Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011

Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011Bai giang benh hoc noi khoa t2 tran ngoc an năm 2011

TRl/ONG DAI HOC Y HA NOI

CAC BO MON NOI

BAI GIANG

BENH HOC NOI KHOA

TAP II

(Tdi ban Ian thit mitdi co sita chiia vd bo sung)

NHA XUAT BAN Y HOC

Tham gia bien soan:

GS.TS TRAN NGOC AN

PGS.TS PHAM THI THU HO

TS PHAM MANH HUNG

GS PHAM KHUE

PGS.TS NGUYEN THI NGOC LAN

TS NGUYEN VlNH NGOC

GS.TS NGUYEN KHANH TRACH

GS.TS NGUYEN LAN VIET

Thtfky bien soan:

GS.TS TRAN NGOC AN

PGS.TS PHAM THI THU HO

LOTI NOI OAU

Bai gidng benh hoc noi khoa do can bo gidng day cdc bomon noi thuoc Trtfbng Dai hoc Y Ha Noi bien soan nham

cung cap mot so tdi lieu de sinh vien cdc Idp Y3 - Y6 theo

chtfOng trinh cdi each mdi dung de hoc tap vd tham khao khi

hoc ly thuyet cung nhu khi thUc hanh d benh vien.

Noi khoa la mot trong nhiCng mon hoc chinh cua cdc TrUdng Dai hoc Y Noi dung can duac sita doi bo sung cho

phii hap vdi sU tien bo khong ngitng cua y hoc.

Ldn tdi ban nay hdu het cdc chuang da duac viet lai vd

bo sung de cap nhdt cdc kien thiCc mdi cua y hoc.

Tuy nhien trong dieu kien so can bo con it di, thdi gian han che cudn sdch khong trdnh khdi thieu sot nhdt dinh, mong ban doc gop y de ldn tdi ban sau cudn sdch dUOc hodnthien hdn.

Xin trdn trong cam On

TRirdNG DAI HOC Y HA NOI

Cac bo mon noi

Chtftfng 5

TIM MACH

SUY TIM

GS TS Nguyin Ldn Viet

TS Pham Manh Hung

Suy tim la mot hoi cluing benh iy thu'dng gap trong nhieu benh ve tim machnhu* cac benh van tim, benh cd tim, benh mach vanh, benh tim bam sinh va motso'benh khac co anh hu'dng nhieu den tim

Binh thu'dng khi chiing ta can lam mot hoat clong gang siic nao do (lao dong,

chay nhay ) thi lap trie tim se tang tan so'va tang siic co bop de dtfa d\10c nhieu

mau (tiic la du"a diio'c nhieu oxy) den cho cac mo ciia cd the Nhifng khi tim bi suy,thi tim khong con kha nang cung cap mau theo nhu cau ciia cd the nufa Vi vay

ngiidi ta co the dinh nghia: Suy tim Id trang thai benh ly trong do cung IvCdng tim

khong du dap iCng vdi nhu cau cua cd the ve mat oxy trong moi tinh huong sinh

hoat cua benh nhdn.

Suy tim la mot tinh trang benh ly rat thu'dng gap tren lam sang To chiic Y

te The gi6i \idc tinh co khoang 5 trieu ngUdi mdi mac suy tim hang nam tren toan

the gi6i Theo nghien cu*u Framingham thi co khoang 2,3 trieu ngUdi My bi suytim (1981) va cung d My moi nam co khoang 400.000 benh nhan m6i mac suy tim(thong ke nam 1983)

Can day, tren cd sd nhufng hieu biet sau sac hdn ve cd che benh sinh ciia suytim, ve tinh nang va tac dung ciia mot so' loai thuoc m6i trong dieu tri suy tim,ngLfdi ta da thu dUdc nhi3ng ket qua kha quan trong viec dieu tri hoi chiing nay

I SINH LYBENH

Cung lifting tim thu'dng bi giam trong suy tim Khi cung lUdng tim bi giamxuong thi cd the phan ling lai bang cac cd che bu trii ciia tim va ciia cac he thongngoai tim, de co duy tri cung lUOng nay NhUng khi cac cd che bu trii nay bi vu"dtqua se xay ra suy tim vdi nhieu hau qua ciia no

1 Cac yeu to anh hirong den cung lu'cfng tim

Cung liidng tim phu thuoc vao 4 yeu to' chinh: tien ganh, hau ganh, siic cobop ciia cd tim va tan so' tim

Siic co bop cO tim

1

Tien ganh • Cung lifting tim A Hau ganh

.!.

Tan so tim

1.1 Tien ganh (Preload)

Tien ganh diiPc danh gia bang the tich hoac ap liic cuoi tarn triidng ciia tarn

that Tien ganh la yeu to' quyet dinh miic do keo dai spi cd tim trong thdi ky tamtrifting, triidc liic tam that co bop Tien ganh phu thuoc vao:

- Ap liic do day that, tiic la liidng mau tinh mach trd ve tam that.

- Dp gian ciia tam that, nhiing d miic dp it quan trpng hdn.

1.2 Sue co bop cua cotim

Triidc day bang thiic nghiem noi tieng cua minh, Starling da cho ta hieu rodiidc moi tiidng quan giiia ap liic hoac the tich cuoi tam triidng trong tam that v6ithe tich nhat bop Cu the la:

Khi ap liic hoac the tich cuoi tam triidng trong tam that tang, thi se lamtang siic co bop ciia cd tim va the tich nhat bop se tang len

Nhiing den mot miic nao do, thi du ap liic hoac the tich cuo'i tam tru"dng ciia

tam that co tiep tuc tang len di nufa, thi the tich nhat bop se khong tang ttfdngling ma tham chi con bi giam di

Qua day ta co the hieu dWdc mot van de quan trong trong suy tim la: ap liic

hoac the tich cuo'i tam triidng trong tam that tang do cac nguyen nhan khac nhau,

se lam the tich nhat bop tang, nhiing sau mot thdi gian se dan den suy tim vi siic

co bop cua cd tim kem dan va khi do the tich nhat bop se giam di Tim cang suythi the tich*nhat bop cang giam

1.3 Hau ganh (Afterload)

Hau ganh la siic can cua cac dpng mach do'i vdi su" co bop ciia tam that Siiccan cang cao thi sii co bop cua tam that cang phai ldn Neu siic can thap qua cdthe se lam giam su" co bdp ciia tam that, nhiing neu siic can tang cao se lam tangcong ciia tim cung nhii tang miic tieu thu oxy ciia cd tim, tu* do se lam giam siic cobdp ciia cd tim va lam giam lifu lifting tim

1.4 Tan so tim

Trong suy tim, liic dau nhip tim tang len, se cd tac dung bu trii tot cho tinhtrang giam the tich nhat bdp va qua do se duy tri dUdc cung lu:dng tim Nhiing neu

nhip tim tang qua nhieu thi nhu cau oxy ciia cd tim se lai tang len, cong ciia cd tim cung phai tang cao va hau qua la tim se cang bi suy yeu di mot each nhanh chdng.

2 Cac cd che bu trCr trpng suy tim

2.1 Ca chebu trCt tai tim

Gian tam that: gian tam that chinh la cd che thich ling dau tien de tranh

qua tang ap liic cuoi tam triftmg ciia tam that Khi tam that gian ra, se lam keodai cac spi cd tim va thed luat Starling, se lam tang siic cd bdp ciia cac sdi cd timneu dii trii co cd van con.

Phi dai tam that: tim cung cd the thich ling bang each tang be day cac

thanh tim, nhat la trong triftmg hdp tang ap liic d cac buong tim Viec tang be day

cua cac thanh tim chii yeu la de ddi phd vdi tinh trang tang hau ganh Ta bie'trang khi hau ganh tang se lam giam the tich td'ng mau, do do de bu lai cd timphai tang be day len

He than kinh giao cam dtftfc kich thich: khi cd suy tim, he than kinh giao

cam du'dc kich thich, lifting catecholamin tii dau tan ciing ciia cac spi giap cam hau hach du'dc tiet ra nhieu lam tang siic co bdp ciia cd tim va tang tan so'tim.

Bang ba cd che thich ling nay, cung liidng tim se du'dc dieu chinh lai gan vdi

miic binh thu'dng Tuy nhien cac cd che nay cung chi cd the giai quye't trong mpt

chiing miic nap do ma thdi Thiic vay, neu tam that da gian den miic td'i da va dii truf co cd bi giam thi luat Starling se trd nen rat it hieu liic Cung tiidng tii nhii vay, phi dai cac thanh tim se lam tang cdng ciia tim He than kinh giao cam bi kich thich lau ngay cung se dan den giam mat dp cam thu beta trpng cac sdi cdtim va giam dan dap ling vdi catecholamin

2.2 Cache bu trit ngoai tim

Trong suy tim, de dd'i phd vdi viec giam cung lifting tim, he thong mach mau

d ngoai vi du'dc co lai de tang ciidng the tich tuan hoan hiiu ich Cu the cd ba hethong co mach ngoai vi du'dc huy dpng:

He thong than kinh giao cam: ciidng giao cam se lam co mach ngoai vi d

da, than va ve sau d khu viic cac tang trong o bung va d cac cd.

He Renin-Angiotensin-Aldosteron: viec tang ciidng hoat hda he than

kinh giao cam va giam tiidi mau than (do co mach) se lam tang nong dp renin

trong mau Renin se hoat hda angiotensinogen va cac phan ling tiep theo de tang

td'ng hdp angiotensin II Chinh agiotensin II la mot chat gay co mach rat manh,

ddng thdi no lai tham gia vao kich thich sinh tong hop va giai phdng nor-adrenalin b

dau tan cung cac sdi than kinh giao cam hau hach va adrenalin tCi tiiy thu'dng

than Cung chinh angiotensin II con kich thich vo thu'dng than tiet ra aldosteron,tii do lam tang tai hap thu natri va niidc d d'ng than

He Arginin-Vasopressin: trong suy tim d giai doan mupn hpn, viing diidi

dpi - tuyen yen diidc kich thich de tiet ra arginin - vasopressin, lam tang them tac

dung co mach ngoai vi ciia angiotensin II, dong thdi lam tang tai hap thu niidc d

d'ng than

Ca ba he thong co mach nay deu nham muc dich duy tri cung lifting tim.

nhiing lau ngay chiing lai lam tang tien ganh va hau ganh, tang ti niidc va natri tang cong va miic tieu thu oxy ciia cd tim, tao nen mot "vdng luan quan" benh ly

va lam cho suy tim ngay mot nang hdn

2.3 Cac yeu to khac

Ngoai ra, trong suy tim, nham cd'gang bu dap lai viec co mach khu trii hay toan bp ndi tren, cac he thd'ng gian mach vdi bradykmin, cac prostaglandin (PGI, PGEv) va yeu to peptid tang dao thai natri (Natriuretic Peptid, viet tat la cac NP).

Cac yeu to nay dong vai trd khiem ton trong qua trinh suy tim Trong so cac

peptid tang thai natri cd hai loai quan trpng du'dc biet den trpng lam sang do la

ANP (yeu to thai natri cd nguon gd'c tu' nhi) va BNP (yeu to tang thai natri cd

nguon gd'c tii nao) Thiic te la BNP lai chii yeu diidc tiet ra tii tam that ciia tim va

xua't hien kha sdm khi tim bi suy Hien nay, xet nghiem danh gia BNP va cac danxua't ciia no cd gia tri quan trpng trong sang lpc benh nhan suy tim cung nhii tienlifting benh va theo doi ket qua dieu tri

3 Hau qua cua suy tim

Khi cac cd che bu tru (cd che thich ling) noi tren bi viip't qua thi se xay ra suytim vdi cac hau qua nhu' sau:

3.1 Giam cung luong tim

Cung lifting tim giam se gay

- Giam van chuyen oxy trong mau va giam cung cap oxy cho cac to chutengoai vi

- Cd su" phan phoi lai hiu lifting mau den cac cd quan trong cd the: lu'u liidng mau giam bdt 6* da d cac cd, d than va cuoi cung d mot so tang khac de u'utien mau cho nao va dpng mach vanh

- Neu cung liidng tim rat thap thi lu'u liidng nude tieu du'dc lpc ra khoi ongthan cung se rat it.

