Nội khoa Đông Tây Y

Copyright@Ministry Of Health

B Y t

Bnh hc v iu tr ni khoa

(kt hp ng - ty y) (Sch o to bc s y hc c truyn)

M s: D.08.Z.24

Ch bin: PGS. TS. Nguyn Th Bay

Nh xut bn y hc

1

H ni - 2007


Ch o bin son

V Khoa hc & o to, B Y t

Ch bin

PGS.TS. Nguyn Th Bay

Nhng ngi bin son

PGS. TS. Phan Quan Ch Hiu

ThS. Ng Anh Dng

PGS. TS. Nguyn Th Bay

BSCKII. Nguyn Th Lina

Tham gia t chc bn tho

ThS. Ph Vn Thm

Bn quyn thuc B Y t (V khoa hc v o to)

2


Li gii thiu

Thc hin mt s iu ca Lut Gio dc, B Gio dc v o to v B Y t ban hnh chng trnh khung o to bc s y hc c truyn. B Y t t chc bin son ti liu dy - hc cc mn c s, chuyn mn v c bn chuyn ngnh theo chng trnh trn nhm tng bc xy dng b sch chun v chuyn mn m bo cht lng o to nhn lc y t.

Sch Bnh hc v iu tr ni khoa kt hp ng - Ty y c bin son da trn chng trnh gio dc ca i hc Y Dc Thnh ph H Ch Minh trn c s chng trnh khung c ph duyt. Sch c cc nh gio giu kinh nghim v tm huyt vi cng tc o to bin son theo phng chm: kin thc c bn, h thng; ni dung chnh xc, khoa hc, cp nht cc tin b khoa hc, k thut hin i vo thc tin Vit Nam.

Sch Bnh hc v iu tr ni khoa kt hp ng - Ty y c Hi ng chuyn mn thm nh sch v ti liu dy - hc chuyn ngnh bc s y hc c truyn ca B Y t thm nh vo nm 2006. B Y t quyt nh ban hnh l ti liu dy - hc t chun chuyn mn ca ngnh Y t trong giai on 2006-2010. Trong qu trnh s dng, sch phi c chnh l, b sung v cp nht.

B Y t xin chn thnh cm n cc cn b ging dy B mn Khoa Y hc c truyn, Trng i hc Y Dc Thnh ph H Ch Minh ginh nhiu cng sc hon thnh cun sch ny, cm n PGS. TS. Nguyn Nhc Kim; PGS. Nguyn Vn Thang c, phn bin cun sch c hon chnh, kp thi phc v cho cng tc o to nhn lc y t.

V ln u xut bn, chng ti mong nhn c kin ng gp ca ng nghip, cc bn sinh vin v cc c gi ln xut bn sau c hon thin hn.

V Khoa hc v o to

B Y t

3


4


LI NI U

Bnh hc v iu tr l hai mn hc c tm quan trng c bit mang tnh quyt nh trong ngh nghip ca mi ngi thy thuc.

p ng kp thi yu cu ca sinh vin v hc vin v cng hng ng vic bin son sch gio khoa trong d n Gio dc i hc ca i hc Y Dc TP.HCM ca B Y t, chng ti bin son cun Bnh hc v iu tr ni khoa kt hp ng - Ty y ny.

Trong thi i bng n thng tin nh hin nay, vic tip cn vi nhng tin b khoa hc k thut khng kh, gip chng ta bit rng s tin b mnh m trong lnh vc chn on ca y hc hin i, s ra i ca nhng thuc mi gp phn lm cho iu tr ni khoa khng ngng pht trin, tuy nhin ngi ta cng nhn nhn rng y hc c truyn c mt vai tr nht nh i vi cc bnh mn tnh v nhng phng php t dng thuc y hc c truyn (YHCT) n khng dng thuc nh chm cu, dng sinh, xoa bp bm huyt, tp luyn, cch n ung h tr cho iu tr v phng bnh mt cch tch cc v hiu qu.

Quyn Bnh hc v iu tr ni khoa kt hp ng - Ty y c hnh thnh t vic hiu chnh, b sung, sa cha gio trnh bnh hc v iu tr kt hp a ra ging dy nhiu nm ti Khoa Y hc c truyn i hc Y Dc TPHCM, b sung thm mt s bi mi cng nhng ni dung t cc kt qu nghin cu v bnh hc kt hp v ng dng iu tr bng YHCT trong nhng nm gn y. Ni dung sch c phn thnh 31 bi tng ng vi 31 bnh in hnh ca bnh hc ni khoa ph bin, hay gp trong lm sng thuc v cc phn: tim mch, h hp, bnh l xng khp.

Chng ti (ch bin v tp th cc tc gi) c gng th hin tnh kinh in, tnh hin i v tnh thc t trong vic bin son sch gio khoa ny, qua chng ti tham kho nhiu t liu ca nhiu tc gi trong v ngoi nc, chng ti xin trn trng cm n cc tc gi .

D ht sc c gng, nhng thiu st l iu kh trnh khi, rt mong nhn c kin nhn xt v ng gp ca cc bn sinh vin - hc vin, cng qu ng nghip quyn sch ngy c tt hn

Chn thnh cm n

Ch bin


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HNG DN CCH S DNG SCH

p ng nhu cu o to v t o to ca sinh vin, hc vin, sch Bnh hc v iu tr ni khoa kt hp ng Ty ybao gm:

Phn mc lc Phn ni dung Phn index

Mi bi hc c:

Mc tiu Ni dung bi hc Phn cu hi n tp (t lng gi)

c gi v hc vin c th chn bi hc t mc lc v tham kho index tra cu t ng mun tm.

Ty thuc vo yu cu hc tp ca mi i tng, mi bi hc c nhiu mc tiu cho hc vin chn la, t nhng ni dung bt buc phi bit, n nhng ni dung cn bit v nn bit dnh cho sinh vin, n nhng phn trin khai rng hn tin cho vic tham kho dnh cho hc vin sau i hc, cui mi bi hc c bi tp gip cho vic t lng gi cho qu trnh t hc .

Mi ni dung trong bi hc, chng ti bin son theo trnh t song song ng y v Ty y, bnh danh l h thng bnh danh y hc hin i (YHH).

Phn i cng lun c nh ngha, c im dch t hc ca bnh v phn loi theo c YHH v y hc c truyn (YHCT), trong cc khi nim v t ng YHCT c gii thch nhm gip hc vin lin h v kt ni vi cc phn khc trong bi hc d dng hn.

Phn nguyn nhn v c ch bnh sinh ca YHCT da vo cc triu chng YHH ca bnh, tm hiu c ch bnh sinh ca YHCT sinh ra cc triu chng y ri tng hp li chn ra nhng c ch bnh sinh tng ng, nhng nguyn nhn gy bnh ph hp v cc biu hin l nhng th lm sng YHCT.

Phn iu tr, ch nu nguyn tc iu tr theo YHH v iu tr theo YHCT t dng thuc n khng dng thuc, n cc kinh nghim dn gian thng s dng.

Thay mt cc tc gi

Ch bin


6


MC LC

Li gii thiu 3

Li ni u 5

Hng dn s dng sch 6

Tng huyt p PGS. TS. Phan Quan Ch Hiu 9

Thiu mu c tim PGS. TS. Phan Quan Ch Hiu 34

X m ng mch PGS. TS. Phan Quan Ch Hiu 53

Vim ph qun cp v mn PGS. TS. Nguyn Th Bay 63

Hen ph qun PGS. TS. Nguyn Th Bay 86

Cc ri lon vn ng ca thc qun ThS. Ng Anh Dng 110

Vim d dy ThS. Ng Anh Dng 120

Lot d dy t trng ThS. Ng Anh Dng 127

Ri lon hp thu ThS. Ng Anh Dng 144

H chng i trng kch ng ThS. Ng Anh Dng 165

Vim gan mn ThS. Ng Anh Dng 174

X gan ThS. Ng Anh Dng 192

Si mt PGS. TS. Nguyn Th Bay 214

Nhim trng tit niu PGS. TS. Nguyn Th Bay 223

Si tit niu PGS. TS. Nguyn Th Bay 241

Chng suy sinh dc nam (impotence) ThS. Ng Anh Dng 252

Bnh vim sinh dc n PGS. TS. Nguyn Th Bay 271

Thiu mu PGS. TS. Nguyn Th Bay 300

Bnh i tho ng PGS. TS. Nguyn Th Bay 327

Bnh bo ph PGS. TS. Nguyn Th Bay 367

Chng rng tc (alopecia) ThS. BS. Ng Anh Dng 380

Bnh long xng PGS. TS. Nguyn Th Bay 383

Tai bin mch mu no PGS. Phan Quan Ch Hiu 399

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Lit mt nguyn pht BSCK II Nguyn Th Li Na 420

Bi no BSCK II Nguyn Th Li Na 429

Vim a dy thn kinh PGS. TS. Phan Quan Ch Hiu 440

iu tr au thn kinh ta theo YHCT PGS. TS. Phan Quan Ch Hiu 469

Hi chng suy nhc mn tnh (CFS) PGS. TS. Phan Quan Ch Hiu 482

Vim khp dng thp PGS. TS. Nguyn Th Bay 497

Thoi ho khp PGS. TS. Nguyn Th Bay 520

Thng phong - Goutte PGS. TS. Nguyn Th Bay 538

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Bi 1

TNG HUYT P

MC TIU

1. Nu c nh ngha v nhng yu t dch t hc ca bnh tng huyt p.

2. Trnh by c nguyn nhn v c ch sinh bnh tng huyt p theo l lun y hc c truyn.

3. Chn on c 3 th lm sng tng huyt p theo y hc c truyn. 4. Trnh by c nhng nguyn tc iu tr tng huyt p theo y hc

hin i v y hc c truyn.

5. Trnh by c phng php iu tr tng huyt p (dng thuc v khng dng thuc ca y hc c truyn).

6. Gii thch c c s l lun ca vic iu tr tng huyt p bng y hc c truyn.

1. I CNG

1.1. nh ngha

Tng huyt p l mt hi chng lm sng do nhiu nguyn nhn khc nhau gy nn, ni ln tnh trng gia tng p lc mu trong cc ng mch ca i tun hon.

Theo OMS, ngi ln c huyt p (HA) bnh thng, nu huyt p ng mch ti a < 140 mmHg (18,7 kpa) v huyt p ng mch ti thiu < 90 mmHg (12 kpa). Tng huyt p khi huyt p ng mch ti a 160 mmHg (21,3 kpa) v huyt p ng mch ti thiu 95 mmHg (12 kpa). Huyt p ng mch ti a cn gi l huyt p tm thu, huyt p ng mch ti thiu cn gi l huyt p tm trng.

1.2. Phn loi

1.2.1. Da theo nh ngha

Tng huyt p gii hn khi tr s huyt p trong khong 140/90 < PA < 160/95 mmHg

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Tng huyt p tm thu khi huyt p ng mch ti a (PAs) ln hn 160 mmHg v huyt p ng mch ti thiu (PAd) nh hn 90 mmHg.

Tng huyt p tm trng khi huyt p ng mch ti a (PAs) thp hn 140 mmHg v huyt p ng mch ti thiu (PAd) cao hn 95 mmHg.

1.2.2. Da vo tnh trng bin thin ca tr s huyt p

Tng huyt p thng xuyn, c th phn thnh tng huyt p c tnh v tng huyt p lnh tnh

Tng huyt p cn: trn c s huyt p bnh thng hoc gn bnh thng, bnh xut hin vi nhng cn cao vt, nhng lc ny thng c tai bin.

Tng huyt p dao ng: con s huyt p c th lc tng, lc khng tng (OMS khuyn khng nn dng thut ng ny v nn xp vo loi gii hn v tt c cc trng hp tng huyt p u t nhiu dao ng).

1.2.3. Da vo nguyn nhn

Tng huyt p nguyn pht (khng c nguyn nhn), ngi cao tui. Tng huyt p th pht (c nguyn nhn), phn ln tr em v ngi tr

tui.

1.3. c im dch t hc

chu u v Bc M t l ngi ln mc bnh t 15 - 20%. Theo mt cng trnh ca Tcherdakoff th t l ny l 10-20%. Vit Nam t l ngi ln mc bnh tng huyt p l 6 - 12%.

Bnh tng huyt p nguyn pht l bnh ca thi i vn minh. C l tng huyt p nguyn pht ch gp loi ngi.

Bnh ny c lin quan n: + Tui: tui cng cao th cng nhiu ngi bnh huyt p cao. Nu la

tui tr s ngi c bnh huyt p cao chim t l 1-2% th ngi cao tui t l mc bnh tng n 18,2-38% (thm ch n 50,2%). Trn 40 tui s ngi huyt p cao gp 10 ln so vi khi di 40 tui.

+ S pht trin cng nghip: th v ni c nhp sng cng thng, t l mc bnh tng huyt p cao hn. Tng t, cc nc pht trin c mc sng cao v thnh th t l mc bnh tng huyt p nhiu hn nng thn.

Tng huyt p l bnh gy nhiu tai bin: + Trong tui t 50-60 tui: vi huyt p tm trng 85mmHg, t l t

vong l 6,3%. Vi huyt p tm trng ln hn 104 mmHg, t l t vong l 15,3%.

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+ Php, nguyn cu ca F.Forette (1968-1978) cho thy t l tai bin mch no ngi huyt p cao gp i (20,6%) ngi c huyt p bnh thng (9,8%). T l nhi mu c tim l 27,8% (so vi ngi bnh thng 7,8%) nhiu gp 3 ln.

+ M, cng trnh nghin cu do Q.B. Kannel ch o, tin hnh trn 5209 i tng, v theo di lin tc trong 18 nm chng minh: ngi huyt p cao nguy c tai bin mch no cao gp 7 ln so vi ngi huyt p bnh thng, tui cng cao nguy c cng ln. Tr s HA ti a tng thm 10 mmHg th nguy c tai bin mch no tng thm 30%.

