164637110-Benh-ly-hoc

AI HOC HU

TRNG AI HOC Y KHOA

B MN NI

BNH LY HOC NI

KHOA

Hu - 2008

LI NI U

Thc hin ch trng ca i hc Hu, c s nht tr ca Ban Gim Hiu Trng i hc Y khoa Hu, B Mn Ni tin hnh ph bin gio trnh in t Y khoa ln u tin. y l mt phng tin thng tin ph bin nht v thch hp cho cc i tng sinh vin, hc vin khp mi ni c th tham kho cc bi ging ni khoa. y cc bi ging c chn lc, tp trung vo mt s ni dung c bn nht. Mt s hnh nh v s ca bi ging do s khng c a vo. Qu c gi c th lin h tham kho cc phn chi tit tp gio trnh hon chnh ca B Mn Ni hoc vi cc trng phn mn lin h.

Chng ti cng xin lu vic sao chp mt phn hoc ton b tp bi ging ny ngoi mc ch hc tp cn c s ng ca n v ch qun hoc tc gi.

Chn thnh cm n s quan tm v hp tc cng nh rt mong s gp ph bnh ca qu c gi .

TM. Ban ch nhim B Mn Ni kim Ch bin PGS.TS. Hunh vn Minh [email protected]

[email protected]

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CHNG I

TIM MCH

THP TIM Mc tiu 1. Nm c cc du chng lm sng v cn lm sng ca thp tim. 2. Vn dng chn on v iu tr thp tim. 3. Nm c tm quan trng ca phng thp s cp v th cp. Ni dung I. I CNG 1. Thp tim: l mt bnh vim nhim ton th, biu hin nhiu c quan m ch yu l khp v tim, bnh c nhng c im sau: - L hu qu chm ca vim ng h hp trn do liu cu tan huyt nhm A. - Xut hin thnh tng t cch nhau hng thng, hng nm c khi c chc nm. - C ch sinh bnh nghing v t min. - Thng tn van tim c th mn tnh, tin trin a n suy tim. - Phng bnh thng hiu qu. 2. Dch t hc - Tui tr: 5 -15 tui. - Ma lnh m lm d vim hng. - Sinh hot vt cht: bnh thng gp cc nc chm pht trin, c iu kin sng thp. - Bnh xy ra sau vim hng do lin cu, hoc nhim lin cu nhng khng c triu chng, bnh d ti pht nht l bnh nhn thp tim c. II. BNH NGUYN, C CH SINH BNH 1. Bnh nguyn Lin cu tan huyt nhm A l vi trng gy bnh do hin tng qu mn sau nhim lin cu. Nu cn c vo phn loi theo Protein M th c khong 60 type khc nhau, lin cu gy vim hng thuc type 1, 2, 4, 12. T l mc bnh khong 30%. 2. C ch sinh bnh - Cha r, nghing v t min. C s tng t gia khng nguyn ca lin cu v khng nguyn tim (mang khng th chng liu cu v tim, protein M, khng nguyn glycoprotein c bit ging protein ca van tim). - Khng th (KT) c hiu: Khng th chng tim, chng t bo no, KT chng Glycoprotein, Antistreptolysin O. Cc khng th ny tng t tun th 1 n tun th 4 ca bnh. - C a di truyn: D mc bnh, c nguy c ti pht ko di sut i. III. GII PHU BNH Thng tn tin trin 1. Giai on u: Gy ph m lin kt, thm nhim t bo thoi ha dng fibrin, c th hoi t (c tim). 2. Giai on sau - C ht Aschoff nm gn mch mu, ht ny c cu to:

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Ht Aschoff trong c tim: T bo c tim ln, nhiu nhn, c mt s t bo c nhiu ht nhn

+ Trung tm l mt vng hoi t dng fibrin, sau n mt vng t bo dng biu m vi nhng t bo khng l nhiu nhn ngoi cng l t bo a dng nht l lympho v tng bo. + Nhng nt ny tn ti nht l mng trong tim gy ra cc nt so van tim v ct c ca van tim.

-Thng tn tim: c th c 3 lp cu to tim v m lin kt. - Mng trong tim: Thng tn van hai l 40%. Van 2 l kt hp van ng mch ch 40%. Van ng mch ch n thun 10-15%. Van dy x cng cun li gy h, van dnh cc mp li gy hp. - C tim: Gin cc si c tim, vim x, thm nhim t bo a nhn dng Aschoff. - Mng ngoi tim: Tn thng c hnh thi si khng c hiu hay phn ng vim dng fibrin v thng c dch mu vng khong 50-200ml, c khi mu , c. - Tn thng m lin kt: Vim thoi ha dng fibrin. + Tn thng khp: tit dch fibrin, v trng, khng n mn mt khp. + Thng tn no: Gp th vn gy ma git. + Thng tn da: l cc ht Meynet cn gi l ht Aschoff ngoi da. IV. TRIU CHNG HC 1. Lm sng: Thay i nhiu ty c quan b tn thng v trm trng. 1.1. Khi pht - St cao t ngt du nhim c nu biu hin vim khp l chnh. - St t t, st nh khng r nu vim tim l chnh. 1.2. Khp: in hnh l vim cc khp ln l chnh vi sng - nng - - au hn ch c ng, di chuyn hi phc nhanh chng trong vng 2 - 3 tun, nht l khi c iu tr, khi hon ton khng li di chng khp, cc khp thng gp l: khp vai, khp gi, khuu, c tay, c chn, c khi khng vim khp in hnh, mt s trng hp khng c biu hin khp. 1.3. Tim: Vim tim l biu hin nng nht ca thp tim, l biu hin duy nht c li thng tn quan trng vnh vin v gy t vong. C th gy vim c 3 lp cu to ca tim: - Vim mng ngoi tim

+ au vng trc tim. + C khi nghe c ting c mng ngoi tim. - Vim c tim + Ting tim m + Suy tim: nhp tim nhanh, ting nga phi, ngoi tm thu, cng c khi nhp tim rt chm, lon nhp. Bloc nh tht cc cp. - Vim mng trong tim: Hay gp l cc ting thi tm thu mm do h van 2 l v hoc ting thi tm trng y tim do h van MC. 1.4. Nhng biu hin khc

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- Thn kinh: + Ma git: l nhng c ng khng t , nhanh bin ln chi, c, mt. Trng lc c gim, xut hin mun v thng gp n. + Vim no v vim dy thn kinh cng c th gp. - Ngoi da

+ Nt di da (ht Meynet) ng knh vi milimt n 1cm thng thy mt dui ca cc khp ln, mt chc, khng au, du hiu vim thng xut hin mun.

Hnh nh ht di da (hnh 1) v ban vng (hnh 2, 3)

+ Ban vng: vng cung khng thm nhim, thay i nhanh, gp thn v gc chi. - Thn: Vim thn tng : c protein niu nh, huyt niu vi th. Cng c khi gp vim cu thn cp lan ta. - Phi v mng phi: Trn dch mng phi, ph phi xung huyt mt hay hai bn. - Bng: au bng c khi nhm vi rut tha vim. 2. Cn lm sng 2.1. Biu hin phn ng vim cp trong mu - VS tng cao thng >100 mm trong gi u. - Bch cu tng 10.000 - 15.000/mm3 ch yu a nhn trung tnh. - Fibrinogen tng: 6 - 8 g/l; Tng (alpha 2 v gamma Globulin). - Creactive Protein (CRP) dng tnh. 2.2. Biu hin nhim lin cu - Cy dch hng tm lin cu: Thng dng tnh, ngoi t vim ch 10 % dng tnh.

- Khng th khng lin cu tng trong mu > 500 n v Todd/ml. - Antistreptokinase tng gp 6 ln bnh thng. 2.3. in tim: Ri lon dn truyn nh tht, PR ko di. C cc ri lon nhp: Ngoi tm thu, bloc nh tht cc cp. 2.4. X quang: Bng tim c th bnh thng hoc ln hn bnh thng, nu vim c tim thy du tr tun hon phi, bng tim ln.

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Hnh nh XQ tim ca bnh nhn 8 tui b vim c tim do thp tim (trc v sau iu tr)

V. TIN TRIN V BIN CHNG 1.Th thng thng: Lm sng ci thin rt nhanh. - Triu chng khp gim sau 24-48h, PR cn ko di sau vi ngy, VS cn tng sau 2 - 3 tun. - Tt c cc triu chng thng mt sau 2 thng. 2. Th nng - Thp tim c tnh + Gp tr nh < 7 tui. + Vim tim ton b c bit l vim c tim cp hoc no, thn, phi. + St kn o, au khp t. + iu tr t kt qu. - Th tin trin + Tin trin chm hn. + C s ni tip cc t cp v t lui bnh. + Lun b di chng trm trng tim (van tim). 3. Th di chng: Thng mng trong tim: - Van hai l: Tn thng nhiu nht gy h hp van 2 l sau 2 nm. - Van ng mch ch: Hp h van ng mch ch, h MC n thun cn hp th him. - Van 3 l: rt him gp, thng kt hp vi cc van khc. 4. Vim mng trong tim nhim khun: bin chng nng, Osler hay gp h cc van hn l hp. 5. Ti pht: Hay gp bnh nhn khng d phng thp tim tt. VI. CHN ON 1. Chn on xc nh: Kh khn trong t thp u tin, da vo cc tiu chun ca Jones. 1.1. Tiu chun chnh - Vim tim.

- Ban vng.

- Vim khp. - Nt di da. - Ma git. 1.2. Tiu chun ph - St - au khp - PR ko di

- VS tng, bch cu tng, C Reative Protein-CRP (+) - Tin s thp hay b bnh tim sau nhim lin cu. 1.3.Tiu chun mi b nhim liu cu

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- Tng dn nng khng th khng lin cu. - Va b bnh tinh hng nhit (Scarlatine). Khi chn on thp tim phi c 2 tiu chun chnh, hoc 1 tiu chun chnh + 2 tiu chun ph v mi b nhim lin cu. 1.4. Siu m Doppler tim

- Siu m 2 bnh din v M-Mode c th thy trn dch mng tim, cc bin i cc van tim, mc ri lon chc nng tim v tng p phi. - Siu m Doppler v Doppler mu: Pht hin h van 2 l, van MC, cho php nh gi mc h.

H van 2 l trn Doppler mu, van 2 l dy ng khng kht trn 2D

H van ng mch ch trn Doppler mu 2D v ph i tht tri trn siu m 2D

Hp van 2 l trn Doppler mu 2D, trn Doppler lin tc (o din tch van 2 l-MVA=1,2cm2)

v hp van 2 l trn siu m 2D 2. Chn on phn bit 2.1. Vim a khp dng thp: Vim nhiu khp nh, bin dng khp, teo c, cng khp bui sng, tin trin ko di. 2.2. Vim khp do lu cu: Vim thng mt khp, thng khp gi, dch khp c vi khun. 2.3. Lao khp: Thng trn c th suy kit, st dai dng, thng sau lao phi, khp thng gp: khp hng, ct sng lng. 2.4. Lupus ban : Ban hnh cnh bm ngoi da, bin i mu da, au nhiu khp, thng tn thn nng, tn thng mng phi, bng v nhiu c quan.

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2.5. Vim mng ngoi tim, c tim do virus: Bnh tin trin rm r, cp tnh, st cao, c mng ngoi tim, ri lon nhp tim, ri lon dnc truyn c bit l blc nh tht hon ton, c th t vong, i vi th thng thng thng khi hon ton khng li di chng. VII. TIN LNG: Ph thuc vo tn thng tim. - Nu khng tn thng tim trong t u hoc vim tim nhng tim khng to, chn on v iu tr sm, d phng y , khng ti pht th tin lng tt, 90% phng c bin chng tim.

- Nu tn thng tim t u khng d phng y theo phc th tin lng xu i nhiu. - Theo Fridberg v Jones: 10 - 20% bnh sau t thp tim u s tr thnh tr tn ph. T vong sau 2 - 6 nm. - S cn li sng n tui trng thnh: - 65% bnh nhn sinh hat bnh thng. - 25 % sng sc khe gim st nhiu v l gnh nng cho gia nh v x hi. VIII. KT LUN - L bnh gp ngi tr, nguyn nhn do lin cu. - Bnh cnh a dng. - Chn on ban u kh, khi chn on c th tim b tn thng. - Din bin kh lng, d phng sut i ni ln tm quan trng ca thp tim tc ng ln tim c bit l bung tim tri.

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BNH HP VAN HAI L

Mc tiu 1. Nm vng cc triu chng lm sng v cn lm sng ca bnh hp van hai l. 2. Nm c cc th lm sng ca bnh hp van hai l. 3.Nm vng cc phng tin iu tr ni khoa bnh hp van hai l. 4. Nm vng ch nh iu tr ni khoa, iu tr ngoi khoa v phng nga cc bin chng Ni dung I. I CNG Hp van hai l l mt bnh van tim mc phi kh ph bin nc ta, chim khong 40,3% cc bnh tim mc phi. Bnh c pht sinh loi ngi t khi bt u sng thnh tng qun th do iu kin sinh sng thp km, cht chi thiu v sinh d gy ly nhim bnh. T 1887 Bouillaud ri Sokolski m t v bnh. n 1920 Duckett Jones (Hoa k) nghin cu bnh ny v n 1944 ng mi cng b by tiu chun chn on bnh. Cng vo nhng nm ny Cutter v Levine Phillipe (Hoa k) tm cch phu thut hp van hai l, ti Anh Souttar cng m c hp van hai l. Giai on ny bnh hp van hai l l bnh tim mch ph bin nht, gy tn ph v t vong nhiu. T nm 1944 vic pht minh ra Penixillin dit cc loi lin cu v c bit to ra loi Penixillin chm (Benzathyl Penixillin) c tc dng phng nga bnh ny do n nay cc nc pht trin nh Thy in, H lan v c bnh thp tim gn nh mt hn. Tuy vy, cc nc chm pht trin bnh ny cn ang ph bin. Bnh hay gp tui lao ng 20 - 30 tui, t l bnh hp hai l rt cao khong 60 - 70 %, t l t vong n 5%. Bnh c nhiu bin chng phc tp v a n tn ph v t vong. Bnh gp n nhiu hn nam (2/1) v nng thn mc nhiu hn thnh th. II. BNH NGUYN V C CH SINH BNH Tu theo tui, ch yu do thp tim (99%) i vi tui tr, mt s nguyn nhn khc nh bm sinh, Carcinoid c tnh, lupus ban h thng, vim khp dng thp c nhng nghin cu cn cho l do virus Coxsackie gy ra. Tc nhn gy bnh ch yu l do lin cu khun tan huyt nhm A gy vim hng v gy tn thng tim. S d lin cu hng gy bnh thp tim m khng vo cc c quan khc l do i qua bch mch gia hng v tim. Cu trc bo thai hc cng cho thy c ng ni mch mu v thn kinh gia tim v c. Nm 1976 Taranta (Hoa k) chng minh c c ch bnh sinh trc tip ca c t lin cu khun ln tim. Cc khng th khng tim xut hin bnh nhn thp tim c vim tim, c c cc phn ng khng nguyn cho gia cc cu trc tim v lin cu nhm A. C ch sinh bnh c th c ghi nhn nh sau: - Lin cu khun nhm A xm nhp vo c th gy vim hng ng thi sinh ra nhng c t. Ngoi ra, trong m tim, ngi ta cng tm thy nhng cht c cu trc min dch ging protein M v vy cc khng th hnh thnh cng chng lun li cc van tim. - Hin tng t min cho nhm ln gy vim tim v vim khp. Vim tim c th t khi nhng sau 2 nm n c th li di chng van tim, c 3 bnh nhn th c 1 bnh nhn b di chng van tim nh dy dnh x gy hp h van tim. III. TRIU CHNG HC 1. Lm sng

1.1. Ton thn: Nu mc bnh trc tui dy th, bnh nhn km pht trin th cht gi l ln hai l (nanisme mitral). Nu xy ra sau tui dy th tr pht trin gn nh bnh thng. 1.2. C nng - C khi pht hin tnh c bi khm sc khe hng lot mc d bnh nhn khng c triu chng c nng no ngay c khi gng sc. - C khi bnh nhn i khm v kh th, ho v khc ra mu, hi hp nh trng ngc, nut nghn do tm nh tri ln chn p vo thc qun nht l khi gng sc.

