Nghien cuu tam soat va chan doan truoc sinh benh alpha va beta thalassemia
Nghien Cuu Tuoi Dong Mach Tren Benh Nhan Nho i Ma u Co Tim CA p
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BỘ GIÁO DỤC VÀ ĐÀO TẠO BỘ Y TẾ TRƯỜNG ĐẠI HỌC Y HÀ NỘI ………***……… TRẦN HOÀI NAM NGHIÊN CỨU VỀ TUỔI ĐỘNG MẠCH TRÊN BỆNH NHÂN NHỒI MÁU CƠ TIM CẤP KHÓA LUẬN TỐT NGHIỆP BÁC SĨ Y KHOA Khóa 2007 - 2013 Hà Nội – 2013 1
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Transcript of Nghien Cuu Tuoi Dong Mach Tren Benh Nhan Nho i Ma u Co Tim CA p
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B GIO DC V O TO B Y T
TRNG I HC Y H NI
***
TRN HOI NAM
NGHIN CU V TUI NG MCH
TRN BNH NHN NHI MU C TIM CP
KHA LUN TT NGHIP BC S Y KHOA
Kha 2007 - 2013
H Ni 2013
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B GIO DC V O TO B Y T
TRNG I HC Y H NI
***
TRN HOI NAM
NGHIN CU V TUI NG MCH
TRN BNH NHN NHI MU C TIM CP
KHA LUN TT NGHIP BC S Y KHOA
Kha 2007 - 2013
NGI HNG DN KHOA HC
PSG TSPHM MNH HNG
H Ni 2013
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LI CM N
Vi lng knh trng v bit n su sc, ti xin by t lng cm n chnthnh ti:
Ban gim hiu, phng o to i hc, B mn Tim mch trng ihc Y H Ni v vin Tim mch to iu kin cho ti thc hin ti ny.
GS TS Nguyn Ln Vit, Vin trng vin Tim mch Quc gia VitNam, ch nhim B mn Tim mch trng i hc Y H Ni, to miiu kin thun li cho ti hon thnh kha lun.
PGS TS Phm Mnh Hng, Trng n v can thip mch, Ph trngkhoa cp cu tim mch C3, vin Tim mch Quc gia Vit Nam, Nhn ti tVit trong lnh vc Y hc 2010, mt ging vin tm huyt ca B mn Timmch trng H Y H Ni, ngi thy trc tip hng dn, tn tnh gip v ng vin ti trong qu trnh thc hin ti, ch bo tn tnh cho tinhiu kin qu bu trong thi gian hc tp v nghin cu.
ThS BS Vn c Hnh, khoa cp cu tim mch C1, tn tnh hngdn, gii thiu cho ti nhiu ti liu tham kho v nghin cu b ch.
Ccbc s, iu dng, cc anh ch hc vin sau i hc ti cc khoa,phng thuc Vin Tim mch Quc gia Vit Nam, to iu kin cho ti thuthp s liu, v cho ti nhiu li khuyn hu ch trong thi gian 5 thng thchin ti.
Ton th cc thy c gio nhit tnh du dt ti trong sut 6 nm hc tpv rn luyn ti trng i Hc Y H Ni, ti cc bnh vin m ti hc tp.
Nhng bnh nhn NMCT cp iu tr ti Bnh vin Tim mch Qucgia Vit Nam nhit tnh tham gia nghin cu v gip ti c s liu thchin kha lun ny.
Cui cng, xin cm n cha m, gia nh v bn b thn thit lunng vin khch l, chia s mi kh khn v to nhng iu kin tt nht ti c th hon thnh tt kha lun tt nghip.
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LI CAM OAN
Knh gi: - Ban gim hiu trng i hc Y H Ni.
- B mn Tim mch trng i hc Y H Ni.
Ti xin cam oan ti trn l ca ring ti thc hin di s hng
dn ca PGS TS BS Phm Mnh Hng. Cc s liu trong ti l trung thc,
khng trng lp vi bt k ti no khc.
Sinh vin
Trn Hoi Nam
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CC CH VIT TT
Cholesterol TP : Cholesterol ton phn
MV : ng mch vnh
T : i tho ng
FRS : Framingham Risk Score
HA : Huyt p
HATT: : Huyt p tm thu
HDL-C : High Density Lipoprotein Cholesterol
LDL-C : Low Density Lipoprotein Cholesterol
NMCT : Nhi mu c tim
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T VN
Cng vi s pht trin vt bc ca khoa hc, k thut, i sng con
ngi khng ngng thay i v mi mt vn ha, x hi v sc khe. M
hnh bnh tt v t vong thay i, bnh tim mch tr thnh nguyn nhn
hng u dn ti t vong. u th k 20 t vong do bnh tim mch ch chim
10%, n u th k 21 con s ny l 50% cc nc pht trin v 25% cc
nc ang pht trin [43].
c tnh ca T Chc Y T Th Gii (WHO) cho thy, hng nm c
khong 17 triu ngi b t vong do bnh tim mch, trong t l mc/t
vong do NMCT lun chim v tr hng u. Vit Nam trong nhng nm gn
y c rt nhiu s tin b ca khoa hc k thut trong chn on v iu tr,
nhng t l t vong do NMCT vn rt cao vi cc bin chng nguy him,
li di chng nng n, nh sc tim, ri lon nhp tim, ngoi tm thu, nhp
nhanh tht iu ny i hi phi nng cao hiu qu cng tc d phng
NMCT ti cng ng.
Trn th gii c nhiu nghin cu dch t hc ln nhm a ra c
cc thang im lng gi nguy c ca bnh l mch vnh nh cc thang im
Framingham, EUROSCORE, PROCAM, INDIANA da trn cc yu t
kinh in: tui, gii, nng LDH trong mu, cc men tim troponin, huyt p
tm thu, chc nng tht tri trn siu m tim Cc thang im trn gip
ch rt nhiu cho vic d bo nguy c bnh mch vnh ti cng ng tuy
nhin i hi nhiu thng s, tnh ton tng i phc tp v kh khn cho
ngi dn trong vic nm bt v p dng, t c thc thay i li sng v
tun th iu tr gim thiu nguy c mc bnh mch vnh.
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Tui ng mch l mt thng s c a ra tnh ton nguy c mc
bnh mch vnh ti cng ng, vi u im n gin, d p dng v d hiu
i vi c ngi bnh khng c kin thc chuyn mn, hin ang ngy cng
c ng dng rng ri trn th gii. Tuy nhin Vit Nam cha c nghin
cu no nh gi Tui ng mch trn bnh nhn nhi mu c tim cp.
Bi vy em tin hnh ti Nghin cu tui ng mch trn bnh
nhn NMCT cp nhm mc tiu nh gi mi tng quan gia Tui ng
mch vi cc yu t nguy c ca NMCT cp.
T a ra khuyn co gip nng cao hiu qu tuyn truyn d
phng bnh mch vnh trong cng ng v gip ngi bnh c thc tun
th iu tr.
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CHNG 1
TNG QUAN TI LIU
1.1: Tnh hnh bnh Nhi mu c tim cp:
1.1.1: Trn th gii:
Mc d c nhiu tin b trong chn on v iu tr trong vi thp k
qua, song NMCT cp vn l mt vn sc khe cng ng quan trng cc
nc cng nghip v cng ngy cng tr nn quan trng hn cc nc ang
pht trin.
Theo bo co ca t chc y t th gii (WHO), nm 2004 trn ton th
gii c 7,2 triu ngi t vong do bnh tim thiu mu cc b chim 12,2%
cc nguyn nhn gy t vong cho mi la tui [43].
Hoa K t l mc bnh mch vnh l 7,6% k t nm 2006, 16,8 triu
ngi c chn on bnh mch vnh, vi 7,9 triu ngi b MNCT. Bnh
mch vnh chim 35,3% nguyn nhn t vong chung Hoa K nm 2005.
1.1.2: Vit Nam:
Vit Nam, s lng bnh nhn b bnh MV cng ngy mt tng
hn. Theo thng k ca Vin tim mch quc gia Vit Nam, trong nhng nm
1980 ch c khong 1% bnh nhn nm iu tr ni tr l do bnh tim thiu
mu cc b. Trong 10 nm t 1995 n 2005 ch tnh ring s lng bnh
nhn c tin hnh chp v can thip MV c s ca chp 3803 ca trong
can thip 1835 ca. Trong vng 5 nm t 01/01/2003 n 31/12/2007 thy
nhm bnh nhn mc bnh tim thiu mu cc b tng dn sau mi nm, t
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11,2% ( nm 2003 ) ln 24% ( nm 2007 ) trung bnh l 18,3% tng s bnh
nhn nhp vin [18].
1.2: i cng v Nhi mu c tim cp:
1.2.1: nh ngha:
Nm 1994 ngi ta a ra danh t hi chng mch vnh cp, danh t
ny ni ln c bn cht thiu mu c tim xy ra mt cch cp tnh v bao
gm 3 bnh cnh chnh ca tnh trng thiu mu c tim cp tnh: cn au tht
ngc khng n nh chim gn 60%, NMCT cp c ST khng chnh chim
2/3, cn li 1/3 l NMCT cp c ST chnh ln [1].
Nhi mu c tim l tnh trng hoi t mt vng c tim, hu qu ca
thiu mu cc b c tim ko di. Trc y NMCT ch c chn on khi
vng hoi t c din tch t 2cm2 tr ln. Hin nay vi tin b ca k thut
nh lng cc du n sinh hc c hiu cho c tim nh Troponin I, T, nn c
th pht hin vng c tim b hoi t vi trng lng rt nh (
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nm trong rnh nh tht phi chia nhiu nhnh cho tht phi. ng mch vnh
tri cho nhnh ng mch lin tht trc v ng mch m ti mu cho
vng trc bn ca tht tri, ng mch lin tht trc chia cc nhnh cho
cung cp mu cho thnh trc tht tri v mt s nhnh xuyn cho vch lin
tht. a s trng hp, ng mch lin tht trc bao quanh mm tim nt
thng ng mch lin tht sau. ng mch lin tht trc l ng mch ln
v quan trng nht ca h thng mch vnh. ng mch m nm trong cnh
nh tht tri chy quanh mt bn ca tht tri v tn cng bng nhiu nhnh
ng mch b. ng mch vnh phi nui dng phn sau tht tri v 1/3 sau
vch tht tri, c nh sau.
Hnh 1.1: Hnh nh ng mch vnh
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.
Hnh 1.2: Hnh nh gii phu ng mch vnh tri.
Hnh 1.3: Hnh nh gii phu ng mch vnh phi.
1.2.3: Nguyn nhn v c ch bnh sinh trong NMCT cp [1], [7], [9], [17]:
Nguyn nhn ch yu ca NMCT l do tnh trng bt n ca cc mng
x va ng mch tch ra v gy tc hon ton mt nhnh hay nhiu nhnh
ng mch vnh. C rt nhiu nguyn nhn v yu t nh hng n s
khng n nh ca mng x va nh: c tnh d v ca mng x va, hp
ng mch vnh, cc t bo vim kch thch ngng tp tiu cu, tng nng
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catecholamine, thrombin trong mu, p lc thnh mch, tnh trng ng
mu...
Do s khng n nh ca mng x va dn n d nt ra, lp di ni
mc s b l ra v tip xc vi tiu cu, gii phng ra cc cht trung gian ho
hc hot ho cc th th Glycoprotein IIb/IIIa trn b mt cc tiu cu, hot
ho qu trnh ngng kt tiu cu to huyt khi ti v tr tn thng. Nt cc
mng x va cng vi hot ho tiu cu lm cho hot ho dy chuyn ng
mu ni ti v ngoi lai hnh thnh fibrin. Fibrin l yu t lm pht trin, hon
thin v bn vng cc huyt khi. Cc huyt khi hnh thnh trn mng x
va phi hp thm tnh trng co tht ca ng mch vnh lm tc hon ton
hoc mt phn ng mch.Nu huyt khi c hnh thnh t v ln s gy
tc hon ton lng mch ca nhnh ng mch vnh. Cng chnh cc ho cht
trung gian ny gy hin tng co mch lm hp thm lng ng mch vnh.
ng thi, khi mng x va pht trin ln su vo lng mch cng gy hp
lng ng mch vnh. Phi hp cc yu t ny chnh l nguyn nhn gy tc
ng mch vnh v gy nn bnh cnh ca NMCT cp.
