B MN TIM MCH

TRNG I HC Y H NI

Chn on v iu
tr suy tim
PHAN NH PHONG
phong.vtm@gmail.com

Mc tiu hc tp
1. Triu chng suy tim tri
2. Triu chng suy tim phi
3. Cc nhm thuc chnh iu tr suy
tim

nh ngha
Suy tim l tnh trng bnh l trong
cung lng tim khng p ng nhu cu
ca c th v mt xy trong mi tnh
hung sinh hot ca bnh nhn

Suy tim s lm mt dn cc hot ng

hng ngy ca bnh nhn

nh ngha
- Suy tim l mt hi chng lm sng, l
hu qu ca s ri lon chc nng
y v tng mu ca tm tht.
- Suy tim l hu qu ca tt c cc bnh
l thc tn v chc nng nh hng
n hot ng ca tim.
- Chn on suy tim ch yu da vo
khai thc tin s bnh v khm lm
sng.
ACCF/AHA Heart Failure Guideline 2013

Dch t hc suy tim

(t l mc % qua 34 nm theo di
cu framingham - usa)

nghin

T l mc suy tim theo tui

v gii
(Hoa K: 1988-94)

Sources: NHANES III (1988-94), CDC/NCHS and the American Heart Association

Dch t hc suy tim

(tI HOA K hin nay)

- 5,1 triu ngi ang b suy tim (330

triu dn).
- Mi nm c thm 650.000 ca mi
mc suy tim.
- i vi mt ngi M trn 40 tui,
nguy c mc suy tim trong thi gian
cn li ca cuc i l 20%.
ACCF/AHA Heart Failure Guideline 2013

Sinh l bnh
Cc yu t nh hng n cung lng tim
Tin gnh
c nh gi bng V/P cui TTr ca tht
Ph thuc: lng mu TM v tht, gin ca tht
Sc co bp ca tim (lut Starling)
P/V cui TTr trong tm thtco bp c tim, V nht
bp .
Nhng khi suy tim ti mt mc no , th d P/V cui
TTr ca tht tip tc nhng V nht bp s khng t
ng ng, thm ch cn

Sinh l bnh
Hu gnh
HG l sc cn ca cc M i vi s co bp ca tim.
Sc cn cao th sc co bp ca tm tht phi ln. Sc
cn tng cao lm tng cng v tiu th oxy ca tim dn
dn lm gim sc co bp ca c tim v gim lu lng tim.
Tn s tim
Trong suy tim, lc u TS tim tng b vo tnh trng

gim V nht bp, qua duy tr cung lng tim.

Nhng nu TS tim tng qu nhiu th nhu cu oxy ca tim
tng, cng ca tim tng lm tim suy nhanh.

Cc yu t nh hng n
cung lng tim
Sc co bp c tim
Hu gnh

Tin gnh

Th tch
nht bp
S co bp ng b
S ton vn c tht
S ton vn cc van tim

Tn s tim
Cung lng tim

Sinh l bnh
Cc c ch b tr trong suy tim
C ch b tr ti tim
Gin tm tht: thch ng vi p lc cui TTr
ca tht -> ko di cc si c tim -> sc co
bp ca cc si c tim nu d tr co c vn
cn (Starling)
Ph i tm tht: hu gnh -> V tng
mu -> b dy thnh tim (Laplace)

Sinh l bnh
Cc c ch b tr trong suy tim
C ch b tr ngoi tim
H TK giao cm b k.thch, Catecholamin -> co bp c tim v

TS tim; co mch ngoi vi da, thn, c, cc tng trong bng...

H Renin-Angiotensin-Aldosterol: Do cng giao cm v gim ti

mu thn (do co mch) Renin Angiotensin II
H Arginin-Vasopressin: giai on stim mun hn, vng di i
tuyn yn b kthch s tit ra Arginin-Vasopressin t/d comch,
v ti hp thu nc ng thn.
Bradikinin, Prostaglandin (PGI2, PGE2) v yu t tng thi natri
ngun gc tm nh (ANP) cng c huy ng song hiu qu th
ng khng nhiu.

Sinh l bnh
Hu qu ca suy tim
Gim cung lng tim
Gim vn chuyn oxy trong mu, gim cung cp oxy cho t chc.
Lu lng mu gim da, c, thn v 1 s tng khc u tin mu
cho no v ng mch vnh.
Cung lng tim thp lu lng lc ca thn thp

Tng p lc tnh mch ngoi vi

Suy tim phi: Tng P cui TTr tht phi nh phi P cc TM

ngoi viTM c ni, gan to, ph, tm ti...