+ Nht Bn, nghin cu ca K. Isomura trong 10 nm (1970-1980) cho thy: 79-88% nhng ngi tai bin mch no l nhng ngi c bnh tng huyt p.

2. NGUYN NHN

2.1. Theo y hc hin i

Ty theo nguyn nhn, c th chia ra: tng huyt p th pht v tng huyt p nguyn pht. tr em v ngi tr, phn ln l tng huyt p th pht. ngi cao tui, phn ln l tng huyt p nguyn pht.

2.1.1. Tng huyt p th pht

Loi ny chim 11-15% tng s trng hp tng huyt p.

Nguyn nhn thn (chim khong 5-8%): vim cu thn cp, vim cu thn mn mc phi hoc di truyn; thn a nang, nc b thn, u tng tit renin; bnh mch thn (3-4%).

Nguyn nhn ni tit: cng aldosteron nguyn pht (0,5-1%), ph i thng thn bm sinh, hi chng Cushing (0,2-0,5%), u tu thng thn (0,1-0,2%). Tng calci mu, bnh to u chi, cng gip...

Nguyn nhn khc (khong 1%): hp eo ng mch ch, nhim c thai nghn, bnh a hng cu, nguyn nhn thn kinh (toan h hp, vim no, tng p lc ni s...).

2.1.2. Tng huyt p nguyn pht

Khi tng huyt p khng tm thy nguyn nhn gi l tng huyt p nguyn pht. Loi ny chim t l 85-89% trng hp tng huyt p (theo Gifford v Weiss).

Phn ln tng huyt p ngi trung nin v ngi gi thuc loi nguyn pht. C nhiu yu t thun li lm xut hin bnh tng huyt p nguyn pht.

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Yu t di truyn: bnh thng gp nhng gia nh c huyt p cao hn l nhng gia nh c huyt p bnh thng.

Yu t bin dng: nh tha cn, x m ng mch, ch n nhiu mui.

Yu t tm thn kinh: tnh trng cng thng thn kinh. Yu t ni tit: thi k tin mn kinh, dng thuc nga thai

2.2. Theo y hc c truyn

Tm hiu cc ti liu ca YHCT ni v bnh tng huyt p ca y hc hin i (YHH) l iu khng n gin. Tng huyt p l danh t bnh hc YHH v khng c t ng ngha trong bnh hc y hc c truyn (YHCT). T ng ngha d gp gia YHH v YHCT l cc triu chng (v d: au u vi u thng, mt ng vi tht min).

2.2.1. Cc chng trng thng gp trong bnh tng huyt p

Cc triu chng c nng thng gp (nu c xut hin) v c m t trong cc ti liu gio khoa ca mt tnh trng tng huyt p kinh in gm: mt, nhc u, ri lon th gic, hoa mt, chng mt, tai, chy mu cam. Theo bo co ca S Nghin cu cao huyt p Thng Hi (Trung Quc) phn tch trn 550 trng hp tng huyt p: au u chim t l cao nht (74,8%), k n l tim hi hp (52,18%). Ngoi ra c th c cc biu hin khc l nhng hu qu trc tip ca tng huyt p; l nhng tnh trng thiu nng mch vnh, tai bin mch mu no, lit bn thn.

Nh vy, c th tm tt cc triu chng c nng thng gp trong bnh l tng huyt p gm:

Hoa mt, chng mt: YHCT xp vo chng huyn vng hay cn gi l huyn vng.

au u: YHCT xp vo chng u thng, u trng, u trng da vo nhng biu hin khc nhau ca n.

nh trng ngc, hi hp: YHCT xp vo chng tm qu, chnh xung. au ngc gi l tm thng, hoc km kh th th c gi l tm t, tm

trng.

Hn m, lit na ngi: YHCT xp vo chng trng phong. 2.2.2. C ch bnh sinh

Qua vic phn tch c ch bnh sinh ton b cc chng trng thng gp ca YHCT trong bnh l tng huyt p, c th bin lun v c ch bnh sinh theo YHCT nh sau:

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Nguyn nhn ca bnh l ny theo YHCT c th l

Do tht tnh nh gin, lo s gy tn thng 2 tng can, thn m.

Do bnh lu ngy, th cht suy yu; thn m, thn dng suy (thn m suy h ha bc ln, thn dng suy chn dng nhiu lon trn).

Do m thp ng tr gy tr tc thanh khiu. m thp c th do n ung khng ng cch gy tn hi t v hoc do thn dng suy khng kh ha c nc lm sinh m.

S phn chia ny c tnh tng i v gia cc nguyn nhn (theo YHCT) v cc th bnh c mi lin h vi nhau nh can m h c th dn n can dng vng (can dng thng xung), thn m h lu ngy dn n thn dng h hoc nh thn dng h c th gy nn bnh cnh m thp.

Error!

THT TNH (gin, lo s, stress)

TH CHT YU BNH LU NGY

N UNG KHNG NG

Can dng vng

Can m h

Thn m h

Thn dng h m

thp

Dng thng cang

H ha bc ln

Chn dng nhiu lon trn

Lm tc tr thanh khiu

Hnh 1.1. S bnh l bnh tng huyt p theo YHCT

HUYN VNG U THNG TM QU CHNH XUNG

3. CHN ON

3.1. Chn on theo y hc hin i

3.1.1. Triu chng lm sng

Bnh nhn tng huyt p thng khng c triu chng (tr khi h c t tng t bin, tr s huyt p 220/110 mmHg).

Nhng triu chng chc nng ca tng huyt p li l nhng triu chng khng c hiu nh mt mi, au u vng gy nh mch p, nng phng mt, chy mu cam, au ngc, kh th, ri lon th gic v ting ni.

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Tri li, c nhng triu chng lm sng lm gi cho vic tm kim nguyn nhn ca tng huyt p

+ au khp khing cch hi gi cho teo hp ng mch ch. + Mc ru ( ph n), d bm mu gi cho hi chng Cushing. + Tng huyt p ko di hoc tng t, ra nhiu m hi, au u tng

cn, cn hi hp, lo lng, run ry, nn i, mt ti gi cho u ty thng thn.

+ Gim kali mu, yu c, vp b, tiu nhiu, lit, tiu m gi cho cng aldosteron nguyn pht.

+ au vng hng gi cho nhng bnh ca thn v mch mu thn. 3.1.2. Lm th no xc nh chn on

o huyt p lp li nhiu ln, nhiu ni khc nhau, nhiu thi im khc nhau, vi k thut thc hin ng.

Holter huyt p rt tt trong trng hp nghi ng.

3.1.3. Phi lm g sau chn on tng huyt p

C 3 vn phi gii quyt sau chn on tng huyt p: + Tng huyt p th pht hay nguyn pht? + c nh hng trn nhng c quan no? giai on tng huyt p? + C yu t nguy c i km?

tr li 3 cu hi trn, cn ch : + Hi bnh, khm lm sng. + Nhng xt nghim cn lm sng: Xt nghim thng thng ca tng huyt p: xt nghim mu

thng quy; BUN - creatinin; K+ mu; cholesterol, HDL, LDL, triglycerid; ng huyt; o EKG; phn tch nc tiu.

Xt nghim cn nn lm khi c nghi ng v nguyn nhn gy tng huyt p (da trn bnh s, khm lm sng v cc kt qu ca nhng xt nghim trn).

Chp X quang tim phi (hp ng mch ch).

Dexamethason suppression test (hi chng Cushing).

Lng metanephrin v vanillylmandelic acid trong nc tiu (u ty thng thn).

Chp ng mch thn c cn quang (IVP), chp ct lp thn, ng mch (bnh mch mu thn).

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o nng renin hot ng huyt tng (cng aldosteron nguyn pht hay bnh mch mu thn).

3.1.4. Phn loi tng huyt p

Theo WHO: huyt p bnh thng ngi ln l + Huyt p tm thu (HATT)

Nhm nguy c rt cao (nguy c c s c tim mch nng trong 10 nm trn 30%).

Bng 1.2. Bng xp loi nguy c v lng gi tin lng ca bnh tng huyt p

Yu t nguy c khc v bnh s ca bnh

Huyt p (mmHg)

Khng c yu t nguy c khc Thp Trung bnh Cao

1-2 yu t nguy c Trung bnh Trung bnh Rt cao

>3 yu t nguy c

hoc tn thng c quan ch

hoc tiu ng

Cao

Cao

Rt cao

Tnh trng lm sng i km Rt cao Rt cao Rt cao

+ Yu t nguy c: Yu t dng xp loi nguy c:

1. Tng HATT v HATTr ( 1, 2, 3)

2. Nam >55 tui

3. N > 65 tui

4. Ht thuc l

5. Ri lon lipid huyt (cholesterol TP > 6,5mmol tc > 250mg/dl)

6. Tin cn gia nh b bnh tim mch sm

7. Tiu ng

8. Ung thuc nga thai.

Yu t nh hng xu n tin lng:

1. HDL-C gim, LDL-C tng

2. Tiu albumin vi th trn ngi b tiu ng

3. Ri lon dung np ng

4. Bo bu

5. Li sng tnh ti

6. Fibrinogen tng

7. Nhm kinh t x hi nguy c cao

8. Nhm dn tc nguy c cao

9. Vng a l nguy c cao.

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+ Tn thng c quan ch (giai on II theo phn loi c ca WHO): Dy tht tri (in tm , siu m, X quang)

Tiu m v/hoc l tng nh creatinin huyt (1,2 - 2mg/dl)

Hp lan ta hoc tng im ng mch vng mc

Siu m hoc X quang c bng chng mng x va.

+ Tnh trng lm sng i km (giai on III theo phn loi c ca WHO):

Bnh mch no: nhn no, xut huyt no, cn thiu mu no thong qua

Bnh tim: nhi mu c tim, au tht ngc, iu tr ti ti mu mch vnh, suy tim

Bnh thn: suy thn (creatinin huyt >2mg/dl), bnh thn do tiu ng

Bnh mch mu ln ngoi vi c triu chng lm sng i km

Bnh y mt: xut huyt hoc xut tit ng mch vng mc, ph gai th.

3.2. Chn on theo y hc c truyn

3.2.1. Th can dng xung (th m h dng xung)

Trong th bnh cnh ny tr s huyt p cao thng hay dao ng Ngi bnh thng au u vi nhng tnh cht Tnh cht au: cng hoc nh mch p V tr: nh u hoc mt bn u Thng km cn nng phng mt, hi hp trng ngc, ngi bt rt Mch i nhanh v cng (huyn).

3.2.2. Th thn m h

Triu chng ni bt trong th ny, ngoi tr s huyt p cao l

Tnh trng u oi, mt mi thng xuyn au nhc mi lng m Hoa mt chng mt, tai, u nng hoc au m Cm gic nng trong ngi, bc rc, thnh thong c cn nng phng

mt, ng tm phin nhit, ng km, c th c to bn

Mch trm, huyn, sc, v lc.

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3.2.3. Th m thp

Triu chng ni bt trong th bnh l ny:

Ngi bo, tha cn. Li dy, to Bnh nhn thng t than phin v triu chng au u (nu c, thng l

cm gic nng u) nhng d than phin v t nng chi di

Thng hay km tng cholesterol mu Mch hot.

4. IU TR, D PHNG V THEO DI

Mc tiu ca iu tr v d phng bnh tng huyt p l gim bnh sut v t sut bng phng tin t xm ln nht nu c th. C th l lm gim v duy tr HATT

nng l tng, gim ru, b thuc l, c ph; gim cholesterol mu hoc tiu ng, cung cp thc n c nhiu potassium v calci, kim sot tnh trng stress, hn ch Na+.

c nhng cng trnh nghin cu chng minh vic king hon ton mui lm n nh cc trng hp tng huyt p nng. Trong thc t, cch ny khng p dng c, do bnh nhn cn bit nhng ngun thc n ch yu c nhiu mui hn ch s dng (kh, mm, chao, sa, fomat, tht mui).

Vi mc n mn 5-8g NaCl/ngy:

+ nhng bnh nhn huyt p cao th nh: tr s huyt p cao ti a gim 6,3%, huyt p ti thiu gim 6,6% (t 139,9/93,9 cn 130/87,7 mmHg o t th ngi).

+ nhm bnh nhn m tr s huyt p cao khng t xung c na, th ch n gim mui nh trn cng gim c tr s huyt p ti a xung 5,2%, huyt p ti thiu gim xung 3,7%.

+ Trong c 2 nhm, cc bnh nhn u chu ng tt hn nhng gng sc th lc. S bnh nhn phi dng thm thuc gim dn sau tng nm (27% sau 1 nm, 16% sau 3 nm v 6% trong nm th 5).

4.1.3. Hot ng th lc thng xuyn

C th lm gim huyt p trung bnh (l tng l 1 gi/ngy): i b, chy chm, bi li hoc p xe, ty theo thch v sc ca bnh nhn. Nhng bi tp thch hp ca phng php dng sinh nh th gin, th 4 thi c k mng, gi chn v nhng ng tc xoa bp vng u mt cn c p dng u n. Mc tiu l thi quen ny phi c a vo cch sng ca ngi bnh.

Ring vic iu tr bng chm cu s c trnh by v gii thch c th phn sau, phn iu tr c th cho tng th lm sng YHCT.

4.1.4. Gi cn l tng

Ch ny bt buc ngi tha cn.

Cch duy nht l ch n gim calo (phi gii thch r cha c thuc no gip lm gim cn c). Cn ch sau t n gim cn thng c tnh trng tng cn nhiu sau .

4.1.5. Hn ch ru

4.1.6. B thuc l

Cn bit b thuc l khng lm gim huyt p (ngc li cn c th tng cn sau ngng thuc l). Tuy nhin, cn khuyn khch bnh nhn b v hn ch c bin chng trn mch mu.

