Tim mạch

tAn g h u y e t Ap I OAl CIPCTNG Tcing huyet ap (T H A ) ch ie m ti le cao cac benh tim m ach T he o T o c h u c Y te The gidi, ti le TH A - 18% dan so th e g id i Cf V iet N am , theo dieu tra cua V ien Tim m ach (2008), ti le TH A la 25,1% d nhung n g u d i 25 tuoi TH A la nguyen nhan gay tu vong 7,1 trieu n g u d i, chiem 4,5% ganh nang benh tat toan cau II CHAN OOAN C han doan xac djnh D u a vao kham , hoi benh va lam m ot so xet nghiem c o ban th u d n g quy a Lam sang - Hoi benh, huye t ap (H A), tim ton th u o n g c o quan dich TH A - D anh gia cac yeu to ngu y c o khac - Hoi benh: + Khai thac tien s u gia d in h va ban than lien quan: dai th a o d u d n g , roi loan lipid m au, benh m ach v3nh, bgnh than + Phong cach song, an uong, tap luyen the lu c + Tien s u dung cac th u o c va cac chat I3m TH A - Kham xet: + D o HA, dac biet H A tu chi + N ghe tieng th o i dong m ach than d bung, dong m ach canh + Kham bo phan tim m ach, than, m at, nao de xac djnh ton th u o n g c o quan d ich TH A - T im cac yeu to ngu y co: hut th u o c la, roi loan lipid m au, beo phi, tieu d u d n g , benh than, yeu to gia dinh, tuoi, gidi b X t n g h ie m : can lam cac xet nghiem th u d n g quy va ch uye n sau de xac dinh nguyen nhan TH A - Xet nghiem th u d n g quy: + C ong th u c m £u: xem so lu g n g hong cau, bgch cau, hem oglobin + G lucose m au, acid uric m au + Ure, cre a tin in m au + C h o le ste ro l to a n phan, trig lyce rid , H D L-C , LD L-C m au + D ien giai Na, K m au + X q uang tim phoi, dien tam + Tong phan tic h n u d e tieu - Xet ngh iem c h u ye n sau: tim ngu yen nhan T H A th u phat va cac bien ch u n g + Sieu am tim , than + Sieu am D o p p le r d on g m ach than, dong m ach canh + Soi day m it 214 H uong dAn chAn d o An v A o i £ u t r i b En h NQi khoa + D in h lu g n g renin, ald o ste ro n , co rtico ste ro id , ca techo lam in + C hup dong m ach th a n can quang c C han d oa n x a c d jn h THA & n g u o i ton: - HA tam thu 14 m m H g - HA tam tru o n g > m m H g D o d lan kham , m oi lan kham d u o c it nhat lan B enh nhan d u o c n g h i n g o i tru d c phut P h an loai T H A a P h a n th e o co n so H A : d u a th e o phan loai cua W H O /IS H 1999, 0 va JN C VI VII khuyen cao cua Hoi Tim m ach V iet N am 2007 d u a ve phan T H A (bang 1): B a n g P h a n lo a i THA th e o c o n s o H A H A tam thu(m m H g) HA tam truang (mmHg) Uu ng tim m ach tron g qua trin h m ang thai th u ’o n g thap - Theo doi sat va ap dung cac bien phap khon g th u o c (n g h i n g o i, an g ia m m uoi) v o i T H A I (HATT 140-149m m H g, H A TTr 90 - m m H g) - T huoc ap: can th ie t tron g T H A c o ton th u o n g c o quan dich, H A TT ti> 150 - m m H g H ATTr tu 100 - H O m m H g M uc tieu dieu tri la g ia m nguy c o cho me, nhien phai an to a n ch o thai nhi Thuoc nen lu a chon hang dau la: a lpha m e th yld o p a ; cac th u o c khac th e o kh uye n ca o d b an g - Khi HATT >170 va /h o a c H A TTr > 110m m H g: coi la tin h tra n g cap c