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1.3. Du chng thc th: Nghe tim l ch yu, bnh nhn nm nghing tri, c th nghe khi nm nga, hoc c khi phi bnh nhn lm ng tc gng sc. Hp van hai l in hnh thng nghe c cc du chng sau tu theo tn thng van, bnh l phi hp hay bin chng ca hp van 2 l: - Ting T1 anh mm (do van x dy p vo nhau). - Rung tm trng (RTTr) mm do van hp lung mu b tng mnh xung tht tri va vo cc ct c v cu c tht tri b vim dy x cng, vi ha hoc RTTr mt khi van hp rt kht, van v t chc di van dy, vi ha, dnh vi nhau. - T2 mnh y tim do tng p lc ng mch phi van MC v MP ng khng cng lc to nn T2 tch i (van MP ng mun hn van MC). - Ting thi tin tm thu gia tim hay mm do lung mu i qua ch hp mu cn li nh tri, nh tri bp y mu xung tht tri; nhng khi b rung nh hay nh tri gin th khng cn nghe ting thi tin tm thu na. - Ting clc m van hai l mm hoc trong mm. Ting ny ch c khi van cn mm. - Khi p lc ng mch phi tng cao tht phi gin nhiu lm gin vng van MP gy ra ting thi tm trng van MP gi l ting thi Graham - Steel. Cng c nhng trng hp hp van hai l khi khm bnh khng nghe c g m nh cc bin chng (suy tim phi, rung nh, tc mch) v nh cn lm sng nht l siu m tim gi l hp van hai l cm. 2. Cn lm sng 2.1. in quang: C 2 t th thm d trong hp van 2 l: - T th thng: + Bn phi: Tm nh tri to ln sang pha phi thng c 3 giai on. Giai on 1: Nh tri to to thnh 2 cung song song vi b trong l nh tri, b ngoi l nh phi. Giai on 2: Nh tri to ln ra ct cung nh phi, to thnh hai cung ct nhau. Giai on 3: Nh tri to ln ra ngoi to thnh 2 cung song song m cung ngoi l nh tri v cung trong l nh phi (ngc vi giai on 1). + Bn tri: c 4 cung ln lt l cung MC, cung MP, cung tiu nh tri, cung di tri vi mm tim hch ln (tht phi ln). Rn phi: m, to nn 2 bn bng tim hai khong m rng v ranh gii khng r. Hai ph trng m do huyt, c th thy c ng Kerley B. Nu khi c tnh trng tng p lc MP ch ng th thy vng rn phi m v vng ra phi rt sng. - Trn phim nghing c ung bart: thc qun b chn p 1/3 gia. Mt khong sng trc tim hoc sau xng c (tht phi ln).

Hnh nh XQ tim phi thng: Bn tri c hnh nh 4 cung, bn phi c hnh nh 3 cung; trn phim nghing c barit nh tri chn thc qun 1/3 gia 2.2. in tm

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- Giai on u cha hp kht hoc cha nh hng nhiu trn cc khoang tim: in tim cn bnh thng. - Giai on sau: dy nh tri vi P (0,12s hoc P hai pha, pha m ln hn pha (+) V1. Trc in tim lch phi v dy tht phi. Ngoi ra cn c th thy tnh trng ri lon nhp nh ngoi tm thu nh, nhp nhanh nh, rung nh l hay gp hn c. C th c blc nhnh phi khng hon ton.

in tm hp van 2 l: Nhp xoang, trc hng phi, =850, dy nh tri (D1, V1), tng

gnh tht phi (V1, V3R, V4R) 2.3. Siu m tim

L phng tin chn on xc nh chnh xc hp van hai l nht l khi hp van hai l trn lm sng khng pht hin c. Siu m cn cho php ta nh gi van v t chc di van c dy khng ta c quyt nh thay van, nong van hay sa van. Trong hp n thun - Kiu mt bnh din: Van l van trc v sau dnh vo nhau nn di ng song song cng chiu, cc l van dy ln. Van c dng hnh cao nguyn hay giy trt tuyt. dc tm trng EF b gim. Nu hp kht dc tm trng c th gim

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o din tch van 2 l (MVA) qua siu m 2D v Doppler lin tc (PHT)

2.4. Tm thanh c ng Kt hp vi in tm nh gi mc hp ca van da vo khong Q - T1 v khong T2 - CM. Nu Q - T1 cng di v T2 - CM cng ngn th hp van hai l kht, hin nay thm d ny t s dng do c siu m tim 2.5. Thng tim

Thy c s chch lch p tm trng gia nh tri v tht tri, du hiu c trng ca hp hai l. Hin nay, siu m tim c tnh cht quyt nh nn t s dng phng tin ny. Ngi ta ch s dng khi c bnh l tim phc tp phi hp (him). IV. CHN ON 1. Chn on xc nh Da vo cc tiu chun lm sng v cn lm sng, nh m t trn. Quyt nh nht vn l du nghe tim v siu m tim. 2. Chn on phn bit - Rung tm trng trong hp van 3 l: RTTr trong mm, T1 khng anh. in tim c dy nh phi, khng c du dy tht phi. Siu m tim l quyt nh chn on. - U nhy nh tri (Myxoma): nghe rung tm trng thay i theo t th. Khng c T1 anh. Bnh nhn thng hay c ngt. Chn on da vo siu m tim. 3. Chn on giai on C 4 giai on ca hp hai l - Giai on 1: Khng c triu chng c nng k c khi gng sc. Khm lm sng pht hin tnh c. - Giai on 2: C hi chng gng sc r: Kh th, hi hp, nh trng ngc, ho hoc ho ra mu, cha c biu hin suy tim. - Giai on 3: C kh th nhiu, c suy tim phi nhng iu tr c hi phc. - Giai on 4: Hp van 2 l c suy tim nng, iu tr khng hi phc. 4. Chn on th 4.1. Th n thun: c th dung np tt, bnh nhn cha c du hiu c nng v thng pht hin bnh tnh c. - Th in hnh: Nh m t trn v khi khm lm sng, X quang, in tim c th chn on c. - Hp van hi l cm: Bnh nhn c th c hoc khng c triu chng c nng. Nghe tim khng thy cc du hiu c trng cc hp van hai l. Th ny i hi tm cc bin chng ca hp van hai l v cn lm sng nht l siu m tim gip chn on. - Th tin trin: thng l nhng trng hp hp van hai l khp hay rt kht. Bnh nhn vo vin vi cc bin chng nng n. Ri lon nhp, hen tim, ph phi cp, tc mch vv... 4.2. Th phi hp - Hp hai l phi hp h van hai l: phi phn bit h hai l l chnh, hp l ph hay ngc li. Nu h van hai l l ch yu: nghe TTT mnh mm tim ting thi to, lan xa, s c rung miu tm thu, T1 khng anh. Rung tm trng nh, X quang, siu m, in tim c dy gin

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tm tht tri v nh tri. Ch yu siu m tim nh gi c mc h hai l c bit l vi siu m Doppler.

- Phi hp vi bnh van ng mch ch. + Hp van hai l phi hp h ng mch ch: ngoi hp van hai l cn nghe ting thi tm trng lin sn III bn tri v lin sn II bn phi lan xung dc b c tri, in tim c dy tht tri, siu m doppler tim cho php chn on. + Hp hai l kt hp hp ng mch ch: ngoi triu chng hp van hai l cn nghe thm ting thi tm thu lin sn III bn phi v lin sn II bn phi lan ln 2 bn ng mch cnh km s rung mu. Chn on in tim c dy tht tri tm thu, X quang v siu m tim cho php chn on. - Hp van hai l kt hp bnh van 3 l: + Hp hai l kt hp h 3 l: nghe TTT trong mm tim hoc ngay mi c. ting TTT mnh ln khi ht vo su v nn th, c th s gan to v p theo nhp p ca tim. Tnh mch c p. Phi thng sng hn. + Hp van hai l kt thng lin nh: Hp hai l kt hp thng lin nh gi l hi chng Lutembacher. Chn on xc nh nh siu m tim v thng tim. Hp van hai l c th cn phi hp vi cc bnh l tim mch khc nh tng huyt p nhng him gp 5. Chn on bin chng Hp van hai l thng c 4 nhm bin chng sau: 5.1. Ri lon nhp tim - Ri lon nhp xoang thng l nhp nhanh. Ngoi tm thu nh, cn nhanh trn tht. - Cung nh v rung nh l nhng bin chng nng n ca HHL. T nhng ri lon nhp tim nay c th gy ra bin chng tc mch ngoi vi v cng lu s dn n suy tim phi. 5.2. Tc mch: C 2 c ch tc mch: - Tc mch vng i tun hon: Do mu nh tri chm lu chuyn xung tht tri nn mu d ng. Nu cc ri lon nhp nhanh nh rung nh, nhp nhanh trn tht to iu kin thun li hnh thnh cc mu ng. Sau khi nhp tim chm li cc mu c a xung tht tri v vo i tun hon gy tc mch no, chi, thn, mc treo vv... - Tc ng mch phi: Do cc mu ng c hnh thnh t cc tnh mch ngoi bin, vo tht phi gy tc ng mch phi. Hoc c th do p lc phi tng trong hp hai l nn c th hnh thnh cc mu ng ti ch gy tc ng mch phi. 5.3. Nhim trng - Nhim trng ti phi do mu ng mch phi l mi trng pht trin cho vi trng: C th vim phi lan ta, vim phi khu tr. - Nhim trng ti tim c th gy ra vim ni tm mc bn cp Osler. Bin chng ny him gp nhng khi xy ra th tin lng xu v iu tr kh v c th tht bi. 5.4. Suy tim

- C th c cn hen tim ph phi cp hay gp khi gng sc hoc ban m. Do mu ng trong phi nhiu ban m thn kinh ph giao cm hot ng mnh nn lm dn mch, thot huyt tng vo ph nang gy ph phi. - Suy tim phi. y cng l bin chng ng thi cng l giai on cui cng ca bnh. Nu khng c iu tr trit . Cc bin chng trn c th xy ra khi bnh nhn gng sc v tinh thn, th cht v nhn mt nhim trng da, phi. c bit ph n c thai, lc chuyn d hay thi k kinh nguyt. VI. IU TR 1. iu tr ni khoa Ch c tc dng tt khi hp van hai l mc nh v trung bnh. Nu hp kht, vi din tch l van

12

1.1.1. Ch sinh hot n ung Hn ch lao ng nng, n lt, iu tr phng thp ti pht, phng nga Osler. 1.1.2. Li tiu Khi c th tng khong 2 kg so vi trc. Furosemid 40 mg x 1-2 vin/ngy.

Trong cn suy tim cp c th dng Lasix 20 mg tim tnh mch chm. Ch khi dng li tiu cn dng thm kali (nn cho loi mui K+ hu c tt hn v c, nh K+, Mg++ aspartate bit dc Panangin) phng h kali mu, d ng c Digital. 1.1.3. Digital

t c tc dng trong suy tim do hp hai l, ngay c khi c suy tim phi. Digital c tc dng tt trong suy tim do hp hai l c bin chng rung nh ngn nga cc cn rung nh c nhp tht nhanh, lm nng thm tnh trng suy tim, c th dng liu ngm chm. Digital 0,25 mg x 1 vin/ ngy trong 5 ngy, ngh 2 ngy ri dng li. Hoc Digital 0,25 mg x 1 vin / ngy trong 3 ngy, ngh 3 ngy ri dng li. Khi iu tr Digital cn lu du chng ng c Digital nh: - Bnh nhn nn ma, au bng, m mt, nhn i, i cu phn lng. - Ngoi tm thu tht nhp i hay c tnh. - Hoc nhp tim tng vt ln (trong khi ang dng Digital) hoc chm li vi Blc nh tht cc cp, hoc nhp b ni. - Nu xut hin cc triu chng trn nn ngng Digital v cho tng cng thm Kali bng ng tnh mch hoc ng ung, ch b sung thm Mg++. 1.1.4. Cc thuc gin mch - c s dng nhiu trong nhng nm gn y. Thuc gin mch c th iu tr lin tc, ko di. Thuc gin mch c tc dng gim tin gnh, hu gnh gip cho suy tim hi phc tt. - i vi suy tim trong hp hai l tt nht l nhm Nitrat v dn xut nht l khi hp hai l c tng p lc ng mch phi, ph phi mn tnh v cp tnh. Risordan LP 20 mg x 1-2 vin / ngy, hoc Imdur (mononitrate Isosorbid) 60 mg x 1/2 - 1 vin / ngy. 1.2. iu tr phng tc ng mch h thng - Tc mch c th: ng mch no, ng mch mc treo, ng mch ngoi v, ng mch lch, ng mch thn, ng mch vnh..... - Bin chng tc mch gia tng bnh nhn hp van hai l c bin chng rung nh v suy tim, c bit khi mi xut hin rung nh. - Hp van hai l c bin chng tc mch nhiu hn h van hai l. 20-60% tc li ln th hai sau tc ln th nht trong 6-12 thng nu khng c d phng hu hiu bng cc thuc chng ng. - iu tr tc mch cng sm cng tt: + Heparin 10.000 - 20.000 UI / ngy x 5 - 10 ngy. C th dng Heparin c trng lng phn t thp c bit i vi tc mch no. Sau dng cc thuc khng ng loi khng Vitamin K nh Sintrom, Previscan, Dicoumarin gi u 48-72 gi trc khi ngng Heparin duy tr t Prothrombin cn khong 30-35% hoc IRN 2,5-3 l tt nht. + Sau khi chuyn rung nh v nhp xoang bng thuc hoc sc in, nong van hai l l phng php d phng tc mch ti pht tt nht. Hoc nhng bnh nhn khng c iu kin nong van, phu thut s van, thay van c th ung thuc d phng tc mch ko di nhiu nm liu thp 100 - 500 mg / ngy bng Aspirin (aspegic 100mg), dipiridamole vv... 1.3. iu tr d phng - Phng thp ti pht bng Benzathylpenixilin 1,2 triu n v mi 15-20 ngy, tim bp su sau khi th test. - Ngoi ra phng bi nhim phi hoc Osler bng khng sinh Penixilin nhanh hoc Erythromycin 0,5g trc cc can thip nh nh rng, x nht ngoi da vv... Khi c du hiu

