Tài liệu_COPD và bệnh tim mạch

COPD v BNH TIM MCH TS BS TH TNG OANH BV PHM NGC THCH 201 )222200 nh ngha COPD (GOLD n b tnh BPTNMT ml c hũ COPD l m t bnh c ú th p t h phũng nga v u c kốm i tr iu tr c, c c trng bi s giiheo cú ng ng1a t v 000000 m t s nh hng ỏng k ngo ph cú hn thng xuyờn lung khớ th tiin trini 6666 dtn v thng klốm theo st gia ttnỡ g tỏrp h g ú p ph n m n ng h m nh ng h ph qun v phi i ng viờm n tớnm ca ng bnh tr vi hrt ilic v tkhiớ ci kốm Cỏc on ph c cỏc cbnh ngý b t ci p iCOPDl v cỏc tnh lý i kốm gúp s g hn ung kh h khụng h i phn lm btnh phc chn ung tkh hbtinh tri ớỏt nhõn n.ng thihon ờmi on i vlS i gmi ngi t ny hng n t t n dn v hng kốm i heo m ỏ p ng v m b tt h ng c a ph i vi cỏci h c hoc t kh c i COPD v bnh i kốm Bnh nhõn COPD thng tng nguy c mc: Bnh tim mch Cỏc bnh lý i kốm ny Loóng xng cúthnhhngntl Lo Nhim trựng hụ h õu v trm c p nờn luụn c tm tvong v nhp vin vsoỏt m viutrthớchhp Tiu ng Ung th phi GOLD Strategy Document 2011 (http://www.goldcopd.org/) COPD v nguy c xut hin bin c y khoa 400 Nhim trựng hụ hp 300 Rate per 10,000 au tht ngc Góy xng 200 c TTT Viờm phi 100 Nhi Loóng xng mỏu c tim Tng nhón ỏp Bm da 0 RR in COPD versus non-COPD Reproduced with permission of Chest, from Patterns of comorbidities in newly diagnosed COPD and asthma in primary care, Soriano JB et al, Vol 128, pp 2099-2107, Copyright â 2005; permission conveyed through Copyright Clearance Center, Inc Nguyờn nhõn t vong bn COPD 40 37 IHD = ischaemic heart disease CHF = congestive heart failure 35 RF = respiratory failure 30 TM = thoracic malignancy PVD = pulmonary vascular disease 25 22 25 22.5 COPD 20 19 No COPD 13 12 10 15 12 8.5 14 11 10 10 6.5 RF Pneumonia Heart Failure Reproduced with permission of Chest, from Comorbidity and Mortality in COPDRelated Hospitalizations in the United States, 1979 to 2001, Holguin F et al, Vol 128, pp 2005-2011, Copyright â 2005 COPD V BNH I KẩM BN COPD th ng d xut hin cỏc bnh lý i kốm, thng gp l bnh tim mch, K phi, st cõn, loóng xng v tiu ng T n su t c ỏ c b nh i k ố m sai bi t gi a cỏc ngh cu, cỏch ỏnh giỏ, chn oỏn v phõn b dõn s ng cu khỏc T l xu t hi n c ỏ c b nh i k ố m bn COPD tng cao cú YNTK so sỏnh vi nhúm chng cựng tui IHD Hypertension TM Diabetes PVD i t MMMMaaaarrrrkkkkeeeerrrr vvvv COPD ờờờờmmmm r rrrroooonnnngggg r RL PHN B C TH BNH TIM MCH CCCCOOOOPPPPDDDD r t r t VIấM il RRRRRRRRPPPPPPPP CCCCCCCC il TTTTTTTTNNNNNNNNFFFFFFFF I THO NG LONG SSeevvee ee SSeevvee ee XNG CCOOPPDD CCOOPPDD lt lt Mode a e MMooddee aa ee RI LON TIấU HểA COPD d CCOOPPDD v r - ti r t i ( / ) r MM dd Reprinte it r fr i , i fr l i r l , r i - l ( i , / ) MM dd i , t l, r r f i rit i r i obstructi CCOOPPDD l r - , ri t , CCOOPPDD HHeeaa hhyy HHeeaa hhyy 00 1100 2200 3300 4400 5500 6600 7700 SSee uumm CC RReeaacc vvee PP oo ee nn mmgg LL 00 2200 4400 6600 8800 100 SSee uumm TTNNFF AA pphhaa ppgg mmLL i : VVVV ờờờờmmmm tttthhhh tttttttoooonnnn trrrroooonnnng SS gg g ttCCC cc CO õõ OO nn OPPPPDDDD CCCCỏỏỏỏcccc om PulmPharmacolTher Vo 19 F anc os LG e a Ma ke s o d sease seve Cn au tht ngc on i om E sev e Hi chng vnh cp i S S t y n ch on c e pu mona y d sease pp 189 199 Copy gh 2006 w h pe