B Y T TRNG I HC Y H NI ***** NGễ TH THANH HON Nghiên cứu chức nhĩ trái nồng độ NT- proBNP bệnh nhân rung nhĩ mạn tính không bệnh van tim Chuyờn ngnh : Ni - Tim mch Mó s : CK 62722025 LUN VN BC S CHUYấN KHOA CP II Ngi hng dn khoa hc: PGS.TS Nguyn Th Bch Yn H NI - 2015 LI CM N Nhõn dp hon thnh lun tt nghip, vi tt c lũng kớnh trng v bit n sõu sc, tụi xin c by t li cm n ti: Ban giỏm hiu v phũng o to Sau i hc trng i hc Y H Ni Ban Giỏm c Bnh vin Bch Mai Ban lónh o Vin Tim mch Quc gia Vit Nam Ban lónh o Bnh vin Gang thộp Thỏi Nguyờn Tụi xin by t lũng bit n sõu sc n: PGS.TS Nguyn Th Bch Yn, ngi thy ó ht lũng dy bo, to mi iu kin cho tụi quỏ trỡnh hc tp, ngi ó cho tụi ý tng cng nh ó trc tip hng dn tụi cú bn lun tt nghip hụm GS TS Nguyn Lõn Vit, ch tch Hi Tim mch hc Vit nam, ngi thy ca lp lp cỏc th h hc trũ GS.TS Doón Li, Vin trng Vin Tim mch Quc gia, Ch nhim B mụn Tim mch, trng i hc Y H Ni Cỏc thy cụ hi ng chm lun vn, nhng ngi ó úng gúp cho tụi nhng ý kin quý bỏu giỳp tụi hon thin lun ny Tụi xin c cm n: Cỏc thy cụ giỏo B mụn Tim mch - Trng i hc Y H Ni Tp th nhõn viờn Vin Tim mch Quc gia Vit Nam, nhng ngi ó giỳp tụi rt nhiu quỏ trỡnh hc - nghiờn cu Cỏc ng nghip khoa Ni Tim mch - Bnh vin Gang thộp Thỏi Nguyờn, ni tụi cụng tỏc, ó tng tr tụi rt nhiu quỏ trỡnh hc Cỏc bn bố, nhng ngi ó yờu quý, giỳp tụi nhng lỳc khú khn nht Xin gi nhng tỡnh cm yờu thng nht n b, m, chng v cỏc anh ch em tụi, ngun ng viờn ln lao, ó khớch l tụi sut quỏ trỡnh hc tp, nghiờn cu H Ni, ngy 24 thỏng 12 nm 2015 Ngụ Th Thanh Hon LI CAM OAN Tụi l Ngụ Th Thanh Hon, hc viờn CKII khúa 27, chuyờn ngnh Ni - Tim mch, Trng i hc Y H Ni xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca cụ PGS.TS Nguyn Th Bch Yn 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 nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim v nhng cam kt ny H Ni, ngy 24 thỏng 12 nm 2015 Tỏc gi Ngi vit cam oan Ngụ Th Thanh Hon CH VIT TT %D ACC AHA BMI BSA CHA2DS2-VASc CHADS2 Dd Ds KMC KNT T ECG EF ESC HA HATT HATTr : Phõn s phn trm co ngn si c : American Colleage of Cardiology (Trng mụn Tim Mch Hoa K) : American Heart Association (Hi Tim mch Hoa K) : Body Mass Index- Ch s c th : Ch s din tớch da : C (Congestive heart failure -suy tim hoc phõn sut tng mỏu tht trỏi 40%), H (Hypertension -tng huyt ỏp), A (Age -tui 75), D: diabetes (ỏi thỏo ng), S (Stroke -tin s t qu hoc cn thiu mỏu nóo thoỏng qua) A (Age- 65-74 tui) V (Vascular disease-bnh mch mỏu), cho im nguy c tc mch S (Sex category- gii tớnh n) : C (Congestive heart failure -suy tim hoc phõn sut tng mỏu tht trỏi 40%), H (Hypertension tng huyt ỏp), A (Age -tui 75), D (Diabetes ỏi thỏo ng), S (Stroke -tin s t qu hoc