u u can nhap vien th e o doi • THA m an tin h bie n ch u ye n th a n h tien sa n g ia t Tien san giat, tien lu o n g xau ca ch o th a i nhi va me - Phong n g u a tien san giat: xac dinh cac yeu to nguy c o cao cho me, theo doi sat lam sa n g va xet nghiem de phat hien s o m cac ngu y c o nay, th e o doi tich c u e va cho so thai can - D ieu trj bao gom : th e o doi sa t tai benh vien, kiem soat huyet ap kip th o i pha t hien ca c da j hieu san giat va th o i diem can d in h chi thai D ie u trj khon g lam thay doi sinh li benh n h u n g lam b en h c h a m tien trien de co th o i gian cho thai pha t trien - C hi djnh d in h ch i thai co cac dau hieu: cham phat trien th a i hoac co cac d a u hieu ng j y c o cho HUONG d An c h An d o An v A d i £u t r i b £nh NOi khoa 219 m e nhu : TH A n#ng, tang m en gan, giam tieu cau, suy than, giam thj lu c, dau dau, dau da day - T h u o c ap: s u dung de bao ve me, lu a chon loai th u o c va d u o n g dung phu th u o c vao th o i diem d u kien so thai Neu > 48 gio , m e th yld o p a d u o n g uong d u o c u u tien Lab eta lol d u d n g uong, chen beta, chen kenh calci cOng d u o c chap nhan lu a chon Neu phai so thai sd m , can lu a chon cac thuoc tac dung nhanh (d u d n g tin h m ach - bang 2) C ac thuoc can d u o c dung tru d c co c o n co tu cung de tri HATTr -1 05m m H g • THA th a i n g h e n (co hoac khong co protein nieu) co the cho th u o c HA > 140/90m m H g • D ieu trj THA d ba m e g ia i doan cho bu C ac ba m e T H A th u d n g co th e cho bu an toan Tuy nhien, ta t ca cac th u o c ap deu bai tiet qua sua V i vay, cac tru d n g h o p T H A giai doan 1, m uon cho bu vai thang thi co the khong dung thuoc ap, th e o doi chat che, s u dung lai th u o c n g u n g cho bu L u a chon thuoc: m e th yd o p a la lu a chon hang dau, khong co bao cao ve ta c dung phu Khi co chi dmh dung thuoc chen beta giao cam thi labetalol va propranolol d u o c u u tien Khong dung thuoc u c che m en chuyen va chen thu th e an g io te n sin L o i tieu co the lam giam lu o n g su a , vay co the lam m at sua Tre bu m e dang s u dung cac th u o c ap can th e o doi kT cac ta c dung phu t A i l ie u t h a m k h A o K huyen cao cua Hoi Tim m ach V iet N am ve chan doan va dieu trj T H A d n g u d i Idn 2008, “K huyen cdo 0 ve ca c b e n h li tim m ach va ch uye n hoa", N xuat ban Y hoc, trang 235, 294 “KhuySn c6 o c h a n d o a n d ieu trj va d u p h o n g THA cua To chu-c Y te The gi& i/H iep h o i THA the gi& i (W H O /lH )” nam 1999 va 2003 “K h uyen cao p h o n g ngu a, p h a t hien, danh gia va dieu tri ta n g h u ye t ap cua Lien U y ban Q uoc gia H oa K y la n th u (JN C 7)", nam 2003 N o rm a n M K a p la n , “C lin ic a l H y p e rte n s io n ” seventh edition, page 323-344 ROI LOAN LIPID MAU I KH AI NIEM Roi loan lipid m au la tin h tran g tang cholesterol, trig lyce rid (T G s) hu ye t tu a n g hoSc ca hai, hoSc giam nong lip oprotein phan ti> lu’o n g cao (H D L-C ), tang nong lip o p ro te in phan ti> lu’o n g th a p (LDL-C) lam gia tang qua trin h v u a x o dong m ach N guyen nhan co the tien pha t (do di tru ye n ) hod c thi> phdt C han dodn b ln g xet ngh iem cholesterol, trig lyce rid va cac th a n h phan lip o p ro te in m au D ieu tri b ln g thay doi che an uong, hoat dong the ly c va dung th u o c lipid m au va lu u y dieu tri can nguyen ii c h An d o An Roi loan lipid m au du’o c d at d n h u n g benh nhan co trieu c h u n g lam sang ho d c bien ch irn g ciia roi loan lipid m au (vi du benh v u a x o dong m ach) Roi loan lipid tien pha t d u o c nghi n g d d n h u n g benh nhan co dau hieu lam sang cua roi loan lipid m au, benh v u a x o dong m a ch xu a t hien s o m (tru d c 60 tuoi), tien sip gia d in h co n g u d i m lc benh dong m ach hoac c h o le ste ro l m au > ,2 m m o l/L (> 240m g/dL) C han doan xac djnh bang xet ngh iem cac phan lipid m au: c h o le s te ro l tocin p n (TC ), TG , HDLch o le ste ro l (H D L -C ) va L D L -ch o le ste ro l (LD L-C ) Bang g iup chan doan va d an h gia m ire roi loan lipid m au th e o N C E P -A T P III B a n g D a n h g ia cac m ire ro i lo an lip id m au th eo N C E P A T P III (2001) Xet nghiem lipoprotein luc (toi (mmol/L) Xet nghiem lipoprotein luc doi (mmol/l) TC (m g /d l) HDL-cholesterol < 5,17 (< 200) Binh thudng < 1,03 ( < 40) Thap ,1 -6 ,1 (2 0 -2 ) Gidi han cao 1,55 ( 60) Cao ,2 (2 240) Cao LDL-cholesterol TG < 1,695 (< 150) Binh thudng < 2,58 (< 100) Tdi uu ,6 -2 ,2 (1 - 199) Gidi han cao ,5 - 3,33 (1 0 - 129) Gan td i uu ,2 -5 ,6 (2 0 -4 9 ) Cao 3,36 -4,11 (1 - 159) Gidi han cao 5,65 ( 500) Rat cao 4,13 -4 ,8 (1 - 189) Cao 4,91 ( 190) Rat cao Roi logn lipid m au la yeu to nguy c o tim m ach q ua n T rong tru d n g h o p b in h th u d n g nen xet nghiem djnh ki cac th a n h phan lipid m au (ch o le ste ro l toan phan, try g ly c e rid , H D L - C LD L - C) nSm m pt lan doi v d i n g u d i n g u d i tru d n g th a n h d u d i 40 tuoi va m oi nam m pt lan doi v d i nguon tren 40 tu6i de phat hien va xip tri kjp th d i roi loan lipid m au D oi v d i n g u d i m lc cac yeu to ngu y c o tim m a ch (tSng 221 HucSng d A n c h A n o o A n vA o i f u t r i b £ nh N 6i k h o a huyet ap, d£i th a o d u d n g , benh m ach vanh, ) thi co the xet ngh iem s o m h o n va nhieu lan h o n theo tu n g tru o n g hgD cy the T ru d c m ot n g u o i benh roi loan lipid m au, n g u o i th a y th u o c can tien hanh cac b u o c phan tich va x u tri n h u sau: Xac djnh n g u yen nhan gay roi loan lipid m au T h u phat (loi song, an nhieu chat beo bao hoa, dai thao d u o n g , suy than m an, suy giap, dung thuoc, ) hay tien pha t (dot bien gen, co tin h gia dinh, ) D an h gia nguy co> tim m ach di kem Can xac dinh benh li dong m ach vanh (D M V), cac yeu to nguy c o (Y T N C ) tu o n g d u o n g benh m ach vanh (dai thao d u d n g , benh dong m ach ngoai bien, phinh dong m ach chu bung, benh dong m ach canh co trieu ch u n g , nguy c o benh dong m ach vanh > 20% ) N goai lu u y cac yeu to nguy c o sau: - Hut th u o c la - Tang huyet ap (h u ye t ap > 140 /90 m m H g hoac dang dung th u o c ap) - Nong H D L - C th a p (< ,03m m ol/L) - G ia d inh co n g u d i m ic benh m ach vanh (B M V ) sd m (nam < 55 tuoi, n u < 65 tuoi) Sau da xac dinh d u o c cac yeu to nguy c o tim m ach noi tren, tiep tu c u d c tin h nguy c o 10 nam cua BM V (nguy c o m ac B M V hoac cac bien co tim m ach khac tron g 10 nam td i) th e o thang diem F ram m ingham v d i cac m u c < 10% , 10 - 20% va > 20% Xac djn h n 6n g d o L D L -C la m uc tieu dieu trj - Benh nhan ngu y c o cao (B M V hoac tu o n g d u o n g B M V n h u benh dong m ach ngoai bien, phinh dong m ach chu bung, benh dong m ach canh co trieu c h u n g hoa c da yeu to nguy c o tim m ach v d i nguy c o tim m ach 10 nam > 20% th e o thang diem F ram m ingha m ): M uc tieu dieu tri: L D L -C < ,6 m m o l/L (< 100m g/dL) - Benh nhan co n gu y c o rat cao: la n h u n g benh nhan m ac benh dong m ach vanh kem theo: + D a yeu to nguy c o (dac biet la dai th a o d u d n g ) + Co cac yeu to ngu y c o hoac nhu’ng yeu to nguy c o ngh iem tro n g khon g d u o c kiem soat to t (vi du van hut th u o c la) + D a yeu to nguy c o cua hoi c h u n g chuyen hoa (triglycerid > ,2 m m o l/L , H D L-C < 1,03m m ol/L) + D ang bi hoi c h u n g dong m ach vanh cap M uc tieu dieu trj: LD L-C < 1,8 m m ol/L (< 70m g/dL) Tom tat theo bang 2: B a n g D ie u trj ro i lo a n lip id m a u th eo n o n g L D L ■ C Oac diem nguy co Bat dau thay doi loi song neu Dieu tri bang thuoc neu LDL muc tieu Nguy cd thap: khong co BMV hoac tuang LDL > 4,1m m ol/L > 4,9m m ol/L (> 190mg/dL) < ,1 m m o l/L duang BMV vd < 0-1 yeu to nguy co ( > 160mg/dL) (xem xet dim g thuoc neu LDL ( < 160mg/dL) tir 4,13 - 4,88m m ol/L [1 -1 m g /d L ]) Nguy ca tru n g binh: khong co BMV hoac LDL ^ 3,4m m ol/L tuang duang BMV va s YTNC vdi NC 10 ( s 130mg/dL) nam du kien < 10% ^ 4,1m m ol/L ( ^ 160m g/dL) < 3,4m m ol/L (< 130mg/dL) 222 H u Ong dan chan oo An v A o i £u tri b £n h N oi k h o a B a n g (Tiep) Bat dau thay doi Idi song neu Oac diem nguy co Nguy ca trung binh cao: khong m5c BMV hoac tuong duong BMV va ^ LDL s 3,4m m ol/L ( s 130mg/dL) LDL muc ti«u Dieu trj bing thuoc neu < 3,4m m ol/L ^ 3,4m m ol/L (s> 130mg/dL) (< 130m g/dL) (muc tieu lua chon: < 2,6m mol/L YTNC va NC 10 nam du kien 10-20% [ < 100m g/dL]) Nguy co cao: BMV hoac tuong LDL s? 2,6m m ol/L duong BMV (>100m g/dL) 2:100m g/dL ( s 2,6m m ol/L) < 2,6m m ol/L (< lOOmg/dL) (muc tieu lua chon < 1,8m mol/L [< 70m g/dL]) * N C = n g u y co V d i ben h nhan tan g trig ly c e rid (TG ): xu tri th e o bang B a n g Thai x ir tri v&i b en h n h a n ta n g trig ly c e rid Phan loai tang TG Thai xuf tri Gidi han cao (1,695 - ,2 m m o L /L ) M uc tie u dieu trj chinh van la g ia m LDL-C Giam can nang va ta n g cudng h o at dong th e luc Cao (2 ,2 -5 ,6 m m o l/L ) D ieu tr i la m g ia m LDL-C bSng s ta tin hoac th e m n ic o tin ic acid hoac th e m fe n o fib t m ot cach th a n tro n g Rat cao ( > ,6 m m o l/L ) Can dieu trj g ia m