13

vim tnh mch chi di c th phng tc ng mch phi bng cch t li lc tnh mch ch di. 2. iu tr ngoi khoa iu tr phu thut van hai l c nhiu tin b. Nong van hai l bng tay hoc bng dng c hoc bng bng (catheter baloon). 2.1. Nong van hai l bng bng a ng thng qua ng tnh mch i i vo nh phi, xuyn qua vch lin nh vo nh tri nong van 2 l bng bng. K thut ny c thc hin ti Vit Nam. Phng php ny c ch nh cho bnh nhn tr tui

14

+ Van Magovevu-cromt l van Starr ci tin + Van Kuy-Suzuki thay bng bi bng a phng, c nhiu u im v huyt ng hn dng van bi, khi phu thut thay van t l t vong thp hn, gim qu trnh to cc mu ng van v quanh van, l van nhn to mi nht c ci tin t van Starr. Vi hnh dng v cht liu khc nhau nh Titanium, Teflon, Pyrolytic-carbon, Silastic, Polyproline.... to c nhiu loi van khc nhau: + Cuged-ball

+ Starr-Edwards: 7 loi. Smeloff-custer: 2 loi: Braald-custer, Cuged-disc + Beall c 5 loi: Kay-Shiley, Kay Suzuki, Starr-Edwards, Cooley-Cutter, Tilting disc. + Bjork-Shiley c 3 loi + Lalehei-kaster: 4 loi Tng cng c 27 loi van nhn to - Van hai l sinh hc: Phc hi mt cch c bn huyt ng, khng b nhim khun, khng to cc mu ng, khng b thng t vng van sau thi gian di phu thut, v vy n m ra trin vng pht trin sau ny. 2.4. Bin chng sau khi thay van Ngoi cc bin chng nh nong van cn c thm cc bin chng. - t t trong khi phu thut - t t do hot ng ca van b ri lon. - Dnh kt Fibrin, sau vi ho ti van v quanh van mn. - Osler do vi khun v nm. - Abces quanh vng van.

- H quanh vng van hai l. - Block nh tht cp cao hoc bloc b His (do ct cc tr c) - Hp hoc h MC th pht sau thay van hai l - Gim kh nng b p tun hon khi gng sc. - Kh iu tr bng phng php sc in, to nhp khi cn thit. iu tr nong van hai l hay phu thut tim kn hay h cn tip tc iu tr phng thp, phng Osler, iu tr chng ng, suy tim th mi ko di cuc sng ca bnh nhn.

15

TNG HUYT P

Mc tiu

1. Nm vng kin thc c bn v tng huyt p, mt bnh tim mch ph bin hin nay.

2. Nm vng phn loi, cc bin chng ca tng huyt p cng nh cc c ch sinh bnh tng huyt p

3. Nm vng cc nhm thuc v tc dng dc l, ch nh v tc dng ph trong iu tr tng huyt p.

4. Vn dng c phc iu tr tng huyt p trong thc tin lm sng

Ni dung

I. I CNG

1. Dch t hc

Tng huyt p (THA) l triu chng ca nhiu bnh, nhiu nguyn nhn nhng c th l mt bnh, bnh tng huyt p, nu khng tm thy nguyn nhn. cc nc Chu u - Bc M t l tng huyt p trong nhn dn chim 15 - 20% ngi ln. C th nh sau: Benin 14%- Thi lan: 6.8%- Zaire:14%- Chile: 19-21%, Portugaise: 30%, Hoa k: 6-8%. Nhn chung t l rt thay i. Vit Nam, t l tng huyt p chung l 11,8% (B Y T Vit Nam, 1989). T l ny gia tng ng quan tm v trc 1975 t l ny min Bc Vit nam ch c 1-3% (ng Vn Chung). Ti BVTW Hu nm 1980 t l THA trong s cc bnh ni khoa ch c 1% nhng 10 nm sau, nm 1990, tng n 10%. Thng k gn y nht ca Vin Tim Mch ti Min Bc Vit Nam cho thy t l THA l 16,3% (2002).

2. nh ngha

T chc Tng huyt p Th gii (TCYTTG) v U ban Quc gia Cng lc Hoa k, Hi Tng huyt p Vit nam u thng nht mt ngi ln b tng huyt p khi huyt p tm thu trn hoc bng 140mmHg v hoc huyt p tm trng trn hoc bng 90mmHg.

nh ngha ny n gin nhng vn c nhc im l tr s huyt p khng hon ton n nh v huyt p thay i theo tui, gii...

3. Mt s nh ngha mi THA

3.1. THA tm thu n c: i vi ngi ln, huyt p tm thu c xu hng tng v huyt p tm trng c xu hng gim. Khi trung bnh ca huyt p tm thu >140 v huyt p tm trng

16

chong trng l 10%-30% chim mt t l khng phi khng ng k trn nhng i tng THA. THA o chong trng tng theo tui v t l ny < 10% THA 2, 3 khi o ti phng khm. THA o chong trng c th l khi u ca THA thc s v c th lm tng nguy c BTM mc d khng phi nghin cu no cng tr li nh th. Nghi ng THA o chong trng khi HA o ti phng khm tng hoc khng tr khi khng c tn thng c quan ch. Nhng ngi THA phng khm n c c nguy c tim mch thp hn nhng ngi va THA phng khm v THA 24 gi.

3.5.Tng huyt p n du ( masked hypertension) hoc THA lu ng n c: Thng t gp hn tng huyt p o chong trng nhng kh pht hin hn, l tnh trng tri ngc - huyt p bnh thng ti phng khm v THA ni khc, v d ti ni lm vic hay ti nh (tng HA 24 gi n c). Nhng bnh nhn na c tn thng c quan ch nhiu hn v nguy c cao hn nhng i tng huyt p lun lun bnh thng 3.6. Tng huyt p gi to: Trong mt s lng nh bnh nhn ln tui, cc ng mch nui c ngoi bin tr nn cng nn bng cun phi c p lc cao hn nn li. ng mch cnh tay hay ng mch quay vn bt c d bng cun c bm cng (du Osler dng tnh). Khi nghi ng, o huyt p ni ng mch quay c tin hnh xc nh. 3.7. H huyt p t th ng: c nh ngha l s gim huyt p tm thu ti thiu 20 mmHg hoc huyt p tm trng 10 mmHg trong vng 3 pht khi o t th ng. Nu mn tnh, s gim huyt p c th mt phn do s suy gim h thn kinh t ng n thun, suy gim a h thng v mt s trng hp khng c h thn kinh t ng. Nhng bnh nhn ny khng ch c gim huyt p t th ng m tng huyt p trm trng trong t th nm nga trong m.

II. BNH NGUYN V C CH SINH BNH

1. Bnh nguyn

1.1.Tng huyt p nguyn pht: chim gn 90% trng hp b tng huyt p (theo Gifford - Weiss).

1.2. Tng huyt p th pht

- Bnh thn: Vim cu thn cp, vim cu thn mn hai bn do mc phi thn a nng, nc b thn, u thn lm tit rnin, hp ng mch thn...

- Ni tit

+ Bnh v tuyn thng thn, hi chng Cushing, hi chng Conn, u sn xut qu tha cc Corticosteroid khc (Corticosterone, desoxycortisone), sai lc trong sinh tng hp Corticosteroid.

+Bnh ty thng thn, u ty thng thn (Pheochromocytome).

- Bnh tim mch: Bnh hp eo ng mch ch, vim hp ng mch ch bng cho xut pht ng mch thn, h van ng mch ch.

-Thuc: Cc Hormone nga thai, cam tho, carbenoxolone, A.C.T.H. Corticoides, Cyclosporine, cc cht gy chn n, cc IMAO, cht chng trm cm vng...

- Nhim c thai nghn.

- Cc nguyn nhn khc: Bnh cng gip, bnh Beri-beri. Bnh Paget xng, bnh a hng cu, hi chng carcinoid, toan h hp, tng p s no...

2. Mt s yu t lm d (thun li): c xem nh c lin quan n tng huyt p nguyn pht tuy vn cn bn ci l

- Yu t di truyn, bnh tng huyt p c tnh gia nh.

- Yu t n ung, n nhiu mui, n t protit, ung nhiu ru, ung nc mm t Ca

++, Mg

++, K

+. Trong ni bt v c tha nhn l s lin quan gia ion Na+ v tn sut

17

bnh tng huyt p. Ion Na+ lm tng huyt p qua trung gian gia tng th tch mu v nht l qua s co tht mch mu.

- Yu t tm l x hi, c tnh trng cng thng (stress) thng xuyn.

3. C ch sinh bnh ca tng huyt p nguyn pht

Tng huyt p ng mch thng km theo nhng bin i v sinh l bnh lin quan n h thn kinh giao cm, thn, renin-angiotensin v cc c ch huyt ng, dch th khc.

3. 1.Bin i v huyt ng

- Tn s tim tng, lu lng tim tng dn, thi k u c hin tng co mch phn b li mu lu thng t ngoi vi v tim phi do sc cn mch mu cng tng dn. Tim c nhng biu hin tng hot ng b tr v dn n dy tht tri. Huyt p v sc cn ngoi bin ton b tng dn. Lu lng tim v lu lng tm thu cng gim, cui cng a n suy tim.

- Trong cc bin i v huyt ng, h thng ng mch thng b tn thng sm c ton b. Trc kia ngi ta ngh ch c cc tiu ng mch b bin i co mch lm gia tng sc cn ngoi bin. Hin nay, ngi ta thy cc mch mu ln cng c vai tr v huyt ng hc trong tng huyt p. Chc nng t c bit n ca cc ng mch ln l lm gim i cc xung ng v lu lng mu do tim bp ra. Do thng s v n hi ng mch (compliance artrielle) biu th tt kh nng ca cc ng mch. S gim thng s ny cho thy cng ca cc ng mch ln, l din bin ca tng huyt p ln cc ng mch v v lu di s lm tng cng tim dn n ph i tht tri. ng thi vic gia tng xung p (hyperpulsatilit) ng mch a n s h hng cc cu trc n hi sinh hc (bioelastomeres) ca vch ng mch.

- Ti thn, tng sc cn mch thn, gim lu lng mu ti thn chc nng thn suy gim tuy trong thi gian u tc lc cu thn v hot ng chung ca thn vn cn duy tr.

- Ti no, lu lng vn gi c thng bng trong mt gii hn nht nh thi k c tng huyt p r.

- Khi huyt p tng, sc cn ngoi bin tng th tch huyt tng c xu hng gim cho n khi thn suy th tch dch trong mu tng c th tng a n ph.

3.2. Bin i v thn kinh:

thi k u nh hng ca h giao cm biu hin s tng tn s tim v s tng lu lng tim. S hot ng ca h thn kinh giao cm cn biu hin lng Catecholamine trong huyt tng v dch no ty nh adrenaline, no-adrenaline, tuy vy nng cc cht ny cng rt thay i trong bnh tng huyt p.

- H thn kinh t ng giao cm c iu khin bi h thn kinh trung ng hnh no-ty sng v c hai h ny lin h nhau qua trung gian cc th cm p lc. Trong tng huyt p cc th cm p lc c iu chnh n mc cao nht v vi ngng nhy cm cao nht.

3.3. Bin i v dch th

- H Renin-Angiotensine Aldosterone (RAA): Hin nay c chng minh c vai tr quan trng do ngoi tc dng ngoi vi cn c tc dng trung ung no gy tng huyt p qua cc th th angiotensine II . C tc gi chia tng huyt p nguyn pht da vo nng renine cao, thp trong huyt tng, c s t l nghch gia nng renine-angiotensine II trong huyt tng v tui.

- Angiotensine II c tng hp t angiotesinegne gan v di tc dng renine s to thnh angiotesine I ri chuyn thnh angiotesine II l mt cht co mch rt mnh v lm tng tit aldosterone. S phng thch renine c iu khin qua ba yu t: -p lc ti mu thn - lng Na+ n t ng ln xa v h thn kinh giao cm. S thm d h R.A.A, da

18

vo s nh lng renine trc tip huyt tng hay gin tip phn ng min dch v angiotensine II, nhng tt nht l qua tc dng ca cc c ch men chuyn.

- Vasopressin (ADH): c vai tr kh r rng trong c ch sinh bnh tng huyt p c tc dng trung ng gim huyt p (qua trung gian s tng tnh nhy cm thn kinh trung ng i vi phn x p t xoang ng mch cnh v quai ng mch ch) tc dng ngoi vi co mch (trc tip v qua hot ha cc si Adrenergic).

- Cht Prostaglandin: tc dng trung ng lm tng huyt p, tc dng ngoi vi lm gim huyt p.

- Ngoi ra cn c vai tr ca h Kalli-Krein Kinin (K.K.K) trong bnh tng huyt p v mt s h c vai tr cha r nh: h Angiotensine trong no v cc encephaline, h cng dopamine bin i hot ng th cm p lc. Mt c ch iu ha lin quan n cc th th Imidazolique trung ng v ngoi bin c ghi nhn t nhng nm 80 vi s xut hin thuc huyt p tc dng ln th cm Imidazole gy dn mch.

3.4.C ch sinh bnh ca tng huyt p th pht:

Ty vo nguyn nhn gy bnh.

III. TRIU CHNG HC

1. C nng

a s bnh nhn tng huyt p khng c triu chng g cho n khi pht hin bnh. au u vng chm l triu chng thng gp. Cc triu chng khc c th gp l xong, hi hp, mt, kh th, m mt... Khng c hiu. Mt s triu chng khc ca tng huyt p ty vo nguyn nhn tng huyt p hoc bin chng tng huyt p.

2.Triu chng thc th

2.1. o huyt p: l ng tc quan trng, cn bo m mt s quy nh.

- Bng cun tay phi ph c 2/3 chiu di cnh tay, b di bng qun trn khuu tay 2cm. Nu dng my o thy ngn nu dng loi l xo phi iu chnh 6 thng 1 ln.

- Khi o cn bt mch trc. Nn bm n khong 30mmHg trn mc p lc lm mt mch (thng trn 200mmHg) x xp nhanh ghi p lc khi mch ti xut hin, x xp ht. t ng nghe ln ng mch cnh tay, bm nhanh bao hi n mc 30mmHg trn p lc ghi, x chm t t vi tc 2mmHg trong 1 giy (hay mi nhp p). Huyt p tm trng nn chn lc mt mch (pha V Korottkoff). tr em v v ph n c thai nn chn pha IV Korottkoff.

