Hng dn mi v phng nga t quy tin pht-2014

PGS.TS Cao Phi Phong lc dch

Thng 10 nm 2014 Hip hi Tim mch v t qu Hoa k pht hnh

hng dn mi v phng nga t qu tin pht, cp nht hng dn c

nm 2011. Bo co cho thy 76% t qu l mi xy ra ln u- nhn mnh

n tm quan trng ca phng nga tin pht

nh gi nguy c t qu tin pht

C bn

1. Cc cng c nh gi nguy c c ch li nhng cn gii hn.

2. Tuy nhin k hoch iu tr s da trn kt qu xem xt ton b cc yu

t nguy c ca bnh nhn

im ct yu: Mt s tc gi cho rng cng c nh gi nguy c t qu

khng hon ho, khng mt ai trong h xem xt tt c cc yu t c tim

nng gy ra t qu. Nhng chng th c ch xc nh s lng nguy c

t qu. y l l do AHA/ACCCV Risk Calculator cp n trong hng

dn. Bnh nhn b t qu hay c nhiu yu t nguy c, cng c nh gi

nguy c c th khng cn thit v thng ri vo nhm iu tr tn cng.

Nu bnh nhn c rung nh, tnh nguy c bng thang im CHADS2 hay

CHA2DS2-VASc c th ch li.

Yu t di truyn

1. Tin s gia nh c th ch li trong xc nh ai gia tng nguy c t qu

(Class IIa; Level of Evidence A).

2.Gii thiu tham vn v di truyn c th xem xt i vi bn c bnh di

truyn gy t qu (Class IIb; Level of Evidence C).

3. Bnh Fabry: xem xt iu tr thay th enzyme, khng cho thy gim nguy

c t qu, hiu qu cha bit. (Class IIb; Level of Evidence C)

4. Xem xt tm sot khng xm ln phnh mch ni s cha v cho bn c

mc ban u lin h xut huyt di nhn hay phnh mch ni s 2

(Class IIb; Level of Evidence C).

5. Xem xt tm sot khng xm ln phnh mch ni s cha v cho bn

bnh thn a nang do nhim sc th thng tri (Autosomal dominant

polycystic kidney disease: ADPKD) v lin h vi ADPKD v xut huyt

di nhn1 hay lin h ADPKD v phnh mch ni s1 (Class IIb; Level of

Evidence C)

6. Xem xt tm sot khng xm ln phnh mch ni s cha v cho bn lon

sn x c vng c (Cervical fibromuscular dysplasia) (Class IIb; Level of

Evidence C)

7. Xem xt dc di truyn hc (pharmacogenetic) liu i vn vitamin K khi

iu tr khi u iu tr(Class IIb; Level of Evidence C)

8. Tm sot khng xm ln phnh mch ni s cha v khng khuyn co

cho bn khng c hn mt lin h vi xut huyt di nhn hay phnh mch

ni s(Class III; Level of Evidence C)

9. Khng khuyn co tm sot phnh mch ni s cho mi c nhn mang

nhim sc th thng tri thn a nang hay Ehlers-Danlos t bin type IV

10. Tm sot di truyn trong cng ng chung phng nga t qu tin

pht th khng khuyn co (Class III; Level of Evidence C)

11. Tm sot di truyn xc nh nguy c bnh c th khng khuyn co khi

xem xt khi u iu tr statin (Class III; Level of Evidence C)

im ct yu: Mc d nguyn nhn di truyn gy t qu lin quan n

tui v chng tc vn cn l nguy c khng sa i c do khng th

thc hin iu tr gene, vic cung cp li khuyn trong cc bnh CADASIL

(cerebral autosomal dominant arteriopathy with subcortical infarcts and

leukencephalopathy) c th c ch cho gia nh b bnh ny. iu tr thay

th enzyme c ch li trong bnh Fabry, bn ri lon chuyn ha lipid, gia

tng nguy c tim mch. Cui cng xc nh nguy c t qu tim tng nh

phnh ng mch cha v, c th tm kim trong cc trng hp chn lc

Khng vn ng c th (Physical Inactivity)

