HNG DN CHN ON V IU TR TNG HUYT P

1. NH NGHA
Tng huyt p l khi huyt p tm thu 140mmHg v/hoc huyt p tm trng
90mmHg hoc khi ang c iu tr bng mt thuc h huyt p.
2. NGUYN NHN
Phn ln tng huyt p (THA) ngi trng thnh l khng r nguyn nhn
(THA nguyn pht), ch c khong 10% cc trng hp l c nguyn nhn (THA
th pht, xem Ph lc 1- Nguyn nhn gy THA th pht, cc yu t nguy c tim
mch, bin chng & tn thng c quan ch do THA)
3. CHN ON
3.1. Chn on xc nh THA: da vo tr s huyt p o c sau khi o huyt
p ng quy trnh (xem Ph lc 2- Quy trnh o huyt p). Ngng chn on
THA thay i ty theo tng cch o huyt p (Bng 1).
Bng 1. Cc ngng chn on tng huyt p theo tng cch o
Huyt p tm thu

Huyt p tm trng

1. Cn b y t o theo ng quy trnh

140 mmHg

90 mmHg

2. o bng my o HA t ng 24 gi

130 mmHg

3. T o ti nh (o nhiu ln)

135 mmHg

v/hoc

80 mmHg
85 mmHg

3.2. Phn THA: da vo tr s huyt p do cn b y t o c (xem Bng 2).

Bng 2. Phn huyt p
Phn huyt p
Huyt p ti u

Huyt p tm thu
(mmHg)

Huyt p tm trng
(mmHg)

< 120

< 80

Huyt p bnh thng

120 129

v/hoc

80 84

Tin tng huyt p

130 139

v/hoc

85 89

Tng huyt p 1

140 159

v/hoc

90 99

Tng huyt p 2

160 179

v/hoc

100 109

Tng huyt p 3

180

v/hoc

110

Tng huyt p tm thu n c

140

< 90

Nu huyt p tm thu v huyt p tm trng khng cng mc phn th chn

mc cao hn xp loi. THA tm thu n c cng c phn theo cc mc
bin ng ca huyt p tm thu.

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3.3. Phn tng nguy c tim mch: da vo phn huyt p, s lng cc yu t

nguy c tim mch (YTNCTM) v bin c tim mch (xem Bng 3- Phn tng nguy
c tim mch) c chin lc qun l, theo di v iu tr lu di.
Bng 3. Phn tng nguy c tim mch

