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CHNG I TIM MCH

THP TIM Mc tiu 1. Nm c cc du chng lm sng v cn lm sng ca thp tim. 2. Vn dng chn on v iu tr thp tim. 3. Nm c tm quan trng ca phng thp s cp v th cp. Ni dung I. I CNG 1. Thp tim: l mt bnh vim nhim ton th, biu hin nhiu c quan m ch yu l khp v tim, bnh c nhng c im sau: - L hu qu chm ca vim ng h hp trn do liu cu tan huyt nhm A. - Xut hin thnh tng t cch nhau hng thng, hng nm c khi c chc nm. - C ch sinh bnh nghing v t min. - Thng tn van tim c th mn tnh, tin trin a n suy tim. - Phng bnh hu hiu. 2. Dch t hc - Tui tr: 5 -15 tui. - Ma lnh m lm d vim hng. - Sinh hot vt cht: bnh ca th gii chm pht trinth 3, ca nhng tp th sng chen chc cht chi. - Bnh xy ra sau vim hng lin cu nng, c khi sau vim hng lin cu khng r, d ti pht bnh nhn thp tim c khi b ti nhim lin cu. II. BNH NGUYN, C CH SINH BNH 1. Bnh nguyn

Lin cu tan huyt nhm A l vi trng gy bnh do hin tng qu mn sau nhim lin cu. Nu cn c vo Protein M th c khong 60 type khac nhau, lin cu gy vim hng thuc type 1, 2, 4, 12. T l mc bnh khong 30%. 2. C ch sinh bnh - Cha r, nghing v t min. C s tng t gia khng nguyn ca lin cu v khng nguyn tim (mang khng th chng liu cu v tim, protein M, khng nguyn glycoprotein c bit ging protein ca van tim). - Khng th (KT) c hiu: Khng th chng tim, chng t bo no, KT chng Glycoprotein, Antistreptolysin O. Cc khng th ny tng t tun th 1 n tun th 4 ca bnh. - C a di truyn: D mc bnh, c nguy c ti pht ko di sut i. III. GII PHU BNH Thng tn tin trin

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1. Giai on u: c ph m lin kt, thm nhim t bo thoi ha dng fibrin, c th hoi t (c tim). 2. Giai on sau - C ht Aschoff nm gn mch mu, ht ny c cu to: + Trung tm l mt vng hoi t dng fibrin, sau n mt vng t bo dng biu m vi nhng t bo khng l nhiu nhn ngoi cng l t bo a dng nht l lympho v tng bo. + Nhng nt ny tn ti nht l mng trong tim gy ra cc nt so van tim v ct c ca van tim. -Thng tn tim: c th c 3 lp cu to tim v m lin kt. - Mng trong tim: Thng tn vnh vin van hai l 40%.Van 2 l + van ng mch ch 40%. Van ng mch ch n thun 10-15%. Van dy x cng cun li gy h, van dnh cc mp li gy hp. - C tim: Gin cc si c tim, vim x, thm nhim t bo a nhn dng Aschoff. - Mng ngoi tim: Tn thng c hnh thi si khng c hiu hay phn ng vim dng fibrin v thng c dch mu vng khong 200ml c khi mu , c. - Tn thng m lin kt: Vim thoi ha dng fibrin. + Tn thng khp: tit dch fibrin, v trng, khng n mn mt khp. + Thng tn no: Gp th vn gy ma git. + Thng tn da: l cc ht Meynet cn gi l ht Aschoff ngoi da. IV. TRIU CHNG HC 1. Lm sng: Thay i nhiu ty c quan b tn thng v trm trng. 1.1. Khi pht - St cao t ngt du nhim c nu biu hin vim khp l chnh. - St t t, st nh khng r nu vim tim l chnh. 1.2. Khp: in hnh l vim cc khp ln l chnh vi sng - nng - - au hn ch c ng di chuyn hi phc nhanh chng trong vng 2 - 3 tun nht l khi c iu tr, lnh hon ton khng li di chng khp, cc khp thng gp l: khp vai, khp gi, khuu, c tay, c chn, c khi khng vim in hnh, c vi trng hp khng biu hin khp. 1.3. Tim: Vim tim l biu hin nng nht ca thp tim, l biu hin duy nht c li thng tn quan trng vnh vin v gy cht ngi. C th gy vim tim c 3 lp cu to ca tim: - Vim mng ngoi tim + Tim tng gy au vng trc tim. + C khi nghe c ting c mng ngoi tim. - Vim c tim + Ting tim m + Suy tim nhp nhanh, c ting nga phi, c ngoi tm thu, cng c khi nhp tim rt chm, lon nhp. Bloc nh tht cc cp. - Vim mng trong tim: + Hay gp l cc ting thi tm thu mm, ting RTC mm, ting thi tm trng y tim do h van MC.

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1.4. Nhng biu hin khc - Thn kinh: + Ma git: l nhng c ng khng t , nhanh bin ln chi, c, mt. Trng lc c gim, xut hin mun v thng gp n. + Vim no v vim dy thn kinh cng c th gp. - Ngoi da + Nt di da (ht Meynet) ng knh vi milimt n 1cm thng thy mt dui ca cc khp ln, mt chc khng au, khng c du hiu vim thng xut hin mun. + Ban vng: vng cung khng thm nhim, thay i nhanh, gp thn v gc chi. - Thn: Vim thn tng : c protein niu nh, huyt niu vi th. Cng c khi gp vim cu thn cp lan ta. - Phi v mng phi: Trn dch mng phi, ph phi xung huyt mt hay hai bn. - Bng: au bng c khi nhm vi rut tha vim. 2. Cn lm sng 2.1. Biu hin phn ng vim cp trong mu - VS tng cao thng >100 mm trong gi u. - Bch cu tng 10.000 - 15.000/mm3 ch yu a nhn trung tnh. - Fibrinogen tng: 6 - 8 g/l; Tng (2 v gamma Globulin. - Creactive Protein (CRP) dng tnh. 2.2. Biu hin nhim lin cu - Cy dch hng tm lin cu: Ngoi t vim ch 10 % dng tnh. - Khng th khng lin cu tng trong mu > 500 n v Todd/ml. - Antistreptokinase tng gp 6 ln bnh thng. 2.3. in tim: Ri lon dn truyn nh tht, PR ko di. C cc ri lon nhp: NTT, bloc nh tht cc cp. 2.4. X quang: Bng tim c th ln hn bnh thng. V. TIN TRIN V BIN CHNG 1.Th thng thng: Lm sng ci thin rt nhanh. - Triu chng khp gim sau 24h, PR di ra sau vi ngy, VS tng sau 2 - 3 tun. - Tt c cc triu chng mt sau 2 thng. 2. Th nng - Thp tim c tnh + Gp tr nh < 7 tui. + Vim tim ton b c bit l c tim cp hoc no, thn, phi. + St kn o au khp t. + iu tr t kt qu. - Th tin trin + Tin trin chm hn. + C s ni tip cc t cp v t lui bnh. + Lun b di chng trm trng tim.

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3. Th di chng: Thng mng trong tim: - Van hai l: Tn thng nhiu nht gy h hp van 2 l sau 2 nm. -Van ng mch ch: Hp h van ng mch ch, h MC n thun cn hp th him. - Van 3 l: him, thng kt hp vi cc van khc. 4. Vim mng trong tim nhim khun: bin chng ng s nht, Osler hay gp h cc van hn l hp. 5. Ti pht: Hay gp bnh nhn khng d phng tt. VI. CHN ON 1. Chn on xc nh: Kh khn trong t thp u tin, da vo cc tiu chun ca Jones. 1.1. Tiu chun chnh - Vim tim. - Ban vng. - Vim khp. - Nt di da. - Ma git. 1.2. Tiu chun ph - St - au khp - PR ko di - VS tng, bch cu tng, C Reative Protein (+) - Tin s thp hay b bnh tim sau nhim lin cu. 1.3.Tiu chun mi b nhim liu cu - Tng dn nng khng th khng lin cu. - Va b bnh tinh hng nhit (Scarlatine). Khi chn on thp tim phi c 2 tiu chun chnh, hoc 1 tiu chun chnh + 2 tiu chun ph v mi b nhim lin cu. 1.4. Nhng k thut mi - Siu m 2 bnh din c th thy trn dch mng tim, cc bin i cc van tim, mc ri lon chc nng tim. - Siu m Doppler: Pht hin h van 2 l, van MC, nh gi mc h. 2. Chn on phn bit 2.1. Vim a khp dng thp: Vim nhiu khp nh, bin dng khp, teo c, cng khp, tin trin ko di. 2.2. Vim khp do lu cu: Vim 1 khp thng khp gi, dch khp c vi khun. 2.3. Lao khp: C th suy kit, st dai dng, thng sau lao phi, khp thng gp: khp hng, ct sng lng. 2.4. Lupus ban : Ban hnh cnh bm ngoi da, bin i mu da, au nhiu khp, thng tn thn nng, tn thng mng phi, bng. 2.5. Vim mng ngoi tim, c tim do virus: Bnh rm r, cp tnh, st cao, c mng ngoi tim, khi hon ton khng li di chng. VII. TIN LNG: Ph thuc vo tn thng tim.

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- Nu khng tn thng tim t u hoc vim tim nhng tim khng to, chn on v iu tr sm, d phng y , khng ti pht th tin lng tt 90% phng c bin chng tim. - Nu tn thng tim t u khng d phng y theo phc th tin lng xu i nhiu. - Theo Fridberg v Jones: 10 - 20% bnh sau t thp tim u s tr thnh tr tn ph. T vong sau 2 - 6 nm. - S cn li sng n tui trng thnh: - 65% bnh nhn sinh hat bnh thng. - 25 % sng sc khe gim st nhiu v l gnh nng cho gia nh v XH. VIII. KT LUN - L bnh gp ngi tr, nguyn nhn do lin cu. - Bnh cnh a dng. - Chn on ban u kh, khi chn on c k c k thut mi th tim b vim. - Din bin kh lng, d phng sut i ni ln tm quan trng tc ng ln tim c bit l bung tim tri.

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BNH HP VAN HAI L Mc tiu 1. Nm vng cc triu chng lm sng v cn lm sng ca bnh van hai l. 2. Nm c cc th lm sng ca bnh van hai l. 3.Nm vng cc phng tin iu tr ni khoa bnh van hai l. 4. Nm vng ch nh iu tr ni khoa, iu tr ngoi khoa v phng nga cc bin chng Ni dung I. I CNG Hp van hai l l mt bnh kh ph bin nc ta chim khong 40,3% cc bnh tim mc phi. Bnh c pht sinh loi ngi t khi bt u sng thnh tng qun th do iu kin sinh sng thp km, cht chi thiu v sinh d gy ly nhim bnh. T 1887 Bouillaud ri Sokolski m t bnh. n 1920 Duckett Jones (Hoa k) nghin cu bnh ny v n 1944 ng mi cng b by tiu chun chn on bnh.. Cng nhng nm ny Cutter v Levine Phillipe (Hoa k) tm cch phu thut hp van hai l ng thi trong nm Souttar ti Anh cng m c hp van hai l. Giai on ny bnh hp van hai l l bnh tim mch ph bin nht, gy tn ph v t vong nhiu. T nm 1944 vic pht minh ra Penixillin dit cc loi lin cu v c bit to ra loi Penixillin chm (Benzathyl Penixillin) c tc dng phng nga bnh ny do n nay cc nc pht trin nh Thy in, H lan v c bnh thp tim gn nh mt hn. Tuy vy, cc nc chm pht trin bnh ny cn ang ph bin. Bnh hay gp tui lao ng 20 - 30 tui t l bnh hp hai l rt cao khong 60 - 70 %, t l t vong n 5%. Bnh c nhiu bin chng phc tp v a n tn ph. Bnh gp n nhiu hn nam (3/1) v nng thn mc nhiu hn thnh th. II. BNH NGUYN V C CH SINH BNH Ch yu do thp tim 99%, s cn li do bm sinh, hoc do Carcinoid c tnh, lupus ban h thng, vim khp dng thp c nghin cu cn cho l do virus Coxsackie gy ra. Tc nhn gy bnh ch yu l do lin cu khun tan huyt nhm A gy vim hng gy tn thng thp tim. S d lin cu hng gy bnh thp tim m khng vo cc c quan khc l do c cc ng thng bch mch gia hng v tim. Cu trc bo thai hc cho thy c ng ni mch mu v thn kinh gia tim v c. Nm 1976 Taranta (Hoa k) chng minh c c ch bnh sinh trc tip ca c t lin cu khun ln tim. Cc khng th khng tim xut hin bnh nhn thp tim c vim tim, c c cc phn ng khng nguyn cho gia cc cu trc tim v lin cu A. Ni tm li c ch sinh bnh nh sau: - Lin cu khun nhm A xm nhp vo c th gy vim hng ng thi sinh ra nhng c t. Ngoi ra, trong m tim ngi ta cng tm thy nhng cht liu c cu trc min dch ging protein M v vy cc khng th hnh thnh cng chng lun li cc van tim. - Hin tng t min cho nhm ln gy vim tim v vim khp. Vim tim c th t khi nhng sau 2 nm n c th li di chng van tim, c 3 bnh nhn th c 1 bnh nhn b di chng van tim nh dy dnh x gy hp van tim.

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III. TRIU CHNG HC 1. Lm sng 1.1. Ton thn: Nu mc bnh trc tui dy th, bnh nhn km pht trin th cht gi l ln hai l (nanisme mitral). Nu xy ra sau tui dy th tr pht trin gn nh bnh thng. 1.2. C nng - C khi pht hin tnh c bi khm sc khe hng lot m bnh nhn khng c triu chng c nng no ngay c khi gng sc. - C khi bnh nhn i khm v kh th, ho v khc ra mu, hi hp nh trng ngc, nut nghn do tm nh chn p vo thc qun nht l khi gng sc. 1.3. Du chng thc th: Nghe tim l ch yu, c th nghe khi nm nga, nm nghing tri hoc c khi phi bnh nhn lm ng tc gng sc. Hp van hai l in hnh thng nghe c cc du chng sau theo tn sut hay gp. - Ting T1 anh mm (do van x dy p vo nhau). - Rung tm trng (RTTr) mm do van hp lung mu b tng mnh xung tht tri va vo cc ct c v cu c tht tri b vim dy x cng, vi ha hoc RTTr mt khi van hp kht, van v t chc di van dy, vi ha, dnh vi nhau. - T2 mnh y tim do s tng p lc ng mch phi do hai van MC v MP ng khng cng lc to nn T2 tch i (van MP ng mun hn van MC). - Ting thi tin tm thu gia tim hay mm do lung mu i qua ch hp nu cn li nh tri, nh tri phi bp thm mt ln na y nt s mu xung tht tri; nhng khi b rung nh hay nh tri gin ri th khng cn nghe ting thi tin tm thu na. - Ting clc m van hai l mm hoc trong mm. Ting ny ch c khi van cn mm. - Khi p lc ng mch phi tng cao tht phi gin nhiu lm gin vng van MP gy ra ting thi tm trng van MP gi l ting thi Graham - Steel. Cng c nhng trng hp hp van hai l khi khm bnh khng nghe c g m nh bin chng v nh cn lm sng nht l siu m gi l hp van hai l cm. 2. Cn lm sng 2.1. in quang: C 2 t th thm d trong hp van 2 l: - T th thng: + Bn phi: Tm nh tri to ln sang pha phi thng c 3 giai on. Giai on 1: Nh tri to to thnh 2 cung song song vi b trong l nh tri, b ngoi l nh phi. Giai on 2: Nh tri to ln ra ct cung nh phi, to thnh hai cung ct nhau. Giai on 3: Nh tri to ln ra ngoi to thnh 2 cung song song m cung ngoi l nh tri v cung trong l nh phi (ngc vi giai on 1). + Bn tri: c 4 cung: cung MC, cung MP, cung tiu nh tri, cung di tri vi mm tim hch ln (tht phi ln). Rn phi: m, to nn 2 bn bng tim hai khong m rng v ranh gii khng r. Hai ph trng m do huyt, c th thy c hnh Kerley B. Nu khi c tnh trng tng p lc MP ch ng th thy vng rn phi m v vng ra phi rt sng.

