Dc l hc 2007 - i hc Y H ni

sch dng cho sinh vin h bc s a khoa

Bi 24: Thuc iu tr tng huyt p
Mc tiu hc tp: Sau khi hc xong bi ny, sinh vin c kh nng:
1. Phn loi c cc thuc h huyt p
2. Trnh by c c ch tc dng v p dng iu tr ca cc thuc chn knh calci:
nifedipin v verapamil.
1. Trnh by c c ch tc dng v p dng iu tr ca nhm thuc c ch enzym
chuyn dng angiotesin.
1. Huyt p v bnh tng huyt p
1.1. Huyt p
Huyt p
T iu ho
Huyt p = cung lng tim sc cn mch ngoi vi
Th tch Tn s d lng mch
tm thu
Tng HA
| tin gnh co tht Ph i thnh mch
cng g/c
V mu tng stress
Tng nhp Thn gi | Renin
Na
+
Na
+
angiotensin
Vai tr ca thn trong kim tra th tch tun hon:
Khi p lc ti mu cho thn b gim, s c s phn phi li mu trong thn, km theo
lm gim p lc mao mch thn v hot tnh giao cm (thng qua receptor ) dn n
sn xut renin t tng sn xut angiotensin, gy ra:
- Co mch
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
- Kch thch sn xut aldosteron lm gi Na
+
v nc
Tng huyt p thng c chia thnh hai loi:
- Tng huyt p th pht: khi huyt p tng ch l mt triu chng ca nhng tn thng
mt c quan nh: thn, ni t it, tim mch, no... iu tr nguyn nhn, huyt p s tr li
bnh thng.
- Tng huyt p nguyn pht: khi nguyn nhn cha r, lc c gi l bnh tng
huyt p.
C ch bnh sinh ca tng huyt p rt phc tp. Huyt p ph thuc vo lu lng ca
tim v sc cn ngoi vi. Hai yu t ny li ph thuc vo hng lot cc yu t khc, nh
hot ng ca h thn kinh trung ng v thn kinh thc vt, ca v v tu thng thn,
ca hormon chng bi niu (ADH), ca h renin - angiotensin - aldosteron, ca t nh trng
c tim, tnh trng thnh mao mch, khi lng mu, thng bng mui v th dch v.v...
Mt yu t quan trng trong tng huyt p l lng cc ng mch nh v mao mch thu
hp li. Phn ln khng tm c nguyn nhn tin pht ca tng huyt p, v vy phi
dng thuc tc ng ln tt c cc khu ca c ch iu ha huyt p lm gin mch,
gim lu lng tim dn n h huyt p (xem hnh). Tt c u l thuc cha triu chng
v nhiu thuc c trnh by trong cc phn c lin quan (xem bng b).
Bng 24.1: Phn loi cc thuc h huyt p theo v tr hoc c ch tc dng
1. Thuc li niu: lm gim th tch tun hon
- Nhm thiazid
- Thuc li niu quai
2. Thuc hu giao cm
- Tc dng trung ng: methyldopa, clonidin
- Thuc lit hch: trimethaphan
- Thuc phong to nron: guanethidin, reserpin
- Thuc chn : propranolol, metoprolol
- Thuc hu o: prazosin, phenoxybenzamin
3. Thuc gin mch trc tip
- Gin ng mch hydralazin, minoxidil, diazoxid
- Gin ng mch v tnh mch: nitroprussid
4. Thuc chn knh calci
Nifedipin, felodipin, nicardipin, amlodipin.
5. Thuc c ch enzym chuyn angiotensin
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
Captopril, enalapril, ramipril.
6. Thuc i khng ti receptor angiotesin II
Losartan, Irbesartan
2. Thuc chn knh calci
2.1. Khi nim v knh calci
Nng Ca ngoi t bo 10.000 ln hn trong t bo (10
-3
M so vi 10
-7
M) v khi ngh
mng t bo hu nh khng thm vi Ca, ng thi c bm Ca cng vi s trao i Na
+
-
Ca
++
y Ca
++
ra khi t bo.