- Nu o li ln 2 cn ch 30 giy. Nu lon nhp tim phi o li ln 3 v ly trung bnh cng ca cc tr s.

- Phi o huyt p nhiu ln, trong t nht 2 ngy lin. o huyt p c chi trn v chi di, c t th nm v ng. Thng thng chn huyt p tay tri lm chun.

2.2. Du hiu lm sng

- Bnh nhn c th bo ph, mt trn trong hi chng Cushing, c chi trn pht trin hn c chi di trong bnh hp eo ng mch ch. Tm cc biu hin x va ng mch trn da (u vng, u m, cung gic mc..).

- Khm tim mch c th pht hin sm dy tht tri hay du suy tim tri, cc ng mch gian sn p trong hp eo ng mch ch. S v nghe ng mch pht hin cc trng hp nghn hay tc ng mch cnh trong ng mch ch bng...

- Cn lu hin tng (huyt p gi) gp nhng ngi gi i ng, suy thn do s x cng vch ng mch lm cho tr s huyt p o c cao hn tr s huyt p ni mch. C th loi tr bng cch dng th thut Osler hay chnh xc nht l o huyt p trc tip.

19

Mt hin tng khc cng ang c c gng loi tr l hiu qu o chong trng bng cch s dng phng php o lin tc huyt p 24 gi.

- Khm bng c th pht hin ting thi tm thu hai bn rn trong hp ng mch thn, phng ng mch ch hoc khm pht hin thn to, thn a nang.

- Khm thn kinh c th pht hin cc tai bin mch no c hoc nh.

3. Cn lm sng: Cn n gin, mc ch nh gi nguy c tim mch, tn thng thn v tm nguyn nhn.

3.1. Billan ti thiu (theo T chc Y t th gii)

Mu: Kali mu, Cratinine mu, Cholesterol mu, HDL- C, LDL-C, Triglycerid,

ng mu, Hmatocrite, Acide Uric mu. Nc tiu: Hng cu, Protein. Nu c iu kin nn lm thm, soi y mt, in tim, X quang tim, siu m...

3.2. Cc xt nghim hay trc nghim c bit

i vi tng huyt p th pht hay tng huyt p kh xc nh.V d: Bnh mch thn:cn chp U.I.V. nhanh, thn , trc nghim Saralasin. U ty thng thn (Pheochromocytome): nh lng Catecholamine nc tiu trong 24 gi, trc nghim Rgitine.

Cc ngng HA p dng chn on THA theo cch o.

HATT ( mm Hg) HATTr (mm Hg)

o HA ti phng khm/ bnh vin 140 90

o HA lu ng 24 gi * 125 - 130 90

- Ban m 130-135 85

- Ban ngy 120 70

o HA ti nh (t do) 135 -135 85

(*) o chnh xc hn HA vn phng c bit nh gi hiu qu h HA nh iu tr,

l do l khng c hin tng c chong trng v cc yu t nhiu tc ng ngy cng nhiu

sau mi ln . Cho d mt s u im s c th t c nu gia tng s ln o HA vn

phng ln, o HA i li 24 gi trc nhn sut qu trnh iu tr c th c khuyn khch

trong mt vi trng hp vo thi im chn on hoc thm thot sut qu trnh iu tr.

IV. CHN ON

1.Chn on xc nh: Cn phi chn on sm v ng n bnh THA. Ch yu bng cch o huyt p theo ng cc quy nh nu trn. Tuy nhin iu quan trng l nn t chc nhng t khm sc khe khm xt ton din nhm pht hin sm nhng trng hp tim tng hoc cha c triu chng.

2.Chn on giai on tng huyt p: c nhiu cch phn giai on, trong phn giai on ca TCYTTG chi tit v thch hp hn.

2.1.Theo T.C.Y.T.T.G (1996) chia lm 3 giai on. Hin nay phn giai on ny ch c tnh cch tham kho.

- Giai on I: Tng HA tht s nhng khng c tn thng thc th cc c quan.

- Giai on II: C t nht mt trong cc bin i cc c quan sau:

+ Dy tht tri: Pht hin bng lm sng, X quang, in tim, siu m.

20

+ Hp lan ta hay tng vng cc ng mch vng mc (giai on I v II y mt ca Keith-Wagener-Baker).

+ Thn:Anbumine niu vi th, Protein niu, ur hoc cratinine mu tng nh.(1.2-2 mg%)

+ C hnh nh mng va x ng mch trn siu m hoc X quang ( ng mch ch, ng mch cnh, ng mch chu hoc ng mch i)

- Giai on III: C du hiu chc nng v thc th do tn thng cc c quan ch:

+ Tim: suy tim tri, cn au tht ngc, nhi mu c tim.

+ No: tai bin mch no thong qua, xut huyt no, tiu no hoc thn no. Bnh no THA. Lon thn do mch no (vascular dementia)

+ y mt: xut huyt vng mc xut tit c hay khng c ph gai th (giai on III v IV) cc du hiu ny l c bit ca giai on c tnh (giai on tin trin nhanh).

Cc biu hin khc thng gp giai on III nhng khng c hiu lm ca tng huyt p.

+ Thn: creatinine huyt tng tng r (> 2mg%), suy thn.

+ Mch mu: phng tch, bt tc ng mch, tc ng mch ngoi bin c triu chng r.

Tng HA c tnh hay tin trin nhanh l mt hi chng gm c:

- Huyt p ti thiu rt cao trn 130mmHg.

- y mt giai on III v IV theo Keith-Weigener.

- C bin chng thn, tim, no.

- Bnh nhn tr tui di 40.

- Tin trin nhanh, t vong trong vng 2-3 nm.

2.2. Phn loi theo y ban Cng lc Quc gia Hoa k ( 2007)

Phn loi huyt p Huyt p tm thu (mmHg) Huyt p tm trng (mmHg)

Bnh thng

Tin tng huyt p

Tng huyt p giai on 1

Tng huyt p giai on 2

< 120

120 - 139

140 - 159

> 160

v < 80

hoc 80 - 89

hoc 90 - 99

hoc > 100

2.3. Xp loi THA theo T chc Y t th gii ( WHO) v Hi THA th gii (ISH) (2003), Hi Tng huyt p Vit nam v Hi Tng huyt p Chu u ( 2007): y l phn loi c p dng rng ri nht ti nc ta v nhiu nc trn th gii.

Xp loi HA tm thu

(mmHg)

HA tm trng

(mmHg)

Ti u

Bnh thng

Bnh thng cao

< 120

< 130

130-139

< 80

< 85

85-89

THA nh (giai on 1) 140-159 90-99

THA va (giai on 1) 160-179 100-109

THA nng (giai on 2) 180 110

3. Phn loi tng huyt p

3.1- Theo tnh cht:

- Tng huyt p thng xuyn:nh tng huyt p lnh tnh v tng huyt p c tnh.

21

- Tng huyt p giao ng, huyt p c lc cao, c lc bnh thng.

3.2- Theo nguyn nhn: Gm

- Tng huyt p nguyn pht (v cn).

- Tng huyt p th pht.

V- TIN TRIN V BIN CHNG

1. Tim: Suy tim v bnh mch vnh l hai bin chng chnh v nguyn nhn gy t vong cao nht i vi tng huyt p. Dy tht tri l bin chng sm do dy c tim tri. i ph sc cn ngoi bin nn gia tng sc co bp lm cng tim tng ln v vch c tim dy ra. Dn dn suy tim tri v vi kh th khi gng sc, hen tim hoc ph phi cp sau chuyn sang suy tim ton b vi ph, gan to, tnh mch c ni. Xquang v in tim c du dy tht phi.

Suy mch vnh biu hin bng cc cn au tht ngc in hnh hay ch c lon nhp. in tim c ST chnh xung di ng thng in cc chuyn o tim tri, r hn chuyn o gng sc; khi bin chng nhi mu s xut hin sng Q hoi t.

2. No: tai bin mch no, thng gp nh nhn no, xut huyt no, tai bin mch no thong qua vi cc triu chng thn kinh khu tr ch ko di, khng qu 24 gi hoc bnh no do tng huyt p vi l ln, hn m km theo co git, nn ma, nhc u d di.

3. Thn

- Va x ng mch thn sm v nhanh.

- X thn gy tnh trng suy thn dn dn.

- Hoi t dng t huyt tiu ng mch thn gy THA c tnh.

- giai on cui thiu mu cc b nng thn s dn n nng Renin v angiotensine II trong mu gy cng aldosterone th pht.

4. Mch mu

- Tng huyt p l yu t sinh va x ng mch, to iu kin cho s hnh thnh va x ng mch.

- Phng ng mch ch, bc tch. Him gp nhng bnh cnh rt nng n d a n t vong.

5. Mt: khm y mt rt quan trng v l du hiu tt tin lng.

Theo Keith- Wagener-Barker c 4 giai on tn thng y mt.

- Giai on 1: tiu ng mch cng v bng.

- Giai on 2: tiu ng mch hp c du bt cho (du Gunn).

- Giai on 3: xut huyt v xut tit vng mc.

- Giai on 4: ph lan ta gai th.

VI. IU TR

1. Nguyn tc

1.1. Mc tiu

- a huyt p tr v tr s sinh l n nh.

- Ngn nga cc bin chng.

- Ci thin cc bin i bt thng cc ng mch ln.

Do phi gii quyt 3 vn :

+ iu tr nguyn nhn tng huyt p; Ct b u ty thng thn, ct b thn teo, thng ng mch b tc...

+ iu tr triu chng tng huyt p: Bng phng php ni khoa khng dng hoc dng thuc hoc phu thut (v d ct b mt s dy thn kinh giao cm).

22

+ iu tr bin chng ca tng huyt p: Mc tiu chung ca iu tr l nhm a huyt p v tr s bnh thng hay di tr s 140/90mmHg. Tn trng huyt p sinh l ngi gi.

1.2. Nguyn tc chung: Cn lin tc, n gin, kinh t v c theo di cht ch.

2. Phng php iu tr

2.1. Tit thc v sinh hot

Hn ch mui di 5gNaCl mi ngy, hn ch m, cc cht bo ng vt, king ru, thuc l, ch c. Trnh lao ng tr c cng thng, lo lng qu , nn tp th dc nh, i b th gin, bi li.

2.2.Thuc

Cn nm vng c ch tc dng, tc dng phi hp cc loi thuc iu tr tng huyt p v cc tc dng ph khi s dng trc mt v lu di. C 3 nhm thuc chnh:

- Li tiu

+ Thiazide v dn xut

c ch ti hp th Na+ v Cl- trong ng ln xa nh Hydrochlorothiazide (Hypothiazide)... vin 25mg ngy ung 2 vin. Chlorthiazide vin 500mg ung 2 vin/ ngy l nhng loi c dng rng ri trong tng huyt p. Ngoi ra cn c Chlorthalidone (Hygroton) vin 50mg-100mg x 1ln/ngy v Metolazone (Diulo) 2,5mg-5mg x 4ln/ngy hay mi 2 ngy/ln v tc dng ko di.

Tc dng ph thiazide: Tng acid uric, tng cng mu, gim Kali mu, li tiu Thiazides t tc dng khi tc lc cu thn di 25ml/pht, lm tng LDL cholesterol v gim HLD cholesterol.

+ Li tiu quai Henl

Cng lm h Kali mu, nhng khc nhm thiazide l tc dng nhanh v ngn, ph thuc liu.Thng dng l Furosemide (Lasix) vin 40mg x 1-2vin/ngy c ch nh khi suy thn nng, cn tng huyt p cp tnh nhng v lu di tc dng khng hn nhm Hypothiazide. Cc loi khc trong nhm cn c Edecrine (Acide ethacrynique), Burinex (Butnamide). Tc dng ph tng t Thiazide nhng liu cao c c tnh ln tai.

+ Li tiu xa gc Gi Kali, gm c 2 nhm nh:

- Nhm khng Aldosterone nh Spironolactone (Aldactone)vin 25-50mg x 4ln/ngy. Canrnone (Phanurane) c hiu lc i vi nhng trng hp cng Aldostrone, thng dng phi hp thiazide.

- Nhm th 2 l nhm c tc dng trc tip nh Amiloride (Modamide), Triamterene (Teriam) loi ny thng phi phi hp vi cc nhm khc v tc dng thi Na yu. Tc dng ph: v nam, bt lc ri lon kinh nguyt.

+ Li tiu phi hp

C th trnh c tnh trng gim Kali trong mu, loi ny phi hp mt loi Aldosterone v mt loi thiazides nh Aldactazine, Moduretic, Ditriam..

- Loi chn giao cm

Tc dng c ch Renin, gim ng c tim, gim hot ng thn kinh giao cm trung ng, c nhiu nhm. Chn lc tim, khng chn lc tim v loi c tc dng ging giao cm ni ti hay khng c. Thng dng c propranolol (Avlocardyl, Inderal) l loi khng chn lc, khng c tc dng giao cm ni ti (ASI) vin 40mg dng 1-6vin/ngy. Tc dng ph: Lm chm nhp tim, ri lon dn truyn nh tht, lm nng suy tim, co tht ph qun, hen, hi chng Raynaud, h ng mu, ri lon tiu ha, mt ng, d ng hoc tc dng di khi ngng iu tr (gy ra cn au tht ngc, nhi mu c tim cp).

- Cc thuc c ch men chuyn

23

c ch s to thnh angiotensine II, ngoi ra cn c tc dng:

- Tng cng hot ng h Kali-Krine-Kinine ngn cn s phn hy bradykinine.

- Kch thch s tng hp Prostaglandine. Do sau cng a n dn mch.

Ch nh: Tng huyt p cc giai on, k c loi tng huyt p rnine cao v thp.

Tc dng ph: t c tc dng ph ngoi ri lon v thm n, nga, ho khan, lu khi phi hp li tiu gi Kali, thuc chng vim, chng Steroid.

Chng ch nh: Khi tng huyt p c hp ng mch thn hai bn hoc ch c mt, ph n c thai.

C 3 nhm chnh

- Captopril (Lopril, Captolane) vin 25-50mg liu 50mg/ngy.

- Enalapril (Renitec) vin 5-20mg, liu 20mg/ngy.

- Lisinopril (Prinivil, Zestril) vin 5-20mg, liu 20mg/ngy.

Hai nhm sau cng c tc dng ko di v khng c nhm Thiol t tc dng ph nn c a thch hn.

- Thuc c ch Canxi

Ngn cn s i vo t bo ca ion Ca++. c ch lung Ca++ chm ca knh Ca++ ph thuc in th. Tc dng ny t l vi nng v hi quy khi c ion Calcium. C hai ni tc dng.

- Trn mch mu: s gim lung Ca++ a n s dn c v lm dn mch. iu ny lm gim sc cn ngoi bin v ci thin dn n cc mch mu ln.