4. IU TR
4.1. Nguyn tc chung:
- Tng huyt p l bnh mn tnh nn cn theo di st, iu tr hng ngy ng
v , cn iu tr lu di.
- Mc tiu iu tr l t huyt p mc tiu v gim ti a nguy c xut hin
cc bin c tim mch.
- Huyt p mc tiu cn t l < 140/90mmHg. Ngi c THA km theo i
tho ng th huyt p mc tiu cn t l < 130/80 mmHg. Khi iu tr t
huyt p mc tiu, cn tip tc duy tr phc iu tr lu di km theo vic
theo di huyt p cht ch, thng xuyn iu chnh liu thuc kp thi.
- iu tr cn ht sc tch cc bnh nhn c tn thng c quan ch.
Khng nn h huyt p qu nhanh trnh bin chng thiu mu cc c quan
ch.
4.2. Cc bin php tch cc thay i li sng: p dng cho mi bnh nhn
ngn nga tin trin v gim c huyt p, gim s thuc cn dng
- Ch n hp l:
+ Gim n mn (< 3,8 gam mui hay 1,5 gam [65 mmol] natri mi ngy).
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+ Tng cng rau xanh, hoa qu ti giu cht x v protein thc vt.
+ Hn ch thc n c nhiu cholesterol v axt bo no.
- Tch cc gim cn (nu qu cn), duy tr cn nng l tng vi ch s khi c
th (BMI: body mass index) t 18,5 n 22,9 kg/m2.
- C gng duy tr vng bng di 90 cm nam v di 80 cm n.
- Hn ch ung ru, bia: s lng 2 cc chun/ngy v tng cng khng qu
14 cc chun/tun (nam) hoc 9 cc chun/tun (n). 1 cc chun cha 13.6g
ethanol tng ng vi 355ml bia (5%) hoc 148ml ru vang (12%), hoc
44ml ru mnh (40%).
- Ngng hon ton vic ht thuc l hoc thuc lo.
- Tng cng hot ng th lc mc thch hp: tp th dc, i b hoc vn
ng mc va, u n khong 30-60 pht mi ngy, 4-7 ngy/tun.
- Trnh lo u, cng thng thn kinh; cn th gin, ngh ngi hp l.
- Trnh b lnh t ngt.
4.3. iu tr tng huyt p bng thuc ti tuyn c s:
- Chn thuc khi u:
+ Tng huyt p 1: c th la chn mt thuc trong s cc nhm sau
y nu khng c chng ch nh: chn knh canxi loi tc dng ko di;
c ch men chuyn; c ch th th AT1 ca angiotensin II, li tiu
thiazide liu thp; chn beta giao cm ( ngi di 55 tui).
+ Tng huyt p t 2 tr ln: nn phi hp 2 loi thuc trong s cc
nhm sau y nu khng c chng ch nh: chn knh canxi tc dng
ko di, c ch men chuyn, c ch th th AT1 ca angiotensin II, li
tiu, chn bta giao cm.
+ Tng bc phi hp cc thuc h huyt p c bn, bt u t liu thp
nh chn knh canxi dng phng thch chm (nifedipine chm (retard)
10-20mg/ngy), c ch men chuyn (enalapril 5-10mg/ngy; perindopril
2,5-5 mg/ngy), li tiu thiazide (hydrochlorothiazide 12,5mg/ngy).
- Qun l ngi bnh ngay ti tuyn c s m bo bnh nhn c ung
thuc ng, v u; ng thi gim st qu trnh iu tr, ti khm, pht hin
sm cc bin chng v tc dng ph ca thuc theo 4 bc qun l tng huyt
p tuyn c s (Ph lc 3- Quy trnh 4 bc iu tr tng huyt p ti tuyn
c s).
- Nu cha t huyt p mc tiu: chnh liu ti u hoc b sung thm mt loi
thuc khc cho n khi t huyt p mc tiu.
- Nu vn khng t huyt p mc tiu hoc xut hin bin c nng: cn chuyn
tuyn trn hoc gi khm chuyn khoa tim mch.
4.4. Cc l do chuyn tuyn trn hoc chuyn khoa tim mch:
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Cn nhc chuyn n cc n v qun l THA tuyn trn hoc chuyn khoa tim
mch trong cc trng hp sau:
- Tng huyt p tin trin, THA e do c bin chng hoc THA c cc bin
c tim mch (nh tai bin mch no thong qua, t qu no cp, suy tim tri
cp, hi chng vnh cp, suy thn cp, lc tch thnh ng mch ch cp, tin
sn git...).
- Nghi ng tng huyt p th pht hoc THA ngi tr hoc khi cn nh gi
cc tn thng c quan ch.
- Tng huyt p khng tr mc d dng nhiu loi thuc phi hp ( 3 thuc,
trong t nht c 1 thuc li tiu) hoc khng th dung np vi cc thuc h
p, hoc c qu nhiu bnh nng phi hp.
- THA ph n c thai hoc mt s trng hp c bit khc.
4.5. iu tr tng huyt p v cc yu t nguy c tim mch khc tuyn trn:
Qun l tng huyt p v cc yu t nguy c tim mch khc tuyn trn bao gm:
- Pht hin tn thng c quan ch ngay giai on tin lm sng (Ph lc 1Nguyn nhn gy THA th pht, cc yu t nguy c tim mch, bin chng &
tn thng c quan ch do THA).
- Loi tr cc nguyn nhn gy tng huyt p th pht (Ph lc 1).
- Chn chin lc iu tr da vo huyt p v mc nguy c tim mch (Ph
lc 4- Chin lc iu tr theo huyt p v nguy c tim mch).
- Ti u ha phc iu tr tng huyt p: da vo cc ch nh bt buc hoc
u tin ca tng nhm thuc h huyt p trong cc th bnh c th. Phi hp
nhiu thuc tng kh nng kim sot huyt p thnh cng, gim tc dng
ph v tng vic tun th iu tr ca ngi bnh (Ph lc 5- Ch nh bt buc
v u tin i vi mt s thuc h p, s phi hp thuc v Ph lc 6, mc
1- Mt s loi thuc h huyt p ng ung thng dng).
- iu tr cc bnh phi hp v iu tr d phng nhm c nguy c tim mch
cao hoc rt cao.
- S dng cc thuc h huyt p ng tnh mch trong cc tnh hung khn cp
nh THA c tnh; lc tch thnh ng mch ch; suy thn tin trin nhanh; sn
git; THA c km nhi mu c tim (NMCT) cp hoc suy tim tri cp (Ph
lc 6, mc 2- Mt s loi thuc h huyt p ng tnh mch thng dng).