m ss tc cõ õn n i NNNNhhhh YYYYuuuu cccc vvvvõõõõnnnn qqqquuuuaaaannnn cccchhhh ccccmmmm ttttrrrrựựựựnnnnggg Tiu ng Hi chng chuyn húa g pppphhhh UUUUnnnngggg tttthhhh pppphhhh VIấM Loột d dy/ Tro ngc TON Stress Oxy húa TH Trm cm From W MacNee Loóng xng Mi liờn quan COPD v bnh tim mch Tn sut COPD chim 20-32% bnh nhõn suy tim huyt RR ca suy tim huyt 4.5 bnh nhõn COPD Nguyờn nhõn t vong ca bn COPD: Suy hụ hp t cp COPD 4-35% Do bnh tim mch: 25% Ung th phi: 20 30% Rutten FH Am Heart J 2002;143:412-7, O Connor CM.J Card Fail 2005;11:200-5, Gustaffson F Eur Heart J 2004;25:129-35 Tng quan gia FEV1 v nguy c mc bnh TM 2.5 2.0 1.5 0.5 RR 1.0 0.0 109 % 96 % 88 % 80 % 63 % FEV1 NHANES 1; N=1,861 Sin et al, Chest 2005 COPD v bnh tim mch The Lung Health Study* St gim FEV1 mi 10% 30 % increase 20 10 14 All cause CV 28 20 Non-fatal mortality mortality Coronary event *Anthonisen NR, et al AJRCCM 2002;166:333-9 Nguy c mc bnh TM bn COPD * 80 70 C O P D ( N = 11,493) 60 54 *P 30kg/m2 Beta Gión c bng quang RECEPTOR S Gión ng t Kich hot Gim nhu ng Beta receptor rut Gim chuyn húa ng, ly gii m Gión c trn ph q u nh hng ca thuc iu tr COPD trờn bnh tim mch ng Nhanh nhp xoang Khụ ming (thng Lon nhp tht Run tay Khỏng cholinergic gp nht) Cú th lm nng thờm H ka li mỏu bnh glaucoma lit tuyn Gim nh PaO2 Triu chng ca tin R M1: Hin din ni R M2: Hin din cỏc si TK tin hch dn si TK hu hch, truyn n si TK hu phúng thớch Ach hch R M3: Hin din cỏc tb c trn PQ v tuyn di niờm mc Ruben D Restrepo.RespirCare2007;52(7) c ch ngc s AC AC AC AC Anticholinergic UPLIFT Thit k nghiờn cu iu tr mự ụi tun T cai thuc lỏ Tiotropium od + usual care N = 2986 Gi dc od + usual care N = 3006 Bt u Ngy 30 Ngy 1440 Tỏi khỏm sau mi thỏng Kt thỳc Ipratropium iu tr Ngy 1470 Usual care: mi thuc u c phộp dựng, tr khỏng cholinergic hit /30 ngy Nghiờn cu UFLIFT: T l t vong 20 Probability of death [%] Gim t l t vong 15 mi nguyờn nhõn 16% (p=0.016) 10 199 Gim t vong bnh tim mch Control (MI, stroke, suddi etrn icardiac) TT oo oopp uumm Control 124 vs Tio 98, rate ratio 0.73 175 , p 20mg/l nh hng ca thuc iu tr tim mch trờn bnh nhõn COPD C n th n tr ng s d ng c ỏ c thu c theophyllin, ng v n ng u ng, ng ti m v c SABA ng h t li u cao i v i b nh nh õ n COPD c ú k ố m bnh TM Cỏc thuc khỏng cholinergic ó c chng minh an ton v khụng lm gia tng cỏc bin c tim mch trờn bnh nhõn COPD nh hng ca thuc iu tr bnh tim mch trờn COPD Thuc c ch Thuc c ch men chuyn Thuc c ch thu th angiotensin Thuc c ch kờnh calci Thuc li tiu iu tr suy tim theo guidelines T t c b nh nh õ n suy tim r i lo n ch c n ng t õ m thu th t tr ỏ i v i m i phõn theo NYHA nờn u iu tr v i beta blocker b nh c ũ n n nh (ngoi tr cú chng ch nh vi bnh s hen suyn, block tim hoc huyt ỏp thp triu chng) Bisoprolol, carvedilol ho c nebivolol n n c chn la u tiờn i vi bnh nhõn suy tim m n r i lo n ch c n ng t õ m thu tht trỏi Hiu qu ca blocker iu tr COPD: kt qu hi cu Adjusted hazard ratios for all cause mortality among patients with COPD in reference to the control group (who received only inhaled therapy with short acting agonists or antimuscarinics) Short PM et al., 2011 Hiu qu ca blocker iu tr COPD: kt qu hi cu Kaplan-Meier