Tài liệu COPD và bệnh tim mạch

COPD NH TIM M CH v B B M TS BS TH NG OANH TH T T BV PH M NG C TH CH PH NG TH nh ngh ngha COPD (GOLD 2006) 201 BPTNMT l m t c n b1 nh c ú COPD l mt bnh cú th phũng nga v th phũng nga v iu tr c kốm theo iu tr c, c c trng bi s gii mtthng s nhxuyờn hng ỏngkhớ kth ngoi hn lung tinphi trincú thv gúp phnkốm lmtheo nng tỡnhỏp trng dn thng sthờm gia tng caviờm ngi bnh ng mn tớnh ph qun v phi i vi Cỏc lon htri c v ti khớ phi c c c trng bi s cp giiCOPD hn lung khớbnh th lý khụng hi i kốm t v cỏc gúp phclm hon ton S thờm gii hn lung phn bnh nng i vi mikhớ cỏth ny thng tin trin dn v thng kốm nhõn ngi bnh theo mt ỏp ng viờm bt thng ca phi i vi cỏc ht c hoc khớ c COPD v b nh i k ốm v b kố Bnh nhõn COPD thng tng nguy c mc: Bnh tim mch Cỏc bnh lý i kốm ny Loóng xng cú th nh hng n t l t vong v nhp vin v Nhim trựng hụ hp nờn luụn c tm soỏt Lo õu v trm cm v iu tr thớch hp Tiu ng Ung th phi GOLD Strategy Document 2011 (http://www.goldcopd.org/) COPD v nguy c xut hin bin c y khoa 400 au tht ngc Rate per 10,000 300 200 Nhim trựng hụ hp Góy xng c TTT Viờm phi Loóng xng Tng nhón ỏp Nhi mỏu c tim Bm da 100 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 RF = respiratory failure PVD = pulmonary vascular disease TM = thoracic malignancy 35 30 25 25 COPD 22.5 22 No COPD 19 20 14 15 13 12 10 10 12 11 8.5 10 6.5 5 n I H o s p a t i M l o a r t y t i l a ( s % o d f s i c h a g r e s ) RF Pneumonia Heart Failure IHD Hypertension TM Diabetes PVD 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 B NH I K ẩM V B Kẩ BN COPD thng d xut hin cỏc bnh lý i kốm, thng gp l bnh tim mch, K phi, st cõn, loóng xng v tiu ng Tn sut cỏc bnh i kốm sai bit gia cỏc ngh cu, cỏch ỏnh giỏ, chn oỏn v phõn b dõn s ng cu khỏc T l xut hin cỏc bnh i kốm bn COPD tng cao cú YNTK so sỏnh vi nhúm chng cựng tui Marker vi ờm COPD viờ CRP Severe COPD TNF- COPD Severe RL PH N B C TH BCOPD PH B C TH NH TIM M CH M Moderate COPD Moderate COPD ấM VI VIấ Mild COPD Mild COPD O NG II TH TH NG X NG LO LO X NG Healthy Healthy N TI ấU H ểA RI LO LO TIấ Hể 10 20 30 40 50 60 70 Serum C-Reactive Protein (mg/L) 20 40 60 80 100 Serum TNF-Alpha (pg/mL) Reprinted from Pulm Pharmacol Ther, Vol 19, Franciosi LG, et al, Markers of disease severity in chronic obstructive pulmonary disease, pp 189-199, Copyright 2006, with permission from Elsevier ờm to quan ớch Vi Viờ ton th COPD: CCỏỏc cc t ng c Cn au th th ng ng vnh cc p Hi ch ch ựng ph m tr i Nhi Nhi trự ph Ung th ph i th ph St ccõõn vvõõn Yu cc Ti u ng Ti úa ng chuy n h Hi ch ch chuy hú ng Lo Loóóng xx ột d c d Lo Loộ d dy/ Tr Tro ng ng VI VIấấM N TH TO TO TH Stress Oxy h úa hú From W MacNee m cc m Tr Tr ờn quan COPD v b nh Mi li liờ v b tim m ch m 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, OConnor CM.J Card Fail 2005;11:200-5, Gustaffson F Eur Heart J 2004;25:129-35 a FEV1 v nguy Tng quan gi gi v c b nh TM c m m b 2.5 2.0 RR 1.5 1.0 0.5 0.0 109 % 96 % 88 % FEV1 80 % 63 % NHANES 1; N=1,861 Sin et al, Chest 2005 COPD v b nh tim m ch v b m The Lung Health Study Study** m FEV1 m i 10% St gi gi m % increase 30 20 10 14 All cause mortality 20 28 CV mortality Non-fatal Coronary event *Anthonisen NR, et al AJRCCM 2002;166:333-9 Nguy c m c b nh TM bn COPD c m b * 70.4 80 COPD (N=11,493) 70 60 50 * 40 31.3 * 30 22.8 * 21.1 20 11.7 11.2 10 P e 54 *P 30kg/m2 Beta RECEPTOR S Gión c bng quang Gión ng t Kich hot Beta receptor Gim nhu ng rut Gim chuyn húa ng, ly gii m Gión c trn ph qun ng c a thu c iu tr nh h h c thu tr COPD tr ờn b nh tim m ch trờ b m ng v n v Kh ỏng cholinergic Khỏ Nhanh nhp xoang Lon nhp tht Run tay H ka li mỏu Gim nh PaO2 Khụ ming (thng gp nht) Cú th lm nng thờm bnh glaucoma Triu chng ca tin lit tuyn R M1 n di n n i M1:: Hi Hi di n i TK ti n h cỏc ss ti hch d dn n n ss i TK h truy truy hu hch R M3 n di n ccỏỏc M3:: Hi Hi di tb cc tr n PQ vv