Ca vo t bo bng 3 ng (knh):
2.1.1. Knh hot ng theo in p (voltage operated chanel -VOC hoc cn gi l POC:
potential operated channel): hot ng theo c ch tt c hoc khng c g (hoc
hon ton m hoc hon ton khp kn) gy ra do s kh cc mng (t -90mV ln -
40mV). Thuc h knh loi ny cn c c knh Na
+
, K
+
. Tu vo s dn (conductance) v
s cm th (sensitive) vi in th, knh VOC cn c chia thnh 4 loi knh:
- Knh L (long acting): c nhiu trong c tim v c trn thnh mch
- Knh T (transient): c trong cc tuyn tit
- Knh N (neuron): c trong cc nron
- Knh P (purkinje): c trong purkinje tiu no v nron.
Knh T, N v P t cm thu vi thuc chn knh Ca.
2.1.2. Knh hot ng theo receptor (receptor operated channel -ROC): p ng vi cc
cht ch vn.
2.1.3. Knh d :
Tri vi 2 knh trn, knh ny lun c m cho qua lung Ca nh, nhng lin tc.
Ca t bo hoc vo li bo tng v t li bo tng ra, lm cho nng Ca trong bo
tng t 10
-7
M (nng gin c) tng ln 10
-5
M (nng co c), s kt hp c vi
calci protein (troponin/calmodulin-CaM) v gy ra nhiu tc dng sinh l.
2.2. Vai tr sinh l ca Ca trn tim mch
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
10
-3
M Ca
++
VOC
S.R
Dn truyn nh tht Ca
++
10
-7
M 10
-5
M
Troponin Calmodulin
Tnh t ng tim nhp bo/ xut bo
Prot. Co bp Proteinkinase
enzyme gii phng TGHH
Co bp tim Ch.ha co c trn thnh mch
VOC: knh hot ng theo in p
SR: li bo tng
Hnh 24.1: Vai tr ca Ca
++
sau khi qua knh
Trn c tim, Ca
++
gn vo troponin, lm mt tc dng c ch ca troponin trn chc nng
co bp, do cc si actin c th tng tc vi myosin, gy co c tim. Trn c trn thnh
mch, khi calci ni bo tng s to phc vi calmodulin, phc hp ny s hot ha cc
protein-kinase (phosphoryl ha myosin kinase chui nh), thc y s tng tc gia
actin v myosin, gy co c trn thnh mch (Hnh 24.1)
Sau khi tc ng, nng Ca
2+
ni bo s gim do Ca
2+
c bm li vo ti li ni bo
hoc y ra khi t bo do bm v do trao i vi Na
+
.
S trao i Na
+
/Ca
2+
c th thc hin c hai chiu: Na
+
vo Ca
2+
ra, hoc Na
+
ra Ca
2+
vo.
Trong iu kin sinh l bnh thng Na
+
vo v Ca
2+
ra, ngha l s trao i ny c vai
tr chnh trong vic gi nng Ca
2+
thp trong t bo. Khi c tr Na
+
trong t bo (th
d digitalis phong ta bm Na
+
) th hot ng theo chiu ngc li: Ca
2+
vo t bo
trao i vi Na
+
i ra, gy tc dng tng co bp tim.
Khc vi knh Na
+
, knh calci chu nh hng rt mnh ca cc yu t ngoi lai (trung
gian ha hc, hormon) v cc yu t ni ti (pH, ATP). Ni chung, cc knh Ca ch hot
ng khi trc c phosphoryl ha. S phosphoryl ha ph thuc vo hot tnh ca
adenylcyclase.
2.2. Cc thuc chn knh calci
Fleckenstein (1964) ln u tin a ra khi nim chn knh calci khi m t tc dng ca
verapamil trn t bo c tim, l thuc c tng hp phng theo cng thc cu to ca
papaverin. Cc thuc thuc nhm ny gn c hiu trn knh v phong ta knh, tuy cu
trc ha hc rt khc nhau.
2.2.1. Phn loi
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
Theo cu trc ha hc v c im iu tr, c 3 nhm thng thng.