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- Trn phim nghing c ung bart: thc qun b chn p 1/3 gia. Mt khong sng trc tim hoc sau xng c (tht phi ln). 2.2. in tm - Giai on u cha hp kht hoc cha nh hng nhiu trn cc khoang tim: in tim cn bnh thng. - Giai on sau: dy nh tri vi P (0,12s hoc P hai pha, pha m ln hn pha (+) V1. Trc in tim lch phi v dy tht phi. Ngoi ra cn c th thy tnh trng ri lon nhp nh ngoi tm thu nh, nhp nhanh nh, rung nh l hay gp hn c. C th c blc nhnh phi khng hon ton. 2.3. Siu m tim

L phng tin chn on xc nh chnh xc hp van hai l nht l khi hp van hai l trn lm sng khng pht hin c. Siu m cn cho php ta nh gi van v t chc di van c dy khng ta c quyt nh thay van hay tch van. Trong hp n thun

- Kiu mt bnh din: Van l van trc v sau dnh vo nhau nn di ng song song cng chiu, cc l van dy ln. Van c dng hnh cao nguyn hay giy trt tuyt. dc tm trng EF b gim. Nu hp kht dc tm trng c th gim

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- Giai on 1: Khng c triu chng c nng k c khi gng sc. Khm lm sng pht hin tnh c. - Giai on 2: C hi chng gng sc r: Kh th, hi hp, nh trng ngc, ho hoc ho ra mu, cha c biu hin suy tim. - Giai on 3: C kh th nhiu, c suy tim phi nhng iu tr c hi phc. - Giai on 4: Hp van 2 l c suy tim nng, iu tr khng hi phc. 4. Chn on th 4.1. Th n thun: c th dung np tt, bnh nhn cha c du hiu c nng v thng pht hin bnh tnh c. - Th in hnh: Nh m t trn v khi khm lm sng, X quang, in tim c th chn on c. - Hp van hi l cm: Bnh nhn c th c hoc khng c triu chng c nng. Nghe tim khng thy cc du hiu c trng cc hp van hai l. Th ny i hi tm cc bin chng ca hp van hai l v cn lm sng nht l siu m tim gip chn on. - Th tin trin: thng l nhng trng hp hp van hai l khp hay rt kht. Bnh nhn vo vin vi cc bin chng nng n. Ri lon nhp, hen tim, ph phi cp, tc mch vv... 4.2. Th phi hp - Hp hai l phi hp h van hai l: phi phn bit h hai l l chnh, hp l ph hay ngc li.Nu h van hai l l ch yu: nghe TTT mnh mm tim ting thi to, lan xa, s c rung miu tm thu. Rung tm trng nh, X quang, siu m, in tim c dy gin tm tht tri v nh tri. Ch yu siu m tim nh gi c mc h hai l c bit l vi siu m Doppler. - Phi hp vi bnh van ng mch ch. + Hp van hai l phi hp h ng mch ch: ngoi hp van hai l cn nghe ting thi tm trng lin sn III bn tri v lin sn II bn phi lan xung dc b c tri, in tim c dy tht tri, siu m doppler tim cho php chn an. + Hp hai l kt hp hp ng mch ch: ngoi triu chng hp van hai l cn nghe thm ting thi tm thu lin sn III bn phi v lin sn II bn phi lan ln 2 bn ng mch cnh km s rung mu. Chn on in tim c dy tht tri tm thu, X quang v siu m tim cho php chn on. - Hp van hai l kt hp bnh van 3 l: + Hp hai l kt hp h 3 l: nghe TTT trong mm tim hoc ngay mi c. ting TTT mnh ln khi ht vo su v nn th, c th s gan to v p theo nhp p ca tim. Tnh mch c p. Phi thng sng hn. + Hp van hai l kt thng lin nh: Hp hai l kt hp thng lin nh gi l hi chng Lutembacher. Chn on xc nh nh siu m tim v thng tim. Hp van hai l c th cn phi hp vi cc bnh l tim mch khc nh tng huyt p nhng him gp 5. Chn on bin chng

Hp van hai l thng c cc bin chng sau. 5.1. Ri lon nhp tim - Ri lon nhp xoang thng l nhp nhanh. Ngoi tm thu nh, cn nhanh trn tht.

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- Cung nh v rung nh l nhng bin chng nng n ca HHL. T nhng ri lon nhp tim nay c th gy ra bin chng tc mch ngoi vi v cng lu s dn n suy tim phi. 5.2. Tc mch: C 2 c ch tc mch: - Tc mch vng i tun hon: Do mu nh tri chm lu chuyn xung tht tri nn mu d ng. Nu cc ri lon nhp nhanh nh rung nh, nhp nhanh trn tht to iu kin thun li hnh thnh cc mu ng. Sau khi nhp tim chm li cc mu c a xung tht tri v vo i tun hon gy tc mch no, chi, thn, mc treo vv... - Tc ng mch phi: Do cc mu ng c hnh thnh t cc tnh mch ngoi bin, vo tht phi gy tc ng mch phi. Hoc c th do p lc phi tng trong hp hai l nn c th hnh thnh cc mu ng ti ch gy tc ng mch phi. 5.3. Nhim trng - Nhim trng ti phi do mu ng mch phi l mi trng pht trin cho vi trng: C th vim phi lan ta, vim phi khu tr. - Nhim trng ti tim c th gy ra vim ni tm mc bn cp Osler. Bin chng ny him gp nhng khi xy ra th tin lng xu v iu tr kh v c th tht bi. 5.4. Suy tim - C th c cn hen tim ph phi cp hay gp khi gng sc hoc ban m. Do mu ng trong phi nhiu ban m thn kinh ph giao cm hot ng mnh nn lm dn mch, thot huyt tng vo ph nang gy ph phi. - Suy tim phi. y cng l bin chng ng thi cng l giai on cui cng ca bnh. Nu khng c iu tr trit . Cc bin chng trn c th xy ra khi bnh nhn gng sc v tinh thn, th cht v nhn mt nhim trng da, phi. c bit ph n c thai, lc chuyn d hay thi k kinh nguyt. VI. IU TR 1. iu tr ni khoa Ch c tc dng tt khi hp van hai l mc nh v trung bnh. Nu hp kht, vi din tch l van

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Khi iu tr Digital cn lu du chng ng c Digital nh: - Bnh nhn nn ma, au bng, m mt, nhn i, i cu phn lng. - Ngoi tm thu tht nhp i hay c tnh. - Hoc nhp tim tng vt ln (trong khi ang dng Digital) hoc chm li vi Blc nh tht cc cp, hoc nhp b ni. - Nu xut hin cc triu chng trn nn ngng Digital v cho tng cng thm Kali bng ng tnh mch hoc ng ung, ch b sung thm Mg++. 1.1.4. Cc thuc gin mch - c s dng nhiu trong nhng nm gn y. Thuc gin mch c th iu tr lin tc, ko di. Thuc gin mch c tc dng gim tin gnh, hu gnh gip cho suy tim hi phc tt. - i vi suy tim trong hp hai l tt nht l nhm Nitrat v dn xut nht l khi hp hai l c tng p lc ng mch phi, ph phi mn tnh v cp tnh. Risordan LP 20 mg x 1-2 vin / ngy, hoc Imdur (mononitrate Isosorbid) 60 mg x 1/2 - 1 vin / ngy. 1.2. iu tr phng tc ng mch h thng - Tc mch c th: ng mch no, ng mch mc treo, ng mch ngoi v, ng mch lch, ng mch thn, ng mch vnh..... - Bin chng tc mch gia tng bnh nhn hp van hai l c bin chng rung nh v suy tim, c bit khi mi xut hin rung nh. - hp van hai l c bin chng tc mch nhiu hn h van hai l. 20-60% tc li ln th hai sau tc ln th nht trong 6-12 thng nu khng c d phng hu hiu bng cc thuc chng ng. - iu tr tc mch cng sm cng tt: + Heparin 10.000 - 20.000 UI / ngy x 5 - 10 ngy. C th dng Heparin c trng lng phn t thp c bit i vi tc mch no. Sau dng cc thuc khng ng loi khng Vitamin K nh Sintrom, Previscan, Dicoumarin gi u 48-72 gi trc khi ngng Heparin duy tr t Prothrombin cn khong 30-35% hoc IRN 2,5-3 l tt nht. + Sau khi chuyn rung nh v nhp xoang bng thuc hoc sc in, nong van hai l l phng php d phng tc mch ti pht tt nht. Hoc nhng bnh nhn khng c iu kin nong van, phu thut s van, thay van c th ung thuc d phng tc mch ko di nhiu nm liu thp 100 - 500 mg / ngy bng Aspirin (aspegic 100mg), dipiridamole vv... 1.3. iu tr d phng - Phng thp ti pht bng Benzathylpenixilin 1,2 triu n v mi 15-20 ngy, tim bp su sau khi th test. - Ngoi ra phng bi nhim phi hoc Osler bng khng sinh Penixilin nhanh hoc Erythromycin 0,5g trc cc can thip nh nh rng, x nht ngoi da vv... Khi c du hiu vim tnh mch chi di c th phng tc ng mch phi bng cch t li lc tnh mch ch di. 2. iu tr ngoi khoa iu tr phu thut van hai l c nhiu tin b. Nong van hai l bng tay hoc bng dng c hoc bng bng (catheter baloon). 2.1. Nong van hai l bng bng a ng thng qua ng tnh mch i i vo nh phi, xuyn qua vch lin nh vo nh tri nong van 2 l bng bng. K thut ny c thc hin ti Vit

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Nam. Phng php ny c ch nh cho bnh nhn tr tui

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+ Van Kuy-Suzuki thay bng bi bng a phng, c nhiu u im v huyt ng hn dng van bi, khi phu thut thay van t l t vong thp hn, gim qu trnh to cc mu ng van v quanh van, l van nhn to mi nht c ci tin t van Starr. Vi hnh dng v cht liu khc nhau nh Titanium, Teflon, Pyrolytic-carbon, Silastic, Polyproline.... to c nhiu loi van khc nhau: + Cuged-ball + Starr-Edwards: 7 loi. Smeloff-custer: 2 loi: Braald-custer, Cuged-disc + Beall c 5 loi: Kay-Shiley, Kay Suzuki, Starr-Edwards, Cooley-Cutter, Tilting disc. + Bjork-Shiley c 3 loi + Lalehei-kaster: 4 loi Tng cng c 27 loi van nhn to - Van hai l sinh hc: Phc hi mt cch c bn huyt ng, khng b nhim khun, khng to cc mu ng, khng b thng t vng van sau thi gian di phu thut, v vy n m ra trin vng pht trin sau ny. 2.4. Bin chng sau khi thay van Ngoi cc bin chng nh nong van cn c thm cc bin chng. - t t trong khi phu thut - t t do hot ng ca van b ri lon. - Dnh kt Fibrin, sau vi ho ti van v quanh van mn. - Osler do vi khun v nm. - Abces quanh vng van. - H quanh vng van hai l. - Block nh tht cp cao hoc bloc b His (do ct cc tr c) - Hp hoc h MC th pht sau thay van hai l - Gim kh nng b p tun hon khi gng sc. - Kh iu tr bng phng php sc in, to nhp khi cn thit. iu tr nong van hai l hay phu thut tim kn hay h cn tip tc iu tr phng thp, phng Osler, iu tr chng ng, suy tim th mi ko di cuc sng ca bnh nhn.

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TNG HUYT P Mc tiu 1. Nm vng kin thc c bn v tng huyt p, mt bnh tim mch ph bin hin nay. 2. Nm vng phn loi, cc bin chng ca tng huyt p cng nh cc c ch sinh bnh tng huyt p 3. Nm vng cc nhm thuc v tc dng dc l, ch nh v tc dng ph trong iu tr tng huyt p. 4. Vn dng c phc iu tr tng huyt p trong thc tin lm sng Ni dung I. I CNG 1. Dch t hc Tng huyt p (THA) l triu chng ca nhiu bnh, nhiu nguyn nhn nhng c th l mt bnh, bnh tng huyt p, nu khng tm thy nguyn nhn. cc nc Chu u - Bc M t l tng huyt p trong nhn dn chim 15 - 20% ngi ln. C th nh sau: Benin 14%- Thi lan: 6.8%- Zaire:14%- Chile: 19-21%, Portugaise: 30%, Hoa k: 6-8%. Nhn chung t l rt thay i. Vit Nam, t l tng huyt p chung l 11,8% (B Y T Vit Nam, 1989). T l ny gia tng ng quan tm v trc 1975 t l ny min Bc Vit nam ch c 1-3%(ng Vn Chung). Ti BVTW Hu nm 1980 t l THA trong s cc bnh ni khoa ch c 1% nhng 10 nm sau, nm 1990, tng n 10%. Thng k gn y nht ca Vin Tim Mch ti Min Bc Vit Nam cho thy t l THA l 16,3% (2002). 2. nh ngha T chc Tng huyt p Th gii (TCYTTG) v U ban Quc gia Cng lc Hoa k (1997) u thng nht mt ngi ln b tng huyt p khi huyt p tm thu trn hoc bng 140mmHg v hoc huyt p tm trng trn hoc bng 90mmHg. nh ngha ny n gin nhng c nhc im l tr s huyt p khng hon ton n nh v huyt p thay i theo tui, gii... II. BNH NGUYN V C CH SINH BNH 1. Bnh nguyn 1.1.Tng huyt p nguyn pht: chim gn 90% trng hp b tng huyt p (theo Gifford - Weiss). 1.2. Tng huyt p th pht

- Bnh thn: Vim cu thn cp, vim cu thn mn hai bn do mc phi thn a nng, nc b thn, u thn lm tit rnin, hp ng mch thn...

- Ni tit + Bnh v tuyn thng thn, hi chng Cushing, hi chng Conn, u sn

xut qu tha cc Corticosteroid khc (Corticosterone, desoxycortisone), sai lc trong sinh tng hp Corticosteroid.

+Bnh ty thng thn, u ty thng thn (Pheochromocytome). - Bnh tim mch: Bnh hp eo ng mch ch, vim hp ng mch ch

bng cho xut pht ng mch thn, h van ng mch ch. -Thuc: Cc Hormone nga thai, cam tho, carbenoxolone, A.C.T.H.

Corticoides, Cyclosporine, cc cht gy chn n, cc IMAO, cht chng trm cm vng...