- Trn tim: lm chm nhp tim cn bng t nhiu phn x nhp nhanh th pht v gim s co bp c tim.

Cc tc dng ny ty vo loi c ch Ca++ c s dng. Loi 1-4 dihidropyridine c tc dng chn lc mnh i vi mch mu, cn Verapamil v Diltiazem tc dng ln c hai ni. Cc loi c ch Ca++ tc dng tt i vi tng huyt p renine thp (ngi ln tui) c th:

+ Nhm 1-4 Dihydropyridine: Nifedipine (Adalate) vin nhng 10mg-20mg LP, liu 2 vin/ngy.

+ Diltiazem (Tildiem) 300mg LP, liu 1 vin/ngy.

+ Verapamil (Isoptine) 120-240 LP, liu 1-2 vin/ngy.

Tc dng ph chim 10-20% trng hp. Thng thng l nhc u, ph ngoi bin, phng mt. Him hn l h huyt p th ng, mt, xong, ri lon tiu ha, hi hp, pht ban, bun ng v bt lc. Cc loi Verapamil, Diltiazem c th gy ri lan dn truyn nh tht, nhp chm. Khng c dng c ch Canxi khi c thai, i vi Verapamil v Diltiazem khng dng khi c suy tim, blc nh tht nng nhng cha t my to nhp.

- Thuc tc dng ln thn kinh trung ng

C nhiu loi nhng hin nay t dng do c nhiu tc dng ph d c hiu qu.

- Anphamethyldopa (Aldomel, Dopegyt): H huyt p do to ra anpha-methylnoadrenaline lm hot ha cc c quan th cm giao cm no, do c ch trng lc giao cm. Vin 250mg hoc 500mg, liu t 500mg n 1,5g trong 24 gi. c s dng khi c suy thn. Tc dng ph: h huyt p th ng, thiu mu huyt tn, bt lc, suy gan.

- Reserpine vin 0,25mg liu 2-6 vin/ngy. Tc dng ph h huyt p th ng, thiu mu huyt tn, bt lc, suy gan, hin nay t dng.

- Clonidine (Catapressan): Tc dng ln vng hnh ty cng trng lc giao cm h huyt p. Vin 0,150mg liu 3-6 vin/ngy. Cn lu phi ngng thuc t t nu khng s lm huyt p tng vt ln. Tc dng ph: Trm cm kh ming, to bn, ri lon tnh dc.

- Cc thuc tc dng trung ng khc: Guanabenz, Guafacine, Tolonidine, Hyperium.

24

- Thuc dn mch

- Prazosin (Minipres): Tc dng c ch cm th anpha sau tip hp nn c hiu lc tt. Vin 1mg dng liu tng dn t 1-2 vin - 10 vin/ngy nu cn. Tc dng ph: chng mt, ri lon tiu ha d kch ng, tiu kh, h huyt p th ng, nht l vi liu u tin.

- Dihydralazine (Nepressol) vin 25mg, liu t 1-4 vin/ngy. c dng khi c suy thn, c nhiu tc dng ph. Nhp tim nhanh, gi mui nc, hi chng gi luput ban , vim a dy thn kinh ngoi bin khng dng khi c suy vnh, phng ng mch ch bc tch, thng c ch nh trong tng huyt p c suy thn.

- Minoxidil (Loniten) tc dng rt mnh, ch dng khi tng huyt p khng cc loi khc, suy thn mn; t dng hin nay.

3. iu tr c th

3.1. nh gi THA theo mc nguy c ca T chc y t Th Gii v Hi tng huyt p Th Gii (ISH) nm 2003, 2007.

Theo cc bc sau:

* nh gi cc yu t nh hng n tin lng, bao gm:

+ Yu t nguy c ca bnh tim mch:

- Mc huyt p tm thu v tm trng (1-3).

- Nam > 55tui.

- N > 65 tui.

- Ht thuc l.

- Cholesterol ton phn > 250mg%.

- Tiu ng.

- Tin s gia nh b bnh tim.

+ Yu t khc nh hng xu tin lng:

- HDL-C gim.

-LDL-C tng.

-Albumine niu vi th bnh nhn tiu ng.

-Ri lon dung np Glucose.

-Bo ph.

-Li sng tnh ti.

-Fibrinogene mu tng.

-Nhm kinh t x hi cao.

-Nhm dn tc nguy c cao.

- Vng a l nguy c cao.

+ Tn thng c quan ch: nh giai on II ca tng huyt p theo phn ca t chc y t th gii trc y bao gm: c dy tht tri, tn thng y mt, c prtin niu,...

+ Tnh trng lm sng i km: nh giai on III theo theo phn ca t chc y t th gii trc y bao gm: suy tim tri, suy vnh, suy thn, suy tun hon no.

3.2. Phn loi nguy c gip tin lng bnh

Bng 1:

THA I THA II THA III

Khng c yu t nguy c (YTNC)

Nguy c thp Nguy c trung bnh Nguy c cao

25

1-2 YTNC Nguy c trung bnh. Nguy c trung bnh Nguy c rt cao

3 YTNC hoc tn thng c quan ch hoc tiu ng.

Nguy c cao. Nguy c cao Nguy c rt cao

Bnh tim mch i km Nguy c rt cao Nguy c rt cao Nguy c rt cao

i vi tng huyt p nguy c thp v trung bnh cn theo di thi gian ri nh gi li huyt p v yu t nguy c, p dng cc bin php khng dng thuc. i vi nhm nguy c cao v rt cao cn iu tr thuc ngay phi hp vi khng dng thuc.

* p dng phc iu tr theo c nhn. C th tm lc theo s di (trang sau):

- Trong iu tr 2 loi thuc, loi th 2 c chn vn trong 4 nhm thuc bc 1. Nu tht bi, sau khi cn nhc cc kh nng khng iu tr, liu lng cha thch hp... th c th xt n vic phi hp thm loi th 3 nh loi dn mch hay cc loi khng adrenergic trung ng

- Ch nh chn lc thuc theo phng php iu tr tng c nhn bnh nhn (ca Hi ng quc gia v tng huyt p ca Hi Tim mch Hoa k JNC VI ).

+ Li tiu: Ngi gi, da en, ph n tin mn kinh, c ri lon nhu m thn.

+ Chn bta: Ngi tr, da trng, nam gii bnh nhn cng giao cm, hot tnh renine cao, bnh mch vnh, bnh nhn b glaucom v au na u.

+ c ch men chuyn: Tng huyt p nng, khng iu tr, hot tnh renine cao, suy tim hay suy thn, ri lon tnh dc, tng lipt mu, i ng, tng acide urc mu.

+ c ch canxi: ngi gi, da en, bnh mch vnh, i ng. Bo ph tng huyt p khng kim sot c bng chn bta th pht sau cng aldosterol nguyn pht, bt lc, tng lipt mu v tng acide urc mu.

+ Khng adrenergique ngoi bin: Bnh nhn tr b trm ut, hen suyn, bnh phi tt nghn, i ng tng lipit mu.

X tr THA theo phn nguy c tim mch

Nhng yu t nguy c, tn thng c quan v bnh cnh lm sng

Bnh

thng Bnh

thng cao

THA 1 THA 2 THA 3

Khng c yu t nguy c

Khng iu tr HA

Khng

iu tr HA

Thay i li sng vi thng ri dng thuc nu HA khng gim

Thay i li sng vi tun ri dng thuc nu HA khng

gim

Thay i li sng+ dng thuc ngay

C 1-2 yu t nguy c

Thay i li sng

Thay i li sng


gim


gim


26

C 3 yu t nguy c, hi chng chuyn ho, tn thng c quan ch hoc i tho ng

Thay i li sng

Thay i li sng

Thay i li sng+ dng thuc

Thay i li sng +dng thuc


i tho ng Thay i li sng

Thay i li sng+ xt dng

thuc




C tnh trng lm sng i km hoc bnh thn

Thay i li sng + dng thuc ngay

Thay i li sng+ dng

thuc ngay




* iu tr cn tng huyt p cp tnh

Cn phi dng loi h huyt p bng ng tnh mch nh:

27

- Nitroprussiate de Na (Nipride) chuyn tnh mch liu 0,5-2mg/pht (10mg/gi) c chn dng trong hu ht cn tng huyt p. Tc dng ph: ng c Thiocyanate.

- Nitroglycerine chuyn tnh mch dng bnh nhn c suy vnh cp khi khng chng ch nh, liu 5 - 10mg/pht.

- Labetalol (Trandate) loi c ch c anpha v bta giao cm, dng tt nhng bnh nhn nhi mu c tim cp, chuyn tnh mch 1-2mg/pht.

- Anpha Methyldopa hay clonidine chuyn tnh mch.

- Cc loi c ch men chuyn: Captopril 25mg ngm di li.

- Thng phi hp thm Lasix chch tnh mch.

VII. D PHNG

1. D phng cp I

i vi nhng ngi cha b tng huyt p cn lu vn sinh hot hng ngy nht l cc thi quen c hi sc khe phi khm nh k pht hin tng huyt p hay cc bnh lin quan. Trong i tng ny ch n nhng ngi c yu t nguy c mc bnh cao cho d nhng ln u cha pht hin THA nhng cn trao i tuyn truyn phi hp d phng cng nhn vin y t tuyn trc.

2.D phng cp II

i vi ngi tng huyt p, cn phi cht ch hn na trong ch n ung, ngh ngi theo di huyt p u n v c k hoch iu tr ngoi tr theo di tin trin, tc dng ph ca thuc. Cn ch yu t kinh t trong iu tr v y l mt liu trnh lu di, tn km.

VIII. TIN LNG

Tin lng bnh nhn thng ph thuc vo:

- Tr s huyt p: Tr s huyt p cng cao th t l t vong cng ln.

- Cc bin chng: L yu t tin lng gn rt quan trng nht l khi c bin chng.

- V tin lng xa: Cholesterol mu c v tr quan trng v d a n x va ng mch vnh, nhi mu c tim sau ny.

- Vn iu tr cng gi vai tr ng k, tin lng kh quan nu iu tr sm, ng cch, c theo di lu di.

IX. KT LUN

Tng huyt p l mt bnh chn on xc nh d nhng vn cn phc tp v bnh nguyn, c ch, vic iu tr c nhiu tin b nhng khng trnh khi nhng tc dng ph ng k. Bnh nh hng ln n sc khe con ngi. V vy tng huyt p l vn ln ang c nc ta v th gii quan tm. Trong iu tr tng huyt p cn ch phi hp iu tr bnh nguyn v c bit l cc yu t nguy c.

28

SUY TIM

Mc tiu

1. Nu c cc nguyn nhn suy tim.

2. Trnh by c cc triu chng lm sng v cn lm sng.

3. Vn dng c trong chn on suy tim.

4. Hc thuc cc thuc s dng iu tr suy tim

5. Nm vng cc phc iu tr suy tim

Ni dung

I. I CNG

1. nh ngha: Suy tim l trng thi bnh l, trong c tim mt kh nng cung cp mu theo nhu cu c th, lc u khi gng sc ri sau c khi ngh ngi.

Quan nim ny ng cho a s trng hp, nhng cha gii thch c nhng trng hp suy tim c cung lng tim cao v c trong giai on u ca suy tim m cung lng tim cn bnh thng.

2. Dch t hc: Ti chu u trn 500 triu dn, tn sut suy tim c lng t 0,4 - 2% ngha l c t 2 triu n 10 triu ngi suy tim. Ti Hoa K, con s c lng l 2 triu ngi suy tim trong 400.000 ca mi mi nm. Tn sut chung l khong 1-3% dn s trn th gii v trn 5% nu tui trn 75. Ti nc ta cha c thng k chnh xc, nhng nu da vo s dn 70 triu ngi th c n 280.000 - 4.000.000 ngi suy tim cn iu tr.

II. NGUYN NHN

1. Suy tim tri: Tng huyt p ng mch, h hay hp van ng mch ch n thun hay phi hp, nhi mu c tim, vim c tim do nhim c, nhim trng, cc bnh c tim, cn nhp nhanh kch pht trn tht, cn cung ng nh, rung nh nhanh, cn nhp nhanh kch pht tht, blc nh tht hon ton, hp eo ng mch ch, tim bm sinh, cn ng ng mch, thng lin tht.

2. Suy tim phi: Hp van 2 l l nguyn nhn thng gp nht, tip n l bnh phi mn nh: Hen ph qun, vim ph qun mn, lao x phi, gin ph qun, nhi mu phi gy tm ph cp. G vo ct sng, d dng lng ngc, bnh tim bm sinh nh hp ng mch phi, t chng Fallot, thng lin nh, thng lin tht giai on mun, vim ni tm mc nhim trng, tn thng van 3 l, ngoi ra mt s nguyn nhn t gp nh u nhy nh tri. Trong trng hp trn dch mng ngoi tim v co tht mng ngoi tim, triu chng lm sng ging suy tim phi nhng thc cht l suy tm trng.

3. Suy tim ton b: ngoi 2 nguyn nhn trn dn n suy tim ton b, cn gp cc nguyn nhn sau: bnh c tim gin, suy tim ton b do cng gip trng, thiu Vitamine B1, thiu mu nng.

III. C CH BNH SINH

Chc nng huyt ng ca tim ph thuc vo 4 yu t: Tin gnh, hu gnh, sc co bp c tim v nhp tim.

1. Tin gnh: l ko di ca cc si c tim sau tm trng, tin gnh ph thuc vo lng

Sc co bp

Hu gnh

Tn s tim

Cung lng tim Tin gnh

29

mu dn v tht v c th hin bng th tch v p lc mu trong tm tht th tm trng.

2. Hu gnh: hu gnh l sc cn m tim gp phi trong qu trnh co bp tng mu, ng hng u l sc cn ngoi vi, hu gnh tng th tc cc si c tim gim; do th tch tng mu trong th tm thu gim.

3. Sc co bp c tim: Sc co bp c tim lm tng th tch tng mu trong th tm thu, sc co bp c tim chu nh hng ca thn kinh giao cm trong c tim v lng catcholamine lu hnh trong mu.

4. Tn s tim: Tn s tim tng s tng cung lng tim, tn s tim chu nh hng ca thn kinh giao cm trong tim v lng Catcholamine lu hnh trong mu. Suy tun hon xy ra khi ri lon cc yu 1,2 v 4, suy tim xy ra khi thiu yu t 3.

Trong suy tim, cung lng tim gim, giai on u s c tc dng b tr

- Mu li tm tht lm cc si c tim b ko di ra, tm tht gin, sc tng mu mnh hn nhng ng thi cng tng th tch cui tm trng.

- Dy tht do tng ng knh cc t bo, tng s lng ti lp th, tng s n v co c mi nh du bt u s gim st chc nng co bp c tim. Khi cc c ch b tr b vt qu, suy tim tr nn mt b v cc triu chng lm sng s xut hin.