3.2 Tang ap luc tinh mach ngoai vi

- Suy tim phai: tang ap liic cuo'i tam triidng d that phai se jam tang ap hie

d nhi phai roi tii do lam tang ap luc d cac tinh mach ngoai vi va lam cho tinh mach

cd ndi, gan to phii, tim tai

- Suy tim trai: tang ap liic cuoi tam tn.idng d thai trui se lam tang ap liic

nhi trai, roi tiep den lam tang ap liic d tinh mach phoi va mao mach phoi Khi mau

li cang d cac mao mach phoi se lam the tich khi d cac phe nang bi giam xuong su"trao doi oxy d phdi se kem di lam benh nhan khd thd Dae biet khi ap liic mao mach

ph6i tang den mot miic nao do se pha vd hang rao phe nang - mao mach phoi va

buyet tiidng se cd the tran vao cac phe nang, gay ra hien tiidng phii phdi.

1 Phan loai suy tim

Co the co nhieu each phan loai suy tim khac nhau, dvta tren cd sd:

- Hinh thai dinh khu: suy tim phai, suy tim trai va suy tim toan bp

- Tinh trang tien trien: suy tim cap va suy tim man tinh

- Lu'u liidng tim: suy tim giam lu'u liidng va suy tim tang lu'u liidng

- Suy tim tam thu va suy tim tam triidng

Tuy nhien, tren lam sang ngiidi ta thiidng hay chia suy tim lam ba loai: su.tim trai, suy tim phai va suy tim toan bp

2 Nguyen nhan suy tim

2.1 Suy tim trai

a Tang huyet dp dong mach: la nguyen nhan thiidng gap nhat gay ra suy

tim trai Chinh tang huyet ap da lam can trd su" td'ng mau ciia that trai tiic la lamtang hau ganh

b Mot so benh van tim

Hd hay hep van dpng mach chii ddn thuan hoac phoi hdp vdi nhau.

Hd van hai la.

c Cdc ton thu'dng cd tim

Nhdi mau cd tim

- Viem cd tim do thap tim, nhiem ddc hay nhiem khuan

- Cac benh cd tim

d Mot so roi loan nhip tim

~ Cd ba loai rd'i loan nhip tim chii yeu cd the diia den benh canh ciia suy

tim trai:

+ Cdn nhip nhanh kich phat tren that, nhat la cdn rung nhi hay cdn cuongdong nhi.

+ Cdn nhip nhanh that

+ Bloc nhi - that hoan toan.

e Mot so'benh tim bam sinh:

•- Hep eo dpng mach chii

- Cdn ong dpng mach

- Ong nhi - that chung

Chii y: triidng hdp hep van hai la, do tang cao ap liic trong nhi trai va mao

mach phdi nen dan den nhiing trieu chiing giong nhu' suy tim trai Nhiing su" thtfc

thi hep hai la ddn thuan khong gay du'dc suy tim trai theo diing nghia ciia no vihep hai la da tao nen mot sii can trd dong mau di tdi that trai, lam cho ap liic (haythe tich) cuo'i tam triidng ciia that trai lai bi giam hdn binh thu'dng; tam that traikhong bi tang ganh nen khong suy du'dc.

2.2 Suy tim phai

a Suy tim trdi lau ngay

Suy tim trai lau ngay se dan den suy tim phai, day cd le la nguyen nhan khathu'dng gap

b Cdc nguyen nhan ve phoi vd di dang long ngitc, cot song

Cac benh phdi man tinh: hen phe quan, viem phe quan man, gian phe nang,gian phe quan, xd phdi, benh bui phoi dan dan diia den benh canh ciia tam phe

m a n

Nhoi mau phoi gay ra benh canh tam phe cap

Tang ap liicddng mach phoi tien phat

Gii veo cot sd'ng, cac di dang long ngiic khac

c Cdc nguyen nhan tim mach

Hep van hai la la nguyen nhan thu'dng gap nhat d cac niidc dang phat trien.Mot so' benh tim bam sinh: hep dpng mach php'i, tam chiing Fallot Mot sd'benh tim bam sinh khac cd luong shunt trai ->phai (thong lien nhi, thong lienthat vv ) den giai doan mudn se cd bien chiing ciia tang ap dpng mach phoi vagay suy tim phai

Viem ndi tam mac nhiem khuan gay ton thu'dng nang d van ba la

Mot sd nguyen nhan it gap: u nhay nhi trai, vd tiii phinh xoang Valsalva vaocac buong tim ben phai, tang ap liic dpng mach phoi tien phat v.v

Chii y: triidng hop tran dich mang ngoai tim hoac viem mang ngoai tim co

that se cd bieu hien gid'ng nhii suy tim phai, nhiing thiic chat do chi la nhiingtriidng hdp thieu nang tam triidng chii khong phai suy tim phai theo diing nghia

ciia no.

2.3 Suy tim toan bo

a Thu'dng gap nhdt la cdc trUdng hdp suy tim trdi tien trien thanh suy tim

toan bo.

b Cdc benh cd tim, gian.

c Viem tim toan bo do thap tim, viem cd tim.

d Cuoi cung cdn phai nhdc den mot sd nguyen nhan dac biet gay suy tim toan bo vdi "lu'u lUdng tang":

- Ciidng giap trang

- Thieu vitamin B^

- Thieu mau nang.

- Rd dpng - tinh mach

III TRIEU CHLTNG

1 Suy tim trai

1.1 Trieu chiing car nang

a Khd thd: la trieu chiing hay gap nhat Liic dau chi khd thd khi gang siic,

ve sau khd thd xay ra thiidng xuyen, benh nhan nam cung khd thd nen thu'dng

phai ngoi day de thd Dien bien va miic dp khd thd cung rat khac nhau: cd khi khd

thd mot each dan dan, nhiing nhieu khi den dot ngot, duE dpi nhu" trong cdn hen

tim hay phii phoi cap

b Ho: hay xay ra vao ban dem hoac khi benh nhan gang siic Thu'dng la ho

khan nhiing cung cd khi ho ra ddm Ian it mau

1.2 Trieu chung thut the

a Khdm tim

Nhin, sd tha'y mom tim dap hdi lech sang trai Nghe tim: ngoai cac trieu

chiing cd the gap ciia mot vai benh van tim da gay nen suy that trai, ta thiidng

tha'y cd ba dau hieu:

- Nhip tim nhanh

- Cd the nghe tha'y tie'ng ngiia phi

- Cung thiidng nghe tha'y mot tie'ng thdi tam thu nhe d mom, dau hieu ciia

hd van hai la cd nang vi buong that trai gian to

b Khdm phdi

Thu'dng tha'y ran am rai rac hai ben day phoi Trong triidng hdp cdn hen tim

cd the nghe du'dc nhieu ran rit va ran am d hai phoi, cdn trong triidng hdp phu phoi cap se nghe tha'y rat nhieu ran am to, nhd hat dang nhanh tii hai day phoilen khap hai phe triidng nhii "thiiy trieu dang"

c Do huyet dp: trong da so' cac triidng hdp, tmyet ap dpng mach td'i da

thu'dng giam, huyet ap td'i thieu lai binh thu'dng nen so' huyet ap chenh lechthu'dng nhd di

1.3 Cac xet nghiem chan do an

a Cdc xet nghiem mau

- Cac xet nghiem mau cd ban: giiip cho danh gia tinh trang chung ciia benhnhan va cac roi loan, benh ly lien quan

Xet nghiem BNP va cac dan xua't: trong thuc te, khi suy tim, se tiet ra pro BNP va chuyen hda ra NT-proBNP va BNP Xet nghiem ca hai chat BNP hoac NT-pro BNP deu cd gia tri trong suy tim Tuy vay, NT-proBNP cd dp ben viing hdn

-BNP Trong suy tim, cac dean xua't nay xua't hien kha sdm ddi khi triidc ca trieu

chiing lam sang va kha nhay Gia tri ciia BNP thay doi theo tudi, neu BNP > 100 pg/ml; NT-proBNP > 125 pg/ml d benh nhan nhd hdn 75 tudi va > 140 pg/ml d benh

nhan ldn hdn 75 tudi thi coi la tang Vai trd ciia xet nghiem cac NP ngay cangdiidc de cap den va cd nhieu ting dung trong lam sang:

+ Sang lpc benh nhan suy tim: cd gia tri sang lpc sdm benh nhan cd tonthu'dng tim nhiing chiia ro trieu chting (vi du d benh nhan sau NMCT, THA ).+ Chan doan loai trti nguyen nhan khd thd cap: thu'dng gap d khoa cap ctiucan loai trti nhanh khd thd la do nguyen nhan suy tim hay do benh phdi Xetnghiem BNP cd gia tri chan doan loai trti, gia tri du" bao am tinh ciia no tren 90%.Tuy nhien BNP cd the chiia tang ro d benh nhan phti phdi cap huyet dpng trongmot vai gid dau.

+ Theo doi dieu tri suy tim: nong dp cac NP nay se giam tiiPng ting vdi mticcai thien trieu chting va choc nang d benh nhan suy tim Cac bien ddi NP thu'dngxua't hien sdm va cd gia tri dii bao ket qua dieu tri

+ Gia tri tien liidng benh: d nhiing benh nhan suy tim hoac cac benh tim mach,nong dp cac NP huyet thanh cd lien quan den ty le tii vong va bien chting ve sau

- Cac xet nghiem mau khac gitip danh gia cac nguyen nhan suy tim:hormone tuyen giap; thieu mau

- Cac xet nghiem cd ban de theo ddi dieu tri: dien giai do; choc nang than;chtic nang gan

- Cac xet nghiem danh gia cac yeu to' nguy cd chinh ciia benh tim mach:lipid mau cholesterol, du'dng huyet

"canh biidm" kinh dien d hai rd'n phdi trong triidng hdp cd phti phdi

c Dien tam do: Thiidng chi tha'y dau hieu tang ganh cac buong tim ben trai:

True trai day nhi trai, day that trai.

d Sieu dm tim: Thiidng tha'y kich thudc cac buong tim trai (nhi trai that

trai) gian to Ngoai ra sieu am con gitip ta biet du'dc sii co bdp ciia cac vaeh timcung nhii danh gia diidc chinh xac chtic nang tam thu ciia that trai Trong nhieutriidng hd]) sieu am tim cdn gitip cho ta khang dinh mot so'nguyen nhan da gay rasuy tim trai (benh van tim, benh tim bam sinh).

e Thdm do huyet dong

- Tbam do huyet dpng chi dinh trong cac triidng hop dieu tri tich ciic cactinh trang suy tim cap va nang (sd'c tim) can dieu tri cac thudc du'dng truyen lien

tuc Thong thu'dng dting dng thong loai Swan Ganz cd bdng d dau de diia len dpngmach phdi Thong tim cdn thu'dng du'dc tien hanh khi benh nhan diidc lam cac thuthuat tim mach can thiep (dpng mach vanh, van tim).