tr n d i ni ờm m tuy d niờ mc Ruben D Restrepo Respir Care 2007;52(7) R M2 n di n M2:: Hi Hi di si TK h hu h hch, ng c ss c ch ch ng úng th ph phú thớớch Ach AC AC AC AC Anticholinergic t k nghi ờn c u UPLIFT Thi Thi k nghiờ c ự ụ i iu tr tr m mự tu n tu n cai T v v c llỏ ỏ thu thu Tiotropium od + usual care N = 2986 d c od + usual care Gi Gi d N = 3006 y 30 Ng Ng Bt u iu tr tr Tỏi khỏm sau mi thỏng ỳc Ipratropium Kt th thỳ y 1440 /30 ngy Ng Ng Ngy 1470 Usual care: m i thu c u c ph ộp d ựng, tr kh ỏng cholinergic hit m thu phộ dự tr khỏ ờn c u UFLIFT: T tt vong Nghi Nghiờ c T ll Probability of death [%] 20 m tt ll tt vong Gi Gi ờn nh õn 16% mi nguy nguyờ nhõ (p=0.016) 15 Control 199 10 Gim t vong bnh tim mch (MI, stroke, sudden cardiac) Tiotropium Control 124 vs 175, Tio 98, rate ratio 0.73 p 20mg/l ng c a thu c iu tr nh h h c thu tr tim m ch tr ờn b nh nh õn COPD m trờ b nhõ C n th n tr ng s d ng c ỏ c thu c theophyllin, ng v n ng u ng, ng tiờm v c SABA ng hớt liu cao i vi bnh nhõn COPD cú kốm 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 ng c a thu c iu tr nh h h c thu tr ch tr ờn COPD bnh tim m m trờ Thuc c ch Thuc c ch men chuyn Thuc c ch thu th angiotensin Thuc c ch kờnh calci Thuc li tiu iu tr tr suy tim theo guidelines b nh nh õ n suy tim rr i lo n Tt c c b nhõ lo c n ng ttõ õ m thu th t tr ỏi v i m i ch ch n th trỏ v m õ n theo NYHA n n kh i u i u ph phõ nờ kh i beta blocker b nh c ũn tr tr v v b cũ 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 ờn c chn la u tiờn i vi bnh nhõn suy tim mn ri lo n chc nng tõm thu tht trỏi u qu c a blocker iu Hi Hi qu c t qu h i c u tr tr COPD: k k qu h c 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 antimuscarinics) Short PM et al., 2011 u qu c a blocker iu tr Hi Hi qu c tr COPD: k t qu h i c u k qu h c 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 m ch m ỏu v m mỏ 1205 bn COPD, 462 iu tr vi BB trc PT mch vnh Van Gestel et al AJRCCM 2008 Khuynh h ng iu tr i h tr suy tim v v kh ụng COPD blocker bn COPD v v khụ NM Hawkins et al Eur J Heart Failure 2010;12:17-24 n ll c tr n tim cho tt t D ự ng beta-blockers ch ch trờ nh nh õ n suy tim rr i lo n ch c n ng c b b nhõ lo ch n t tr ỏi, bao g m c : tõm thu th th trỏ g c Ngi gi Bnh nhõn cú bnh mch mỏu phi, bnh phi mụ k, COPD (khụng hi phc), tiu ng, ri lon cng ng Chuy n i sang nh ú m thu c beta blocker n ll c tr n tim i v i nh ng b nh nh õn ch ch trờ v nh b nhõ suy tim n nh ang s d ng thu c beta nh kh ỏc blocker iu tr tr b b khỏ Beta blocker iu tr tr COPD n ll c: blocker ch ch 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 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 c ỏc thu c tim m ch kh ỏc v cỏ thu m khỏ 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 c ỏc thu c tim m ch kh ỏc v cỏ thu m khỏ 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 c ỏc thu c tim m ch kh ỏc v cỏ thu m khỏ 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 c ỏc thu c tim m ch kh ỏc v cỏ thu m khỏ 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 N KT LU LU Bnh tim mch l bnh i kốm thng gp nh t bn COPD, t n su t c ú t ng quan thun vi nng ca bnh, cựng chia s YTNC hỳt thuc lỏ v hu qu ca tỡnh trng viờm ton th. Tm soỏt, nhn bit sm, lng giỏ v cú 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 gúp phn lm ci thin kt cc lõm sng ca bnh COPD XIN C M N S THEO D ếI C A C S Dế C í NG NGHI P QU QUí NGHI ... COPD v suy tim Mi li liờ v Suy tim COPD COPD suy tim Hỳt thuc lỏ lm gia tng COPD chớnh l yu t tiờn 50% nguy c suy tim lng t l nhp vin, thi gian n m vi n v t l t T n su t suy tim huy... Mi li liờ v b tim m ch m 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%... ph mn hoc n SUY TIM suy thuyờn tc phitim T va - Hi chng vnh cp 90% PPV Chc chn suy tim T UCMC, li tiu 2D Doppler siờu õm tim n nh COPD & R i lo n nh R lo nhp tim RLNT tht v trờn tht khỏ ph bin