Sau li chia thnh th h: th h 1 l thuc chn knh Ca mng t bo v mng ti
li ni bo; th h 2 tc dng nh th h 1 nhng chn lc trn t bo c trn thnh
mch hoc tim hn. Tc dng ko di.
Bng 24.2: Cc thuc chn knh calci
Nhm ha hc Tc dng c hiu Th h 1 Th h 2
Dihydropyridin ng mch > tim Nifedipin
Felodipin
Nicardipin
Nimodipin
Amlodipin
Benzothiazepin ng mch = tim Diltiazem Clentiazem
Phenyl alkyl amin Tim > ng mch Verapamil Gallopamid
Anipamil
Thuc c tc dng trn ng mch mnh hn trn tim do lm gin mch nhanh v mnh,
d gy h huyt p nhanh, dn n phn x lm tn g nhp tim, khng li, nht l trn c
tim b thiu mu. Verapamil do c tc dng c ch trn tim mch hn trn ng mch
nn thng c ch nh trong lon nhp tim (xin xem thm bi Thuc cha lon nhp
tim).
2.2.2. Dc ng hc
Cc thuc chn knh calci tc dng theo ng ung v chu s chuyn ha qua gan ln
th 1, v vy ngi ta nghin cu thay i cc nhm chc trong cng thc cu to, lm
cho thuc chm b chuyn ha, chm b thi tr hoc n nh hn, c tnh chn lc hn.
Do to ra cc thuc th h 2, 3.
Bng 24.3: Dc ng hc mt s thuc chn knh calci
Thuc Hp thu
(ung)
Khi pht tc
dng
t/2
(gi)
Phn phi
Nifedipin 45- 70% - tm: < 1 pht
- Ngm, ung
5- 20 pht
4 - Gn protein huyt tng90%
- B chuyn ha, thi qua thn
Nicardipin 35% ung: 20 pht 2- 4 - Gn protein huyt tng 95%
- B chuyn ha, thi qua gan
Felodipin 15- 20% ung: 2- 5 h 11- 16 - Gn protein huyt tng >
99%
- B chuyn ha nhanh gan
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
Nimodipin 13% cha c ti liu 1- 2 - B chuyn ha nhiu
- Lm gin mch no mnh
Nisoldipin < 10% - 2- 6 - B chuyn ha nhiu
- Lm gin mch vnh mnh
Amlodipin 65- 90% - 30- 50 - Gn protein huyt tng
>90%
- B chuyn ha nhiu
Bepridil 60% Ung: 1 h 24- 40 - Gn protein huyt tng >
99%
- B chuyn ha nhiu
Diltiazem 40- 65% - Tim tnh
mch < 3 pht
- Ung:>30 pht
3- 4 - Gn protein huyt tng
70-80%
- B chuyn ha, thi qua phn
Verapamil 20- 35% - Tim tnh
mch: < 1,5pht
- Ung: 30 pht
6 - Gn protein huyt tng 90%
- Thi qua thn 70%
- Thi qua rut 15%
2.2.3. C ch tc dng
Cc thuc chn knh Ca gn ch yu vo knh L, l knh c nhiu t bo c tim v c
trn thnh mch. Nifedipin v cc thuc nhm dihydropyridin (DHP) gn vo mt v tr
mt trong knh, trong khi verapamil v diltiazem gn vo tr tr khc. Knh L c nhiu
di n v o
2
, , v o. DHP gn ch yu vo o. Ngoi ra, DHP c th cn c ch
nucleotid phosphodiesterase vng nn lm tng nucleotid vng, gy gin c trn: thuc
cng phong ta knh hot ng theo receptor, nhng mc km hn.
Knh T v N rt km nhy cm vi thuc nn nron v cc tuyn tit t chu nh hng
ca cc thuc ny.
2.2.4. Cc tc dng trn c quan
2.2.4.1. Trn c trn
Lm gin cc loi c trn: kh - ph qun, tiu ha, t cung, nhng c bit l thnh mch
(mao ng mch nhy cm hn mao tnh mch).