19


4.1.7. Vic iu chnh cholesterol/mu tng v ng/mu tng l bt buc v lm gim bin chng mch mu.

4.2. iu tr dng thuc

4.2.1. Theo y hc hin i

Thuc iu tr tng huyt p thng c dng l nhng nhm sau: + Nhm c ch calci + Nhm chng cao huyt p trung ng + Nhm c ch men chuyn + Nhm c ch alpha () v beta () + Nhm gin mch c tc dng trc tip + Nhm li niu

Trong c 4 loi thuc c khuyn s dng trong tng huyt p v: + Dng mt ln trong ngy + C hiu qu + Tc dng ph lm phi ngng iu tr l 25% a. Thuc li tiu

c chng minh tnh hiu qu hn tt c cc loi khc. N lm gim huyt p nh cc loi khc, hn na n cn c dng nh

iu tr c bn ca tt c cc th nghim chng minh vic iu tr tng huyt p; lm gim t sut, t l t vong bnh tim mch v t l t vong chung.

Cc cng trnh nghin cu rt ng tin cy chng minh li tiu c tc dng tt trong tng huyt p va ( ngi trng thnh v ngi cao tui) trong cc th lm sng tng tm thu v tm trng hoc ch tng tm trng.

Tp hp tt c cc cng trnh li, ta chng minh c vic gim tr s huyt p lm gim ng k nguy c chy mu no, suy tim v suy thn. Vic gim nguy c suy mch vnh t thy r hn, nhng li rt c ngha ngi cao tui.

Thuc li tiu nn dng (thng l phi hp trong 1 vin): Thiazid: tng thi K +

Anti aldosteron: gim K +

Phi hp: aldactiazin (loi ny thng gy gim K + hn l tng K +). Chng ch nh: suy gan nng, suy thn mn ( lc cu thn < 30ml/mm).

20


b. Thuc c ch beta ( - bloquants) c chng minh bng cc nghin cu ng tin cy v mt hiu qu

trn t sut, t l t vong do bnh tim mch v t l t vong chung (nh thuc li tiu).

Hiu qu ny so vi thuc li tiu trn bnh nhn cao tui c km hn cht t:

+ C tc dng h p: c nhng loi m tc dng ko di 24h p ng c yu cu iu tr n liu.

+ C ch: cho rng thuc kha mt phn h thng renin angiotensin -aldosteron bng tc dng trn th th beta kim sot tit renin. Sau khi gim tm thi cung lng tim, cc thuc c ch beta lm gim khng lc ngoi vi...

+ Chng ch nh: suyn, COPD, vim tc mch chi di, suy tim bt hi, tiu ng l thuc insulin.

c. c ch men chuyn Tc dng h p nh cc loi thuc trn. N cha c nghin cu xc nh hiu qu trn t sut, t l t vong

nh cc loi thuc trn v n c lu hnh trong thi k m khng c mt nghin cu no vi placebo cho php. Cn nu dng thuc lm chng th cn s lng bnh nhn rt ln.

Tr captopril ung 2 ln/ngy, cn cc loi khc dng 1 ln/ngy. C ch: ct t vic chuyn t angiotensin I sang angiotensin II (gy co

mch), ct t tit aldosteron (gi li Na+). ng thi lm gim s ph hy bradykinin (degradation ny c thc hin bi men chuyn)==> bradykinin tng trong mu ==> lm gin mch. Kt qu l lm gim khng lc ngoi vi.

Tc dng ph: ch yu l ho khan (c l do bradykinin tng trong mu), rt thng gp nu c yu t kch thch ph qun v/hoc ngi cao tui. Nhng tc dng ph khc c lin quan n vic dng thuc trn ngi bnh c mt nc, c bit ang iu tr vi thuc li tiu.

d. i khng calci

Tc dng h p nh cc loi trn. Cng khng nghin cu t sut, t l t vong nh nhm c ch men chuyn v cc l do nu trn.

C 2 loi chnh: + Dihydropyridines (nifedipin): loi khng nh hng trn nhp tim hoc

lm tng nhp tim.

+ Loi lm gim nhp tim: diltiazem.

21


C ch: gim Ca++ vo trong cc t bo c trn thnh mch mu, dn n gin mch v cui cng l gim khng lc ngoi vi.

Tc dng ph ch yu: ph 2 chi di, au u. y l do tc dng gin ng mch m khng km gin tnh mch (thng gp khi dng adalat hn nhm tildiem hay verapamil).

Cch s dng thuc: quyt nh s dng thuc trong iu tr huyt p cao l mt quyt nh nng n, bi v sau rt c th quyt nh ny s b ngng li.

Quyt nh ny phi c nu sau khi lm ton b bilan nh trn v sau khi p dng cc ch sinh hot, n ung. chc chn rng n cng kt hp vo ton b cch iu tr.

L tng l dng mt ln trong ngy v vic chn la ty thuc ch nh v chng ch nh.

Hiu qu ca vic tr liu ch c xc nh sau vi tun iu tr.

Cc cng thc cn quan tm: + Chn beta + li tiu: kinh in v rt hiu qu. + c ch men chuyn + li tiu: rt hp l v nhm li tiu hot ho h

thng renin v nh vy lm mnh thm nhm c ch men chuyn (IEC), ngc li IEC tng hot bi tnh trng gim Na+ mu.

+ Chn beta + khng calci: thng dng trn tng HA c bnh mch vnh.

4.2.2. Theo y hc c truyn

Yu cu p ng c nhng nguyn tc iu tr sau:

H p: r nhu. An thn: to nhn, tho quyt minh. Li tiu: trch t, m , ngu tt. Bn thnh mch: hoa he.

a. Th can dng xung Php tr:

+ Bnh can, ging nghch. + Bnh can, tc phong (nu l cn tng huyt p).

Nhng bi thuc v cng thc huyt s dng: + Bi Thin ma cu ng m: thin ma 8g, cu ng 12g, hong cm

10g, chi t 12g, tang k sinh 12g, h th 10g, trng 10g, phc linh 12g, ch mu 12g, thch quyt minh 20g, ngu tt 12g

22


V thuc Tc dng Vai tr

Thin ma Ngt, cay, hi ng, bnh, thng thanh, ging trc, tn phong, gii c

Qun

Cu ng Ngt, hn: thanh nhit, bnh can, trn kinh Qun

Hong cm ng, hn: t ph ha, thanh thp nhit Thn

Chi t ng, hn: thanh nhit t ha, li tiu, cm mu Thn

Tang k sinh ng, bnh: b can thn, mnh gn ct Thn

H th B huyt, thm tinh Thn

trng Ngt, n, hi cay: b can thn, mnh gn ct Thn

Phc linh Ngt, nht, bnh: li thy, thm thp, b t, nh tm T

ch mu Cay, ng, hn: thng huyt, iu kinh T

Thch quyt minh Tr st cao, n khng tiu, thanh nhit T

Ngu tt Chua, ng, bnh: b can thn, tnh i xung Thn - T - S

+ Bi Linh dng cu ng thang: linh dng gic 4g, trc nh 20g, cu ng 12g, sinh a 20g, bch thc 12g, tang dip 8g, phc thn 12g, cc hoa 12g, bi mu 8g, cam tho 4g


Linh dng gic Lng can, tc phong Qun

Trc nh Ngt, hi lnh: thanh nhit, lng huyt Qun

Cu ng Ngt, hn: thanh nhit, bnh can trn kinh Qun

Sinh a Ngt, ng, hn: sinh tn dch, lng huyt Thn

Bch thc ng, cht, chua: nhun gan, dng huyt, lim m, li tiu Thn

Tang dip Ngt, mt: thanh nhit, lng huyt Thn

Phc thn Ngt, nht, bnh; li thy, thm thp, b t, nh tm T

Cc hoa Ngt, mt: tn phong nhit, gii c, ging ha T

Bi mu ng, hn: thanh nhit, tn kt, nhun ph, tiu m T

Cam tho Ngt, bnh: b t, nhun ph, gii c S

+ Cng thc huyt s dng gm: hnh gian, thiu ph, can du, thn du, thi kh, phi dng, ni quan, thi dng, bch hi, n ng.

b. Th thn m h Php tr:

+ T m, ghm dng. + T b can thn.

Nhng bi thuc v cng thc huyt s dng: 23


+ Bi thuc h p (xut x 30 cng thc thuc): thc a 20g, ngu tt 10g, r nhu 20g, trch t 10g, m 20g, to nhn 10g, hoa ho 10g.


Thc a Ngt, hi n: b thn, t m, b huyt Qun

Ngu tt Chua, ng, bnh: b can thn, tnh i xung Qun

R nhu ng, hn: bnh can, tim dng, an thn Thn

Trch t Ngt, nht, mt: thanh t thp nhit bng quang T

M Ngt, hn: li tiu, thanh ph can phong nhit, thm bng quang, thp kh

T

To nhn Ngt, chua, bnh: dng tm, an thn, sinh tn, ch kht T

Hoa he ng, bnh: thanh nhit, lng huyt, ch huyt T

+ Bi thuc Lc v a hong hon gia quy thc: thc a 32g, hoi sn 16g, sn th 8g, n b 12g, phc linh 12g, trch t 6g, ng quy 12g, bch thc 8g. Bi ny thng c s dng khi tng huyt p c km triu chng au ngc, au vng tim


Thc a Ngt, hi n: nui thn dng m, b thn, b huyt Qun

Hoi sn Ngt, bnh: b t v, b ph thn, sinh tn ch kht Qun

Sn th Chua, sp, hi n: n b can thn, sp tinh, ch hn Thn

n b Cay, ng, hi hn: thanh huyt nhit, tn huyt, cha nhit nhp doanh phn

T



+ Bi thuc b can thn: h th 10g, thc a 15g, hoi sn 15g, ng quy 12g, trch t 12g, si h 10g, tho quyt minh 10g


H th B huyt, thm tinh Qun



ng quy Dng can huyt Thn


Si h Bnh can, h st T

Tho quyt minh Thanh can, nhun to, an thn T

24


+ Cng thc huyt s dng: thn du, phc lu, tam m giao, can du, thi xung; gia gim: thn mn, ni quan, bch hi, a th huyt.

c. Th m thp

Php tr: ha m tr thp. Bi thuc v cng thc huyt s dng: bi thuc h p (xut x 30 cng

thc thuc), gm:

Thc a 20g Ngu tt 10g

R nhu 20g Trch t 10g

M 20g To nhn 10g

Hoa ho 10g

5. PH LC - CNG TRNH NGHIN CU TC DNG IU TR CA BI THUC H P

5.1. Kt qu nghin cu v ha thc vt

5.1.1. Kt qu nh tnh mt s hp cht hu c

Dch chit ton phn tr h p c cha: saponin, glycosid, flavon. Dch chit ton phn tr h p khng c cha anthraquinond, alcaloid,

coumarin v tinh du.

Kt qu nh tnh cc hp cht hu c c trong dch chit ton phn tr h p bng phng php sc k:

+ Hp cht hu c trong dch chit ether du ha: nhm hp cht hu c khc vi alcaloid, flavon, saponines, tinh du, coumarin, anthraquinon.

+ Cc hp cht hu c trong dch chit etyl acetat ca tr h p: sau khi tch bng phng php sc k trn ct silic v nh tnh trn tm SKLM, chng ti c c 9 phn on vi Rf tun t l 0,82; 0,72; 0,70; 0,65; 0,55; 0,50; 0,45 trong dung mi ca SKLM, ether du ha; AcOEt (50;50). C 2 phn on khng cho phn ng vi cc loi thuc th thng thng. Nhng phn on ny u cho phn ng dng tnh vi flavon v khng cho phn ng vi anthraquinon, alcaloid, tinh du v coumarin.

5.1.2. Kt lun chung v nghin cu thnh phn ha hc ca bi thuc

Dch chit ton phn tr h p c cha: saponin, glycozid, flavon. Dch chit ton phn tr h p khng c cha anthraquinon, alcaloid,

coumarin v tinh du.

25


c mt s hp cht hu c hin din trong cc v thuc khng c trong ch phm tr h p m cc v thuc nu trn cu thnh.

5.2. Kt qu nghin cu c tnh ca tr h p

c tnh cp din ca thuc: thuc dng vi liu rt cao nhng khng gy ng c cp, khng xc nh c liu LD50.

c tnh trng din ca tr h p: thuc khng gy c khi dng di ngy

Thuc khng lm gim cn sc vt th nghim khi dng di ngy. Thuc khng lm thay i ng k s lng hng cu, bch cu. Thuc khng nh hng n chc nng gan. Thuc khng lm thay i cu trc gan, thn. S khc bit gia 2 nhm khng c ngha thng k (P>0,05; =8).

5.3. Kt qu nghin cu dc l thc nghim ca tr h p

nh hng ca thuc trn huyt p mo: tc dng h p r rt liu 2g/kg, tc dng h p chm (sau 15 pht), h t t v ko di n 100 pht. S sai bit c ngha vi tin cy 95% (P = 0,05; =7).

nh hng ca thuc trn nhp tim (tim c lp): thuc lm chm nhp tim, gim nh co bp c tim cc nng 1/50, 1/10 (sai bit c ngha vi tin cy 95%; =9). Khi ngng tim, thy tim cht th tm trng.

nh hng ca thuc trn vn ng t nhin ca sc vt th nghim: thuc khng nh hng trn vn ng t nhin ca sc vt th nghim. Sai bit khng c ngha thng k (=38; P>0,05).

nh hng ca tr h p trn m hnh kho st tc dng li tiu: lng nc tiu bi tit trung bnh c 2 nhm khng khc nhau. S khc bit gia 2 nhm khng c ngha thng k (P>0,05; =38). Khng c s khc nhau ng k v s bi tit ion trc v sau khi ung thuc. S khc bit khng c ngha (P>0,05; =18).

