B GIO DC V O TO

B Y T

TRNG I HC Y DC CN TH
KHOA DC LIN B MN DC L DC LM SNG

NGHIN CU CAC YU T TIN LNG

NGUY C T VONG VA TAI NHP VIN BNH NHN
HI CHNG VANH CP SAU XUT VIN
TAI BNH VIN A KHOA TRUNG NG CN TH VA
BNH VIN A KHOA THANH PH CN TH NM 2015
Phm Thnh Sul
Thi Ngc Dim Trang
L Kim Khnh

Cn Th Nm 2016

T VN
HI CHNG VANH CP: T l t vong

Nc pht trin

Nc ang pht trin

nh gi cc yu t tin lng
Phn tng nguy c
ti: Nghin cu cc yu t tin lng nguy
c t vong v ti nhp vin bnh nhn hi chng vnh
cp sau xut vin ti bnh vin a khoa Trung ng Cn
Th v bnh vin a khoa Thnh ph Cn Th nm 2015
2

MC TIU NGHIN CU
1

Xc nh t l t vong v ti nhp vin trong 1

thng v 6 thng sau xut vin
nh gi cc yu t tin lng nguy c t
vong v ti nhp vin trong 1 thng v 6 thng
sau xut vin

nh gi gi tr tin lng ngn hn v di hn

v nguy c t vong ca thang im GRACE
3

c im hi chng vnh cp
au ngc

Nhp vin

Hi chng vnh cp

Chn on s b
in tm

ST chnh
ln dai dng

Sinh ha
Chn on
xc nh

NMCT cp
c ST
chnh ln

Bt thng
ST/T

ECG
bnh thng

Troponin
tng

Troponin
bnh thng

NMCT cp
khng ST
chnh ln

TNK

iu tr hi chng vnh cp

iu tr ti bnh vin
Mc tiu: Gim triu chng thiu mu cc b c tim
Phng nga bin chng ngn hn v di hn
Chng thiu mu
cc b
1. iu tr ni khoa

Chng kt tp
tiu cu

Khng ng
2. iu tr can thip
5

iu tr hi chng vnh cp

Phng nga th pht

Mc tiu: Gim bin c tim mch v t l t vong
Chng kt tp
tiu cu
ACEI/ ARB

1. Dng thuc
Chn th th
Statin

2. Khng dng thuc

6

Yu t tin lng
YTNC
HCVC

Tui
Gii tnh

C a

YTTL

Cn
lm
sng

S lng YTNC BMV

Tin s: NMCT, suy tim, t
qu, Chc nng thn

Lm
sng

Thi gian
Nhp tim
Huyt p
Killip

ECG: sng Q, v tr nhi mu,

ri lon nhp
Sinh ha: troponin, BNP, CRP
CT mu: thiu mu, s lng
bch cu
7

Thang im GRACE
Tui
Ngng tim

Creatinin

Killip

GRACE

Tng men tim

Nhp tim

Bin i ST
Huyt p
tm thu

Nhiu yu t lin tc chnh xc cao

i tng nghin cu
Tt c bnh nhn HCVC ti 2 bnh vin, xut vin
trong khong thi gian t 26/01/2015 26/10/2015
Tiu chun chn mu

Tiu chun loi tr

Tt c BN ni tr khoa Tim
mch c chn on xut
vin:

1. Khng c n thuc
xut vin

1. TNK
2. NMCT cp khng ST
chnh ln
3. NMCT cp c ST chnh
ln

2. BN ti nhp vin
c tn trong nghin cu

3. Khng ng tham
gia hoc khng c ST
4. Khng thng tin
v yu t tin lng
9

Phng php nghin cu

1. Thit k nghin cu:
Tin cu, ct ngang m t c phn tch
2. C mu:

N 1,96 x
2

p(1 p)

p: t l ti nhp vin. Chon p = 0,201*

: sai s mong mun. Chon = 0,05 KTC t 95%

N: c mu nghin cu N = 247
trnh hao ht, tng c mu thm 30%
C mu cn thit l 322 BN
* Sangu PV (2012)

