Đánh giá thực trạng tắc mạch ngoại vi ở bệnh nhân trên 65 tuổi có rung nhĩ không do bệnh van tim tại viện tim mạch việt nam

B GIO DC V O TO B Y T TRNG I HC Y H NI TRNH TH HOT ĐáNH GIá THựC TRạNG TắC MạCH NGOạI VI BệNH NHÂN TRÊN 65 TUổI Có RUNG NHĩ KHÔNG DO BệNH VAN TIM TạI VIệN TIM MạCH VIệT NAM Chuyờn ngnh : Tim mch Mó s : 60720140 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS INH TH THU HNG H NI 2015 LI CM N Xin by t lũng chõn thnh v bit n sõu sc ti: ng y Ban Giỏm hiu Trng i hc Y H Ni, Phũng o to sau i hc, B mụn ni Tim mch trng i hc Y H Ni, Ban giỏm c Bnh vin Bch Mai, Ban lónh o Vin Tim mch ó ht sc quan tõm, giỳp v to iu kin thun li cho em quỏ trỡnh hc v nghiờn cu Em xin c trõn trng cm n GS.TS Doón Li - ch nhim b mụn Tim mch, Vin trng Vin tim mch Vit Nam - ngi thy tụn kớnh luụn to mi iu kin, khuyn khớch, ng viờn chỳng em hc v hon thin bn thõn Xin t lũng bit n sõu sc ti cụ PGS.TS inh Th Thu Hng l ngi cụ trc tip dỡu dt, hng dn, giỳp em sut quỏ trỡnh hc v hon thnh lun Em xin chõn thnh cm n cỏc thy cụ giỏo b mụn Tim mch, nhng ngi thy ỏng kớnh ó dy d v giỳp em hai nm qua Em xin cm n cỏc cụ chỳ, anh ch bỏc s, iu dng, h lý v nhõn viờn ca Vin Tim mch ó to mi iu kin thun li cho em sut quỏ trỡnh hc ti vin Xin chõn thnh cm n Ban lónh o v ng nghip ni em cụng tỏc ó to iu kin cho em cú thi gian hc tt nht Cui cựng em xin by t tỡnh yờu v s bit n ti gia ỡnh luụn l hu phng vng chc em yờn tõm hc v cụng tỏc H Ni, ngy 02 thỏng 11 nm 2015 Trnh Th Hot LI CAM OAN Tụi l Trnh Th Hot, hc viờn cao hc XXII Trng i hc Y H Ni, Chuyờn ngnh Tim mch, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca PGS TS inh Th Thu Hng 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 s xỏc nhn v chp thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 02 thỏng 11 nm 2015 Tỏc gi Trnh Th Hot DANH MC CH VIT TT ACC AHA BMI BN CHA2DS2VASc CHADS2 CRP Dd K MC KNT KTP MV Ds T ECG EF ERHA ESC HA HAS-BLED HDL-C INR LDL-C NOAC NYHA : 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 : Bnh nhõn : 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) : C-reactive protein- protein C : ng kớnh tht trỏi tõm trng : ng kớnh ng mch ch : ng kớnh nh trỏi : ng kớnh tht phi : ng mch vnh : ng kớnh tht trỏi tõm thu : ỏi thỏo ng : Electrocardiogram - in tõm : Phõn sut tng mỏu tht trỏi : Emory Reproductive Health Association- Hi Nhp Tim chõu u :European Society of Cardiology - Hi Tim mch chõu u : Huyt ỏp : H (Hypertension- Tng huyt ỏp), A (ABNormal - Chc nng gan, thn bt thng), S (Stroke t qu), B (Bleeding- Chy mỏu), L (Labile INR- INR khụng n nh), E (Elderly- Tui gi > 65 tui), D (Drug Thuc hoc ru) : High density lipoprotein (Lipoprotein cú t trng cao) : International normalized ratio - t s gia t l prothrombin ca bnh trờn t l prothrombin chng ó c chun húa quc t : Low density lipoprotein (Lipoprotein cú t trng thp) : Thuc chng ụng ng ung thờ h mi : New York Heart Association-Phõn khú th theo hihi Tim OR(CI 95%) PTNC RN THA TIA TMP TNT ` VKA WHO X SD YTNC mch New York : T sut chờnh, khong tin cy 95% : Phõn tng nguy c : Rung nh : Tng huyt ỏp : Transient Ischemic Attack-Thiu mỏu nóo thoỏng qua : Tnh mch phi : Tiu nh trỏi : Khỏng vitamin K : World Health Organization-T chc Y t Th Gii : Trung bỡnh lch chun : Yu t nguy c MC LC T VN CHNG TNG QUAN 1.1 Cu to c tim v h thng dn truyn 1.1.1 Cu to c tim [14], [15], [16] 1.1.2 in sinh lý hc c tim [15], [16], [17], [18] .5 1.2 nh ngha rung nh 1.3 Cỏc gi thit v c ch hỡnh thnh v trỡ rung nh 1.3.1.Thuyt vũng vo li (multiple wavelet re-entry) 1.3.2 Gi thuyt v cú t ng tớnh (Automatic Focus Theory) 10 1.3.3 Gi thuyt a súng nh (Mutiple wavelet Hypothesis) 11 1.3.4 Cỏc yu t khỏc úng gúp vo hỡnh thnh rung nh .12 1.4 Nhng thay i sinh lý bnh dn n rung nh .13 1.4.1 Nhng thay i sinh lý bnh rung nh gõy .14 1.5 c im lõm sng v cn lõm sng ca rung nh 15 1.5.1 Cỏc yu t lm tng nguy c ca rung nh [1], [6], [35] 15 1.5.2 Cỏc bin c tim mch rung nh [1], [43] .20 1.6 Tc mch huyt rung nh 21 1.6.1 nh ngha tc ng mch ngoi vi 21 1.6.2 Sinh bnh hc 22 1.6.3 Cỏc yu t nguy c tc mch v cỏc thang im ỏnh giỏ .23 1.7 iu tr rung nh 26 1.7.1 iu tr kim soỏt tn s tht 27 1.7.2 Chuyn rung nh v nhp xoang .27 1.7.3 Cỏc phng phỏp iu tr khụng dựng thuc 27 1.7.4 iu tr chng ụng 28 CHNG 30 I TNG V PHNG PHP NGHIấN CU .31 2.1 i tng nghiờn cu .31 2.1.1 Tiờu chun chn bnh nhõn 31 2.1.2 Tiờu chun loi tr 31 2.1.3 Tiờu chun chn oỏn rung nh .31 2.1.4 Tiờu chun chn oỏn tc ng mch ngoi biờn 31 2.2 Phng phỏp nghiờn cu .32 2.2.1 Thit k nghiờn cu 32 2.2.2 Cỏc bc tin hnh 32 2.3 X lý s liu nghiờn cu 37 2.4 S cỏc bc tin hnh nghiờn cu 38 CHNG 38 KT QU NGHIấN CU 38 3.1 Tỡnh hỡnh chung ca bnh nhõn nghiờn cu 39 3.1.1 Phõn b theo nhúm tui 39 3.1.2 Phõn b theo gii tớnh .40 3.1.3 Phõn b tui theo gii tớnh 40 3.1.4 Phõn BMI 41 3.1.5 Cỏc bnh lý phi hp .41 3.1.6 Triu chng phõn loi rung nh .42 3.1.7 Mt s c im xột nghim sinh húa mỏu c bn .44 3.1.8 Mt s c im siờu õm tim 46 3.1.9 Bnh lý mch mỏu da trờn siờu õm mch, chp MSCT mch mỏu, chp mch vnh .46 3.1.10 iu tr chng ụng trc vo vin 46 3.1.11 Tỡnh trng bnh nhõn vin 47 3.2 Cỏc kt qu v yu t nguy c tc mch 47 3.2.1 Cỏc kt qu v yu t nguy c tc mch ca thang im CHADS2 v CHA2DS2-VASc 48 3.2.2 im v phõn tng nguy c theo thang im CHADS2 v CHA2DS2-VASc 48 3.3 Liờn quan gia bin c tc mch huyt vi thang im CHADS2 v CHA2DS2-VASc 