5.4. Kt qu dc l lm sng ca tr h p (gm 68 nam; 29 n)

nh hng ca thuc trn tr s huyt p ca ngi tng huyt p:

Thay i tc thi tr s huyt p sau khi dng thuc: + Tr h p c kh nng h c huyt p ngay t gi u. Tc dng

ny xut hin r rt 2 giai on (I v II) ca tng huyt p. Sai bit nhm tng huyt p giai on III khng c ngha (P> 0,05;=3).

26


+ Tuy nhin mc h huyt p khng nhiu. nhm tng huyt p giai on I: tr s huyt p h c l 18mmHg huyt p tm thu v 5 mmHg huyt p tm trng; nhm tng huyt p giai on II: tr s huyt p h c l 7mmHg huyt p tm thu v 3 mmHg huyt p tm trng.

Thay i tr s huyt p khi dng thuc di ngy: + Tr h p n nh c huyt p giai on I v II ca bnh tng

huyt p. Sai bit c ngha thng k (P = 0,05; 1=44; 2=47). + Tr s huyt p c n nh r nht sau ngy th 5.

Thay i tr s huyt p sau khi ngng thuc: sau khi ngng thuc, khng thy c hin tng ny ngc ca huyt p.

Din bin thay i tr s huyt p trong 90 ngy dng thuc (trn 9 bnh nhn tng huyt p nh v trung bnh): thuc c kh nng gi huyt p n nh trn nhng trng hp tng huyt p nh v trung bnh. Sai bit c ngha (P=0,05; =8).

5.5. Nhng tc dng dc l lm sng khc

nh hng ca thuc trn s bi tit nc tiu: tr h p khng lm thay i natri v clo trong mu v nc tiu, trc v sau khi dng thuc. Sai bit khng c ngha (P >0,05; =90).

nh hng ca thuc trn nhp tim ca bnh nhn: + Trn 97 bnh nhn dng thuc, tr h p khng lm thay i nhp tim

(s sai bit ca cc kt qu khng c ngha thng k).

+ Thuc dng sau 10 ngy khng lm thay i cc men gan, sai bit khng c ngha (P>0,05; =96).

nh hng ca thuc trn cc triu chng chc nng: + Sau khi dng thuc, c cm gic d chu, c cm gic mt trong ngi. + Thuc c mi v d ung. + Khng c bt k tc dng ph no.

5.6. Kt lun chung v tc dng ca tr h p

Chng minh c mt mt ca ngha b m ghm dng ca YHCT. ng dng vo iu tr bnh tng huyt p nh v trung bnh cho c 3 th

lm sng YHCT.

27


T lng gi

I. Cu hi 5 chn 1:chn cu ng

1. T l ngi ln mc bnh tng huyt p Vit Nam

A. 1-2%

B. 3-5%

C. 6-12%

D. 12-16%

E. 16-20% 2. T l ngi trn 40 tui mc bnh tng huyt p

A. Cao gp 2 ln ngi di 40 tui

B. Cao gp 4 ln ngi di 40 tui

C. Cao gp 6 ln ngi di 40 tui

D. Cao gp 8 ln ngi di 40 tui

E. Cao gp 10 ln ngi di 40 tui 3. T l tng huyt p th pht trong tng s trng hp tng huyt p

A. 0,5%

B. 1%

C. 3-4%

D. 5-8%

E. 11-15% 4. Yu t khng lin quan n tng huyt p

A. S tch tui

B. i sng cng thng

C. Ung ru

D. Di truyn

E. Tnh trng tha cn 5. Theo YHCT, n ung khng ng cch gy tng huyt p theo c ch

A. T v b tn thng, khng vn ha c thy thp nn sinh m

B. Lm chc nng t sinh huyt b tn thng, can huyt h nn can dng xung

28


C. Lm chc nng t, thn m b tn thng, khin h ha bc ln

D. n nhiu thc n cay nng lm can dng thng xung

E. Lm thn dng h dn n chn dng nhiu lon trn 6. Triu chng lm sng gp trong tng huyt p th can dng xung

A. au u nh hoc mt bn u, mch huyn sc v lc.

B. au u nh hoc mt bn u, au cng nh mch p

C. au nng u, au m c u

D. Hoa mt, chng mt, u oi, mt mi thng xuyn

E. Hi hp, trng ngc, mch hot 7. Triu chng lm sng gp trong tng huyt p th thn m h

A. au u, hoa mt, chng mt, mch hot

B. au u, hoa mt, chng mt, mch huyn sc

C. au u, hoa mt, chng mt, ng tm phin nhit

D. Thng than t nng h chi, au lng

E. Hi hp, trng ngc, bt rt, au cng u nh mch p 8. Triu chng lm sng gp trong tng huyt p th m thp

A. au cng u nh mch p

B. Ngi mt mi, mch huyn sc v lc

C. au nng ngc, li dy nht, mch hot

D. Cm gic nng trong ngi, bc rc, mch hot

E. au u d di, chng mt, mch nhanh v cng 9. Nguyn tc iu tr tng huyt p th can dng xung

A. Ha m tr thp

B. T m ghm dng

C. T b can thn

D. Dn ha quy nguyn

E. Bnh can ging nghch 10. Nguyn tc iu tr tng huyt p th thn m h

A. Ha m tr thp

B. S can l kh

C. T b can Thn

29


D. Dn ha quy nguyn

E. Bnh can ging nghch 11. Nguyn tc iu tr tng huyt p th m thp

A. Ha m tr thp

B. T m ghm dng

C. T b can thn

D. Dn ha quy nguyn

E. Bnh can ging nghch

II. Cu hi nhn qu

1. a. Trong hi chng can dng xung, c du hiu run ry, co git bi v

b. Can dng xung l do can huyt h, nay can huyt km nn khng nui dng c cn

A. Nu a ng, b ng, a v b c lin quan nhn qu

B. Nu a ng, b ng, a v b khng lin quan nhn qu

C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai

2. a. Trong hi chng can dng xung, c du hiu run ry, co git bi v

b. Can dng xung c th dn n can nhit ng phong



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai

3. Trong bi thuc h p (gm thc a, ngu tt, r nhu, toan to nhn, m , trch t, hoa ho) cha chng can dng xung

a. Hai v thc a, ngu tt cng tng tu vi nhau, bi v

b. Hai v ny cng c tnh i xung nn lm cho dng ging



C. Nu a ng, b sai

30


D. Nu a sai, b ng

E. Nu a sai, b sai

4. Trong bi thuc h p (gm thc a, ngu tt, r nhu, toan to nhn, m , trch t, hoa ho) cha chng can dng xung

a. V r nhu lm qun, bi v

b. R nhu c tc dng bnh can tim dng



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai

5. Trong bi Thin ma cu ng m cha chng can phong ni ng (gm thin ma, cu ng, hong cm, chi t, tang k sinh, h th ch, trng, phc linh, ch mu, tho quyt minh, ngu tt)

a. Hai v thin ma, cu ng tng tu vi nhau, bi v

b. C hai u c tc dng thng thanh ging trc



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai


a. Ba v tang k sinh, trng, ngu tt tng tu vi nhau, bi v:

b. C 3 v u b can thn



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai


31


a. V phc linh lm t, bi v

b. Phc linh c tnh nh tm an thn



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai

8. Trong bi Linh dng cu ng thang cha chng can phong ni ng (gm linh dng gic, trc nh, cu ng, sinh a, bch thc, tang dip, phc thn, cc hoa, bi mu, cam tho)

a. Hai v trc nh, cu ng cng tng tu vi nhau, bi v

b. C hai u c tc dng trn kinh tc phong



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai

9. Trong bi Linh dng cu ng thang cha chng can phong ni ng (gm linh dng gic, trc nh, cu ng, sinh a, bch thc, tang dip, phc thn, cc hoa, bi mu, cam tho)

a. Hai v sinh a, bch thc u lm thn, bi v

b. Hai v u c tc dng sinh tn



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai

10. a. Trong phng huyt iu tr chng thn m h (gm thn du, phc lu, tam m giao, can du, thn mn, thi xung), chm b huyt phc lu bi v

b. B huyt phc lu b thn thy theo nguyn tc con h b m



C. Nu a ng, b sai

32


D. Nu a sai, b ng

E. Nu a sai, b sai

11. a. Trong phng huyt iu tr chng thn m h (gm thn du, phc lu, tam m giao, can du, thn mn, thi xung), chm t huyt thi xung thanh can ho, bi v

b. Chm huyt ny theo nguyn tc m thc t con



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai

12. a. Trong phng huyt iu tr chng thn m h (gm thn du, phc lu, tam m giao, can du, thn mn, thi xung) chm b huyt thn mn thanh tm ho, bi v

b. Chm huyt ny theo nguyn tc con h b m



C. Nu a ng, b sai

D. Nu a sai, b ng

E. Nu a sai, b sai

33


Bi 2

THIU MU C TIM

MC TIU

1. Nu c nh ngha v nhng yu t dch t hc ca bnh thiu mu c tim.

2. Trnh by c nguyn nhn v c ch sinh bnh thiu mu c tim theo l lun YHCT.

3. Chn on c 5 th lm sng thiu mu c tim theo YHCT. 4. Trnh by c nhng nguyn tc iu tr thiu mu c tim theo

YHHD v YHCT.

5. Trnh by c phng php iu tr thiu mu c tim (dng thuc v khng dng thuc ca y hc c truyn).

6. Gii thch c c s l lun ca vic iu tr thiu mu c tim bng YHCT.

1. I CNG

1.1. nh ngha

Bnh c tim thiu mu c xem l hu qu ca tnh trng x m ng mch vnh tim (xem bi x m ng mch). Tnh trng teo hp ng mch vnh ng k, ng thi vi nhng ri lon c ch iu ha co tht v gin n mch vnh l nhng yu t hnh thnh nhng triu chng rt phong ph ca bnh.

1.2. c im dch t hc

Bnh c tim thiu mu l nguyn nhn ch yu nh hng n t l t vong v t l bnh tt trn ngi sau tui 40. T vong do bnh tim mch chim khong 40% trn tng s t vong. Thng k cho thy c khong 800.000 trng hp nhi mu c tim mi, 450.000 trng hp nhi mu c tim ti pht v 520.000 t vong/nm.

Bnh c tim thiu mu tc ng rt ln n chm sc y t ca mt nc. Ti M, nm 1989, bnh c tim thiu mu c 56 triu t khm bnh, 455 triu ngy hn ch lm vic, 184 triu ngy nm vin v mt 23 triu ngy

34


cng. Bnh thiu mu c tim hin ng hng th 3 v loi bnh phi nm vin ngn ngy (sau sinh v chn thng). chn on v iu tr bnh c tim thiu mu rt tn km.

2. NGUYN NHN, BNH SINH


2.1.1. Nhim m x mch

L nguyn nhn trong 90% cc trng hp.

2.1.2. Nhng nguyn nhn khc (10%)

Tn thng thc th ng mch vnh tim.

Vim ng mch vnh do giang mai, vim quanh nt ng mch, tc mch vnh do cc mu t xa n.

V c ch bnh l bnh c tim thiu mu c lin quan cht ch n s cn bng ca 2 yu t cung cp v nhu cu oxy ca c tim. Do , nhng yu t thun li sau c th c tm thy trong bnh l ny nh:

Khi s cung cp oxy cho c tim khng : thiu mu nng. Khi nhu cu s dng oxy gia tng: tng huyt p, ph i tht tri, hot

ng th lc t ngt gia tng


Bnh thiu mu c tim c th xut hin vi bnh cnh au ngc (vi rt nhiu mc khc nhau) hoc khng c biu hin lm sng (bnh c pht hin tnh c trong khi khm, iu tr mt bnh l khc). Nh vy, c th tm tt cc triu chng c nng thng gp trong bnh l c tim thiu mu gm:

Nhng triu chng c th gp trong bnh l x m ng mch (xem bi x m ng mch).

au ngc cn gi l tm thng; nu km kh th th c gi l tm t, tm trng, hung hip thng.

Qua vic phn tch c ch bnh sinh ton b cc chng trng thng gp ca YHCT trong bnh c tim thiu mu, c th bin lun v c ch bnh sinh theo YHCT nh sau:

Nguyn nhn ca bnh l ny theo YHCT c th l:

Do tht tnh nh gin, lo s, gy tn thng 2 tng can v thn m. Do bnh lu ngy, th cht suy yu, m (huyt) v dng (kh) suy, h

ha bc ln, nung nu dch thnh m, m ha gp li gy bnh.

35


Do m thp ng tr gy tr tc kinh mch, m thp c th do n ung khng ng cch gy tn hi t v

Error!

THT TNH (gin, lo s, stress)

TH CHT YU BNH LU NGY

N UNG KHNG NG

Can m h

Thn m h

Thn dng h

m thp

H ha hun t tn dch

Lm tc tr kinh mch

TM THNG TM TRNG HUNG T M THP

Hnh 2.1. S bnh l bnh c tim thiu mu theo YHCT

3. CHN ON

3.1. Chn on theo y hc hin i

3.1.1. Suy mch vnh mn

a. Khi no th ngh n vic tm kim suy mch vnh mn?