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- Nhim c thai nghn. - Cc nguyn nhn khc: Bnh cng gip, bnh Beri-beri. Bnh Paget

xng, bnh a hng cu, hi chng carcinoid, toan h hp, tng p s no... 2. Mt s yu t lm d (thun li): c xem nh c lin quan n tng huyt p nguyn pht tuy vn cn bn ci l - Yu t di truyn, bnh tng huyt p c tnh gia nh. - Yu t n ung, n nhiu mui, n t protit, ung nhiu ru, ung nc mm t Ca++, Mg++, K+. Trong ni bt v c tha nhn l s lin quan gia ion Na+ v tn sut bnh tng huyt p. Ion Na+ lm tng huyt p qua trung gian gia tng th tch mu v nht l qua s co tht mch mu. - Yu t tm l x hi, c tnh trng cng thng (stress) thng xuyn. 3. C ch sinh bnh ca tng huyt p nguyn pht Tng huyt p ng mch thng km theo nhng bin i v sinh l bnh lin quan n h thn kinh giao cm, thn, renin-angiotensin v cc c ch huyt ng, dch th khc (Phm Khu -1982). 3. 1.Bin i v huyt ng - Tn s tim tng, lu lng tim tng dn, thi k u c hin tng co mch phn b li mu lu thng t ngoi vi v tim phi do sc cn mch mu cng tng dn. Tim c nhng biu hin tng hot ng b tr v dn n dy tht tri. Huyt p v sc cn ngoi bin ton b tng dn. Lu lng tim v lu lng tm thu cng gim, cui cng a n suy tim. - Trong cc bin i v huyt ng, h thng ng mch thng b tn thng sm c ton b. Trc kia ngi ta ngh ch c cc tiu ng mch b bin i co mch lm gia tng sc cn ngoi bin. Hin nay, ngi ta thy cc mch mu ln cng c vai tr v huyt ng hc trong tng huyt p. Chc nng t c bit n ca cc ng mch ln l lm gim i cc xung ng v lu lng mu do tim bp ra. Do thng s v dn ng mch (compliance artrielle) biu th tt kh nng ca cc ng mch. S gim thng s ny cho thy cng ca cc ng mch ln, l din bin ca tng huyt p ln cc ng mch v v lu di s lm tng cng tim dn n ph i tht tri. ng thi vic gia tng nhp p (hyperpulsatilit) ng mch a n s h hng cc cu trc n hi sinh hc (bioelastomeres) ca vch ng mch. - Ti thn, tng sc cn mch thn, gim lu lng mu ti thn chc nng thn suy gim tuy trong thi gian u tc lc cu thn v hot ng chung ca thn vn cn duy tr. - Ti no, lu lng vn gi c thng bng trong mt gii hn nht nh thi k c tng huyt p r. - Khi huyt p tng, sc cn ngoi bin tng th tch huyt tng c xu hng gim cho n khi thn suy th tch dch trong mu tng c th tng a n ph. 3.2. Bin i v thn kinh: thi k u nh hng ca h giao cm biu hin s tng tn s tim v s tng lu lng tim. S hot ng ca h thn kinh giao cm cn biu hin lng Catecholamine trong huyt tng v dch no ty nh adrenaline, no-adrenaline, tuy vy nng cc cht ny cng rt thay i trong bnh tng huyt p. - H thn kinh t ng giao cm c iu khin bi h thn kinh trung ng hnh no-ty sng v c hai h ny lin h nhau qua trung gian cc th cm p lc.

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Trong tng huyt p cc th cm p lc c iu chnh n mc cao nht v vi ngng nhy cm cao nht. 3.3. Bin i v dch th - H Renin-Angiotensine Aldosterone (RAA): Hin nay c chng minh c vai tr quan trng do ngoi tc dng ngoi vi cn c tc dng trung ung no gy tng huyt p qua cc th th angiotensine II (UNGER-1981, M. PINT, 1982). C tc gi chia tng huyt p nguyn pht da vo nng renine cao, thp trong huyt tng, c s t l nghch gia nng renine-angiotensine II trong huyt tng v tui. - Angiotensine II c tng hp t angiotesinegne gan v di tc dng renine s to thnh angiotesine I ri chuyn thnh angiotesine II l mt cht co mch rt mnh v lm tng tit aldosterone. S phng thch renine c iu khin qua ba yu t: -p lc ti mu thn - lng Na+ n t ng ln xa v h thn kinh giao cm. S thm d h R.A.A, da vo s nh lng renine trc tip huyt tng hay gin tip phn ng min dch v angiotensine II, nhng tt nht l qua tc dng ca cc c ch men chuyn. - Vasopressin (ADH): c vai tr kh r rng trong c ch sinh bnh tng huyt p c tc dng trung ng gim huyt p (qua trung gian s tng tnh nhy cm thn kinh trung ng i vi phn x p t xoang ng mch cnh v quai ng mch ch) tc dng ngoi vi co mch (trc tip v qua hot ha cc si Adrenergic) (J.F. Liard, 1982. B.Bohns,1982). - Cht Prostaglandin: tc dng trung ng lm tng huyt p, tc dng ngoi vi lm gim huyt p (F.H. UNGER, 1981; MA Petty, 1982). - Ngoi ra cn c vai tr ca h Kalli-Krein Kinin (K.K.K) trong bnh tng huyt p v mt s h c vai tr cha r nh: h Angiotensine trong no v cc encephaline, h cng dopamine bin i hot ng th cm p lc. Mt c ch iu ha lin quan n cc th th Imidazolique trung ng v ngoi bin c ghi nhn t nhng nm 80 vi s xut hin thuc huyt p tc dng ln th cm Imidazole gy dn mch. 3.4.C ch sinh bnh ca tng huyt p th pht: Ty vo nguyn nhn gy bnh. III. TRIU CHNG HC 1. C nng a s bnh nhn tng huyt p khng c triu chng g cho n khi pht hin bnh. au u vng chm l triu chng thng gp. Cc triu chng khc c th gp l xong, hi hp, mt, kh th, m mt... Khng c hiu. Mt s triu chng khc ca tng huyt p ty vo nguyn nhn tng huyt p hoc bin chng tng huyt p. 2.Triu chng thc th 2.1. o huyt p: l ng tc quan trng, cn bo m mt s quy nh. - Bng cun tay phi ph c 2/3 chiu di cnh tay, b di bng qun trn khuu tay 2cm. Nu dng my o thy ngn nu dng loi l xo phi iu chnh 6 thng 1 ln. - Khi o cn bt mch trc. Nn bm n khong 30mmHg trn mc p lc lm mt mch (thng trn 200mmHg) x xp nhanh ghi p lc khi mch ti xut hin, x xp ht. t ng nghe ln ng mch cnh tay, bm nhanh bao hi n mc 30mmHg trn p lc ghi, x chm t t vi tc 2mmHg trong 1 giy (hay

17

mi nhp p). Huyt p tm trng nn chn lc mt mch (pha V Korottkoff). tr em v v ph n c thai nn chn pha IV Korottkoff. - Nu o li ln 2 cn ch 30 giy. Nu lon nhp tim phi o li ln 3 v ly trung bnh cng ca cc tr s. - Phi o huyt p nhiu ln, trong 5 ngy lin. o huyt p c chi trn v chi di, c t th nm v ng. Thng thng chn huyt p tay tri lm chun. 2.2. Du hiu lm sng - Bnh nhn c th bo ph, mt trn trong hi chng Cushing, c chi trn pht trin hn c chi di trong bnh hp eo ng mch ch. Tm cc biu hin x va ng mch trn da (u vng, u m, cung gic mc..). - Khm tim mch c th pht hin sm dy tht tri hay du suy tim tri, cc ng mch gian sn p trong hp eo ng mch ch. S v nghe ng mch pht hin cc trng hp nghn hay tc ng mch cnh trong ng mch ch bng... - Cn lu hin tng (huyt p gi) gp nhng ngi gi i ng, suy thn do s x cng vch ng mch lm cho tr s huyt p o c cao hn tr s huyt p ni mch. C th loi tr bng cch dng th thut Osler hay chnh xc nht l o huyt p trc tip. Mt hin tng khc cng ang c c gng loi tr l hiu qu o chong trng bng cch s dng phng php o lin tc huyt p (Holter tensionnel). - Khm bng c th pht hin ting thi tm thu hai bn rn trong hp ng mch thn, phng ng mch ch hoc khm pht hin thn to, thn a nang. - Khm thn kinh c th pht hin cc tai bin mch no c hoc nh. 3. Cn lm sng: Cn n gin, mc ch nh gi nguy c tim mch, tn thng thn v tm nguyn nhn. 3.1. Billan ti thiu (theo T chc Y t th gii) Mu: Kali mu, Cratinine mu, Cholestrol mu, ng mu, Hmatocrite, Acide Uric mu. Nc tiu: Hng cu, Protein. Nu c iu kin nn lm thm, soi y mt, in tim, X quang tim, siu m... 3.2. Cc xt nghim hay trc nghim c bit i vi tng huyt p th pht hay tng huyt p kh xc nh.V d: Bnh mch thn:cn chp U,I,V nhanh, thn , trc nghim Saralasin. U ty thng thn (Pheochromocytome): nh lng Catecholamine nc tiu trong 24 gi, trc nghim Rgitine. IV. CHN ON 1.Chn on xc nh: Cn phi chn on sm v ng n bnh THA. Ch yu bng cch o huyt p theo ng cc quy nh nu trn. Tuy nhin iu quan trng l nn t chc nhng t khm sc khe khm xt ton din nhm pht hin sm nhng trng hp tim tng hoc cha c triu chng. 2.Chn on giai on tng huyt p: c hai cch phn giai on, trong phn giai on ca TCYTTG chi tit v thch hp hn. 2.1.Theo T.C.Y.T.T.G (1996) chia lm 3 giai on. - Giai on I: Tng HA tht s nhng khng c tn thng thc th cc c quan. - Giai on II: C t nht mt trong cc bin i cc c quan sau: + Dy tht tri: Pht hin bng lm sng, X quang, in tim, siu m.

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+ Hp lan ta hay tng vng cc ng mch vng mc (giai on I v II y mt ca Keith-Wagener-Baker). + Thn:Anbumine niu vi th, Protein niu, ur hoc cratinine mu tng nh.(1.2-2 mg%) + C hnh nh mng va x ng mch trn siu m hoc X quang ( ng mch ch, ng mch cnh, ng mch chu hoc ng mch i) - Giai on III: C du hiu chc nng v thc th do tn thng cc c quan ch: + Tim: suy tim tri, cn au tht ngc, nhi mu c tim. + No: tai bin mch no thong qua, xut huyt no, tiu no hoc thn no. Bnh no THA. Lon thn do mch no (vascular dementia) + y mt: xut huyt vng mc xut tit c hay khng c ph gai th (giai on III v IV) cc du hiu ny l c bit ca giai on c tnh (giai on tin trin nhanh). Cc biu hin khc thng gp giai on III nhng khng c hiu lm ca tng huyt p. + Thn: creatinine huyt tng tng r (> 2mg%), suy thn. + Mch mu: phng tch, bt tc ng mch, tc ng mch ngoi bin c triu chng r. Tng HA c tnh hay tin trin nhanh l mt hi chng gm c:

- Huyt p ti thiu rt cao trn 130mmHg. - y mt giai on III v IV theo Keith-Weigener. - C bin chng thn, tim, no. - Bnh nhn tr tui di 40. - Tin trin nhanh, t vong trong vng 2-3 nm.

2.2. Xp loi THA theo T chc Y t th gii v Hi THA th gii (2003) Xp loi HA tm thu

(mmHg) HA tm trng (mmHg)

Ti u Bnh thng Bnh thng cao

< 120 < 130 130-139

< 80 < 85 85-89

THA nh (giai on 1) 140-159 90-99

THA va (giai on 1) 160-179 100-109

THA nng (giai on 2) 180 110

3. Phn loi tng huyt p 3.1- Theo tnh cht: - Tng huyt p thng xuyn:nh tng huyt p lnh tnh v tng huyt p c tnh. - Tng huyt p giao ng, huyt p c lc cao, c lc bnh thng. 3.2- Theo nguyn nhn: Gm - Tng huyt p nguyn pht (v cn). - Tng huyt p th pht.

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V- TIN TRIN V BIN CHNG 1. Tim: Suy tim v bnh mch vnh l hai bin chng chnh v nguyn nhn gy t vong cao nht i vi tng huyt p. Dy tht tri l bin chng sm do dy c tim tri. i ph sc cn ngoi bin nn gia tng sc co bp lm cng tim tng ln v vch c tim dy ra. Dn dn suy tim tri v vi kh th khi gng sc, hen tim hoc ph phi cp sau chuyn sang suy tim ton b vi ph, gan to, tnh mch c ni. Xquang v in tim c du dy tht phi. Suy mch vnh biu hin bng cc cn au tht ngc in hnh hay ch c lon nhp. in tim c ST chnh xung di ng thng in cc chuyn o tim tri, r hn chuyn o Pescador khi bin chng nhi mu s xut hin sng Q hoi t. 2. No: tai bin mch no, thng gp nh nhn no, xut huyt no, tai bin mch no thong qua vi cc triu chng thn kinh khu tr ch ko di, khng qu 24gi hoc bnh no do tng huyt p vi l ln, hn m km theo co git, nn ma, nhc u d di. 3. Thn - Va x ng mch thn sm v nhanh. - X thn gy tnh trng suy thn dn dn. - Hoi t dng t huyt tiu ng mch thn gy THA c tnh. - giai on cui thiu mu cc b nng thn s dn n nng Renin v angiotensine II trong mu gy cng aldosterone th pht. 4. Mch mu - Tng huyt p l yu t sinh va x ng mch, to iu kin cho s hnh thnh va x ng mch. - Phng ng mch ch, bc tch. Him gp nhng bnh cnh rt nng n d a n t vong. 5. Mt: khm y mt rt quan trng v l du hiu tt tin lng. Theo Keith- Wagener-Barker c 4 giai on tn thng y mt. - Giai on 1: tiu ng mch cng v bng. - Giai on 2: tiu ng mch hp c du bt cho (du Gunn). - Giai on 3: xut huyt v xut tit vng mc. - Giai on 4: ph lan ta gai th. VI. IU TR 1. Nguyn tc 1.1. Mc tiu - a huyt p tr v tr s sinh l n nh. - Ngn nga cc bin chng. - Ci thin cc bin i bt thng cc ng mch ln. Do phi gii quyt 3 vn : + iu tr nguyn nhn tng huyt p; Ct b u ty thng thn, ct b thn teo, thng ng mch b tc... + iu tr triu chng tng huyt p: Bng phng php ni khoa khng dng hoc dng thuc hoc phu thut (v d ct b mt s dy thn kinh giao cm).