cn thiu mỏu nóo thoỏng qua : ng kớnh tht trỏi tõm trng : ng kớnh tht trỏi tõm thu : ng kớnh ng mch ch : ng kớnh nh trỏi : ỏi thỏo ng : Electrocardiogram - in tõm : Phõn sut tng mỏu tht trỏi : European Society of Cardiology (Hi Tim mch chõu u) : Huyt ỏp : Huyt ỏp tõm thu : Huyt ỏp tõm trng INR IVSd IVSs LAEF LAVI LAVmax LAVmin LPWd LPWs NYHA RN RNKVT TBMMN TCYTTG TIA TMHK TNT TST THA Vd Vs YTNC : International normalized ratio - t s gia t l prothrombin ca bnh trờn t l prothrombin chng ó c chun húa quc t : B dy vỏch liờn tht tõm trng : B dy vỏch liờn tht tõm thu : Phõn s lm rng nh trỏi : Ch s th tớch nh trỏi : Th tớch nh trỏi ti a : Th tớch nh trỏi ti thiu : B dy thnh sau tht trỏi cui tõm trng : B dy thnh sau tht trỏi cui tõm thu : New York Heart Association (Phõn khú th theo hip hi Tim mch New York) : Rung nh : Rung nh khụng van tim : Tai bin mch mỏu nóo : T chc Y t th gii : Transient Ischemic Attack-Thiu mỏu nóo thoỏng qua : Tc mch huyt : Tiu nh trỏi : Tn s tim : Tng huyt ỏp : Th tớch tht trỏi cui tõm trng : Th tớch tht trỏi cui tõm thu : Yu t nguy c MC LC T VN Chng 1: TNG QUAN TI LIU 1.1 i cng rung nh 1.1.1 nh ngha 1.1.2 Phõn loi rung nh 1.1.3 Nguyờn nhõn v cỏc yu t lm tng nguy c rung nh 1.1.4 C ch bnh sinh ca rung nh 1.1.5 c im lõm sng v cn lõm sng ca rung nh 13 1.1.6 Tin trin t nhiờn ca bnh: 15 1.1.7 Cỏc bin c tim mch rung nh 16 1.1.8 iu tr rung nh 19 1.2 Chc nng nh trỏi 25 1.2.1 Chc nng nh trỏi chu chuyn tim 25 1.2.2 Mt s thụng s ỏnh giỏ kớch thc v chc nng nh trỏi trờn siờu õm tim 27 1.3 B-Type Natriuretic Peptide 28 1.3.1 Cu trỳc v hot tớnh sinh hc NT- proBNP 28 1.3.2 NT- proBNP cỏc bnh lý tim mch 31 1.3.3 NT- proBNP bnh nhõn Rung nh: 33 1.3.4 Nguyờn lý nh lng NT- proBNP huyt tng 34 1.4 Cỏc nghiờn cu v ngoi nc v chc nng nh trỏi v NTproBNP bnh nhõn RN 36 Chng 2: I TNG V PHNG PHP NGHIấN CU 38 2.1 Thi gian, a im nghiờn cu 38 2.2 i tng nghiờn cu 38 2.2.1 Nhúm i tng bnh nhõn rung nh 38 2.2.2 Nhúm chng 39 2.3 Phng phỏp nghiờn cu 39 2.3.1 Cỏc bc tin hnh nghiờn cu 39 2.3.2 Khỏm lõm sng 39 2.3.3 Ghi in tõm 40 2.3.4 Xột nghim mỏu c bn 40 2.3.5 nh lng NT -proBNP 40 2.3.6 Siờu õm tim 42 2.3.7 Tiờu chun xỏc nh cỏc yu t nguy c 44 2.4 X lý s liu 45 2.5 o c nghiờn cu 46 Chng 3: KT QU NGHIấN CU 47 3.1 Mt s c im lõm sng, cn lõm sng bnh nhõn rung nh mn tớnh khụng bnh van tim 47 3.1.1 c im lõm sng 47 3.1.2 c im cn lõm sng 52 3.2 Chc nng nh trỏi trờn siờu õm tim, nng NT - proBNP, liờn quan gia chc nng nh trỏi vi nng NT- proBNP v thang im CHA2DS2-VASc 54 3.2.1 Kt qu v chc nng nh trỏi trờn siờu õm tim ca nhúm nghiờn cu so vi nhúm chng 54 3.2.2 c im Nng NT- proBNP ca bnh nhõn nhúm nghiờn cu57 3.2.3 Mi liờn quan gia