- Tham do huyet dpng chp phep danh gia miic dp suy tim trai thdng qua viec

do cung liidng tim (CO) va chi so' tim (CI: binh thu'dng tti 2-3,5 1/phut/m2) va do apliic cuo'i tam triidng ciia that trai (tang trong suy tim trai binh thu'dng < 5 mmHg)

- Tham do huyet dpng chp phep danh gia chinh xac mtic dp nang nhe ciiampt so'benh van tim

2 Suy tim phai

2.1 Trieu chung ca nang

a Khd thd: it heac nhieu, nhiing khd thd thu'dng xuyen, ngay mpt nang dan

va khdng cd cac cdn kich phat nhii trong suy tim trai

b Ngoai ra, benh nhan hay co cam gidc dau titc viing ha su'dn phdi (do gan

to vd dau).

2.2 Trieu chung thuc the

a Chii yeu la nhiCng dau hieu it mau ngoai bien

- Gan to deu, mat nhan, bd tti, dau mpt each tii phat hoac khi sd vao ganthi dau Liic dau gan nhd di khi du'dc dieu tri va gan to lai trong ddt suy tim sau,nen cdn gpi la gan "dan xep" Ve sau, do ti mau lau ngay nen gan khdng the nholai du'dc ntia va trd nen cting

- Tinh mach cd noi to va dau hieu phan hoi gan - tinh mach cd du'dng tinh

Ap liic tinh mach trung lidng va ap liic tinh mach ngoai bien tang cao

- Tim da va niem mac: tim la do mau bi ti tre d ngoai bien, nen liidnghemoglobin khti tang len trong mau Tiiy mtic dp suy tim ma tim nhieu hay it.Neu suy tim nhe thi chi tha'y tim it d mdi va dau chi Cdn neu suy tim nang thi cdthe tha'y tim rd d toan than

- Phti: phti mem, luc dau chi khu trti d hai chi dtidi, ve sau neu suy timnang thi cd the tha'y phii toan than, tham chi cd the cd them tran dich cac mang(tran dich mang phoi, co triidng ) Benh nhan thu'dng dai it (khdang 200 -500ml/ngay) Niidc tieu sara mau

+ Cung cd khi nghe tha'y tie'ng thdi tam thu nhe d trong mom hoac d viingmui tic do hd van ba la cd nang Khi hit vao sau, tie'ng thdi nay thiidng ro hdn(dau hieu Rivero-Carvalho).

+ Huyet ap dpng mach td'i da binh thu'dng, nhiing huyet ap td'i thieu thu'dngtang len.

2.3 Cac xet nghiem chan doan

Trti triidng hdp suy tim phai dd hep dpng mach phdi cd nhiing dac diemrieng ciia no, cdn trong da so'cac triidng hdp khac ta tha'y:

a Cdc xet nghiem mau: nhii da neu trong suy tim trai Lu'u y la khi suy tim

phai don thuan do cac nguyen nhan hd hap thi nong dp cac NP chi tang khiem ton

b X quang

- Tren phim tim phdi thang:

+ Cung diidi phai (tam nhi phai) gian

+ Mom tim nang cao hdn phia tren vdm hoanh trai, do tam that phai gian.+ Cung dpng mach phdi cung gian to

+ Phdi md nhieu do ti mau d phdi

- Tren phim nghieng trai: that phai to lam cho khoang sang sau xiidng tic

bi hep lai.

c Dien tam do: thu'dng tha'y cac dau hieu ciia true phai, day nhi phai, day

that phai.

d Sieu am tim: chii yeu tha'y kich thiidc that phai gian to Trong nhieu

triidng hdp cd the tha'y cac dau hieu ciia tang ap dpng mach phdi

e Tham do huyet dong

Cd the tha'y:

- Ap lift cuo'i tam triidng ciia that phai tang (thu'dng la tren 12 mmHg)

- Ap liic dpng mach phdi cung thu'dng tang.

3 Suy tim toan bo

- Thu'dng la benh canh ciia suy tim phai d mtic dp nang:

- Benh nhan khd thd thu'dng xuyen, phti toan than

- Tinh mach cd ndi to, ap liic tinh mach tang rat cao

- Gan to nhieu

- Thu'dng cd them tran dich mang phdi, mang tim hay cd triidng

- Huyet ap td'i da ha, huyet ap td'i thieu tang, lam cho huyet ap trd nen ket

- X quang: tim to toan bp.

- Dien tam dp: cd the cd bieu hien day hai that

IV CHAN DOAN XAC OjNH SUY TIM

De chan doan xac dinh suy tim, cd mpt so' tieu chuan du'dc dat ra, trong docac yeu to' quan trpng nhii hoi benh va tham kham ky lam sang, cac xet nghiemcan lam sang (dac biet la xet nghiem BNP hoac NT-Pro BNP cd gia tri), dien tam

dd, X quang tim phdi thang, sieu am tim gitip chan doan xac dinh suy tim.Trong thiic te, hai tieu chuan thu'dng du'dc dting tren lam sang de chan doansuy tim la: tieu chuan Framingham (bang 5) va Tieu chuan ciia Hpi Tim machchau Au Trong do, tieu chuan ciia Hpi Tim mach chau Au (bang 6) chp phep tiepcan ddn gian hdn trong chan doan suy tim

Bang 1 Tieu chuan Framingham

- Tieu chuan chinh:

Cdn khd thd kich phat ve derm hoac khd thd pha ngoi

Thdi gian tuan hoan > 25 giay

Phan hoi gan TM cd? du'dng tinh

- Tieu chuan phu

Phu co' chan

Ho ve dem

Khd thd gang stic

Gan to

Tran dich mang phdi

Dung tich song giam 1/3 so vdi td'i da

Tim nhanh (> 120/phut)

- Tieu chuan chinh hay phu

Giam 4,5 kg/5 ngay dieu tri suy tim

- Chan doan xac dinh suy tim:

2 tieu chuan chinh hoac 1 tieu chuan ch 'nh kem 2 tieu chuan phu

Bang 2 Cac tieu chuan xac dinh suy tim theo Hoi Tim mach chau Au

(Cac tieu chuan 1 va 2 can co trong moi triidng hop)

1 Cd trieu chting cd nang suy tim (luc nghi hay trong khi gang siic) va

2 Chiing cd khach quan ciia rd'i loan chiic nang tim (tren tham kham va cac tham dd) (lucnghi) va

3 Dap ling vdi dieu tri suy tim (trong triidng hdp cd nghi ngd chan doan)

V DANH GIA ML/C 00 SUY TIM

Co nhieu each de danh gia mtic dp suy tim, nhiing trong thiic te lam sang,each phan loai mtic dp suy tim theo Hoi Tim mach hoc New York (New YorkHeart Association) viet tat la NYHA, diia tren sii danh gia mtic dp hoat dpng theluc va cac trieu chting cd nang ciia benh nhan la diidc chap nhan va ting dungrdng rai.

1 Phan loai mure do suy tim theo NYHA

Bang 3 Phan loai mtic do suy tim theo NYHA

Cac trieu chiing cd nang xua't hien ke ca khi gang siic rat it, lam han che nhieu cac

hoat dpng the liic.

Cac trieu chiing cd nang ton tai mpt each thu'dng xuyen, ke ca liic benh nhan nghingdi khdng lam gi ca.

Trong thiic te lam sang, each phan loai nay rat td't dd'i vdi suy tim trai.nhiing khdng that thich hdp lam dd'i vdi cac benh nhan suy tim phai

2 Phan loai mure do suy tim tren lam sang theo Hoi Noi Khoa Viet Nam

0 niidc ta so liidng cac benh nhan suy tim phai thu'dng chiem mpt ty le khaldn trong so' cac benh nhan bi suy tim Vi vay, sd bp tren lam sang cac thaythud'c thiidng quv lidc mtic dp suy tim theo khuyen cao ciia Hpi Ndi khoa Viet

Nam nhii sau:

Bang 4 Phan loai mtic do suy tim tren lam sang

I Benh nhan cd khd thd nhe nhiing gan chiia sd tha'y

II Benh nhan khd thd viia, gan to diidi bd stidn vai cm.

III Benh nhan khd thd nhieu, gan to gan sat rd'n nhiing khi du'dc dieu tri gan cd the nhd

lai.

IV Benh nhan khd thd thudng xuyen, gan ludn to nhieu mac du da dUdc dieu tri.

3 Phan loai suy tim theo giai doan cua cac Hoi Tim mach hoc Hoa ky (AHA/ACC)2005

Cach phan loai nay nhan manh den sii tien trien va cac giai dean ciia suy tim

Bang 5 Phan loai giai doan suy tim theo AHA/ACC

A Benh nhan cd cac nguy cd cao ciia suy tim nhiing chiia cd cac benh ly ton

thu'dng cau true tim

Benh nhan da cd cac benh ly anh hiidng cau true tim nhiing chiia cd trieuchiing va bieu hien ciia suy tim

Benh nhan cd benh tim va cd trieu chiing ciia suy tim; cd anh hiidng den cautrue ciia tim

D Benh nhan suy tim giai doan cuoi can Gdi bi6n phap JJeu tri d,fic biet T

1 Nhting bien phap dieu trj chung

1.1 Cac bien phap khong dung thudc

a Che do nghi ngdi: nghi ngdi la mpt viec kha quan trpng vi no gdp phan

lam giam cong ciia tim Ndi chung benh nhan can giam hoac bd han cac hoat dpnggang stic Trong triidng hdp suy tim nang thi phai nghi tai giiidng theo tii the niianam niia ngdi Tuy nhien, trong triidng hdp suy tim ma benh nhan phai nam dieutri lau ngay thi khi hoan canh cho phep, nen khuyen khich benh nhan xoa bdp,liic dau la thu dpng, sau dd la chii dpng d cac chi, nhat la hai chi diidi de lam chomau tinh mach trd ve tim du'dc de dang hdn, giam bdt cac nguy cd huyet khd'i tinhmach thiidng hay gap d nhting benh nhan nay

b Che do an giam mudi

- Che dp an giam mudi la can thie't, vi mudi an (NaCT) lam tang ap liictham thau trong mau, do dd lam tang khd'i liidng tuan hoan, tti do gay tang ganhnang cho tim.

- Mpt ngiidi binh thu'dng hap thu khoang 6 18g mudi NaCl/ngay, tiic la 2,4 7,2g (100 - -SOOmmol) Na+/ngay Dd'i vdi benh nhan suy tim, tuy tting triidng hdp cuthe ma ap dung che dp an giam mudi hoac che' dp an gan nhii nhat hoan toan

-+ Che dp an giam mud'i: benh nhan chi diidc dting < 3g mud! NaCl/ngay, ttic

la < l,2g (50 mmol) Na+/ngay

+ Che dp an gan nhu nhat hoan toan: benh nhan chi du'dc an < l,2g mud'i

NaCl /ngay ttic la < 0,48g (20mmol) Na+/ngay

c Han che liidng niidc va dich diing cho benh nhan

- Can han che liidng niidc va dich dting cho benh nhan hang ngay nhamgiam bdt khd'i liidng tuan hoan va giam ganh nang vdi tim

- Ndi chung chi nen dting cho benh nhan khoang 500 - 1000ml liidng dichdiia vao cd the mdi ngay.

d Thd oxy: la bien phap can thiet trong nhieu triidng hdp suy tim vi no tang

cung cap them oxy cho cac mo, giam bdt mtic dp khd thd ciia benh nhan dong thdilam han che sii co mach phdi thu'dng gap d nhting benh nhan thieu oxy

e Loai bo cdc yeu to nguy cd khac

- Bo ru'du, thud'c la, ca phe

- Giam can nang 0 nhting benh nhan beo phi

- Tranh cac xtic cam manh (stress).