10

Phng php nghin cu

3. Phng php thu thp s liu
Xy dng phiu thu thp thng tin
v thu thp thng tin
Xc nh cc yu t tin lng
Xc nh hng dn iu tr
Xy dng phiu thu thp thng tin
ban u

Thu thp th 10 HSBA

Xy dng phiu thu thp thng tin
hon chnh

Thu thp s liu t HSBA

11

Phng vn bnh nhn

Nm vin

Sau xut vin 1 thng

Sau xut vin 6 thng

12

Phng php nghin cu

MT1: Xc nh t l t vong v ti nhp vin trong 1 thng v 6
thng sau xut vin
T l TV (TNV) =

S BN TV trong 1 thng (6 thng) sau xut vin

Tng s BN c phng vn

- Ti nhp vin: BN nhp vin li vo khoa Tim mch bt k bnh

vin no do tt c nguyn nhn
- BN c ti nhp vin v t vong th bin c t vong c tnh

- Ngn hn (1 thng): 30 ngy t khi xut vin

- Di hn (6 thng): 6 thng dng lch
13

Phng php nghin cu

MT2: Yu t tin lng nguy c t vong v ti nhp
vin trong 1 thng v 6 thng
Bin c

Yu t tin lng

T vong

- Vic p dng hng dn iu tr ca bc s

Ti nhp

- S lng yu t nguy c bnh mch vnh

vin

- Tui cao, gii tnh

- Nhp tim*, Killip
- Tin s: NMCT, suy tim, chc nng thn, t qu**

- ECG: Q hoi t, v tr nhi mu, rung nh, lon nhp tht

- Sinh ha mu: troponin T
- Cng thc mu: s lng bch cu, thiu mu*
* Yu t tin lng ch trong 1 thng sau xut vin
** Yu t tin lng ch trong 6 thng sau xut vin

14

Phng php nghin cu

MT3: nh gi gi tr tin lng ca thang im GRACE*
im nguy cThp
Thang im
<30
0
Tng im
Mc nguy c
Trung bnh
mi BN
GRACE
30 39
8
40 49
25
Cao
50 59
41
Tui
60 69
58
ng cong
70T
79
vong thc t 75
ROC
80 89
91
>90
100
C
14
Men tim tng
Khng
0
Thang im
GRACE
gi tr tin
lngp
khitm
p < thu)
0,05 + (Nhp tim) +
Tng
im c
= (Killip)
+ (Huyt
(Creatinin)
+ (Ngng
lc nhp
Gi tr tin(Tui)
lng+cng
tt khi AUC
cng tim
ln (tin
v 1)vin) + (Thay
i ST trn ECG) + (Men tim tng)
Yu t nguy c

* Global Registry of Acute Coronary Events

15

Phng php nghin cu

Phng php x l s liu
Thng k m t
Phn tch c
im bnh nhn

Phn tch Chi-squared

Hi quy logistic
Yu t tin lng

tT l t vong
T l ti nhp
vin

Bin c

16

S chn mu

322 BN tham gia nghin cu

Loi 290 HSBA:

+ Khng c n thuc xut
vin: 65
+ Ti nhp vin: 24
+ Khng c s in thoi: 89
+ Khng YTTL: 112

257 BN c theo di
sau 1 thng

65 BN khng c theo di:

+ Khng lin lc c: 58
+ T chi tham gia: 7

612 HSBA HCVC

206 BN khng ti
nhp vin v khng
t vong

37 BN ti
nhp vin

14 BN
t vong

243 BN c theo di sau 6 thng

142 BN khng ti
nhp vin v
khng t vong

86 BN ti
nhp
vin

29 BN
t vong
17

c im chung ca i tng nghin cu

Phn b bnh nhn theo thng tin ban u lc nhp vin

Thng tin ban u S bnh nhn
lc nhp vin

(N = 257)

