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Huấn luyện nâng cao và chuyên sâu

Tóm tắt hướng dẫn chẩn đoán và quản lý rung nhĩ của ESC 2020 được phát triển với sự hợp tác của hội ngoại khoa tim lồng ngực Châu Âu – P4

1497

TS. PHẠM HỮU VĂN

 

8.2 Chất nền bệnh

Chất nền cho AF liên quan đến sự giãn và xơ hóa LA với rối loạn chức năng LA tiếp theo và sự chậm trễ trong dẫn truyền điện cơ học.

Các khuyến cáo cho đánh giá chẩn đoán bệnh nhân rung nhĩ

Khuyến cáo Classa Levelb
Ở bệnh nhân AF, khuyến cáo nên:

• Đánh giá các triệu chứng liên quan đến AF (gồm mệt mỏi, trạng thái muốn đươ nghỉ, ngủ, khó thở khi gắng sức, đánh trống ngực và đau ngực) và định lượng tình trạng triệu chứng của bệnh nhân bằng cách sử dụng thang điểm triệu chứng EHRA đã sửa đổi trước và sau khi bắt đầu điều trị. [230,232]

• Đánh giá các triệu chứng liên quan đến AF trước và sau khi chuyển nhịp AF dai dẳng để hỗ trợ quyết định điều trị kiểm soát nhịp. [230,232]

  

 

 

I

  

 

 

C

AF = rung nhĩ; EHRA = Hội nhịp tim châu Âu.

a Class khuyến cáo.

b Mức độ bằng chứng.

 Hình ảnh đa phương thức, không xâm lấn có thể cung cấp tất cả thông tin cần thiết (Hình 9). [249.250]

Hình 9. Hình ảnh trong AF.

Hình ảnh giải phẫu cung cấp kích thước, hình dạng và xơ hóa LA. Đánh giá chính xác nhất về sự giãn LA được thực hiện bằng CMR hoặc CT. Thông thường, siêu âm tim qua lồng ngực hai chiều (2D) hoặc (tốt nhất là) ba chiều (3D) được sử dụng. Giá trị thể tích bình thường của siêu âm tim 3D là 15 – 42 mL / m2 đối với nam và 15 – 39 mL / m2 đối với nữ.[250] Đánh giá xơ hóa LA bằng LGE-CMR đã được mô tả nhưng hiếm khi được áp dụng trong thực hành lâm sàng. [251] Hình ảnh chức năng bao gồm TDI và sức căng. TDI đo vận tốc của cơ tim trong tâm trương và tâm thu, trong khi sức căng LA phản ánh sự co bóp LA hoạt động. Khoảng PA-TDI phản ánh độ trễ cơ điện tâm nhĩ (tổng thời gian dẫn truyền LA, khoảng thời gian giữa sóng P trên ECG và A’ [vận tốc đỉnh tâm nhĩ] trên TDI) và phản ánh độ căng LA. [252] Thành LA được thấm mỡ vùng mỏm là chỉ dấu sớm tiềm tàng của sự thấm và có thể được phát hiện bằng CT hoặc MRI tim. [253] Trước khi triệt phá AF, giải phẫu tĩnh mạch phổi có thể được hình dung bằng CT hoặc CMR. AF = rung nhĩ; CT = chụp cắt lớp vi tính; EP = điện sinh lý học; LA = tâm nhĩ trái; LAA = tiểu nhĩ trái; LV = thất trái; LGE-CMR = cộng hưởng từ tim tăng cường tương phản gadolinium muộn; MRI = chụp cộng hưởng từ; TDI = hình ảnh doppler mô; TOE = siêu âm tim qua thực quản; TTE = siêu âm tim qua lồng ngực.

Ở những bệnh nhân được chọn, siêu âm tim qua thực quản (TOE) có thể được sử dụng để đánh giá bệnh van tim (valvular heart disease:VHD) hoặc huyết khối tiểu nhĩ trái (LAA); Chụp CT mạch vành có thể được thực hiện để đánh giá bệnh động mạch vành (CAD); chụp cát lớp vi tính / cộng hưởng từ (CT / MRI) não có thể được thực hiện khi nghi ngờ đột quỵ. Các yếu tố dự báo cụ thể của đột quỵ đã được gợi ý: giãn LA, cản quang LA tự phát, giảm sức căng LA, huyết khối LAA, vận tốc đỉnh LAA thấp (<20 cm / s), và cấu hình LAA mất đi hình cánh gà (trên CT). [250]

  1. Quản lý tổng hợp bệnh nhân rung nhĩ

9.1 Định nghĩa và các thành phần của quản lý tổng hợp bệnh nhân rung nhĩ

Quản lý tổng hợp bệnh nhân AF đòi hỏi một lộ trình chăm sóc cá thể hóa được điều phối và đồng ý với bệnh nhân để đưa ra phương pháp điều trị tối ưu (Hình 10) bằng một nhóm liên ngành (Hình 11). Trung tâm của cách tiếp cận này là bệnh nhân; Các lựa chọn điều trị nên được thảo luận và kế hoạch quản lý được thống nhất trong cuộc thảo luận với các chuyên gia chăm sóc sức khỏe. Việc điều trị có thể thay đổi theo thời gian với sự phát triển của các yếu tố nguy cơ mới, các triệu chứng, sự tiến triển của bệnh và sự ra đời của các phương pháp điều trị mới.

Hình 10. Các thành phần của quản lý AF tích hợp. AF = rung nhĩ; HCP = chuyên gia chăm sóc sức khỏe; MDT = nhóm đa ngành.

(Vui lòng xem tiếp trong kỳ sau)

 

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