Ngoi ra trong mt s trng hp c th gp tn thng ng mch
vnh do cc nguyn nhn khc gy tn thng mch vnh nh: bt thng
ng mch vnh bm sinh, vim ni tm mc nhim khun, bc tch ng
mch vnh, giang mai.
Nhi mu c tim l tnh trng thiu mu c tim t ngt v hoi t mt
vng c tim, do s tc ngn mt hoc nhiu nhnh ng mch vnh
1.2.4: Chn on bnh nhn NMCT cp [11] [22]
Theo WHO: Chn on xc nh NMCT cp khi c t nht 2 trong 3 tiu
chun sau:
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1. au ngc in hnh, ko di 30 pht, dng cc thuc gin ng mch
vnh khng .
2. C thay i c trng trn in tm .
3. Men tim tng cao t nht gp 2 ln gi tr gii hn cao ca bnh thng.
1.2.4.1: Lm sng: Cn au ngc in hnh:
+ Xy ra t ngt, thng lc khng c gng sc.
+ V tr ngay sau xng c, ngang gia ngc.
+ Cng : au d di lm bnh nhn lo s, c cm gic cht n ni.
+ Hng lan: cnh tay, vai, hm di.
+ Thi gian au: ko di nhiu gi, khng p ng vi Nitroglycerin.
+ C th c v m hi v cc ri lon tiu ha (nht l nhi mu c tim
vng di).
- Mt s trng hp khng in hnh: au bng vng thng v d
nhm vi triu chng ca mt cp cu v tiu ha (vim ty cp, thng tng
rng), ph n, ngi cao tui v bnh nhn tiu ng nhi mu c tim c
th khng au v d b b st.
1.2.4.2: Cn lm sng:
- in tm [7] [11]:
L phng php n gin, tin li c th p dng rng ri, gip chn
on xc nh cng nh nh khu vng NMCT mt cch nhanh chng. Cn
phi lm in tm sm trong vng 10 pht k t khi xut hin cn au
vlm nhc li nhiu ln sau gip chn on v theo di din bin bnh.
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Ngoi cc chuyn o thng thng cn lm thm cc chuyn o
V3R, V4R chn on NMCT tht phi trong trng hp NMCT thnh
di.
Cc tiu chun chn on NMCT cp trn in tm l:
+ Xut hin sng Q mi (rng 0,04 giy v su 0,2 mV) t nht
hai trong cc chun o sau: DII, DIII, aVF; V1 n V6; DI v aVL; hoc
+ Xut hin on ST chnh ln hoc chnh xung ( 0,1mV) t nht
hai trong cc chuyn o ni trn ( cc chuyn o i xng thng c hnh
nh "soi gng" ST chnh xung), hoc:
+ Xut hin bloc nhnh tri hon ton trong bnh cnh lm sng ni trn.
Trng hp NMCT khng c sng Q, l cc trng hp hoi t khng
xuyn thnh, thng do hp nhiu ch nhng ng mch nh hoc do di
chng ca NMCT c iu tr tiu si huyt sm. Trn in tm thy ST
chnh xung ko di biu hin NMCT di ni tm mc. Cc du hiu lm
sng v men tim ging trng hp NMCT xuyn thnh. Trng hp nng c
th gp cc ri lon nhp phc tp khc: Bloc nh tht cp 2, cp 3, nhp nhanh
tht, rung tht
Tiu chun chn on nh khu vng NMCT trn T: Da vo cc
chuyn o c on ST chnh ln v/hoc c sng Q bnh l chn on
nh khu vng NMCT trn T theo khuyn co ca Hi tim mch quc gia Vit
Nam [11].
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Bng 1.1: chn on nh khu vng NMCT trn in tm
V tr tn thng Chuyn o c hnh nh tn thng
Thnh trc
1. Vch V1, V22. Trc V3, V43. Trc vch V1, V2, V3, V44. Mm V5, V6 + V45. Bn cao D1, aVL6. NMCT trc rng V1, V2, V3, V4, V5, V6 v D1, aVL7. Trc vch bn cao V2, V3, V4 v D1, aVL8. Trc bn D1, aVL, V5, V6
Thnh di
9. NMCT thnh di D2, aVF v D3
10. Thnh sauR cao V1 hoc V2
(hnh nh trc tip V7, V8, V9)
11. Tht phiST chnh ln 1mm mt trong cc
chuyn o V3R, V4R, V5R, V6R
- Cc men sinh hc trong huyt thanh bnh nhn [11], [7], [9]
+ Creatinin Kinase (CK): c 3 iso-enzym ca men ny l CK-MB, CK-MM,
CK-BB i din cho c tim, c vn v no theo th t trn. Bnh thng CK-
MB < 5% lng CK ton phn (bnh thng CK ton phn trong huyt thanh
c gi tr t 24 -190U/L 37C v CK-MB < 24 U/L).
CK-MB tng trong vong 3 n 12 gi sau NMCT, t nh vo khong
24 gi v tr v bnh thng sau 48 n 72 gi.
Mt s trng hp c s tng ca CK v CK-MB nhng khng phi
NMCT l: vim c tim, sau m tim, sau sc in, chn thng tim, chn
thng ng dp c nhiu
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+ Troponin: bao gm c troponin T v troponin I l hai loi men c gi tr
chn on NMCT cao do kh c hiu cho c tim. Cc men ny tng kh sm
3 n 12 gi sau MNCT t nh sau 24 n 48 gi v ko di 5 n 14 ngy.
Trong NMCT cp, nh lng cc men ny ngay sau khi xut hin au
ngc v mi 6 gi sau s gp phn chn on v tin lng. Ngoi ra cn
c s tng ln ca cc men khc nhng khng c hiu cho NMCT nn ch
dng tham kho nh Lactat Dehydrogenase (LDH), cc transaminase
SGOT v SGPT.
- Siu m tim [6]:
L mt phng tin chn on hnh nh tin li, c gi tr gip pht
hin ri lon vn ng vng cc thnh tim h tr cho chn on v gp phn
tin lng. Ri lon vn ng vng c nh gi da trn cn c vo vn
ng ca 17 vng c tim theo khuyn co ca hi siu m Hoa K nm 2005.
C 4 hin tng ri lon v co c c th xy ra khi MV b tc: mt
ng b v thi gian co c, gim vn ng, mt vn ng v vn ng nghch
thng.
nh gi ri lon chc nng tm thu tht tri ca tim da vo phn s
tng mu (EF - Ejection Fraction) trn siu m 2D. Phng php Simpson c
gi tr chnh xc hn bnh nhn bnh MV.
+ Chc nng tm thu tht tri bnh thng: EF > 60%.
+ Chc nng tm thu tht tri gim nh: 50% < EF 60%.
+ Chc nng tm thu tht tri gim va: 40% < EF 50%.
+ Chc nng tm thu tht tri gim nng: EF 40%.
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Siu m tim cn gip nh gi cc bin chng c hc ca NMCT
(thng thnh tim, thng vch lin tht gy thng lin tht, t dy chng gy
h van tim), trn dch mng ngoi tim, huyt khi trong bung tim
- Thm d phng x ti mu c tim: thng khng cn dng trong giai
on cp, cc thm d ny c ch giai on sau gip nh gi s ti mu
cho tng vng c tim v s sng cn ca c tim.
- Chp ng mch vnh: Chp MV t lu c coi l tiu chun "vng"
chn on bnh MV, t nh gi c im hnh thi tn thng, lm c
s a ra cc chin lc iu tr ti u nht. Mt s trng hp kh khn c
th cn kt hp thm cc bin php khc nh gi tn thng nh siu m
trong lng mch vnh, nh gi phn s d tr lu lng vnh (Fractional
Flow Reserve - FFR). Chp MV gip chn on xc nh NMCT v kt hp
iu tr can thip ti ti mu MV khi c ch nh.
1.2.6: Nhng yu t nguy c trong NMCT cp [1], [6], [14]:
Trong bi cnh s hiu bit chung cn hn ch v nguyn nhn gy ra
cc bnh tim mch v t qu, trong khi t l t vong do cc bnh l ny ngy
cng tng cao n mc nguy him, t nm 1948, Vin tim quc gia Hoa K
nay l Vin tim, phi v mu quc gia Hoa K NHLBI bt u tin hnh
nghin cu on h Framingham. Mc tiu chnh l xc nh cc yu t hoc
c im chung (common factors or characteristics) lin quan n cc bnh l
tim mch (cardiovascular diseases CVD). Kt qu tm thy t nghin cu
Framingham gip xc nh c cc 06 yu t nguy c chnh (major risk
factors major RF) ca CVD, bao gm Tng huyt p, Ri lon lipid mu,
Ht thuc l, Bo ph, i tho ng v li sng t vn ng. V mc d
nghin cu Framingham nguyn thy c tin hnh trn ngi da trng
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(caucasian), nhng kt qu nghin cu c cng nhn v s dng rng ri
trn ton cu, vi mi sc tc v chng tc. Hin nay, dn s nghin cu
Framingham m rng n th h th 3.
Theo Khuyn co 2008 ca Hi Tim mch hc Vit Nam v nh gi,
d phng v qun l cc yu t nguy c ca bnh tim mch [12], cc yu t
nguy c gy nn NMCT cp c th chia lm 02 nhm sau:
Cc yu t nguy c c th thay i c:
- Tng huyt p: Tng huyt p lm nguy c tng bnh MV ln 3 ln, khi
phi hp vi cc yu t nguy c khc lm tng vt (theo cp s nhn) nguy c
bnh mch vnh. Trn th gii, s ngi b THA nhiu hn s ngi b bnh
tim thiu mu cc b 8 ln v thng xy ra trc bnh tim thiu mu cc b [18].
- Ht thuc l: Ht thuc l l nguyn nhn gy t vong ng th 2 trn th
gii, mi nm c khong 5 triu trng hp t vong lin quan n thuc l.
Hin nay trn th gii c khong 1,3 t ngi ht thuc l, 84% cc nc
ang pht trin (Esson, 2004). Ht thuc l lm tng nguy c bnh mch vnh
ln 3050% .Nguy c mc bnh s gim ngay sau khi ngng ht thuc l, ngay
c vi nhng ngi ht thuc l nhiu nm [6]
- Ri lon Lipid mu: Ri lon lipid mu l mt trong nhng yu t nguy c
chnh ca bnh MV tng lipoprotein t trng thp (LDL-C), gim
lipoprotein t trng cao (HDL-C), tng triglyceride l nhng yu t nguy c
c lp ca bnh MV.
- i tho ng: i tho ng l mt trong nhng yu t nguy c chnh
ca bnh MV. NMCT tng ln gp 23 ln nhm bnh nhn i tho ng
tp II [20]. Theo cc nghin cu cho thy 65% bnh nhn i tho ng tp
II t vong do bnh tim mch [21]. V vy gim thiu bnh tim mch ni
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chung v NMCT ni ring bnh nhn i tho ng tp II chng ta cn
kim sot ng huyt.
- Bo ph: Tha cn/Bo ph cc mc khc nhau u lm tng nguy c
mc bnh tim mch. Bo ph c th tc ng ti s hnh thnh cc yu t nguy
c khc. Bo ph cng nhiu th kh nng xut hin cc yu t tin cho x
va ng mch nh tng huyt p, i tho ng cng nh nguy c mc
bnh tim mch cng cao. tnh cn nng l tng, ngi ta da trn chiu
cao v cn nng ca bn tnh ra ch s khi lng c th (BMI) [6]
- t hot ng th lc: Li sng tnh ti c coi l mt nguy c ca cc nguy
c tim mch. Vic vn ng hng ngy u n t nht 30 pht mang li li
ch r rt trong gim nguy c bnh tim mch. Ngi ta chng minh vic
tp luyn th lc thng xuyn lm gim nguy c xut hin nhi mu c tim
ng thi nng cao kh nng sng st khi xy ra nhi mu c tim.
Cc yu t nguy c khng thay i c:
- Tui: Nguy c xy ra cc bin c tim mch tng ln khi tui cao hn. Cc
nghin cu dch t hc cho thy, tui tc l mt trong nhng yu t d on
bnh tt quan trng nht. Hn na s ngi b t qu tim mch v ti bn
phn nm s ngi b cht v t qu c tui cao hn 65.