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+ iu tr bin chng ca tng huyt p: Mc tiu chung ca iu tr l nhm a huyt p v tr s bnh thng hay di tr s 140/90mmHg. Tn trng huyt p sinh l ngi gi. 1.2. Nguyn tc chung: Cn lin tc, n gin, kinh t v c theo di cht ch. 2. Phng php iu tr 2.1. Tit thc v sinh hot

Hn ch mui di 5gNaCl mi ngy, hn ch m, cc cht bo ng vt, king ru, thuc l, ch c. Trnh lao ng tr c cng thng, lo lng qu , nn tp th dc nh, i b th gin, bi li. 2.2.Thuc

Cn nm vng c ch tc dng, tc dng phi hp cc loi thuc iu tr tng huyt p v cc tc dng ph khi s dng trc mt v lu di. C 3 nhm thuc chnh: - Li tiu + Thiazide v dn xut c ch ti hp th Na+ v Cl- trong ng ln xa nh Hydrochlorothiazide (Hypothiazide)... vin 25mg ngy ung 2 vin. Chlorthiazide vin 500mg ung 2 vin/ ngy l nhng loi c dng rng ri trong tng huyt p. Ngoi ra cn c Chlorthalidone (Hygroton) vin 50mg-100mg x 1ln/ngy v Metolazone (Diulo) 2,5mg-5mg x 4ln/ngy hay mi 2 ngy/ln v tc dng ko di. Tc dng ph thiazide: Tng acid uric, tng cng mu, gim Kali mu, li tiu Thiazides t tc dng khi tc lc cu thn di 25ml/pht, lm tng LDL cholesterol v gim HLD cholesterol. + Li tiu quai Henl Cng lm h Kali mu, nhng khc nhm thiazide l tc dng nhanh v ngn, ph thuc liu.Thng dng l Furosemide (Lasix) vin 40mg x 1-2vin/ngy c ch nh khi suy thn nng, cn tng huyt p cp tnh nhng v lu di tc dng khng hn nhm Hypothiazide. Cc loi khc trong nhm cn c Edecrine (Acide ethacrynique), Burinex (Butnamide). Tc dng ph tng t Thiazide nhng liu cao c c tnh ln tai. + Li tiu xa gc Gi Kali, gm c 2 nhm nh: - Nhm khng Aldosterone nh Spironolactone (Aldactone)vin 25-50mg x 4ln/ngy. Canrnone (Phanurane) c hiu lc i vi nhng trng hp cng Aldostrone, thng dng phi hp thiazide. - Nhm th 2 l nhm c tc dng trc tip nh Amiloride (Modamide), Triamterene (Teriam) loi ny thng phi phi hp vi cc nhm khc v tc dng thi Na yu. Tc dng ph: v nam, bt lc ri lon kinh nguyt. + Li tiu phi hp C th trnh c tnh trng gim Kali trong mu, loi ny phi hp mt loi Aldosterone v mt loi thiazides nh Aldactazine, Moduretic, Ditriam.. - Loi chn giao cm Tc dng c ch Renin, gim ng c tim, gim hot ng thn kinh giao cm trung ng, c nhiu nhm. Chn lc tim, khng chn lc tim v loi c tc dng ging giao cm ni ti hay khng c. Thng dng c propranolol (Avlocardyl, Inderal) l loi khng chn lc, khng c tc dng giao cm ni ti (ASI) vin 40mg dng 1-6vin/ngy. Tc dng ph: Lm chm nhp tim, ri lon dn truyn nh tht, lm nng

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suy tim, co tht ph qun, hen, hi chng Raynaud, h ng mu, ri lon tiu ha, mt ng, d ng hoc tc dng di khi ngng iu tr (gy ra cn au tht ngc, nhi mu c tim cp). - Cc thuc c ch men chuyn c ch s to thnh angiotensine II, ngoi ra cn c tc dng: - Tng cng hot ng h Kali-Krine-Kinine ngn cn s phn hy bradykinine. - Kch thch s tng hp Prostaglandine. Do sau cng a n dn mch. Ch nh: Tng huyt p cc giai on, k c loi tng huyt p rnine cao v thp. Tc dng ph: t c tc dng ph ngoi ri lon v thm n, nga, ho khan, lu khi phi hp li tiu gi Kali, thuc chng vim, chng Steroid. Chng ch nh: Khi tng huyt p c hp ng mch thn hai bn hoc ch c mt, ph n c thai. C 3 nhm chnh

- Captopril (Lopril, Captolane) vin 25-50mg liu 50mg/ngy. - Enalapril (Renitec) vin 5-20mg, liu 20mg/ngy. - Lisinopril (Prinivil, Zestril) vin 5-20mg, liu 20mg/ngy.

Hai nhm sau cng c tc dng ko di v khng c nhm Thiol t tc dng ph nn c a thch hn. - Thuc c ch Canxi Ngn cn s i vo t bo ca ion Ca++. c ch lung Ca++ chm ca knh Ca++ ph thuc in th. Tc dng ny t l vi nng v hi quy khi c ion Calcium. C hai ni tc dng. - Trn mch mu: s gim lung Ca++ a n s dn c v lm dn mch. iu ny lm gim sc cn ngoi bin v ci thin dn n cc mch mu ln. - Trn tim: lm chm nhp tim cn bng t nhiu phn x nhp nhanh th pht v gim s co bp c tim. Cc tc dng ny ty vo loi c ch Ca++ c s dng. Loi 1-4 dihidropyridine c tc dng chn lc mnh i vi mch mu, cn Verapamil v Diltiazem tc dng ln c hai ni. Cc loi c ch Ca++ tc dng tt i vi tng huyt p renine thp (ngi ln tui) c th: + Nhm 1-4 Dihydropyridine: Nifedipine (Adalate) vin nhng 10mg-20mg LP, liu 2 vin/ngy. + Diltiazem (Tildiem) 300mg LP, liu 1 vin/ngy. + Verapamil (Isoptine) 120-240 LP, liu 1-2 vin/ngy. Tc dng ph chim 10-20% trng hp. Thng thng l nhc u, ph ngoi bin, phng mt. Him hn l h huyt p th ng, mt, xong, ri lon tiu ha, hi hp, pht ban, bun ng v bt lc. Cc loi Verapamil, Diltiazem c th gy ri lan dn truyn nh tht, nhp chm. Khng c dng c ch Canxi khi c thai, i vi Verapamil v Diltiazem khng dng khi c suy tim, blc nh tht nng nhng cha t my to nhp. - Thuc tc dng ln thn kinh trung ng C nhiu loi nhng hin nay t dng do c nhiu tc dng ph d c hiu qu. - Anphamethyldopa (Aldomel, Dopegyt): H huyt p do to ra anpha-methylnoadrenaline lm hot ha cc c quan th cm giao cm no, do c ch trng lc giao cm. Vin 250mg hoc 500mg, liu t 500mg n 1,5g trong 24

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gi. c s dng khi c suy thn. Tc dng ph: h huyt p th ng, thiu mu huyt tn, bt lc, suy gan. - Reserpine vin 0,25mg liu 2-6 vin/ngy. Tc dng ph h huyt p th ng, thiu mu huyt tn, bt lc, suy gan, hin nay t dng. - Clonidine (Catapressan): Tc dng ln vng hnh ty cng trng lc giao cm h huyt p. Vin 0,150mg liu 3-6 vin/ngy. Cn lu phi ngng thuc t t nu khng s lm huyt p tng vt ln. Tc dng ph: Trm cm kh ming, to bn, ri lon tnh dc. - Cc thuc tc dng trung ng khc: Guanabenz, Guafacine, Tolonidine, Hyperium. - Thuc dn mch - Prazosin (Minipres): Tc dng c ch cm th anpha sau tip hp nn c hiu lc tt. Vin 1mg dng liu tng dn t 1-2 vin - 10 vin/ngy nu cn. Tc dng ph: chng mt, ri lon tiu ha d kch ng, tiu kh, h huyt p th ng, nht l vi liu u tin. - Dihydralazine (Nepressol) vin 25mg, liu t 1-4 vin/ngy. c dng khi c suy thn, c nhiu tc dng ph. Nhp tim nhanh, gi mui nc, hi chng gi luput ban , vim a dy thn kinh ngoi bin khng dng khi c suy vnh, phng ng mch ch bc tch, thng c ch nh trong tng huyt p c suy thn. - Minoxidil (Loniten) tc dng rt mnh, ch dng khi tng huyt p khng cc loi khc, suy thn mn; t dng hin nay. 3. iu tr c th 3.1. nh gi THA theo mc nguy c ca T chc y t Th Gii v Hi tng huyt p Th Gii (ISH) nm 2003. Theo cc bc sau: * nh gi cc yu t nh hng n tin lng, bao gm: + Yu t nguy c ca bnh tim mch: - Mc Huyt p tm thu v tm trng (1-3). - Nam > 55tui. - N > 65 tui. - Ht thuc l. - Cholesterol ton phn > 250mg%. - Tiu ng. - Tin s gia nh b bnh tim. + Yu t khc nh hng xu tin lng: - HDL-C gim. -LDL-C tng. -Albumine niu vi th bnh nhn tiu ng. -Ri lon dung np Glucose. -Bo ph. -Li sng tnh ti. -Fibrinogene mu tng. -Nhm kinh t x hi cao. -Nhm dn tc nguy c cao.

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- Vng a l nguy c cao. + Tn thng c quan ch: nh giai on II ca tng huyt p theo phn ca t chc y t th gii trc y bao gm: c dy tht tri, tn thng y mt, c prtin niu,... + Tnh trng lm sng i km: nh giai on III theo theo phn ca t chc y t th gii trc y bao gm: suy tim tri, suy vnh, suy thn, suy tun hon no. 3.2. Phn loi nguy c gip tin lng bnh Bng 1: THA I THA II THA III

Khng c yu t nguy c (YTNC)

Nguy c thp Nguy c trung bnh Nguy c cao

1-2 YTNC Nguy c trung bnh. Nguy c trung bnh Nguy c rt cao

(3 YTNC hoc tn thng c quan ch hoc tiu ng.

Nguy c cao. Nguy c cao Nguy c rt cao

Bnh tim mch i km Nguy c rt cao Nguy c rt cao Nguy c rt cao

i vi tng huyt p nguy c thp v trung bnh cn theo di thi gian ri nh gi li huyt p v yu t nguy c, p dng cc bin php khng dng thuc. i vi nhm nguy c cao v rt cao cn iu tr thuc ngay phi hp vi khng dng thuc. * p dng phc iu tr theo c nhn. C th tm lc theo s di (trang sau): - Trong iu tr 2 loi thuc, loi th 2 c chn vn trong 4 nhm thuc bc 1. Nu tht bi, sau khi cn nhc cc kh nng khng iu tr, liu lng cha thch hp... th c th xt n vic phi hp thm loi th 3 nh loi dn mch hay cc loi khng adrenergic trung ng - Ch nh chn lc thuc theo phng php iu tr tng c nhn bnh nhn (ca Hi ng quc gia v tng huyt p ca Hi Tim mch Hoa k JNC VI nm 1999). + Li tiu: Ngi gi, da en, ph n tin mn kinh, c ri lon nhu m thn. + Chn bta: Ngi tr, da trng, nam gii bnh nhn cng giao cm, hot tnh renine cao, bnh mch vnh, bnh nhn b glaucom v au na u. + c ch men chuyn: Tng huyt p nng, khng iu tr, hot tnh renine cao, suy tim hay suy thn, ri lon tnh dc, tng lipt mu, i ng, tng acide urc mu. + c ch canxi: ngi gi, da en, bnh mch vnh, i ng. Bo ph tng huyt p khng kim sot c bng chn bta th pht sau cng aldosterol nguyn pht, bt lc, tng lipt mu v tng acide urc mu. + Khng adrenergique ngoi bin: Bnh nhn tr b trm ut, hen suyn, bnh phi tt nghn, i ng tng lipit mu.

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IU TR KHNG DNG THUC - Gim cn nng. - Hot ng th lc. - iu chnh cc yu t nguy c. IU TR DNG THUC S dng mt trong cc loi thuc: - Chn giao cm anpha hoc bta. - L tiu. - c ch canxi. - c ch men chuyn, c ch angiotensine II Tht bi Hai loi thuc Tht bi -iu chnh liu lng Ba loi thuc hoc Tht bi - Th thay 1 loi thuc trong 4 loi trn. nh gi nguyn nhn, s chp hnh iu tr * iu tr cn tng huyt p cp tnh Cn phi dng loi h huyt p bng ng tnh mch nh: - Nitroprussiate de Na (Nipride) chuyn tnh mch liu 0,5-2mg/pht (10mg/gi) c chn dng trong hu ht cn tng huyt p. Tc dng ph: ng c Thiocyanate. - Nitroglycerine chuyn tnh mch dng bnh nhn c suy vnh cp khi khng chng ch nh, liu 5 - 10mg/pht. - Labetalol (Trandate) loi c ch c anpha v bta giao cm, dng tt nhng bnh nhn nhi mu c tim cp, chuyn tnh mch 1-2mg/pht. - Anpha Methyldopa hay clonidine chuyn tnh mch. - Cc loi c ch men chuyn: Captopril 25mg ngm di li. - Thng phi hp thm Lasix chch tnh mch. VII. D PHNG 1. D phng cp I i vi nhng ngi cha b tng huyt p cn lu vn sinh hot hng ngy nht l cc thi quen c hi sc khe phi khm nh k pht hin tng huyt p

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hay cc bnh lin quan. Trong i tng ny ch n nhng ngi c yu t nguy c mc bnh cao cho d nhng ln u cha pht hin THA nhng cn trao i tuyn truyn phi hp d phng cng nhn vin y t tuyn trc. 2.D phng cp II i vi ngi tng huyt p, cn phi cht ch hn na trong ch n ung, ngh ngi theo di huyt p u n v c k hoch iu tr ngoi tr theo di tin trin, tc dng ph ca thuc. Cn ch yu t kinh t trong iu tr v y l mt liu trnh lu di, tn km. VIII. TIN LNG Tin lng bnh nhn thng ph thuc vo: - Tr s huyt p: Tr s huyt p cng cao th t l t vong cng ln. - Cc bin chng: L yu t tin lng gn rt quan trng nht l khi c bin chng. - V tin lng xa: Cholesterol mu c v tr quan trng v d a n x va ng mch vnh, nhi mu c tim sau ny. - Vn iu tr cng gi vai tr ng k, tin lng kh quan nu iu tr sm, ng cch, c theo di lu di. IX. KT LUN Tng huyt p l mt bnh chn on xc nh d nhng vn cn phc tp v bnh nguyn, c ch, vic iu tr c nhiu tin b nhng khng trnh khi nhng tc dng ph ng k. Bnh nh hng ln n sc khe con ngi. V vy tng huyt p l vn ln ang c nc ta v th gii quan tm. Trong iu tr tng huyt p cn ch phi hp iu tr bnh nguyn v c bit l cc yu t nguy c.

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SUY TIM Mc tiu 1. Nu c cc nguyn nhn suy tim. 2. Trnh by c cc triu chng lm sng v cn lm sng. 3. Vn dng c trong chn on suy tim. 4. Hc thuc cc thuc s dng iu tr suy tim 5. Nm vng cc phc iu tr suy tim Ni dung I. I CNG 1. nh ngha: Suy tim l trng thi bnh l, trong c tim mt kh nng cung cp mu theo nhu cu c th, lc u khi gng sc ri sau c khi ngh ngi. Quan nim ny ng cho a s trng hp, nhng cha gii thch c nhng trng hp suy tim c cung lng tim cao v c trong giai on u ca suy tim m cung lng tim cn bnh thng. 2. Dch t hc: Ti chu u trn 500 triu dn, tn sut suy tim c lng t 0,4 - 2% ngha l c t 2 triu n 10 triu ngi suy tim. Ti Hoa K, con s c lng l 2 triu ngi suy tim trong 400.000 ca mi mi nm. Tn sut chung l khong 1-3% dn s trn th gii v trn 5% nu tui trn 75. Ti nc ta cha c thng k chnh xc, nhng nu da vo s dn 70 triu ngi th c n 280.000 - 4.000.000 ngi suy tim cn iu tr. II. NGUYN NHN 1. Suy tim tri: Tng huyt p ng mch, h hay hp van ng mch ch n thun hay phi hp, nhi mu c tim, vim c tim do nhim c, nhim trng, cc bnh c tim, cn nhp nhanh kch pht trn tht, cn cung ng nh, rung nh nhanh, cn nhp nhanh kch pht tht, blc nh tht hon ton, hp eo ng mch ch, tim bm sinh, cn ng ng mch, thng lin tht. 2. Suy tim phi: Hp van 2 l l nguyn nhn thng gp nht, tip n l bnh phi mn nh: Hen ph qun, vim ph qun mn, lao x phi, gin ph qun, nhi mu phi gy tm ph cp. G vo ct sng, d dng lng ngc, bnh tim bm sinh nh hp ng mch phi, t chng Fallot, thng lin nh, thng lin tht giai on mun, vim ni tm mc nhim trng, tn thng van 3 l, ngoi ra mt s nguyn nhn t gp nh u nhy nh tri. Trong trng hp trn dch mng ngoi tim v co tht mng ngoi tim, triu chng lm sng ging suy tim phi nhng thc cht l suy tm trng. 3. Suy tim ton b: ngoi 2 nguyn nhn trn dn n suy tim ton b, cn gp cc nguyn nhn sau: bnh c tim gin, suy tim ton b do cng gip trng, thiu Vitamine B1, thiu mu nng. III. C CH BNH SINH Chc nng huyt ng ca tim ph thuc vo 4 yu t: Tin gnh, hu gnh, sc co bp c tim v nhp tim.