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S 1. Quy trnh iu tr tng huyt p

S 2. Gi la chn thuc h p u tin

5. TIN TRIN

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Tng huyt p khng c iu tr v kim sot tt s dn n tn thng nng

cc c quan ch v gy cc bin chng nguy him nh tai bin mch no, nhi
mu c tim, phnh tch thnh ng mch ch, suy tim, suy thn thm ch dn
n t vong (Ph lc 1).
6. PHNG BNH
Cc bin php tch cc thay i li sng (Phn 4.2) l nhng bin php phng
nga tng huyt p ngi trng thnh, phi hp vi vic gio dc truyn thng
nng cao nhn thc v hiu bit v bnh tng huyt p cng nh cc bin chng
ca tng huyt p v cc yu t nguy c tim mch khc./.

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PH LC 1
NGUYN NHN GY TNG HUYT P TH PHT, CC YU T
NGUY C TIM MCH, BIN CHNG
V TN THNG C QUAN CH DO TNG HUYT P
1. Nguyn nhn gy tng huyt p th pht (cn ch tm kim nguyn nhn
trong cc trng hp nh THA tui tr (di 30 tui); THA khng tr; THA tin
trin hoc c tnh)
- Bnh thn cp hoc mn tnh: vim cu thn cp/mn, vim thn k, si thn,
thn a nang, thn nc, suy thn.
- Hp ng mch thn.
- U ty thng thn (Pheocromocytome).
- Cng Aldosterone tin pht (Hi chng Conn).
- Hi chng Cushings.
- Bnh l tuyn gip/cn gip, tuyn yn.
- Do thuc, lin quan n thuc (khng vim non-steroid, thuc trnh thai,
corticoid, cam tho, hot cht ging giao cm trong thuc cm/thuc nh
mi).
- Hp eo ng mch ch.
- Bnh Takayasu.
- Nhim c thai nghn.
- Ngng th khi ng.
- Yu t tm thn
2. Cc yu t nguy c tim mch
- Tng huyt p.
- Ri lon lipid mu.
- i tho ng.
- C microalbumin niu hoc mc lc cu thn c tnh <60 ml/ph.
- Tui 55.
- Gii nam.
- Tin s gia nh mc bnh tim mch sm (nam trc 55, n trc 65 tui).
- t hot ng th lc
- Ch n khng ph hp: qu nhiu mui, t rau qu, nhiu cht bo
- Tha cn/bo ph; bo bng.
- Ht thuc l, thuc lo.
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- Stress v cng thng tm l.