- Gii: Nam gii c nguy c mc bnh mch vnh, t qu v cc bnh tim
mch khc cao hn so vi n gii tui tr. Tuy nhin, n gii tui cao, sau
mn kinh cng c nguy c b bnh tim mch khng khc nhiu so vi nam
gii. Hin nay, bnh tim mch n gii ang tr thnh vn ng bo ng
v s ch quan ca chnh chng ta.
- Yu t di truyn: Nhng bng chng nghin cu cho thy nhng ngi c
yu t di truyn b bnh tim mch hoc t qu (nam trc 55 tui v n
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trc 65) s c nguy c b bnh tim mch cao hn nhng ngi khc. Yu t
di truyn cn bao gm c vn chng tc (VD: ngi M gc Phi thng b
mc bnh tiu ng v tng huyt p cao hn so vi ngi M da trng).
1.3: Cc phng php lng gi nguy c tim mch:
Nh vy, ph hp vi c s sinh l bnh hc t y hc bin chng, cc
NC ln xc nh c t nht 06 yu t nguy c quan trng bc nht ca
nhm bnh l tim mch ni chung, v bnh mch vnh ni ring. ng thi,
cc lun c ny cng khng nh rng, bnh tim mch l nhm bnh a c
ch bnh sinh v a yu t nguy c, mc d tng RF n c cng vn l mt
th bnh c lp v nh hng c lp ln h thng tim mch.
Thc t ny t ra yu cu l phi c mt m hnh a bin nh
lng ha nguy c bnh tim mch trn nhng c th khc nhau. ng thi
can thip vo bnh l tim mch, s dn chuyn dch t iu tr phng nga
cp hai hoc cp ba sang d phng cp mt, ngha l d phng tin pht, v
ch can thip l a yu t nguy c. Cc thang im lng gi nguy c tim
mch ra i p ng yu cu .
Trong thc hnh lm sng ti Vit Nam, theo khuyn co 2008 v cc
bnh tim mch v chuyn ha ca Hi tim mch hc Vit Nam [12], hai cng
thc thng c s dng rng ri nht l thang im nguy c Framingham
v thang im nguy c SCORE, vn c xy dng v pht trin tng ng
trn 02 qun th dn c M v Chu u. Thang im cho 02 gii nam v n
ring bit, khc nhau cch chm im tng thng s, bao gm tui,
cholesterol ton phn (hoc thay bng LDLc), HDLc, huyt p, ht thuc l
v i tho ng.
1.3.1: Thang im Framingham [24], [28], [36], [42]:
20
-
Thang im Framingham c thit k da trn nghin cu thun tp
Framingham. i tng ca nghin cu l ngi M da trng, tui t 30 - 74.
Thi gian theo di 12 nm. Thang im c p dng ring cho nam gii v
n gii, c pht trin qua nhiu nm:
+ 1976: Thang im Framingham nh gi nguy c tim mch ni chung [36].
+ 1998: Thang im Framingham nh gi nguy c xy ra bin c ng mch
vnh [42].
+ 2008: Nghin cu Tim Framingham nh gi tui Tim/Tui ng mch &
cc bin c tim mch lin quan ti mng x va [28].
Ngoi ra cn cc thang im Framingham khc hng n nh gi cc
bin c tim mch ring l nh: bnh mch mu ngoi vi (1997), t qu
(1991), suy tim (1999), nguy c bnh tim mch c i (2006), nguy c BMV
c i (1999) v nguy c bnh tim mch trong 30 nm (2009).
Hn ch ca thang im Framingham [24]
+ Khng cp yu t chng tc.
+ Khng cp tin s gia nh.
+ Khng coi bnh nhn 75 tui l yu t nguy c cao.
+ Khng tnh n: bo ph, li vn ng, ht thuc b, bnh nhn
THA ang iu tr.
+ Khng ph hp cho bnh nhn c nguy c cao: T, ri lon
lipid mu
+ Bnh nhn c nguy c khc: bnh cht to keo, ang dng thuc tm
thn
21
-
1.3.2: Thang im EURO SCORE (2003)[24], [27]:
c cng b trong bn Hng dn d phng bnh tim mch ca Hi
tim mch Chu u (ESC) 2007. Thang im c xy dng da trn kt qu
theo di hn 200.000 bnh nhn 12 nc chn u, trong n lc nhm cung
cp cng c tin lng tt hn cho nhng bnh nhn chu u. Thi gian theo
di trung bnh l 13 nm, vi bin c ch l T vong do nguyn nhn tim
mch. Nh vy, c th thy thang im SCORE s khc FRS c bn c
im tiu ch chnh, SCORE ch tnh nguy c T vong do nguyn nhn tim
mch. Do vy SCORE, cng vi mt s thang im ca Anh, hoc New
Zealand khng c p dng rng ri bng FRS [27]. Thang im c p
dng ring cho Nam gii v N gii, p dng theo phn tng nguy c cho cc
nc Chu u.
Hn ch ca thang im EURO SCORE [24]:
+ Thang im EURO SCORE c xy dng d bo cc bin c t
vong lin quan ti bnh l tim mch KHNG d bo cc bin c tim mch
KHNG T VONG.
+ Khng xem xt ti cc yu t nh i tho ng, Tin s gia nh
c ngi b bnh tim mch, Tha cn/Bo ph.
+ Ngay ti cc nc c nh gi l phn tng nguy c thp vn c
nhng bnh nhn nguy c tim mch cao.
1.4: Lo ha mch mu (Vascular Aging) v Lo ha mch mu sm
(Early Vascular Aging EVA)
1.4.1: Lo ha mch mu:
22
-
Gi i l mt qu trnh hon ton t nhin, c th hin qua tui i
ngy cng tng. Nhng thc t cho thy d cng s nm tui vi nhau, nhng
c ngi khe mnh, sng lu, ngi th m yu, bnh tt v qua i sm.
Xt trn kha cnh Tim mch hc, tuy cng tui, nhng cu trc v kh
nng thc hin chc nng ca h tim mch mi ngi l khng nh nhau, dn
n nhng nguy c v din bin khc nhau v bnh l tim mch.
Cc yu t nguy c tim mch c xc nh r rng nh ni
trn, tch ly v gy tn thng mch mu trong mt khong thi gian di,
khi gp nhng iu kin nht nh, s gy nn bnh cnh NMCT cp m c s
sinh l bnh ct li l qu trnh x va ng mch. Trong , qu trnh vim
vi s phng thch rt nhiu ha cht trung gian (cathecolamine, CRP,
Interleukin, PAI-1, Growth Factor, Cytokine, VCAM/ICAM) m stress oxy
ha v stress c hc hay qu trnh ri lon chc nng ni mc l nhng im
khi u. Bi vy vic theo di v nh gi chc nng ni mc h mch mu
c vai tr then cht trong vic nh gi nguy c xy ra NMCT cp.
H thng mch mu, cng nh cc c quan b phn khc, cng tun
theo tin trnh lo ha t nhin. Qu trnh ny c gi l Lo ha mch mu
(Vascular Aging). Trong qu trnh lo ha mch mu bnh thng, c s thay
i chm chp cu trc v chc nng mch mu, dn n gim n hi v
tng cng ca cc ng mch ln [31]. Qu trnh ny c lin quan vi
nhng thay i v cu trc v sinh ha ph thuc tui, v d thay i lng
elastin v collagen trong thnh mch.
1.4.2: Lo ha mch mu sm (EVA):
23
-
nhiu ngi, song song vi qu trnh lo ha mch mu t nhin, c
s lo ha bnh l ca ng mch (x va ng mch) vi nhng sang
thng c trng v s hnh thnh mng x va trong thnh ng mch.
S lo ha bnh l bt u vi hin tng tng b dy ca lp o trong-
o gia (intima-media thickness, vit tt l IMT) thnh ng mch, i km
vi bt thng ca gin mch qua trung gian ni m v gim hot tnh tiu si
huyt [25].
Khi lo ha mch mu bnh l kt hp vi lo ha mch mu t nhin,
lo ha chung ca mch mu s xut hin sm hn v tin trin nhanh hn.
iu ny dn ti khi nim Lo ha mch mu sm (EVA: Early Vascular
Aging). Nhng c trng c bn ca EVA:
+ Tng cng thnh mch v vn tc sng mch.
+ Suy gim chc nng ni mc v gim gin mch.
+ Vim mch mn tnh.
+ Lm dy lp o gia v x va ng mch sm.
+ Lm ri lon dng mu chy trong lng mch.
+ Ri lon chuyn ha glucose v lipid. Tng khng insulin.
+ Tng stress oxi ha.
+ Tng calci ha ng mch.
+ Ph i thnh tim tri.
+ Tng thoi ha mch mu nh no v thn.
24
-
H qu ca lo ha mch mu sm l s xut hin sm ca nhng bnh
tim mch nh bnh mch vnh, bnh mch mu no (t qu, cn thiu mu
no thong qua) v bnh ng mch ngoi vi. Sa st tr tu do nguyn nhn
mch mu vi nhng biu hin nh ri lon chc nng nhn thc, trm cm,
mt tr nh cng c ngun gc t lo ha mch mu sm.
1.4.3: Pht hin Lo ha mch mu sm (EVA):
Lo ha mch mu sm c th pht hin bng nhng nghim php cn
lm sng nh: o IMT ng mch cnh, o vn tc sng mch (pulse wave
velocity) v tnh cc ch s huyt p ng mch ch trung tm.
Nghiu nghin cu chng minh cc phng php cn lm sng ny
khi phi hp vi cc yu t nguy c kinh in gip tng kh nng d bo cc
bin c tim mch nng.
1.4.4: Phng nga v iu tr Lo ha mch mu sm:
Cc tc gi Nilsson, Boutouyrie v Laurent dng cch chi ch khi ni
v phng nga v iu tr lo ha mch mu sm: ngn chn EVA (lo
ha mch mu sm) th phi nh n ADAM, vi ADAM l vit tt ca
Aggressive Decrease of Atherosclerosis Modifiers, ngha l gim tch cc
cc tc nhn lm thay i x va ng mch.
ADAM bao gm cc bin php thay i li sng v dng thuc iu
chnh cc yu t nguy c tim mch. Nhiu nghin cu chng minh cc
bin php thay i li sng nh gim cn, n t mui v cc thuc iu tr
tng huyt p, tng cholesterol v tng ng huyt c tc dng gim cng
ng mch.
25
-
Nghin cu MRFIT (Multiple Risk Factor Intervention Trial) trong thi
gian theo di 16 nm, cho thy tc ng ng thi ln nhiu yu t nguy c
tim mch gip gim r rt t vong tim mch v di hn. Ngay c nhng
ngi c tn thng ng mch tin trin, v d ngi bnh thn mn giai
on cui, tc ng ln cc yu t nguy c tim mch cng c li.
Nghin cu ca Guerin v cng s cho thy ngi bnh thn mn
giai on cui, kim sot huyt p tch cc phi hp vi iu chnh cc yu t
nguy c khc gip lm gim cng ng mch v km theo l gim t
vong v bin c tim mch nng.
1.5: Tui ng mch [28]:
C th khng nh tnh trng Lo ha mch mu sm (EVA), l h qu
chung ca s tch ly cc yu t nguy c c nh gi qua cc thang im
lng gi nguy c tim mch, bn thn n li trc tip gy ra bnh cnh
NMCT cp. Nh vy EVA chnh l l cu ni gia cc yu t nguy c NMCT
v bnh cnh lm sng NMCT cp.
i vi cc yu t nguy c, c cc thang im lng gi gip cho
cng tc d phng v tm sot rng ri. Nhng cc thang im ny kh kh
khn cho ngi bnh ti cng ng trong vic hnh dung r rng nguy c ca
bn thn do s phc tp v i hi kin thc chuyn mn.
i vi bnh cnh lm sng NMCT cp, n nay c cc phng
php iu tr c khuyn co y , t cc bin php iu tr ban u
(Nitroglycerin, thuc chng ngng kt tiu cu, thuc chng ng, thuc chn
giao cm) n bin php iu tr c hiu l ti ti mu ng mch vnh
(dng thuc tiu huyt khi, can thip ng mch vnh v m bc cu ni
ch-vnh cp) [4]. Cc bin php trn u cn phi nh gi v tnh trng ca
ng mch vnh.