2.2.4.2. Trn c tim
Hot ng ca tim ph thuc nhiu vo dng Ca (xem in sinh l ca tim). Thuc chn
knh Ca lm gim to xung tc, gim dn truyn v gim co bp c tim, v th lm gim
nhu cu oxy trn bnh nhn c co tht mch vnh. Mc tc dng gia cc thuc c
khc nhau.
2.2.4.3. Mch no
Nimodipin c i lc cao vi mch no, v vy c dng cho bnh nhn c tai bin mch
no (chy mu di mng nhn gy co mch do chn p; t qu c vim tc mch).
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
Nhng cn cha r kt qu iu tr l do gin mch no hay l do lm gim nhu cu oxy
ca nron.
2.2.5. Tc dng khng mong mun v c tnh
- Tc dng nh, khng cn ngng iu tr: cn nng bng, nhc u, chng m t (do phn
x gin mch, tng nhp tim nn dng cng vi thuc chn giao cm), bun nn, to.
- Tc dng nng hn, lin quan n tc dng iu tr do c ch qu mnh knh Ca: tim
p chm, nghn nh tht, suy tim xung huyt, ngng tim. Him gp.
2.2.6. p dng lm sng trong iu tr THA
- Do lm gim lc co bp c tim, gim nhu cu oxy ca c tim, gim trng lc v sc
cn mch ngoi bin nn cc thuc ny c dng iu tr THA. Cho ti nay, cc
thuc chn knh calci c coi l thuc iu tr THA an ton v c hiu qu. Verpamil,
nifedipin, nicardipin v diltiazem u c hiu qu h p nh nhau. Tuy nhin, do c s
khc nhau v hiu qu huyt ng hc nn vic chn la iu tr c khc nhau:
Nifedipin c tc dng chn lc nht trn mch v tc dng c ch tim li yu nht. Phn
x giao cm hi lm tng nhp tim v lm tng hiu sut tim.
Verapamin c tc dng trn tim mnh nht, lm gim nhp tim v gim hiu sut tim.
Diltiazem c tc dng trung gian
- Ngn cn co tht mch vnh khu tr, c ch ch nh ca cn au tht ngc
- Verapamil, diltiazem lm gim dn truyn nh tht, c ch nh trong nhp tim nhanh
trn tht do ti nhp (xin xem bi Thuc chng lon nhp tim).
2.2.7. Ch phm
- Amlodipin: vin nn 2,5- 5- 10 mg
- Diltiazem: vin nn 30- 60- 90- 120 mg
Vin nang gii phng chm: 60- 90- 120- 180 mg
Thuc tim 5 mg/ mL
- Felodipin (Plendil): vin gii phng chm 2,5 - 5- 10 mg
- Nifedipin (Adalat): vin nang 10- 20 mg
Vin gii phng chm 30- 60- 90 mg
- Nimodipin (Nimotop): vin nang 30 mg
- Verapamil: vin nn 40- 80- 120 mg
Vin gii phng chm 120- 180- 200 mg
Thuc tim 5 mg/ 2mL
3. Thuc c ch enzym chuyn angiotensin (ECA)
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
Enzym chuyn angiotensin (ECA) hay bradykinase II l mt peptidase c tc dng:
- Chuyn angiotensin I (decapeptid khng c hot tnh) thnh angiotensin II (octapepetid
c hot tnh) l cht c tc dng co mch v chng thi tr Na
+
qua thn.
- Lm mt hot tnh ca bradykinin, l cht gy gin mch v tng thi Na
+
qua thn.
Sau khi c hnh thnh, angiotensin II s tc ng trn cc receptor ring, hin c bit
l AT
1
, AT
2
, AT
3
, AT
4
, trong ch c AT
1
l c bit r nht (s ).
Hnh 24.2: Tc dng ca ECA v thuc c ch ECA
Cc receptor AT
1
c nhiu mch mu, no, tim, thn, tuyn thng thn. Vai tr sinh l :
co mch, tng gi Na
+
, c ch tit renin, tng gii phng aldosteron, kch thch giao cm,
tng co bp c tim v ph i tht tri.
