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CHN ON V IU

TR BNH NG
MCH VNH MN
PGS.TS. Phm Nguyn Vinh
Bnh Vin Tim Tm c
i Hc Y Khoa Phm Ngc Thch
Vin Tim Tp.HCM
1

C v t bnh MV mn

Cac the lam sang


Bnh
MV mn:
BMV
* Cn au tht ngc n nh (CTN/)
* CTN Prinzmetal
* Thiu mu c tim yn lng (TMCT)
* Bnh c tim TMCB
* H van 2 l do BMV

Hi chng MV cp:
* NMCT c ST chnh ln
* NMCT khng ST chnh ln
* CTN khng n nh (CTNK)
2

C v t bnh MV mn

Bnh nhn n khm v au ngc :


Hi

bnh s
Khm thc th
Lng gi yu t nguy c

=>

Kh nng bnh MV
(TD : thp, trung bnh, cao)

Ti liu : ACC/AHA/ACP - ASIM Chronic Stable Angina Guidelines JACC Vol


33, No 7 1999, p.2098
3

C v t bnh MV mn

PHAN LOAI LAM SANG


CTN

CTN ien hnh (chac chan)


1. au, tc sau xng c vi tnh chat cn au
va thi gian ien hnh
2. Xay ra khi gang sc hoac stress tnh cam
3. Giam khi ngh hoac s dung Nitroglycerine
CTN khong ien hnh (co the co benh) : Ch 2
trong 3 tieu chuan tren
au ngc khong do tim : Ch mot hay khong co
tieu chuan tren
TL : Diamond, JACC, 1983 (45)

C v t bnh MV mn

KH NNG B BMV CH DA VO TRIU


CHNG C NNG, THEO TUI V GII TNH
Tui
(Nm)

au ngc
khng do BMV
Nam

30 - 39
40 - 49
50 - 59
60 - 69

N
4
13
20
27

2
3
7
14

CTN khng
in hnh
Nam
34
51
65

N
12
22
31
72

CTN
in hnh

76
87
93
51

Nam
26
55
73
94

86

* Mi tr s biu hin phn trm ca BMV c ngha pht hin khi thng tim.
Ti liu: N.Eng J Med 1979; 300:1350-8
Circulation 1981; 64:360-7

C v t bnh MV mn

Quy trnh chn on BMV ti Vin Tim


TP HCM v BV Tim Tm c
LS:
- Trieu chng c nang va
thc the
- Tien s ban than va gia
nh
- Yeu to nguy c

ECG luc
ngh
- Xquang
ngc
- Sieu am
tim luc
ngh
- Huyet o,
Cholesterol,
TG, HDL-C,

ECG gang sc
va/hoac Echo
Dobutamin, Xa ky c
tim, MSCT ong mach
vanh
Hoi chan
noi
Chup ong mach
vanh

C v t bnh MV mn

nhy v c hiu ca trc nghim


chn on TN n nh

TL: Morrow DA, Gersh BJ. Chronic Coronary Artery Disease. In Braunwalds
Heart Disease, Saunders Elsevier, 8th ed 2008, p. 1353-1401
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C v t bnh MV mn

Cc xt nghim cn thc hin nhm kho st


ban u bnh nhn au tht ngc (1)
Loai I (cho moi benh nhan)
1. Cholesterol mau, triglyceride mau, HDL C, LDL C (mc
chng c B)
2. ng mau/ oi (mc chng c B)
3. Huyet o (B)
4. Creatinine mau (C)
Loai I (tuy theo lng nh lam sang)
1. Chat ch iem ton thng c tim neu nghi ng H/C MV
cap (mc chng c A)
2. Chc nang tuyen giap neu lam sang nghi ng (mc
chng c C)
TL: Fox K et al. Guidelines on the management of stable angina pectoris. Eur. Heart Journal 2006; 27:
8
1341 - 1381

C v t bnh MV mn

Cc xt nghim cn thc hin nhm kho st


ban u bnh nhn au tht ngc (2)
Loai IIa
1. Trac nghiem dung nap glucose qua ng uong
(mc chng c B)
Loai IIb
1. Hs CRP (B)
2. Lipoprotein a, ApoA va ApoB (B)
3. Homocysteine (B)
4. HbA1c (B)
5. NT BNP (B)

TL: Fox K et al. Guidelines on the management of stable angina


pectoris. Eur. Heart Journal 2006; 27: 1341 - 1381
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C v t bnh MV mn

ECG gng sc/ chn on au tht ngc


Loai I
1. Co trieu chng au that ngc kem kha nang b
BMV trung bnh en cao da theo tuoi, gii tnh
va trieu chng (mc chng c B)
Loai IIb
1. Benh nhan co ST chenh xuong > 1mm tren ECG
luc ngh hay ang uong digoxin (mc chng c B)
2. Benh nhan co kha nang BMV thap (< 10%) da
theo tuoi, gii tnh va trieu chng (mc chng
c B)
TL: Fox K et al. Guidelines on the management of stable angina pectoris. Eur. Heart
Journal 2006; 27: 1341 - 1381

