B GIO DC V O TO B Y T TRNG I HC Y H NI - HONG KIM LINH GIá TRị CủA thang ĐIểM AGEF TRONG dự báo BệNH THậN DO THUốC CảN QUANG sau can thiệp động mạch vành LUN VN THC S Y HC H NI - 2015 B GIO DC V O TO B Y T TRNG I HC Y H NI - HONG KIM LINH GIá TRị CủA thang ĐIểM AGEF TRONG dự báo BệNH THậN DO THUốC CảN QUANG sau can thiệp động mạch vành Chuyờn ngnh: Tim mch Mó s: 60720140 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS Phm Mnh Hựng H NI - 2015 LI CM N Tụi xin chõn thnh cm ti: - Ban Giỏm hiu, Phũng o to sau i hc, B mụn Tim mch Trng i hc Y H Ni - Ban Giỏm c Bnh vin Bch Mai, ban lónh o Vin Tim mch Quc Gia Vit Nam - Ban Giỏm c Bnh vin Xõy Dng, th cỏc bỏc s, iu dng khoa Tim mch ó giỳp v to iu kin thun li cho tụi c hc v thc hin lun ny sut nm qua Vi lũng kớnh trng v bit n, tụi xin gi li cm n chõn thnh ti: - GS.TS Nguyn Lõn Vit, GS.TS Doón Li, PGS.TS Phm Mnh Hựng, nhng ngi thy, ó tn tỡnh hng dn, truyn t nhng kin thc lõm sng quý bỏu sut quỏ trỡnh tụi hc v thc hin lun ny ti Vin Tim mch - PGS.TS Phm Mnh Hựng l ngi ó trc tip hng dn tụi thc hin v hon thnh ti nghiờn cu ny - Cỏc thy cụ B mụn Tim mch ó dy d, hng dn tụi sut thi gian hc ti Vin Tim mch - Cỏc bỏc s, cỏc cụ chỳ, anh ch, em ti cỏc khoa phũng ca Vin Tim mch Quc Gia Vit Nam ó to iu kin cho tụi c hc tp, rốn luyn chuyờn mụn v kinh nghim ngh nghip Mi ngi ó dnh cho tụi mt mụi trng tt nht hc v tri nghim cuc sng sut thi gian qua Tụi xin trõn trng cm n cỏc thy, cụ hi ng ó úng gúp nhng ý kin khoa hc quý bỏu tụi hon thin lun ny Tụi xin chõn thnh cm n ton th bn bố ng nghip ó luụn quan tõm, ng viờn v giỳp tụi sut quỏ trỡnh hc v hon thnh lun ny Cui cựng, tụi xin dnh tt c tỡnh cm, s quý trng v lũng bit n n b m; n v, con, v gia ỡnh ó luụn sỏt cỏnh ng viờn, giỳp tụi cú ngh lc v quyt tõm hc v nghiờn cu Xin cm n tt c mi ngi./ H Ni, ngy 26 thỏng 11 nm 2015 Tỏc gi Hong Kim Linh LI CAM OAN Tụi l Hong Kim Linh, hc viờn Cao khc khúa 22, Trng i hc Y H Ni, chuyờn ngnh Tim mch, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca PGS.TS Phm Mnh Hựng Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim v nhng cam kt ny H Ni, ngy 26 thỏng 11 nm 2015 Hong Kim Linh CC CH VIT TT ACC : American College of Cardiology - Trng mụn Tim mch Hoa K AHA : American Heart Association Hip hi Tim mch Hoa k ALTT : p lc thm thu BMI : Body Mass Index BN : Bnh nhõn BTDTCQ : Bnh thn thuc cn quang MV : ng mch vnh T : ỏi thỏo ng EF : Ejection Fraction: Phõn xut tng mỏu ESC : Europen Society of Cardiology Hi Tim Chõu u HA : Huyt ỏp HCVC : Hi chng vnh cp MLCT : Mc lc cu thn NMCT : Nhi mỏu c tim NYHA : New York Heart Association RL : Ri lon THA : Tng Huyt ỏp TV : T vong WHF : World Health Foundation Liờn on tim th gii WHO : World Health Organization T chc Y t Thộ gii MC LC PH LC DANH MC BNG DANH MC BIU 10 T VN Bnh ng mch vnh (MV) l tỡnh trng bnh lý khỏ thng gp cỏc nc phỏt trin v ang cú xu hng gia tng cỏc nc phỏt trin Theo c tớnh M hin cú