- Khng dung np vi iu tr ko di.
- Ung nhiu ru, bia.
3. Bin chng ca tng huyt p hoc tn thng c quan ch do THA
- t qu no (thiu mu no, xut huyt no, chy mu khoang di nhn),
thiu mu no thong qua,
- Sa st tr tu.
- Ph i tht tri (trn in tm hay siu m tim), suy tim.
- Nhi mu c tim, cn au tht ngc.
- Bnh mch mu ngoi vi, phnh tch thnh ng mch ch.
- Xut huyt hoc xut tit vng mc, ph gai th.
- Protein niu, tng creatinin huyt thanh, suy thn mn
4. Cc xt nghim tm tn thng c quan ch, nguyn nhn tng huyt p
v yu t nguy c tim mch
- Xt nghim thng quy:
o Sinh ho mu: ng mu khi i; thnh phn lipid mu (Cholesterol ton
phn, HDL-C, LDL-C, Triglycerid); in gii mu (c bit l kali); axt
uric mu; creatinine mu.
o Huyt hc: Hemoglobin and hematocrit.
o Phn tch nc tiu (albumine niu v soi vi th).
o in tm .
- Xt nghim nn lm (nu c iu kin):
o Siu m Doppler tim.
o Siu m Doppler mch cnh.
o nh lng protein niu (nu que th protein dng tnh).
o Ch s huyt p mt c chn/cnh tay (ABI: Ankle Brachial Index).
o Soi y mt.
o Nghim php dung np glucose.
o Theo di huyt p t ng 24 gi (Holter huyt p).
o o vn tc lan truyn sng mch
- Xt nghim khi c bin chng hoc tm nguyn nhn:
o nh lng renin, aldosterone, corticosteroids, catecholamines mu/niu.
o Chp ng mch.
o Siu m thn v thng thn.
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o Chp ct lp, cng hng t

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PH LC 2
QUY TRNH O HUYT P NG
1. Ngh ngi trong phng yn tnh t nht 5-10 pht trc khi o huyt p.
2. Khng dng cht kch thch (c ph, ht thuc, ru bia) trc 2 gi.
3. T th o chun: ngi c o huyt p ngi gh c ta, cnh tay dui thng
trn bn, np khuu ngang mc vi tim. Ngoi ra, c th o cc t th nm,
ng. i vi ngi cao tui hoc c bnh i tho ng, nn o thm huyt
p t th ng nhm xc nh c h huyt p t th hay khng.
4. S dng huyt p k thy ngn, huyt p k ng h hoc huyt p k in t
(loi o cnh tay). Cc thit b o cn c kim chun nh k. B di bao
o (nm trong bng qun) ti thiu bng 80% chu vi cnh tay, b rng ti thiu
bng 40% chu vi cnh tay. Qun bng qun cht, b di ca bao o trn
np ln khuu 2cm. t my v tr m bo my hoc mc 0 ca thang o
ngang mc vi tim.
5. Nu khng dng thit b o t ng, trc khi o phi xc nh v tr ng
mnh cnh tay t ng nghe. Bm hi thm 30mmHg sau khi khng cn
thy mch p. X hi vi tc 2-3mmHg/nhp p. Huyt p tm thu tng
ng vi lc xut hin ting p u tin (pha I ca Korotkoff) v huyt p tm
trng tng ng vi khi mt hn ting p (pha V ca Korotkoff).
6. Khng ni chuyn khi ang o huyt p. Khng bt cho chn.
7. Ln o u tin, cn o huyt p c hai cnh tay, tay no c con s huyt p
cao hn s dng theo di huyt p v sau.
8. Nn o huyt p t nht hai ln, mi ln cch nhau t nht 1-2 pht. Nu s o
huyt p gia 2 ln o chnh nhau trn 10mmHg, cn o li mt vi ln sau khi
ngh trn 5 pht. Gi tr huyt p ghi nhn l trung bnh ca hai ln o cui
cng.
9. Trng hp nghi ng, c th theo di huyt p bng my o t ng ti nh
hoc bng my o huyt p t ng 24 gi (Holter huyt p).
10. Ghi li s o theo n v mmHg di dng HA tm thu/HA tm trng (v d
126/82 mmHg), khng lm trn s qu hng n v v thng bo kt qu cho
ngi c o.

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