Sc co bp

Hu gnh

Tn s tim

Cung lng tim Tin gnh

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1. Tin gnh: l ko di ca cc si c tim sau tm trng, tin gnh ph thuc vo lng mu dn v tht v c th hin bng th tch v p lc mu trong tm tht th tm trng. 2. Hu gnh: hu gnh l sc cn m tim gp phi trong qu trnh co bp tng mu, ng hng u l sc cn ngoi vi, hu gnh tng th tc cc si c tim gim; do th tch tng mu trong th tm thu gim. 3. Sc co bp c tim: Sc co bp c tim lm tng th tch tng mu trong th tm thu, sc co bp c tim chu nh hng ca thn kinh giao cm trong c tim v lng catcholamine lu hnh trong mu. 4. Tn s tim: Tn s tim tng s tng cung lng tim, tn s tim chu nh hng ca thn kinh giao cm trong tim v lng Catcholamine lu hnh trong mu. Suy tun hon xy ra khi ri lon cc yu 1,2 v 4, suy tim xy ra khi thiu yu t 3. Trong suy tim, cung lng tim gim, giai on u s c tc dng b tr

- Mu li tm tht lm cc si c tim b ko di ra, tm tht gin, sc tng mu mnh hn nhng ng thi cng tng th tch cui tm trng. - Dy tht do tng ng knh cc t bo, tng s lng ti lp th, tng s n v co c mi nh du bt u s gim st chc nng co bp c tim. Khi cc c ch b tr b vt qu, suy tim tr nn mt b v cc triu chng lm sng s xut hin.

IV. CHN ON 1. Suy tim tri 1.1. Triu chng lm sng - Triu chng c nng: C 2 triu chng chnh: Kh th v ho. Kh th l triu chng thng gp nht. Lc u kh th khi gng sc, v sau tng cn, c khi kh th t ngt, c khi kh th tng dn; ho hay xy ra vo ban m khi bnh nhn gng sc, ho khan, c khi c dm ln mu. - Triu chng thc th: - Khm tim: Nhn thy mm tim lch v pha bn tri, nghe c ting thi tm thu nh mm do h van 2 l c nng. - Khm phi: Nghe c ran m 2 y phi. Trong trng hp cn hen tim c th nghe c nhiu ran rt, ran ngy. - Huyt p: HATT bnh thng hay gim, HATTr bnh thng. 1.2. Cn lm sng - X quang: Phim thng tim to, nht l cc bung tim tri, nh tri ln hn trong h 2 l, tht tri gin vi cung di tri phng v dy ra, phi m nht l vng rn phi. - in tm : Tng gnh tm trng hay tm thu tht tri. Trc tri, dy tht tri. - Siu m tim: Kch thc bung tht tri gin to, siu m cn cho bit c chc nng tht tri v nguyn nhn ca suy tim tri nh h van ng mch ch...vv. 1.3. Thm d huyt ng: Nu c iu kin thng tim, chp mch nh gi chnh xc mc nng nh ca mt s bnh van tim. 2. Suy tim phi 2.1. Lm sng 2.1.1. Triu chng c nng: kh th nhiu hay t ty theo mc suy tim, kh th

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thng xuyn, nhng khng c cn kh th kch pht nh suy tim nh suy tim tri. Xanh tm nhiu hay t ty nguyn nhn v mc ca suy tim phi. 2.1.2.. Du chng thc th: Ch yu l mu ngoi bin vi gan to, b t, mt nhn, n au tc, iu tr tch cc bng tr tim v li tiu gan nh li, ht iu tr gan to ra gi l gan n xp, nu gan b mu lu ngy gan khng nh li c gi l x gan tim vi gan b sc, mt chc. Tnh mch c ni, phn hi gan tnh mch c (+) t th 450. p lc tnh mch trung ng v tnh mch ngoi bin tng cao. - Ph: Ph mm lc u 2 chi di v sau ph ton thn, c th km theo c trng, trn dch mng phi. Tiu t 200-300ml/ 24gi. - Khm tim: Ngoi cc du hiu ca nguyn nhn suy tim, ta cn nghe nhp tim nhanh, c khi c ting nga phi phi, thi tm thu van 3 l do h van 3 l c nng hu qu ca dn bung tht phi. Huyt p tm thu bnh thng, huyt p tm trng tng. 2.2. Cn lm sng - X quang: Tr trng hp suy tim phi do hp van ng mch phi c c im l phi sng, cn li cc nguyn nhn suy tim phi khc trn phim thng phi m, cung ng mch phi gin, mm tim hch ln do tht phi gin. Trn phim nghing tri mt khong sng sau xng c. - in tm : Trc phi, dy tht phi. - Siu m tim: Tht phi gin to, tng p ng mch phi. - Thm d huyt ng: Tng p lc cui tm trng tht phi, p lc ng mch ch thng tng. 3. Suy tim ton b: Bnh cnh suy tim phi thng tri hn. Bnh nhn kh th thng xuyn, ph ton thn, tnh mch c ni t nhin, p lc tnh mch tng cao, gan to nhiu, thng c c trng, trn dch mng phi, huyt p tm thu gim, huyt p tm trng tng, Xquang tim to ton b, in tm c th dy c 2 tht. V. PHN SUY TIM 1. Theo Hi Tim Mch New York: Chia lm 4 : 1: Bnh nhn c bnh tim nhng khng c triu chng c nng, hot ng th lc vn bnh thng. 2: Cc triu chng c nng ch xut hin khi gng sc nhiu, hn ch hot ng th lc. 3: Cc triu chng c nng xut hin ngay c khi gng sc nh, lm hn ch hot ng th lc. 4: Cc triu chng c nng xut hin thng xuyn k c khi bnh nhn ngh ngi. 2. Phn suy tim mn theo Trn Trinh & V nh Hi

- Suy tim 1: Kh th khi gng sc, ho ra mu, khng ph, gan khng to. - Suy tim 2: Kh th khi i li vi vn tc trung bnh, khi i phi ngng li th, ph nh, gan cha to hoc to t, 2cm di b sn. Phn hi gan tnh mch c (+) t th 450. - Suy tim 3: Kh th nng hn hoc gim i, ph ton, gan > 3cm di sn, mm, phn hi gan tnh mch c (+) t th 450, iu tr gan nh li hon ton. - Suy tim 4: Kh th thng xuyn, bnh nhn phi ngi dy th, gan > 3cm di b sn, mt chc, b sc, iu tr khng p ng hoc nh li t.

VI. IU TR SUY TIM 1. Cc thuc iu tr suy tim. 1.1. Digitalis

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c a vo s dng iu tr suy tim t lu, hin gi vn cn c s dng rng ri. N c c tnh sau: - Tng sc co bp c tim. - Lm chm nhp tim. - Lm gim dn truyn trong tim. - Tng tnh kch thch c tht. * Ch nh Digital c ch nh r rng trong suy tim tr c rung nh. Tuy nhin nu l nhp xoang th vai tr ca n vn cn b tranh ci. Ngoi ra ch nh khc ca n l trong cc lon nhp trn tht nh rung nh, cung nh, nhp nhanh trn tht kch pht kiu Bouveret. * Chng ch nh Tuyt i khi c nhim c digital. Cc chng ch nh khc: - Bloc nh tht 2 v 3 khng c my to nhp. - Trng thi tht cng kch thch nng. - Bnh c tim nghn. - Thiu oxy. - H kali mu. Digital t c li v thm ch c th cn nguy him khi: nhi mu c tim cp (ngoi tr nu c cn rung nh nhanh), suy tim nhp chm khng c my to nhp, suy tim giai on cui, tm ph mn, vim mng ngoi tim co tht, suy tim c cung lng tim cao, cc bnh tim do qu ti chuyn ha nh nhim thit huyt t, nhim bt. * Giao thoa thuc Cc thuc sau c th lm tng nng digoxin: erythromycin, tetracycline, quinidine, amiodarone, verapamine. Trong iu tr suy tim mn c hai loi hay c dng l digoxin v digitoxin nhng v digoxin tc dng nhanh, thi nhanh do t hiu qu iu tr nhanh trong khi kh gy ng c nn c a dng hn. Lu l digoxin thi qua thn v digitoxin thi qua gan v th nu suy thn nn dng digitoxin trong khi suy gan th nn dng digoxin. ph n c thai digitoxin qua c hng ro nhau thai trong khi digoxin th khng. Trn thc t khng c mt phc no hon ton ng cho mi bnh nhn. Liu iu tr ty theo nhy cm ca ngi bnh vi thuc theo nguyn tc l ngi gi hoc l suy tim vi tim dn rt ln, ngi bnh gy th phi gim liu thuc. Ni chung liu thng thng iu tr tn cng l digoxin 0,25mg (2 ln / ngy trong vng mt tun sau tr v liu duy tr l1/2 - 1 vin / ngy, ung cch nht hoc l thm ch c th ung hng ngy khng ngh ty theo i tng. i vi digitoxin bt buc phi ngh chng hn ung 3 ngy ngh 3 ngy do thi gian na i di. Vng iu tr ca thuc: digoxin mu 1- 2,5ng/ml, digitoxin mu 15- 35 ng/ml. Tuy nhin i vi tr em vng hiu qu xung quanh 3 (1ng/ml khi iu tr phi theo di cc triu chng ng c c thi x tr kp thi. 1.2. Ch ngh ngi v tit thc Ch hot ng ca ngi bnh ty thuc vo mc suy tim. Khi c suy tim nng phi ngh ngi tuyt i ti ging bnh. n nht l cn thit di 2gam mui /ngy nu suy tim I v II, di 0,5gam/ngy nu suy tim II,IV. 1.3. Thuc li tiu

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Vn c coi l ch o trong iu tr suy tim tr. Vi suy tim nh th li tiu thiazide liu va phi cng p ng tt phi hp vi ch n nht. Khng nht thit phi cho sm thuc li tiu quai tr phi khng c p ng vi Thiazide. Liu thuc Thiazide 25mg (1-4 vin / ngy, Trofurit 40 mg (2-3 vin/ ngy. Hai loi ny l li tiu thi mui cho nn phi cho tng t mui kali km theo (1-2g/ngy). Khi tnh trng tr nng c th phi hp tng t vi li tiu gi kali tc dng ng ln xa (Spironolactone) v lc hay c cng aldosterone th pht. 1.4. Thuc dn mch * Cc dn cht nitrate c s dng rng ri nhm gim triu chng h hp (kh th) ca suy tim. Liu khi u nh sau tng t t nhm trnh tc dng ph nh au u. Liu iu tr i vi Isosorbide dinitrate khong 120mg/ngy. Tng t c th dng mononitrate, trinitrine dn, molsidomine. * Cc cht dn ng mch C tc dng ci thin tnh trng cung lng thp. Hydralazine hiu qu nhng nhc im phi dng liu cao kh thc hin (12 - 16 vin chia 4). Prazosine c tc dng cng tt nhng b yu i kh nhanh chng sau . Ni chung ngy nay cc thuc ny t c s dng. * Cc thuc c ch men chuyn lm ci thin r rt tin lng ca bnh nhn b suy tim. N khng nhng ci thin triu chng m cn ci thin c c tin lng sng. Nguyn tc s dng phi tun theo nhm trnh tai bin do thuc c th xy ra nht l nhng bnh nhn ang c dng li tiu. Liu khi u nh (6,25mg/ngy vi Catopril) sau tng ln ti liu 50 - 150mg/ngy ty theo trng hp. 1.5. Cc thuc c ch beta Trc kia c xem nh chng ch nh. Tuy nhin gn y chnh thc a vo iu tr suy tim. Cc loi thuc sau c chp nhn rng ri: metoprolol, bisoprolol v nht l Carvedilol. S dng thuc ny theo nguyn tc l cho khi suy tim n nh (khng dng trong suy tim cp), liu nh tng dn. Vi Carvedilol vin 12,5mg liu khi u 1/4-1/2 vin/ngy. 1.6.Cc cht c ch phosphodiesterase (Amrinone, Milrinone, Enoximone) C ch tc dng l tng lng AMPc t c hai tc dng:dn ng mch v tng co bp c tim khng l thuc vo cc th th (. Thuc c dng trong suy tim vi biu hin suy huyt ng nng sau khi dng dopamin v dobutamin khng c hiu qu. 2. iu tr theo th loi suy tim 2.1.Suy tim cp Bng 1. Cc bin php x tr trong suy tim cp

1. Bin php chung An thn bng morphin

2. iu chnh cc yu t lm d Lon nhp, thiu mu, tng huyt p

3. iu chnh thiu oxy Th oxy, h hp h tr nu cn.

4. iu tr c hiu Thuc: li tiu, gin mch,tng co bp c tim, bng ni ng mch ch, phu thut: thay van, ng l thng bm sinh.

Bng2. Cc thuc dng trong iu tr suy tim tri cp.

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Thuc C ch Tc dng sinh l Hiu qu iu tr

Li tiu *Furosemide 40-80mg tim TM

Li tiu

Gim tin gnh

Chng ph phi

Dn mch *Morphin 5-10mg TM, TB, TDD. *Trinitrin:10-150(g/pht truyn tnh mach hoc cc dn cht nitrat dng ngm, ung. *Nitroprusside: 25-150(g/pht

Dn tnh mch Dn tnh mch Dn tiu ng mch v tnh mch

Gim tin gnh Gim tin gnh Gim tin gnh v hu gnh

Chng ph phi Chng ph phi Chng ph phi v tng lu lng tim

Tng co bp c tim *Dobutamine: 250-750(g/pht *Dopamine: 100-600(g/pht *Digital(lanatoside C, digoxine)1 ng tnh mch

Ging giao cm Ging giao cm c ch bm Na-K ATPase

Tng co bp tim Tng co bp tim, gim hu gnh (liu thp), tng hu gnh (liu cao). Tng co bp tim, gim tin gnh v hu gnh.

Tng lu lng tim Tng lu lng tim, tng huyt p (liu cao). Chng ph phi lm gim p lc phi.

2.2.Suy tim mn tnh * Cc mc tiu iu tr suy tim mn

IU TR SUY TIM

IU TR NGUYN NHN

IU TR TNH TRNG SUY

TIM

IU TR CC YU T LM D

GIM TIN GNH

(li tiu)

GIM HU GNH

(dn mch)

TNG CO BP C TIM (tr tim)

GIM TN S TIM

(c ch beta)

S 1: Thi x tr suy tim mn Bng3. Phc iu Tr Suy Tim (Theo M. KOMAJDA v Y. GROSGOGEAT)

Giai on suy tim (NYHA)

Phng php kinh in Phng php thay th

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I Khng iu tr Khng iu tr

II - Hn ch th lc - Ch n king mui - Digital -Digital + Li tiu Thiazid

- Hn ch th lc - Ch n king mui - Li tiu? c ch men chuyn? - Li tiu + CMC hoc Li tiu + Dn mch

III - Digital + Li tiu quai. - Digital + Li tiu + Dn mch

IV - Digital + Li tiu + Dn mch + Thuc tr tim mi - Ghp tim

- Li tiu + CMC hoc Dn mch + Digital ? hoc - Li tiu + CMC hoc Dn mch + thuc tr tim? - Chn bta? - Ghp tim.

