Professional Documents
Culture Documents
i cng Mc tiu iu tr NMCT cp ST chnh ln iu tr ban u NMCT cp iu tr NMCT cp sau ti ti mu iu tr lu di (sau xut vin)
i cng
CC NH NGHA
NMCT cp l 1 bin c do hu qu ca cht t bo c tim lin quan n thiu mu cc b c tim (ch khng phi do chn thng hay vim c tim).
i cng
NMCT cp ST chnh ln: th bnh quan trng trong Hi chng mch vnh cp (HCMVC) HCMVC: cp cu ni khoa. nguyn nhn hng u v bnh sut v t sut cc nc phng Ty.
i cng
Sinh l bnh NMCT cp ST chnh ln: huyt khi gy tc hon ton lng MV (90%)
i cng
i cng
Mng x va t v phi by thnh phn bn trong li mng x va vi dng mu Yu t m v hot ho ng ng mu ngoi sinh
Tc nghn c hc
Co mch (serotonine)
i cng
Chn on NMCT cp ST chnh ln:
au ngc>20 pht Khm thc th: bin chng, c phn bit in tm : gip chn on trong giai on sm (+++) 10 pht Men tim: khng nh chn on nhng tr
ECG: ST 0,1mV /t nht 2 c lin tip V2,V3: ST 0,25mV (nam<40t) ST 0,2mV (nam 40t) ST 0,15mV (n ) V7-V9: ST 0,05mV ST 0,1mV (nam <40t) V3R-V4R: ST 0,05mV ST 0,1mV (nam < 30t)
Nhng biu hin khng in hnh trn ECG bn c TC in hnh TMCT m cn can thip khn
Bloc nhnh tri: nu khng c ECG c>xem nh miti ti mu CTMVCC>TSH My to nhp bung tht: chp mch vnh khn tr khi c th chnh my d thy c nhp t nhin ca bn /bn khng l thuc my ECG: khng bin i nhng TC TMCT in hnh: do tc nhnh m, nhnh bc cu. NMCT cp thnh sau n thun: ST 0,05mV V1V3 ST>0,1mV trn 8 c km ST avR v/hoc V1: tc thn chung hay nhiu nhnh
i cng
Siu m tim ti ging:
Ri lon vn ng vng (c hay mi?) Gip chn on: au ngc khng r rng Khng RLV vng loi tr TMCT cp quan trng trn bn ang au ngc cp
MC TIU IU TR
Trong vi gi u:
Gim au Chn on v iu tr kp thi cc bin chng nguy him (tt HA, ph phi cp,RN nhp) . Khi u iu tr ti ti mu trn nhng bn c ch nh (quan trng nht)
MC TIU IU TR
Cc mc tiu iu tr cn t trong vi gi u (tip theo)
S dng thuc chng huyt khi (khng ng v khng kt tp tiu cu) phng nga huyt khi trong stent hay ti pht huyt khi mch vnh. c ch bta phng nga ti pht thiu mu cc b hay lon nhp tht nguy him
MC TIU IU TR
Mc tiu trong giai on sau ca iu tr cp nhm ci thin d hu lu di
Khng kt tp tiu cu: gim nguy c ti pht huyt khi mch vnh hay huyt khi trong stent c ch men chuyn: gim ti cu trc c tim Statin Khng ng: khi c huyt khi trong bung tht tri hay rung nh mn.
IU TR BAN U NMCT CP
iu tr cp cu chung iu tr ti ti mu
IU TR BAN U NMCT CP
IU TR CP CU CHUNG:
Cc nguyn tc chung:
tin hnh ngay ti phng cp cu (hoc ngay trn xe cp cu nu phng tin).ICU hay CCU, t ng truyn tnh mch (kim ln: 18), theo di in tm v sinh hiu, SpO2 lin tc. Nu chn on NMCT cp ST chnh ln trc NV th khi n BV nn a vo thng phng thng tim nu bn ch nh lm can thip mch vnh cp cu (CTMVCC)
CCU
Theo di lin tc ECG, sinh hiu Theo di xm ln: HA M y cc lai thuc: chng RLNT, suy bm My sc in My th Bng di ngc MC
Ngng tim
Theo ESC 2012: Nn dng liu php h thn nhit cho bn hn m ngay sau hi sc ngng tim Nn chp MV khn nhng bn sau hi sc tim m ECG nghi NMCT ST hay LS nghi TMCT
IU TR BAN U NMCT CP
iu tr cp cu chung bao gm:
Oxy Gim au, gim lo u Cc thuc chng huyt khi:
Khng kt tp tiu cu Khng ng
Nitrate c ch bta
iu tr ban u
Nitrate:
C ch: dn tnh mch gim tin ti, dn ng mch vnh tng ti mu cho vng c tim ang thiu mu cc b.