Suy tim tri: Tng P cui TTr tht tri nh triP TM phi v mao
mch phi. Mu phi th tch kh cc ph nang, trao
i oxy phi kh th, ph phi.

Phn loi
Theo nh khu: ST phi, ST tri, ST
ton b
Tnh trng tin trin: ST cp, ST mn
Lu lng tim: ST gim lu lng, ST tng lu
lng
Suy tim tm thu v suy tim tm tr
ng

Triu chng suy tim

Triu chng suy tim tri

PHI

NG
MCH

Triu chng suy tim tri

Triu chng c nng
Kh th: kh th khi gng sc kh
th thng xuyn, phi ngi th,
c cn hen tim hay ph phi cp
Ho khan/ c m ln t mu, ho v
m hoc khi BN gng sc

Triu chng suy tim tri

Triu chng thc th ngoi bin
Ran m ri rc hai y phi.
Hen tim: ran rt, ran ngy.
Ph phi: ran m to v nh ht dng nhanh t hai y
phi ln khp 2 ph trng nh nc thu triu dng

HA ti a , HA ti thiu nn HA chnh.
Mch nhanh nh, ngoi tm thu nhp i
Trn dch mng phi

Triu chng suy tim tri

Triu chng thc th ti tim
Mm tim lch sang tri.
Tim nhanh, nga phi tri.
Thi tm thu nh mm
do HoHL c nng (gin tht
tri).
Bnh tim gy ST tri.

Triu chng suy tim tri

Xquang: tim to, cung di tri phng to v ko di do
tht tri gin. Hai phi m nht l vng rn phi, ng
Kerley do ph cc khong k ca h thng bch huyt
phi, hnh nh cnh bm 2 rn phi khi c ph
phi.
T: Trc tri, dy nh tri, dy tht tri.
Siu m tim: Nh tri v tht tri gin, co bp ca cc
thnh tim , chc nng tm thu tht tri . Siu m tim
cho bit nguyn nhn stim tri.
Thm d huyt ng: Ch s tim gim (BT: 23,5l/ph/m2), p lc cui TTrTT tng. nh gi mc
HoHL, HoC...

Triu chng suy tim tri

X quang: cung di tri gin

Triu chng suy tim tri

T: ph i tht tri

Triu chng suy tim tri

Siu m tim: tht tri gin, EF gim

Triu chng suy tim phi

TNH MCH,
GAN

PHI

Triu chng suy tim phi

Triu chng c nng
Kh th: ngy mt dn khng c
cn kch pht nh suy tim tri.
au tc h sn phi do gan to v
au.

Triu chng suy tim phi

Triu chng thc th: Cc du hiu ngoi bin
Gan to, n xp.
TM c ni, phn hi gan-TM c (+).
p lc TM trung tm v ngoi bin tng.
Tm da v nim mc
Ph mm 2 chi di ph ton thn; trn dch
cc mng.
i t, nc tiu sm mu (200-300 ml/ngy).
Phi: trn dch mng phi.

Triu chng suy tim phi

Triu chng thc th: Cc du hiu ti tim
Du hiu Hartzer: tht phi to, p
vng mi c.
Tim nhanh, nga phi phi.
T2 mnh, thi tm trng do gin van
MP
Thi tm thu nh trong mm do HoBL
c nng.
HA ti a BT, HA ti thiu tng.

Triu chng suy tim phi

Xquang: Cung di phi (nh phi) gin.
Mm tim nng cao do tht phi gin. Cung
MP gin. Tht phi to lm hp khong
sng sau xng c
T: trc phi, dy nh phi, dy tht phi.
Siu m tim: Tht phi to, cc du hiu
tng p MP, h van ba l.
Thm d huyt ng: p lc cui TTrTP
(>12 mmHg), p lc MP.

Triu chng suy tim phi

X quang: mm tim chch ln

Triu chng suy tim phi

T: tng gnh tht phi

Triu chng suy tim phi

Siu m tim: tht phi gin

Triu chng suy tim ton b

Kh th thng xuyn, ngi cng kh th
TM c ni to. p lc TM tng rt cao
Mch nhanh yu
Ph ton thn v ni tng
Gan to nhiu
Trn dch mng tim, mng phi, c chng
Ha ti a h, HA ti thiu tng HA kt
Xquang: tim to ton b
T: dy hai tht.

nh gi mc suy tim
(theo NYHA)
NYHA I: Bnh nhn c bnh tim nhng khng c
triu chng c nng, sinh hot v hot ng th
lc gn nh bnh thng
NYHA II: Cc triu chng c nng ch xut hin
khi gng sc nhiu, gim nh cc hot ng th
lc.
NYHA III: Cc triu chng c nng x/hin k c
khi gng sc rt t lm hn ch nhiu cc hot
ng th lc.
NYHA IV: Cc triu chng c nng tn ti thng
xuyn k c khi ngh.