n hanh de tra n h v ie m tu y cap Sau TG < ,6 m m o l/L , m uc tie u d ie u tr j c h in h la i la LDL- C D i§ u trj cu th e a V&i b e n h n h a n ta n g ch o le s te ro l m a u lo a i LD L - C cao - D ieu chinh che an uong, sinh hoat: tang cu’d n g van dong, an g ia m beo, han che an cac loai phu tang dong vat, thay th e m d d on g va t b ln g dau thu’c vat, an nhieu th u c ph a m co ch a t x o , kh uye n khich an ca nu’d c ngot, - D ung thuoc: co the dung m ot tron g nhu’ng statin sau (nen b i t dau t u lieu thap Lu’u y r in g lieu ndy van co the tang g lp doi neu khon g dat hieu qua sau - t u ln dieu trj T h a m k h a o th e m lieu lu o n g thuoc lipid m au tro n g bang 4): + S im va sta tin (Zocor, S im va h e xa l, V ida, ) 10m g/ngay + A to rv a s ta tin (Lipitor, A ztor, A to rva st) 10m g/ngay + F lu va sta tin (L e sco l) 20m g/ngay + P va sta tin (P va ch o l) 10m g/ngay + R u so va sta tin (C re sto r) - 10m g/ngay b V&i b e n h n h a n ta n g c h o le s te ro l m a u lo a i p h o i h o p tang LD L - C va tn g ly c e n d - D ieu ch inh ch e an uong, sin h hoa t n h u da trin h bay d tren - D ung thuoc: + Neu can g iam n nh TG de tra n h bien c h u n g : b i t d lu b ln g fibrat: • G e m fib ro zil (L o p id ) 0 m g /n g a y (sau an toi) H U N G d A n c h A n d o A n VA 330 0l £ u tr i bEnh Noi khoa - Roi loan tri g ia c (lan Ion, kich th ich va t va, hon m e) C ac trieu c h u n g rat th a y doi th u o c vao T B M M N t ie m ach hay xuat huyet nao vi tri n£o bi t6n thu’o n g va rong cua vung nao bi ton thu’o n g , C ac th am ho tr o chan doan Du hoi benh va kham lam sang ti m i cung khong the phan biet d u ’o c T B M M N la xuat huyet hay tic m ach nao (nhun nao) m a s i/ phan biet lai e y e ki quan tron g b d i th u o c d ieu tri T B M M N t ic mach nao lai co the gay nguy hiem cho benh nhan T B M M N x u lt huyet a C h up C T so (C o m p u te d T o m o g p h y S c an ) La tham dau tien nen du’o c lu a chon d benh nhan T B M M N , no g iup n g u o i t h ly thuoc phan biet d u g c T B M M N la x u lt huye t hay nhun nao, ngoai giup pha t hien d u g c u nao hay cac bat th u o n g khac tron g nao co the gay cac trieu c h u n g giong T B M M N Tuy nhien, ch u p C T sg co the bo sot nhieu tru o n g hgp , d a c biet la chup 12 g io dau d n h u n g benh nhan nhun n§o h o n nCra U TAI B l£ N M ACH NAO D ieu trj c l p c u u a B a o d am th o n g kh i - D a t n g u o i benh tu the n im nghieng an toan - Loai bo cac dj vat tro n g m ieng (rang gia) neu co - O at canu yn m ieng hut d o m dai can - Neu benh nhan hon m e G la sg o w < diem va co u dgng d o m dai phai d a t noi kh i quan (NKQ ) va th o m ay can b Theo d o i s a t c a c c h i so sin h ton (N hjp tim , huye t ap, nhjp th d , tri g ia c ) de co bien p p x u tri th ic h h g p kjp th d i c L a m n g a y c a c x e t n g h ie m c o ban : (X qua ng tim phoi, d ien ta m do, sieu am tim , cac xet nghiem H i/ O n g d An c h An o o An v A p i £u tri b £n h N oi k h o a 331 sinh hoa, h u ye t h