1.5.1: nh ngha v Tui ng mch (VA Vascular Age):
26
-
Da trn nhng kin thc v EVA, DAgostino v cng s (2008)
a ra khi nim v Tui tim (Heart Age). Tui tim ca mt c th c
tnh ton da trn tui thc ca c th v cc nguy c km theo.
Tuy nhin, tui tim ch l khi nim n gin trong thc hnh chm
sc sc khe ban u gip BN d dng tun th iu tr. Tui tim phn nh
mc gi i ca mch mu ==> Tui tim trn thc t phn nh Tui ng
mch (Vascular Age).
Tui ng mch l mt thng s phn nh mc tnh trng lo ha
ca ng mch, gy nn do s tn thng lp ni mc.
1.5.2: Phng php tnh tui ng mch [28]:
- o IMT b dy lp ni trung mach ng mch cnh: o IMT ng
mch cnh c thc hin vi u d siu m B-mode c phn gii cao.
Cc v tr c kho st gm ng mch cnh chung, hnh cnh v ng
mch cnh trong. Nghin cu ln nht xc nhn gi tr d bo cc bin c tim
mch nng ca IMT ng mch cnh l nghin cu ARIC. Kt qu cho thy
IMT ng mch cnh cng dy th nguy c b cc bin c tim mch nng
trong tng lai cng cao [35], [36].
- S dng thang im Framingham ci tin (2008): Hin nay trong thc
hnh lm sng cng nh trong cng tc d phng sng lc v tm sot nguy
c bnh mch vnh, nghin cu EVA Vit Nam khuyn co s dng thang
im Framingham ci tin (2008) a ra c mc Tui ng mch
da trn 6 yu t nguy c gm: tui, HA tm thu, HDL cholesterol,
Cholesterol ton phn, tin s ht thuc v i tho ng [28].
Chng 2I TNG V PHNG PHP NGHIN CU
27
-
2.1: i tng nghin cu:
118 bnh nhn tui t 30-74, c chn on NMCT cp iu tr ti
Vin Tim mch Quc gia Vit Nam t thng 01/2013 n thng 05/2013.
2.1.1: Tiu chun la chn bnh nhn:
Cc bnh nhn c chn on xc nh nhi mu c tim cp theo cc
tiu chun ca T chc Y t th gii nm 1971 khi c t nht 2 trong 3 tiu
chun sau [11] [22]:
1. au ngc in hnh, ko di 30 pht, dng cc thuc gin ng
mch vnh khng .
2. in tm c cc bin i c hiu: ST chnh ln 1mm t nht
2 chuyn o ngoi vi, hoc 2mm t nht 2 chuyn o trc tim lin tip.
3. Men tim tng cao: CPK tng ln t nht gp 2 ln gii hn trn ca
bnh thng.
2.1.2: Tiu chun loi tr: nhng bnh nhn sau s b loi tr khi phm vi
nghin cu:
- Bnh nhn hoc ang b bin c tim mch nng: hi chng ng
mch vnh cp, Suy tim nng, giai on cp ca tai bin mch no, phnh tch
ng mch ch giai on cp tnh...
- Bnh nhn b bnh l ni khoa nng: COPD, suy thn, suy gan...
- Bnh nhn khng ng tham gia nghin cu.
2.2: Phng php nghin cu:
2.2.1: Thit k nghin cu: nghin cu m t.
28
-
2.2.2: Quy trnh nghin cu:
Trn tt c cc bnh nhn tiu chun a vo nghin cu, chng ti
tin hnh cc bc nh sau:
2.2.2.1: Bc 1: Thu thp s liu
Tt c bnh nhn tham gia nghin cu u c hi bnh, khai thc
tin s, thm khm lm sng theo mu bnh n thng nht, cc xt nghim
c thc hin ti khoa Sinh ho, Huyt hc, Bnh vin Bch Mai.
Hi bnh
- Khai thc tnh cht cn au tht ngc.
- Khai thc tin s bn thn:
+ Tin s mc cc bnh tim mch: NMCT, cn au tht ngc,
TBMN, bnh mch ngoi bin.
+ Cc yu t nguy c: Ri lon lipid mu, ht thuc l, i tho
ng, tng huyt p v tnh trng tun th iu tr.
- Tin s gia nh: c ngi t vong do cc bnh tim mch hoc tai
bin mch no.
Khm bnh
Bnh nhn c thm khm ton thn, ch ti nhp tim, huyt p v
lm bnh n theo mu ring (ph lc 1).
Cn lm sng
Theo di cc kt qu thm khm cn lm sng ca bnh nhn bao gm:
29
-
- Cc xt nghim c bn (cng thc mu v sinh ho mu):
+ Acid uric mu.
+ Men tim (CK, CKMB, Troponin, nng CK nh hay CK max).
+ ng mu.
+ Lipid mu.
+ Ur, creatinine.
- in tm .
- Chp ng mch vnh.
2.2.2.2: Bc 2: nh gi cc s liu thu thp c:
- Xc nh v tr vng nhi mu trn in tm .
- Ri lon lipid mu: BN c tin s RL lipid mu hoc xt nghim c tnh
trng RL chuyn ha t nht mt trong cc thnh phn lipid mu theo tiu
chun ca NCEP-ATP III [40] nh sau:
+ Cholesterol 5,2 mmol/l.
+ HDL-C < 1,03 mmol/l.
+ LDL-C 2,6 mmol/l.
+ Triglyceride 1,7 mmol/l.
- nh gi tn thng mch vnh:
+ S nhnh mch vnh tn thng.
30
-
+ Mc hp mch vnh: c biu th bng t l phn trm (%)
hp so vi on mch vnh bnh thng ngay st ch hp. Theo khuyn co
ca Hip hi Tim mch Hoa k/Trng mn Tim mch Hoa K (AHA/ACC)
nm 2009, mc hp mch vnh c chia nh sau:
Bng 2.1: Phn chia mc hp ng mch vnh
Mc hp Phn trm (%) hpMV bnh thng hoc x va nh 70% mch vnh phi, mch lin
tht trc v nhnh m, hoc >50%
vi ng mch vnh tri, hoc tc
hon ton
Hp trn 50% l c gi tr xc nh thng tn.
2.2.2.3: Bc 3:Tnh nguy c tim mch theo thang im Framingham.
2.2.2.4: Bc 4: Tnh Tui ng mch da vo thang im Framingham
ci tin (2008).
2.2.2.5: Bc 5: nh gi mi tng quan gia Tui ng mch vi
cc yu t nguy c NMCT cp.
2.2.2.6: Bc 6: nh gi mi tng quan gia Tui ng mch vi
tnh trng tn thng mch vnh.
2.2.3: X l thng k s liu:
2.2.3.1: Phn mm x l s liu: Microsoft Excel 2010 v SPSS 16.0
nhp v tnh ton cc thng s thc nghim: trung bnh thc nghim,
phng sai, lch chun, mi tng quan tuyn tnh Gi tr p < 0,05 c
coi l c ngha thng k.
2.2.3.2: X l s liu bng cc thut ton thng k ph hp:
31
-
- Kim nh s khc bit bin nh lng: ttest, singrank test.
- Mi tng quan gia cc bin nh lng: Hi quy tuyn tnh.
- Mi tng quan gia cc bin nh tnh: Hi quy Logistic.
118 bnh nhn c chn on NMCT cp
Thu thp s liu
nh gi s liu
Tnh Tui ng mch
Hnh 2.1: S thit k nghin cu
Chng 3KT QU NGHIN CU
32
Kt qu
-
3.1: c im chung ca i tng nghin cu:
Qua nghin cu 118 bnh nhn c chn on NMCT cp iu tr ti
Vin Tim mch Quc gia, bnh vin Bch Mai t thng 01/2013 n thng
5/2013 chng ti thy c cc c im sau:
Bng 3.1: c im chung ca nhm nghin cu
c im Kt quNam 82(69,49%)
Tui ( nm) 63.95 11.48 (34-86)Tui ng mch ( XSD ) 73,44 7,33Ht thuc l 9 (7,63%)
HA tm thu (mmHg) ( XSD ) 133 18,56
HA tm trng (mmHg) ( XSD ) 87,8 16,3
Tng huyt p 69 (58,48%)
i tho ng 8 (6,78%)
RL Lipid mu 110 (93,22%)
Cholesterol TP (mmol/l) ( XSD ) 5,53 1,01
Triglyceride (mmol/l) ( XSD ) 2,47 0,99HDL - Cholesterol (mmol/l) ( XSD ) 1,04 0,38
LDL - Cholesterol (mmol/l) ( XSD ) 3,31,21Nguy c FRS (%)( XSD ) 13,58 8,28
33
-
3.2: c im Tui ng mch nhm bnh nhn nghin cu:
Bng 3.2: c im Tui ng mch ca nhm nghin cu
Tui ng mch Nam N Chung51 64 20 4 24
65 74 17 10 27
75 >80 45 22 67
Tng 82 36 118
Hnh 3.1: Phn b Tui ng mch
Nhn xt:
- Tui ng mch ca bnh nhn dao ng t 51 80+ tui. T l Tui
ng mch trong khong 76 80+ l tp trung nht (67%). Tui ng mch
trung bnh ca cc bnh nhn l 73,44 7,33 trong nam l 72,78 7,59 v
n l 74,94 6,56. Tui ng mch ca n cao hn nam c ngha thng k
(p=0,02).
34
-
3.3: nh gi mi lin quan gia Tui ng mch vi cc yu t nguy c
ca Nhi mu c tim cp:
3.3.1: Tui thc:
Bng 3.3: Mi lin quan gia Tui ng mch vi Tui thc
Tui thc Tui ng mch pNam N Chung
34 5468,22 8,20
n=1866,8 9,34
n=567,91 8,26
n=23
-
Hnh 3.2: Tng quan gia Tui ng mch v Tui thc
Nhn xt:
- Da vo biu chng ti nhn thy c mi tng quan thun c
ngha thng k gia Tui ng mch v Tui thc (p < 0,001), mc tng
quan cht ch vi r=0,55 nam gii v r = 0,627 n gii.
- Xt trn c nhm nghin cu c mi tng quan thun gia Tui ng
mch v Tui thc (p
-
- T l THA bnh nhn nam NMCT cp l 46/82 (56,98%), bnh nhn
n l 23/36 (63,89%).
- nhm bnh nhn THA, tui ng mch trung bnh ca nam l 74,98
6,76, n l 76,61 5,82, xt chung c hai gii l 75,52 6,47.
- nhm bnh nhn khng c THA, tui ng mch trung bnh ca nam
l 69,97 7,76, n l 72,00 6,97, xt chung c 2 gii l 70,51 7,54.
- p dng phng trnh tuyn tnh tm mi tng quan gia Tui ng mch
v HA tm thu chng ti c kt qu sau cho 2 nhm bnh nhn nam v n:
Hnh 3.3: Tng quan gia Tui ng mch v HA tm thu (mmHg)
Nhn xt:- C mi tng quan tuyn tnh thun gia HA tm thu v Tui ng
mch nam gii c ngha thng k (p < 0,001), mc tng quan trungbnh vi r = 0,31.
- n gii cng c mi tng quan thun c ngha thng k gia HAtm thu v Tui ng mch, mi tng quan mc trung bnh, r = 0,33.
- Xt chung c nhm nghin cu c mi tng quan tuyn tnh thungia HA tm thu v Tui ng mch c ngha thng k (p
-
Bng 3.5: Mi lin quan gia Tui ng mch vi RL Lipid mu
RL Lipid
muTui ng mch
pNam N Chung
C73,06 7,36
n=78
74,88 6,67
n=34
73,62 7,18
n=1120,01
Khng67,25 11,12
n=4
76 5,66
n=2
70,17 10,05
n=60,107
p 0,16 0,39 0,2
50
55
60
65
70
75
80
85
90
Ri lon Lipid mu
Tui
M
C Khng
Hnh 3.4: Tng quan gia Tui ng mch v tnh trng RL Lipid mu
Nhn xt:
- T l ri lon lipid mu bnh nhn nam NMCT l 78/82 (95,12%),
bnh nhn n l 34/36 (94,44%).