50 3.3.1 T l tc mch 50 3.3.2 Phõn b v trớ tcmch huyt 51 3.3.3 T l tc mch tng phõn loi rung nh .51 3.3.4 Mi liờn quan tc mch v yu t nguy c .52 CHNG 58 BN LUN 59 4.1 c im chung 59 4.1.1.Phõn b theo tui .59 4.1.2 Phõn b theo gii tớnh 59 4.1.3 Phõn b tui theo gii tớnh 60 4.1.4 Phõn BMI 60 4.1.5 Bnh lý phi hp bnh nhõn rung nh 60 4.1.6 Cỏc triu chng lõm sng ca bnh nhõn rung nh 64 4.1.7 Tỡnh hỡnh ung thuc chng ụng trc vo vin 65 4.1.8 Tỡnh hỡnh bnh nhõn vin 65 4.2 Cỏc yu t nguy c tc mch theo thang im CHA2 DS2-VASc 66 4.3 Liờn quan gia tc mch v cỏc yu t nguy c thuc thang im CHADS2 v CHA2DS2-VASc 72 4.3.1 Liờn quan gia tc mch v gii tớnh 73 4.3.2 Liờn quan gia tc mch v tui .73 4.3.3 Liờn quan gia tc mch v phõn loi rung nh 74 4.3.4 Liờn quan gia tc mch v suy tim 74 4.3.5 Liờn quan tc mch v THA .76 4.3.6 Liờn quan tc mch v ỏi thỏo ng 77 4.3.7 Liờn quan tc mch vi tin s t qu hoc TIA 77 4.3.8 Liờn quan tc mch v bnh mch mỏu 78 4.3.9 Liờn quan gia thang im CHADS2, CHA2DS2-VASs v tc mch 78 CHADS2 v CHA2DS2-VASc cho thy cú giỏ tr tiờn lng t qu Trong nghiờn cu ca chỳng tụi CHADS2 im cú nguy c t qu OR= 14,65 (CI 95% l 6,36-34,17) Khi CHA2DS2-VASc im cú nguy c t qu OR= 9,57 (CI 95% l 4,64- 21,8) (Bng 3.23) .79 KT LUN 80 KIN NGH 80 TI LIU THAM KHO PH LC DANH MC BNG Bng 1.1 Cht nn gii phu v in sinh lý to phỏt v/ hoc trỡ rung nh 11 Bng 1.2 Phõn loi cỏc triu chng liờn quan rung nh 19 Bng 1.3 Thang im CHADS2 v CHA2DS2-VASc 24 Bng 1.4 im CHADS2 v t l t qu/nm [59] .25 Bng 1.5 im CHA2DS2-VASc v t l t qu/nm [60] 25 Bng 1.6 Phng phỏp d phũng huyt bnh nhõn rung nh 29 Bng 2.1 Tiờu chun chn oỏn suy tim (tiờu chun Framimgham) .35 Bng 2.2 Phõn loi THA theo JNC VII .35 Bng 3.1 Phõn b nhúm tui theo phõn tng nguy c ca thang im CHADS2 v CHA2DS2-VASc 39 Bng 3.2 Phõn b tui theo gii tớnh 40 Bng 3.3 Phõn BMI .41 Bng 3.4 Cỏc bnh lý phi hp 41 Bng 3.5 Phõn loi rung nh 44 Bng 3.6 Xột nghim sinh húa mỏu 44 Bng 3.7 Xột nghim Lipid mỏu 45 Bng 3.8 Mt s c im siờu õm tim .46 Bng 3.9 Bnh lý mch mỏu 46 Bng 3.10 Cỏc yu t nguy c 48 Bng 3.11 Phõn tng nguy c theo thang im CHADS2, CHA2DS2VASc 48 Bng 3.12 Bng i chiu im CHADS2 v CHA2DS2-VASc 49 Bng 3.13 Liờn quan gia tc mch v gii tớnh .52 Bng 3.14 Liờn 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al.