Biological changes
Inflammation, abnormal flow dynamics, LDL oxidation, infection?, etc.
Mechanical obstruction
with
Ischemia Opening Infarction PCI or Thrombolysis Sudden death
c ch th th Glycoproteine (GP)IIb/IIIa
Triazolopyrimidine: Ticagrelor
Do tc thi gian tc dng nhanh va t b bi chuyn ha, Ticagrelor v prasugrel c a chung hn clopidogrel tr khi chng ch hay khng sn c
c ch th th Glycoproteine (GP)IIb/IIIa:
C ch: c ch s gn kt ca th th GPIIb/IIIa vi fibrinogen c ch s kt t tiu cu. Ch nh: CTMVCC trn bn c iu tr vi heparine hay bivalirudine cng vi liu php kp chng kt tp tiu cu (aspirin-thienopyridine) khi cn:
huyt khi ln bn cha c dng liu np ca thienopyridine
Khng thrombine trc tip: hirudin, bivalirudine Heparine pentasacharide tng hp (khng yu t Xa): fondaparinux
Fondaparinux: 2,5mgTM bolus sau 2,5mgTDD1l/ng (TSH hay khng ti ti mu) CC: suy thn nng
Khng ng:
Enoxaparine hoc Heparine khng phn on hoc Fondaparinux
Thuc chng huyt khi dng khi CTMV sau khi TSH: ging nh khi CTMVCC
Hiu qu: nhng bn NMCT cp c dng c ch bta sm c t l t vong, suy tim, ri lon nhp tht quan trng
IU TR TI TI MU
Tm quan trng ca thi gian ti ti mu:
Phc hi sm ti mu c tim
kch thc vng nhi mu bo tn chc nng tht tri t sut ngn hn v di hn.
IU TR TI TI MU
Tm quan trng ca thi gian ti ti mu:
TG khi pht TC thi im TTM cng lng c tim c cu vn cng (90 ph #50%, 4-6h: rt t).. TG ti u cho ti ti mu: TSH (Thi gian ca-kim): (tip xc bn bt u TSH) 30 ph CTMVCC: thi gian ca-bng ( tip xc bn bm bng u tin) 90 pht. , ti u 60 pht (bn n sm , nguy c cao)
IU TR TI TI MU
Ch nh ti ti mu:
C cn au ngc ko di >20 pht trong vng 12 gi km vi ST chnh ln >0,1mV (>1mm) t nht 2 chuyn o gn nhau. au ngc ko di trong vng 12 gi km blc nhnh tri mi xut hin.
IU TR TI TI MU
Cc phng thc iu tr ti ti mu:
CTMVCC cp cu Tiu si huyt Phu thut bc cu mch vnh
IU TR TI TI MU
CTMVCC cp cu (CTMVCC)
u im:
Ti thng mch mu vi dng chy bnh thng trong hn 95% cc trng hp NMCT cp ST chnh ln. Xc nh c cc tn thng nhng mch vnh khc nu c. nh gi chc nng co bp tht tri nh chp bung tht tri cn quang. Nguy c xut huyt t hn.
IU TR TI TI MU
CTMVCC cp cu (CTMVCC) Nhc im: Thi gian chun b lm th thut >thi gian chun b thuc tiu si huyt (TSH) Ch c th p dng c nhng trung tm c phng thng tim v nhn s c hun luyn tt
IU TR TI TI MU
CTMVCC cp cu (CTMVCC) Ch nh: Mi bn b NMCT ST vi iu kin thi gian ca-bng < 120 ph v ti phng thng tim c kinh nghm. Bn nv t 12-24 gi k t lc khi pht TC: vn cn triu chng TMCT tip din suy tim nng RL huyt ng hc hay in hc quan trng
Tiu si huyt
Khi CTMVCC khng thc hin c trong thi gian khuyn co. Li ch:
gim 30 ca t vong sm/1000 bn (gi dc) nu TSH 6 h sau khi pht TC C li ngay c /bn >75 t c TC km ST chnh ln hay Blc nhnh tri mi xut hin
IU TR TI TI MU Tiu si huyt
u im: c th s dng mi c s v s dng sm cho bn. Nhc im:
Nguy c XH nng khang 10%, trong xut huyt no: 0,7-0,9% Ch phc hi dng chy bnh thng mch mu th phm trong 30-60% trng hp trong vng 90 pht ty theo loi thuc. 10-20% bn s tc li sau ti ti mu thnh cng trong vng 24gi
IU TR TI TI MU Tiu si huyt
Ch nh TSH: khng c CC NMCT ST nv<12h+thi gian ca- bng >120ph hay khng c phng thng tim c kinh nghim au ngc ko di+bloc nhnh tri mi xut hin nv<12h+thi gian ca- bng >120ph hay khng c phng thng tim c kinh nghim Bn nv sm( au ngc <2h), NMCT rng v nguy c chy mu thp, nn TSH nu thi gian- ca bng>90 ph
