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Hng dn mi v phng nga t quy tin pht-2014
PGS.TS Cao Phi Phong lc dch
Thng 10 nm 2014 Hip hi Tim mch v t qu Hoa k pht hnh
hng dn mi v phng nga t qu tin pht, cp nht hng dn c
nm 2011. Bo co cho thy 76% t qu l mi xy ra ln u- nhn mnh
n tm quan trng ca phng nga tin pht
nh gi nguy c t qu tin pht
C bn
1. Cc cng c nh gi nguy c c ch li nhng cn gii hn.
2. Tuy nhin k hoch iu tr s da trn kt qu xem xt ton b cc yu
t nguy c ca bnh nhn
im ct yu: Mt s tc gi cho rng cng c nh gi nguy c t qu
khng hon ho, khng mt ai trong h xem xt tt c cc yu t c tim
nng gy ra t qu. Nhng chng th c ch xc nh s lng nguy c
t qu. y l l do AHA/ACCCV Risk Calculator cp n trong hng
dn. Bnh nhn b t qu hay c nhiu yu t nguy c, cng c nh gi
nguy c c th khng cn thit v thng ri vo nhm iu tr tn cng.
Nu bnh nhn c rung nh, tnh nguy c bng thang im CHADS2 hay
CHA2DS2-VASc c th ch li.
Yu t di truyn
1. Tin s gia nh c th ch li trong xc nh ai gia tng nguy c t qu
(Class IIa; Level of Evidence A).
2.Gii thiu tham vn v di truyn c th xem xt i vi bn c bnh di
truyn gy t qu (Class IIb; Level of Evidence C).
3. Bnh Fabry: xem xt iu tr thay th enzyme, khng cho thy gim nguy
c t qu, hiu qu cha bit. (Class IIb; Level of Evidence C)
4. Xem xt tm sot khng xm ln phnh mch ni s cha v cho bn c
mc ban u lin h xut huyt di nhn hay phnh mch ni s 2
(Class IIb; Level of Evidence C).
5. Xem xt tm sot khng xm ln phnh mch ni s cha v cho bn
bnh thn a nang do nhim sc th thng tri (Autosomal dominant
polycystic kidney disease: ADPKD) v lin h vi ADPKD v xut huyt
di nhn1 hay lin h ADPKD v phnh mch ni s1 (Class IIb; Level of
Evidence C)
6. Xem xt tm sot khng xm ln phnh mch ni s cha v cho bn lon
sn x c vng c (Cervical fibromuscular dysplasia) (Class IIb; Level of
Evidence C)
7. Xem xt dc di truyn hc (pharmacogenetic) liu i vn vitamin K khi
iu tr khi u iu tr(Class IIb; Level of Evidence C)
8. Tm sot khng xm ln phnh mch ni s cha v khng khuyn co
cho bn khng c hn mt lin h vi xut huyt di nhn hay phnh mch
ni s(Class III; Level of Evidence C)
9. Khng khuyn co tm sot phnh mch ni s cho mi c nhn mang
nhim sc th thng tri thn a nang hay Ehlers-Danlos t bin type IV
10. Tm sot di truyn trong cng ng chung phng nga t qu tin
pht th khng khuyn co (Class III; Level of Evidence C)
11. Tm sot di truyn xc nh nguy c bnh c th khng khuyn co khi
xem xt khi u iu tr statin (Class III; Level of Evidence C)
im ct yu: Mc d nguyn nhn di truyn gy t qu lin quan n
tui v chng tc vn cn l nguy c khng sa i c do khng th
thc hin iu tr gene, vic cung cp li khuyn trong cc bnh CADASIL
(cerebral autosomal dominant arteriopathy with subcortical infarcts and
leukencephalopathy) c th c ch cho gia nh b bnh ny. iu tr thay
th enzyme c ch li trong bnh Fabry, bn ri lon chuyn ha lipid, gia
tng nguy c tim mch. Cui cng xc nh nguy c t qu tim tng nh
phnh ng mch cha v, c th tm kim trong cc trng hp chn lc
Khng vn ng c th (Physical Inactivity)
C bn
1. Khuyn co vn ng c th bi v lm gim nguy c t qu (Class I;
Level of Evidence B)
2. Ngi ln khe mnh: th dc th thao tng cng nhp h hp, nhp
tim cng trung bnh n mnh t nht 40 pht/ngy, 3-4 ngy/ tun
(Class I; Level of Evidence B)
im ct yu
Nhiu nghin m t cho thy ch li vic vn ng c th gim nguy c t
qu. Con ngi s tm nhng vn ng m h thch th, th d ngay c i
b cng cho thy gim nguy c t qu. Thi gian luyn tp c th tn ra
cho nhng ngi kh khn luyn tp y thi gian theo khuyn co
Ri lon lipid mu
C bn
Can thip vo li sng (Lifestyle), nguy c tim mch trong 10 nm cao: khi
u iu tr statin
1. Thm vo iu tr thay i li sng, iu tr thuc HMG coenzyme-A
reductase inhibitor (statin) c khuyn co trong phng nga t qu
thiu mu tin pht cho bn c tnh c nguy c tim mch 10 nm cao
(2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to
Reduce Atherosclerotic Cardiovascular Risk in Adults) (Class I; Level of
Evidence A).