Cc receptor AT
2
c nhiu tuyn thng thn, tim, no, c t cung, m bo thai. Vai tr
sinh l: c ch s tng trng t bo, bit ha t bo, sa cha m, kch hot
prostaglandin, bradykinin v NO thn.
3.1. C ch v c im tc dng
Cc thuc do c ch ECA nn lm angiotensin I khng chuyn thnh angiotensin II c
hot tnh v ngn cn ging ha bradykin, kt qu l lm gin mch, tng thi Na
+
v h
huyt p.
Trong iu tr tng huyt p, cc thuc ny c cc c im sau:
- Lm gim sc cn ngoi bin nhng khng lm tng nhp tim do c ch trng lc giao
cm v tng trng lc ph giao cm.
- Khng gy tt huyt p th ng, dng c cho mi la tui.
- Tc dng h huyt p t t, m du, ko di.
- Lm gim c huyt p tm thu v tm trng.
- Lm gim thiu mu c tim do tng cung cp mu cho mch vnh.
- Lm chm dy tht tri, gim hu qu ca tng huyt p.
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
- Trn thn kinh trung ng: khng gy trm cm, khng gy ri lon gic ng v khng
gy suy gim tnh dc.
3.2. Ch nh
- Thuc c tc dng iu tr tt cho mi loi tng huyt p:
. Trn ngi c tui, h huyt p khng nh hng n tun hon no v kh ng nh
hng n phn x p lc.
. Trn ngi c i tho ng: khng nh hng n chuyn ha glucid, lipid. Mt khc,
insulin lm K
+
vo t bo, gy h K
+
mu; thuc c ch ECA lm gim aldosteron nn gi
li K
+
.
. Trn ngi c bnh thn, do angiotens in II gim, lm lu lng mu qua thn tng nn
lm gim bi tit
- Suy tim sung huyt sau nhi mu c tim.
3.3. Tc dng khng mong mun
- H huyt p mnh c th xy ra khi dng liu u trn nhng bnh nhn c th tch mu
thp do ang s dng thuc li niu, ch n gim mui hoc mt nc qua tiu ha.
- Suy thn cp nht l trn bnh nhn c hp mch thn.
- Tng Kali mu khi c suy thn hoc i tho ng.
- Ho khan v ph mch l do bradykinin khng b ging ha, prostaglandin tch lu
phi gy ho (nhiu khi lm bnh nhn phi b thuc).
- Khng dng cho ph n c thai 3 - 6 thng cui v thuc c th gy h huyt p, v
niu, suy thn cho thai, hoc gy qui thai, thai cht.
3.4. Phn loi v dc ng hc
3.4.1. Thuc c ch ECA
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
Thuc
Cc thng s
Captopril Enalapril Perindopril Benezepril Lisinopril
Sinh kh dng % 70 40 70 17 25
Gn protein huyt
tng %
30 50 9- 18 95 3- 10
t/2 (h) 2 11 9 11 12
Khi pht tc dng
(h)
0,25 2- 4 1- 2 0,5 1- 2
Thi gian tc dng
(h)
4- 8 24 24 24 24
Liu ung 24h (mg) 75- 300 5- 20 2- 8 5- 20 5- 20
Enalapril, perindopril, benezepril u l tin thuc, vo c th phi c gan chuyn
ha mi c tc dng.
3.4.2. Thuc c ch ti receptor ca angiotensin II
Do vic chuyn angiotensin I thnh II cn c s tham gia ca cc enzym khc (nh
chymase) khng chu tc ng ca thuc c ch ECA nn s to thnh angiotensin II vn
cn. Mt khc, do thuc c ch ECA ngn cn s ging ha ca bradykinin nn
bradykinin phi tng, kch ng gy cn ho khan rt kh tr. V vy kch thch vic
nghin cu cc thuc c ch angiotensin II ngay ti receptor ca n: thuc c ch AT
1
.
Cc thuc ny cn ang c nghin cu, nh gi trn cc th nghim lm sng. V
nguyn tc, do c tc dng chn lc trn AT
1
nn trnh c tc dng ph ca bradykinin
(ho, ph mch).