Nhng yu t nguy c: nhng ngi au ngc, c nguy c thiu nng vnh (bng 2.1)

Bng 2.1. Nhng yu t nguy c ca tim mch

Yu t nguy c

Ni dung bnh Phng nga

Tui tc Trong tui t 45 - 60 tui: nguy c thiu mu tim tng 2 ln khi gi i 10 tui

Di truyn Tin cn gia nh c nhi mu c tim hoc t t ==> nguy c thiu mu tim tng gp 1,5 ln

Tin cn gia nh c nhi mu c tim hoc t t + THA ==> nguy c thiu mu tim tng gp 3,1 ln

36


Thuc l Nguy c thiu mu tim tng

1,4 ln nu ht 5 iu/ngy

2,1 ln nu ht 5 - 10 iu/ngy


2,8 ln nu ht > 20 iu/ngy

T l t vong do bnh tim mch tng


2,6 ln nu ht > 25 iu/ngy

Gim c 50-70% nguy c nhi mu c tim sau 5 nm ngng ht

Gim 50% t t sau 1 nm ngng ht

Tng cholesterol mu

Nguy c bnh tim thiu mu tng gp 4 ln nu cholesterol: 1,8 - 2,8 g/l

C gim c 1% lng cholesterol ton phn th gim c 2-3% nguy c NMCT

Gia tng c HDL tng ng vi gim nguy c bnh mch vnh

Tng huyt p

Nguy c bnh tim thiu mu tng theo mc trm trng ca bnh

Gp 5,4 ln nu HA TT: 130-190mmHg

Gp 3,3 ln nu HA TTr: 90-110mmHg

Lm gim c 1mmHg ca huyt p ti thiu s lm gim 2-3% nguy c NMCT

Lm gim nguy c xut huyt no

Tiu ng Nguy c bnh tim thiu mu gp 2,8 ln nu c bnh tiu ng

Cha r

Bo ph Nguy c bnh tim thiu mu tng gp i nu cn nng vt qu 120% cn nng l tng (y khng phi l yu t nguy c c lp m thng qua tng huyt p, cholesterol mu cao)

Gim cn lm gim c 35-55% nguy c bnh tim thiu mu

Tng triglycerid mu

Khng phi l yu t nguy c n ng. Ch l yu t nguy c ph n

Tng acid uric mu

Yu t ny thng kt hp vi nhng yu t nguy c khc. Do khng th nh gi nguy c ca n ring l c

Ru Vai tr ca n c tnh 2 mt:

Thng kt hp vi tng huyt p

L yu t bo v nhi mu c tim (NMCT)

Nu dng 1 ly ru vang/ngy lm gim 35-55% nguy c NMCT

Trng thi t vn ng

Nguy c t vong do bnh tim mch l 1,9 Nu ti lp trng thi vn ng s lm gim 35-55% nguy c NMCT

Thuc nga thai ung

Nguy c NMCT tng gp 4 ln k t sau 1 thng s dng

Nguy c ny s tng ln gp 39 ln nu c km ht thuc > 20/ ngy

Estrogen sau tt kinh

Cung cp oestrogen sau mn kinh lm gim 44% nguy c nhi mu c tim

37


au ngc + in hnh: au ngc vi cc tnh cht co tht hoc cm gic nng nh

b . au tng khi c ng, khi gng sc (lm ngi bnh s khng dm c ng).

+ V tr au: sau xng c, lan ln hm, vai, tay. + au ngc c th bt u t t v ch ko di khong vi pht. + Khng in hnh au c cm gic chn, tc ngc (lm bnh nhn chm

hoc ngng bc). V tr khng in hnh hm hoc tay. C v nh au khng tng khi gng sc v khng gim vi nm ngh.

C mt chu k kh r rt: nh cao ca triu chng ny l 4 gi sau khi thc dy (thi im m noradrenalin cao nht trong ngy).

Ch : ty theo mc ca tnh trng lo u, ca nhng yu t nguy c ca XMM, m chng ta thy cn thit hay khng thc hin cc xt nghim cn lm sng xc nh.

Kh th: trong nhiu trng hp kh th ch xut hin n c v l triu chng ch yu (c xem nh tng ng au ngc).

Nhng trng hp khng c triu chng lm sng: + Nhng trng hp bnh mch vnh ang c iu tr: l nhng

ngi m chng ta mun kim tra hu qu ca vic iu tr (nh lm cu ni, nong rng mch vnh). Thng lm phim mch vnh (coronarographie).

+ Nhng trng hp c bnh ng mch (ng mch chu hay ng mch no). y l nhng ngi c nguy c t vong rt cao do thiu nng vnh. V vy, lut bt buc trn nhng ngi ny trc khi tin hnh phu thut phi tin hnh xc nh c suy mch vnh? ( trnh tai bin phu thut).

b. Xc nh suy mch vnh mn bng cch no?

Chn on suy mch vnh c khi khng phi d dng, cn da vo nhng yu t sau:

+ au ngc. + Nhng yu t nguy c: phi, di truyn, ht thuc, t vn ng th lc,

bo ph, tng huyt p, stress, ch n nhiu m, tiu ng.

+ Khm lm sng (mc ch ch yu): Loi b nhng nguyn nhn him ca suy mch vnh nh hp van

ng mch ch, thiu mu nng

Tm ra thm x m ng mch c phm n nhng vng c th khc nh khng bt c mch chn, m thi ng mch cnh, ng mch di n, huyt p 2 bn khng ging nhau.

38


Chn on khch quan suy mch vnh bng cc nghim php: + in tim, in tim gng sc (c th lm holter/24 gi): Kt qu in tim (trong tnh trng ngh): him khi bt thng, sng

T o ngc (vi iu kin phi rt r); T m, nhn v tp trung vo mt vng mch mu c th (Vd, D2, D3, aVF). Trong cn au cp (c gi tr quan trng): nu in tm (EKG) bnh thng th c th loi b thiu mu c tim; nu ST chnh xung: chc chn c thiu mu c tim.

Kt qu EKG gng sc (quan trng nht): nu ST chnh xung, ln hn 1mm, trn 2 chuyn o tng xng, th rt c ngha. Trn bnh nhn c au ngc: ==> do thiu mu c tim. Trn bnh nhn khng c au ngc: ==> c th c suy mch vnh. Khi kt qu (+) sm xut hin trn nhng gng sc nh (cha cao) nh ST chnh xung rt su hay xut hin trn nhiu chuyn o hoc nu c ri lon nhp tim km theo trong nghim php gng sc th gi thuyt v mch vnh tc nghn l rt ng tin cy v nn ngh n nghim php chp cn quang ng mch vnh tim (coronarography).

Kt qu EKG holter (vi mt vi loi my, ta c th phn tch chnh xc ST, o c tn s v di ca cc on ST chnh/24 gi): c gi tr nhiu trong nh gi hiu qu tr liu thiu mu c tim, gi tr t hn cho chn on, thng cho dng tnh gi nhiu v c nhiu nguyn nhn nh hng n ST. Chp nhp nhy c tim (vi thallium 201 = ng v phng x) kch hot vi dipyridamol.

Kt qu nghim php nhp nhy vi thalium 201: nghim php ny tt hn EKG gng sc (nht l c gi tr nh v tn thng rt r), thallium l cht tng t nh K v c phn b cc t bo c ti mu. Nu c vng nhi mu ==> trn hnh s c l khuyt. Nu vng c tim ch c nui bi mt mch mu b teo hp ==> kt qu c th bnh thng lc ngh ngi, nhng s bt thng lc gng sc. Nu nghim php gng sc khng th thc hin c, c th thay th bng chch dipyridamol (y l thuc gin ng mch mnh) ==> hnh nh tng ti mu vng c tim bnh thng. Trong khi , vng ti mu bi ng mch b teo hp khng c hnh nh tng ti mu hoc hnh nh gim ti mu (do hin tng cp mu sang vng lnh).

Tuy nhin phng php ny vn cn mt s bt li: gi thnh t, kt qu cho hnh nh p thng him, chuyn gia cn t.

+ Siu m tim: suy mch vnh mn thng cho kt qu bnh thng trn siu m tim. c nhiu nhm nghin cu dng siu m tim gng sc, siu m tim vi dipyridamol, siu m tim vi dobutamin. T nm 1993, nhng k thut ny khng cn dng nhiu trong chn on thiu mu c tim.

Ngc li, siu m tim quy c c gi tr xc nh tnh trng tm tht tri.

39


nhy v c hiu ca cc test ny khng phi 100%, do ch c ch nh trn nhng ngi v mt lm sng ngh nhiu n thiu mu c tim (khng nu ch nh cho nhng ngi au ngc khng in hnh v hon ton khng c yu t nguy c ca x m ng mch v s gp (+) gi rt cao.

b. Phi thc hin xt nghim g khi nghi ng c suy mch vnh mn?

ng huyt lc i, ng huyt sau khi n. Bilan m: cholesterol, HDL, LDL, triglycerid. Nhng quan trng hn c l cn xem xt c lm mch vnh

(coronarographie) hay khng?. y l xt nghim gip chn on dng tnh c suy mch vnh mn hay khng gip quyt nh ch nh gii phu ti lp tun hon tim?

Thng thng ta c th iu tr trc trong 3 trng hp sau: + au ngc gim ch cn nhng cn tha tht xut hin trong nhng

gng sc khng thng thng.

+ Kt qu ch dng tnh trong nhng giai on gng sc sau cng. + Nu bnh nhn khng c triu chng au ngc. Vn ny cng r

hn nu bnh nhn cng ln tui.

Ngc li ch nh mch vnh (coronarography) cao khi: + au ngc lm nh hng n nhng sinh hot thng ngy ca bnh nhn. + Kt qu dng tnh ngay vi nhng gng sc nh. + Suy gim chc nng tht tri. Vn ny cng r hn khi bnh nhn tr.

3.1.2. Co tht mch vnh/thiu mu c tim mn

a. Khi no ngh n co tht mch vnh/thiu mu c tim mn

Khi c au ngc in hnh m khng c gng sc (khi ng) hoc khi th nhanh:

+ in hnh l xut hin ban m, khong 4 gi sng. + Thnh thong lo u, hi hp vo cui cn. + Dng trinitrin gim au ngay. + Trn in tim: ST chnh ln nhng chuyn o tng ng vi mt

vng ti mu.

+ Mch vnh : dng methergin thy du co tht. Bnh cnh ny nu xut hin:

+ ngi khng c nguy c x m ng mch ==> co tht mch vnh. Tin lng tt.

40


+ ngi c nguy c x m ng mch ==> co tht mch vnh trn nn x m ng mch.

b. Lm cch no chn on co tht mch vnh/thiu mu c tim mn

Xc nhn c thiu mu c tim khi: + EKG (ch gi tr trong cn) ==> ST chnh ln v quan trng l s bin

mt khi cn qua i.

+ EKG gng sc t c gi tr lm xut hin du bt thng (nu khng c nn x m ng mch).

+ Holter 24h: rt hiu qu v bt gp lc ln cn r rng. Xc nhn c co tht mch vnh:

+ Khi dng nhm c ch calci: du hiu au ngc mt hon ton. + Mch vnh vi methergin (R): xut hin du co tht. c. Phi lm nhng xt nghim cn lm sng g?

l: mch vnh .

3.1.3. Thiu mu c tim cp khng c hoi t (au ngc khng n nh)

Thc t, khng c gii hn r rng gia au tht ngc n nh vi au tht ngc khng n nh; cng nh khng c gii hn r rng gia au tht ngc khng n nh vi nhi mu c tim. S phn chia nh trn ca chng ti nhm gip hc vin theo di v ng x d dng hn trong thc t lm sng.

a. Khi no ngh n thiu mu c tim cp khng c hoi t (au ngc khng n nh)

Nhng cn au tht ngc xut hin vi mc thng xuyn. Chng xut hin trong nhng hot ng gng sc khng ln v thm ch c trong lc ngh (au tht ngc khng n nh gn).

Nhng cn au tht ngc xut hin vi mc thng xuyn hn. Chng xut hin trong nhng hot ng gng sc khng ln, ko di hn v khng p ng vi thuc gin mch vnh tc dng nhanh (au tht ngc nng).

b. Lm cch no chn on thiu mu c tim cp khng c hoi t (au ngc khng n nh)

in tim: on ST chnh xung. Vic xc nh s tr nn d dng hn nu bnh nhn c tin cn v bnh

mch vnh hoc c nhng yu t nguy c ca bnh l thiu mu c tim.

Mch vnh : Vic chn on xc nh c th rt kh khn khi cc triu chng lm

sng v in tim khng in hnh. Tht s rt kh chn on phn bit vi

41


vim mng ngoi tim cp, nhi mu phi, cng nh trng hp au ngc do nguyn nhn ngoi tim.

Ngoi ra, cng tht s kh phn bit c gia au ngc khng n nh v trng hp nhi mu c tim cp khng c sng Q (nhi mu di ni tm mc). Trng hp ny thng dng cc xt nghim v men tim chn on phn bit.

c. Phi thc hin nhng xt nghim cn lm sng g?

EKG khng quan trng trong trng hp ny. EKG gng sc l chng ch nh (cng nh vi nghim php vi persantin). Cc xt nghim men tim: CPK, CPK-MB, SGOT, SGPT, LDH, troponine-

test.

Mch vnh : rt quan trng v nh hng rt ln vo iu tr. 3.2. Chn on theo y hc c truyn

Da vo nguyn nhn v c ch bnh l YHCT, bnh l thiu mu c tim theo YHCT c th c biu hin di nhng th lm sng sau y:

3.2.1. Th kh tr huyt

au vng tim tng cn (tha tht hoc lin tc). Cht li tm hay c im huyt. Mch trm, t, sc.

3.2.2. Th can thn m h

au ngc (nu c) thng c tnh cht hoc co tht, hoc nhi nh kim m. Ngi d b kch thch, cu gt.

Tnh trng u oi, mt mi thng xuyn. au nhc mi lng m . Hoa mt chng mt, tai, u nng, au m . Cm gic nng trong ngi, bt rt, thnh thong c cn nng phng

mt, ng tm phin nhit, ng km, c th c to bn.

Mch trm, huyn, sc, v lc. 3.2.3. Th m thp

au ngc (nu c) thng c tnh cht nh c mt vt nng chn trn ngc, thng km kh th.

Ngi bo, tha cn; li dy, to. 42


Bnh nhn thng than phin v triu chng t nng chi. Thng hay km tng cholesterol mu. Mch hot.