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C v t bnh MV mn

Khuyn co s dng trc nghim gng sc


bng hnh nh (siu m hoc x k) nhm
kho st ban u au tht ngc (1)
Loai I
1. Benh nhan co bat thng ECG luc ngh,
bloc nhanh trai, ST sup xuong > 1mm, nhp
may hoac hoi chng Wolf Parkinson White
(mc chng c B)
2. Benh nhan ma ECG gang sc khong ket
luan c, chan oan con nghi ng (mc
chng c B)
TL: Fox K et al. Guidelines on the management of stable angina pectoris.
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Eur. Heart Journal 2006; 27: 1341 - 1381

C v t bnh MV mn

Khuyn co s dng siu m tim nhm kho


st ban u au tht ngc
Loai I
1. Nghe tim thay bat thng, nghi co benh van
tim hoac benh c tim ph ai (mc chng c
B)
2. Nghi co suy tim (mc chng c B)
3. Co tien s NMCT (mc chng c B)
4. Co bloc nhanh trai, co song Q hoac co
bien oi benh ly ECG bao gom bloc phan
nhanh trai trc (C)
TL: Fox K et al. Guidelines on the management of stable angina
pectoris. Eur. Heart Journal 2006; 27: 1341 - 1381

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C v t bnh MV mn

Khuyn co s dng Holter ECG (ECG di


ng) nhm kho st ban u au tht ngc
Loai I
1. au that ngc tren benh nhan nghi co
loan nhp tim (mc chng c B)
Loai IIa
1. Nghi au that ngc do co mach (mc chng
c C)

TL: Fox K et al. Guidelines on the management of stable angina


pectoris. Eur. Heart Journal 2006; 27: 1341 - 1381

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C v t bnh MV mn

Khuyn co s dng chp MV nhm chn


on au tht ngc n nh (1)
Loai I
1. au that ngc on nh, nang (CCS > 3) kem
kha nang benh MV cao; ac biet khi ieu
tr noi khong kiem soat c trieu chng
(chng c B)
2. Song sot sau ot t (chng c B)
3. Loan nhp that nang (chng c C)
4. Benh nhan co tien s tai lu thong MV
(PCI, BCMV), co xuat hien au that ngc
nang hay va (C)
TL: Fox K et al. Guidelines on the management of stable angina
pectoris. Eur. Heart Journal 2006; 27: 1341 - 1381

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C v t bnh MV mn

Lng nh nguy c (risk


stratification) rt cn thit c ch
nh iu tr v tin lng bnh

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C v t bnh MV mn

Ch so tham lan
(Treadmill score)
Duke Treadmill score = Thi gian gang sc - (5 x ST chenh)
- (4 x ch so au ngc)
Thi gian gang sc : tnh theo phut
ST chenh : tnh theo mm
0 : khong au ngc
1 : co
2 : au lam ngng van ong
TD : 4 - (5x2) - (4x2) = -14
Nguy c cao: -11; Nguy c trung bnh:[(-11)-(+4)]
Nguy c thp 5
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C v t bnh MV mn

Lng nh nguy c da vo trc nghim khng


xm nhp (1)
Nguy c cao (t vong hang nam > 3%)
1. PXTM < 35%
2. Ch so tham lan nguy c cao (< -11)
3. Roi loan chc nang that trai nang khi gang sc
(< 35%)
4. Vung khiem khuyet ti mau rong khi co stress
(ac biet vung trc)
5. Nhieu vung khiem khuyet ti mau va phai
khi co stress
6. Roi loan van ong vung tren sieu am (> 2
vung) lieu thap dobutamine (< 10mg/kg/phut)
hoac tan so tim thap (< 120 phut)
Nguy c cao: ieu tr noi va chup MV
TL: Gibbons RJ et al. ACC/AHA 2002 Guideline update for the management of patients with17
chronic stable angina. www.acc.org

C v t bnh MV mn

Cc vn v iu tr bnh ng
mch vnh mn
Th no l iu tr ni khoa ti u?
PCI ng mch vnh c ko di i sng
bnh nhn?
Khi no cn ti lu thng MV: PCI hoc
BCMV?
Li im v chi ph?