2. Niacin c th xem xt dng cho bn c HDL cholesterol thp hay tng
Lp(a), nhng hiu qu trong phng nga t qu thiu mu cha c
thit lp. Thn trng khi dng niacin v gia tng nguy c bnh c. (Class IIb;
Level of Evidence B).
3. Cc dn xut Fibric acid c th xem xt cho bn tng triglyceride mu,
nhng hiu qu ca n trong phng nga t qu thiu mu cha thit lp
(Class IIb; Level of Evidence C).
4. Nu khng dung np Statin: xem xt iu tr thuc h lipid khc nh dn
xut fibric acid, acid mt kh ion( bile acid sequestrants), niacin v
ezetimibe, mc d hiu qu phng nga t qu cha thit lp (Class IIb;
Level of Evidence C).
im ct yu: iu tr Statin c ch nh lm gim nguy c t qu x
va mch bn nguy c tim mch 10 nm cao, xc nh qua tnh nguy c
tim mch. Hin nay xut hin thm Ezetimibe phng nga bnh tim v t
qu, thuc ngn chn ti hp thu cholesterol rut. Trong nghin cu
IMPROVE-IT, kt hp ezetimibe v simvastatin phng nga tim v t qu
tt hn simvastatin n thun. Ezetimibe c th chn la bn khng dung
np statin.
Ch n v dinh dng
C bn
1. Gim sodium (
4. Ch n ca vng a Trung Hi (Mediterranean diet) b sung qu
nhn(nuts) c th xem xt lm gim nguy c t qu (Class IIa; Level of
Evidence B).
im ct yu: ch n DASH v Mediterranean-style lin quan gim
nguy c t qu. DASH nhn mnh n tri cy, rau qu, ng cc, b v
ph- mt t cht bo, c, tht gia cm v du thc vt nhng hn ch
sodium v m bo ha. Ch n Mediterranean tng t nhn mnh u
tin thc n c bn l thc vt v m tt cho sc khe (th d: du olive),
nhng cng cho php i khi dng c v tht gia cm v khng thng
xuyn dng tht. Ru vang ung trung bnh.
Tng huyt p
C bn
1. Tm sot huyt p thng xuyn v iu tr thch hp: thay i li sng
v dng thuc (Class I; Level of Evidence A).
2. Bnh nhn tin tng huyt p (systolic BP: 120-139 mm Hg hay diastolic
BP: 80-89 mm Hg): thc hin tm sot huyt p hng nm v thay i li
sng (Class I; Level of Evidence A).