C bn

1. Khuyn co vn ng c th bi v lm gim nguy c t qu (Class I;

Level of Evidence B)

2. Ngi ln khe mnh: th dc th thao tng cng nhp h hp, nhp

tim cng trung bnh n mnh t nht 40 pht/ngy, 3-4 ngy/ tun

(Class I; Level of Evidence B)

im ct yu

Nhiu nghin m t cho thy ch li vic vn ng c th gim nguy c t

qu. Con ngi s tm nhng vn ng m h thch th, th d ngay c i

b cng cho thy gim nguy c t qu. Thi gian luyn tp c th tn ra

cho nhng ngi kh khn luyn tp y thi gian theo khuyn co

Ri lon lipid mu

C bn

Can thip vo li sng (Lifestyle), nguy c tim mch trong 10 nm cao: khi

u iu tr statin

1. Thm vo iu tr thay i li sng, iu tr thuc HMG coenzyme-A

reductase inhibitor (statin) c khuyn co trong phng nga t qu

thiu mu tin pht cho bn c tnh c nguy c tim mch 10 nm cao

(2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to

Reduce Atherosclerotic Cardiovascular Risk in Adults) (Class I; Level of

Evidence A).

2. Niacin c th xem xt dng cho bn c HDL cholesterol thp hay tng

Lp(a), nhng hiu qu trong phng nga t qu thiu mu cha c

thit lp. Thn trng khi dng niacin v gia tng nguy c bnh c. (Class IIb;

Level of Evidence B).

3. Cc dn xut Fibric acid c th xem xt cho bn tng triglyceride mu,

nhng hiu qu ca n trong phng nga t qu thiu mu cha thit lp

(Class IIb; Level of Evidence C).

4. Nu khng dung np Statin: xem xt iu tr thuc h lipid khc nh dn

xut fibric acid, acid mt kh ion( bile acid sequestrants), niacin v

ezetimibe, mc d hiu qu phng nga t qu cha thit lp (Class IIb;

Level of Evidence C).

im ct yu: iu tr Statin c ch nh lm gim nguy c t qu x

va mch bn nguy c tim mch 10 nm cao, xc nh qua tnh nguy c

tim mch. Hin nay xut hin thm Ezetimibe phng nga bnh tim v t

qu, thuc ngn chn ti hp thu cholesterol rut. Trong nghin cu

IMPROVE-IT, kt hp ezetimibe v simvastatin phng nga tim v t qu

tt hn simvastatin n thun. Ezetimibe c th chn la bn khng dung

np statin.

Ch n v dinh dng

C bn

1. Gim sodium (

4. Ch n ca vng a Trung Hi (Mediterranean diet) b sung qu

nhn(nuts) c th xem xt lm gim nguy c t qu (Class IIa; Level of

Evidence B).

im ct yu: ch n DASH v Mediterranean-style lin quan gim

nguy c t qu. DASH nhn mnh n tri cy, rau qu, ng cc, b v

ph- mt t cht bo, c, tht gia cm v du thc vt nhng hn ch

sodium v m bo ha. Ch n Mediterranean tng t nhn mnh u

tin thc n c bn l thc vt v m tt cho sc khe (th d: du olive),

nhng cng cho php i khi dng c v tht gia cm v khng thng

xuyn dng tht. Ru vang ung trung bnh.

Tng huyt p

C bn

1. Tm sot huyt p thng xuyn v iu tr thch hp: thay i li sng

v dng thuc (Class I; Level of Evidence A).

2. Bnh nhn tin tng huyt p (systolic BP: 120-139 mm Hg hay diastolic

BP: 80-89 mm Hg): thc hin tm sot huyt p hng nm v thay i li

sng (Class I; Level of Evidence A).