- Tui ng mch nhm bnh nhn c RL lippid mu l 73,62 7,18
so vi70,17 10,05 nhm bnh nhn khng c RL lipid mu (p=0,2).
3.3.3.1: Cholesterol TP:
Bng 3.6: Mi lin quan gia Tui ng mch vi nng Cholesterol TP
38
-
Cholesterol TP(mmol/l)
Tui ng mchpNam N Chung
< 5,269,91 7,56
n=3573,15 7,77
n=1370,79 7,67
n=480,25
5,274,92 6,96
n=4775,96 5,7
n=2375,26 6,55
n=700,105
p < 0.001 0,145 < 0,001
Nhn xt:
- Tui ng mch nhm bnh nhn c Cholesterol TP 5,2 mmol/l l
75,26 6,55 so vi 70,79 7,67 nhm bnh nhn c Cholesterol TP
-
- Khng c mi lin quan gia Tui ng mch vi nng cholesterol
ton phn n gii (r=0,141).
- Xt chung cho c nhm nghin cu c mi tng quan tuyn tnh thun
mc trung bnh (r=0,32) gia Tui ng mch vi nng cholesterol
ton phn c ngha thng k (p
-
Hnh 3.6: Tng quan gia Tui ng mch v tng Triglyceride
- Xt ring tng gii khng c s lin quan gia Tui ng mch vi
tng nng triglyceride trong mu.
- Xt chung cho c nhm nghin cu khng c s lin quan gia Tui
ng mch vi tng nng triglyceride trong mu.
3.3.3.3: HDL cholesterol:
Bng 3.8: Mi lin quan gia Tui ng mch vi nng HDL-C
HDLc
(mmol/l)Tui ng mch
pNam N Chung
1,0369,18 7,43
n=44
73,53 6,96
n=19
70,49 7,5
n=630,01
< 1,0376,95 5,38
n=38
76,53 5,86
n=17
76,82 5,48
n=550,39
p < 0,001 0,09 < 0,001
41
-
Nhn xt:
- Tui ng mch nhm c HDL-c >1,03 mmol/l l 70,49 7,5 so vi
nhm c HDL-c 1,03 mmol/l l 69,18 7,43 so vi nhm c HDL-c 1,03 mmol/l ta thy tui ng mch ca
n gii l 73,53 6,96 so vi nam gii 69,18 7,43 c ngha thng k
(p=0,01). Cn nhm bnh nhn c HDL-c 0,05).
- p dng phng trnh tuyn tnh vi h s tng quan r c kt qu nh sau:
Hnh 3.7: Tng quan gia Tui ng mch v nng HDL-C
Nhn xt:- C mi tng quan tuyn tnh nghch mc trung bnh (r=0,36) gia Tui
ng mch vi mc tng HDL-c nam gii c ngha thng k (p
-
3.3.3.4: LDL cholesterol:
Bng 3.9: Mi lin quan gia Tui ng mch vi nng LDL-C
LDLc
(mmol/l)Tui ng mch
pNam N Chung
< 2,672,16 7,55
n=31
73,39 8,14
n=13
72,52 7,65
n=440,13
2,673,16 7,67
n=51
75,82 5,47
n=23
73,99 7,13
n=740,5
p 0,18 0,4 0,09
Nhn xt:
- Xt trn c nhm nghin cu thy Tui ng mch nhm c LDL-c
0,05)
- Xt trn nhm bnh nhn nam thy Tui ng mch nhm c LDL-c
0,05).
- Xt trn nhm bnh nhn n thy Tui ng mch nhm c LDL-c
0,05)
- Xt trn cng nhm bnh nhn thy Tui ng mch ca nhm bnh
nhn nam thp hn so vi Tui ng mch nhm bnh nhn n khng c
ngha thng k (p>0,05).
- p dng phng trnh tuyn tnh vi h s tng quan r c kt qu nh sau:
43
-
Hnh 3.8: Tng quan gia Tui ng mch v LDL-cholesterol
Nhn xt:
- C mi tng quan tuyn tnh thun mc yu (r=0,291) gia Tui
ng mch vi mc tng LDL-c n gii c ngha thng k (p
-
50
55
60
65
70
75
80
85
90
Hut thuoc
Tuoi
don
g m
ach
C Khng
Hnh 3.9: Tng quan gia Tui ng mch v ht thuc l
Nhn xt:
- Trong 118 bnh nhn NMCT cp, c 9 bnh nhn ht thuc l, 100% l
nam gii.
- Tui ng mch nhm c ht thuc l l 74,22 6,96, cao hn so vi
nhm khng ht thuc l l 72,60 7,69 khng c ngha thng k (p=0,26).
3.3.5: i tho ng
Bng 3.11: Mi lin quan gia Tui ng mch vi tnh trng T
i tho
ngTui ng mch
pNam N Chung
Khng T72,72 7,51
n=76
74,88 6,71
n=34
73,39 7,31
n=1100,08
T73,5 9,33
n=6
76 4,24
n=2
74,13 8,13
n=80,45
p 0,46 0,35 0,49
45
-
Hnh 3.10: Tng quan gia Tui ng mch v T
Nhn xt:
- Tui ng mch nhm khng c T thp hn so vi nhm c T
khng c ngha thng k (p>0,05) xt c hai gii ln xt chung c nhm
nghin cu.
3.3.6: Nguy c mc bnh mch vnh trong 10 nm theo thang im
Framingham Risk Score:
Bng 3.12: Mi lin quan gia Tui ng mch vi Nguy c mc bnh mchvnh trong 10 nm theo FRS
Nguy c bnh
mch vnh 10
nm theo FRS
Tui ng mchp
Nam N Chung
< 10 %
69,53
6,92
n=34
70,89 7,94
n=9
69,81 7,07
n=430,61
10 20 %72 8,16
n=28
74,74 5,99
n=19
73,11 7,41
n=470,22
> 20 %79,4 1,47
n=20
80
n=8
79,57 1,26
n=280,26
p < 0,001 0,01
-
- Tui ng mch nhm c nguy c thp mc bnh mch vnh l 69,81
7,07 thp hn nhm c nguy c trung bnh (73,11 7,41), thp hn nhm
c nguy c cao (79,57 1,26) c ngha thng k (p
-
Nhn xt:
- C mi tng quan tuyn tnh thun mc cht (r=0,57) gia Tui
ng mch vi nguy c mc bnh mch vnh theo thang im Framingham
risk score nam gii c ngha thng k (p
-
Hnh 3.13: Phn b Tui ng mch theo v tr nhi mu
3.5: Lin quan gia Tui ng mch vi tnh trng tn thng mch vnh:
3.5.1: Mc x va mch vnh:
Bng 3.13: T l tn thng mch vnh
Mc hp MV Nam N Chung
50 61 74,39% 24 66,67% 85 72,03%
Tng 82 36 118 100%
Bng 3.14: Mi lin quan gia Tui ng mch vi tnh trng tn thng MV
Mc hp MV < 50% > 50% p
Tuingmch
Nam 73.31 7.18n=2172.37 8.16
n=61 0.35
N 72.71 5.85n=1275.38 7.59
n=24 0.19
Chung 73.1 6.59n=3373.21 8.06
n=85 0.46
p 0,42 0,1
49
-
Hnh 3.14: Phn b tn thng MV theo gii
Hnh 3.15: T l tn thng mch vnh theo nhm Tui ng mch
Nhn xt:
- c 2 nhm khng c tn thng MV v c tn thng MV, t l
nam gii cao hn nhiu n gii khng c ngha thng k (p>0,05).
- nhm tui ng mch ln hn th t l tn thng mch vnh cng
cao: 50% nhm Tui ng mch t 51-60, 75,86% nhm Tui ng mch
61-70 v 80,25% nhm Tui ng mch 71-80+.
50
-
3.5.2: S nhnh mch vnh tn thng:
Bng 3.15: T l s nhnh mch vnh tn thng
S nhnh mch
vnh tn thngnam n chung
1 nhnh 53 64.63% 19 52.78% 72 61.02%
2 nhnh 22 26.83% 8 22.22% 30 25.42%
3 nhnh 7 8.54% 9 25% 16 13.56%
Tng 82 100% 36 100% 118 100%
Bng 3.16: Mi lin quan gia Tui ng mch vi s nhnh mch vnhtn thng
S nhnh mch
vnh tn
thng
Tui ng mchp
Nam N Chung
171 8,07
n=53
76 5,29
n=19
72,81 7,53
n=720,003
271,14 6,31
n=22
67 8,12
n=8
70,05 6,85
n=300,3
379 2
n=7
74,86 6,64
n=9
74,86 5,35
n=160,08
p 0,13 0,051 0,07
51
-
Hnh 3.16: T l s nhnh mch vnh tn thng cc nhm tui ng mch
Nhn xt:
- V phn b t l s lng nhnh MV tn thng, th trong ton b
phn nhm c 72/118 (61.02%) c tn thng 1 nhnh MV, 30/118
(25.42%) c tn thng 2 nhnh MV, 16/118 (13,56%) c tn thng 3
nhnh MV.
- Xt trn nhm bnh nhn c tn thng 1 nhnh MV ta thy nhm
ny Tui ng mch ca n l 76 5,29 trong khi ca nam l 71 8,07. Tui
ng mch ca n cao hn nam c ngha thng k (p
-
Chng 4BN LUN
4.1: c im chung ca i tng nghin cu:
4.1.1 c im v tui v gii:
Nhm nghin cu ca chng ti gm 118 bnh nhn vo vin Tim
mch Quc gia Vit Nam, bnh vin Bch Mai vi chn on NMCT cp
trong thi gian t 01/2013 n 05/2013.
c im tui trung bnh ca bnh nhn l 63,95 11,48, tui thp nht l
34 v cao nht l 86 tui. Tui trung bnh ca n cao hn ca nam b bnh:
Tui trung bnh nam gii 62,51 11,52
Tui trung bnh n gii 67,22 10,84
Nh vy n gii b nhi mu c tim tui cao hn nam gii. Kt
qu nghin cu ny tng t nh mt s tc gi khc trong nc [8] [5].
Nghin cu Framingham c tin hnh t nm 1948 cho thy n gii b
NMCT cp mun hn nam gii [24].
T l mc bnh tng dn theo nhm tui: 75 tui c 25 bnh
nhn. Nh vy tui ca bnh nhn NMCT cp trong nghin cu cao nht
l nhm tui 55-74 (59.32%). iu ny ph hp vi nghin cu
Framingham [24].
53
-
Bng 4.1: So snh tui trung bnh vi cc nghin cu khc
Chng ti GUSTO [20] Kim Dung [18]
63,95 11,48 62 65,93 12.25c im v gii: Nam gii chim t l 69,49% vi 82 bnh nhn trong
khi n gii l 36 bnh nhn chim t l 30,51%.
T l nam/n l 2,3/1. So snh vi cc nghin cu khc v t l phn
b gii: ca L Th Kim Dung (2008) l 4/1 [18].
4.1.2 c im v lm sng v cn lm sng:
4.1.2.1: Tng huyt p:
Trong nhm nghin cu ca chng ti, t l THA l 58,48%, cao hn
t l THA trong nghin cu ca Vn c Hnh l 46,5% [42] v xp x trong
nghin cu ca Ahmadi l 55,5% [43].
Tr s HA tm thu trung bnh trong nghin cu ca chng ti l 133
18,56 mmHg, cao hn so vi nghin cu ca Vn c Hnh l 120,6 24,6
mmHg [42] v Ahmadi l 125 23 mmHg [43] thp hn nghin cu ca
Konstantinou l 140,4 24,4 [44]. HA tm trng trung bnh l 87,8
16,3mmHg, cao hn so vi kt qu ca Amadi l 78 15 mmHg [43].
4.1.2.2: Ri lon lipid mu:
Trong nghin cu ca chng ti, 110 (93,22%) bnh nhn c ri lon
lipid mu, cao hn kh nhiu so vi nghin cu ca V..Hnh l 69,3% [42]
v Ahmadi l 49,4% [43].
C th thy nng cholesterol ton phn, triglyceride v LDL-C trong
nghin cu ca chng ti u cao hn so cn nng HDL-c th thp hn so
vi nghin cu ca Ahmadi [43] v Konstantinou [44] mt cch c ngha
thng k. iu ny cho thy tnh trng ri lon lipid mu ti Vit Nam ang
mc cao so vi th gii.