khong triu ngi b au tht ngc v khong triu bnh nhõn nhp vin mi nm vỡ nhi mỏu c tim Trong ú HCVC, c bit l nhi mỏu c tim (NMCT) cp l mt nhng nguyờn nhõn hng u gõy t vong Hoa K v cỏc nc Chõu u phỏt trin, khong 200000 n 300000 bnh nhõn t vong vỡ NMCT cp [73, 74] Vit Nam s bnh nhõn (BN) mc bnh MV ngy cng cú xu hng gia tng nhanh chúng Theo thng kờ ca Vin Tim mch Quc gia Vit Nam t l mỏc bnh MV nm 1991 l 3%, nm 1996 l 6.1% v nm 1999 l 9.5% [62, 73, 75] Hin can thip MV qua da cựng vi nhng tin b ca thuc cng nh Stent mi hiu qu hn ó lm gim t l t vong (TV) NMCT t 30% xung khong 7% [73] Can thip MV qua da l phng phỏp iu tr bnh MV cú hiu qu nht, lm gim t l TV v ngy cng c ỏp dng rng rói cú ch nh [81] Tuy nhiờn vỡ can thip MV qua da l phng phỏp chy mỏu v phi s dng thuc cn quang ng ng mch bm trc tip thuc cn quang vo MV bc l tn thng Vỡ vy mt nhng bin chng cú th gp sau can thip mch vnh ú l suy gim chc nng thn cp thuc cn quang (hay bnh thn thuc cn quang: BTDTCQ) õy l mt bin chng hay gp nhng cha c chỳ ý ỳng mc [46, 47] Tỡnh trng ny hay xy vi nhng bnh nhõn cú nhiu yờu t nguy c nh tin s b suy thn, huyt ng khụng n nh, ỏi thỏo ng, suy tim, tui cao v nhng yu t ny hay kốm theo nguy c mch vnh Suy gim chc nng thn thuc cn quang lm tng thi gian nm vin cng nh tng t l t vong v chi phớ nm viờn M cú khong 83 Trong nghiờn cu ca chỳng tụi nguy c TV bnh thn thuc cn quang gp 18.6 ln so vi nhúm khụng cú suy thn thuc cn quang, vi p < 0.05 4.4.3 Bn lun v thi gian nm vin vi suy gim chc nng thn thuc cn quang Suy gim chc nng thn thuc cn quang sau can thip MV qua da s lm tng thi gian nm vin, nghiờn cu ca chỳng tụi so sỏnh thi gian nm vin ca hai nhúm nghiờn cu (bng 3.14), chỳng tụi thy nhúm bnh nhõn cú BTDTCQ cú thi gian nm vin kộo di hn so vi nhúm Khụng BTDTCQ, vi p < 0.05 Hu ht cỏc nghiờn cu u ch rng nhng bnh nhõn mc suy gim chc nng thn thuc cn quang sau can thip ng mch vnh qua da u cú thi gian nm vin kộo di hn Trong nghiờn cu ca G.Marenzi v cng s thi gian nm vin trung bỡnh ca nhúm BTDTCQ (13 ngy), nhúm Khụng BTDTCQ (8 ngy), nghiờn cu c thc hin trờn nhng bnh nhõn NMCT cp cú can thip thỡ u, nghiờn cu ca G.Andũ cng trờn nhng bnh nhõn cú NMCT cp can thip qua da thỡ u cú s ngy nm vin tng ng l ngy vi nhúm BTDTCQ v ngy vi nhúm Khụng BTDTCQ v s khỏc bit cú ý ngha thng kờ p < 0.05 S khỏc v s ngy nm vin so vi nghiờn cu ca chỳng tụi cú l l i tng nghiờn cu, nhng tu chung li nhng bnh nhõn cú BTDTCQ cú nguy c nm vin cao hn so vi nhúm Khụng BTDTCQ, v s khỏc bit ny cú ý ngha thng kờ [5, 45] 84 KT LUN Kho sỏt t l bnh thn thuc cn quang v cỏc yu t liờn quan - T l bnh thn thuc cn quang l 16.8% - T l t vong chung vin l 2.7%, t vong liờn quan n BTDTCQ l 2.07% - T l BTDTCQ nam gii l 16.72%, n gii l 17.02% - T l BTDTCQ Bn trờn 70 tui l 24.61%, bnh nhõn di 70 tui l 11.68% - T l NMCT l 61.83%, THA l 63.8%, T l 23.8%, RLCH lipid l 40.7%, hỳt thuc lỏ l 26.1% - Suy gim chc nng thn sau can thip MV qua da lm tng