- Ngting nhting thud'c lam giam siic bdp ciia cd tim neu dang dung, vi du:cac thud'c chen beta giao cam hoac verapamil hay disopyramid, Flecainid

- Dieu tri nhting yeu to lam nang them tinh trang suy tim nhii nhiemtruing, rdi loan nhip tim

1.2 Cac thuoc trong dieu tri suy tim

a Glucosid trd tim

- Cac dang glucosid trd tim du'dc dting tren lam sang la:

+ Digitalis vdi cac dang digitalin hay digitoxin lay tti digitalis purpurea:Digoxin va isolanid lay tti digitalis Lanata

+ Strophantus vdi cac dang G Strophantin (ttic Uabain) lay tti strophantus

Kombe.

Trong thuc hanh lam sang hien nay digoxin la loai thud'c trd tim tieu bieuthu'dng du'dc cac thay thud'c hay sii dung nhieu nhat

- Cd che tac dung:

+ Digoxin lam tang stic co bdp ciia cd tim gian tiep thong qua viec tic chemen natri - kali - adenosine triphosphatase (Na+-K+-ATPase) ciia bdm ion d mang

te bao cd tim, tti do can trd viec ion Na+ thoat ra ngoai mang te bao Do sii tic chenay lam cho nong dp Na+ trong te bao tang cao, vi vay sii van chuyen Na+ - Ca++qua mang tebao cung bi rd'i loan, lam tang nong dp Ca++ trong te bao cd tim, tti dothuc day cac sdi cd tim tang ciidng co bdp

+ Mat khac digoxin cdn tac dpng tren he thd'ng than kinh tii dpng ciia tim,lam giam nhip tim va giam td'c dp din truyen nhi - that.

+ Ngoai ra digoxin cdn lam tang triidng liic he phd giao cam va lam giamhoat tinh ciia he giao cam

- Du'dc dpng hoc:

+ Digoxin thu'dng du'dc dting diidi dang ud'ng (vien nen, vien nang, dangcon) hoac tiem.

+ O dang ud'ng, phan ldn digoxin du'dc hap thu d rudt non sau do se du'dc

phan bd' tiep tai mpt sd' md Ndng dp digpxin thu'dng du'dc tap trung chii yeu d

than, tim, gan, tuye'n thu'dng than, d'ng tieu hda

+ Digoxin diidc chuyen hda chii yeu tai gan Phan ldn digoxin du'dc thai trtiqua diidng niidc tieu, chi cd mpt phan nhd (khoang 25%) diidc thai trti qua diidngphan.

+ 0 ngiidi ldn, vdi chtic nang gan, than binh thu'dng thi thdi gian ban huytrung binh ciia digoxin (theo du'dng ud'ng) la 36 gid

+ Mpt sd nghien ctiu da cho thay la nong dp trung binh trong huyet tiidng

ciia digoxin cd tac dung dieu tri thu'dng trong khoang tti 0,5 hoac 0,8 den

2,0ng/ml Tuy nhien khoang each gitia nong dp dieu tri va nong dp ngd ddc la rathep Cd benh nhan phai dting tren 2,0 ng/ml mdi cd tac dung dieu tri, ngiidc laimpt so benh nhan khac d nong dp 0,8 - 1,5 ng/ml da cd trieu chting ciia ngd ddcdigoxin

- Lieu liiOng va each dting:

+ Trade day ngiidi ta hay dting bat dau bang lieu tan cong sau ctd chuyensang lieu duy tri

+ Lieu tan cong thu'dng la 0,25 - 0,5mg, roi cti sau 6 gid cd the cho them 0,25mg de dat tong lieu la 1 - 1,5 mg/ngay

+ Khi dat du'dc hieu qua, thu'dng chuyen sang lieu duy tri tti 0,125 0,375mg/ngay»

-+ Ngay nay ngiidi ta thu'dng khdng cdn dung lieu tan cong vdi mpt liidngthudc ldn trong mpt thdi gian ngan nhii tren vi each nay rat de gay nguy hiem chobenh nhan Trong da so cac triidng hdp, cac thay thud'c thu'dng bat dau ngay banglieu duy tri nhii da trinh bay d tren de dat dan tdi lieu cd hieu liic dieu tri

+ Viec theo ddi ndng dp digoxin trong huyet tiidng se gitip ta dieu chinhdiidc tdi lieu dieu tri td'i ifu Nong dp digoxin huyet tiiOng trong khoang tti 1,8 - 2ng/ml du'dc coi la ndng dp cd hieu liic dieu tri, qua nong dp do thi di bi nhiem ddcDigoxin

- TiiOng tac thudc:

+ Mpt sd thud'c cd the lam giam viec hap thu digoxin nhu": cholestyramin,cholestipol, kaolin-pectin, sulfasalazin, neomycin v.v Ngiidc lai, mpt so'thud'c cd

the lam tang viec hap thu digoxin nhii tetracyclm hoac erythromycin Mpt sdthudc khac cd the lam giam dang ke dp thanh thai Digoxm do dd cd the lam tangndng dp cua digoxin trong mau nhii: quinidin verapamil, spironolacton.amiodaron

+ Can dac biet chii y khdng bao gid diidc dung phdi hdp digoxin vdi cac mudi calci (diidng tinh mach) vi sii phdi hop nay cd the gay nen nhting rdi loan nhip timnang tie, tham chi cd the gay tii vong

- Chi dinh:

+ Suy tim vdi cung liidng tim thap, dac biet khi cd rung nhi nhanh

+ Cac rdi loan nhip tren that, dac biet trong rung nhi hay cuong dpng nhi.+ Chti y: nhiing triidng hdp suy tim vdi cung liidng tim cao (thieu maunang nhiem ddc giap ro dpng - tinh mach benh thieu vitamin 131 ) hoac suy tim

cd lien quan den mpt tac nghen cd hoc hay suy tim trong tam phe man khdng phai

la nhiing chi dinh ciia digoxm

- Chd'ng chi dinh:

+ Nhip tim cham

+ Bloc nhi - that cap II, cap III chiia du'dc dat may tao nhip

+ Ngoai tam thu that

+ Nhip nhanh that va rung that

+ Hpi chting Wolff - Parkinson - White

+ Benh c(J tim tac nghen.

+ Can than trpng trong triidng hdp: nhoi mau cd tim cap (vi digoxin lamtang nhu cau oxy ciia cd tim) va cac roi loan dien giai dac biet la ha K+ mau va /hoac ha Mg ++ mau

- Nhiem ddc digoxin

+ Mpt so' thong ke da cho tha'y so' benh nhan dting digoxin bi nhiem ddcchiem khoang 5 - 15% td'ng so'benh nhan dting thudc

+ Yeu to' thuan ldi cho nhiem ddc digoxin la:

Rdi loan dien giai: ha K+ mau, ha Mg++ mau, tang Ca++ mau

• Tudi cao: lam tang dp nhay cam vdi digoxin do giam dp lpc ciia than, tti

dd de lam ti dong thud'c

• Nhiem kiem chuyen hda.

• Giam oxy mau.

• Suy than, suy gan

+ Bieu hien lam sang ciia nhiem ddc digoxin: khi benh nhan dang dungdigoxin, tii nhien tha'y mpt sd'bieu hien sau:

• Rdi loan tieu hda: chan an, buon ndn, ndn rniia, ia chay.

• Rd'i loan than kinh: cd the chi la dau dau chdng mat nhiing cd the

nang hdn nhii ao giac, mat phiidng hiidng, me sang

• Rdi loan tim mach: do tang tinh kich thich, tang tinh tii dpng va giamtinh dan truyen ciia te bao cd tim

Ngoai tam thu nhi va that, hay gap la ngoai tam thu that nhip ddi, ngoaitam thu that da dang hoac tting churn

Nhip nhanh bp nd'i, nhip nhanh that

Bloc xoang - nhi

Bloc nhi - that cac loai.

Xoan dinh, rung that

+ Xii tri nhiem ddc digoxin:

• Ngting ngay viec dieu tri bang digoxin

• Theo ddi chat che nhting dien bien tren dien lam do

• Dieu chinh kip thdi cac roi loan ve dien giai va thang bang toan kiem,trong do can dac biet lu'u y cd tinh trang ha K+ mau khdng? Neu cd ha K+ mau cancho benh nhan ud'ng khoang 20 - 50 ml dung dich kalichlorua 10%) Triidng hdpcan thiet cd the truyen nhd gipt kalichlprua vap tinh mach sau khi da pha thud'ctrong dung dich dang triidng, nhiing vdi dieu kien dam dp K+ truyen tinh machkhdng du'dc viidt qua 13 - 15mmol/gid

Cd the dting atropin tiem tinh mach vdi lieu tti 0,5 - lmg khi cd nhip chamxoang hoac nhip cham do Bloc nhi - that

Vdi cac loai rd'i loan nhip that, dac biet la ngoai tam thu that, ta cd the dieutri bang each truyen lidocain vdi dam dp 2mg/phut

Cd the dting khang the dac hieu ciia digoxin (Fab fragments, digibind) vathu'dng diidc viet tat la Fab Thu'dng Fab du'dc dting theo diidng truyen tinh mach

Cd che: phtic hdp digoxin ke't hdp vdi Fab se du'dc ctao thai qua than, lammat tac dung ciia digoxin Mpt d'ng Fab 40mg trung hda 0,6mg digoxin

Vdi ngd ddc man digoxin: So' d'ng Fab can dting = [nong dp digpxin mau(ng/ml) x can nang cd the (kg)] / 100

Vdi ngd ddc cap digoxin: so'dng Fab can dting = [lieu liidng digoxin da dtingcho benh nhan (mg) x 0,8] / 0,6

b Thudc Idi tieu

Thud'c ldi tieu lam tang dao thai niidc tieu, qua do lam giam khd'i liidng niidctrong cd the, giam khd'i liidng mau lu'u hanh, lam bdt liidng mau trd ve tim va lamgiam the tich cung nhii ap liic cuoi tam triidng ciia tam that, lam giam tien ganh,tao dieu kien cho cd tim da bi suy yeu hoat dpng du'dc tot hdn

Bien chting cd the gap khi dting cac thud'c ldi tieu la ha K+ mau, ha Na+ mau, lam giam the tich va kiem hda mau Ha K+ mau la mpt bien chting quan trpng, cd

the de dpa tinh mang ciia benh nhan, nhat la khi dting cting vdi digoxin Do do

khi dieu tri bang thud'c ldi tieu, can phai thee ddi chat che dien giai mau Viec bu mud'i kali hoac phoi hdp vdi ldi tieu giti kali la van de ludn ludn phai nhd den.