Bng 24.4: Mt s c im dc ng hc ca cc thuc c ch AT
1
Thuc
Cc thng s
Losartan Valsartan Irbesartan Telmisartan
i lc gn vo AT
1
+ +++ ++++ +++
Sinh kh dng 33 25 70 43
t/2 (h) 2 (6- 9)* 9 11- 15 24
Thi tr Thn v gan Gan 70%; thn
30%
Gan 80%, thn
20%
Gan
Liu ung (mg/ 24 h) 50- 100 80- 320 150- 300 40- 80
* t/2 ca loscartan l 2 gi, nhng ca cht chuyn ha cn hot tnh l 6-9 gi.
4. Cc thuc h huyt p khc
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
4.1. Clonidin (2,6 diclorophenyl - amino - 2 imidazolin - catapres)
L thuc kch thch receptor o
2
ca h giao cm trung ng nn lm gim trng lc giao
cm ngoi bin.
4.1.1. Tc dng
- Lm h huyt p do:
. Lm gim cng nng tim, gim nhp tim
. Lm gim sc cn ngoi bin, nht l khi trng lc giao cm tng.
. Lm gim sc cn mch thn, duy tr dng mu ti thn.
. Nh methyl dopa, clonidin rt t khi gy tt huyt p th ng.
- Cc tc dng khng lin quan n h huyt p:
. An thn (do hu giao cm trung ng?) khong 50% trng hp.
. Kh ming do c ch trung ng: khong 50% trng hp.
. Gim au do gim hot tnh nron sng sau tu sng.
Nhng tc dng ny l do thuc gn vo receptor imidazolin c trong thn kinh trung
ng.
4.1.2. Dc ng hc
Thuc tan nhiu trong m, vo thn kinh trung ng nhanh. Ung hp thu tt, sinh kh
dng ti 100%, t c pic huyt tng sau 1 -3gi, t/2 khong 12gi. Thi tr qua thn
50% di dng nguyn cht.
4.1.3. Ch nh
- Tng huyt p
- Tin m: do c tc dng an thn, gim au nn lm gim c lng thuc m v tng
n nh huyt ng.
- Cai nghin: ma tu, ru, thuc l.
4.1.4. c tnh
- Kh ming, an thn: l tc dng trung ng, lin quan n liu dng.
- Ngng thuc sau dng lu v liu cao (>1mg/ngy) c th gp cn tng huyt p kch
pht do tng trng lc giao cm: bun nn, tim nhp nhanh, nhc u, v m hi.
Cn gim liu dn v dng thuc thay th. iu tr nn tng huyt p ny bng dng li
clonidin v dng cc thuc chn o, chn giao cm.
4.1.5. Ch phm v liu lng
Clonidin (Catapres)
Vin nn: 0,1 - 0,2 - 0,3mg
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
Ung 0,2 -1,2 mg/ngy, chia lm 2 ln
Cao dn: Gii phng 0,1 - 0,2 - 0,3mg/24gi. C tc dng 7 ngy cho 1 ln dn. C th c
phn ng ti ch dn.
4.2. Natri nitroprussid
L thuc gin mch mnh dng theo ng tim iu tr cp cu cn tng huyt p v
suy tim nng. Lm gin c ng mch v tnh mch. C ch: hot ho guanyl cyclase do
tc dng kch thch trc tip hoc th ng qua gii phng NO, dn n lm tng GMPv, gy
gin c trn.
Nitroprussid l mt phc hp ca st,
cc nhm cyanid v phn nitroso. c
tnh nng nht lin quan n s tch lu
cyanid; ngoi ra cn gp nhim acid,
lon nhp, tt huyt p.
Hydroxocobalamin (vitamin B
12
) kt
hp vi cyanid to cyanocobalamin
khng c, do c dng gii
c nitroprussid.
CN
CN
|
2Na NC Fe CN
|
ON CN
Natrinitroprussid c ch nh trong cn tng huyt p, suy tim sung huyt (do lm gim
c tin gnh v hu gnh) v lm gim nhu cu oxy ca c tim sau nhi mu c tim.