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C v t bnh MV mn

iu tr ni khoa ti u: iu tr ton
din, thuc ci thin tin lng

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C v t bnh MV mn

IU TR CTN N NH :
IU TR KHNG THUC

Gim m
Thuc l : ngng
Ru : va phi
Vn ng th lc +++
Bt stress tnh cm
Hn ch mui Natri / THA
Gim cn nng
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C v t bnh MV mn

Ch dinh dng da theo Mediterranean diet

TL : Sacks FM, McManus K. In


Cardiovascular Therapeutics
ed. E. Antman, Saunders
2007, 3rd ed, p.548

21

C v t bnh MV mn

Khuyn co s dng thuc iu tr nhm ci thin


tin lng bnh nhn au tht ngc n nh (1)
Loi I
Aspirin 75mg/ngy tr phi c CC (chng c A)
Statin: tt c bnh nhn (chng c A)
UCMC: b/n c km THA, suy tim, ri lon chc nng TT,
tin s NMCT km RLCN TT hoc T (chng c A)
Chn bta: b/n sau NMCT hoc km suy tim (chng c A)

TL: Fox K et al. Guidelines on the management of stable angina pectoris. Eur. Heart Journal
2006; 27: 1341 - 1381
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C v t bnh MV mn

Thuc l
I IIa IIb III

Ngng thuc l. Trnh ni c


ht thuc
Chng trnh cai thuc l
Chin lc tng bc 5A (Ask,
Advise, Assess, Assist, Arrange)

TL : Fraker TD, Fihn SD et al. JACC 2007, 23 : 2264-2274

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C v t bnh MV mn

Kim sot lipid


I IIa IIb III

S dng omega 3 1g/ngy


t vin nang hoc t c.

Liu omega 3 cao hn nu


b/n c tng triglyceride mu

I IIa IIb III

TL : Fraker TD, Fihn SD et al. JACC 2007, 23 : 2264-2274

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C v t bnh MV mn

Kim sot
lipid
Cc la chn gim non- HDL-C:
I IIa IIb III

I IIa IIb III

Niacin
Fibrate
Statins

Nu TG > 500 mg/dL:


Gim TG trc bng fibrates hoc
niacin; sau statins
Mc tiu: non HDL C < 100mg/dL

TL : Fraker TD, Fihn SD et al. JACC 2007, 23 : 2264-2274

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C v t bnh MV mn

Chn h thng Renin-Angiotensin-Aldosterone


I IIa IIb III

UCMC : tt c bnh nhn PXTM < 40% v


bnh nhn T, bnh thn mn
I IIa IIb III

UCMC : tt c bnh nhn nhm nguy c thp


(nguy c thp : PXTM bnh thng, YTNC kim
sot tt v ti lu thng MV)

TL : Fraker TD, Fihn SD et al. JACC 2007, 23 : 2264-2274

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C v t bnh MV mn

iu tr i tho ng
I IIa IIb III

Thay i li sng
iu tr bng thuc, gi HbA1C# bnh
thng

I IIa IIb III

Ci thin tch cc cc YTNC (TD : vn


ng, cn nng, huyt p, cholesterol)

TL : Fraker TD, Fihn SD et al. JACC 2007, 23 : 2264-2274

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C v t bnh MV mn

Chng kt tp tiu cu/khng ng


I IIa IIb III

ASA 75-162mg/ngy
Sut i

I IIa IIb III

Warfarin + ASA v/hoc clopidogrel : kh


nng tng xut huyt, cn theo di st

TL : Fraker TD, Fihn SD et al. JACC 2007, 23 : 2264-2274

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C v t bnh MV mn

iu tr chng kt tp tiu cu trn


bnh nhn c triu chng tiu ho do
aspirin
- Thay bng clopidogrel
-

Trng hp cn kt hp aspirin v clopidogrel:


Thuc c ch tit acid d dy:
TD: Pantoprazole hoc Ranitidine
Dit Helicobacter Pylori
Liu thp aspirin 75-81 mg/ngy
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C v t bnh MV mn

Chn bta
I IIa IIb III

Chn bta : tt c bnh nhn


NMCT, hc/MV cp hoc RLCN
TT c hay khng triu chng c
nng

TL : Fraker TD, Fihn SD et al. JACC 2007, 23 : 2264-2274

30

C v t bnh MV mn

Hu qu
ca chn
bta trn
bnh nhn
TMCB

TL: Morrow DA, Gersh BJ. Chronic Coronary Artery Disease. In Braunwalds
Heart Disease, Saunders Elsevier, 8th ed 2008, p. 1353-1401

31

C v t bnh MV mn

C ch tc dng ca Nitrate

TL: Morrow DA, Gersh BJ. Chronic Coronary Artery Disease. In Braunwalds
Heart Disease, Saunders Elsevier, 8th ed 2008, p. 1353-1401

32

C v t bnh MV mn

Phng nga cm
I IIa IIb III

Thc hin hng nm trn tt c


bnh nhn tim mch

TL : Fraker TD, Fihn SD et al. JACC 2007, 23 : 2264-2274

33

C v t bnh MV mn

Ti lu thng ng mch vnh

Phu thut bc cu MV (CABG)