54
-
So snh cc thnh phn lipid mu:
Bng 4.2: So snh thnh phn lipid mu vi cc nghin cu khc
Chng ti Ahmadi [43]Konstantinou
[44]Cholesterol TP
(mmol/l) ( XSD )5,53 1,01 4,3 1,34 4,73 1,11
Triglyceride
(mmol/l) ( XSD )2,47 0,99 1,43 0,96 1,48 0,52
HDL - Cholesterol
(mmol/l) ( XSD )1,04 0,38 1,11 0,46 1,29 0,36
LDL - Cholesterol
(mmol/l) ( XSD )3,3 1,21 2,5 1,11 2,77 0,96
4.1.2.4: Mc x va mch vnh:
74,03% trn tng s 77 bnh nhn c chp mch vnh c tn thng
mch vnh (hp >50% ng knh lng ng mch) trong nam b tn
thng mch vnh l 75,93%, n l 69,57%.
4.1.2.5: Phn b vng nhi mu trn in tm :
Trong nhm nghin cu ca chng ti c 68 bnh nhn (57.63% ) c
xc nh nhi mu trc rng, ngoi ra cn mt t l khng nh nhi mu
sau di vi 32 bnh nhn (27,12%) v trc vch vi 13 bnh nhn
(11,02%).
T l bnh nhn nhi mu vng trc rng trong nghin cu ca chng
ti cao hn kh nhiu so vi nghin cu ca Nguyn Quang Tun (30%) [5]
v Hong Quc Ha (19%) [47] trong khi t l nhi mu sau di l 27,12%
55
-
tng t nh nghin cu [5] v thp hn nghin cu [47], c th do nghin
cu [47] la chn c nhng bnh nhn khng c ST chnh ln.
Vng trc rng l v tr nhi mu c t l t vong cao nht (19,6%
trong 30 ngy u v 25,6% trong 1 nm tip theo). Tui ng mch ca bnh
nhn nhi mu v tr ny l 74,53 7,15, thp dn cc nhm nhi mu ti
nhng v tr khc, thp nht nhm nhi mu tht phi v nhi mu khng c
sng Q, y cng l nhng nhm c t l t vong thp nht.
Tuy nhin t l v tr nhi mu trong nghin cu ca chng ti khng
ph hp vi cc nghin cu t trc .
4.2: c im v Tui ng mch:
Tui ng mch ca bnh nhn dao ng t 51 80+ tui. T l Tui
ng mch trong khong 76 80+ l tp trung nht (67%). Tui ng mch
trung bnh ca cc bnh nhn l 73,44 7,33 trong nam l 72,78 7,59 v
n l 74,94 6,56. Tui ng mch ca n cao hn nam c ngha thng k
(p=0,02).
56,78% s bnh nhn thuc nhm Tui ng mch t 75-80+ tng
ng vi t l cao 59.32% ca tui thc 55-74.
4.3. Mi lin quan gia Tui ng mch vi cc yu t nguy c NMCT cp:
4.3.1: Tui thc:
C th thy tui ng mch cao hn tui thc ca bnh nhn c 2
gii c ngha thng k (p
-
Hnh 4.1: Tui ng mch cao hn so vi tui thc
4.3.2: Tng huyt p:
Tui ng mch nhm bnh nhn nam c THA cao hn tui ng
mch nhm bnh nhn nam khng THA c ngha thng k (p
-
Tui ng mch nhm bnh nhn c ri lon lipid mu cao hn so vi
nhm bnh nhn khng ri lon lipid mu, nhng kt qu khng mang
ngha thng k (p=0,2).
Xt ring nhm bnh nhn c ri lon lipid mu, th Tui ng mch
ca n cao hn nam c ngha thng k (p=0,01). Vy c kh nng nhm
bnh nhn ny gii tnh c vai tr trong s gia tng tui ng mch.
Xt ring tng thnh phn lipid mu:
Tui ng mch nhm c tng cholesterol TP cao hn so vi nhm
cholesterol bnh thng c ngha thng k. ng thi cng c mi tng
quan tuyn tnh thun mc trung bnh (r=0,32) gia tng Cholesterol ton
phn vi tng tui ng mch.
Tui ng mch nhm c nng HDL-c cao thp hn so vi nhm
c nng HDL-c thp c ngha thng k. ng thi cng c mi tng
quan tuyn tnh nghch mc trung bnh (r= -0,32) gia nng HDL-c vi
tui ng mch.
Khi so snh theo tng gii th cc nhm bnh nhn c tng HDL-c,
tui ng mch ca n cao hn nam c ngha thng k. Cn trong tt c cc
nhm khc tui ng mch ca n tuy c cao hn nhng khng mang ngha
thng k.
Nhn chung tui ng mch nhm bnh nhn c tng triglyceride v
LDL-c mu cao hn nhm bnh nhn khng tng triglyceride v LDL-c, tuy
nhin iu ny khng c ngha thng k v cng khng c mi tng quan
ng k gia tng tui ng mch v tng triglyceride khi xt ring tng gii
v xt chung c nhm nghin cu.
58
-
Theo khuyn co ca ca NCEP-ATP III, LDL-c l mc tiu th nht
trong kim sot ri lon lipid mu, nng LDL-C di 2,6 mmol/l l mc
tiu cn t gim nguy c bnh mch vnh nhng i tng nguy c cao
trong c bnh nhn T [40].
Theo nghin cu HPS (Heart Protection Study), gim LDL-c di 2,6
mmol/l lm gim 26% bin c mch vnh [48].
Nghin cu Strong Heart Study: t l bnh mch vnh nhm c LDL-c
> 2,6mmol/l cao hn c ngha vi nhm LDL-c < 2,6 mmol/l, gim mi
0,26 mmol/l LDL-c lm gim 12% nguy c bnh mch vnh [49].
Cc nghin cu ch ra rng HDL-c v triglyceride ng vai tr quan
trng trong nguy c tn d i vi mch mu ln ni chung trong c bnh
mch vnh, ngay c khi nng LDL-c < 1,8 mmol/l khi iu tr bng statin liu
cao th nguy c bnh mch vnh vn tng 56% nhm c triglyceride > 2,3
mmol/l so vi nhm triglyceride < 2,3mmol/l (nghin cu PROVE-IT 22) [50].
NCEP-ATP III coi HDL-c l yu t nguy c bnh mch vnh c lp [40].
Theo nghin cu PROCAM [51], HDL-c v triglyceride l cc yu t
nguy c c lp i vi bnh mch vnh, gim HDL-c v tng triglyceride
lm tng nguy c bnh mch vnh tt cc mc nng LDL-c, cng nhiu
yu t lipid bt thng th nguy c bnh mch vnh cng cao.
Tuy nhin trong nghin cu ca chng ti LDL-c v Triglyceride
khng c nhiu vai tr i vi s tng Tui ng mch trn bnh nhn NMCT
cp, c th mt phn v c mu nh, mt phn do thang im ny khng a
LDL-c v Triglyceride vo trong cng thc tnh ton.
4.3.4: Ht thuc l:
Ht thuc l l mt yu t nguy c tim mch quan trng. Nguy c nhi
mu c tim gim ngay trong ngy u b thuc l ng thi vi nhng bnh
59
-
nhn tim mch ngng ht thuc l lm gim mt na nguy c nhi mu c
tim ti pht v t vong [52].
Trong c nhm nghin cu c 9 ngi ht thuc l, 100% l nam gii.
Tui ng mch ca nhm c ht thuc l l 74,22 6,96 cao hn so vi
nhm khng ht thuc l l 72,60 7,69, s khc bit khng c ngha thng
k (p>0,05), c th do c mu cn nh.
Nghin cu INTERHEART, t l bnh mch vnh tng 3 ln bnh
nhn nam ht thuc l trn 20 iu/ngy so vi nam khng ht thuc l. Nh
vy khng c mi lin quan gia tui ng mch v tnh trng ht thuc l
trong nhm bnh nhn nghin cu ca chng ti.
4.3.5: i tho ng:
Tui ng mch nhm khng c T l 73,39 7,31thp hn so vi
nhm c T 74,13 8,13 khng c ngha thng k (p>0,05) xt c hai
gii ln xt chung c nhm nghin cu.
Trong nghin cu MRFIT (Multiple Risk Factor Intervention Trial), t
l bnh mch vnh bnh nhn nam c T gp 3 ln bnh nhn nam khng
T ngay c khi hiu chnh theo tui, gii, chng tc [45].
Trong nghin cu ln UKPDS (United Kingdom Prospestive Diabetes
Study) tin hnh theo di trong vng 10 nm, 3898 bnh nhn T mi pht
hin cha c bin chng mch mu trm trng hay tai bin mch no trong
vng 1 nm trc thy t l bin c mch vnh l 6,3% [45].
Nh vy r rng i tho ng l mt yu t nguy c quan trng
bnh nhn NMCT cp. Tuy nhin kt nghin cu ca chng ti li khng ch
ra c vai tr ca T trong vic tng Tui ng mch, mt thng s lng
gi nguy c tim mch. C th v vic chn c mu nh v khai thc tin s
T khng tt hoc bnh nhn cng cha c pht hin T. Trong 118
60
-
bnh nhn ch c 8 bnh nhn (6,78%) ghi nhn c T. iu ny cn c
khc phc trong cc nghin cu tip sau.
4.3.6: Lin quan gia Tui ng mch vi nguy c mc bnh mch vnh
trong 10 nm theo Framingham Risk Score:
Nhn thy Tui ng mch tng cao tng ng vi tng mc nguy c
bnh l mch vnh 10 nm theo FRS, c mi tng quan tuyn tnh thun
mc cht (r=0,58) gia Tui ng mch vi nguy c mc bnh mch vnh
theo thang im Framingham risk score c ngha thng k (p
-
mch v khng c yu t T, th 4 yu t cn li u c lng gi tt qua
c FRS v thang im tnh Tui ng mch, v Tui ng mch cng c
tnh t Thang im Framingham ci tin, nn c s tng quan cht ch gia
Nguy c theo FRS v Tui ng mch. Tng tui ng mch tng ng vi
s gia tng nguy c bnh mch vnh ni chung v bnh NMCT cp ni ring.
Tm li, i vi cc yu t nguy c NMCT cp, tng thng s Tui
ng mch c tng quan cht ch vi tng tui thc, tng Cholesterol ton
phn, gim HDL-cholesterol, vi gii, v c ngha tng i vi tng LDL-
cholerterol, Triglyceride, tin s T, ht thuc l. Tng tui ng mch
cng tng ng vi tng nguy c bnh mch vnh 10 nm theo thang im
Framingham risk score.
Bng 4.3: H s tng quan gia Tui ng mch vi cc yu t nguy c
Yu t nguy c rTui 0,58
Cholesterol ton phn 0,32HDL-cholesterol - 0,32LDL-cholerterol 0,11
HA tm thu 0,32
M hnh hi quy tuyn tnh:
Tui_ng_mch = 51.21 + 0.35xTui_thc +0.35xCholesterol_TP
5.25xHDL + 0.03xHATT
4.4: Lin quan gia Tui ng mch vi tnh trng tn thng mch vnh:
Nhm tui ng mch cng cao th t l bnh nhn b tn thng hp
>50% ng mch vnh cng ln.
Nhm c Tui ng mch cao hn th t l tn thng 3 nhnh
MV ln hn nhm c Tui ng mch thp hn.
62
-
Nhm Tui ng mch t 71-80+ c t l tn thng 1 nhnh MV
gim i tng ng vi s gia tng t l tn thng 3 nhnh MV.
Xt chung c nhm nghin cu, nhn thy phn b nhng bnh nhn
tn thng 3 nhnh MV ch yu nhm c Tui ng mch cao vi tui
trung bnh l 74,86 5,35.
Tuy nhin khng c s khc bit c ngha thng k v tng quan
gia tng tui ng mch vi mc tn thng mch vnh cng nh s nhnh
mch vnh tn thng. Mc d Tui ng mch l thng s i din cho s
lo ha v cu trc v chc nng ca mch mu.