T l

Trung bnh

(%)

( lch chun)
67 13

Tui

Nam gii

158

61,5

Tin s NMCT

74

28,8

Tin s PCI/ CABG

11

4,3

Tin s t qu

15

5,8

18

c im chung ca i tng nghin cu

Phn b bnh nhn theo yu t nguy c, bnh l
km theo v chn on khi xut vin
c im
Yu t nguy c
Tui 65
Tin s gia nh mc BMV
Ht thuc l
Tng huyt p
i tho ng
Ri lon lipid mu
Chn on khi xut vin
HCVC khng ST chnh ln
HCVC c ST chnh ln

S bnh nhn
(N = 257)

T l (%)

140
14
111
207
62
66

54,5
5,4
43,2
80,5
24,1
25,7

194
63

75,5
24,5
19

MT1: Xc nh t l t vong v ti nhp vin

S BN gp bin c cc
th bnh

STT

Bin c do tt c
nguyn nhn

HCVC khng HCVC c ST

ST chnh ln chnh ln
n=194; (%)
n=63; (%)

Tng s BN gp
bin c
N = 257; (%)

Ti nhp vin 1 thng

30
7
Trn Th Trc o: 16,8%
(15,5)
(11,1)

37
(14,4)

T vong 1 thng

10Cm Chu: 11,1%

4
Dng Th
(5,2)
(6,3)

14
(5,4)

Ti nhp vin 6 thng

67
19
20,1%
(34,5) Sangu VS:
(30,2)

86
(33,5)

T vong 6 thng

18
11
Fox KAA: 9,1%
(9,3)
(17,5)

29
(11,3)
20

MT2: nh gi cc yu t tin lng

Yu t tin lng t vong trong 1 thng sau xut vin
T vong 1 thng
Yu t

Suy tim

Sng Q hoi t
Troponin T
Rung nh
Lon nhp tht

Hi quy n bin

Hi quy a bin

OR
(KTC 95%)

OR
(KTC 95%)

8,96
(2,70 29,72)

<0,001

6,33
(1,68 23,89)

0,006

0,015

> 0,05

0,048

> 0,05

0,002

> 0,05

<0,001

9,80
(1,69 56,73)

0,011

3,59
(1,20 10,67)
0,78
(0,73 0,84)
7,09
(1,68 29,92)
12,98
(2,75 61,39)

21

MT2: nh gi cc yu t tin lng

Yu t tin lng t vong trong 6 thng sau xut vin
Yu t

Tui
Suy tim
Sng Q hoi t

Troponin T
Lon nhp tht
Rung nh

T vong 6 thng
Hi quy n bin
Hi quy a bin
OR
OR
p
p
(KTC 95%)
(KTC 95%)
2,93
0,014
> 0,05
(1,20 7,13)
6,66
3,52
<0,001
0,007
(2,94 15,08)
(1,40 8,81)
3,13
2,78
0,004
0,024
(1,41 6,96)
(1,14 6,78)
0,77
0,003
> 0,05
(0,72 0,82)
5,15
0,017
> 0,05
(1,16 22,79)
4,40
22
0,013
> 0,05
(1,24 15,66)

MT2: nh gi cc yu t tin lng

Yu t tin lng ti nhp vin trong 1 thng sau xut vin
Ti nhp vin 1 thng
Yu t

Hi quy n bin
OR
(KTC 95%)

p dng hng

dn iu tr
Chc nng thn
Sng Q hoi t

1,75

(1,04 2,96)
3,35
(1,64 6,86)
2,65
(1,27 5,52)

p
0,001
0,001
0,007

Hi quy a bin
OR
(KTC 95%)
2,75

(1,28 5,93)
2,89
(1,30 6,42)
2,23
(1,03 4,81)

p
0,010
0,009
0,041
23

MT2: nh gi cc yu t tin lng

Yu t tin lng ti nhp vin trong 6 thng sau xut vin
Ti nhp vin 6 thng
Yu t

Hi quy n bin
OR
(KTC 95%)

p dng hng

dn iu tr
Tin s NMCT
Chc nng thn

1,75

(1,04 2,96)
1,82
(1,04 3,18)
2,01
(1,17 3,44)