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SUY MCH VNH Mc tiu 1. Nm c nguyn nhn chnh gy bnh mch vnh. 2. Nm c triu chng, cch chn on. 3. Nm c cc th lm sng ca au tht ngc 4. Nm vng nguyn tc iu tr, cc phng tin ni ngoi khoa iu tr suy vnh. Ni dung I. I CNG 1. Bnh mch vnh (BMV) l mt bnh rt thng gp trong s cc bnh tim cc nc pht trin. Thng thng bnh sinh ca SMV l do lng ng m lp di ni mc cc ng mch vnh. Tnh trng x va tin trin dn dn lm hnh thnh cc mu ng gy thuyn tc trong lng mch. Bin chng ch yu ca bnh mch vnh l gy cn au tht ngc, nhi mu c tim v cht t t. 2. Dch t hc ca BMV: bao gm au tht ngc v nhi mu c tim chim khong chng 6% n ng > 50 tui. chu u hng nm c thm khong chng 0,3-0,6 % ngi mc bnh. V t l t vong th mi nm chim khong 120-250 ngi cht / 100.000 ngi dn cc nc cng nghip pht trin. T l ny tng ln vi tui: 800 - 1000 ngi cht /100.000 la tui 65 - 74 i vi nam gii, 300/100.000 i vi ph n cng la tui (Vademecum clinique 1988). Vit nam cha c thng k ton dn nhng cc thng k ti cc bnh vin ln cho thy bnh nhn b bnh mch vnh hu ht tui 50 tr ln. Nm 1996 thnh ph H ni c khong 200 bnh nhn BMV nhp vin cn thnh ph H ch Minh c khong 400 bnh nhn. II. BNH NGUYN 1. Bnh mch vnh: l nguyn nhn ch yu. - a s l do x va mch vnh. - Khng phi do x va: co tht mch vnh, vim mch (vim nhiu ng mch dng nt, lupus ban , bt thng bm sinh). 2. Bnh van tim: Bnh van ng mch ch: hp, h van ng mch ch, giang mai. 3. Bnh c tim ph i: Hai nhm nguyn nhn sau ny c th gy suy vnh c nng trong mch vnh khng c hp. III. C CH BNH SINH 1. C tim v oxy S tiu th oxy c tim: ph thuc vo: + Tn s nhp tim + S co bp c tim (inotropisme) + Sc cng trong thnh tim. + Sc cng ny ph thuc vo p lc trong bung tht v th tch tm tht. S gia tng mt trong cc yu t trn s lm gia tng s tiu th oxy c tim. Ni cch khc s tiu th ny t l theo: + Tn s tim x p lc ng mch tm thu + Hoc tn s tim x p lc ng mch tm thu x thi gian tng mu. 2. D tr vnh: gm 2 thnh phn

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- D tr vnh (Reserve coronaire): D tr vnh c thc hin bng cch ly oxy ca c tim, hu nh ti a trng thi c bn. D tr lu lng vnh c kh nng gia tng n 300 - 400% tr s c bn. S thch nghi v gia tng nhu cu oxy thng km theo s gia tng song song ca lu lng vnh. Lu lng vnh ph thuc vo: p lc ti mu v sc cn vnh do kh nng dn mch di ngoi tm mc. - Dng vnh (flux coronaire) thng ti a k tm trng. Do kh nng dn cc mch mu ni tm mc rt yu, v vy khi c gim lu lng vnh s ti mu s xy ra ch yu di ni mc. 3. Kh nng vn mch ca ng mch vnh: ph thuc vo - Yu t co tht mch + Sc bp k tm thu: quan trng i vi tht tri hn tht phi. + Cu c bt qua mt ng mch vnh thng tm mc. + Kch thch th th alpha, c ch th th bta vi Dopamine liu trn 15mg/kg/ph qua trung gian noadrenaline, trc nghim lnh, dn xut ca lo mch - thromboxane A2 - prostaglandine F - Neuropeptide Y. - Yu t dn mch + Cc cht bin dng do TMCT: adenoside, lactate, ion H+, CO2, bradykinine. + c ch th th alpha - kch thch th th bta vi dopamine liu di 5mg/kg/ph - cc th th i giao cm kch thch i giao cm qua trung gian acetylcholine, c ch calci, dn xut nitr - prostacycline - prostaglandine E, EDRF (yu t dn ni mc) - VIP (peptid rut dn mch: vasodilatator intestinal peptid) cht P. 4. Tnh trng thiu mu c tim (TMCT) Xut hin khi c s mt thng bng gia cung cp oxy v nhu cu oxy c tim. - C ch: c th do hu qu + Gia tng nhu cu oxy (thiu mu th pht) khi gng sc s gia tng tiu th oxy c tim c thc hin qua s gia tng tn s tim, HA tm thu v s co bp c tim. Trong trng hp hp MV c ngha ngha l trn 70% ng knh ng mch vnh, lu lng vnh khng th gia tng thch ng v song song vi s gia tng nhu cu oxy nn a n TMCT. + S gim t ngt lu lng vnh (thiu mu nguyn pht) tng ng vi s co tht mch vnh m khng c tn thng mch mu, tuy vy cng c th xy ra trn mt ng mch vnh b hp t trc. Cn au tht ngc xy ra khi nhu cu oxy ca c tim vt qu kh nng chu cp ca h thng mch vnh. au l biu hin trc tip ca thiu mu cc b c tim v s tch ly cc cht chuyn ha do thiu oxy. Mt khi c tim thiu mu cc b pH gim trong xoang vnh, mt kali t bo, tng sn xut lactat, xut hin cc bt thng ECG, chc nng tht xu i. Cc yu t xc nh tiu th oxy c tim l nhp tim, s co bp c tim, p lc tm thu. Khi c tng mt hoc l nhiu yu t ni trn cng vi tnh trng dng mu vnh gim th s to ra cn au tht ngc. 5. Hu qu TMCT: theo cc bc sau: - V bin dng: tit lactate. - V huyt ng: ri lon s th gin, gim co dn tht v sau l gim s co bp. - V ECG: xut hin ri lon s ti cc. - V lm sng: xut hin cn au tht ngc.

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III. GII PHU BNH Mt hoc nhiu ng mch vnh b hp do mng x va. C nhng vng hoi t v x trong c tim, thng thng khu tr trong lp di ni tm mc. Tht tri c th ph i. IV. TRIU CHNG 1. Triu chng c nng: l cn au tht ngc vi c im sau V tr: sau xng c. Hng lan: xung mt trong cnh tay ngn tay tri, tuy nhin n c th lan ln vai ra sau lng, ln xng hm, rng, ln c. Tnh cht au: c th m h kiu nh c g chn ngc, co tht hoc l nh l c vt g nng p ln ngc. Ngi bnh hay khng c cm gic nh l au. Lu l nhng ngi bnh m t im au chnh xc vng mm tim, au nhi nng thong qua th thng khng phi l au tht ngc do suy vnh. Thi gian: au ngn v ko di khng qu vi pht. au thng khi pht sau gng sc, gim v mt khi ngh ngi hoc l dng thuc gin vnh. Lnh cng l yu t d gy khi pht cn au. 2.Triu chng thc th Trong cn c th chng c g tuy nhin c th c tng tn s tim v tr s huyt p, nghe c th c thi tm thu gia v cui tm thu do lon chc nng c nh v thiu mu cc b. 3. Triu chng ECG: ghi c trong cn au ngc l c ch nht qua cho php thy cc bin i xy ra trong cn suy vnh: ST chnh xung l in hnh, ngoi ra i khi thy ST chnh ln, ri lon nhp nht l ngoi tm thu tht. Ngoi cn khi ngi bnh ngh ngi ECG thy bnh thng 30% ngi bnh c au tht ngc in hnh. V. CHN ON 1. Chn on xc nh 1.1. Chn on lm sng:: da trn bnh cnh au ngc c trng nh m t trn xy ra khi gng sc v gim bt sau khi ngh ngi. C th khng nh chn on bng theo di ECG thy hi phc tr v bnh thng cc bin i do thiu mu cc b hoc bng dng test iu tr th vi nitroglycerin di li thy bin mt cn au trong vng 1,5-3 pht. Khng thy p ng gim au nhanh c th loi tr nghi ng c cn au tht ngc (tc l khng phi au tht ngc do suy vnh hoc l ngc li l dng nng nht ca suy vnh l nhi mu c tim). 1.2. Chn on cn lm sng 1.2. 1. in tim gng sc: gip chn on sm, d hu v theo di iu tr. - K thut: dng xe p lc k hay thm ln, tng dn cng mi 30W i vi xe p hoc dng biu Bruce i vi thm ln. Cn c chuyn vin theo di ECG v HA lin tc khi tin hnh. nhy ca phng php: 60% v c hiu 80% trong pht hin mch vnh. T l t vong di 0,01%. - Ch nh: + Chn on cn au tht ngc n nh hay cn au ngc khng in hnh. + Bilan ngi tr c nhiu nguy c bilan b bnh mch vnh n nh c hay khng iu tr. + nh gi hiu qu ca iu tr TMCT

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+ nh gi kt qu phu thut mch vnh hay sau nng mch vnh, bilan sau nhi mu c tim vo ngy th 10 - 15. + nh gi chc nng ca mt s bnh van tim (tr hp van ng mch ch). + nh gi chc nng ca suy tim cn b. - Tiu chun nh gi: c da vo nhiu yu t nh: ST chnh xung v nm ngang trn 1mm hoc i xung trn 0,08 mm sau phc b QRS; ST chnh ln (him gp); thi gian gng sc; cng ti a t c; xut hin cn T in hnh; in tm bin i trong hay sau trc nghim gng sc; huyt p v tn s tim; mc t tn s tim theo l thuyt; xut hin lon nhp khi lm test v/ hoc c du suy tim tri. Kt qu test gng sc gn lin vi tui v gii ngi bnh (kh kt lun ph n 20% ngi < 40 tui trong khi gim cn < 10% ngi > 60 tui). 1.2.2. o in tim Holter trong 24 gi: Gip chn on bnh mch vnh im lng, chn on v theo di cn TN Prinzmetal, hoc s gia tng kch thch tm tht. 1.2.3. ng v phng x - Nguyn tc: Kho st s ti mu c tim vng bng cch so snh s phn b cht ng v phng x Thalium 201 vo c tim khi ang gng sc v sau mt thi gian ti ti mu khi ngh ngi. - ch li v hn ch: Nhy hn trc nghim gng sc (80%), c hiu hn (90%) cho php xc nh vng b thiu mu, nh gi chc nng c tim. Gii hn ca phng php: dng tnh gi nu c block nhnh tri, gi thnh cao. - Chp bung tht bng phng x: bm tnh mch cht Technium. C th nh gi s co bp tng vng v ton b tht tri cng nh chc nng tim tri. 1.2.4. Siu m tim v Doppler - Siu m 2 chiu: nhm: + Phn tch s hot ng tng phn nh gim co bp, khng co bp thm ch ri lon co bp khu tr, tim bt thng thn chung ca ng mch vnh nh calci ha. + Tnh ch s co hi tht tri nhm nh gi chc nng tht tri ton b. Vi Doppler gip chn on h van 2 l do thiu mu c tim, p lc mch phi. Cc bin i v s lm y tht, nh gi lu lng ng mch khi gng sc v ngh ngi. - Siu m tim gng sc chn on thng qua vic thy bt thng vn ng thnh tim cho nhy cm chn on > 90% nu hnh nh tt. 1.2.5. Chp mch: Bm cht cn quang chp ton b h mch vnh v bung tht. i vi h mch vnh c gi tr nh gi mc , v tr tn thng mch vnh cng nh tnh trng ti mu, phn b mch mu v s calci ha, cc bt thng bm sinh, i vi bung tht nhm phn tch s co bp tng phn, chc nng tht tri, ch s tng mu v h 2 l do thiu mu c tim. Chp ng mch vnh l phng tin quyt nh dng nh gi nng ca bnh mch vnh cng nh dng chn on khi cc phng tin thm d khc khng cho php xc nh suy vnh. C th ni chp mch vnh l xt nghim khng th thiu c i vi bnh l mch vnh c bit khi cn thit phi can thip ngoi khoa, tuy vy y l k thut tn km v i hi chuyn vin. 1.2.6. Chp nhp nhy c tim bng Thallium 201 hoc Technitium 99m: c nhy cm 70-90% v c hiu 60-90% nhng t tin.

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2. Chn on phn bit 2.1. au vng trc tim do ri lon thn kinh thc vt: l thng gp trn thc t nht l tui tr. au thng mm tim, khng c khi pht khi gng sc m l khi ngh ngi. Cn au c th ko di hng gi hng ngy. Ngoi ra c th km thm cc triu chng ri lon thn kinh thc vt khc. 2.2. au do bnh ct sng - xng sn: vim khp, vim thn kinh lin sn. Khm n au khu tr, au khng c lan. 2.3. au do bnh ng tiu ha - au do co tht thc qun cng sau xng c, c km kh nut, . i khi lan ra hai cnh tay v cng gim bt sau khi dng nitroglycerin. Chp cine thc qun cho php chn on chnh xc. 2.4. Hi chng tro ngc d dy - thc qun: gy cm gic nng sau xng c, nng ln khi nm nga, du bt sau khi dng cc thuc khng acide. VI. CC TH LM SNG CN AU THT NGC: 1. au tht ngc n nh: cn au xy ra lin h vi gng sc. 2. au tht ngc khng n nh - Mi khi pht cn au tht ngc nng (< 2 thng) v/hoc xy ra cn = 3 cn/ngy. - au khi ngh ngi hoc l ch khi hot ng rt nh nhng. - Cn au tht ngc tng tin: thuc loi n nh nhng gn y nng hn, au ko di hn, hay xy ra hn v xy ra vi gng sc nh hn trc. Bnh nhn c mt trong 3 tiu chun trn c gi l c cn au tht ngc khng n nh (Harrson 2005). 3. Co tht vnh: cn c gi cn au tht ngc Prinzmetal. Xy ra trn mch vnh hon ton bnh thng hoc l c mng x va gy hp gn v tr ca co tht. au tht ngc c tnh tng t nhng m trm trng hn v xy ra in hnh khi ngh ngi cng vi hnh nh on ST chnh ln rt cao trn ECG. Lu l co tht vnh c th gy nn nhi mu c tim cng nh cc ri lon nhp c tnh. Chn on xc nh da trn chp ng mch vnh c tim TM Methergin (ergonovine). 4. Thiu mu cc b c tim yn lng: c pht hin bi ghi Holter hoc l trc nghim ECG gng sc ch yu xy ra nhng ngi c thiu mu cc b c tim c triu chng. Ghi nhn c bin i ST-T nhng v triu chng mc d c bnh mch vnh. 5. Nhi mu c tim: Xy ra khi tc mt hoc nhiu nhnh ca mch vnh. Nhi mu c tim (NMCT) l s hoi t thiu mu nng v h thng c tim vi in tch tn thng bng hay trn 2cm2. 5. 1. Triu chng lm sng: au ngc tng t nh l cn au tht ngc tuy nhin cng mnh hn nhiu v ko di hn (> 30 pht), t thuyn gim khi ngh ngi v sau khi dng nitroglycerine. Tuy nhin 25% ca nhi mu c tim l im lng v mt lm sng. 5.2. Triu chng cn lm sng 5.2.1. in tm thng thng Nhi mu c sng Q: ST chnh ln, T o ngc, sng Q hoi t. Nhi mu khng c sng Q: ST chnh xung, bin i dai dng ST-T m khng c xut hin sng Q. 5.2.2. Men: tng CPK, CPK-MB, GOT, LDH, Troponin T.