5. C ch b tr trong suy tim

5.1. B tr ti tim

Gin tm tht: L c ch thch ng u tin trnh qu tng p lc cui tm trng ca tm tht. Khi tm tht gin ra s lm ko di cc si c tim v theo nh lut Frank-Starling s lm tng sc co bp cc si c tim nu d tr co c vn cn.

Ph i tm tht: Tim cng c th thch ng bng cch tng b dy cc thnh tim nht l trong cc trng hp tng p lc trong bung tim. Vic tng b dy cc thnh tim ch yu i ph vi tnh trng tng hu gnh v ci thin th tch tng mu b gim trong suy tim .

Hnh : T bo c tht bnh c tim ph i v suy tim. S kch thch tng trng dn n s

khc bit v hnh thi hc ca t bo c.

5.2. B tr ngoi tim

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- Kch thch h thn kinh giao cm: Khi c suy tim h thn kinh giao cm c kch

thch, lng catecholamine t cc u tn cng cc si giao cm hu hch c tit ra nhiu

lm tng sc co bp ca c tim v tng tn s tim. Cng giao cm s co mch ngoi vi nh

da, c, thn v cc tng bng u tin ti mu cho no v tim.

- Kch thch h Renin-Angiotensin-Aldosteron: Tng hot ha giao cm v ti mu ti

thn s kch thch b my cnh cu thn ch tit nhiu renin v lm tng nng renin trong

mu. Renin s hot ha Angiotensinogen v cc phn ng tip theo tng tng hp

Angiotensin II. Chnh Angiotensin II l cht co mch mnh, ng thi li tham gia kch thch

tng hp Noradrenalin u tn cng cc si thn kinh giao cm hu hch v Adrenalin t

ty thng thn. Cng chnh Angiotensin II cn kch thch v thng thn tit Aldosteron lm

tng ti hp thu Natri v nc ng thn.

- H Arginin-Vasopressin: suy tim giai on mun, vng di i- tuyn yn c

kch thch tit ra Arginin-Vasopressin (ADH). ADH lm tng thm tc dng co mch ngoi

vi ca Angiotensin II v lm gim bi tit nc ng thn. C 3 h thng co mch b tr ny

nhm duy tr cung lng tim, nhng lu ngy chng li lm tng tin gnh v hu gnh, tng

nc v Natri, tng cng v mc tiu th oxy c tim, to nn vng xon bnh l lm tim

ngy cng suy thm.

- Nhng yu t khc: Trong suy tim nhm c gng hn ch vic co mch khu tr hay

ton thn qu mc, cc cht gin mch khc cng c gia tng sn xut nh: Bradykinin,

Prostaglandin (PGI2,PGE2), Endothelin v c bit l yu t li niu nh ANP , m ngy nay

ch yu l BNP c xem l yu t quan trng trong vic chng ri lon chc nng tht tri,

lm ci thin tnh trng suy tim.

IV. PHN LOI SUY TIM

4.1. Suy tim cp v suy tim mn

Biu hin ca suy tim ty thuc vo tc din tin v thi gian hin tng tch t

dch m k xy ra. Nhn chung nu bnh tim gc din tin chm, cc c ch b tr c thi

gian hot ha, bnh nhn c kh nng iu chnh ph hp vi tnh trng thay i cung

lng tim. Nu bnh l gc din tin nhanh hoc km yu t thc y suy tim, kt qu c th

l ti mu c quan khng hoc sung huyt cp tnh. Ging tnh mch dn lu v tht b

nh hng, gy ra mt b tim t ngt km theo gim cung lng tim v khi pht cp tnh

cc triu chng.

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Trong suy tim mn, c ch thch nghi c hot ha mt cch t t v tim ph i dn. Nhng

thay i ny cho php bnh nhn iu chnh v dung np hin tng gim cung lng d dng

hn. Khi suy tim tri xy ra t t, tim phi to ra p lc cao hn p ng vi tnh trng khng

lc mch mu phi cao; trng hp khng lc mch mu phi tng cp tnh ti mc tng t c

th gy nn bnh cnh suy tim phi cp. Bnh nhn suy tim mn c th t c tnh trng b

tr nhng sau c th mt b cp tnh nu c yu t thc y.

4.2. Suy tim phi v suy tim tri

Suy tim thng ch b mt bn nu khi u t ngt (v d: Trong NMCT). Kh nng cha

mu ca h tnh mch bn tri nh hn h tnh mch ton thn bn phi, v tng p lc tnh

mch cng nh cc triu chng km theo ca suy tim tri xy ra khi c s tch t dch tng

i t hn. Mc d qu trnh bnh ban u c th ch lin quan n mt tht, nhng v sau

thng c hai tht u b suy, nht l khi tht tri b tn thng trc. C hai tht c chung

vch lin tht v nhng thay i sinh ha khng ch gii hn bung tht b tn thng m

nh hng n bung tht bn kia. Thm vo , do c bn bung tim nm trong khoang

mng ngoi tim, khi kch thc ca bt k bung no tng ln t ngt, bung tim i din s

b chn p v p lc y tht tng ln (iu ny c nh ngha nh l s ph thuc ln

nhau gia cc bung tht). Suy tim tri thng gy suy tim phi, nhng suy tim phi n c

(V d: Thng lin nh, tm ph mn) him khi gy suy tim tri nu khng c mt bnh l tim

tri ring km theo (V d: Bnh mch vnh vi thiu mu cc b hoc NMCT). cc bnh

nhn b suy tht tri, tim phi suy c th lm gim cc triu chng h hp (kh th khi gng

sc, kh th khi nm, kh th v m) thng c trong suy tim tri .

4.3. Suy tim cung lng cao v suy tim cung lng thp

Phn ln trng hp suy tim thng km theo tnh trng cung lng thp, gy ra nhng

thay i tun hon ngoi bin (co mch), bao gm biu hin u chi lnh, m v xanh tm;

thiu niu; p lc mch thp v chnh lch oxy gia mu trn tnh mch v mu ng

mch thng ln. Suy tim cung lng cao, vn t gp hn, thng kt hp vi trng thi tng

ng tun hon (thiu mu, nhim c tuyn gip, c thai, bnh xng Paget, d ng tnh

mch). Cc tnh trng ny thng lm khi pht suy tim trn nn mt bnh l tim c sn.

Khng ging nh tnh trng suy tim cung lng thp c tnh trng co mch, trong suy tim

cung lng cao bnh nhn c tnh trng gin mch, da m, phng v mch ny mnh.

chnh lch oxy gia mu ng mch v mu trn tnh mch bnh thng hay gim nhng

thng cao hn mc ca bnh nhn suy tim cung lng thp. Mc d ch s tim thng cao

32

hn bnh thng (

33

tim dn n bt thng v y tht (suy tim tm trng). Gim y tht tri do ri lon

chc nng tm trng gy gim th tch nht bp v cc triu chng ca cung lng tim thp,

trong khi tng p lc y dn n cc triu chng ca sung huyt phi. V vy, mt s c

trng ca suy tim (v d: Tht tri mt kh nng cung cp cung lng v pha trc p

ng nhu cu ca c vn khi vn ng, ng thi duy tr p lc y tht bnh thng) c th

ban u l do ri lon chc nng tm trng, v c th xy ra mt s bnh nhn c chc nng

tm thu tht tri bnh thng. Khng c d liu chnh xc no v tn sut ca ri lon chc

nng tm trng dn n suy tim, vi cc chc nng tm thu bnh thng. Tuy nhin nhiu

nghin cu chng minh rng c n 40% bnh nhn trong s cc bnh nhn c chn on

lm sng suy tim c chc nng tm thu tht tri bo tn, v nhiu ngi trong s cc bnh nhn

ny c bng chng ca ri lon chc nng tm trng. Mt vi yu t c th lm tng nguy c

ri lon chc nng tm trng trong trng hp chc nng tm thu tht tri bnh thng.

Nhng yu t lin quan vi ri lon chc nng tm trng tht tri

- Bnh ng mch vnh

+ Thiu mu c tim

+ So v ph i th pht sau nhim trng c tim

- Ph i tht tri

- Bnh c tim gin

- Qu ti th tch

- Gia tng hu ti

- X ha c tim

- Hn ch y

+ Vim mng ngoi tim co tht

+ Bnh c tim tc nghn

+ Bnh thm nhim c tim (v d: amyloidosis)

Biu hin lm sng chnh ca suy tim tm thu l do cung lng tim v pha trc khng

; hu qu chnh ca suy tim tm trng lin quan n s gia tng p lc y tht v p

lc tnh mch pha trc tm tht, gy ra sung huyt phi hoc sung huyt tnh mch h thng

hoc c hai. Suy tim tm thu gy ra do suy chc nng co bp c tim mn tnh sau hoi t c

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tim do nhi mu trc v s gim sc co bp c tim cp tnh trong thiu mu cc b c

tim. Mt khc, suy tim tm trng cc bnh nhn b bnh ng mch vnh trc tin l do

gim n hi ca tht v tng cng do m c tim bnh thng, n hi b thay th bi

m so x khng cng gin (v d: Vng NMCT) cng nh do gin tm trng ca c tim

bnh thng b gim cp tnh trong giai on thiu mu c tim thong qua. Suy tim cc bnh

nhn b bnh ng mch vnh thng l kt qu ca s kt hp gia ri lon chc nng tm

thu v tm trng .

V. CHN ON

1. Suy tim tri

1.1. Triu chng lm sng

- Triu chng c nng:

C 2 triu chng chnh: Kh th v ho. Kh th l triu chng thng gp nht. Lc u kh th khi gng sc, v sau tng cn, c khi kh th t ngt, c khi kh th tng dn; ho hay xy ra vo ban m khi bnh nhn gng sc, ho khan, c khi c dm ln mu.

- Triu chng thc th:

- Khm tim: Nhn thy mm tim lch v pha bn tri, nghe c ting thi tm thu nh mm do h van 2 l c nng.

- Khm phi: Nghe c ran m 2 y phi. Trong trng hp cn hen tim c th nghe c nhiu ran rt, ran ngy.

- Huyt p: HATT bnh thng hay gim, HATTr bnh thng.

1.2. Cn lm sng

- X quang: Phim thng tim to, nht l cc bung tim tri, nh tri ln hn trong h 2 l, tht tri gin vi cung di tri phng v dy ra, phi m nht l vng rn phi.

- in tm : Tng gnh tm trng hay tm thu tht tri. Trc tri, dy tht tri.

- Siu m tim: Kch thc bung tht tri gin to, siu m cn cho bit c chc nng tht tri v nguyn nhn ca suy tim tri nh h van ng mch ch...vv.

1.3. Thm d huyt ng: Nu c iu kin thng tim, chp mch nh gi chnh xc mc nng nh ca mt s bnh van tim.

2. Suy tim phi

2.1. Lm sng

2.1.1. Triu chng c nng: kh th nhiu hay t ty theo mc suy tim, kh th thng xuyn, nhng khng c cn kh th kch pht nh suy tim nh suy tim tri. Xanh tm nhiu hay t ty nguyn nhn v mc ca suy tim phi.

2.1.2.. Du chng thc th: Ch yu l mu ngoi bin vi gan to, b t, mt nhn, n au tc, iu tr tch cc bng tr tim v li tiu gan nh li, ht iu tr gan to ra gi l gan n xp, nu gan b mu lu ngy gan khng nh li c gi l x gan tim vi gan b sc, mt chc. Tnh mch c ni, phn hi gan tnh mch c (+) t th 450. p lc tnh mch trung ng v tnh mch ngoi bin tng cao.

- Ph: Ph mm lc u 2 chi di v sau ph ton thn, c th km theo c trng, trn dch mng phi. Tiu t 200-300ml/ 24gi.

- Khm tim: Ngoi cc du hiu ca nguyn nhn suy tim, ta cn nghe nhp tim nhanh, c khi c ting nga phi phi, thi tm thu van 3 l do h van 3 l c nng hu qu ca dn

35

bung tht phi. Huyt p tm thu bnh thng, huyt p tm trng tng.

2.2. Cn lm sng

- X quang: Tr trng hp suy tim phi do hp van ng mch phi c c im l phi sng, cn li cc nguyn nhn suy tim phi khc trn phim thng phi m, cung ng mch phi gin, mm tim hch ln do tht phi gin. Trn phim nghing tri mt khong sng sau xng c.

- in tm : Trc phi, dy tht phi.

- Siu m tim: Tht phi gin to, tng p ng mch phi.

- Thm d huyt ng: Tng p lc cui tm trng tht phi, p lc ng mch ch thng tng.

3. Suy tim ton b: Bnh cnh suy tim phi thng tri hn. Bnh nhn kh th thng xuyn, ph ton thn, tnh mch c ni t nhin, p lc tnh mch tng cao, gan to nhiu, thng c c trng, trn dch mng phi, huyt p tm thu gim, huyt p tm trng tng, Xquang tim to ton b, in tm c th dy c 2 tht.

VI. PHN SUY TIM

1. Theo Hi Tim Mch New York: thng dng nht hin nay.

Chia lm 4 : 1: Bnh nhn c bnh tim nhng khng c triu chng c nng, hot ng th lc vn bnh thng. 2: Cc triu chng c nng ch xut hin khi gng sc nhiu, hn ch hot ng th lc. 3: Cc triu chng c nng xut hin ngay c khi gng sc nh, lm hn ch hot ng th lc. 4: Cc triu chng c nng xut hin thng xuyn k c khi bnh nhn ngh ngi.

2. Phn suy tim mn theo Trn Trinh & V nh Hi: t x dng hin nay

- Suy tim 1: Kh th khi gng sc, ho ra mu, khng ph, gan khng to.

- Suy tim 2: Kh th khi i li vi vn tc trung bnh, khi i phi ngng li th, ph nh, gan cha to hoc to t, 2cm di b sn. Phn hi gan tnh mch c (+) t th 45

0.

- Suy tim 3: Kh th nng hn hoc gim i, ph ton, gan > 3cm di sn, mm, phn hi gan tnh mch c (+) t th 450, iu tr gan nh li hon ton.

- Suy tim 4: Kh th thng xuyn, bnh nhn phi ngi dy th, gan > 3cm di b sn, mt chc, b sc, iu tr khng p ng hoc nh li t.

3 . Chn on suy tim theo tiu chun Framingham: tiu chun mi c ch x dng gn

y nhng kh p dng trn lm sng,

Tiu chun chnh Tiu chun ph

- Kh th kch pht v m hoc kh th

t th nm.

- Tnh mch c ni.

- Ran m phi.

- Tim to.

- Ph phi cp.

- Ting nga phi T3 tim.

- Ph c chn.

- Ho v m.

- Kh th khi gng sc.

- Gan ln.

- Trn dch mng phi.

- Dung tch sng gim 1/3 so vi ti a.

- Nhp tim nhanh >120 ln/pht.

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- p lc tnh mch tng (> 16cm H2O).

- Thi gian tun hon >25 giy.

- Phn hi gan tnh mch c (+).