NYHA I

NYHA II

NYHA III

NYHA IV

Theo ACC/AHA 2001:

4 giai on suy tim:
Giai on A: Bnh nhn c nguy c cao b suy tim trong
thi gian ti, nhng cha c ri lon c nng hoc thc tn
ca tim.
Giai on B: C thc tn tim, nhng cha c biu hin
c nng ca suy tim.
Giai on C: C thc tn tim, v trong tin s hoc hin
ti c triu chng c nng ca suy tim, v iu tr ni khoa
c kt qu tt.
Giai on D: Bnh tim tin trin nng, i hi phi iu
tr ti bnh vin, hoc ni khoa tch cc hoc thay tim.

Phn suy tim

Giai on suy tim theo ACCF/AHA

NYHA

Bnh nhn c nguy c cao b suy tim

trong thi gian ti, nhng cha c ri
lon c nng hoc thc tn ca tim.

C bnh thc tn tim, nhng cha

c biu hin c nng ca suy tim.

C thc tn tim, v trong tin s

hoc hin ti c triu chng c nng
ca suy tim, v iu tr ni khoa c kt
qu tt.

Bnh tim tin trin nng, i hi

phi iu tr ti bnh vin, hoc ni
khoa tch cc hoc thay tim.

Bnh nhn c bnh tim nhng

khng c triu chng c nng,
sinh hot v hot ng th lc
gn nh bnh thng

II

Cc triu chng c nng ch xut

hin khi gng sc nhiu, gim
nh cc hot ng th lc.

III

Cc triu chng c nng x/hin

k c khi gng sc rt t lm hn
ch nhiu cc hot ng th lc.

IV

Cc triu chng c nng tn ti th

ng xuyn k c khi ngh.

Nguyn nhn suy tim

Nguyn nhn suy tim tri
THA
Bnh van tim: HoHC (n thun hoc phi hp),
HoHL
Cc tn thng c tim: NMCT; vim c tim do thp,
nhim c, nhim khun; cc bnh c tim.
Mt s ri lon nhp tim
Mt s bnh tim bm sinh: hp eo MC; cn ng M...
Ch : HHL biu hin triu chng nh suy tim tri nhng
bn cht li gy suy tim phi.

Nguyn nhn suy tim

Nguyn nhn suy tim phi
Suy tim tri
Cc bnh phi, d dng lng ngc-ct sng
Cc nguyn nhn tim mch:
HHL l nguyn nhn thng gp nht
Bnh van ba l v van MP
Bnh tim bm sinh (hp phi, tam chng Fallot); cc
bnh tim bm sinh c o lung shunt; u nhy nh tri,
v ti phnh xoang Valsava vo cc bung tim phi...
Ch : TDMT; Vim MNT co tht

Nguyn nhn suy tim

Nguyn nhn suy tim ton b
Thng gp nht l ST tri tin trin thnh
ST ton b.
Bnh c tim gin; Vim tim ton b do thp
tim, vim c tim.
Suy tim ton b c tng cung lng: cng
gip, thiu vitamin B1, thiu mu nng,
d M-TM

iu tr suy tim
Thay i li sng.
iu tr ni khoa.
Thit b h tr chc nng tim: bng i xung
ng mch ch, thit b h tr tht tri
My to nhp ti ng b tim CRT.
Ghp tim

Thay i li sng
Duy tr cn nng hp l, gim cn nng nu
tha cn.
Hn ch mui, nc
Ngng ht thuc l.
Hn ch ru v cc cht gy c cho tim
Tp luyn th lc va sc.

iu tr ni khoa
iu tr tt THA, ri lon lipid mu, i tho
ng, cc ri lon nhp tim (rung nh),
bnh ng mch vnh
Cc thuc chng suy tim: thuc li tiu,
thuc c ch men chuyn, thuc chn beta
giao cm, nitrates, digoxin
Thuc chng ng d phng tc mch.

Thit b h tr tht tri

(LVAD)

Bng i xung ng mch ch

(IABP)

My to nhp ti ng b tim
(CRT)

Ghp tim
(Cardiac transplant)

Xin cm n s ch !