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5.3.Chn on Theo T chc Y t th gii NMCT c chn on xc nh khi c hai trong 3 du hiu sau: cn au tht ngc bin i, thay i ECG theo tin trin ca bnh v s gia tng men tim. Mt s trng hp khng c th chn on xc nh NMCT m ch c th ni c th c NMCT. Thng th c triu chng lm sng in hnh rt gi nhng m thiu bng chng khch quan trn ECG v men. Nu lm sng nghi ng nhiu th c th l NMCT nh. Trc mt bnh nhn nam gii >35 tui, n gii >50 tui c au ngc th phi xem xt iu tra c NMCT hay khng. Phi chn on phn bit vi au do vim phi, tc ng mch phi, vim mng ngoi tim, gy xng sn,co tht thc qun, phnh tch ng mch ch v nhng tnh hung gy bnh cnh au bng cp tnh do bnh trong bng. 5.4. Bin chng 5.4.1. Ri lon nhp: ngoi tm thu, rung tht, nhp nhanh tht, bloc nh tht... 5.4.2. Suy tim: c chong hoc khng. 5.4.3. Phnh thnh tim. VII. IU TR 1. Nguyn tc iu tr 1.1 Ci thin cc yu t nguy c y l bin php hng u c gi tr v t tn km, p dng c cho cc i tng giu/ngho nhng i hi s quyt tm v cng tc ca bnh nhn. C th nh v sinh i sng v ch n ung gim m, tp luyn th dc i b, bi li, i xe p, trnh stress, theo di, khm bnh, xt nghim lipid u n, lm trc nghim gng sc hng nm. 1.2. iu tr cn nguyn Nu bit c. Tuy c kh nng ci thin r nhng ch p dng trong nhng c nhn, n v c iu kin kinh t cao. V d: iu tr x va ng mch bng cc thuc gim m, iu tr phu thut vi cc tn thng van tim bm sinh hay mc phi. 2. Phng tin 2.1. iu tr ni khoa Bng cc thuc nh: dn xut nitrs, molsidomine, chn bta, c ch calci, cc phn t khc, maleate de perexilline (Pexid), chng ngng tp. 2.2. Nong ng mch vnh qua da (Angioplastie coronaire transluminale percutane) (PTCA) X dng mt catheter a vo M vnh qua da xc nh mc hp mch vnh, sau s x dng mt bong bng nh, ng knh 2-4mm bm ln v tr b hp, c xem kt qu khi nng c trn 50% so vi khu knh trc, t l thnh cng thng t n 90-95% trong giai on u tin. 2.3. Phng php phu thut cu ni ch - vnh (Pontage aorto-coronaire) Phng php c thc hin bng cch ghp tnh mch hin trong v nht l ng mch v trong vo v tr mch vnh b tn thng. T vong phu thut khong 1-4%, phng php ny ci thin d hu v triu chng ca bnh nhi mu c tim. 3. iu tr c th cn au tht ngc gng sc 3.1. iu tr ct cn au tht ngc gng sc

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Nn ap dng ngay trc khi vo vin v p dng cng sm s cng c tc dng ngn nga bin chng xu hn xy ra. - Ngh ngi, trnh gng sc. - Dng cc dn xut Nitrs ngm di li (Natirose vin 0,75mg) c th lp li sau 5pht hay bm Natispray liu 0,4mg lp li sau 5 pht nu cn, nu khng gim sau 15 pht cn phi t vn c phi cn au tht ngc khng n nh hoc nhi mu c tim. 3.2. iu tr lu di cn au tht ngc gng sc * Cc loi chn bta Tr phi c chng ch nh, y l thuc iu tr chn lc cn au tht ngc gng sc, iu tr hu hiu khi nhp tim ngh ngi t 50-60/ph v khi gng sc di 100/pht. Khi u bng liu thp, tng dn liu ln khi khng c bin chng. C th: - Propranolol (Avlocardyl vin 40mg) loi khng chn lc, khng c hot tnh giao cm ni ti, liu 2-4 vin chia 2 ln mi ngy. - Atenolol (Tenormine) vin 50-100mg, loi chn lc ln tim nhng c hot tnh giao cm ni ti, liu 50-100mg, ngy 1 ln. - Metoprolol (Lopressor) vin 100mg hay Seloken vin 100-200mg, chn lc tim, khng c hot tnh giao cm ni ti, liu 50-100mg/ngy 1 ln. - Acebutolol (Sectral) vin 200-400mg, chn loc ln tim, c hot tnh giao cm ni ti, liu 400mg/ngy ch dng 1 hay 2 ln (khi u 200mg/ngy chia 2 ln). Nu khng c p ng cn xem c c ch co tht ng mch vnh trong cn, ch quan trng l khng bao gi ngng t ngt iu tr chn bta v d c nguy c dn n lon nhp, nhi mu c tim v t t. * Cc dn xut Nitrat Thng c s dng u tin v phi hp vi 1 loai thuc khc (nh chn bta v hay chn calci) gm: - Nitroglycerine (vin hay bm xt) rt t chng ch nh (ngoi tr bnh c tim tc nghn) v t tc dng ph (thng gp l h huyt p, nhc u). - Cc dn xut Nitrat n, i hoc Nitrat dng vin hay bng dn. Hin tng dung np (tolerance) vi cc dn xut Nitrs hay gp vi liu cao, ko di. Hin tng gim i, nu tn trng khong trng Nitrat, ngha l khng ung Nitrs sau 18h v khng dn t 20 gi v 8 gi sng, iu ny gii thch s quan trng phi hp vi chn bta hoc c ch calci c bit bnh nhn c cn au ban m. C th: - ng ung: + Trinitrine (Lnitral) nang 2,5 mg v 7,5mg liu: 2 nang/ngy chia 2 ln. + Isosorbide dinitrate nh: Langoran nang 20-40mg hay 80mg L.P. Liu 40-80mg/ngy. Risordan vin 10-20mg liu 40mg/ngy chia 2,3 ln mi ngy. Risordan LP vin 20-40mg liu 40mg/ngy. + hay 5- isosorbide mononitrate nh: Monicor LP 20mg ngy ung 2 nang. + Molsidomine (Corvasal) khng phi l dn xut Nitrs nhng c tc dng tng t ngoi ra cn c tc dng chng ngng tp tiu cu. Bit dc: Corvasal vin 2-4mg, liu 1/2 - 1vin. ch li ca nhm ny l khng c hin tng dung np.

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- ng dn: Trinitrine nh Cordipath liu 5mg, dn vo bui sng v bn ngc, nn dn ngt qung, ch dn vo ban ngy. * Thuc c ch canxi Nu chng ch nh chn bta (nh suy tim mt b, ri lon dn truyn nh- tht, hen ph qun hi chng Raynaud) th ngai cc dn xut Nitrat v Molsidomine, vic s dng cc loi c ch calci l thuc chn lc nht l trong cn au tht ngc hn hp hay co tht ch yu. C th: - Diltiazem (Tildiem) vin 60mg hay Bi-Tildiem vin 90-120mg liu 2 vin 60mg/ngy trc khi n hay vin 90mg 2 ln/ngy. th nng: 180mg/ngy chia 3-4 ln, chng ch nh: suy nt xoang, bloc nh tht 2, 3 khng t my to nhp, suy tim tri, c thai. Tc dng ph: nhp chm xoang, bloc nh tht, ph chi di, suy nhc, bun ng, ri lon tiu ho. - Nifedipine (Adalate) vin 10mg. Liu 2 nang mi ngy khi n, th nng c th dng 3-4 nang ngy. Chng ch nh: c thai, tc dng ph, phng mt, nhc u, ph chn, au bng, h huyt p, nhp nhanh. - C th phi hp c 2 loi trong th nng hoc khng nong mch vnh c nh: + Tenormine 80-100mg/ngy + Adalate 3 nang/ngy hay Monicor LP 1 nang/ngy. Khi phi hp chn beta v Diltazem cn theo di tn s tim v ri lon nhp xoang. + Hoc Seloken 100-200mg/ngy + Corvasal 4mg 3 ln/ngy + Adalate 1 nang 4 ln/ngy. Nitriderm TTS. 5mg dn t 20 gi n 8gi. + Hoc ngoi l th khng: Pexid vin 100mg 1 vin/ngy trong 3ngy + sau 2 vin/ngy cn theo di chc v tc dng ph nhiu nh: xong, tn thng gan, thn kinh. * Cc thuc khc - Thuc hot ho knh kali (Nicorandil) tc dng dn ng v tnh mch vnh v c ngoi bin. Khng gim co bp tim v khng c hin tng khng tr. - Amiodarone tc dng chng lon nhp v chng thiu mu cc b. Lu tc dng ph. - Trimetazidine. - Gim au v an thn. * Phng php can thip - Nong v t stent (gi ): da vo kt qu chp mch v c chng minh c s thiu mu bng nghim php gng sc thallium. Chng ch nh khng nhiu ngoi tr hp thn chung ng mch vnh tri hoc ng mch vnh vi ho. - Bc cu ni ng mch ch - vnh:khi bnh nhn c triu chng lm sng, nong vnh tht bi km hp ti pht, tn thng nhiu nhnh nht l thn chung vnh tri km suy chc nng c tim nng. 4. iu tr cn TN Prinzmetal - Trong cn: Nitroglycerine hay 1 nang Adalate ngm t t khi nm. - Tip theo cn phi iu tr bng c ch calci, heparine, dn xut nitrate liu cao, khng dng cc cht c ch bta. Ch : Chng ch nh phi hp Tildiem vi Cordium hay Tildiem vi Isoptine. 5. iu tr cn au tht ngc khng n nh

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Cn nm ti trung tm hi sc tim mch. Nu - Do co tht (ban m, ngh ngi) cn cho Nitrat v c ch calci. - Do cn TN gng sc tng dn hay nng ln: Cho chn beta, Nitrat v/hay c ch canxi. C th: - Ngh ngi, monitoring, Oxy. - Theo di lm sng, in tm v sinh ha (CPK). - An thn: Tranxene 15-30mg/ngy. - Chng au: Morphine 1/2 -1ctg di da hoc tnh mch, nu khng p ng dn xut Nitrs. - Dn xut Nitrat: chuyn lin tc bng bm in nh Risordan liu 2-5mg/gi hay Lenitral liu 1mg/gi hay Corvasal, khng nn chuyn qa 48 gi. - c ch calci: Tildiem 3-4 vin/ngy. - Chn beta: nu khng do c ch co tht. Acebutolol 200-400mg/ ngy - Tenormine 80-100ng/ngy. - Heparine chuyn lin tc 400-800 v/kg hoc heparin trng lng phn t thp (Enoxaparin 1mg/kg tim di da 2 ln/ngy). - Aspirine 250-300mg/ngy. Nu khng p ng d iu tr phi hp nitres + c ch bta + c ch canxi:can thip mch vnh cp. 6. iu tr thiu mu c tim im lng - Cn tng cng iu tr chng au tht ngc. - Lp bilan mch vnh. 7. iu tr nhi mu c tim Nhi mu c tim c xem l mt bin chng trm trng ca suy mch vnh hocthiu mu c tim. Vic iu tr phi thc hin ti trung tm hi sc tim mch. Mc ch iu tr l gim au, hn ch ti a s lan rng m nhi mu, phng nga/ iu tr ri lon nhp v cc bin chng c hc. C th: - Nhp vin ti trung tm sn sc tng cng tim mch theo di tim lin tc. - Gi mt ng tnh mch cp cu nhng trng hp lon nhp. - iu tr tiu si huyt sm vi streptokinase, APSAC, hay cht hot ha plasminogene m (tPA) c th gim thiu din tch nhi mu v t vong v gii hn ri lon chc nng tht tri. nhng i tng thch hp, tiu si huyt cn cho cng sm cng tt ti cc n v tng cng hoc trung tm chm sc mch vnh. Bnh nhn c cho trong vng 3 gi sau khi xut hin triu chng kt qu tt hn c, tuy nhin cho php s dng thuc < 12 gi sau nhi mu. Bin chng bao gm xut huyt, ri lon nhp do ti ti mu, v trong trng hp x dng vi streptokinase c th c d ng. Thuc chng ng (aspirine v heparine) bt u cng lc vi thuc tiu si huyt. Chp mch vnh tip theo thng dnh cho nhng bnh nhn b au ngc ti din hoc trc nghim gng sc dng tnh trc khi ra vin. bnh nhn chng ch nh tiu si huyt, cn thc hin nng mch vnh ban u m bo lu lng vnh. cc trung tm c can thip mch vnh thng c a chung hn tiu si huyt

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- Kim sat cn au: Morphine sulfate 2-4 mg TM mi 5-10 pht cho n khi ht au hoc cc triu chng ph xut hin (x tr bng naloxone 0.4-1.2mg TM) ; h huyt p (nu nhp tim chm x tr bng atropine 0.5mg TM, nu khng c th chuyn dch vi s thn trng). - Nitroglycerine 0.3 mg ngm di li nu HA tm thu trn 100mmHg; nu vn cn au ngc cn cho TM nitroglycerine (bt u vi 10microgam/pht, tng dn n mc ti a 200 microgam/pht, theo di cht ch bng monitor). - Oxygen 2-4 lt/pht bng xng mi, nhm duy tr nng bo ha O2 >90%. - An thn nh (V d: Diazepam 5 mg ung X 4ln / ngy). - n nh chng to bn: Dng cc cht nho phn Vd. docusate sodium 100-200mg/day) - Chn bta: c tc dng gim tiu th O2 c tim, hn ch din tch nhi mu, gim t l t vong. Thuc c tc dng tt trong trng hp tng huyt p, nhp tim nhanh, au tht ngc tn ti; chng ch nh khi suy tim, HA tm thu di 95 mmHg, nhp tim < 50l/pht, bloc nh tht hoc tin s b bnh co tht ph qun. Cho TM v d metoprolol 5mg / 5-10 pht cho n liu tng cng 15mg sau cho ng ung metoprolol 25-100mgX 2 ln/ ngy. - Thuc chng ng/ thuc chng ngng tp tiu cu: Bnh nhtsau khi c dng tiu s huyt thng c tip ni chng ng bng aspirine v heparine, thi gian bt u ty thuc loi tiu si huyt. Trong trng hp khng th dng tiu si huyt c th cho aspirin 80-325mg/ngy v liu thp Heparin 5000 v tim di da hoc tim tnh mch / 12 gi. Liu heparin hu hiu (thi gian PTT gp i thi gian chng) sau duy tr bng thuc chng ng ung c khuyn co x dng nhng bnh nhn suy tim nng, c cc mu ng tm tht chn on bng siu m, hoc c vng ri lon vn ng ln trong NMCT trc. - Cc thuc c ch men chuyn: gim t vong nhng bnh nhn ri lon chc nng tht tri khng c triu chng sau NMCT (ch s tng mu di 40%) v c th cho nhng bnh nhn huyt ng n nh. Vd: captopril 6.25mg liu tt u tin sau tng ln 50mg ung 3ln / ngy. VIII. D PHNG Gm nhiu bc tin hnh mt cch c h thng: 1. Xc nh nguy c Thu thp ng thi cc thng tin v cc yu t nguy c phi hp cho php nh gi ton b mc rng nguy c mang tnh c th ca ng mch vnh c li khuyn c hiu. 2. Li khuyn c hiu Dnh cho c ngi cha b v c ngi b ri - Ht thuc: b hon ton thuc l. Nguy c ht thuc li ln hn khi c nhiu yu t phi hp. Vic d phng cn ch c bit nu l nam gii. - Huyt p: cn c ch iu tr theo di cht ch nhng trng hp mc bnh d ch mi giai on u tin hoc ch tng huyt p gii hn. - Tng cholesterol mu: cn ch khi cholesterol mu tng trn 220 mg% vi s khuyn dng ch n c bit cng nh cn phi c khm xt v iu tr dc bit khi tng trn 260mg%. -Tng cng luyn tp v hot ng th lc nhiu hn. Vic gim th trng bao hm vic gim r cc yu t nguy c.

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- i tho ng: s iu tr lin tc c theo di cht ch vi mt trung tm chuyn khoa l s chn la thch hp cho bnh nhn. -Thuc nga thai ph n bng ng ung: gim thiu ti a vic x dng.

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BNH C TIM Mc tiu

1. Nm c nguyn nhn, c c ch bnh sinh 3 nhm bnh c tim khc nhau, ch yu vo bnh c tim dn l nhm bnh thng gp nc ta. 2. Nm ca triu chng lm sng v cn sng cc bnh c tim dn gip vn dng trong thc hnh lm sng. 3. Chn on phn bit c ba loi bnh c tim. 4. Bit vn dng iu tr cc loi thuc theo cc tnh hung cng nh bin chng ca tng bnh c tim. 5. Bit r cc bin php phng nga cc bnh c tim.