L gii cho iu ny c th do hn ch v bng tnh tui ng mch
theo thang im Framingham ci tin (2008). Thang im c tnh ring cho
tng gii v n gi tr ti a l 80. Trn thc t khi tnh ton tui ng mch
cho ton b nhm nghin cu, c kh nhiu bnh nhn m im nguy c
trc khi quy i ra tui ng mch cao hn nhiu so vi im 17 nam v
15 n, nhng vn c tnh l 80 im. Trong khi t l bnh nhn tn
thng mch vnh nhm tui ng mch trn 75t chim ti 80%, nn khi
tnh gi tr trung bnh v tui ng mch nhm tui ny s khng thy c
s khc bit v tng tui ng mch vi tnh trng tn thng mch vnh c
ngha thng k.
4.5. Hn ch ca nghin cu.
+ S lng mu nh. Hin ti mi ngy vin Tim mch quc gia, bnh
vin Bch Mai tip nhn hng trm bnh nhn mc cc bnh l tim mch,
trong c hng chc bnh nhn mc bnh l mch vnh, tuy nhin do hn
ch v ngun lc v thi gian nn chng ti khng th thu thp c ht cc
bnh nhn NMCT cp t thng 1/2013 n thng 5/2013. Vi mt bnh c c
63
-
ch bnh sinh, din bin lm sng phc tp vi nhiu th bnh nh NMCT
cp th s lng mu 118 l khng .
+ Do NMCT cp l bnh l nguy him gy e da n tnh mng ngi
bnh nn hu ht cc trng hp bnh cnh lm sng nng n, tin lng t
vong cao u c theo di lin tc, gy kh khn cho vic thm khm v thu
thp s liu, nn cc bnh nhn trong nghin cu ca chng ti ch yu l
ang trong giai on n nh, ch c th quan st h s bnh n tm cc du
hiu lm sng nng lc mi nhp vin. Khin cho tnh ngu nhin ca vic
chn mu b nh hng.
+ T l bnh nhn T thp hn cc nghin cu khc. C th do
nhng bnh nhn T bin chng NMCT u bnh cnh lm sng nng n
phi HSTC v chng ti khng c c hi tip cn, hoc khng khai thc tt v
tin s bnh T ca bnh nhn.
+ S lng bnh nhn ht thuc cng thp. C th do bnh nhn khng
khai bo tin s khi lm bnh n. Cng c th do bnh nhn b thuc t
lu hoc b thuc t khi c nhng triu chng bnh l lin quan n tim
mch.
64
-
KT LUN
Qua nghin cu 118 bnh nhn NMCT cp c khm v iu tr ti
vin Tim mch quc gia, bnh vin Bch Mai trong thi gian t thng
01/2013 n thng 05/2013, chng ti rt ra c kt lun sau:
1/ Tui ng mch trn bnh nhn NMCT cp cao hn tui thc:
Tui thc trung bnh ca cc bnh nhn NMCT cp trong nhm nghin cu
l 63,95 11,48 trong khi tui ng mch nhm bnh nhn ny l 73,44 7,33.
Tui ng mch ca n cao hn nam c ngha thng k ph hp vi
cc nghin cu dch t trn tui thc. C mi lin quan gia Tui ng mch
v Tui thc vi h s tng quan l r=0,54.
2/ Tui ng mch c mi tng quan vi cc yu t nguy c NMCT cp:
Tui ng mch c tng quan ng bin vi cc yu t nguy c tim
mch nh Tui thc, Huyt p tm thu, Cholesterol ton phn, LDL
cholesterol, tng quan nghch bin vi HDL cholesterol.
M hnh hi quy tuyn tnh:
Tui_ng_mch = 51.21 + 0.35xTui_thc +0.35xCholesterol_TP
5.25xHDL + 0.03xHATT
3/ Tui ng mch cao l yu t lm tng nguy c tn thng mch vnh.
65
-
TI LIU THAM KHO
Ting Vit
1. on Thi, ng Vn Phc (2006), "Nhi mu c tim cp c ST
chnh ln", Bnh ng mch vnh trong thc hnh lm sng, NXB Y
hc, Tr. 251 - 286.
2. Kim Bng, "Nghin cu kh nng d on v tr tn thng ng
mch vnh bng in tm bnh nhn nhi mu c tim cp", K yu
ton vn cc ti khoa hc 2004, Tr. 127 - 135.
3. Hong Quc Ha (2010), Kho st thiu mu c tim tn lu sau nhi
mu c tim, Tp ch Y hc TP H Ch Minh, tp 14, ph bn ca s 2
4. L Th Kim Dung (2005), Nghin cu nhng c im lm sng v
cn lm sng cc bnh nhn 70 tui b nhi mu c tim cp, lun
vn thc s y hc.
5. L Xun Thc, Cc yu t nguy c bnh nhn Nhi mu c tim cp
K yu ton vn cc ti khoa hc nm 2000, Hi tim mch Vit Nam.
6. Nguyn Anh V (2010), Bnh mch vnh Siu m tim cp nht chn
on, Nh xut bn i hc hu, tr 148-158.
7. Nguyn Ln Vit, Bnh hc nhi mu c tim, Thc hnh bnh tim
mch. NXB Y hc 2007. Tr. 68 111.
8. Nguyn Ln Vit (2012), Bnh hc Ni khoa, tp 1. NXB Y hc.
9. Nguyn Quang Tun (2005),Nghin cu hiu qu ca phng php
can thip ng mch vnh qua da trong nhi mu c tim cp, Lun n
tin s y hc H Ni.
-
10. Nguyn Th Hi Yn (2008), Nghin cu mt s yu t nh hng n
tin lng sm v ngn hn (3 thng) bnh nhn nhi mu c tim
thnh di cp, lun vn tt nghip bc s ni tr.
11. Phm Gia Khi, Nguyn Ln Vit v cng s (2006), Khuyn co v
cc bnh tim mch v chuyn ha giai on 2006-2010, Nh xut bn Y
hc chi nhnh Thnh ph H Ch Minh, tr 87-152.
12. Phm Mnh Hng (2005), Cc yu t nguy c ca bnh tim mch,
Tp ch tim mch hc Vit Nam, (40), Tr 103104.
13. Phm Mnh Hng, Tui ng mch: Cch tip cn ton din trong iu
tr bnh nhn tng huyt p i hi tim mch ton quc ln th 13.
14. Phm Gia Khi, Nguyn Ln Vit, Don Li, Phm Mnh Hng,
Khuyn co 2008 ca Hi Tim mch hc Vit Nam v nh gi, d
phng v qun l cc yu t nguy c ca bnh tim mch. Khuyn co
2008 cc bnh l tim mch v hi chng chuyn ha. Nh xut bn Y
hc 2008.
15. Phm Th Khnh, Phm T Dng , Xt nghim s dng trong lm
sng, Nh xut bn Y hc 2005.
16. Trn Th Hi Yn (2008) nghin cu vai tr thang im Framingham
trn bnh nhn T type 2, lun vn tt nghip bc s ni tr
17. Trng Quang Bnh (2006), Sinh bnh hc va x ng mch, bnh
ng mch vnh trong thc hnh lm sng, Nh xut bn y hc, tr.3638.
18. Vn c Hnh (2010). "Nghin cu nng glucose mu v mi lin
quan vi mt s yu t nguy c khc trong tin lng Nhi mu c tim
cp." Lun vn tt nghip bc s ni tr bnh vin. Trng i hc Y
H Ni.
-
Ting nc ngoi
19. Frank H., Netter MD, Atlas Gii phu ngi, Tr. 224 - 225.
20. Uwe Zeymer, Md et al (1998), Effects of Thrombolytic Therapy in
Acute Inferior Myocardial Infarction with or without Right Ventricular
Involvement, JACC, vol.32,no.4, 8768117/ PGS TS Phm Th Minh
c, Sinh l hc, Nh xut bn Y hc 2007.
21. GUSTO Angiographic invenstigators, The effect s of tissue
plasminogen Activartor, Streptokinase, or both on coronaryartyry
patency, ventricular function, and survival after acute myocardial
infaction, New England J, vol 329,(16151621).
22. Antman EM, et al (2008), 2007 Focused Update of the ACC/AHA
2004 Guidelines for the Management of Patients with ST-Elevation
Myocardial Infarction, J Am Coll Cardiol, (51), 210-47.
23. Barbara V.Howard, David C. Robbins, Maurice L. Sievers, Dorothy
Rhoades Elisa, v cs (2000). "LDL Cholesterol as a Strong Predictor of
Coronary Heart Disease in Diabetic Individuals With Insulin Resistance
and Low LDL-The Strong Heart Study". Arterioscler Thromb Vasc Biol.
(20): tr. 830-835.
24. Berger JS, J Am Coll Cardiol 2010; 55: 1169 77.
25. Bots ML, Grobbee DE. Intima media thickness as a surrogate marker
for generalised atherosclerosis. Cardiovasc Drugs Ther 2002; 16:341-351
26. Chambless LE, Folsom AR, Clegg LX, et al. Carotid wall thickness is
predictive of incident clinical stroke: the atherosclerosis risk in
communities (ARIC) study. Am J Epidemiol 2000;151:478-487.
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27. Conroy RM, Eur Heart J (2003); 24: 987
28. DAgostino RB Sr., Vasan RS, Pencina MJ, et al. General
cardiovascular risk profile for use in primary care: the Framingham
Heart Study. Circulation 2008; 117: 74353.
29. David A. Morrow, MD et al, TIMI Risk Score for STElevation
Myocardial InfarctionJournal of the American Heart Association.
30. Dimitris M. Konstantinou, Yiannis S. Chatzizisis, George E.
Louridas & George D. Giannoglou (2010). "Metabolic Syndrome and
Angiographic Coronary Artery Disease Prevalence in Association with
the Framingham Risk Score". Metabolic syndrome and related
disorders. 8(3): tr. 201-208.
31. Edward G, Lakatta EG, Najjar SS. Vascular aging: An emerging new
global cardiovascular risk. The Valencia Forum 2002
32. E Negri, C La Vecchia, B D'avanzo, A Nobili, v cs (1994). "Acute
myocardial infarction: association with time since stopping smoking in
Italy. GISSI-EFRIM Investigators. Gruppo Italiano per lo Studio della
Sopravvivenza nell'Infarto. Epidemiologia dei Fattori di Rischio
dell'Infarto Miocardico. ". J Epidemiol Community Health 1994;48:129-
133.
33. Fruster V, Badimon L, et al (1992) The pathogenesis of coronary
artery disease and the acute Coronary syndromes, N Engl J Med, (326) :
242250.
34. Gerd Assmann (2006). "Dyslipidaemia and global cardiovascular risk:
clinical issues". Eur Heart Journal 8(Suppl ): tr. F40-46
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35. Heart Protection Study Collaborative Group (2002). "MRC/BHF
Heart Protection Study of cholesterol lowering with simvastatin in
20,536 high-risk individuals: a randomised placebo-controlled trial.".
Lancet. 360(9326): tr. 7-22
36. Kannel WB, McGee D, Gordon T. A general cardiovascular risk
profile: the Framingham Study. Am J Cardiol 1976;38: 4651.
37. Miller M, Cannon Cp, Murphy Sa, Qin J, v cs (2008). "Impact of
triglyceride levels beyond low-density lipoprotein cholesterol after acute
coronary syndrome in the PROVE IT-TIMI 22 trial". Am Coll Cardiol.
51: tr. 724-30.
38. Naser Ahmadi et al (2011). "Mortality in Individuals Without Known
Coronary Artery Disease but With Discordance Between the
Framingham Risk Score and Coronary Artery Calcium". Am J Cardiol.
107: tr. 799-804.
39. Nilson P, Vascular Health and Risk Management 2008; 4(3) 547 - 52
40. Scott M. Grundy, Diane Becker, Richard S. Cooper, D. Roger
Illingworth, v cs (2002). "Third Report of the National Cholesterol
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Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel
III) Final Report". Circulation. 106: tr. 3413-3421.
41. The Merck Manual of Diagnosis and therapy (2006), "Acute
coronary, syndrones", pp. 635 - 652.
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43. WHO, 2004, The Global Burden of Disease, 2004 Update.89
-
MU BNH N NGHIN CU
A/ Hnh chnh:
- M s BA: .
- H v tn: Tui: ...
Gii: Nam N
- Ngh nghip:
- a ch:......