2. Tng huyt p: iu tr ch huyt p < 140/90 mm Hg (Class I; Level of

Evidence A)

3. H huyt p thnh cng th quan trng hn chn thuc chuyn bit

trong gim nguy c t qu v iu tr ty thuc tng bnh nhn, trn c

s c im v dung np thuc ca bnh nhn (Class I; Level of Evidence

A). BP

4. T o huyt p v theo di huyt p c khuyn co ci thin kim

sot huyt p(Class I; Level of Evidence A).

im mu cht: hng dn mi ch ra tng huyt p vn cn l im

quan trng nht, yu t nguy c c chng minh v sa i c, iu tr

tng huyt p c nhn mnh hiu qu nht trong chin lc phng

nga c t qu thiu mu v xut huyt. Mc d mt vi nghin cu

ngh h huyt p tn cng c th lin kt vi d hu xu nhng ngi ln

tui yu ui, phn ln ng h iu tr huyt p trn 140/90mmHg. Nu bn

huyt p tm thu trn 160mmHg, xem xt khi u iu tr 2 loi thc tng

huyt p nh li tiu v c ch men chuyn

Bo ph v phn b m trong c th

C bn

1. Nhng ngi d cn (BMI=25 - 29 kg/m2) v bo ph (BMI >30 kg/m2)

khuyn co gim cn gim huyt p (Class I; Level of Evidence A).

2. Nhng ngi d cn (BMI=25 - 29 kg/m2) v bo ph (BMI >30 kg/m2)

khuyn co gim cn gim nguy c t qu (Class I; Level of Evidence

B)

im mu cht: Mc d kh chng minh gim cn trc tip gim nguy c

t qu, bng chng c th to ln ng h s lin kt gia tng cn v t l

mc t qu ln hn. Hng dn khuyn co gim cn nhng ngi d

cn(BMI=25-29kg/ m2) v bo ph(BMI >30 kg/m2) trong c gng lm gim

huyt p v gim nguy c t qu

i tho ng

C bn

1. i tho ng Type 1 hay type 2: kim sot huyt p theo khuyn co

AHA/ACC/CDC ch huyt p < 140/90 mm Hg(Class I; Level of Evidence A).

2. iu tr ngi ln i tho ng vi statin, c bit cc trng hp c

thm yu t nguy c, khuyn co lm gim nguy c t qu tin pht(Class

I; Level of Evidence A).

3. ch li dng aspirin trong phng nga t qu tin pht cho bn i tho

ng nhng nguy c bnh tim mch trong 10 nm thp th khng r

rng(Class IIb; Level of Evidence B).

4. Thm vo fibrate cho bn i tho ng gim nguy c t qu th

khng hu ch(Class III; Level of Evidence B).

im mu cht: bn i tho ng, kim sot tt huyt p vi thuc c

ch men chuyn hay c ch th th angiotensin gim nguy c t qu. Mc

d kim sot ng huyt gim hay khng nguy c t qu th khng r,

d liu ngh iu tr statin gim nguy c t qu tin pht bnh nhn

i tho ng

Ht thuc l

C bn

1.Tham vn, cho nhng ngi ang ht thuc gip h ngng ht thuc,

kt hp iu tr thuc dng nicotine thay th, bupropion hay varenicline

(Class I; Level of Evidence A).

2. Trnh ht thuc l c khuyn co cho nhng ngi cha tng ht

thuc, trn c s nghin cu dch t hc cho thy s tng quan kin nh

v mnh gia ht thuc v c t qu thiu mu v xut huyt di

nhn(Class I; Level of Evidence B).

im mu cht: c s lin kt r rng gia ht thuc l v gia tng nguy

c t qu thiu mu v xut huyt di nhn. D liu cho thy k hoch

ngng ht thuc gim t l mi mc t qu hin khng y . Tuy nhin

nghin cu dch t hc ngh ngng ht thuc lin h gim nguy c t

qu. Hng dn mi nhn xt vic cm ht thuc ni cng cng rng ri

trong cng ng hay c nc l c c s mun lm gim nguy c t qu

v nhi mu c tim

Rung nh

C bn

1. Bnh nhn rung nh c bnh van tim nguy c cao t qu, xc nh im

CHA2DS2-VASc 2 v nguy c bin chng xut huyt thp chp nhn

c, khuyn co iu tr khng ng ung warfarin lu di ch INR t

2.0-3.0 (Class I; Level of Evidence A).

2. Bnh nhn rung nh khng bnh van tim, c