Ni dung I. NH NGHA Theo bo co ca Lc lng c nhim T chc Y t th gii (TCYTTG): Bnh c tim l bnh gy tn thng c tim m nguyn nhn thng khng bit r. Bnh thng khng lin quan n cc bnh nh tng huyt p, bnh tim bm sinh, bnh van tim, bnh ng mch vnh hay bnh mng ngoi tim. II. PHN LOI C 3 loi da vo c ch sinh bnh - Bnh c tim dn n hay sung huyt (Dilated cardiomyopathy) - Bnh c tim hn ch (Restrictive cardiomyopathy) - Bnh c tim ph i (Hypertrophy cardiomyopathy) y l cch phn loi thng dng nht hin nay da vo khi nim ban u ca Goodwin v c TCYTTG cng nhn. Ngoi ra cn c cch phn loi theo nguyn nhn l bnh c tim tin pht v bnh c tim th pht nhng hin nay t dng. Bnh c tim tin pht cn c tn gi l bnh c tim, cn bnh c tim th pht gi l bnh c tim c hiu ngha l cc bnh c nguyn nhn r rng hoc l hu qu ca bnh ca cc c quan khc. III. DCH T HC Bnh c tim c m t u tin t nm 1957 v pht hin khp th gii. Tuy vy ty theo c im chng tc, vn ha, a l ca tng quc gia m tn xut ca cc bnh rt khc nhau. Bnh c tim dn l nhm bnh gp hu ht cc ni trn th gii, cn bnh c tim hn ch l bnh him gp nht. Bnh c tim ph i chim t l trung bnh. Bnh c tim dn v ph i gp cc nc vng chu v Thi bnh dng. Trong khi bnh c tim hn ch li gp cc vng chu Phi, Nam M, Trung M v mt s vng ti n . T l mc bnh c tim dn ti Thy in c c tnh l 10/10.000 dn/ nm. Ti Trung quc trong mt nghin cu ti mt nh my trn 60.000 cng nhn ghi nhn 65 ngi b, trong c 52 ngi b BCT dn v 4 trng hp b BCT ph i. Ti Chandigarh Chu Phi 3,7% trng hp m t thi c bnh c tim. Trong 38 trng hp pht hin th 28 ca b BCT dn, 9 ca b x ha c tim ni tm mc, 1 ca b bnh c tim, ph i. i vi bnh c tim ph i th t l chnh xc cha bit r v d nhm ln cc bnh khc.

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Trong khi bnh c tim hn ch hu nh gp cc nc nhit i. Uganda 14% trng hp t vong suy tim l do x ha c tim- ni tm mc. Nigeria l 10%. nc ta, hin nay cha c t l ton dn; tuy nhin nhiu tc gi ghi nhn t l BCT dn chim a s v gy nguy c t vong rt cao. BNH C TIM DN I. NH NGHA Bnh c tim dn l hi chng dn tht tri vi s gia tng khi lng tht ch yu l tht tri vi ri lon chc nng tm thu hay tm trng m khng c tn thung nguyn pht mng ngoi tim, van tim hay thiu mu c tim. Trn lm sng bnh c tim dn c biu th qua s dn hai tht, tht tri nhiu hn tht phi, do s tr trong bung tht, l ngun gc cc cc mu ng gy tc mch. V gii phu bnh, l s x ha k c tim, cc t bo c ph i v thoi ha khng c hiu. II. NGUYN NHN: Thng iu tr bng cch loi tr. 1. Mt s yu t c ra nh: Nhim trng (entrovirus), dinh dng, ng c (ru), tng HA, tn thng vi tun hon vnh, min dch, sau sinh. 2. Chn on bnh c tim dn v cn: Ch xc nh khi loi tr cc nguyn nhn bit c. III. SINH L BNH 1. S dn tht v gim co bp: a n s gim ch s tng mu v s gia tng th tch cui tm trng. iu ny s lm gim s lm rng tm nh, lm tng p lc nh tri v p lc cui tm trng ca tht tri. giai on u, nhp tim nhanh b tr vi s gim th tch tng mu tm thu nhm duy tr lu lng tim (Q = FxV). V sau s xut hin gim lu lng tim, s gia tng p lc mao mch phi (OAP) v sau cng l s gia tng p lc mao mch phi v suy tht phi. 2. S gim p lc ti mu thn: a n s kch thch h renine - angiotensine -aldostrone. iu ny lm gia tng th tch mu nhng gy s co mch ngoi bin. S thiu mu di ni tm mc thng gp do s gim d tr vnh. VI. LM SNG 1. Hi bnh 1.1. Tin s - Tin s c nhn v iu tr hin ti hay trc y. - Gia nh. 1.2. Triu chng c nng: - Mt mi, kh th cc mc . - Ph ngoi bin, au ngc, hi hp, tin s thuyn tc ngoi bin hay no. 2. Khm lm sng - Tim: Nhp tim nhanh, huyt p ng mch bnh thng hay thp, mm tim lch tri, ting T3, T4, thi tm thu h hai l v/hay h ba l, cc du hiu ca suy tht phi. - Phi: Ran m phi, trn dch mng phi.

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V. CN LM SNG 1. X quang phi: Tim to vi s gia tng t l tim/lng ngc, du xung huyt phi, trn dch mng phi. 2. in tim: Nhp nhanh xoang, bt thng khng c hiu on ST-T, ph i tht tri, bloc nhnh tri khng hon ton hay hon ton, bt thng nh , sng R gim bin . i khi c sng Q d nhm hoi t c tim, ri lon nhp nh v nhp tht. 3. Sinh ha: Ion : gim Natri mu, suy thn chc nng, CPK bnh thng. 4. Siu m tim vi Doppler tim 4.1. Siu m 2 bnh in v TM: Dn cc bung tim nht l tht tri, gim ch s co hi, gim co bp ton th vch tim, c khi khng co bp d nhm suy mch vnh, c th thy cc mu ng v trn dch mng tim. 4.2. Doppler tim: Tm du h 2 l (c nng), du h 3 l hay h ng mch phi, s ri lon chc nng tm trng, nh gi cung lng tim. 5. Cc phng php thm d c bit: 5.1. Chp nhp nhy c tim: ch s tng mu gim. 5.2. Thng tim: cho php nh gi p lc bung tim, s hot ng cc bung tim, cc van tim. Sinh thit c tim ch cn khi mun tm nguyn nhn. 5.3. Holter nhp, trc nghim gng sc, kch thch tim. VI. TIN TRIN 1. Bin chng: Suy tim ton b, rung nh, nhp nhanh tht v t t, tc mch ngoi bin v no b, phi. 2. T l sng trung bnh: 6 thng n 3 nm sau khi xut hin cc triu chng, 20% bnh nhn c din tin thun li hn. VII. CHN ON PHN BIT - Bnh c tim thiu mu tin trin. - Bnh c tim do tng huyt p tin trin. - Bnh van tim, c bit l h van hai l nng. - Bnh c tim tc nghn. Ni chung, bnh c tim dn nguyn pht c chn on khi loi tr sau khi loi tr tt c cc nguyn nhn dn tht tri, c bit l bnh mch vnh nng hay h van tim nng. VIII. HNG IU TR 1. Bin php chung 2. iu tr thuc: kt hp thuc dn mch v li tiu c nh gi cao. 3. iu tr bin chng: nh ph phi cp, chong tim, rung nh, ri lon nhp tht. 4. Ghp tim.

BNH C TIM TC NGHN (BCT PH I) I- NH NGHA: Bnh c tim tc nghn c tim (BCTTN) l s ph i tt c hay mt phn lm tc nghn ng tng mu k tm thu. Th ph i vch tim thng gp nht v l nguyn nhn do tc nghn bung y tht tri. II- NGUYN NHN: Cha r.

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1. Di truyn: Theo nhim sc th tri chim 55% trng hp, c th do: - Ri lon hot ng cc catecholamines. - S gia tng lu di calcium t bo gy ra s ri lon chc nng c tim v mch mu. 2. Trong 45% trng hp: bnh xy ra n c v khng r nguyn nhn do (2/3 nam gii). 3. i khi bm sinh khng c ngun gc gia nh. III- SINH L BNH 1. Chc nng tm thu tht tri: ri lon v gim hot ng tng mu tht tri, qua c 2 gii thch: - Gradient trong tht tri l hu qu ca s lm rng sm tht tri tng ng. 75% lung mu tm thu c tng ra 1/3 u k tm thu. S di chuyn van 2 l ra trc (SAM) ch l hu qu s xon vn ca bung tht tri. - S di chuyn ra trc van 2 l (hiu qu Venturi) do s gia tng tc qua mt bung y c th tch thu nh. 2. Ri lon chc nng tm trng tht tri: a n - Nhng bt thng v s dn n v s lm y tht tri. - Cc ri lon trn c th ci thin vi cc thuc c ch canxi (Verapamil).

Khi u tm thu Thi k tm thu sm Gia tm thu S di chuyn l van ra pha trc trong k tm thu bnh c tim ph i IV- CHN ON XC NH TH THNG THNG BCTTN 1. Hon cnh pht hin: Xy ra ngi tr, tui trung bnh: 25 - 30 tui, khng THA, ph i vch khng i xng 1.1. Khm h thng: (nghe tim) v bnh nhn thng chu ng tt trong mt s na trng hp. 1.2. Du hiu chc nng: (khng c hiu) pht hin bng hi bnh. - Kh th, gng sc, hi hp, nhp nhanh, au ngc khng in hnh xy ra khi gng sc. - Hi bnh gip xc nh v tin s c nhn gia nh (t t, tui cht b m). C th pht hin nhng du hiu gi nh: au tht ngc (30%), ngt, xu (25%) nhng ph phi, ri lon nhp t gp hn. 2. Khm thc th - Huyt p bnh thng. - S vng trc tim c du chm mm, lch tri.

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- Nghe tim: thi tm thu (90% ca) kiu tng mu gia k tm thu, vng gia tim lan ra mm, cng thay i theo thi gian, gia tng khi gng sc, ngoi tm thu tht, khi lm nghim php Valsalva, gim khi ht vo, cc ting tim bnh thng, c T4 thng. C thi ton k tm thu do h 2 l vi cng gim khi ht Nitrite d Amyle hay khi lm th thut Valsalva. 3. in tim: Khng c du c hiu. - Nhp tim: thng l nhp xoang, ngoi ra cn gp rung nh (5-10%), ri lon nhp tht. - Ph i tht tri (60%), c khi 2 tht. - Ph i vch tim: sng Q thanh mnh (< 0,04), su (50%) V5, V6, D1, aVL.

Tnh mch c ng mch cnh Nghe tim V tr v tnh cht cc ting thi trong bnh c tim ph i i khi c sng Q rng, gi nhi mu, d iu tr nhm khi c cn au tht ngc. - Ri lon ti cc thng gp vi ST chnh xung, sng T m tnh. - Ri lon dn truyn: bloc khng hon ton nhnh tri, bloc phn nhnh tri trc. 4. X quang ngc - Tim bnh thng nhng khi bng tim ln cn tm du h 2 l vi dn nh tri. ng mch ch nh, m, khng b canxi ha. 5. Tm thanh : c gi tr hn ch. C th gip iu tr phn bit thi tm thu tng mu vi thi 2 l. Gip tm ting nga phi v ting T2 tch i nghch l. 6. Siu m tim 6.1. Siu m 2 bnh din: gip xc nh. - Tnh cht ph i: m bt thng trong vch, phn b ca ph i, tn thng phi hp vi tht phi. - C ch tc nghn: lch b phn van 2 l, xon vn bung tht tri. - Kch thc bung tim (nh tri dn). - Ch s co hi bnh thng hay gia tng.

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- Tnh trng van tim: s di chuyn van 2 l ra trc. - Mng ngoi tim bnh thng. - Chuyn ng ra trc van 2 l k tm thu (S.A.M). - S ng li sm gia k tm thu ca van MC kiu cnh bm. Tuy vy, 3 du ny khng thung xuyn v khng c hiu. 6.2. Doppler tim. - Doppler mu: cho thy s gia tng tc trong bung tng mu tht tri gia k, du h 2 l phi hp. - Doppler mch: cho thy nhng bin i c bit ca s lm y tht tri. - Doppler lin tc: c gi tr cao v cho php xc nh gradient ti a trong bung tht tri, l d 2 l v p lc ng mch phi. 6.3. Cc xt nghim c hiu khc - h tr cho iu tr trc m hay khi c nghi ng tn thng vnh phi hp nh k thut thng tin, chp mch vnh. - o in tim lin tc 24-48 gi Holter. - in tim khuch i cao tm in th chm. - in tim gng sc khi hp qu kht. - ng v phng x bng Thallium, IRM... t dng. V- TIN TRIN - Suy tim tri. - Ri lon nhp: rung nh, ngoi tm thu nh, ngoi tm thu tht, nhp nhanh tht. - Bin chng khc xen k vo: vim ni tm mc, tai bin thuyn tc. - t t do cn nhp nhanh, nghn bung tht, chim 2-3%. VI- TH LM SNG C BIT 1. Bnh c tim ph i khng c gradient trong tht tri v cn phi s dng cc trc nghim dc l, da vo tin s gia nh iu tr. 2. Bnh c tim ph i mm: c tin lng nh hn, gp nam gii tui trung bnh 35, c sng T m, su khng l trc vng tim. 3. Bnh c tim ph i ngi THA ln tui. - THA trc y khng c tin s gia nh b bnh c tim tc nghn, tin lng kh hn nu iu tr sm. VII- CHN ON PHN BIT 1. Lm sng - Hp van ng mch ch: da vo c im ting tim v siu m. - H 2 l: hay kt hp bnh c tim tc nghn, da vo Doppler iu tr. -Xa hn: vi thng tht, hp phi. 2. ECG. Cn phn bit sng Q suy vnh, nu cn chp ng mch. 3. Siu m - Khi c ph i tht tri, siu m cn tm nguyn nhn (THA, hp ch). - C th c s phi hp bnh c tim tc nghn v bnh tim THA. VII- HNG IU TR - Thuc: chn bta, c ch canxi,disopyramide, amiodarone.

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- iu tr phu thut. - iu tr bin chng nh ph phi cp, rung nh, lon nhp tht. -Khng sinh d phng.

BNH C TIM HN CH I- NH NGHA: Bnh c tim hn ch l mt triu chng lin quan n tr ngi lm y tht vi bt thng chc nng tm trng (s dn c tim) do bnh ni tm mc, di ni mc v c tim. II- NGUYN NHN 1. X ha ni mc c tim l nguyn nhn thng gp ca bnh c tim hn ch vng nhit i. Bnh Loeffler: hay gp Chu u. Cn phi phn bit 3 giai on qua sinh thit c tim: giai on hoi t sm, giai on thuyn tc v giai on x ha mun. 2. Cc nguyn nhn khc: bnh nhim kt, nhim huyt t, bnh sarcoidose, x cng b, bnh glycogen, K, chiu x, thi ghp. III- BIU HIN LM SNG 1. Hi bnh - Tin s (d ng, i xa...) - Triu chng: suy nhc, kh th gng sc, suy tht phi, ph c chng. 2. Lm sng: o HA, nhp nhanh xoang thng xuyn, pht hin cc du hiu suy tim (P) (d nhm vim mng ngoi tim co tht) v du suy tim (T). IV- CN LM SNG 1. X quang lng ngc: bng tim ln, va phi, trn dch mng phi, cc du hiu dn nh, xung huyt phi. 2. ECG: Du dy tht (P), tht (T), bin i on ST-T, c th