- Nhom thuoc M tieu thiazid (chlorothiazid, hydrochlothiazid, metolazpn

indapamid):

+ Thiidng du'dc dung mpt each kha phd' bien treng dieu tri suy tim d nhting

benh nhan ma chtic nang than cdn binh thu'dng

+ Vi tri tac dpng ciia thud'c la d d'ng liidn xa (rieng metelazpn cdn tac dpngtren ca d'ng liidn gan), vdi cd che lam tang bai tiet mud'i, de dd se lam tang thainiidc Hydrochlothiazid cdn diidc dting nhieu vi gia kha re

+ Bien chting cd the gap khi dting thiazid la ha K+, Na+, Ca++ mau Thud'c cung cd the lam tang ure, creatimin mau, cd khi gay viem tuy, viem mach Ganday ngiidi ta de cap den tac dung phu lam tang LDL-cholesterol khi dting thiaziddai ngay (trong nhdm nay Indapamide it anh hiidng den chuyen hda lipoprotein)

- Nhom thuoc lpfi tieu tac dung len quai Henle (furosemid, bumetanid,

acid ethacrynic ):

+ Vi tri tac dpng chii yeu ciia thud'c la d nhanh len ciia quai Henle Ldi tieunhdm nay lam tang thai natri len den 25%, ngoai ra chting cdn cd tac dung lamtang dong mau den than do lam tang hoat hda prostaglandin PGE cd tac dunggian mach than Vi cd tac dung ldi tieu manh va khdng lam giam chtic nang thannen ldi tieu nhdm nay diidc chi dinh d benh nhan suy tim ma ddi hoi phai giamthe tich tuan hoan nhanh hoac d benh nhan suy than

+ Furosemid ngoai kha nang lam giam tien ganh nhanh, khi dting tiemtinh mach no cdn cd tac dung gay gian mach triic tiep Vi vay, furosemid dac biet

cd hieu qua trong dieu tri benh nhan suy tim nang hoac bi phti phdi cap

+ Ldi tieu nhdm nay cd the gay ha K+, Na+, Ca++, Mg++ mau Ngoai ra mpt sd'benh nhan ddi khi cd the cd bieu hien noi ban, viem mach

- Nhom thuoc lc/i tieu giuf kali (spironolacton, triamteren, amilorid):

+ Ldi tieu nhdm nay tac dpng tren dean cud'i cua d'ng liidn xa Spironolactontac dpng thong qua viing nhay cam aldosteron; Triamteren va amilorid cung tacdpng 0 vting cud'i cua d'ng liidn xa nhiing khdng chiu sii kiem soat ciia aldosteron.+ Tac dung ldi tieu ciia cac thud'c thudc nhdm nay yeu neu chi dting mptminh Nhiing vi ldi ich giti kali nen chting thu'dng du'dc phd'i hdp vdi ldi tieuthiazid hoac ldi tieu quai Henle Ldi tieu giti kali thu'dng tac dung cham va keodai Ndi chung vdi loai ldi tieu giti kali nay, khi dung cung phai thee doi kali mau,dac biet chti y khi dting cting vdi thud'c tic che' men chuyen, hoac thud'c giam viemkhdng steroid Ngoai ra nhdm ldi tieu giti kali nay cung ddi khi cting cd the gay ratang ure mau, sdi than (vdi triamterene) hoac chting vti to d nam gidi (vdispironolacton)

+ Trong chien liidc dieu tri suy tim nang hien nay, vai trd ciia thud'c khangaldosteron da du'dc chting minh ro Thud'c khang aldosteron khdng chi cd tac dungldi tieu ma no dac biet cd ldi ich lam giam cac qua trinh bti trti thai qua ciia tangaldosteron trong suy tim nang, do dd lam giam sii co mach, giti mud'i va niidc, siiphi dai cd tim, suy than, rd'i loan chtic nang ndi mach Do vay, thud'c ldi tieukhang aldosteron da lam giam ty le tii vong va nhap vien d nhting benh nhan suytim nang.

Bang 6 Mot so thuoc ldi tieu dung trong suy tim.

Thuoc Du'dng dung Lieu TB ngay

(mg)

Bat dau tac dung

c Cdc thudc gidn mach trong dieu tri suy tim

Nhii chting ta da ro, cP che bti trti d benh nhan suy tim bao gdm ca sii cothat d he ddng mach va tinh mach Sii co that he ddng mach lam tang hau ganh

va sii co he tinh mach lam tang tien ganh Hdn ntia trong suy tim, sii co that hemach phdi cdn la hau qua ciia thieu oxy mau, hoac sii dap ting lau dai vdi viectang ddng mau qua phoi (vi du khi cd Shunt trai -> phai trong tim) hoac dap tinglau dai vdi viec tang ap liic nhi trai (Vi du: hep hai la, suy tim trai )

Cac thud'c gian mach cd the liu tien tac dung giam hau ganh tien ganh hoac

ca hai Nhting thud'c lam gian tinh mach nhieu hdn se lam giam tien ganh va apliic do day that Cdn cac thud'c lam gian ddng mach se lam giam hau ganh Vi vay.ndi chung cac thud'c gian mach se cai thien du'dc cung liidng tim, giam ap liic doday tim va giam siic ep len thanh tim 6 nhting benh nhan hd van tim, suy timnang hoac cd tang trd khang mach, hoac suy tim cd tang huyet ap thi dting cacthud'c gian ddng mach rat cd hieu qua

Tac dung phu ndi chung ciia cac thud'c gian mach trong dieu tri suy timthu'dng la: ha huyet ap (nhat la ha huyet ap trong tii the dting) tang nhe uremau Dting thuoc gian mach can het stic than trpng d nhiing benh nhan cd hanche cung liidng tim (Vi du: hep van ddng mach chii, benh cd tim phi dai tac nghen)hoac d nhting benh nhan cd rd'i loan chtic nang tam triidng (Benh cd tim han che)

- Thud'c tic che men chuyen dang angiotensin (UCMC)

+ Cac thudc thudc nhdm nay cd tac dung tic che men cd nhiem vu chuyen ttiangiotensin I thanh angiotensin II tti dd tic che sii tong hop angiotensin II la mptchat gay co mach, ddng thdi lai lam tang bradykmin la mpt chat gay gian mach.Ket qua chung la cac thud'c tic che men chuyen nay se lam gian mach nhieu gianc;i tieu ddng mach va tinh mach, do vay lam giam ca hau ganh vn tien ganh, tti dolam giam ganh nang cho tim va giam suy tim

•+ Thudc itc che men chuyen diidc coi Id, lita chgn hang dau trong dieu tri suy tim Cac nghien ctiu da chting minh ro vai trd cua thudc UCMC trong dieu tri suy

tim, khdng chi lam giam trieu chting ma cdn cai thien dupe tien liidng benh ratdang ke.

+ Chd'ng chi dinh: hep ddng mach than hai ben phu nu cd thai

+ Nhting tac dung phu cd the gap la: ho ndi ban tut huyet ap, loan vi giac.tang creatinin mau tang kali mau

+ Than trpng khi dting thud'c tic che men chuyen cung vdi loai ldi tieu gitikali hoac dting thud'c cho benh nhan cd huyet ap thap

Bang 7 Mot so thuoc tic che men chuyen thu'dng dung

(mg/ngay)

Trung binh (mg/ngay)

Benazepril (Cibace, Cibacen, Lotensin) 5- 10 10 40

Captopril (Capoten, Lopril, Lopiril, Captopril) 12,5-25 12,5 - 100 Enalapril (Innovace, Pres, Renitec, Renivace, Vasotec) 2,5-5 2,5-40

Ramipril (Altace, Delix, Ramace, Triatec, Tritace) 1,25- 2.5 1,25-20

- Nhdm thud'c tic che triic tiep thu the ATI ciia angiotensin II

+ Cac thudc nhdm nay kha mdi va cd che la tic che triic tiep thu the ATI ndi

ma angiotensin II gay ra tac dung tren cac to chtic dich (mach, than tim) Khac

vdi thud'c tic che men chuyen cac thud'c tic che thu the ATI ciia angiotensin II khdng lam tang bradykinm nen cd the khdng gay ra cac trieu chting phu nhii la

ho khan (mpt tac dung phu rat phd bien khi dting UCMC va la han che dang ke

ciia UCMC)

+ Cac thudc nay diidc dting chii yeu de dieu tri benh nhan THA nhiing cac nghien ctiu mdi day cung chting minh vai trd tot trong dieu tri suy tim va la thudc

cd the thay the hoac phdi hdp vdi UCMC

Bang 8 Mot so thuoc tic che thu the AT1 cua angiotensin II trong dieu tri suy tim

25 mg 20-40 mg

80 mg

Lieu trung binh

2-32 mg 400-800 mg 75-300mg 25-100 mg

day tim, ngoai ra chting cdn lam gian triic tiep ddng mach vanh.

Bang 9 Mot so nitrat thiidng dung

Dang thuoc

Nitroglycerin (ngam)

Dinitrat Isosorbid (ngam)

Dinitrat Isosorbid (ud'ng)

Mononitrat Isosorbid (ud'ng)

Nitroglycerin (cao dan)

Lieu (mg)

0,3-0,6 2,5- 10

5 - 2 0 10-20

5 - 15

Bat dau (phut)

2 - 5 10-30

Khdng du'dc dting cting vdi sinadefil

+ Nitrat cd the diidc dting diidi dang ud'ng, md bdi da cao dan, ngam diidi

hidi hoac tiem truyen tinh mach.

+ Nitrat chii yeu du'dc dting d benh nhan suy tim trong benh ddng mach

vanh, hoac khi khdng the dting cac thud'c gian mach nhdm tic che men chuyen

hoac chen thu the ATI.

- Hydralazin:

+ Lam gian he ddng mach do tac dung lam gian triic tiep cd trdn ciia thanh

mach mau, tti do lam giam hau ganh Vi vay, hydralazin rat cd ich trong dieu tri

suy tim va thu'dng phdi hdp vdi nitrat

+ Chti y: thud'c cd the gay tang nhip tim phan xa, dau dau, ndn, lam xua't

hien cOn dau that ngiic Lieu dting trung binh la ud'ng 20 lOOmg, chia thanh 2

-3 Ian trong ngay Thudc nay khong phdi la lita chqn Wu tien trong dieu tri suy tim.

- Mpt sd' thud'c gian mach dting diidng tiem truyen:

Cac thud'c nay thiidng du'dc chi dinh cho nhting benh nhan cap ctiu, ddt cap cua suy tim nang Khi dting, can bat dau bang lieu nhd va theo ddi chat dien bien

ve huyet ddng Khi ngting thud'c, can giam lieu dan dan de tranh cac phan xa co

mach dot ngpt.

+ Nitroglycerin: lam gian he thd'ng tinh mach va cd tac dung gian triic

tiep mach vanh

Nitroglycerin du'dc de nghi trong dieu tri suy tim d nhiing benh nhan

bi nhoi mau cd tim cap hoac benh nhan dau ngiic khdng on dinh

Thdi gian bat dau tac dung ciia thud'c rat nhanh: ban hiiy thu'dng tti 1

-3 phut.

Lieu dting ban dau thu'dng la lOug/phut (dting bdm tiem dien) Bien

chting nguy hiem cd the gap la tut huyet ap

+ Natri nitroprussid: gay gian triic tiep ddng mach lam giam hau ganh.

cdn tac dung gian he tinh mach thu'dng khdng nhieu

Thud'c du'dc chi dinh d nhting benh nhan suy tim cap nang do tanghuyet ap hoac hd van tim nang

Lieu ban dau thiidng la 10 ug/phut (td'i da 300 - 400 ug/phut) Thdigian ban hiiy ciia thud'c la 1-3 phut

Tut huyet ap cting la bien chting quan trpng can theo doi Vi thudc diidc chuyen hda diidi dang cyanid, nen cd the gay ngd ddc vdi ndng dp thiocyanat

tren 10 ng /dl, do do can than trpng d benh nhan suy than

+ Enalaprilat:

La dang hoat hda mat este ciia enalapnl d dang tiem tinh mach Thdi

gian bat dau tac dung nhanh, thdi gian ban hiiy ngan

Lieu ban dau thiidng la 1, 25mg tiem tinh mach cho mdi 6 gid 0

nhting benh nhan cd dting kem ldi tieu hoac suy than nen giam lieu (0,025mgtiemTM/6gid).

d Thudc chen beta giao cam

- Trpng nhting nam gan day, vai trd cua thud'c chen beta giae cam trcng dieu tri suy tim ngay cang du'dc nhan manh Cd che la ngan chan tac dung kich

thich thai qua ciia he than kinh giac cam trpng suy tim ti huyet man tinh.

- Cac nghien ctiu chp tha'y viec dung cac thud'c chen beta giae cam ket hdp

trpng dieu tri suy tim nang da cai thien du'dc tien liidng benh dang ke.

- Cac thud'c chen beta giao cam diidc chi dinh trong dieu tri suy tim man tinh, n^ng va khi da dting day du cac thud'c thiidng quy khac Tuy nhien, cung

phai het stic than trpng khi dung d benh nhan suy tim da qua nang mat bti.

