B GIO DC O TO B Y T TRNG I HC Y H NI ****** NGUYN C NHNG NGHIÊN CứU KếT QUả SớM Và NGắN HạN BệNH NHÂN Bị BệNH ĐộNG MạCH VàNH ĐƯợC ĐặT STENT PHủ THUốC Có CHIềU DàI 48 MM Chuyờn ngnh : Ni Tim mch Mó s : 62722025 LUN VN TT NGHIP BC S NI TR Ngi hng dn khoa hc: TS.BS NGUYấN QUễC THAI PGS.TS NGUYấN QUANG TUN H NI 2014 LI CM N Trc tiờn, cho phộp tụi c by t lũng bit n sõu sc v li cm n chõn thnh ti GS.TS Nguyn Lõn Vit, PGS TS Doón Li va cac thõ y cụ bụ mụn Tim m ch - trng a i hc Y Ha Ni la nhng ng i ó tn tỡnh hng dn, to mi iu kin thun li cho tụi sut quỏ trỡnh hc v nghiờn cu Xin chõn thnh cm n PGS.TS Nguyn Quang Tun, TS.BS Nguyờn Quụ c Thai la ngi thy, ngi anh ó giỳp tụi rt nhiu ng tr thnh bỏc s Tim mch Xin trõn trng cm n cac thy cụ Ban giỏm hiu, cỏc thy cụ phũng o to sau i hc trng i hc Y H Ni ó to mi iu kin thun li cho tụi sut thi gian hc ti trng Tụi cng xin chõn cm n cac bac s, iu dng cỏc phũng ban ca Vin Tim mch- Bnh vin Bch Mai ó giỳp v to iu kin cho tụi quỏ trỡnh nghiờn cu Xin trõn trng cm n cac BN la i tng cng nh la ng lc giỳp tụi thc hin nghiờn cu ti ny Cui cựng, xin chõn thnh cm n gia ỡnh, bn bố luụn l ngun ng viờn, khớch l tụi c gng hc tp, hon thnh tt lun tt nghip bỏc s ni trỳ ny H Ni, ngy 16 thỏng 11 nm 2014 Nguyn c Nhng LI CAM OAN Tụi xin cam oan õy la cụng trỡnh nghiờn cu ca tụi Cỏc s liu lun l trung thc va cha c cụng b bt k cụng trỡnh nghiờn cu khỏc Hc viờn Nguyn c Nhng CC CH VIT TT TRONG TI TING VIT BN : Bnh nhõn M : ng mch MC : ng mch ch MLTS : ng mch liờn tht sau MLTTr : ng mch liờn tht trc MV : MV T : in tõm Dd : ng kớnh tht trỏi cui tõm trng Ds : ng kớnh tht trỏi cui tõm thu EF : Phõn s tng mỏu tht trỏi YTNC : Yu t nguy c NMCT : Nhi mau c tim TBMN : Tai bin mch nóo CTNKễ : Cn au tht ngc khụng n nh Nễ : au ngc n nh THBH : Tun hon bng h TM : Tnh mch ALMP : p lc ng mch phi THA : THA BTTMCB : Bnh tim thiu mỏu cc b ALMP : p lc ng mch phi HoHL : H hai lỏ TING ANH ACC : Trng mụn Tim mch Hoa K (American College of Cardiology) AHA : Hi Tim mch Hoa K (American Heart Association) BMS : Stent kim loi trn (Bare Metal Stent) DES : Stent ph thuc (Drug Eluting Stent) Killip : Cach anh mc suy tim giai on cp ca NMCT NYHA : Cach anh gia mc suy tim theo Hi Tim mch New York (New York Heart Association) MACE : Cỏc bin c tim mch chớnh (Major Adverse Cardiac Events) TIMI : Cach anh gia mc dũng chy MV da trờn nghiờn cu TIMI (Thrombolysis In acute Myocardial Infarction) TMP : Mc ti mau c tim (TIMI myocardial perfusion) MC LC T VN CHNG 1: TNG QUAN TI LIU 1.1 TèNH HèNH MC BNH NG MCH VNH 1.1.1 Tỡnh hỡnh mc bnh ng mch vanh trờn th gii 1.1.2 Tỡnh hỡnh mc bnh MV ti Vit Nam 1.2 C IM GII PHU V CHC NNG H NG MCH VNH 1.2.1 Gii phu MV 1.2.2 Cỏch gi tờn theo nghiờn cu phu thut