- Gim 4,5kg/ngy iu tr suy tim.

Chn on xc nh suy tim khi c: 2 tiu chun chnh hoc 1 tiu chun chnh km

theo 2 tiu chun ph.

4. Phn suy tim theo Hunt SA

Suy tim l mt hi chng ca nhiu bnh l khc nhau, c th tin trin khng ngng. iu tr

suy tim cng thay i theo tng giai on tin trin ca bnh. Do , t nm 2001, Hunt SA

v cng s phn suy tim ra lm nhiu giai on: A, B, C, D.

- Giai on A: Bao gm nhng bnh nhn c nguy c suy tim (V d: Tng huyt p, i tho

ng, Hi chng chuyn ho...) nhng cha c tn thng thc th trn tim v cha c triu

chng c nng suy tim.

- Giai on B: L mc tin trin ca giai on A, bnh nhn c tn thng thc th ca tim

nhng cha c triu chng c nng hay triu chng thc th ca suy tim.

- Giai on C: Nng hn, bnh nhn c tn thng thc th ca tim, tin s hay hin ti c

triu chng c nng ca suy tim.

- Giai on D: L giai on nng nht, suy tim khng tr, kh th khi ngh d dng thuc

ti a, cn nhng bin php iu tr c bit nh my tr tim, ghp tim. . .

VII. IU TR SUY TIM

1. Cc thuc iu tr suy tim.

1.1. Digitalis

c a vo s dng iu tr suy tim t lu, hin gi vn cn c s dng rng ri. N c c tnh sau:

- Tng sc co bp c tim.

- Lm chm nhp tim.

- Lm gim dn truyn trong tim.

- Tng tnh kch thch c tht.

* Ch nh

Digital c ch nh r rng trong suy tim tr c rung nh. Tuy nhin nu l nhp xoang th vai tr ca n vn cn b tranh ci. Ngoi ra ch nh khc ca n l trong cc lon nhp trn tht nh rung nh, cung nh, nhp nhanh trn tht kch pht kiu Bouveret.

* Chng ch nh

Tuyt i khi c nhim c digital.

Cc chng ch nh khc:

- Bloc nh tht 2 v 3 khng c my to nhp.

37

- Trng thi tht cng kch thch nng.

- Bnh c tim nghn.

- Thiu oxy.

- H kali mu.

Digital t c li v thm ch c th cn nguy him khi: nhi mu c tim cp (ngoi tr nu c cn rung nh nhanh), suy tim nhp chm khng c my to nhp, suy tim giai on cui, tm ph mn, vim mng ngoi tim co tht, suy tim c cung lng tim cao, cc bnh tim do qu ti chuyn ha nh nhim thit huyt t, nhim bt.

* Giao thoa thuc

Cc thuc sau c th lm tng nng digoxin: erythromycin, tetracycline, quinidine, amiodarone, verapamine.

Trong iu tr suy tim mn c hai loi hay c dng l digoxin v digitoxin nhng v digoxin tc dng nhanh, thi nhanh do t hiu qu iu tr nhanh trong khi kh gy ng c nn c a dng hn. Lu l digoxin thi qua thn v digitoxin thi qua gan v th nu suy thn nn dng digitoxin trong khi suy gan th nn dng digoxin. ph n c thai digitoxin qua c hng ro nhau thai trong khi digoxin th khng. Trn thc t khng c mt phc no hon ton ng cho mi bnh nhn. Liu iu tr ty theo nhy cm ca ngi bnh vi thuc theo nguyn tc l ngi gi hoc l suy tim vi tim dn rt ln, ngi bnh gy th phi gim liu thuc. Ni chung liu thng thng iu tr tn cng l digoxin 0,25mg (2 ln / ngy trong vng mt tun sau tr v liu duy tr l1/2 - 1 vin / ngy, ung cch nht hoc l thm ch c th ung hng ngy khng ngh ty theo i tng. i vi digitoxin bt buc phi ngh chng hn ung 3 ngy ngh 3 ngy do thi gian na i di. Vng iu tr ca thuc: digoxin mu 1- 2,5ng/ml, digitoxin mu 15- 35 ng/ml. Tuy nhin i vi tr em vng hiu qu xung quanh 3 (1ng/ml khi iu tr phi theo di cc triu chng ng c c thi x tr kp thi.

1.2. Ch ngh ngi v tit thc

Ch hot ng ca ngi bnh ty thuc vo mc suy tim. Khi c suy tim nng phi ngh ngi tuyt i ti ging bnh. n nht l cn thit di 2gam mui /ngy nu suy tim I v II, di 0,5gam/ngy nu suy tim II,IV.

1.3. Thuc li tiu

Vn c coi l ch o trong iu tr suy tim tr. Vi suy tim nh th li tiu thiazide liu va phi cng p ng tt phi hp vi ch n nht. Khng nht thit phi cho sm thuc li tiu quai tr phi khng c p ng vi Thiazide. Liu thuc Thiazide 25mg (1-4 vin / ngy, Trofurit 40 mg (2-3 vin/ ngy. Hai loi ny l li tiu thi mui cho nn phi cho tng t mui kali km theo (1-2g/ngy). Khi tnh trng tr nng c th phi hp tng t vi li tiu gi kali tc dng ng ln xa (Spironolactone) v lc hay c cng aldosterone th pht.

1.4. Thuc dn mch

* Cc dn cht nitrate

c s dng rng ri nhm gim triu chng h hp (kh th) ca suy tim. Liu khi u nh sau tng t t nhm trnh tc dng ph nh au u. Liu iu tr i vi Isosorbide dinitrate khong 120mg/ngy. Tng t c th dng mononitrate, trinitrine dn, molsidomine.

* Cc cht dn ng mch C tc dng ci thin tnh trng cung lng thp. Hydralazine hiu qu nhng nhc im phi dng liu cao kh thc hin (12 - 16 vin chia 4). Prazosine c tc dng cng tt nhng b yu i kh nhanh chng sau . Ni chung ngy nay cc thuc ny t c s dng.

* Cc thuc c ch men chuyn

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lm ci thin r rt tin lng ca bnh nhn b suy tim. N khng nhng ci thin triu chng m cn ci thin c c tin lng sng. Nguyn tc s dng phi tun theo nhm trnh tai bin do thuc c th xy ra nht l nhng bnh nhn ang c dng li tiu. Liu khi u nh (6,25mg/ngy vi Catopril) sau tng ln ti liu 50 - 150mg/ngy ty theo trng hp.

1.5. Cc thuc c ch beta

Trc kia c xem nh chng ch nh. Tuy nhin gn y chnh thc a vo iu tr suy tim. Cc loi thuc sau c chp nhn rng ri: metoprolol, bisoprolol v nht l Carvedilol. S dng thuc ny theo nguyn tc l cho khi suy tim n nh (khng dng trong suy tim cp), liu nh tng dn. Vi Carvedilol vin 12,5mg liu khi u 1/4-1/2 vin/ngy.

1.6.Cc cht c ch phosphodiesterase (Amrinone, Milrinone, Enoximone)

C ch tc dng l tng lng AMPc t c hai tc dng:dn ng mch v tng co bp c tim khng l thuc vo cc th th (. Thuc c dng trong suy tim vi biu hin suy huyt ng nng sau khi dng dopamin v dobutamin khng c hiu qu.

2. iu tr theo th loi suy tim

2.1.Suy tim cp

Bng 1. Cc bin php x tr trong suy tim cp

1. Bin php chung An thn bng morphin

2. iu chnh cc yu t lm d Lon nhp, thiu mu, tng huyt p

3. iu chnh thiu oxy Th oxy, h hp h tr nu cn.

4. iu tr c hiu Thuc: li tiu, gin mch,tng co bp c tim, bng ni ng mch ch, phu thut: thay van, ng l thng bm sinh.

Bng2. Cc thuc dng trong iu tr suy tim tri cp.

Thuc C ch Tc dng sinh l Hiu qu iu tr

Li tiu

*Furosemide 40-80mg tim TM

Li tiu

Gim tin gnh

Chng ph phi

Dn mch

*Morphin 5-10mg TM, TB,

TDD.

*Trinitrin:10-150(g/pht truyn tnh mach hoc cc dn cht nitrat dng ngm, ung.

*Nitroprusside: 25-150(g/pht

Dn tnh mch

Dn tnh mch

Dn tiu ng mch v tnh mch

Gim tin gnh

Gim tin gnh

Gim tin gnh v hu gnh

Chng ph phi

Chng ph phi

Chng ph phi v tng lu lng tim

Tng co bp c tim

*Dobutamine: 250-750(g/pht

*Dopamine: 100-600(g/pht

*Digital(lanatoside C,

digoxine)1 ng tnh mch

Ging giao cm

Ging giao cm

Tng co bp tim

Tng co bp tim, gim hu gnh (liu thp), tng hu gnh (liu cao).

Tng lu lng tim

Tng lu lng tim, tng huyt p (liu cao).

Chng ph phi lm

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c ch bm

Na-K ATPase

Tng co bp tim, gim tin gnh v hu gnh.

gim p lc phi.

2.2.Suy tim mn tnh

* Cc mc tiu iu tr suy tim mn

S 1: Thi x tr suy tim mn

Phc iu Tr Suy Tim (Theo M. KOMAJDA v Y. GROSGOGEAT)

Giai on suy tim (NYHA)

Phng php kinh in Phng php thay th

I Khng iu tr Khng iu tr

II - Hn ch th lc

- Ch n king mui

- Digital

-Digital + Li tiu Thiazid

- Hn ch th lc

- Ch n king mui

- Li tiu? c ch men chuyn?

- Li tiu + CMC hoc

Li tiu + Dn mch

III - Digital + Li tiu quai.

- Digital + Li tiu + Dn mch

- Li tiu + CMC hoc Dn mch + Digital ? hoc

- Li tiu + CMC hoc Dn mch + thuc tr tim?

- Chn bta?

- Ghp tim.

IV - Digital + Li tiu + Dn mch + Thuc tr tim mi

- Ghp tim

Phc iu tr suy tim theo cc giai on ABCD ca Hi Tim mch Hoa k

40

TL: Jessup M et al. N Engl J Med 2003; 348: 2007 - 2018

Phc iu tr suy tim phn xut tng mu gim theo Hi Tim mch Hoa k

TTLL :: MMaannnn DDLL.. HHaarrrriissoonnss PPrriinncciipplleess ooff IInntteerrnnaall MMeeddiicciinnee 1177tthh eedd MMccGGrraaww HHiillll,,

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SUY MCH VNH

Mc tiu

1.Nm c nguyn nhn chnh gy bnh mch vnh.

2.Nm c triu chng, cch chn on.

3.Nm c cc th lm sng ca cn au tht ngc

4.Nm vng nguyn tc iu tr, cc phng tin ni ngoi khoa iu tr suy vnh.

Ni dung

I. I CNG

1.1.i cng:

Bnh mch vnh l mt bnh rt thng gp trong s cc bnh tim cc nc pht trin. C ch bnh sinh ca suy mch vnh l do lng ng m lp di ni mc cc ng mch vnh. Tnh trng x va tin trin dn dn lm hnh thnh cc mu ng gy thuyn tc trong lng mch. Bin chng ch yu ca bnh mch vnh l gy cn au tht ngc, nhi mu c tim v t t.

1.2.Dch t hc ca BMV:

au tht ngc v nhi mu c tim chim khong 6% n ng >50 tui. chu u hng nm c thm khong 0,3-0,6 % ngi mc bnh. V t l t vong th mi nm c khong 120-250 ngi cht / 100.000 ngi dn cc nc cng nghip pht trin. T l ny tng ln vi tui: 800 - 1000 ngi cht /100.000 la tui 65 - 74 i vi nam gii, 300/100.000 i vi ph n cng la tui (Vademecum clinique 1988).

Vit nam cha c thng k ton dn nhng cc thng k ti cc bnh vin ln cho thy bnh nhn b bnh mch vnh hu ht tui 50 tr ln. Nm 1996 thnh ph H ni c khong 200 bnh nhn BMV nhp vin cn thnh ph H ch Minh c khong 400 bnh nhn.

II. BNH NGUYN

2.1.Bnh mch vnh: l nguyn nhn ch yu.

- a s l do x va mch vnh.

- Khng phi do x va: co tht mch vnh, vim mch (vim nhiu ng mch dng nt, lupus ban , bt thng bm sinh).

2. Bnh van tim: Bnh van ng mch ch: hp, h van ng mch ch do x va v giang mai.

3. Bnh c tim ph i:

Hai nhm nguyn nhn sau ny c th gy suy mch vnh c nng trong ng mch vnh khng c hp.

III. C CH BNH SINH

3.1. C tim v oxy

S tiu th oxy c tim: ph thuc vo:

+ Tn s tim

+ S co bp c tim.

+ Sc cng trong thnh tim: Sc cng ny ph thuc vo p lc trong bung tht v th tch tm tht.

S gia tng mt trong cc yu t trn s lm gia tng s tiu th oxy c tim. Ni cch khc s tiu th ny t l theo:

42

-Tn s tim x p lc ng mch tm thu

-Tn s tim x p lc ng mch tm thu x Thi gian tng mu.

3.2. D tr vnh: gm 2 thnh phn: d tr vnh v dng mu vnh.

- D tr vnh (reserve coronaire): D tr vnh c thc hin bng cch ly oxy ca c tim, hu nh ti a trng thi c bn. D tr lu lng vnh c kh nng gia tng n 300 - 400% tr s c bn. S thch nghi v gia tng nhu cu oxy thng km theo s gia tng song song ca lu lng vnh. Lu lng vnh ph thuc vo: p lc ti mu v sc cn vnh do kh nng dn mch di ngoi tm mc.

- Dng mu vnh (flux coronaire): thng ly mu ti a k tm trng. Do kh nng dn cc mch mu ni tm mc rt yu, v vy khi c gim lu lng vnh s ti mu s xy ra ch yu di ni mc.

3.3. Kh nng vn mch ca ng mch vnh: ph thuc vo

- Yu t co tht mch

+ Sc bp k tm thu: quan trng i vi tht tri hn tht phi.

+ Cu c bt qua mt ng mch vnh thng tm mc.

+ Kch thch th th alpha, c ch th th bta vi Dopamine liu trn 15mg/kg/ph qua trung gian noradrenaline, trc nghim lnh, dn xut ca lo mch - thromboxane A2 - prostaglandine F - Neuropeptide Y.

- Yu t dn mch

+ Cc cht bin dng do TMCT: adenoside, lactate, ion H+, CO2, bradykinine.

+ c ch th th alpha - kch thch th th bta vi dopamine liu di 5mg/kg/ph - cc th th i giao cm kch thch i giao cm qua trung gian acetylcholine, c ch calci, dn xut nitr - prostacycline - prostaglandine E, EDRF (yu t dn ni mc) - VIP (peptid rut dn mch: vasodilatator intestinal peptid).