- Hien nay, cd ba loai thud'c chen beta giao cam da du'dc chting minh la cd

the dting trong dieu tri suy tim do la: carvedilol (Dilatrend); metoprolol (Betaloc)

va bisoprolol (Concor)

- Khi dting thud'c chen beta giao cam trong dieu tri suy tim nen bdt dau

bdng lieu rat thap, theo doi chat che vd tang dan lieu cham Ldi ich thiic te khi

dting chen beta giao cam chi xua't hien cham va lau dai

e Cdc thuoc chen kenh calci

- Tuy la cac thud'c gian mach nhiing cac thud'c chen kenh calci khong du'dc

chi dinh de dieu tri suy tim vi no cd the anh hiidng stic cc cd tim, nhat la cac thud'cthe he thti nhat.

- Mpt sd' thud'c the he thti hai (amlodipin, lacidipin) it anh hiidng den stic co

cd tim nhiing cting khdng phai la chpn liia de dieu tri suy tim

g Cdc thudc lam tang siic co bdp cd tim khac

- Cac thud'c gid'ng giao cam

Thu'dng du'dc dting de dieu tri trong cac triidng hdp cap ctiu hoac dot nang

ciia suy tim nang ma cac thud'c thong thu'dng khdng cd hieu qua Mpt sd' tac dung

phu ciia thud'c cd the gap la: lam tang thieu mau cd tim, nhip tim nhanh, rd'i loannhip that, co mach ngoai bien Khi dieu tri ta can phai theo doi chat che tinhtrang huyet dpng va dien tim ciia benh nhan

+ Dopamin:

• Lieu 1-3 ug/kg/phtit cd tac dung lam gian mach than va mac treo,thong qua kich thich thu the dopamin, ket qua lam tang ddng mau den than va sd'lu'dng niidc tieu

• Lieu 2 - 5ug/kg/phut lam tang stic co bdp ciia cd tim do kich thich thuthe beta.

• Lieu cao hdn 5-10 ug/mg/phut thi thud'c se kich thich thu the alphagiao cam gay co mach ngoai bien, tang trd khang he mach anh hiidng xau dencung lu'dng tim

• Dopamin rat cd y nghia khi ta dung cho benh nhan suy tim nang cd hahuyet ap Mpt nhiidc diem ciia thud'c la hay lam cho nhip tim nhanh nhieu

-r Dobutamin:

Chti yeu kich thich chpn lpc pi-giao cam tac dung tren (32 va cc-giao cam yeu hdn nhieu Thud'c cd tac dung cai thien tinh trang huyet dpng, thong qua viec kich thich triic tiep tac dung co cd tim va lam gian he ddng mach phan xa, tti

do lam giam hau ganh va tang ciidng cai thien cung liidng tim Khi dting thudc nay thiidng huyet ap va nhip tim thay ddi khdng qua nhieu Tuy nhien nhip tim

nhanh van cd the xay ra khi dting lieu cao

Lieu dting ban dau bang diidng truyen tinh mach hang dinh tti 1 - 2 ug/kg/phut va dieu chinh cho den khi dat diidc hieu qua huyet ddng can thiet.

Nhting benh nhan suy tim nang, man tinh, cd the dting tting ddt dobutamin trong 2-4 ngay, de guim mpt each dang ke cac trieu chting ciia suy tim Nhting benh nhan phai dting dobutamin keo dai, can theo doi chat che va

khdng nen viidt qua lieu 10 u g/kg/phtit

Khdng nen chi dinh thud'c nay trong dieu tri suy tim d nhting benh

nhan cd rdi loan chtic nang tam triiOng (vi du: benh cd tim phi dai) hoac d benh

nhan suy tim cd tang cung liidng

Cac nghien ctiu cho tha'y viec dting thiidng quy cac thud'c gid'ng giao cam nay de dieu tri suy tim (truyen ngat quang, tting ddt), khdng nhting khdng

mang lai ldi ich ma cdn lam tang ty le tii vong.

- Cac thud'c tic che men phosphodiesterase:

+ Lam tang stic co bdp ciia cd tim va gian mach do lam tang adenosm mono

phosphate vdng (AMPc)

•+- Hai loai thud'c da diidc sii dung trong lam sang la amnnon va milrmon.

Chiing diidc chi dinh trong nhting ddt cap hoac dieu tri ngan ngay d benh nhan suy tim dai dang, khd dieu tri Amnnon cd tac dung cai thien huyet ddng nhii dobutamin, nhiing lam gian mach manh hdn Vi vay ha huyet ap cd the xay ra d nhting benh nhan cd dting thud'c nay cting vdi mpt thud'c gian mach khac.

+ Lieu liidng:

Amnnon tiem tinh mach 750 ug/kg trong 2-3 phut sau do truyen tinhmach vdi lieu 2.5 - 10,0 ug/kg/phut.

Milrmon: lieu ban dau la 50 ug/kg tiem tinh mach trong 10 phut sau

do truyen TM vdi lieu 0,375 - 0.750 ug/kg/phut

Tac dung phu ciia cac thudc tic che men phosphodiesterase: cd the gay

loan nhip nhi hay that va ddi khi gay tac mach

-+- Vesnarinon:

La mot dan xua't ciia qumolm, thuoc cd tac dung lam tang co bdp cd tim Khi ket hdp vdi digoxin va thud'c tic che men chuyen trong dieu tri suy tim thudc cd

the cai thien diidc tot hdn tinh trang suy tim Lieu trung binh la 60mg/ngay, dting

keo dai Tac dung phu cd the gap la giam bach cau hat Ldi ich ciia thud'c nay cdn

chiia du'dc ro.

h Van de thudc chdng dong trong suy tim

- Trong suy tim, mau thiidng ti lai d cac cd quan ngoai bien nen rat de tao

thanh cac cue mau ddng trong he thong tuan hoan va tti dd gay ra nhting tai bien tac nghen mach mau Vi vay, ngiidi ta phai dting thud'c chdng ddng khdng nhting trong nhting triidng hdp cap tinh nhii tac dpng mach phdi, nao, chi ma cdn phai dieu tri dii phdng trong cac triidng hdp suy tim cd tim to, nhat la trong cac triidng

hdp cd them rung nhi

- Heparin va heparin trpng liidng phan tii thap diidc sii dung trong cac

triWng hdp tac mach cap

- Cac thud'c chdng ddng thudc nhdm khang vitamin K diiOc chi dinh d benh

nhan suy tim cd nhieu nguy cd tac mach, cac buong tim qua gian hoac cd bang

chting ciia huyet khd'i tuan hoan

1.3 Dieu tri nguyen nhan

- Trong moi triidng hdp, can phai danh gia va tim nguyen nhan gay benh

de cd the dieu tri mpt each triet de neu cd the:

- Suy tim do ciidng giap: phai dieu tri being khang giap trang tong hdp hoac

phiidng phap phdng xa hay phau thuat

- Suy tun do thieu mau: can tim nguyen nhan dieu tri va bti dii mau

- Suy tim do thieu vitamin Bl: can dting vitamin Bl lieu cao.

- Suy tim do rd'i loan nhip tim keo dai thi phai cd bien phap dieu tri cac rd'i loan nhip tim mpt each hdp ly: dting thud'c soc dien hay dat may tao nhip.

- Suy tim do nhdi mau cd tim va cac benh mach vanh: ngiidi ta cd the can thiep triic tiep vao chd tac ciia ddng mach vanh bang thud'c tieu sdi huyet nong va

dat Stent ddng mach vanh hoac mo bac cau noi chii vanh

- Suy tim do mpt so'benh van tim hoac di tat bam sinh: neu cd the, can xem

xet sdm chi dinh can thiep qua da (nong van bang bang, ddng cac Id thdng bang

du ) hoac phau thuat siia chtia cac di tat, thay van tim

1.4 Mot so bien phap dieu tri dac biet khac

a Bien phap tdi ddng bo cd tim bang may tao nhip tim hai buong

- Cd che: may tao nhip tim hai buong vdi lap trinh de cho thdi gian tam

triidng va tam thu hdp ly tao ra svi co bdp ciia tim hieu qua hdn trong hoan canhcho phep

- Hien nay, phiidng phap dieu tri nay diidc chi dinh kha rdng rai d nhting benh nhan suy tim nang (EF < 30%), cd bloc nhanh trai hoac QRS rdng tren 120 ms.

b Bien phap ho trd tuan hoan ddc biet: cd the diidc ap dung d nhting benh

nhan suy tim cap trong liic can nhting can thiep dac biet khac

c Ddt bdng trong dong mach chit: bang phiidng phap thdng tim, ngiidi ta

diia mpt d'ng thdng cd gan mpt qua bdng dac biet, tti ddng mach dtii d'ng thdng

diidc day len tdi ddng mach chti Bdng se diidc dat d vi tri trong long ddng mach

chii diidi cho phan nhanh ra ddng mach diidi ddn trai Bdng se diidc bdm cang ra

mpt each dong bd vao thdi ky tam triidng ciia chu chuyen tim Nd lam giam dang

ke'hau ganh cai thien mot each ro ret cung kidng tim cho benh nhan Nd cdn

lam tang lu'dng mau den tiidi cho ddng mach vanh va lam giam nhu cau oxy ciia

cd tim.

e Thiet bi ho trd that: la thiet bi phai mo de cay ghep gitip cac benh nhan

suy tim qua nang de keo dai them thdi gian chd thay tim.

g Thay (ghep) tim

- La bien phap htiu hieu cud'i cting cho nhting benh nhan suy tim giai doan

cuoi da khang lai vdi tat ca cac bien phap dieu tri noi ngoai khoa thdng thiidng.

Dd thiidng la nhting triidng hdp cd ton thiidng cd tim rat rdng va nang ne.

- Chi nen chi dinh d nhting benh nhan ma thdi gian tide liidng cho cudc

song cdn cd y nghia

- Mpt thong ke gan day cho tha'y ke tti khi cd thud'c giam mien dich cyclosporin, ty le song sot sau mpt nam ghep tim la 90% va sau 5 nam la 65 - 70% Ndi chung thi chtic nang va chat liidng cudc song ciia benh nhan diiOc cai thien

dang ke sau ghep tim

- Cac thud'c thiidng hay dting nhat de dieu tri giam mien dich sau ghep tim

la: glucocorticoid, cyclosporin va azathioprin Mpt so loai thud'c giam mien dich

mdi khac cdn dang trong giai doan thu" nghiem

- Nhting bien chting cd the gap sau ghep tim bao gom: thai ghep sdm, nhiem trung do dting thudc giam mien dich Sii phat trien ciia benh mach vanh sau mo cting la mpt nguyen nhan quan trpng gay tii vong sau nam dau tien diidc

ghep tim

1.5 Van de giao due benh nhan suy tim va theo doi

- Day la mpt bien phap rat quan trpng va mang lai hieu qua ddi vdi benh

nhan suy tim man tinh

- Benh nhan diidc giao due ky ve ld'i song, ve che dp an ud'ng, tranh nhiing yeu to nguy cd (hut thud'c la, riidu), tranh cac thud'c cd hai den suy tim nhu:

corticoid, thud'c chdng viem khac

- Tiep tuc dieu tri tot cac yeu to nguy cO nhii tang huyet ap dai thao

du'dng rd'i loan lipid mau

- Benh nhan can du'dc chuan bi tam ly, cd sii phd'i hdp tot trong dieu tri vachung song vdi benh

- Benh nhan van diidc khuyen khich tap the due deu dan trong kha nangcho phep.