(2009), The Registry of the German Competence NET work on Atrial Fibrillation: patient characteristics and initial management, Europace,11(4), 423-434 MU BNH N NGHIấN CU S th t bnh ỏn: Hnh chớnh: - H tờn bnh nhõn:.tui.gii - a ch:in thoi - Ngh nghip: - Mó s bnh ỏn: - Ngy VV.Ngy RV - Ni vin: n nh vin Nng xin v T vong Chuyn tuyn chuyờn khoa 2.Tin s: - Cỏc bnh nhim trựng - Cỏc bnh ung th - Bnh lý ni tit: ỏi thỏo ng Bnh tuyn giỏp - Sau phu thut - S dng cỏc cht kớch thớch hoc thuc - Bnh lý phi(COPD hoc ngng th ng) - Bnh lý thn - Bnh tim mch +THA +Bnh mch mỏu +t qu hoc TIA +Suy tim hoc EF 40% +Bnh van tim +Bnh tim mch khỏc - Hỳt thuc lỏ(bao nm) 3.Triu chng lõm sng Rung nh Hi hp ỏnh trng ngc Khú th Mc NYHA au ngc Choỏng ngt Triu chng khỏc Khụng cú triu chng Phõn loi theoERHA ERHA I ERHAII ERHA III ERHA IV Thi gian b RN (nm) Loi RN 1.Cn RN chn oỏn ln u tiờn 2.RN kch phỏt 3.RN bn b 4.RN dai dng kộo di 5.RN vnh vin 4.Thc th Ton trng Cõn nng Chiu cao BMI Khỏm tim mch: Tn s tim Nghe ting tim MHA Khỏm h mch mỏu Khỏm h thn kinh Khỏm h tiờu húa Khỏm h c xng khp C quan khỏc 5.Cn lõm sng: 5.1 Cụng thc mỏu Ngy Ch s Hng cu(T/l) Hematocrit Hemoglobin(g/l) Bch cu(G/l) Trung tớnh(%) Tiu cu(G/l) 5.2 ụng mỏu c bn: Ngy Ch s PT% INR Trc vv Ngy vv Ra vin 5.3 Sinh húa mỏu: Ngy Ch s Ure Creatinin Ngy vv Ra vin Glucose HbA1c GOT GPT Na K Ca CK CK-MB Cholesterol HDL-C LDL-C Triglycerid ProBNP CRPhs ProCancitonin Troponin T 5.4 in tim:+Trc: +Tn s:súng f .QRS +Du hiu: Dy nh phi nh trỏi tht phi tht trỏi +Du hiu khỏc: 5.5 Holter T 5.6 XQ tim phi: 5.7 Siờu õm mch Mch cnh:Trỏi Phi Mch thn: Trỏi Phi Mch chi trờn: Trỏi Phi Mch chi di: Trỏi Phi Khỏc 5.8 Siờu õm tim ng kớnh cỏc bung tim Nh trỏi(mm) Nh phi(mm) Tht trỏi Dd(mm) Ds(mm) Tht phi(mm) EF(%) Huyt bung tim Tỡnh trng van tim Gim ng vựng Bt thng khỏc 5.9 Siờu õm tim qua thc qun 5.10 Chp MSCT h mch:v trớ tc mch Mch cnh Mch chi trờn Mch chi di Mch thn Mch ch bng Mch chu Mch chi di 5.11 Chp mch vnh 5.12 Cn lõm sng khỏc iu tr d phũng huyt trc vo Vin Tim mch Vit Nam - Khụng - Cú CNTTC (liu) VAK(liu) PT% .INR 7.im CHADS2 im CHA2DS2-VASc BNG CHA2DS2-VASc CHA2DS2-VASc im C: Suy tim/RLCN tht trỏi H: Tng huyt ỏp A: Tui 75 D: ỏi thỏo ng S: t qu/TIA V: Bnh mch mỏu A: Tui 65-74 S: gii tớnh n BNG IM CHADS2 CHADS2 im C: Suy tim/RLCN tht trỏi H: Tng huyt ỏp A: Tui 75 D: ỏi thỏo ng S: t qu/TIA 3,6,9,13,20,26,40,42,43,47,50,51,57 1,2,4,5,7,8,10-12,14-19,21-25,27-39,41,44-46,48,49,52-56,58- ... rung nhĩ không bệnh van tim Vi n Tim mạch Vi t Nam" , nhằm hai mục tiêu sau: Phân tầng nguy tắc mạch bệnh nhân 65 tuổi có rung nhĩ không bệnh van tim điều trị Vi n Tim mạch Vi t Nam theo thang... sỹ đánh giá mức độ nguy tắc mạch bệnh nhân RN lựa chọn phương thức điều trị chống đông thích hợp Chúng tiến hành đề tài: "Đánh giá thực trạng tắc mạch ngoại vi bệnh nhân 65 tuổi có rung nhĩ không. .. liên quan tắc mạch ngoại vi bệnh nhân 65 tuổi có rung nhĩ không bệnh van tim với yếu tố nguy 3 CHƯƠNG TỔNG QUAN 1.1 Cấu tạo tim hệ thống dẫn truyền 1.1.1 Cấu tạo tim [14], [15], [16] Cơ tim gồm