MV 1.2.3 Sinh lý ti mỏu ca tun hon vnh 1.3 I CNG V BNH TIM THIU MU CC B 1.3.1 au tht ngc n nh 1.3.2 au ngc khụng ụ n inh 1.3.3 Nhi mau c tim cp 10 1.4 CAN THIP NG MCH VNH 12 1.4.1 Lch s v nguyờn lý 12 1.4.2 K thut can thip MV qua da 13 1.4.3 Cỏc yu t nh hng n kt qu can thip MV 16 1.4.4 Cỏc bin chng liờn quan n can thip MV 20 1.5 CC NGHIấN CU V IU TR TN THNG DI, LAN TA 22 1.5.1 nh hng ca di tn thng n tiờn lng can thip MV 22 1.5.2 nh hng ca di stent lờn tiờn lng lõu di bnh nhõn can thip MV 23 1.5.3 t stent ph thuc iu tr bnh MVcú tn thng dai va nh hng ca chng stent lờn tiờn lng lõu di 24 1.5.4.S i ca Stent di v mt vai c im ca Stent 48 mm 26 1.5.5 Mt s k thut a Stent dai vao tn thng 29 CHNG 2: I TNG V PHNG PHAP NGHIấN CU 30 2.1 I TNG NGHIấN CU 30 2.1.1 Tiờu chuõ n la cho n bờ nh nhõn va phõn nhúm nghiờn cu 30 2.1.2 Tiờu chuõ n loa i tr 31 2.2 PHNG PHP NGHIấN CU 31 2.2.1 Thit k nghiờn cu 31 2.2.2 Cac bc tin hnh 31 2.2.3 anh gia kt qu can thip MV 33 2.2.4 Kt qu theo dừi dc theo thi gian 36 2.2.5 Phng phap can thip MV qua da 37 2.3 PHNG PHP X Lí S LIU 39 CHNG 3: KT QU NGHIấN CU 41 3.1 C IM CHUNG CA CC I TNG NGHIấN CU 41 3.2 C IM LM SNG V CN LM SNG 42 3.2.1 c im chung 42 3.2.2 c im lõm sng 43 3.2.3 c im cn lõm sng ca nhúm nghiờn cu 46 3.3 C IM V CHP V CAN THIP NG MCH VNH 48 3.4 KT QU THEO DếI DC THEO THI GIAN 55 3.4.1 Theo dừi cỏc bin c tim mch chớnh v t l tỏi nhp vin 55 3.4.2 c im nhúm cú bin c 58 CHNG 4: BN LUN 64 4.1 BN LUN C IM LM SNG V CN LM SNG CA NHểM NGHIấN CU 64 4.1.1 V tui v gii 64 4.1.2 c im v cỏc YTNC tim mch 65 4.1.3 Tỡnh trng lõm sng v cn sng nhp vin 67 4.2 BN LUN V KT QU CHP V CAN THIP MV 71 4.2.1 V v trớ can thip v s nhỏnh tn thng 71 4.2.2 V c im ca tn thng MV 72 4.2.3 Kt qu thnh cụng v mt th thut 73 4.2.4 Kt qu thnh cụng v mt BN 77 4.3 BN LUN V KT QU THEO DếI DC CC BIN C TIM MCH CHNH 78 4.4 BN LUN V CC NGUYấN NHN TI NHP VIN 82 4.5 BN LUN V C IM CA NHểM Cể BIN C V KHễNG Cể BIN C 84 4.6 HN CH CA NGHIấN CU 85 KT LUN 86 TI LIU THAM KHO PH LC DANH MC BNG Bng 3.1 Mt s c im chung ca hai nhúm nghiờn 41 Bng 3.2 c im v chn oan ca nhúm nghiờn cu 43 Bng 3.3 c im v cỏc yu t nguy c 43 Bng 3.4 c im lõm sng ca nhúm nghiờn cu nhp vin 44 Bng 3.5 Phõn Killip nhp vin nhúm NMCT 45 Bng 3.6 c im kt qu xột nghim mỏu ca nhúm nghiờn cu 46 Bng 3.7 c im in tõm ca nhúm nghiờn cu 47 Bng 3.8 c im siờu õm tim ca nhúm nghiờn cu 47 Bng 3.9 Tn sut xut hin cac nhanh MV can thip 48 Bng 3.10 Kt qu chp MV theo s lng nhỏnh tn thng 49 Bng 3.11 c im tn thng MV ca nhúm nghiờn cu 50 Bng 3.12 Kt qu can thip MV qua da 51 Bng 3.13 Mt s k thut a stent 48 mm vao v trớ tn thng 53 Bng 3.14 Bin c xy sau can thip v thi gian nm vin 54 Bng 3.15 So sỏnh bin c tim mch chớnh v t l tỏi nhp vin sau 