- Benh nhan can tii minh theo doi cac dien bien stic khde va cac rdi loan

nhu1 huyet ap nhip tim, trieu chting lam sang, mtic dp khd thd de dieu chinh va

thdng bao cho cac bac si biet

TANG HUYET AP

I MO DAU

Tang huyet ap (THA) la mpt benh ly rat thiidng gap va la van de xa hpi 6

cac niidc phat trien ty le THA d ngiidi ldn (>18 tudi) theo dinh nghia ciia JNC VI la

khoang gan 30 % dan sd'va cd tren mpt ntia dan sd'> 50 tudi cd THA Theo thong

ke d Viet Nam nhting nam cud'i thap ky 80 ty le THA d ngiidi ldn la khoang 11%,

nam 2001 la 16% thi thong ke gan day ty le THA d ngiidi ldn da khoang 27 %.

THA nguy hiem bdi cac bien chting ciia nd khdng chi cd the gay chet ngiidi

ma cdn de lai nhting di chting nang ne (vi du: tai bien mach nao) anh hiidng den chat lu'dng cudc sd'ng ciia benh nhan va la ganh nang cho gia dinh va xa hpi.

Ngay nay da cd kha nhieu thay doi trong quan niem ve THA, phiidng thtic dieu tri cung nhu" viec giao due benh nhan da tac dpng den tien lu'dng ciia THA.

II.DjNH NGHIA THA

1 Cho den nay, To chtic Y te The gidi va hpi THA qud'c te (World Health

Organization - International Society of Hypertension WHO - ISH) da thong nhat gpi la THA khi huyet ap tam thu > 140 va /hoac huyet ap tam triidng > 90 mmHg Con so nay cd diidc la do diia tren nhting nghien ctiu ldn ve dich te cho tha'y:

- C6 sii gia tang dac biet nguy cd tai bien mach nao (TBMN) va tim mach d

ngiidi ldn cd con so'huyet ap > 140/90 mmHg

- Ty le TBMN d ngiidi cd so'huyet ap < 140/90 mmHg giam ro ret

2 Giai doan THA

Cho den nay, each phan loai ciia WHO-ISH du'dc dting rdng rai do tinh thiic tien va tien dung ciia nd Cach phan loai ciia JNC VI - 1997 (Uy ban phdng chdng huyet ap Hoa Ky) cting tiidng tii va gan day nhat la each phan loai ciia Hpi tang huyet ap chau Au (ESH) nam 2007 cting chia ra cac giai doan ciia THA gan tiidngtii, chi khac la thuat ngti (bang 1)

Bang 1 Phan loai THA theo WHO-ISH va JNC VI (1997)

~~T

Khai niem

HA tam thu (mmHg)

> 180

Va/ hoac Va/ hoac Va/hoac

(JNC VII) nam 2003 nhii sau:

Bang 2 Phan do THA theo JNC VII nam 2003

< 120 120- 139

140 - 159

> 160

HATTr (mmHg)

< 80

80 -89 90-99

>100

Nhting diem chti y trong each phan loai mdi nay:

- Da de cap den khai niem tien THA chti khdng cd HA binh thiidng cao, vi

nhting nghien ctiu cho tha'y trong mpt so triidng hdp vdi nhting nguy cd cao (vi du:

dai thao diidng) thi da can cd thai dp quyet liet hdn trong dieu tri.

- Tuy nhien trong thiic tien ting dung hien nay, each phan loai theo ISH to ra thiic tien hdn va Hpi Tim mach hoc Viet Nam van khuyen cao dting each

WHO-phan loai nay

3 Mot so d|nh nghta tang huyet ap khac

3.1.Tang huyet ap tam thu dan doc

Dd'i vdi ngiidi ldn HATT cd xu hiidng tang va HATTr cd xu hiidng giam Khi tri so cua HATT >140 mmHg va HATTr <90 mmHg benh nhan diidc gpi la THA tam thu don ddc Dp chenh HA (tam thu - tam triidng) cting la mpt yeu to dii bao

nguy cd quan trpng ve tim mach.

3.2 Tang huyet ap ao choang trang va hieu ufng ao choang trang

Mpt sd' benh nhan HA thu'dng xuyen tang tai benh vien hoac phdng khamciia bac si, trong khi HA hang ngay hoac do 24h lai binh thu'dng Tinh trang na>gpi la THA ao choang trang, cho du mpt thuat ngti khac it mang tinh cd che hdn laTHA phdng kham hoac benh vien ddn ddc Ty le hien mac THA ao choang trang la

10 - 30%, chiem mpt ty le khdng phai khdng dang ke tren nhting dd'i tiidng THA

THA ao choang trang tang theo tudi va ty le nay < 10% b THA dp 2, dp 3 khi dp

tai phdng kham Tang HA ao choang trang cd the la khdi dau cua THA thiic sii va

cd the lam tang nguy cd benh tim mach mac du khdng phai nghien ctiu nao ctingtra ldi nhu5 the Nghi ngd THA ad choang trang khi HA do tai phdng kham tanghoac khang tri trong khi khdng cd ton thu'dng cd quan dich Nhting ngiidi THAphdng kham ddn ddc cd nguy cd tim mach thap hdn nhting ngiidi vtia THA phdngkham va THA 24 gid

Chan doan THA phdng kham ddn ddc khi HA phdng kham 140/90 mmHg dpnhieu Ian di kham trpng khi dd HA 24 gid <125/80 mm Hg Nen tham kham timkiem cac yeu to' nguy cd chuyen hoa va ton thu'dng cd quan dich Sti dung thudcchi nen ap dung khi cd bang chting ton thiidng cd quan dich hoac nguy cd timmach cao Thay doi phong each song va theo doi sat nen diidc ap dung cho tat cabenh nhan vdi THA phdng kham ddn ddc chiia sti dung thud'c

III XAC OjNH VA DANH GIA MOT BENH NHAN THA

1 Xac d|nh chan doan mot ngiidi bj THA: rat ddn gian la phai dd huyet ap

1.1 Nhuhg luit y khi xac dinh huyet ap

- Benh nhan phai trong trang thai nghi ngdi (it nhat 5 phut trtidc dd), khongdting cac chat kich thich cd anh hiidng den huyet ap (vi du: ca phe, hut thud'c la).

- Benh nhan nen d tii the ngdi ghe tiia, tay de tren ban sad chd nep khuyungang vdi mtic tim

- Trong mpt sd' triidng hdp dac biet can do HA bca tii the nam va ngdi hoac dting.

- Be rdng bao do huyet ap nen bang 80% chu vi canh tay, do do, d mpt sdbenh nhan tay to can dung loai bao rdng hdn va ngiidc lai

- Nen dting loai may do huyet ap thuy ngan

- Con so' huyet ap tam thu tiidng ting vdi pha I ciia Korotkoff (xua't hientie'ng dap dau tien) va huyet ap tam triidng la d pha V (mat tieng dap) Can chti y

la khoang trd'ng HA cd the gap d mpt so'benh nhan

- Nen dp HA ca hai tay va lay tri so' d ben cd so' do cao hdn

- Can thiet phai do it nhat 2 Ian each nhau it nhat 2 phut va con so' cud'icting la trung binh cong neu cd sti khac biet > 5 mmHg

1.2 Xac dinh la THA (bang 3)

- Tai phdng kham: khi benh nhan cd tri so HA > 140/90 mmHg Sau kham

sang lpc lam sang it nhat 2 va 3 Ian khac nhau Moi Ian kham HA du'dc do it nhat

2 Ian.

- Tai nha: khi do nhieu Ian dting phiidng phap THA khi cd tri so HA >135/85 mmHg.

- Do HA bang may do HA Holter 24 gid: HA > 125/ 80 mmHg

Bang 3 Cac ngtidng HA ap dung de chan doan THA theo each do

HATT ( mm Hg) HATTr (mm Hg)

- Neu khi do ngay Ian dau HA > 160/100 mmHg thi cd the xac dinh la biTHA, neu khdng thi nen tham kham lai de khang dinh (bang 4)

Bang 4 Thai do doi vdi benh nhan THA khi do Ian dau (theo JNC VI)

HA toi da

(mmHg)

HA toi thieu (mmHg)

Thai do

< 130 <85 Kiem tra lai trong 2 nam

130-139 85-89 Kiem tra lai trong 1 nam

140-159 90-99 Khang dinh lai trong vdng 2 thang

160-179 100-109 Danh gia va dieu tri trong vdng 1 thang

> 180 > 110 Lap tire danh gia va dieu tri ngay hoac trong vdng

1 tuan tuy tinh hinh lam sang

1.3 Mot so phwong phap do huyet ap khac

- Giao due benh nhan tii do huyet ap de theo doi, viec nay cd nhting ldi ichla: tranh cho benh nhan phai den cd sd y te lien tuc do dd se giam chi phi, gitiptheo ddi dieu tri td't; tranh hien tiidng THA ao choang trang; lam benh nhan tichciic hdn trong dieu tri THA.

- Do huyet ap lien tuc (Holter huyet ap) Bien phap nay khong dting de apdung thu'dng quy, nd cd ich trong mpt so' triidng hdp nhu" nghi ngd benh nhan cd

THA ao choang trang, THA cOn, THA khang lai dieu tri, tut HA do dting mpt so'

thud'c ha HA.

2 Danh gia mot benh nhan THA

Viec tham kham mpt benh nhan THA nham vao ba muc dich sau:

- Tim hieu nguyen nhan (neu cd)

- Danh gia cac bien chting (ten thu'dng cd quan dich).

- Danh gia cac yeu to nguy cd ve tim mach hoac cac rd'i loan khac de cd thai

dp dieu tri dting mtic va tien liidng benh

2.1 Khai thac benh sir

- Khai thac ve tien sti bi THA, thdi gian bi neu cd, mtic dp THA

- Tien sti cac benh tim mach, cac trieu chting benh tim mach, suy tim,

TBMN, benh mach ngoai vi, benh than, dai thae du'dng, rd'i loan md mau

- Cac thdi quen, ldi sd'ng (beo phi, hut thud'c la, ud'ng riidu, che dp an nhieu

mud'i ), trinh dp giao due, dieu kien sd'ng

- Tien sti gia dinh ve THA va cac benh tim mach

- Cac thud'c chiia THA da dting va mtic dp dap ting

2.2 Tham kham thuc the

- Dp huyet ap (da neu tren) Treng mpt sd' triidng hdp nghi ngd can dphuyet ap cac tii the va do HA tti chi

- Tham kham toan trang chung, chti y den chieu cao, can nang.

- Tham kham day mat

- Tham kham he tim mach, chti y cac tie'ng thdi d tim, nhip tim, cac dauhieu suy tim, tie'ng thdi d cac mach mau ldn

- Tham kham bung chti y tie'ng thoi d ddng mach chti hay dpng mach than,than te hay khdng, cac khd'i bat thu'dng d bung

2.3 Cac tham do can lam sang

a Cdc tham do thu'dng quy trong THA la

- Phan tich niidc tieu.

- Cong thtic mau

- Sinh hoa mau (dien giai do, glucose khi ddi, cholesterol toan phan,triglycerid va LDL va HDL- cholesterol)

- Dien tam dd 12 chuyen dao

b Cdc tham do hd trd: trong mpt so' triidng hdp neu can thi cd the tham dd

them:

- Creatinin mau, protein nieu 24 gid, acid uric

- Nong dp renin, catecholamin mau trong mpt so triidng hdp han htiu de

tim nguyen nhan

- Sieu am tim de danh gia khd'i liidng cd that trai va chtic nang that trai

hoac cd kem theo benh hay cac bien chting tim mach khac.

IV NGUYEN NHAN TANG HUYET AP

Dai da so THA d ngiidi ldn la khdng cd can nguyen (hay THA nguyen phat) chiem tdi > 95% Mpt sd' yeu td' diidc cei la yeu to nguy cd cua THA se diidc trinh

bay trong phan V

THA thti phat hay THA cd can nguyen can diidc chti y, nhat la trdng cac

triidng hdp sau:

- Phat hien ra THA d tudi tre < 30 hoac gia > 60 tudi.