Can thip MV qua da (PCI)

34

C v t bnh MV mn

Ch nh ti lu thng MV
1.
2.
3.
4.

iu tr ni khng kim sot triu chng


Trc nghim khng xm nhp: nhiu vng c tim c
nguy c
Kh nng thnh cng cao; nguy c tt bnh v t vong
chp nhn c
Bnh nhn mun can thip d c ct ngha nguy
c TT can thip

TL: Fox K et al. Guidelines on the management of stable angina pectoris. Eur. Heart Journal
2006; 27: 1341 - 1381

35

C v t bnh MV mn

Chng ch nh ti lu thng ng mch vnh


Tn thng 1 hoc 2 nhnh MV khng phn gn LTT,
c t hay khng TCCN v cha iu tr ni hoc vng
TMCB t
2. Hp tng i (50-70%) khng thn chung MV v
khng TMCB /TNGS
3. Hp khng c ngha (<50%)
4. Th thut nguy c cao (>10-15% t vong)
LTT = nhnh lin tht trc; TCCN = triu chng c nng
1.

TL: Fox K et al. Guidelines on the management of stable angina pectoris. Eur. Heart Journal
2006; 27: 1341 - 1381

36

C v t bnh MV mn

PCI c li hn iu tr ni bnh
MV mn khng?

37

C v t bnh MV mn

Hu qu trn t vong do NMCT v do mi nguyn nhn /


iu tr ni ti u so snh vi PCI: n/c COURAGE

TL: Boden WE et al. N. Engl J Med 2007: 356:1503

38

C v t bnh MV mn

J Am Coll Cardiol Intern 2008; 1: 34 - 43

39

C v t bnh MV mn

Nghien cu gop so sanh PCI vi


ieu tr noi

TL : Holmes DR et al. J Am Coll Cardiol Interv 2008 ; 1 : 34 - 43

40

C v t bnh MV mn

Phu thut bc cu ng mch vnh

TL: Tector AJ et al. J


Thorac Cardiovasc Surg
1986; 91:9
41

C v t bnh MV mn

Khuyn co iu tr ti lu thong mch nhm


ci thin tin lng b/n au tht ngc n nh
(1)
Loai I
1. BCMV/ hep co y ngha than chung MV hoac tng ng
(hep nang phan gan nhanh xuong trc hoac nhanh
mu (chng c A)
2. BCMV/ hep co y ngha phan gan 3 nhanh MV (chng
c A)
3. BCMV/ hep nang phan gan nhanh xuong trc MV/
TMCB cai thien c khi trac nghiem khong xam nhap
(chng c A)
4. BCMV/ hep co y ngha MV kem roi loan chc nang
that trai/ con cai thien c (chng c B)
BCMV = bac cau ong mach vanh; TMCB = thieu mau cuc
bo
TL: Fox K et al. Guidelines on the management of stable angina pectoris. Eur. Heart Journal 2006; 27: 1341 - 1381
42

C v t bnh MV mn

nh hng ca phu thut BC


MV trn sng cn

TL: Morrow DA, Gersh BJ. Chronic Coronary Artery Disease. In Braunwalds
Heart Disease, Saunders Elsevier, 8th ed 2008, p. 1353-1401
43

C v t bnh MV mn

Ch nh ti thng MV bng phu thut hay


bng PCI (2009)

TL:Patel MR et al. ACCF/SCAI/ AATS/ AHA/ ASNC 2009 Appropriateness Criteria for
Coronary Revascularization. J Am Coll Cardiol 2009; 53: xxx- xx
A= appropriate (ph hp); U : Uncertain (khng chc chn)
I = Inappropriate(khng ph hp)
44

C v t bnh MV mn

Phng nga tin pht v th pht


bnh MV mn: hiu qu cao

45

C v t bnh MV mn

Tin trin ca x va ng mch

TL: Gaziano JM et al. Primary and secondary Prevention of Coronary Heart Disease. In Braunwalds 46
Heart Disease, ed by Libby, Bonow, Mann, Zipes Saunders Elsevier 2008, 8 th ed p. 1119-1145

C v t bnh MV mn

Cc yu t nguy c can thip c


hay khng can thip c

TL: Gaziano JM et al. Primary and secondary Prevention of Coronary Heart Disease. In Braunwalds 47
Heart Disease, ed by Libby, Bonow, Mann, Zipes Saunders Elsevier 2008, 8 th ed p. 1119-1145

C v t bnh MV mn

Kt Lun

Chn on BMV: lm sng, cn lm sng


khng xm nhp, MSCT angio, chp MV.
Ch : ch nh MSCT angio: II b
iu tr BMV mn
- Ni khoa c bn
- Ti lu thng MV: cn cn nhc k
Phng nga tin pht v th pht: rt cn thit

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