30 ngy ca nhúm nghiờn cu 55 Bng 3.16 So sỏnh bin c tim mch chớnh v tỏi nhp vin nhúm nghiờn cu thi gian theo dừi 56 Bng 3.17 Mt s c im nhúm cú bin c v khụng cú bin c 58 Bng 3.18 Mụ hỡnh hi quy COX gia nhúm nghiờn cu v mt s yu t tiờn lng vi bin c phi hp theo dừi 30 ngy 60 Bng 3.19 Mụ hỡnh hi quy COX gia nhúm nghiờn cu v mt s yu t tiờn lng vi bin c phi hp thi gian theo dừi 62 Bng 4.1 Bng so sỏnh cỏc YTNC gia cỏc nghiờn cu 66 Bng 4.2 So sỏnh bin c tim mch chớnh gia cỏc nghiờn cu 80 DANH MC BIU Biu 3.1: T l nam v n nhúm nghiờn cu 42 Biu 3.2: Phõn b cac i tng nghiờn cu theo nhúm tui 42 Biu 3.3: Phõn b theo thi gian nhp vin 45 Biu 3.4: Phõn b phõn sut tng mỏu ca nhúm 48 Biu 3.5: Phõn b i tng nghiờn cu theo nhỏnh can thip MV 49 Biu 3.6: S thay i TIMI trung bỡnh trc v sau can thip 52 Biu 3.7: Mc hp MV trung bỡnh trc v sau can thip 52 Biu 3.8: T l cỏc nguyờn nhõn tỏi nhp vin sau 30 ngy 56 Biu 3.9: T l bin c tim mch chớnh v nguyờn nhõn tỏi nhp vin nhúm nghiờn cu 57 Biu 3.10: Mụ hỡnh ng cong Kaplan - Meier so sỏnh nhúm nghiờn cu thi gian theo dừi 30 ngy 59 Biu 3.11: Mụ hỡnh hi quy COX gia nhúm nghiờn cu v mt s yu t tiờn lng vi bin c phi hp theo dừi 30 ngy 61 Biu 3.12: ng cong Kaplan Meier t l khụng xut hin bin c 62 Biu 3.13: Mụ hỡnh hi quy COX gia nhúm nghiờn cu v mt s yu t tiờn lng vi bin c phi hp thi gian theo dừi 63 17 Levine, G.N., et al., 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions Circulation, 2011 124(23): p e574-651 18 Thygesen, K., et al., Third universal definition of myocardial infarction J Am Coll Cardiol, 2012 60(16): p 1581-98 19 Thach Nguyen, Cayi Lesions, Practical Lu, Shiwen Handbook of Wang (2003), Complex Advanced Interventional Cardiology (Second edition,181-186 20 Lee, C.W., et al., Predictors of restenosis after placement of drugeluting stents in one or more coronary arteries Am J Cardiol, 2006 97(4): p 506-11 21 Fihn, S.D., et al., 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, 2012 126(25): p e354-471 22 Stone, G.W., et al., Primary Stenting in Acute Myocardial Infarction: Design and Interim Results of the PAMI Stent Pilot Trial J Invasive Cardiol, 1997 Suppl B: p 24B-30B 23 Tracy, R.P., et al., Relation of coagulation parameters to patency and recurrent ischemia in the Thrombolysis in Myocardial Infarction (TIMI) Phase II Trial Am Heart J, 1998 135(1): p 29-37 24 Hur, S.H., et al., Comparison of long-term outcomes following sirolimus-eluting stent vs paclitaxel-eluting stent implantation in patients with long calcified coronary lesions Clin Cardiol, 2009 32(11): p 633-8 25 Witzenbichler, B., et al., Paclitaxel-eluting stents compared with bare metal stents in diabetic patients with acute myocardial infarction: the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial Circ Cardiovasc Interv, 2011 4(2): p 130-8 26 Detre, K.M., et al., Baseline characteristics and therapeutic goals in the New Approaches to Coronary Intervention (NACI) registry Coron Artery Dis, 1993 4(11): p 1013-22 27 Mauri, L., et al., Comparison of thrombosis and restenosis risk from stent length of sirolimus-eluting stents versus bare metal stents Am J Cardiol, 2005 95(10): p 1140-5 28 Chang, S.H., et al., Lesion length impacts long term outcomes of drugeluting stents and bare metal stents differently PLoS One, 2013 8(1): p e53207 29 Grines, C.L., et al., Coronary angioplasty with or without stent implantation for acute myocardial infarction Stent Primary Angioplasty in Myocardial Infarction Study Group N Engl J Med, 1999 341(26): p 1949-56 30 Tcheng, J.E., et al., Benefits and risks of abciximab use in primary angioplasty for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial Circulation, 2003 108(11): p 1316-23 31 Hoffmann, R., et al., Randomized comparison of success and adverse event rates and cost effectiveness of one long versus two short stents for treatment of long coronary narrowings Am J Cardiol, 2002 90(5): p 460-4 32 Hoffmann, R., et al.(2002) Comparing one XIENCE Xpedition 3.0 x 48 mm stent versus two XIENCE Xpedition 3.0 x 28 mm stents" Bench Data on file "Randomized Comparison of Success and Adverse Event Rates and Cost Effectiveness of One Long Versus Two Short Stents for Treatment of Long Coronary Narrowings" Am J Cardiol 2002;90:460464 33 Levine, G.N., et al., 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions J Am Coll Cardiol, 2011 58(24): p e44-122 34 Gibson CM, Murphy SA, Menown I, et al for the TIMI study group (1999), Determinants of coronary blood flow following thrombolytic administration J Am Coll Cardiol, (34), 1403-1412 35 Stone GW, Brodie BR, Morice MC et al (1998), Prospective, multicenter study of the safety and feasibility of primary stending in acute myocardial infarction: in-hospital and 30-day results of the PAMI stent pilot trial, J Am Coll Cardiol, 31, 23 30 36 Nguyn Quang Tun (2005),Nghiờn cu hiu qu ca phng phapcan thip ng mch vnh qua da nhi mau c tim cp, Lun ỏn tin s y hc H Ni 37 Nguyn Quc Thỏi (2011) " Nghiờn cu hiu qu can thip ng mch vnh ca Stent ph thuc bnh nhõn NMCT cp., Lun ỏn tin s y hc, i hc Y H Ni 38 Lờ c Thnh (2011).Nghiờn cu c im lõm sng v cn lõm sng v kt qu iu tr can thip ng mch vnh qua da bnh nhõn cú tn thng ng mch vnh di.Lun thc s y khoa, i hc Y H Ni nm 2011 39 Sakai K, Nakagawa Y, Kimura T et al (2002), Comparison of results of coronary angioplasty for acute myocardial infarction in patients 75 years of age versus patients