- Ngy vo vin: .....
- Ngy ra vin:.
- Chn on:
B/ Chuyn mn:
1. L do vo vin:
2. Bnh s:
au tht ngc: 1 2 3 4 5
( 1: khng au ngc; 2: au ngc khi gng sc nhiu;
3: au ngc khi gng sc nh; 4: au ngc khi ngh; 5: khng in hnh)
Thi gian au: .. pht S cn au: .. cn/ngy
Thi gian t lc au n khi nhp vin: .. gi.
-
3. Tin s:
3.1: Tin s tim mch:
3.1.1: au tht ngc: in hnh Khng au Khng in hnh
3.1.2: NMCT: C Khng
3.1.3: TBMN: C Khng
3.1.4: Bnh mch ngoi bin: C Khng
3.2: Cc yu t nguy c:
3.2.1: Ht thuc l: ang ht Khng ngng
3.2.2: i tho ng: C Khng
3.3.3: Tng huyt p: C Khng
Thi gian pht hin: nm
S o HA cao nht: ../ mmHg v/hoc HA thng ngy .../mmHg
iu tr: u Khng u Khng iu tr
3.3.4: Tin s gia nh:
4. Thm khm khi vo vin:
4.1: Tim mch:
Tn s: . ck/p Nhp: u Khng u
HA: ../. mmHg
-
T1,T2: R Khng r
Ting thi:.
Mch ngoi bin: R Khng r
NYHA: Kh th khi gng sc Kh th khi lm vic nng
Kh th khi lm vic nh Kh th thng xuyn
Killip: Killip 1 phi khng ran Killip 2 ran di bn phi
Killip 3 suy tim nng, ph phi cp Killip 4chong do tim
4.2: H hp:
Tn s th: . l/p
Ran phi: ..
..
4.3: Thn kinh:
Tnh Hn m Glassgow: im
Lit na ngi: C Khng
Du hiu khc: .
4.4: Cc c quan b phn khc:
-
5. Cn lm sng:
5.1: Sinh ha:
Ure: mmol/l
Creatinine mol/l
Acid uric: mol/l
Glucose (lc i): mmol/l
CK (cao nht): U/l
CK-MB (cao nht): U/l
HDL: mg/dL
Cholesterol TP: mg/dL
5.2: in tm :
Nhp: Tn s: ck/p
Bloc nhnh: (phi, tri, AV 1, 2, 3)
ST chnh ln: C Khng
Chnh ln cao nht: .. mm gi th chuyn o
Sau can thip ST chnh ln chuyn o
ST chnh xung: C Khng
ST khng chnh: C Khng
Sng Q: C Khng
-
Chn on vng nhi mu trn in tm :
Trc vch (V1, V2, V3 + V4 2 C)
Mm (V5, V6 + V4 2 C)
Bn cao (D1, aVL)
Trc (V1V5,6 4 C)
Trc rng (V1V6 + D1, aVL)
Sau (V7, V8, V9; h/nh gin tip V1, V2: R cao, ST chnh
xung)
Di (D3, aVF + D2 2 C)
Tht phi (ST chnh ln 1mm V3RV5R)
5.3: Chp ng mch vnh:
1 C 2 Khng
Kt qu: s nhnh ng mch vnh tn thng:
MV tri: thn chung . % hp LAD .% hp
LCx . % hp nhnh cho % hp
Nhnh b . % hp
MV phi: Nhnh b . % hp M qut % hp
M lin tht sau . % hp
-
5.4: Siu m:
Dd: ..; Ds: ..
Vd: ..; Vs: ..
%V: ..; %D: ..
EF: ..
Ri lon vn ng vng c tim: 1 C 2 Khng
Vng: ....
Mc : 1 2 3 4
Huyt khi tim: ..
HoHL: khng 1 2 3 4
HoC: khng c
Chc nng tm thu tht tri bnh thng gim nh gim nng
Nhn xt khc:
.
.....
-
MC LC
T VN .......................................................................................................................................6
TNG QUAN TI LIU.........................................................................................................................8
1.1: Tnh hnh bnh Nhi mu c tim cp:.....................................................................................8
1.1.1: Trn th gii:....................................................................................................................8
1.1.2: Vit Nam:.....................................................................................................................8
1.2: i cng v Nhi mu c tim cp:........................................................................................9
1.2.1: nh ngha:......................................................................................................................9
1.2.2. c im gii phu v chc nng ng mch vnh [19]..................................................9
1.2.3: Nguyn nhn v c ch bnh sinh trong NMCT cp [1], [7], [9], [17]:...........................11
1.2.4: Chn on bnh nhn NMCT cp [11] [22]....................................................................12
1.2.6: Nhng yu t nguy c trong NMCT cp [1], [6], [14]:....................................................17
1.3: Cc phng php lng gi nguy c tim mch:...................................................................20
1.3.1: Thang im Framingham [24], [28], [36], [42]:..............................................................20
1.3.2: Thang im EURO SCORE (2003)[24], [27]:...................................................................22
1.4: Lo ha mch mu (Vascular Aging) v Lo ha mch mu sm (Early Vascular Aging EVA)22
1.4.1: Lo ha mch mu:.......................................................................................................22
1.4.2: Lo ha mch mu sm (EVA):......................................................................................23
1.4.3: Pht hin Lo ha mch mu sm (EVA):......................................................................25
1.4.4: Phng nga v iu tr Lo ha mch mu sm:...........................................................25
1.5: Tui ng mch [28]:............................................................................................................26
1.5.1: nh ngha v Tui ng mch (VA Vascular Age):.........................................................26
1.5.2: Phng php tnh tui ng mch [28]:........................................................................27
I TNG V PHNG PHP NGHIN CU................................................................................27
2.1: i tng nghin cu:..........................................................................................................28
2.1.1: Tiu chun la chn bnh nhn:...................................................................................28
2.1.2: Tiu chun loi tr: nhng bnh nhn sau s b loi tr khi phm vi nghin cu:......28
2.2: Phng php nghin cu:....................................................................................................28
2.2.1: Thit k nghin cu: nghin cu m t.........................................................................28
2.2.2: Quy trnh nghin cu:....................................................................................................29
2.2.3: X l thng k s liu:....................................................................................................31
KT QU NGHIN CU....................................................................................................................32
-
3.1: c im chung ca i tng nghin cu:.........................................................................33
3.2: c im Tui ng mch nhm bnh nhn nghin cu:.................................................34
3.3: nh gi mi lin quan gia Tui ng mch vi cc yu t nguy c ca Nhi mu c tim
cp:.....................................................................................................................................35
3.3.1: Tui thc:.......................................................................................................................35
3.3.2: Huyt p:.......................................................................................................................36
3.3.3: RL Lipid mu..................................................................................................................37
3.3.4: Ht thuc l:..................................................................................................................44
3.3.5: i tho ng..............................................................................................................45
3.3.6: Nguy c mc bnh mch vnh trong 10 nm theo thang im Framingham Risk Score:
....................................................................................................................................46
3.4: Lin quan gia Tui ng mch vi v tr nhi mu trn in tm :..............................48
3.5: Lin quan gia Tui ng mch vi tnh trng tn thng mch vnh:...............................49
3.5.1: Mc x va mch vnh:...........................................................................................49
3.5.2: S nhnh mch vnh tn thng:.................................................................................51
BN LUN........................................................................................................................................53
4.1: c im chung ca i tng nghin cu:.........................................................................53
4.1.1 c im v tui v gii:................................................................................................53
4.1.2 c im v lm sng v cn lm sng:..........................................................................54
4.2: c im v Tui ng mch:...............................................................................................56
4.3. Mi lin quan gia Tui ng mch vi cc yu t nguy c NMCT cp:...............................56
4.3.1: Tui thc:.......................................................................................................................56
4.3.2: Tng huyt p:...............................................................................................................57
4.3.3: RL Lipid mu:.................................................................................................................57
4.3.4: Ht thuc l:..................................................................................................................59
4.3.5: i tho ng:.............................................................................................................60
4.3.6: Lin quan gia Tui ng mch vi nguy c mc bnh mch vnh trong 10 nm theo
Framingham Risk Score:..............................................................................................61
4.4: Lin quan gia Tui ng mch vi tnh trng tn thng mch vnh:...............................62
4.5. Hn ch ca nghin cu.......................................................................................................63
KT LUN.........................................................................................................................................65
TI LIU THAM KHO.......................................................................................................................66
-
DANH MC BNG
Bng 1.1: chn on nh khu vng NMCT trn in tm ...........................15
Bng 2.1: Phn chia mc hp ng mch vnh...........................................31
Bng 3.1: c im chung ca nhm nghin cu............................................33
Bng 3.2: c im Tui ng mch ca nhm nghin cu.............................34
Bng 3.3: Mi lin quan gia Tui ng mch vi Tui thc............................35
Bng 3.4: Mi lin quan gia Tui ng mch vi Huyt p............................36
Bng 3.5: Mi lin quan gia Tui ng mch vi RL Lipid mu......................38
Bng 3.6: Mi lin quan gia Tui ng mch vi nng Cholesterol TP......38
Bng 3.7: Mi lin quan gia Tui ng mch vi nng Triglyceride..........40
Bng 3.8: Mi lin quan gia Tui ng mch vi nng HDL-C...................41
Bng 3.9: Mi lin quan gia Tui ng mch vi nng LDL-C...................43
Bng 3.10: Mi lin quan gia Tui ng mch vi tnh trng ht thuc.........44
Bng 3.11: Mi lin quan gia Tui ng mch vi tnh trng T.................45
Bng 3.12: Mi lin quan gia Tui ng mch vi Nguy c mc bnh mch vnh trong 10 nm theo FRS............................................................................46
Bng 3.13: T l tn thng mch vnh...........................................................49
Bng 3.14: Mi lin quan gia Tui ng mch vi tnh trng tn thng MV.........................................................................................................................49
Bng 3.15: T l s nhnh mch vnh tn thng...........................................51
Bng 3.16: Mi lin quan gia Tui ng mch vi s nhnh mch vnh tn thng.............................................................................................................51
Bng 4.1: So snh tui trung bnh vi cc nghin cu khc.............................54
Bng 4.2: So snh thnh phn lipid mu vi cc nghin cu khc...................55
Bng 4.3: H s tng quan gia Tui ng mch vi cc yu t nguy c......62
-
DANH MC HNH
Hnh 1.1: Hnh nh ng mch vnh................................................................................................10
Hnh 1.2: Hnh nh gii phu ng mch vnh tri..........................................................................11
Hnh 1.3: Hnh nh gii phu ng mch vnh phi........................................................................11
Hnh 2.1: S thit k nghin cu................................................................................................32
Hnh 3.1: Phn b Tui ng mch..................................................................................................34
Hnh 3.2: Tng quan gia Tui ng mch v Tui thc................................................................36
Hnh 3.3: Tng quan gia Tui ng mch v HA tm thu (mmHg)..............................................37
Hnh 3.4: Tng quan gia Tui ng mch v tnh trng RL Lipid mu..........................................38
Hnh 3.5:Tng quan gia Tui ng mch v tng Cholesterol ton phn....................................39
Hnh 3.6: Tng quan gia Tui ng mch v tng Triglyceride....................................................41
Hnh 3.7: Tng quan gia Tui ng mch v nng HDL-C.......................................................42
Hnh 3.8: Tng quan gia Tui ng mch v LDL-cholesterol......................................................44
Hnh 3.9: Tng quan gia Tui ng mch v ht thuc l...........................................................45
Hnh 3.10: Tng quan gia Tui ng mch v T......................................................................46
Hnh 3.11: Tng quan gia Tui ng mch v nguy c mc bnh mch vnh 10 nm theo Framingham risk score.....................................................................................................................47
Hnh 3.12: Phn b vng nhi mu trn T..................................................................................48
Hnh 3.13: Phn b Tui ng mch theo v tr nhi mu................................................................49
Hnh 3.14: Phn b tn thng MV theo gii...............................................................................50
Hnh 3.15: T l tn thng mch vnh theo nhm Tui ng mch..............................................50
Hnh 3.16: T l s nhnh mch vnh tn thng cc nhm tui ng mch..............................52
Hnh 4.1: Tui ng mch cao hn so vi tui thc........................................................................57
