường tĩnh mạch⁽¹⁸³⁾.

Ở những bệnh nhân được áp dụng chiến lược kiểm soát tần số, thuốc ức chế kênh calci non-dihydropyridine, chẹn beta hoặc kết hợp cả hai được ưa dùng. Digoxin có thể được chỉ định khi ở bệnh nhân BCTPĐ không tắc nghẽn. Ở những bệnh nhân tụt huyết áp, khó thở khi nghỉ và chênh áp qua đường ra thất trái lúc nghỉ rất cao (trên 100 mmHg), verapamil nên tránh dùng. Đốt nút nhĩ thất cùng với đặt máy tạo nhịp, có thể là chọn lựa sau cùng ở những trường hợp không đáp ứng với điều trị bằng thuốc.

Cắt đốt qua ống thông là thủ thuật an toàn và đóng vai trò quan trọng trong điều trị rung nhĩ. Kết quả từ các nghiên cứu cho thấy, tỷ lệ tái phát cao gấp hai lần, tần suất lặp lại của thủ thuật và sử dụng đồng thời thuốc chống loạn nhịp cao hơn ở người BCTPĐ so với người không mắc BCTPĐ⁽¹⁸⁴⁾. Sự khác biệt này là do tái cấu trúc nhĩ với các yếu tố góp phần bao gồm nghẽn đường ra thất trái, suy chức năng tâm trương, hở van hai lá và các yếu tố khác.

Cắt rung nhĩ bằng phẫu thuật là phương pháp kiểm soát nhịp có tiềm năng, đặc biệt là khi bệnh nhân có phẫu thuật tim hở nhằm mục đích cắt vách. Giảm nghẽn đường ra thất trái cùng với giảm mức độ hở van hai lá có thể hạn chế hoặc thậm chí đảo ngược tái cấu trúc nhĩ trái⁽¹⁸⁵⁾. Trong một nghiên cứu gần đây, báo cáo loạt ca lớn nhất về điều trị rung nhĩ bằng phẫu thuật  cho thấy 44% số bệnh nhân (n = 49) không tái phát rung nhĩ ở thời điểm một năm và 79% số bệnh nhân (n = 72) được áp dụng phẫu thuật Maze (p dưới 0,001)⁽¹⁸²⁾.

Bảng 5. Lựa chọn thuốc chống loạn nhịp trên bệnh nhân BCTPĐ và rung nhĩ

6.4 Điều trị bệnh nhân BCTPĐ và rối loạn nhịp thất

Ở bệnh nhân BCTPĐ đã được đặt ICD, việc phòng ngừa nhịp nhanh thất tái phát là mục tiêu quan trọng vì những cù sốc của ICD làm giảm chất lượng cuộc sống và đưa đến kết cục xấu⁽²⁰⁶⁾. Có ít dữ liệu liên quan đến điều trị rối loạn nhịp thất ở người BCTPĐ. Sự lựa chọn thuốc nên được cá thể hóa. Tuy nhiên, amiodarone ưu thế hơn cả dù có nhiều tác dụng phụ và không cải thiện tỷ lệ sống còn. ICD lập trình nhịp nhanh có thể tối thiểu hóa nguy cơ sốc vì nhịp nhanh thất đơn dạng và cuồng thất thường xảy ra. Trong trường hợp không đáp ứng với thuốc điều trị rối loạn nhịp và đã tối ưu chương trình ICD, triệt đốt qua đường ống thông là một giải pháp.

Ghép tim nên tuân theo các khuyến cáo hiện tại⁽²⁰⁷⁾. Ghép tim trong BCTPĐ không đợi đến khi phân suất tống máu giảm vì bệnh nhân có phân suất tống máu bảo tồn cũng có thể phát triển suy tim tiến triển hoặc rối loạn nhịp khó chữa^(195,196).