3.2.4. Th tm t h

au ngc (nu c) thng c tnh cht m . Trng ngc, hi hp, ng t, hay m, hay qun. Mt mi, gy yu, n km, bng y, i tin lng. Li nht bu, mch t nhc.

3.2.5. Th tm thn dng h

Ph n, au vng ngc, hi hp. S lnh, thch ung nc m, au bng, tiu chy, nc tiu trong, t

hn, tay chn lnh.

Li nht, tm xm, mch v lc. Nu nng hn, tm dng h thot s c thm triu chng: ra m hi

khng ngng, chn tay quyt lnh, mi xanh tm, th nh yu, li tm xm, mch nh, h mun tuyt.

4. IU TR KT HP V THEO DI

4.1. Suy mch vnh mn

Vic iu tr bnh suy mch vnh mn phi m bo nhng nguyn tc tr liu sau:

Chng nhng yu t nguy c ca x m ng mch. Lm gim s tiu th O2 ca c tim. Chng tnh trng to mng x va. Ti lp tun hon mch vnh (revascularisation).

4.1.1. Phng chng nhng nguy c ca x m ng mch

Ngng ht thuc l (di mi dng): cng vic ny i hi ch ca bnh nhn v cc phng tin h tr (cho tng c nhn; tm l tr liu cho c nhm).

n nh tnh trng tng huyt p (xem bi tng huyt p). iu tr tng cholesterol mu. Khi cholesterol TP > 200 mg% v LDL > 130 mg%.

43


Nu LDL > 130 - 160 mg% v c < 2/5 yu t nguy c ==> iu tr bng tit ch (nhiu cht x + tri cy) (xem bi x m ng mch).

Nu LDL > 130 - 160%: c >2/5 yu t nguy c: ==> tit ch + thuc. Nu LDL > 160%: c < 2/5 yu t nguy c: ==> tit ch + thuc.

NB: tit ch gim cholesterol l sa i ch n t nhiu cht bo no sang bo khng no.

Thuc YHH v YHCT iu tr gim cholesterol mu (xem bi x m ng mch).

4.1.2. Lm gim s tiu th O2 ca c tim

S tiu th O2 ty thuc nhp tim, co bp ca c tim, khng lc ca huyt p khi tim co (huyt p ng mch), khng lc ca tm trng (huyt p tim tri cui tm trng). Thuc YHH hoc thuc YHCT u phi lm th no p ng c yu cu ny.

YHCT c nhng bi thuc tham gia vo c ch ny qua vic lm gim huyt p (xem bi tng huyt p). YHH c 3 nhm thuc phc v cho yu cu ny gm: chn beta, nhm khng calci, dn xut nitrit.

Chn beta: rt hiu qu v lm gim nhp tim, gim co c tim, gim huyt p tm thu. Do , loi ny c chng minh phng nga tt t vong sau nhi mu c tim.

Nhm khng calci: c tc dng lm gim co c tim, gim huyt p. Cn ch nhm nifedipin v lm tng nhp tim, c kh nng lm tng nguy c thiu mu. Thuc hay dng l tildiem (diltiazem), isoptin (verapamil). C th phi hp gia chn beta v nhm khng calci v rt hiu qu chng au ngc nhng c bt li l lm chm nhp tim nhiu.

Nhm dn xut nitrit: dng t 100 nm tr au tht ngc v gim c p lc lm y tht tri v nh th lm gim ti tm trng. Loi nhanh: dng di li hoc xt (spray). Loi iu tr cng c: c cc dng dng ngoi da (khng c dng 24/24, nn b ra lc ng), dng thuc ung LP. Dng phi hp vi chn beta trong suy mch vnh rt tt. Cnh nhm ny c nhm molsidomin (corvasal (R)) 6 - 12mg/24h chia 3 ln. C ch ging nh nhm dn xut nitrit.

Vic nh gi da trn kt qu nhp tim chm r rng hoc c ch c nhp tim nhanh tng trn 115 ln/pht khi lm nghim php gng sc. Cng c th kim tra hiu qu vi EKG gng sc ==> nghim php gng sc ko di hn v lm c nhng bc cao hn ca nghim php gng sc.

4.1.3. Chng tnh trng to mng x va

Aspirin liu thp 75 - 100 mg: rt thng dng. c chng minh lm gim tn sut nhi mu c tim.

44


YHCT tuy cha c nghin cu v tc dng dc l ny nhng c kinh nghim qu vi nhm thuc hot huyt, kh nh: an sm, o nhn, hng hoa, ch mu. Nhng dc liu nh ngu tt, ngh th c tc dng gin tip thng qua tc dng h cholesterol mu (xem bi x m ng mch).

4.1.4. Ti lp tun hon mch vnh (thuc lnh vc ngoi khoa)

Angioplastie coronaire.

Pontage aorto coronaire.

4.2. Co tht mch vnh/thiu mu c tim mn

Trong cn au cp ngi ta thng kt hp thuc vi chm cu, bm huyt.

4.2.1. Dng thuc

Hai nhm thuc YHH c hiu qu trong au ngc do co tht mch vnh tim.

Khng calci liu cao: Adalat (R) 40 - 80mg/24h.

Tildiem (R) 240 - 480 mg/24h.

Isoptil (R) (Vrapamil) 240 - 480 mg/24h.

Nhm dn xut nitrit: S dng nhm tc dng nhanh trong cn au cp.

S dng nhm tc dng chm (khi khng calci km hiu qu).

i vi thuc YHCT, hin nay ch ghi nhn nhng bo co v thuc ca Trung Quc c s dng; ch yu l nhng dc liu c tnh cht hot huyt, kh mnh.

Theo cc ti liu th ti Trung Quc c bo ch cc loi thuc phun sng tm thng th hn (ch yu thnh phn c cha nhc qu, hng ph), thuc phun sng tm thng th nhit (ch yu cha n b, xuyn khung.) c tc dng khng km nitroglycerin. Ngoi ra, cn c nhng bo co v s dng thuc dng tim (an sm IM, IV; xuyn khung IV; nhn sm; mch mn IV).

4.2.2. Dng chm cu

Cc huyt thng dng: chin trung phi hp ni quan, c khuyt, gin s, tc tam l.

Dng theo kinh nghim: + Day bm im gia ng ni 2 huyt tm du v quyt m du bn tri

trong 1-2 pht.

+ Bm mnh huyt ni quan phi hp bnh nhn th su. 45


Ngoi cn, nu c du hiu gi ca x m ng mch vnh tim th cch iu tr s nh phng php iu tr suy mch vnh mn.

4.3. Thiu mu c tim cp khng hoi t (au tht ngc khng n nh)

Thiu mu c tim cp khng hoi t (au tht ngc khng n nh) phi c iu tr v theo di trong mt n v sn sc tch cc (ICU) v tim mch v bao gm chng thiu mu c tim, chng to mng x va v phng php ti lp ti mu.

4.4. Nhng phng php YHCT iu tr bnh l c tim thiu mu

Tc dng tr liu ca nhng phng php YHCT, ngoi vic p ng nhng yu cu tr liu ca bnh l c tim thiu mu, cn ch n tng trng chung ca c th, gii quyt nhng ri lon thc vt km theo.

4.4.1. Th kh huyt tr

Php tr: hnh kh hot huyt. Nhng bi thuc v cng thc huyt s dng:

+ Bi thuc gm: qua lu nhn 20g, c h 12g, o nhn 12g, v chanh gi 12g.

+ Cng thc huyt s dng gm: ni quan, tm du, chin trung; chm loa tai: huyt tm, thn mn, giao cm.

4.4.2. Th thn m h

Php tr: t m ghm dng, t b can thn. Nhng bi thuc v cng thc huyt s dng:

+ Bi thuc h p (xut x 30 cng thc thuc) gm: thc a 20g, ngu tt 10g, r nhu 20g, trch t 10g, m 20g, to nhn 10g, hoa ho 10g.


Thc a Ngt, hi n: b thn t m, b huyt Qun

Ngu tt Chua, ng, bnh: b can thn, tinh i xung Qun



M Ngt, hn: li tiu, thanh ph can phong nhit, thm bng quang thp kh

T


Hoa he ng, bnh: thanh nhit, lng huyt, ch huyt T

46


+ Bi thuc Lc v a hong hon gia quy thc gm: thc a 32g, hoi sn 16g, sn th 8g, n b 12g, phc linh 12g, trch t 6g, ng quy 12g, bch thc 8g. Bi ny thng c s dng khi tng huyt p c km triu chng au ngc, au vng tim.




Sn th Chua, sp, hi n: n b can thn, sp tinh ch hn Thn

n b Cay, ng, hi hn: thanh huyt nhit, tn huyt, cha nhit nhp doanh phn

T



+ Bi thuc b can thn gm: h th 10g, thc a 15g, hoi sn 15g, ng quy 12g, trch t 12g, si h 10g, tho quyt minh 10g.


H th B huyt, thm tinh Qun



ng quy Dng can huyt Thn


Si h Bnh can, h st T

Tho quyt minh Thanh can, nhun to, an thn T

+ Cng thc huyt s dng: thn du, phc lu, tam m giao, can du, thi xung, thn mn, ni quan, bch hi, a th huyt.

4.4.3. Th m thp

Php tr: ha m tr thp. Nhng bi thuc v cng thc huyt s dng:

Bi thuc h p gia o nhn, hng hoa (xut x 30 cng thc thuc) gm: thc a 20g, ngu tt 10g, r nhu 20g, trch t 10g, m 20g, to nhn 10g, hoa ho 10g, o nhn 12g, hng hoa 8g.

47



Thc a Ngt, hi n: b thn t m, b huyt Qun

Ngu tt Chua, ng, bnh: b can thn, tnh i xung Qun



M Ngt, hn: li tiu, thanh ph can phong nhit, thm bng quang thp kh

T


Hoa he ng, bnh: thanh nhit, lng nguyt, ch huyt T

o nhn Ngt, ng, bnh: hot huyt T

Hng hoa Cay, m, hot huyt T

4.4.4. Th tm thn dng h

Php tr: n thng tm dng (tm dng h), hi dng cu nghch (tm dng h thot).

Nhng bi thuc y hc c truyn c th s dng: + Lc v hi dng m + Hi dng cp cu thang. + Sinh mch tn.

Nhng bi thuc v cng thc huyt s dng: + Bi thuc Lc v hi dng thang: nhn sm 8g, ph t (ch) 8g, ng

quy 12g, an sm, nhc qu 6g, nhc thung dung 12g, ba kch 12g V thuc Tc dng Vai tr

Nhn sm Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn

Qun

Ph t Cay, ngt, rt nng: b mnh mn ha, kin t Qun

ng quy Ngt, cay, m: b huyt, hnh huyt Thn

an sm ng, lnh: hot huyt, kh T

Nhc qu Cay, ngt, rt nng: b mnh mn ha, kin t, dn thuc T, s

Nhc thung dung Ngt, mn, m: n b thn dng, nhun trng T

Ba kch Cay, ng, m: n thn dng T

+ Bi thuc sinh mch tn gia v: nhn sm 40g, mch mn 40g, ng v t 7 ht, hong k 12g, cam tho 6g.

48



Nhn sm Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Qun

Mch mn Ngt, ng, lnh: nhun ph, sinh tn dch Thn

Ng v t Mn, chua, m: lim hm, c tinh T

Hong k Ngt, m: b tm kh, thng dng kh ca t T

Cam tho Ngt, m: b t th, b trung kh S

+ Bi thuc Hi dng cu cp thang: ph t ch 4g, can khng 4g, nhc qu 4g, nhn sm 12g, bch trut 8g, phc linh 8g, ng v t 10 ht, trn b 4g, cam tho nng 2g.


Ph t n trung tn hn, hi dng cu nghch Thn

Can khng n trung tn hn, hi dng cu nghch Thn

Nhc qu Cay, ngt, rt nng: b mnh mn ha, kin t, dn thuc Thn

Nhn sm Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Qun

Bch trut Ngt, ng, hi m: kin t, to thp, cm m hi T

Phc linh Ngt, bnh: li tiu thm thp, kin t, an thn T

Ng V T Mn, chua, m: lim hm, c tinh T

Trn b Cay, m: ha kh, tiu m T


+ Cng thc huyt s dng: n trung, c khuyt, kh hi, quan nguyn, cao hoang, ni quan.

4.4.5. Th tm t h

Php tr: b ch tm t. Nhng bi thuc y hc c truyn c th dng gm:

+ Bi thuc Quy t thang gia v: phc thn 3g, toan to nhn 3g, long nhn 3g, nhn sm 3g, hong k 3g, bch trut 3g, ng quy 3g, vin ch 3g, i to 2 qu, mc hng 1,5g, cam tho 1g, ut kim 4g

49



Phc thn Tit tm nhit, bnh n tm thn Qun

Toan to nhn Ngt, chua, bnh: dng tm an thn, sinh tn dch Qun

Long nhn B huyt, kin t Qun

Nhn sm Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Thn

Hong k Ngt, m: b tm kh, thng dng kh ca t Thn

Bch trut Ngt, ng, hi m: kin t, to thp, cm m hi Thn

ng quy Ngt, cay, m: b huyt, hnh huyt T

Vin ch ng, m: b tm thn, an thn T

i to Ngt, bnh: b t v, iu ha tnh nng ca thuc T

Mc hng Hnh kh ch thng, kin t T


Ut kim Cay, ng, n; vo t, can: hnh kh, hnh huyt, ph , gii ut T

+ Cng thc huyt s dng: n trung, c khuyt, t du, cch du, thi bch, phong long, ni quan.