2. Tng huyt p: iu tr ch huyt p < 140/90 mm Hg (Class I; Level of
Evidence A)
3. H huyt p thnh cng th quan trng hn chn thuc chuyn bit
trong gim nguy c t qu v iu tr ty thuc tng bnh nhn, trn c
s c im v dung np thuc ca bnh nhn (Class I; Level of Evidence
A). BP
4. T o huyt p v theo di huyt p c khuyn co ci thin kim
sot huyt p(Class I; Level of Evidence A).
im mu cht: hng dn mi ch ra tng huyt p vn cn l im
quan trng nht, yu t nguy c c chng minh v sa i c, iu tr
tng huyt p c nhn mnh hiu qu nht trong chin lc phng
nga c t qu thiu mu v xut huyt. Mc d mt vi nghin cu
ngh h huyt p tn cng c th lin kt vi d hu xu nhng ngi ln
tui yu ui, phn ln ng h iu tr huyt p trn 140/90mmHg. Nu bn
huyt p tm thu trn 160mmHg, xem xt khi u iu tr 2 loi thc tng
huyt p nh li tiu v c ch men chuyn
Bo ph v phn b m trong c th
C bn
1. Nhng ngi d cn (BMI=25 - 29 kg/m2) v bo ph (BMI >30 kg/m2)
khuyn co gim cn gim huyt p (Class I; Level of Evidence A).
2. Nhng ngi d cn (BMI=25 - 29 kg/m2) v bo ph (BMI >30 kg/m2)
khuyn co gim cn gim nguy c t qu (Class I; Level of Evidence
B)
im mu cht: Mc d kh chng minh gim cn trc tip gim nguy c
t qu, bng chng c th to ln ng h s lin kt gia tng cn v t l
mc t qu ln hn. Hng dn khuyn co gim cn nhng ngi d
cn(BMI=25-29kg/ m2) v bo ph(BMI >30 kg/m2) trong c gng lm gim
huyt p v gim nguy c t qu
i tho ng
C bn
1. i tho ng Type 1 hay type 2: kim sot huyt p theo khuyn co
AHA/ACC/CDC ch huyt p < 140/90 mm Hg(Class I; Level of Evidence A).
2. iu tr ngi ln i tho ng vi statin, c bit cc trng hp c
thm yu t nguy c, khuyn co lm gim nguy c t qu tin pht(Class
I; Level of Evidence A).
3. ch li dng aspirin trong phng nga t qu tin pht cho bn i tho
ng nhng nguy c bnh tim mch trong 10 nm thp th khng r
rng(Class IIb; Level of Evidence B).
4. Thm vo fibrate cho bn i tho ng gim nguy c t qu th
khng hu ch(Class III; Level of Evidence B).
im mu cht: bn i tho ng, kim sot tt huyt p vi thuc c
ch men chuyn hay c ch th th angiotensin gim nguy c t qu. Mc
d kim sot ng huyt gim hay khng nguy c t qu th khng r,
d liu ngh iu tr statin gim nguy c t qu tin pht bnh nhn
i tho ng
Ht thuc l
C bn
1.Tham vn, cho nhng ngi ang ht thuc gip h ngng ht thuc,
kt hp iu tr thuc dng nicotine thay th, bupropion hay varenicline
(Class I; Level of Evidence A).
2. Trnh ht thuc l c khuyn co cho nhng ngi cha tng ht
thuc, trn c s nghin cu dch t hc cho thy s tng quan kin nh
v mnh gia ht thuc v c t qu thiu mu v xut huyt di
nhn(Class I; Level of Evidence B).
im mu cht: c s lin kt r rng gia ht thuc l v gia tng nguy
c t qu thiu mu v xut huyt di nhn. D liu cho thy k hoch
ngng ht thuc gim t l mi mc t qu hin khng y . Tuy nhin
nghin cu dch t hc ngh ngng ht thuc lin h gim nguy c t
qu. Hng dn mi nhn xt vic cm ht thuc ni cng cng rng ri
trong cng ng hay c nc l c c s mun lm gim nguy c t qu
v nhi mu c tim
Rung nh
C bn
1. Bnh nhn rung nh c bnh van tim nguy c cao t qu, xc nh im
CHA2DS2-VASc 2 v nguy c bin chng xut huyt thp chp nhn
c, khuyn co iu tr khng ng ung warfarin lu di ch INR t
2.0-3.0 (Class I; Level of Evidence A).
2. Bnh nhn rung nh khng bnh van tim, c