Chng ch nh tuyt i
Tin s xut huyt ni s Nhi mu no trong vng 6 thng (tr mi Nm no trong vng 3 gi) D dng mch mu no hay khi u c tnh ni so nguyn pht hay di cn Chn thng s no hay phu thut u<3 tun XHTH < 1thng Ri lon ng mu Nghi bc tch ng mch ch Mi chch m khng p c <24 gi (sinh thit gan, chc d ty sng)
Chng ch nh tng i
Cn thong thiu mu no <6 thng ang iu tr bng khng ng ng ung C thai hay mi sanh <1 tun Tng huyt p nng khng kim sot c lc nhp vin (>180/110mmHg) Bnh gan tin trin Vim ni tm mc nhim trng Chng mt tr Bt k bnh l ni s no m khng phi l chng ch nh tuyt i Xut huyt ni trong vng 2-4 tun Lot d dy t trng ang hot ng i vi Streptokinase/anistreplase: c tip xc trc (c bit l trong vng 5 ngy-2 nm) hoc c phn ng d ng trc
Chng ch nh TSH
IU TR TI TI MU Tiu si huyt
La chn thuc TSH:
Ty thuc:
hiu qu, t l bin chng s sn c v gi thnh. Alteplase t gp 8-10l > streptokinase, Alteplase hiu qu > streptokinase 1% Alteplase tai bin XH no >streptokinase 0,3%.
IU TR TI TI MU Tiu si huyt
nh gi hiu qu ca thuc TSH:
triu chng au ngc
gim chnh ST >50% sau khi bt u dng TSH 60-90 pht.
ri lon nhp sau dng TSH khng l du hiu ng tin cy cho s ti thng.
Nhng bn TSH tht bi (cn au ngc v ST vn cn chnh cao sau 90 pht) chp mch vnh khn v CTMVCC cu vn.
Liu TSH
Phu thut bc cu MV
t dng trong cp cu Ch nh:
Khng tr hay chong tim m gii phu hc ca mch vnh khng thch hp cho k thut can thip hay can thip tht bi. C bin chng c hc: h van hai l cp, thng vch lin tht, v tim, phnh vch tht
Nn ngng khng th th P2Y12 tiu cu (clopidigrel: 5 ngy, prasugrel: 7ngy, ticagrelor: 3-5 ngy)
khi u liu thp (trnh tt HA) v tng dn. Khng nn dng ng TM (nguy c tt HA)
Valsartan
eplerenone
25mg
50mg/ngy
iu tr thng thng lu di
Thuc chng huyt khi: (ESC 2012)
Aspirine 75-100mg/ngy, sut i
Khng dng np Aspirine: Clopidogrel 75mg/ng
c ch th th P2 Y12
Dng km vi Aspirine CTMVCC: prasugrel, ticagrelor, clopidogrel stent ph thuc: ti thiu 6 thng12 thng Stent thng: ti thiu 1 thng12 thng Tiu si huyt: ch dng clopidogrel, c th 12 thng (d liu chc chn 1 thng) Khng ti ti mu: ch dng clopidogrel, ti thiu 1 thng12 thng Tin s XHTH: c th dng km c ch bm proton
Tng huyt p: kim sot tt HA vi mc tiu Ha tm thu <140mm Hg nhng>110mmHg bng nhng bin php khng dng thuc v thuc
nh gi nguy c v hnh nh hc
Mc tiu: xc nh nhng bn c nguy c cao b NMCT ti pht hay t vong Siu m tim trc xut vin: kch thc vng NM, chc nng tht tri khi ngh Cc yu t tin lng nng khc: ln tui, nhp tim nhanh, Killip>I, NMCT cp thnh trc,tin s b NMCT, suy tim trc , tng creatinine /mu, lon nhp tht c tnh, au ngc ko di hay xut hin li khi gng sc nh
nh gi nguy c v hnh nh hc
Nu nghi ng cn TMCT: lm sau 4-6 tun
Nghim php gng sc: r tin nhng chnh xc km Xt nghim gng sc bng hnh nh hc:
chnh xc hn v nh v vng TMCT X hnh hay siu m tim gng sc
Nu lo ngi v BC lon nhp: c th thm d in sinh l v lp li SAT sau xut vin xt kh nng cy my ph rung
nh gi sng cn c tim s gip quyt nh CTMV thm sau NMCT Phng tin: PET, SPECT, ( nhy cao nhng tn km),siu m tim vi dobutamine (d lm VN do gi thnh r)
Kt lun
NMCT cp ST l c/c ni khoa quan trng Thi gian ti ti mu l quan trng nht Ty iu kin m la chn pp ti ti mu tt nht Cc bin php iu tr chung cn bn l nn tng cho iu tr ti ti mu v iu tr NMCT cp thnh cng