Phần lớn bệnh nhân BCTPĐ có nhịp nhanh thất thường được chỉ định thuốc chẹn beta như là chọn lựa đầu tiên. Bởi vì, không có nghiên cứu nào về thuốc được tiến hành trên bệnh nhân BCTPĐ đã được đặt ICD với mục tiêu phòng ngừa ICD sốc. Vì vậy, khuyến cáo được suy ra từ nghiên cứu trên nhiều bệnh khác nhau. Trong nghiên cứu OPTIC (Optimal Pharmacological Therapy in Cardioverter Defibrillator Patients) với 412 bệnh nhân đã được đặt ICD điều trị thuốc chẹn beta, sotalol đơn độc, hoặc amiodarone kết hợp thuốc chẹn beta. Sau 1 năm, ICD sốc xảy ra ở 38,5% bệnh nhân dùng thuốc chẹn beta, 24,3% bệnh nhân dùng sotalol đơn độc, 10,3% bệnh nhân dùng amiodarone kết hợp thuốc chẹn beta⁽¹⁹⁷⁾. Như vậy, amiodarone hết hợp với chẹn beta hiệu quả nhất nhưng tăng tác dụng phụ⁽¹⁹⁷⁾. Trong một nghiên cứu trên 30 bệnh nhân được đặt ICD phòng ngừa thứ phát nhịp nhanh thất và rung thất, dofetilide đã chứng minh làm giảm tần suất nhịp nhanh thất / rung thất và ICD sốc khi những thuốc chống loạn nhịp khác, kể cả amiodarone, không hiệu quả⁽¹⁹⁹⁾. Mexiletine được thêm vào khi amiodarone  không hiệu quả, làm giảm nhịp nhanh thất, rung thất ở bệnh nhân đã được đặt ICD⁽²⁰⁰⁾. Phân tích tổng hợp trên 2268 bệnh nhân thể hiện thuốc chống loạn nhịp (chủ yếu là amiodarone) làm giảm ICD sốc không thích hợp, tuy không có lợi trên tỷ lệ sống còn⁽¹⁹⁸⁾. Hiệu quả và sự an toàn của các thuốc trong khuyến cáo loại 1 bao gồm propafenone và flecaine là không chắc chắn.

Ở trẻ em mắc BCTPĐ có nhịp nhanh thất tái phát, thuốc chẹn beta thường là chọn lựa hàng đầu. Dữ liệu về các biện pháp điều trị thay thế khi ICD sốc nhiều lần dù đã dùng thuốc tối đa như triệt đốt qua đường ống thông còn hạn chế. Cắt giao cảm mới chỉ báo cáo dưới dạng từng ca⁽²⁰⁸⁾.

Điều trị bằng ICD đã được chứng minh giúp phòng ngừa đột tử và cải thiện tỷ lệ sống còn ở bệnh nhân BCTPĐ⁽²⁰⁹⁾. Rối loạn nhịp thất có thể kết thúc bằng tạo nhịp nhanh, bao gồm nhịp nhanh thất đơn dạng và cuồng thất. Một nghiên cứu với 71 bệnh nhân BCTPĐ được đặt ICD, có 149 rối loạn nhịp được ghi nhận; trong đó rung thất hiện diện 74 lần, nhanh thất 57 lần và cuồng thất 18 lần và tạo nhịp nhanh thành công trong 74% các cơn⁽²⁰¹⁾. Điều này đặc biệt quan trọng đối với những bệnh nhân có nguy cơ nhịp nhanh thất đơn dạng như phình mỏm.

Ở bệnh nhân BCTPĐ có rối loạn nhịp thất tái phát, dù đã được điều trị bằng thuốc, cắt đốt được chứng minh là có lợi. Tỷ lệ thành công được ghi nhận là 73% không biến chứng⁽²⁰¹⁾. Trong một báo cáo loạt ca, phẫu thuật cắt túi phình mỏm thất trái ở ba bệnh nhân phình mỏm thất trái và nhịp nhanh thất kéo dài là biện pháp thay thế cắt đốt⁽²¹⁰⁾. Hủy giao cảm tim trái có hiệu quả đã được báo cáo ở vài trường hợp nhịp nhanh thất / rung thất trơ⁽²¹⁰⁾.

6.5 Điều trị bệnh nhân BCTPĐ suy tim rất nặng (Advanced Heart Failure)

Hình 4. Điều trị triệu chứng bệnh nhân BCTPĐ

BCTPĐ, bệnh cơ tim phì đại; XNDT, xét nghiệm di truyền

Hình 5. Sơ đồ điều trị suy tim

ARNI,  Angiotensin Receptor-Neprilysin inhibitors, Ức chế thụ thể angiotensin receptor-neprilysin; ARB, angiotensin receptor blocker, Ức chế thụ thể angiotensin; CRT, Cardiac Resynchronization Therapy, Điều trị tái đồng bộ tim; MRA, mineralocorticoid receptor antagonist, Kháng thụ thể mineralocorticoid; PSTM, Phân suất tống máu; PSTMTT, Phân suất tống máu thất trái.