T lng gi

I. Cu hi 5 chn 1: chn cu ng

1. Yu t khng phi l nguyn nhn ca bnh c tim thiu mu

A. Nhim m x mch

B. Tng huyt p

C. Vim ng mch vnh do giang mai

D. Vim nt quanh ng mch

E. Tc mch vnh do cc mu ng

2. Yu t khng tham gia vo c ch bnh c tim thiu mu theo YHCT

A. Bnh lu ngy lm m (huyt) suy h, h ha hun t tn dch sinh m, gy tc tr

B. Th cht suy h dn n thn dng h, chn dng nhiu lon trn gy bnh.

C. n ung khng ng cch sinh m lm tc tr kinh mch

50


D. Gin, lo s gy can thn m h khin h ha bc ln hun t tn dch sinh m

E. Gin d lm can kh ut kt gy tc tr kinh lc 3. Yu t khng phi yu t nguy c ca thiu nng vnh

A. Tui tc (mi tui) B. Thuc l C. Di truyn (gia nh) D. Tiu ng E. Tng cholesterol mu

4. Trn bnh nhn nghi ng thiu mu c tim, c in tim bnh thng, cn lm xt nghim g chn on

A. in tim gng sc B. in tim holter C. Chp nhp nhy c tim kch hot vi dipyridamol D. Siu m tim E. Cholesterol, HDL, LDL, triglycerid

5. Bnh nhn c triu chng au ngc khng n nh (angor instable), phi lm xt nghim g?

A. in tim B. in tim gng sc C. in tim holter D. Siu m tim E. Men tim: CPK, CPK-MB, SGOT, SGPT, LDH

6. Triu chng lm sng gp trong thiu mu c tim th kh tr huyt

A. au ngc nh c vt nng B. au ngc m , hi hp, kh th C. au ngc, cht li tm hoc c im huyt D. au nhi ngc nh co tht, ng tm phin nhit E. au ngc d di, t hn, ngi lnh

7. Triu chng lm sng gp trong thiu mu c tim th can thn m h

A. au ngc m , bng y, i tin lng B. au ngc, au nhi, cu gt, mch trm sc v lc C. au ngc, tha cn, mch hot D. Hi hp, kh th, on kh, au nng ngc

51


E. au vng ngc nh c , kh th, t tay chn 8. Triu chng lm sng gp trong thiu mu c tim th m thp

A. au ngc nh , mch trm v lc B. au nhi ngc, au co tht, ngi bt rt C. au nng ngc, mt mi, i tin lng D. au ngc, hi hp, hoa mt, chng mt, t hn E. au nng ngc, bo bu, li dy nht

9. Triu chng lm sng gp trong thiu mu c tim th tm t h

A. au ngc nh , mch trm v lc B. au nhi ngc, au co tht, ngi bt rt C. au nng ngc, mt mi, i tin lng D. au ngc, hi hp, hoa mt, chng mt, t hn E. au nng ngc, bo bu, li dy nht

10. Triu chng lm sng gp trong thiu mu c tim th tm thn dng h

A. au ngc d di, li tm, c im huyt B. au ngc d di, li tm, xm, t hn C. au ngc d di, bt rt, cu gt, to bn. D. au ngc m , mt mi, i tin lng E. au nng ngc, li dy nht, mch hot

II. in vo ch trng

1. Khi no ngh n vic tm kim suy mch vnh mn

A. . B. . C. . D. .

2. Khi no ngh n co tht mch vnh/thiu mu c tim mn

A. . B. .

3. Nguyn tc tr liu YHH suy mch vnh mn

A. . B. . C. . D. .

52


Bi 3

X M NG MCH

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca bnh nhim m

x mch.

2. Trnh by c nguyn nhn v c ch sinh bnh nhim m x mch theo l lun YHCT.

3. Trnh by c nhng nguyn tc iu tr nhim m x mch theo YHHD v YHCT.

4. Trnh by c phng php iu tr v phng bnh nhim m x mch ca y hc c truyn.

5. Gii thch c c s l lun cu vic iu tr nhim m x mch bng YHCT.

1. I CNG

X m ng mch l nguyn nhn dn u gy t vong v tn tt cc nc pht trin. Mc d bnh kh ph bin, nhng mt vi tnh cht c bn ca bnh vn cha c hiu bit y .

Atherosclerosis, tn gi ca bnh ni ln tnh trng tch t ca m (athere, gruel, cho) lm thnh trong ca mch mu b dy ln (sclerosis: dy cng).

Bnh khng xut hin trn tt c cc ng mch ca c th. Thng thng n xut hin ng mch ch bng, k n l ng mch vnh tim trc khi tn cng n cc ng mch chu v ng mch no (cc ng mch cnh ngoi, ng mch v, ng mch nch khng bao gi thy x m d cha r l do).

Ch nhng bin chng ca bnh mi lm thy r bnh: trong mt thi gian di, tin trin ca x m ng mch rt yn lng, khng triu chng v n thun ch l nhng thay i v gii phu. Nhng sang thng trn di dn trong lng ng mch lm dng mu chy chm li, to nn tc nghn mch a n nhng hi chng thiu mu cp v mn.

Nhng bin chng ca x m ng mch gm (bng 3.1):

53


Bng 3.1. Nhng bin chng ca x m ng mch

ng mch Bin chng

Mch vnh tim

au tht ngc

Nhi mu c tim (NMCT)

t t

Suy tim

Di n Cp mu di n

ng mch cnh

H thng ng mch ty - thn nn

ng mch no

Cn thiu mu no thong qua

Tai bin mch mu no do thiu mu nui

ng mch thn

Suy thn

Huyt p cao

ng mch mc treo

Thiu mu mc treo

Nhi mu mc treo

ng mch chi di

Khp khnh cch hi

Thiu mu nui chi di cp tnh

2. NGUYN NHN V DCH T HC


Cho n nay, bnh x m ng mch vn cha r c nguyn nhn. Ngi ta nhn thy c nhiu yu t tham gia vo s hnh thnh bnh l ny. Nhng nghin cu dch t hc tin hnh trong vng 35 nm gn y xc nh c nhng yu t thc y qu trnh pht trin bnh. Chng c gi di tn l nhng yu t nguy c (c th tham kho thm bng nhng yu t nguy c trong bi thiu mu c tim, trang 30-32).

Tuy nhin, gip nh hng x tr, cn ch u l yu t nguy c ca x m ng mch gii phu v u l yu t nguy c ca nhng bin chng ca x m ng mch.

Yu t nguy c ca nhng bin chng ca x m ng mch: th hin mi lin quan gia yu t phi nhim (exposed) v bin chng: ==> ta c th d kin rng nu tc ng trn yu t ny s lm gim nhanh tn s xut hin bin chng y (v d: ht thuc v bin chng mch vnh).

54


Yu t nguy c ca x m ng mch gii phu: th hin mi lin h nhn qu gia yu t phi nhim (exposed) v s pht trin v mt gii phu ca mng x va: ==> ta c th d kin rng nu tc ng trn yu t ny s lm gim t t tn s xut hin bin chng y (v d: tnh trng tng cholesterol mu v tng atherom ==> bin chng mch vnh).

Do , d nguyn nhn ca bnh x m ng mch cha r nhng vi nh ngha tm thi v nguyn nhn (yu t m khi gim s dn n s gim bt tn thng gii phu XMM hoc tn sut bnh) v yu t nguy c (yu t m s hin din gia tng s dn n s gia tng tn thng gii phu XMM hoc tn sut bnh).

2.1.1. Tng cholesterol mu c xp vo nhng nguyn nhn ca x m ng mch

C mt mi lin quan trn khp th gii gia con s trung bnh cholesterol mu trong mt quc gia, s pht trin v mt gii phu ca x m ng mch v tn sut cc bnh tim thiu mu trong quc gia y. Nhiu nghin cu cho thy vic lm gim cholesterol mu, d vi phng tin no cng lm chm s pht trin x m ng mch v cui cng l gim t l t vong cc bnh mch vnh.

Bng 3.2. Gi tr cholesterol i hi mt s tr liu

Tui Cholesterol ton phn

20 - 29

30 - 39

> 40

2g/l = 5,16mmol/l

2,2 g/l = 5,68mmol/l

2,4 g/l = 6,19mmol/l

Cholesterol di chuyn trong mu bng cch gn vo cc protein to thnh cc lipoprotein. C hai nhm lipoprotein chnh:

Nhm t trng thp LDL (low density lipoprotein): trong nhm ny chuyn ch ch yu l apoprotein B. y l dng m cholesterol c mang n cc t bo ==> Nu LDL hay apoprotein B cng cao, nguy c XMM cng ln

Nhm t trng cao HDL (high density lipoprotein): nhm protein chuyn ch ch yu l apoprotein A1. y l dng m cholesterol d tha c mang ra khi cc t bo. Do nu HDL hay apoprotein A1 cng cao nguy c XMM cng thp.

2.1.2. Tng huyt p c xp vo nguyn nhn XMM

XMM ch thy xut hin trong nhng vng chu nh hng ca p lc ng mch cao: ngi ta khng thy XMM trong cc tnh mch saphene

55


hoc ng mch phi (tr khi tnh mch saphene trong tnh trng ng mch ha hoc c tnh trng tng p ng mch phi).

Tnh trng huyt p cng tng, tnh trng pht trin gii phu ca XMM cng nhiu v bin chng XMM cng ln.

Hin nay cha c chng minh r rng gim huyt p lm gim s pht trin XMM, nhng chng minh c mi quan h gia gim huyt p v gim bin chng thiu mu no v thiu nng vnh.

2.1.3. Ht thuc l c xp vo nhng nguyn nhn ca nhng bin chng ca XMM

Tn s ca NMCT, t t, vim tc ng mch chi di mn tnh u tng mt cch ng k vi s kin ht thuc l. Khng thy c mi lin h gia ht thuc l v s pht trin gii phu ca XMM.

2.1.4. Nhng yu t nguy c ca bin chng XMM t mnh m hn

Tnh trng gim vn ng th lc Stress Bo ph Tng triglycerid (TG) mu Dng thuc nga thai ung

2.1.5. Nhng yu t nguy c rt ln ca XMM nhng khng c cch nga

Phi nam Tui Yu t di truyn


X m ng mch l bnh l rt ph bin: nh trn nu, phn ln mng x va khng gy ra triu chng v rt nhiu trng hp khng bao gi c biu hin triu chng lm sng. Trong khi nhng bnh danh YHCT ch yu c da trn nhng triu chng chc nng khi bin chng ca bnh xut hin.

Da vo nhng c s l lun YHH v YHCT, c th bin lun v c ch bnh sinh bnh l XMM theo YHCT nh sau:

56


C th ni rng nhim m x mch theo YHCT, d do nguyn nhn no, cng u gy bnh thng qua c ch m thp. m thp (c th ha ha hoc khng) s lm tc tr kh huyt lu thng trong kinh mch. Ty theo tnh trng tc tr kinh mch xy ra u m biu hin lm sng s l:

Tht tnh (gin, lo lng)

(stress ko di)

Tin thin bt tc, bnh lu ngy

Tc tr kinh mch

Can m h

m (huyt) h

Dng (kh) h

m thp

m ho

H ha hun t

n ung khng ng

tn dch

+ tm vi triu chng tm thng, tm trng (xem bi c tim thiu mu). + kinh lc m xut hin triu chng t, au, yu lit (xem bi tai bin

mch mu no).

+ can, thn gy chng huyn vng, u thng (xem bi tng huyt p).

3. IU TR KT HP V THEO DI i vi bnh l x m ng mch, phng bnh l yu t quan trng hng

u. Vic phng bnh cn phi thc hin t lc cn tr v sut cuc i, ch yu l loi tr nhng yu t nguy c.

3.1. Tit ch

Ch n nhiu rau xanh, tri cy ti l ngun cung cp sinh t, ion K+, Mg++, cc cht anti oxydant.

Cn quan tm n sinh t E (l mt cht anti oxydant rt c li cho phng x m ng mch): sinh t E c nhiu trong thc n tho mc v trong cc loi du nh du mng la m, du hng dng, du bp

Cht x ngoi tc dng chng to bn cn c tc dng gi li cholesterol trong lng ng tiu ha, hn ch s hp thu cholesterol vo mu, lm gim LDL, VLDL, triglycerid trong mu.

57


Do c nhiu loi tng m trong mu khc nhau, ngi thy thuc cn ch n nhng ch tit ch ph hp.

Bng 3.3. Bng phn loi ri lon bin dng m trong mu

Cholesterol >2g/l

LDL > 130mg%

Tng cholesterol mu

Tng m trong mu phi hp

Tng triglycerid mu

1,5 g/l = 1,71mmol/l

Tit ch gim cholesterol l sa i ch n t nhiu cht bo no sang bo khng no

Bo no Bo khng no

Sa v cht ch bin t sa

M ng vt

C

Du hng dng

n King

Rau

Tri cy

C

Thc n nng

Du: liu, hng dng, u nnh

Yaourt

C th dng margarin t hng dng

Trng > 2 trng/tun

S hn

Heo

B, b

Du u phng

Sa, b, pho mt

Ch lm gim m (dnh cho bnh nhn tng lipid huyt)

King Gim

Bnh m

Bnh nng

Khoai ty

u H Lan

Bp

Go

Bt

Thc ung c ng, xir

Ru

Trng ming c ng

Tri cy kh

Tht heo

Tht cu

Tht b

Tht vt

C hi

C mi

Pho mt (tr yaourt)

Chui

Nho

58


Ch n lm gim triglycerid: King: thc n ngt, bnh ga-t, s-a, xi-r, chocolat, ru

3.2. Thay i cch sng

Cng nhm loi b nhng yu t nguy c nh:

B ngay thuc l. Gi thi tm thn thch hp, lc quan, trnh cng thng thn kinh

(xem bi thi tm thn trong cuc sng - dng sinh v hc thuyt m dng ng hnh).

Phi hp vi ch n: thit lp ch vn ng th lc u n/ngy, nht l ngi cao tui. Nguyn tc ca ch tp luyn ny l dng nhiu c t u i bt dng c tim. Thc hin nhng bi tp dng sinh u n (xem bi th gin - th 4 thi - nhng bi tp cc t th nm, ng).