Hi quy a bin
OR
(KTC 95%)

0,035

> 0,05

0,035

> 0,05

0,010

> 0,05
24

MT3: Gi tr tin lng ca thang im GRACE

Thang im GRACE ch p dng cho BN khng PCI tng
s BN c nh gi bng thang im GRACE: 177 BN.

im GRACE trung bnh: 142,5 37,1

im GRACE cao nht: 245
im GRACE thp nht: 67
Nguy c
thp 8,5%
Nguy c
trung bnh
21,5%
Nguy c
cao 70%
25

MT3: Gi tr tin lng ca thang im GRACE

T vong trong 1 thng theo nhm nguy c GRACE

Nhm nguy c

Nguy c cao
Nguy c thp - trung
bnh
Tng cng

T vong thc t
C
Khng
n (%)
n (%)
12
112
(6,8)
(63,3)
0
53
(0,0)
(29.9)
12
165
(6,8)
(93,2)

Ch thch: * Fishers Exact Test

Tng
cng

p*

124
(70,1)
53
(29,9)
177
(100,0)

0,019

26

MT3: Gi tr tin lng ca thang im GRACE

nhy

ng cong ROC im GRACE v t vong trong 1 thng

AUC: 0,685
p = 0,032

1 c hiu

27

MT3: Gi tr tin lng ca thang im GRACE

T vong trong 6 thng theo nhm nguy c GRACE

Nhm nguy c

Nguy c cao
Nguy c thp - trung
bnh
Tng cng

T vong thc t
C
Khng
n (%)
n (%)
23
101
(13,0)
(57,1)
2
51
(1,1)
(28,8)
25
152
(14,1)
(85,9)

Ch thch: * Fishers Exact Test

Tng
cng

p*

124
(70,1)
53
(29,9)
177
(100,0)

0,009

28

MT3: Gi tr tin lng ca thang im GRACE

nhy

ng cong ROC im GRACE v t vong

trong 6 thng

AUC: 0,628
p = 0,041

1 c hiu

29

KT LUN
1. c im bnh nhn: 30% BN b NMCT trc . 75% BN HCVC
khng ST chnh ln v 25% BN HCVC c ST chnh ln
2. T l t vong v ti nhp vin trong 1 v 6 thng sau xut vin
- 1 thng: 5,4% BN t vong v 14,4% BN ti nhp vin
- 6 thng: t l t vong tch ly 11,3% v ti nhp vin tch ly 33,5%
3. Yu t tin lng t vong v ti nhp vin trong 1 v 6 thng
- YTTL 1 thng: p dng HDT, chc nng thn, suy tim, sng Q hoi
t, troponin T, rung nh v lon nhp tht
- YTTL 6 thng: p dng HDT, tui, tin s NMCT, chc nng thn,
suy tim, sng Q hoi t, troponin T, rung nh v lon nhp tht
4. Gi tr tin lng v nguy c t vong ca thang im GRACE
Thang im GRACE tin lng tt cho nguy c t vong ngn hn v
di hn BN HCVC
30

KIN NGH
1. nh gi li cc yu t nh hng n bin c t vong, ti
nhp vin di hn qua cc mc 6 thng v 1 nm
2. nh gi gi tr tin lng nguy c t vong ngn hn v di
hn ca thang im GRACE mi gm 9 yu t c th p dng
cho BN c v khng c PCI
3. Ngi iu tr cn ch trong vic phn tng nguy c, da

vo cc yu t tin lng c chng minh gip cc

bc s cn nhc hn trong vic s dng thuc
31

Chan thanh cam n