estimate of probability of survival among patients with COPD by use of blockers eta -blocker lm gim t vong 22% (HR 0.78; 95% CI 0.67- 0.92) Short PM et al., 2011 BB, COPD v PT mch mỏu 1205 bn COPD, 462 iu tr vi BB trc PT mch vnh Van Gestel et al AJRCCM Khuynh hng iu tr suy tim vi blocker bn COPD v khụng COPD NMHawkinsetalEurJHeartFailure2010;12:17-24 D ự ng beta-blockers ch n l c tr n tim cho t t c b nh nh õn suy tim r i lon ch c n ng tõm thu tht trỏi, bao gm c: Ngi gi Bnh nh õ n c ú b nh m ch mỏ u ph i, b nh ph i mụ k , COPD (kh ụng h i ph c), tiu ng, r i lon cng ng Chuy n i sang nh ú m thu c beta blocker ch n l c tr n tim i v i nh ng b nh nh õ n suy tim n nh ang s d ng thu c beta blocker iu tr bnh khỏc Beta blocker iu tr COPD blocker chn lc: i lc trờn receptor gp 20 ln trờn receptor Tớnh chn lc gim s dng liu cao Khụng lm gim tỏc dng gión ph qun ca thuc ng Cha cú s liu y v hiu qu ca BB t cp COPD Camsari A.Heart vessels 2003;18:188-92 Beta blocker iu tr COPD COPD cú kốm bnh mch vnh hoc suy tim mn RLCNTT tht trỏi: Dựng c ch cú tớnh chon lc cao (carvedilol, metoprolol, bisoprolol) Khi u bng liu thp Cn trng bn cú mc tc nghn nng Khụng dựng nhng bnh nhõn cú liờn quan n hen COPD cú kốm cao huyt ỏp: Thuc c ch khg phi l thuc chn la u COPD v cỏc thuc tim mch khỏc Thuc c ch men chuyn: Thng gõy ho khan kộo di (3 20%), Cú th che giu hay ln ln vi cn ho co tht hoc cú th gõy cn khú th thiu oxy mỏu bn COPD nng Khụng l chng ch nh nhng khụng nờn l thuc chn la u i vi bn COPD cú kốm bnh TM COPD v cỏc thuc tim mch khỏc Thuc c ch thu th angiotensin: Khụng gõy ho nh thuc UCMC Cú ch nh iu tr bn COPD cú bnh tim mch i kốm, cú kốm ỏi thỏo ng v bnh lý thn Cú th lm gim IL qua ú lm gim viờm ton th COPD v cỏc thuc tim mch khỏc Thuc c ch kờnh calci: An ton v bn COPD, nht l nhúm dihydropyridine Cú t/dng i khỏng vi cn co tht c trn KPQ v tng hiu qu GPQ ca thuc ng Chn la u cho bn COPD cú kốm THA COPD v cỏc thuc tim mch khỏc Thuc li tiu: Lu ý nguy c h kali mỏu Thn trng bn COPD vỡ ng lm gim K+/ mỏu a K+ vo ni bo v GCS ton thõn lm tng bi tit K+ qua nc tiu bn COPD nng, lu ý nguy c kim chuyn húa h K+ mỏu lm thiu oxy mỏu nng thờm Nờn dựng thuc li tiu liu thp hoc phi hp vi cỏc li tiu gi kali KT LUN B nh tim m ch l b nh i k ốm th ng g p nh t bn COPD, t n su t c ú t ng quan thun vi nng ca bnh, cựng chia s YTNC h ỳ t thu c l ỏ v h u qu c a t ỡ nh trng viờm ton th. T m so ỏ t, nh n bi t s m, l ng gi ỏ v c ú bin phỏp x trớ thớch hp cỏc bnh tim mch, cõn nhc s tng tỏc gia nh hng ca thuc v cỏc biu hin bnh lý khỏc s bnh COPD gúp phn lm ci thin kt cc lõm sng ca XIN CM N S THEO DếI CA QUí NG NGHIP ... C u r k e n d a l Mi liờn quan COPD v suy tim l Suy tim COPD COPD suy tim S M , H ỳ t thu c l ỏ l m gia t ng 50% nguy c suy tim T n su t suy tim huy t cha phỏt hin bn COPD COPD chớnh... ph Phõn NYHA Cn lõm sng Xquang tim phi in tõm Siờu õm tim 2D Test gng sc BNP / NTproBNP COPD v suy tim trờn phim Xquang tim phi khớ phi lm gim ch s tim Phự phi khụng lng ngc i xng,... quan COPD v bnh tim mch Tn sut COPD chim 20-32% bnh nhõn suy tim huyt RR ca suy tim huyt 4.5 bnh nhõn COPD Nguyờn nhõn t vong ca bn COPD: Suy hụ hp t cp COPD 4-35% Do bnh tim mch: 25% Ung