- THA rat khd khdng che bang thud'c.

- THA tien then nhanh hoac THA ac tinh

- Cd bieu hien benh ly cd quan khac ma cd the la nguyen nhan ciia THA.

Bang 5 Mot sd nguyen nhan THA thti phat

Cac benh ve than

Viem cau than cap

Viem cau than man Sdi than

Viem than keHep dpng mach than

Cac benh noi tiet

U tuy thu'dng than (Pheocromocytom)Cushing

Cifdng aldosteron Ciidng giapCiidng tuye'n yen

Cac benh he tim mach

Hd van DMC (gay THA tam thu ddn ddc)Hep eo OMC (gay THA chi tren)

Benh vo mach (Takayasu)Hep, xd vtia OMC bung cd anh hiidng den DM than

Do dung mot so thuoc

Cam thao

Cac thuoc ciidng alpha giao cam (vd: cac thudc nho mui chtia ngat )Thuoc tranh thai

Mot sd nguyen nhan khac

Ngp doc thai nghen, yeu tdtam than

V PHAN TANG NGUY CO CHO BENH NHAN TANG HUYET AP

Viec phan tang cac nguy cd chd benh nhan THA la rat quan trpng, gitip hoach dinh chien liidc dieu tri THA che benh nhan hdp ly Viec phan tang THA diia tren cac yeu td nguy cd tim mach d benh nhan THA va cac tdn thiidng cd

quan dich.

1 Cac yeu to nguy cd benh tim mach d benh nhan THA

- Hut thud'c la.

- Rd'i loan lipid mau

- Dai thao du'dng

- Tudi > 60

- Nam gidi hoac phu nti da man kinh

- Tien sti gia dinh cd ngiidi than bi benh DMV: nti < 65 tudi hoac nam < 55 tudi

2 Ton thu'dng cd quan dich (bien chting) co the gap trong THA

2.1 Tim

- Cap: phti phdi cap, NMCT cap.

- Man: day that trai, benh dpng mach vanh man tinh (dau that ngiic dn

dinh), suy tim

- Phti, xua't huyet, xua't tiet, mach co nhd b day mat

2.5 Benh dong mach ngoai vi

- Phinh/tach thanh ddng mach chti

- Benh dpng mach ngoai vi khac

3 Phan tang nguy cd doi vdi benh nhan THA.

Cd ba nhdm nguy cd (theo JNC VI):

- Nhdm A: la nhting benh nhan THA nhe hoac THA ma khdng cd tdn thtidng

cd quan dich, khdng cd cac nguy cd benh mach vanh, khdng cd bieu hien benhtim mach.

- Nhdm B: la nhting benh nhan THA chiia cd tdn thtidng cd quan dich va

khong"co benh tim mach kem theo ma cd it nhat mpt yeu to nguy cd benh tim

mach da ndi tren nhiing khdng phai la dai thao diidng

- Nhdm C: la nhdm cd benh tim mach kem theo hoac cd tdn thu'dng cd quan

dich hoac cd dai thao diidng va cd the cd hoac khdng kem theo yeu to nguy cd benh

tim mach.

Bang 6 Phan tang nguy cd va thai do dieu tri benh nhan THA

Giai doan THA

Binh thu'dng cao

Dung thud'c

Ghi chu: (*) Cho nhting benh nhan cd nhieu yeu to nguy cd, can nhac cho ngay thud'c phdi

hdp vdi dieu chinh ldi sd'ng; (**) Cho nhting benh nhan cd suy tim, suy than, dai thao du'dng.

VI OIEU TR| THA

1 Muc dich va nguyen tac dieu tri

- Ngan ngtia lau dai cac bien chting

- Diia du'dc HA ve tri so binh thu'dng (< 140/90mmHg, neu cd DTD hoacnguy cd cao khac thi HA phai <130780 mmHg).

- Dieu tri can he't stic tich ciic d benh nhan da cd tdn thiiOng cd quan dich.

- Phai can nhac tting ca the benh nhan, cac benh kem theo, cac yeu to nguy

cd, cac tac dung phu va anh hiidng cd the ciia thud'c ma cd che do dting thud'c thich

hdp.

- Neu khdng cd nhting tinh hudng THA cap ctiu thi HA nen diidc ha tti tti

de tranh nhting bien chting thieu mau cd quan dich (nao)

- Viec giao due benh nhan can phai nhan manh: (1) Dieu tri THA la mpt

dieu tri sud't ddi; (2) Trieu chting cd nang ciia THA khdng phai ltic nao cting gap

va khdng phai ludn tiidng xting vdi mtic dp nang nhe ciia THA; (3) Chi cd tuan thu

che dp dieu tri thich hdp mdi giam du'dc dang ke cac tai bien de THA.

2 Che do dieu trj khong dung thuoc (thay doi loi song)

La phiidng phap dieu tri bat budc dii cd kem theo dting thud'c hay khdng.

2.1 Giam can nang neu thua can

- Che dp giam can can dac biet diidc nhan manh d nhting benh nhan nam

gidi beo phi the trung tam (bung)

- Viec giam bee phi da diidc chting minh lam giam cholesterol va giam phi

dai that trai.

- Khdng ap dung che dp nay cho phu nti cd thai bi THA

2.2 Han che ruau

- Neu dting qua nhieu riidu lam tang nguy cd tai bien mach nao b benh

nhan THA, lam tang trd khang vdi thud'c dieu tri THA

- Mpt so dieu tra cho tha'y neu dting lu'dng riidu thich hdp thi cd the lam

giam nguy cd benh mach vanh (hieu ting ngiidc).

- Do dd liidng riidu neu cd dting can han che it hdn 30 ml ethanol /ngay (it

hdn 720 ml bia, 300 ml riidu vang va 60 ml riidu Whisky).

2.3 Tang cudng luyen tap the luc

- Neu tinh hud'ng lam sang cho phep nen khuyen khich benh nhan tap the

due deu.

- Che dp luyen tap can deu dan it nhat 30 - 45 phut /ngay va tat ca cac

ngay trong tuan.

- Vdi nhting benh nhan cd trieu chting hoac nguy cd benh mach vanh can

phai cho benh nhan lam cac nghiem phap gang stic the liic trade khi quyet dinh

cho benh nhan che dp tap the liic b mtic thich hdp nhat.

2.4 Che do an

- Giam mud'i (natri), da dadc chting minh lam giam so huyet ap va nguy cd

bien chting d benh nhan THA Che dp an giam mud'i nen thiic hien vdi ladng mud'i

< 6 g (NaCl)/ ngay hoac < 2,4 g natri/ngay

- Duy tri day dii ladng kali khoang 90 mmol /ngay, dac biet d benh nhan cd

dting thud'c ldi tieu de dieu tri THA Bao dam day dii calcium va magnesium.

- Che dp an han che cac md ddng vat bao hoa, cac thtic an giau cholesterol

(phti tang ddng vat, long do truing ) Han che an qua nhieu cac chat ngpt, tinh bdt.

2.5 Bo thudc la

- Can het stic nhan manh va cadng quyet trong moi tradng hdp.

- Day la mpt trong nhting nguy cd manh nhat ciia cac bien chting tim mach.

3 Cac thuoc dieu tri THA

3.1 Thudc tac dong len he giao cam

3.1.1 Thuoc chen beta giao cam (bang 7)

- La mpt trong nhting thti thud'c tting dadc hia chon hang dau trong dieu tri THA, da dadc chting minh lam giam ty le TBMN, va dac biet la giam NMCT.

- Tuy nhien mpt so nghien ctiu gan day cho thay, thudc chen beta giao cam khdng ngan ngtia dadc dang ke bien chting tai bien mach nao va sii xua't hien dai thao dadng mdi d benh nhan THA Do vay viec chpn thud'c chen beta giao cam

nha thud'c liia chpn hang dau dang dadc xem xet lai.

- Cd che: lam ha huyet ap do chen thu the beta giao cam vdi catecholamin

do do lam giam nhip tim va cung ladng tim Nd cung lam giam ndng dp renin

trong mau, lam tang giai phdng cac prostaglandins gay gian mach.

- Phan loai: diia tren mtic chpn lpc tren tim ma cd the chia ra nhdm cd chpn

lpc vdi thu the (31 va khdng chpn lpc (chen ca pi va 02) Tuy nhien vdi lieu cao thi cac thudc chpn lpc pi se khdng cdn chpn lpc ntia Cac thud'c chen beta giao cam

nay cdn dadc phan biet bdi nhting thud'c cd hoat-tinh giao cam ndi tai (ISA) va

khdng cd Nhting thud'c cd hoat tinh ISA thi it gay ha nhip tim hdn.

- Chdng chi dinh va tac dung phu: cac thudc chen beta giao cam cd kha

nhieu chdng chi dinh:

+ Nhip cham, dac biet la bloc nhi that do cao

+ Suy tim nang.

+ Cac benh phoi co that (hen phe quan)

+ Benh ddng mach ngoai vi

+ Than trpng d benh nhan cd dai thao dadng rd'i loan lipid mau.

+ Thud'c dting lau cd the gay hpi chting Raynaud, liei dadng mat ngii tram

c a m

+ Cd hieu ting cdn THA bung phat neu ngting thud'c dot ngdt.

Bang 7 Cac loai thuoc chen beta giao cam thtidng dung

Cac loai thuoc ISA Lieu khdi dau /ngay Lieu duy tri /ngay i

200 mg x 2

25- 100 mg 5-40 mg 2,5-20 mg 50-450 mg 50-400 mg

Thuoc chen ca beta va

alpha giao cam

(ISA: hoat tinh gidng giao cam ndi tai, tiic la cac thudc nay it lam cham nhip tim hdn cac thudc

khac)

3.1.2 Cac thuoc chen alpha giao cam (bang 8)

- Cd che tac dung: Cac thud'c nay tic che thu the al giao cam, lam bloc thuthe alpha giao cam hau hach, dan den gian ddng mach va tinh mach

- Dac diem: cac thud'c chen alpha giao cam thadng cd hpi chting lieu dautien ttic la tac dung rat manh khi dting lieu dau tien, cd the dan den tut huyet ap,

do do khi dting lieu dau tien can bat dau tti lieu rat thap va theo doi chat che Cacthud'c nay cd the gay tut huyet ap ta the, dau dau, chdng mat Thud'c chpn lpc al

giao cam dting lau dai cd the cai thien tinh trang rd'i loan lipid mau Thud'c cdn cd tac dung td't chtia trieu chting d nhting benh nhan cd phi dai tien liet tuye'n lanh

tinh.

- Thud'c nhdm nay khdng phai la ltia chpn hang dau trpng dieu tri THA

Bang 8 Cac thuoc chen alpha giao cam thtidng dung

[

Cac loai thuoc Ten thu'dng mai Lieu khdi dau /ngay Lieu duy tri /ngay

Prazosin hydrochlorid Minipress 1 mg x 2 1-20 mg

3.7.3 Cac thuoc chen ca alpha va beta giao cam (bang 7)

- Do chen ca thu the beta d tim va alpha d mach ngoai vi nen cd dadc ca haicci che gay ha HA ciia hai nhdm ndi tren

- Carvedilol la mot thti thud'c hien nay dadc de xua't khdng nhting dieu triTHA suy vanh ma cd tac dung td't trong suy tim vdi lieu kiem soat chat che

- Tac dung phu gidng nha cac thud'c chen beta giao cam, ngoai ra cd the gay

huy hoai te bao gan, ha HA ta the, hpi chting gidng lupus ban dd, run chan tay, va

bung phat THA khi ngting thudc dot ngdt