3.3. iu tr tch cc, ng n nhng bnh c lin quan

iu tr bnh tng huyt p, tiu ng (xem phn bnh l tng huyt p, tiu ng).

iu tr gim cholesterol mu bng thuc.

C ch Tc dng Tc dng ph Ch nh Liu dng

Nhm fibrat

c ch tng hp cholesterol gan

Gim 20% cholesterol, gim 40% TG

- Lm tng tc dng thuc chng vitamin K

- Tng creatinin

- Tng transaminase

Tng lipid huyt (nht l khi cholesterol > 2,8 g/l)

Lipanthyl 100-300mg/ 24h

- Lipur (R) (gemfibrozil) 900mg/24h

- Ciprofibrat Lipanor (R): 100mg/24h

- Bezafibrat, befizal (R): 400-600mg/24h

Nhm c ch HMG -CoA reductase

Gim 30% cholesterol, rt hiu qu trong tng cholesterol mu gia nh

- au c

- Tng transaminases v CPR

- Tng nh tc dng cc thuc chng vitamin K

Tng cholesterol mu n thun

Simvastatin Zocor (R)

Lodals (R) 10-20mg/24h

Pravastatin

Vasten (R)

Elisor (R) 10-40mg/24h

59


Nhm resin (dng v tc dng ph h tiu ho, dng phi hp vi nhm 2)

Chelation cc acid mt c cha cholesterol

Gim 15% cholesterol

- To bn

- RLTH

- Gim tc dng cc thuc chng vitamin K, digital v kch t gip

Tng cholesterol gia nh

Cholestyramin

Questran (R)

3-6 gi /24h

Ngh Thng mt, li mt, gim cholesterol

V cay ng, tnh n

Quy kinh can t:

ph c huyt, huyt tch, kim sang. Tc dng st trng, khng khun, sinh c v ch huyt

Ngi m h m khng tr th khng nn dng

6-8g

Ngu tt

Li tiu;

v chua ng, tnh bnh, khng c;

vo 2 kinh can, thn

Tc dng ph huyt, hnh (sng), b can thn, mnh gn ct (chn)

12-16g

Ti

H cholesterol, h huyt p.

V cay, tnh n, hi c, vo 2 kinh can v v

Thanh nhit, gii c st trng, cha bng i trng tch, huyt l. Ty u, thng khiu, tiu nht, hch phi, tiu m, y trng

Phm m h ni nhit, thai sn ch dng, hi ming

4-8g

T lng gi

I. Cu hi 5 chn 1: chn cu ng

1. Bnh l no khng do bin chng ca x m ng mch (XMM) trn tim

A. au tht ngc

B. Nhi mu c tim (NMCT)

C. Tng huyt p

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D. t t

E. Suy tim 2. C ch bnh nhim m x mch theo YHCT

A. Can m h gy ni nhit

B. Huyt h sinh huyt nhit

C. Huyt h sinh huyt

D. Kh h sinh kh tr

E. m thp 3. Ch n no khng c li cho bnh XMM

A. Nhiu rau

B. Nhiu tri cy

C. Nhiu c

D. Nhiu du phng

E. Thc n nng 4. Dc liu no c tc dng lm h cholestorol trong mu

A. Sinh a

B. Cc hoa

C. C xc

D. Trch t

E. Hoa i 5. Ngh l v thuc c tc dng

A. Lm lnh so, lnh vt lot

B. H cholesterol mu

C. St trng

D. Nhun gan mt

E. C 4 cu trn u ng

Cu hi 5 chn 1: chn cu sai

1. lm gim m trong mu, cn king

A. Bnh m

B. Khoai ty

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C. Tri cy kh D. Thc n ung c ng E. Yaourt

2. lm gim cholesterol trong mu, cn king

A. Trng B. Tht heo C. Tht b, b D. Sa E. C

3. lm gim triglycerides trong mu, cn king

A. Du hng dng B. Bnh ga-t C. Chocolat D. Thc n ung c ng E. Ru

4. iu tr XMM, tt nht

A. Phng bnh B. n ung ng cch C. Thay i cch sng D. iu tr bnh c lin quan E. Dng thuc h cholesterol mu

5. Cng dng ca c xc

A. An thn B. H huyt p C. Li tiu D. H cholesterol mu E. Cha au khp

6. Cng dng ca ngh

A. Khng khun B. Kch thch tiu ha C. Nhun gan mt D. Lm lnh vt lot E. St trng

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Bi 4

VIM PH QUN CP V MN

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca bnh vim ph

qun cp v mn.

2. Trnh by c nguyn nhn v c ch sinh bnh ca bnh vim ph qun cp v mn theo l lun YHH v YHCT.

3. Chn on c 9 th lm sng ca bnh vim ph qun cp v mn theo YHCT.

4. Trnh by c nhng nguyn tc iu tr ca bnh vim ph qun cp v mn theo YHH v YHCT.

5. Trnh by c phng php iu tr ca bnh vim ph qun cp v mn (dng thuc v khng dng thuc ca y hc c truyn).

6. Gii thch c c s l lun ca vic iu tr bnh vim ph qun cp v mn bng YHCT.

1. I CNG

1.1. nh ngha

Vim ph qun cp (VPQC) l tnh trng vim nhim cp tnh nim mc cy kh ph qun. Thng tin trin t nhin ht, hoc cui cng sau iu tr s lnh hn bnh v hot ng h hp hon ton tr li bnh thng.

Vim ph qun mn tnh (VPQM) l mt bnh c lin quan vi s tip xc lu di vi nhng cht kch thch ph qun khng c th, i i vi s tng tit nim dch cng mt s thay i v cu trc ca ph qun. V mt lm sng, c coi l VPQM khi bnh nhn c ho khc ko di t nht 90 ngy trong mt nm v trong 2 nm lin tc. Ho khc c loi tr l khng do cc bnh khc nh lao, gin ph qun, p - xe, bi phi v.v (Lancet, 1965). nh ngha trn ch nu c mc ti thiu khi u ca VPQM, v VPQM bao gm nhng trng thi bnh l nng nh khc nhau, t ho khc m gim, n nhng t suy h hp thng xuyn m tin lng cng khng km nguy him

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nh nhi mu c tim (Bourgeois, 1979). iu ny ni ln tnh cn thit ca s pht hin v phng tin trin xu.

1.2. c im dch t hc

1.2.1. Vim ph qun cp

C th gp VPQC mi la tui, nhng ch yu l tr em v ngi cao tui. Thng gp VPQC khi tri lnh hoc khi thay i thi tit t ngt.

VPQC chim1,5% cc bnh n bnh vin v 34,5% cc bnh ca c quan h hp (Votral.B. E).

1.2.2. Vim ph qun mn

Thng gp VPQM ngi trung nin v cao tui. Bi nh hng nhiu n VPQM, t l mc bnh cao r rt cng nhn

cc cng trng nhiu khi bi, dn thnh ph mc bnh cao hn nng thn, ngoi tr trng hp nhng ph n nng thn nu nng trong nh bp thiu thng thong, khng ng khi, cht t to nhiu bi bm; min ni t l thp hn ng bng.

Vit Nam: t l VPQM l 4,7%, v chim hn 1/2 tng s ngi mc cc bnh v h hp (Phm Khu v CS). Trong mt iu tra khc ngi trn 60 tui, t l VPQM ln ti 19,6%.

V thi tit, ma lnh lm tng s ngi mc VPQM: ti Scotland t vong l 45% do VPQ mn xy ra trong 3 thng lnh u nm (thng k 1956 - 1963 Crofton, Douglas).

2. NGUYN NHN - BNH SINH V GII PHU BNH

2.1. Nguyn nhn

Yu t Vim ph qun cp Vim ph qun mn

Vi khun

(+) Mycoplasma pneumoniae

() Cc loi vi khun khc, thng l th pht, bi nhim sau nhim siu vi hoc nhim lnh

(+++) Hemophilus influenza 13,5%

(+++) T cu vng 15,5%

(+++) Ph cu 13,5%

(++) Proteus hauseri 12,2%

(++) Pseudomonas aeruginosa 9,6%

(++) Escherichia coli 9%

(+) Klebsiella pneumoniae 1,9%

(++) Streptococus pyogenes 6,4%

() Trc khun Gram (-) (Voisin, 1976)

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Virus

(+++) RSV (Respiratory Syncytial Virus)

(+++) Adenovirus, Para. influenza virus

Virus ch l nguyn nhn ban u to iu kin cho vi khun pht trin v sau

Cc loi virus nh: Influenza, Rhinovirus (Voisin)

Ha hc

(+) nhim khng kh: bi

(+) Hi c: SO2, NO2, NO3. clo, amoniac.s

(+) Khi thuc l

(++) nhim khng kh, kh quyn, hi c cng nghip l iu kin thun li gy bnh

(+++) Khi thuc l: tc nhn ch yu bn cnh vi khun

Vt l

(+) Khng kh qu kh, qu m, qu lnh

(+++) Nhim lnh t ngt

(+++) Ma lnh, nhim lnh

D ng

(+) L yu t c tnh cch thc y bnh sinh: VPQC ngi hen, ph Quincke, m ay

(++) Kt hp gia hen v VPQM

(++) VPQM trn c a d ng

Di truyn

(-)

(+) Thiu ht globulin min dch

(+) Bt thng v gen: mt thng bng gia h thng protease v khng protease

2.2. Bnh l gii phu

2.2.1. Vim ph qun cp

Ty thuc v tr qu trnh vim xm ln ti cy ph qun m VPQC c th c chia ra vim kh ph qun, vim ph qun cp nhng ph qun c thit din ln, trung bnh v nh.

Tn thng ca nim mc ph qun b ph n, sung huyt, cc mch mu gin to c lp dch nhy, m bao ph, bch cu a nhn xm nhp, t bo biu m b bong ra, c ch b lot, cc tuyn nhy cng phng v tng tit. C c lon sn v tng sn t bo biu m lng (cilia cells). Cc hot ng bo v ca nhung mao ph qun, thc bo, bch huyt b ri lon v vi khun c th xm nhp vo cc ph qun thng vn v trng, tip tc gy ra s tch t nhng mnh vn t bo hoc dch r nhy m, c th gy tc nghn ng th, c th gy xp tiu phn thy hoc phn thy.

Theo thi gian qu trnh hi phc din ra th cu trc ca nim mc c phc hi hon ton.

Phn x ho, d c gy suy h hp nhng cng rt cn thit cho tng xut cc dch tit ph qun. C th c tc kh do s ph vch ph qun, do tit dch b ng li v trong mt s trng hp do s co tht ca cc ph qun.

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2.2.2. Vim ph qun mn

a. i th

S phn b tn thng khng phi bao gi cng i xng 2 phi, c mt s tn thng ch khu tr ph qun ln.

C hnh nh vim nhim v tc nghn: s tc nghn thng xy ra cc ph qun c khu knh t 1/2mm n 3mm do qu trnh dy x v s hnh thnh cc nt nhy.

b. Vi th

H thng ph qun bao gm nhiu loi ln nh khc nhau, kch thc v cu trc khc nhau. Ty thuc vo v tr tn thng v giai on tin trin ca bnh m s xut hin ng thi hoc n l cc triu chng lm sng nng nh khc nhau.

Cc ph qun ln: + Tng sinh v ph i cc t bo hnh i (goblet cells). Bnh thng t

l ca t bo hnh i i vi t bo lng (ciliary cells): 10-20%. Trong bnh l VPQM, t l trn c th tng 80-90%.

+ Lp m ph n, lp di nim mc dy ln bi s tng sn cc tuyn nhy.

+ Vo giai on sau, vim nhim lan to vi s thm nhp ca cc t bo vim lm hy hoi t bo c trn v cc t bo sn.

+ Do s tng sinh v ph i cc t bo hnh i nn cc ph qun ln tng tit cht nhy. Thnh phn cht nhy thay i, nht tng lm nh hng nhiu n hot ng ca lp nhy lng. Triu chng ho m s l triu chng ch yu, ty mc nng nh, ty loi vi khun, ty giai on vim nhim, qu trnh tng sn ca tuyn tit cng nh phn ng ca lp nim mc ni chung m ta s c cc loi ho khc khc nhau.

Cc tiu ph qun: + Cc tiu ph qun tn, ph qun h hp c cc tn thng x quanh

ph qun, ph n nim mc v s c mt cc cc nhy, cc c trn dy ln a n tng sc cn kh o.

+ Triu chng c bn l tr ngi lu thng khng kh, biu hin bng kh th vi nhng mc nng nh khc nhau. Giai on u kh th khng thng xuyn v c th phc hi c bng luyn tp. Triu chng c hiu l thm d chc nng thy hi chng tc nghn vi nhng ri lon v phn phi do qu trnh thng kh b tr ngi.

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2.3. Bnh sinh

2.3.1. Nhu m phi

Vim tiu ph qun a n vim ph nang. Ty theo mc tc nghn cc tiu ph qun s c hin tng kh ph nang hay vi xp phi (micro atelectasis). Trong VPQM kh ph nang chim u th r rt thy bn ca phi.

Triu chng ch yu biu hin l kh th, r rt v thng xuyn hn v s tp luyn cho hi phc lc ny tr nn kh khn v chc nng h hp; ngoi hi chng tc nghn, cc ri lon v vn chuyn kh xut hin, suy h hp dn hnh thnh.

2.3.2. Tim mch

Cc tiu ng mch phi cng b nh hng bi qu trnh vim. Hay xy ra hin tng huyt khi lm tc mch. Tnh trng huyt khi ti cc ng mch phi thng l nguyn nhn t vong ca VPQM.

Tim: c ph i tht phi, ph thuc trng thi tng p lc ng mch phi v trng thi ny li do thiu oxy

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