nguy c t vong bnh vin - Suy gim chc nng thn thuc cn quang sau can thip MV qua da lm tng thi gian nm vin iu tr Giỏ giỏ tr ca thang im AGEF v cỏc yu t nguy c - Thang im AGEF l yu t c lp tiờn lng bnh thn thuc cn quang vi im cutoff: 1.666 vi nhy: 75.3%; c hiu: 65.6% Vi BN cú im AGEF > 1.666 nguy c suy gim chc nng thn thuc cn quang cao gp 3.9 ln so vi nhúm BN cú im AGEF < 1.666 - C thang im AGEF, ACEF v thang im Mehran u yu t d oỏn c lp vi bnh thn thuc cn quang sau can thip MV qua da - Thang im AGEF v ACEF cú kh nng d oỏn suy gim chc nng thn thuc cn quang sau can thip MV qua da tng ng 85 - Thang im AGEF cú kh nng d oỏn suy gim chc nng thn thuc cn quang sau can thip MV qua da tt hn tui, creatinin trc can thip v thang im nguy c Mehran - 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93 87 H J Yoon and S H Hur (2011) Determination of safe contrast media dosage to estimated glomerular filtration rate ratios to avoid contrastinduced nephropathy after elective percutaneous coronary intervention, Korean Circ J 41(5), 265-71 BNH N NGHIấN CU S: I Hnh chớnh H v tờn: Tui: Gii: Nam N Nghnghip: . a ch: in thoi:. Ngy vo vin: . Mó BA: Ngy vin Chn oỏn: II Tin s v yu t nguy c Hỳt thuc: Hin cũn hỳt Hỳt nhng ó b Tng huyt ỏp : Cú Khụng S nm THA: Khụng hỳt .HA mmHg Nhp tim Ck/ph Suy tim NYHA: ỏi thỏo ng: Cú Khụng S nm T: Ri lon chuyn húa lipid: Cú Khụng Tha cõn/bộo phỡ :Chiu cao (m): Cõn nng (kg): BMI (kg/m2): TS bnh TM: TS Gia ỡnh CAD Cú Khụng 2.7 Bnh thn trc ú: Cú Khụng 2.8 S dng thuc cn quang trc ú ngy cú 2.9 Cỏc bnh i kốm III Chn oỏn cú bnh mch vnh 3.1 Tin s cú bnh MV: Cú Khụng - M bc cu ni ch vnh - Can thip ng mch vnh (nong, t stent) Thi gian 3.2 au ngc: Cú Khụng 3.2.1 Cn au tht ngc n nh 3.2.2 au tht ngc khụng n nh 3.3 Nhi mỏu c tim cú ST chờnh lờn Hi chng vnh cp khụng ST chờnh lờn Bnh mch vnh n nh Killip: im TIMI Tui 75 im Tui 65 - 74: im Tin s ỏi ng, tng huyt ỏp hoc au ngc: im Huyt ỏp tõm thu < 100 mmHg im Tn s tim > 100 chu kỡ/phỳt im Killip III, IV im Trng lng < 67 kg im NMCT thnh trc hoc blc nhỏnh trỏi im im Thi gian t au ngc ti tỏi ti mỏu > 4gi 3.3 Bin i in tim: Cú Khụng Nhip - Súng Q bnh lớ ST chờnh lờn ST chờnh xung T õm sõu mm Cú bin i cỏc bt thng trờn theo thi gian - RL nhp khỏc: BLock AV( I , II , III ), Rung nh khỏc 3.4 Siờu õm tim 3.4.1 RLvn ng vựng :Cú Khụng EF(Simpson): % Dd Ds Vd Vs 3.4.3 Chp MV khụng xõm ln cú tn thng cú ý ngha: Cú Khụng (Hp 50% thõn chung MV trỏi v/hoc hp 70% ớt nht nhỏnh chớnh (LAD, M m , M vnh phi ) 3.5 Loi thuc cn quang dung: S lng(ml) 3.6 S lng Stent: cỏi 3.7 S dng IABP Cỏc xột nghim khỏc Glucose A1c Choleterol TG HDL LDL CK (mmol/l) (mmol/l) (%) (mmol/l (mmol/l) (mmol/l) (UI/l CKMB Troponin CRP Pro-BNP (Mg/dl) (pmol/l) Ure (mmol/L) Acid Uric Creatinin(mcmol/L Creatinin(mcmol/L Trc can thip GOT Sau can thip Thuc ang dựng: Metformin NSAID 3.Khỏng sinh 4.Cỏc nhúm thuc khỏc UI/l GPT UI/l HC T/l Hb g/l BC G/l TT TC % G/l