Tiếp cận chung trong điều trị suy tim được trình bày trong Hình 2 và Hình 3. Trong BCTPĐ, phân suất tống máu dưới 50% thường liên quan đến những kết cục xấu; vì vậy, tình huống này được xem là chức năng tâm thu giảm quan trọng. Do đó, ở bệnh nhân BCTPĐ, việc điều trị theo khuyến cáo suy tim phân suất giảm được áp dụng khi phân suất tống máu dưới 50% (dưới 40% đối với các nguyên nhân suy tim khác)^(74,120). ICD giúp phòng ngừa đột tử tiên phát. CRT ở bệnh nhân có phân suất tống máu dưới 50% và NYHA III – IV kèm các tiêu chí thỏa điều kiện đặt CRT⁽¹²⁰⁾. Bất kể phân suất tống máu là bao nhiêu, nếu bệnh nhân có rối loạn nhịp thất tái phát hoặc có NYHA III – IV dù đã điều trị nội khoa tối ưu và điều trị giảm bề dày vách thất không được lựa chọn, đánh giá ghép tim nên được tiến hành với phân tầng nguy cơ với CPET. Đôi khi bệnh nhân NYHA III – IV cần dùng dụng cụ hỗ trợ thất trái.

Nhiều nghiên cứu cho thấy bệnh nhân BCTPĐ có phân suất tống máu dưới 50% có tiên lượng sống còn xấu hơn BCTPĐ có phân suất tống máu bảo tồn^(74,211,223). Mặc dù bệnh nhân BCTPĐ bị loại trừ khỏi các thử nghiệm lâm sàng ngẫu nhiên có đối chứngtrong suy tim, việc điều trị suy tim bệnh nhân BCTPĐ có phân suất tống máu giảm vẫn có thể tuân theo khuyến cáo^{(120,166,224)}. Vì BCTPĐ có phân suất tống máu giảm chỉ chiếm khoảng 5% nên việc đánh giá các nguyên nhân gây phân suất tống máu giảm khác nên được thực hiện bao gồm bệnh động mạch vành, bệnh van tim, các rối loạn chuyển hóa. Các thuốc làm giảm sức co bóp cơ tim như verapamil, diltiazem, disopyramide có thể ngưng nếu triệu chứng suy tim nặng hơn.

Bệnh nhân BCTPĐ thường không phải là ứng cử viên lý tưởng cho dụng cụ hỗ trợ thất trái vì buồng thất trái nhỏ và phân suất tống máu bảo tốn. Tuy nhiên, vài trường hợp được báo cáo với kết quả chấp nhận được với dụng cụ hỗ trợ thất trái dòng liên tục ^{(218,225–227)}  và tỷ lệ sống còn tốt hơn sau dụng cụ hỗ trợ thất trái ở bệnh nhân có đường kính buồng thất trái lớn hơn (46 – 50 mm)^(225,227). Dữ liệu liên quan đến hỗ trợ hai thất còn hạn chế.

Dự phòng đột tử tiên phát với ICD khi phân suất tống máu dưới 50% đã được chấp thuận⁽¹²⁰⁾. Ở bệnh nhân BCTPĐ trẻ em, việc đặt ICD cần được cân nhắc kỹ vì kích thước ICD và nguy cơ của dụng cụ này.

CRT đã được chứng minh có lợi về tỷ lệ sống còn và tỷ lệ tái nhập viện vì suy tim ở bệnh nhân suy tim với phân suất tống máu giảm và blốc nhánh trái với QRS ≥ 150 ms⁽¹²⁰⁾. Tuy nhiên, lợi ích của CRT trên bệnh nhân BCTPĐ chưa được chứng minh.

CPET hữu ích trong đánh giá chức năng hệ tim mạch, phổi và cơ xương ở bệnh nhân suy tim cần xét chỉ định ghép tim^(215,216). Tiêu chí chọn bệnh ghép dựa theo khuyến cáo hiện tại⁽²⁰⁷⁾. Khác với BCTDN, ghép tim trong BCTPĐ không chỉ ở giai đoạn phân suất tống máu giảm, ghép tim có thể được chỉ định ở BCTPĐ có phân suất tống máu bảo tồn.

Xem tiếp kỳ sau…

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