Trong ngoi khoa cn dng lm h huyt p c kim tra khi gy m lm gim chy
mu do phu thut.
Nitroprussid (Nipride): l 50mg. Khi dng pha trong dextrose 5% - 250 - 1000 ml, truyn
tnh mch 0,5 ug/kg/pht, c th tng ti 10 ug/kg/pht. Chai thuc phi bc trong giy
mu, trnh nh sng. Kim tra huyt p thng xuyn.
5. Chin thut iu tr tng huyt p v cn
V THA v cn mang tnh cht rt a dng nn vic iu tr cng cn c th ha va
c hiu qu, va c th dung np c.
5.1. Ai cn c iu tr
- Mi ngi khi c HA 140- 90 mmHg
- Khi c tn thng c quan ch hoc c i tho ng, mc du HA cn gii hn
trn (130-139/85-89 mmHg).
Mc tiu iu tr l a HA v chun < 140/99mmHg, nhng khng n gin, M ch
27% bnh nhn THA t c ch t iu ny.
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
5.2. Cch iu tr
5.2.1. Phng php khng dng thuc
- n gim mui, gim ru, gim cn (bo)...
- Th dc u, nh nhng
5.2.2. Thuc
Cn c th ha, vi th cn iu tr th
- Lc u dng li niu, chn , chn knh calci v thm ch c cc t huc khc (chn o
1
c ch ECA).
iu cn tu thuc vo bnh km theo: thuc c ch ECA khi c i tho ng; chn
khi c bnh mch vnh; chn knh Ca (loi dihydropyrindin) khi c THA tm thu ring
bit ngi cao tui. Lc u nn chn mt loi thu c.
- Khi mt thuc khng cho kt qu mong mun:
Khng nn tng liu v s c tc dng ph: thuc li niu (ri lon chuyn ha), chn
(tc dng trung ng, chm nhp tim), chn knh Ca (ph, nh trng ngc, nhc u,
nng mt), chn o
1
(h HA th ng).
Thay thuc khc
Phi hp thuc c c ch khc nhau
Mt thuc h HA c th gy phn ng b tr, lm gim tc dng ca chnh n. Dng
thuc phi hp ngn chn phn ng b tr. Th d thuc li niu lm thi Na, gy tng
renin (dng thm thuc c ch ECA); thuc chn knh Ca gy tng nhp tim phn x
(dng chn ).
Hin c vin thuc phi hp sn. Tin dng nhng khng hay v khng c th ha
c.
Trong nhng nm gn y, vic iu tr THA tr nn n gin hn trc rt nhiu nh
c nhiu loi thuc hiu qu. Vn l phi c th ha trong iu tr mi bnh nhn c
th tm c cho mnh mt thuc thch hp va c hiu qu, va dung np tt.
5.3. Tiu chun thuc h huyt p l tng
- C tc dng h huyt p tt
. H HA t t, m du, ko di
. Gim c s ti a v s ti thiu
. Gim c ngi tr v ngi cao tui
. Lm mt nh tng huyt p trong ngy
- Khng lm mch nhanh do khng lm tng cng c tim v tng nhu cu oxy.
- Khng lm mch chm, trnh c nghn nh - tht
Dc l hc 2007 - i hc Y H ni
sch dng cho sinh vin h bc s a khoa
- Khng lm gim sc co bp ca c tim, nht l tht tri
- Dng c cho nhiu i tng: suy thn, tiu ng, tng lipid mu
- Khi ngng thuc, khng c nguy c "phn hi".
cu hi t lng gi
1. Phn loi cc thuc iu tr tng huyt p theo c ch tc dng ca th uc
2. Trnh by c ch tc dng v phn loi cc thuc chn knh calci.
3. Trnh by cc tc dng iu tr v tc dng khng mong mun ca thuc chn
knh calci.
4. Trnh by c ch tc dng ca thuc c ch enzym chuyn angiotensin (ECA).
5. Nu c im tc dng v ch nh iu tr ca ECA.
6. So snh u- nhc im ca thuc chn knh calci v ECA trong iu tr tng
huyt p.