3.4. Tnh trng thiu mu c tim (TMCT)

Xut hin khi c s mt cn bng gia cung cp oxy v nhu cu oxy c tim.

- C ch: c th do hu qu

+ Gia tng nhu cu oxy (thiu mu th pht): khi gng sc s gia tng tiu th oxy c tim c thc hin qua s gia tng tn s tim, HA tm thu v s co bp c tim. Trong trng hp hp MV c ngha (>70% ng knh ng mch vnh), lu lng vnh khng th p ng vi s gia tng nhu cu oxy s a n TMCT.

+ S gim t ngt lu lng vnh (thiu mu nguyn pht): tng ng vi s co tht mch vnh m khng c tn thng mch mu, tuy vy cng c th xy ra trn mt ng mch vnh b hp t trc.

Cn au tht ngc xy ra khi nhu cu oxy ca c tim vt qu kh nng chu cp ca h thng mch vnh. au l biu hin trc tip ca thiu mu cc b c tim v s tch ly cc cht chuyn ha do thiu oxy. Mt khi c tim thiu mu cc b, pH gim trong xoang vnh, mt kali t bo, tng sn xut lactat, xut hin cc bt thng ECG, chc nng tht xu i. Cc yu t xc nh tiu th oxy c tim l nhp tim, s co bp c tim, p lc tm thu. Khi c tng mt hoc l nhiu yu t ni trn cng vi tnh trng dng mu vnh gim th s to ra cn au tht ngc.

3.5. Hu qu TMCT:

- V bin dng: tit lactate.

- V huyt ng: ri lon s th gin, gim co dn tht v sau l gim s co bp.

- V ECG: xut hin ri lon s ti cc.

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- V lm sng: xut hin cn au tht ngc.

III. GII PHU BNH

Mt hoc nhiu ng mch vnh b hp do mng x va. C nhng vng hoi t v x trong c tim, thng thng khu tr trong lp di ni tm mc. Tht tri c th ph i.

IV. TRIU CHNG

4.1. Triu chng c nng: l cn au tht ngc vi c im sau:

V tr: sau xng c.

Hng lan: xung mt trong cnh tay, tn cng ngn nhn v ngn t ca tay tri, tuy nhin n c th lan ln vai ra sau lng, ln xng hm di, ln c.

Tnh cht au: c th m h kiu nh c g chn ngc, co tht hoc nh c vt g nng p ln ngc khng xc nh chnh xc v tr au. Lu l nhng ngi m t im au chnh xc vng mm tim, au nhi nng thong qua th thng khng phi l au tht ngc do suy vnh.

Thi gian: au ngn v ko di khng qu vi pht.

au thng khi pht sau gng sc, gim v mt khi ngh ngi hoc l dng thuc gin vnh. Lnh cng l yu t d gy khi pht cn au.

4.2.Triu chng thc th

Trong cn c th chng c g tuy nhin c th c tng tn s tim v tr s huyt p, nghe c th c thi tm thu gia v cui tm thu do lon chc nng c nh v thiu mu cc b.

4.3.Triu chng ECG:

in tm trong cn au ngc c ch cho chn on, cho thy cc bin i xy ra trong cn suy vnh nh ST chnh xung l in hnh, ngoi ra i khi thy ST chnh ln, ri lon nhp nht l ngoi tm thu tht. Ngoi cn khi ngi bnh ngh ngi ECG thy bnh thng trong 30% trng hp ngi bnh c au tht ngc in hnh.

Bng 4.1.Phn loi cn TN ca Hi Tim mch Canada (CSS)

Vn ng khi pht cn TN Hn ch hot ng thng ngy

I Gng sc ko di Khng

II i b > 2 khu nh Nh

III i b < 2 khu nh Nhiu

IV Ti thiu hoc lc ngh Nng

V. CHN ON

5.1. Chn on xc nh

5.1.1. Chn on lm sng:

Da trn bnh cnh au ngc c trng nh m t trn xy ra khi gng sc v gim bt khi ngh ngi. C th khng nh chn on bng theo di ECG thy hi phc tr v bnh thng cc bin i do thiu mu cc b hoc bng dng test iu tr th vi nitroglycerin di li thy bin mt cn au trong vng 1-3 pht. Nu khng thy gim au nhanh vi nitroglycerin c th khng phi au tht ngc do suy vnh hoc l dng nng nht ca suy vnh l nhi mu c tim.

5.1.2. Chn on cn lm sng

5.1.2. 1. in tim gng sc: gip chn on sm, d hu v theo di iu tr.

44

- K thut: dng xe p lc k hay thm ln, tng dn cng mi 30W i vi xe p hoc dng biu Bruce i vi thm ln. Cn c chuyn vin theo di ECG v HA lin tc khi tin hnh. nhy ca phng php: 60% v c hiu 80% trong pht hin mch vnh. T l t vong di 0,01%.

- Ch nh:

+ Chn on cn au tht ngc n nh hay cn au ngc khng in hnh.

+ Bilan ngi tr c nhiu nguy c bilan b bnh mch vnh n nh c hay khng iu tr.

+ nh gi hiu qu ca iu tr TMCT

+ nh gi kt qu phu thut mch vnh hay sau nong mch vnh, bilan sau nhi mu c tim vo ngy th 10-15.

+ nh gi chc nng ca mt s bnh van tim (tr hp van ng mch ch).

+ nh gi chc nng ca suy tim cn b.

- Tiu chun nh gi da vo nhiu yu t nh: ST chnh xung v nm ngang trn 1mm hoc i xung trn 0,08 mm sau phc b QRS; ST chnh ln (him gp); thi gian gng sc; cng ti a t c; xut hin cn T in hnh; in tm bin i trong hay sau trc nghim gng sc; huyt p v tn s tim; mc t tn s tim theo l thuyt; xut hin lon nhp khi lm test v/ hoc c du suy tim tri.

Kt qu test gng sc gn lin vi tui v gii ngi bnh (kh kt lun ph n 20% ngi < 40 tui trong khi gim cn < 10% ngi > 60 tui).

5.1.2.2. o in tim Holter trong 24 gi: Gip chn on bnh mch vnh im lng, chn on v theo di cn TN Prinzmetal hoc s gia tng kch thch tm tht.

5.1.2.3. ng v phng x

- Nguyn tc: Kho st s ti mu c tim vng bng cch so snh s phn b cht ng v phng x Thalium 201 vo c tim khi ang gng sc v sau mt thi gian ti ti mu khi ngh ngi.

- ch li v hn ch: Nhy hn trc nghim gng sc (80%), c hiu hn (90%) cho php xc nh vng b thiu mu, nh gi chc nng c tim. Gii hn ca phng php: dng tnh gi nu c block nhnh tri, gi thnh cao.

- Chp bung tht bng phng x: bm tnh mch cht Technium. C th nh gi s co bp tng vng v ton b tht tri cng nh chc nng tim tri.

5.1.2.4. Siu m tim v Doppler

* Siu m 2 chiu: nhm mc ch:

+ Phn tch s hot ng tng phn nh gim co bp, khng co bp thm ch ri lon co bp khu tr, tim bt thng thn chung ca ng mch vnh nh calci ha.

+ Tnh ch s co hi tht tri nhm nh gi chc nng tht tri ton b.

+Vi Doppler gip chn on h van 2 l do thiu mu c tim, p lc mch phi. Cc bin i v s lm y tht, nh gi lu lng ng mch khi gng sc v ngh ngi.

* Siu m tim gng sc: gip chn on khi thy bt thng vn ng thnh tim cho nhy cm chn on > 90% nu hnh nh tt.

5.1.2.5.Chp mch vnh:

Bm cht cn quang chp ton b h mch vnh v bung tht.

i vi h mch vnh c gi tr nh gi mc , v tr tn thng mch vnh cng nh tnh trng ti mu, phn b mch mu, calci ha ng mch, cc bt thng bm sinh.

45

i vi bung tht nhm phn tch s co bp tng phn, chc nng tht tri, ch s tng mu v h 2 l do thiu mu c tim.

Chp ng mch vnh l phng tin quyt nh nh gi nng ca bnh mch vnh cng nh chn on khi cc phng tin thm d khc khng cho php xc nh suy vnh. C th ni chp mch vnh l xt nghim khng th thiu c i vi bnh l mch vnh c bit khi cn thit phi can thip ngoi khoa, tuy vy y l k thut tn km v i hi chuyn khoa c kinh nghim.

5.1.2.6.Chp nhp nhy c tim bng Thallium 201 hoc Technitium 99: c nhy 70-90% v c hiu 60-90% nhng t tin.

5.2. Chn on phn bit

5.2.1. au vng trc tim do ri lon thn kinh thc vt: thng gp trn thc t lm sng nht l tui tr. au thng mm tim, khng c khi pht khi gng sc m l khi ngh ngi. Cn au c th ko di hng gi, hng ngy. Ngoi ra c th km thm cc triu chng ri lon thn kinh thc vt khc.

5.2.2. au do bnh ct sng - xng sn: vim khp, vim thn kinh lin sn. Khm n au khu tr, au khng c lan.

5.2.3. au do bnh ng tiu ha

-au do co tht thc qun cng sau xng c, c km kh nut, . i khi lan ra hai cnh tay v cng gim bt sau khi dng nitroglycerin. Chp thc qun cho php chn on chnh xc.

5.2.4. Hi chng tro ngc d dy - thc qun: gy cm gic nng sau xng c, nng ln khi nm nga, du bt sau khi dng cc thuc khng acide.

VI. CC TH LM SNG CN AU THT NGC:

6.1. au tht ngc n nh: cn au xy ra khi gng sc.

6.2. au tht ngc khng n nh

- Mi khi pht cn au tht ngc nng (< 2 thng) v/hoc xy ra 3 cn/ngy.

- au khi ngh ngi hoc l ch khi hot ng rt nh nhng.

- Cn au tht ngc tng tin: thuc loi n nh nhng gn y nng hn, au ko di hn, hay xy ra hn v xy ra vi gng sc nh hn trc.

Bnh nhn c mt trong 3 tiu chun trn c gi l c cn au tht ngc khng n nh (Harrson 2005).

6.3. Co tht vnh: cn c gi cn au tht ngc Prinzmetal. Xy ra trn mch vnh hon ton bnh thng hoc l c mng x va gy hp gn v tr ca co tht. au tht ngc c tnh tng t nhng m trm trng hn v xy ra in hnh khi ngh ngi cng vi hnh nh on ST chnh ln rt cao trn ECG. Lu l co tht vnh c th gy nn nhi mu c tim cng nh cc ri lon nhp c tnh. Chn on xc nh da trn chp ng mch vnh c tim TM Methergin (ergonovine).

6.4. Thiu mu cc b c tim yn lng: c pht hin bi ghi Holter hoc l trc nghim ECG gng sc ch yu xy ra nhng ngi c thiu mu cc b c tim c triu chng. Ghi nhn c bin i ST-T nhng v triu chng mc d c bnh mch vnh.

6.5. Nhi mu c tim: Xy ra khi tc mt hoc nhiu nhnh ca mch vnh. Nhi mu c tim (NMCT) l s hoi t thiu mu nng v h thng c tim vi din tch tn thng 2cm.

6.5.1. Triu chng lm sng: au ngc tng t nh l cn au tht ngc tuy nhin cng mnh hn nhiu v ko di hn (> 30 pht), t thuyn gim khi ngh ngi v khi dng nitroglycerine. Tuy nhin c 25% nhi mu c tim im lng v mt lm sng.

6.5.2. Triu chng cn lm sng:

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6.5.2.1. in tm thng thng

Nhi mu c sng Q: ST chnh ln, T o ngc, sng Q hoi t.

Nhi mu khng c sng Q: ST chnh xung, bin i dai dng ST-T m khng c xut hin sng Q.

6.5.2.2. Men: tng CPK, CPK-MB, GOT, LDH, Troponin T.

6.5.3.Chn on NMCT

Theo T chc Y t th gii NMCT c chn on xc nh khi c hai trong 3 du hiu sau: cn au tht ngc bin i, thay i ECG theo tin trin ca bnh v s gia tng men tim.

Mt s trng hp khng th chn on xc nh NMCT m ch c th c NMCT. Thng th c triu chng lm sng in hnh rt gi nhng m thiu bng chng khch quan trn ECG v men. Nu lm sng nghi ng nhiu th c th l NMCT nh. Trc mt bnh nhn nam gii >35 tui, n gii >50 tui c au ngc th phi xem xt c NMCT hay khng. Phi chn on phn bit vi au do vim phi, tc ng mch phi, vim mng ngoi tim, gy xng sn, co tht thc qun, phnh tch ng mch ch v nhng tnh hung gy bnh cnh au bng cp tnh do bnh trong bng.

6.5.4. Bin chng

6.5.4.1. Ri lon nhp: ngoi tm thu, rung tht, nhp nhanh tht, bloc nh tht...

6.5.4.2. Suy tim: c chong hoc khng.

6.5.4.3. Phnh thnh tim.

VII. IU TR

7.1. Nguyn tc iu tr

7.1.1 Ci thin cc yu t nguy c

y l bin php hng u c gi tr v t tn km, p dng c cho cc i tng giu/ngho nhng i hi s quyt tm v cng tc ca bnh nhn. C th nh thay i li sng, ch n ung gim m, tp luyn th dc nh: i b, bi li, i xe p, trnh stress. Theo di, khm bnh, xt nghim lipid u n, lm trc nghim gng sc hng nm.

7.1.2. iu tr cn nguyn

Nu bit c. V d: iu tr x va ng mch bng cc thuc gim m, iu tr phu thut vi cc tn thng van tim bm sinh hay mc phi.

7.2. Phng tin

7.2.1. iu tr ni khoa

Bng cc thuc nh: dn xut nitrs, molsidomine, chn bta, c ch calci, c ch knh kali, chng ngng tp.

7.2.2.Nong ng mch vnh qua da (Angioplastie coronaire transluminale percutane) (PTCA)

X dng mt catheter a vo M vnh qua da xc nh mc hp mch vnh, sau s x dng mt bong bng nh, ng knh 2-4mm bm ln v tr b hp, c xem kt qu khi nng c trn 50% so vi khu knh trc, t l thnh cng thng t n 90-95% trong giai on u tin.

7.2.3.Phng php phu thut cu ni ch - vnh (Pontage aorto-coronaire)

Phng php c thc hin bng cch ghp tnh mch hin trong hoc ng mch v trong vo v tr mch vnh b tn thng. T vong phu thut khong 1-4%, phng php ny ci thin d hu v triu chng ca bnh nhi mu c tim.

7.3. iu tr c th:

7.3.1. iu tr cn au tht ngc gng sc

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7.3.1.1.iu tr ct cn au tht ngc gng sc

- Nn p dng ngay trc khi vo vin v p dng cng sm s c tc dng ngn nga bin chng xu xy ra.

- Ngh ngi, trnh gng sc.

- Dng cc dn xut Nitrs ngm di li (Natirose vin 0,75mg) c th

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