mt s thụng s chc nng nh trỏi trờn siờu õm tim, nng NT- proBNP vi mt s yu t khỏc 58 3.2.4 Liờn quan chc nng nh trỏi, NT- proBNP vi t qu 71 Chng 4: BN LUN 75 4.1 c im chung ca i tng nghiờn cu 75 4.1.1 c im lõm sng 75 4.1.2 c im cn lõm sng 81 4.2 Chc nng nh trỏi trờn siờu õm tim, nng NT - proBNP, mi liờn quan gia chc nng nh trỏi trờn siờu õm vi nng NT - proBNP v liờn quan gia cỏc thụng s ny vi thang im CHA2DS2-VASc 82 4.2.1 Th tớch v chc nng nh trỏi trờn siờu õm tim bnh nhõn RN 82 4.2.2 Nng NT - proBNP bnh nhõn rung nh khụng bnh van tim 86 4.2.3 Liờn quan gia chc nng nh trỏi vi mt s yu t v NT proBNP 88 4.2.4 Mi liờn quan gia chc nng nh trỏi, NT - proBNP vi thang im CHA2DS2-VASc v tin s t qu 90 KT LUN 92 TI LIU THAM KHO PH LC DANH MC BNG Bng 1.1 Bng 1.2 Bng 1.3 Bng 1.4 Bng 1.5 Bng 2.1 Bng 3.1 Bng 3.2 Bng 3.3 Bng 3.4 Bng 3.5 Bng 3.6 Bng 3.7 Bng 3.8 Bng 3.9 Bng 3.10 Bng 3.11 Bng 3.12 Bng 3.13 Bng 3.14 Bng 3.15 Phõn loi rung nh theo hng dn ca ACC/AHA/HRS 2014 Cht nn gii phu v in sinh lý to phỏt v/ hoc trỡ rung nh 11 Thang im CHADS2 v CHA2DS2-VASc 17 Nguy c t qu hng nm theo thang im CHA2DS2-VASc 19 iu tr bng thuc chng ụng theo khuyn cỏo 21 Ngng chn oỏn suy tim ca NT- proBNP 42 c im chung ca hai nhúm nghiờn cu 47 Triu chng c nng nhúm nghiờn cu 49 Cỏc yu t nguy c theo thang im CHA2DS2-VASc bnh nhõn nghiờn cu 50 Phõn b theo im CHA2DS2-VASc nhúm Nghiờn cu 51 Phõn b im CHA2DS2-VASc theo nhúm nguy c 52 c im xột nghim mỏu c bn nhúm bnh nhõn nghiờn cu 52 c im in tõm nhúm nghiờn cu 53 Kt qu cỏc thụng s siờu õm tim thụng thng nhúm nghiờn cu so vi nhúm chng 53 Kt qu cỏc thụng s ỏnh giỏ chc nng nh trỏi nhúm nghiờn cu so vi nhúm chng 54 So sỏnh giỏ tr ca cỏc thụng s ỏnh giỏ chc nng nh trỏi theo nhúm tui 55 Cỏc thụng s chc nng nh trỏi gia gii ca nhúm nghiờn cu 56 Nng NT- proBNP(ng/l) ca bnh nhõn RN chung v theo gii 57 T lờ bnh nhõn phõn theo cỏc mc NT- proBNP 57 Nng NT- proBNP ca bnh nhõn nhúm nghiờn cu theo nhúm tui v gii 58 Tng quan chc nng nh trỏi v tui nhúm chng 58 Bng 3.16 Tng quan mt s thụng s chc nng nh trỏi chc nng nh trỏi vi tui bnh nhõn RN 59 Bng 3.17 Tng quan gia cỏc thụng s chc nng nh trỏi vi HA tõm thu v HA tõm trng 59 Bng 3.18 Tng quan gia NT- proBNP vi tui, HA tõm thu, HA tõm trng 66 Bng 3.19 Tng quan gia chc nng nh trỏi v tht trỏi vi NT proBNP 67 Bng 3.20 Ch s chc nng nh trỏi, phõn theo cỏc mc nguy c ca im CHA2DS2-VASc 71 Bng 3.21 Mc nng NT- proBNP theo nhúm thang im CHA2DS2VASc 72 Bng 3.22 c im lõm sng gia bnh nhõn cú v khụng cú tin s t qu 73 Bng 3.23 Siờu õm tim bnh nhõn cú v khụng cú tin s t qu 74 17 Valentin Fuster, C.-C., Lars E Rydộn, Co-Chair, 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