1. 1. AI HOC HU TRNG AI HOC Y KHOA B MN NI BNH LY HOC NI KHOA Hu - 2008
2. 2. LI NI U Thc hin ch trng ca i hc Hu, c s nht tr ca Ban Gim Hiu Trng i hc Y khoa Hu, B Mn Ni tin hnh ph bin gio trnh in t Y khoa ln u tin. y l mt phng tin thng tin ph bin nht v thch hp cho cc i tng sinh vin, hc vin khp mi ni c th tham kho cc bi ging ni khoa. y cc bi ging c chn lc, tp trung vo mt s ni dung c bn nht. Mt s hnh nh v s ca bi ging do s khng c a vo. Qu c gi c th lin h tham kho cc phn chi tit tp gio trnh hon chnh ca B Mn Ni hoc vi cc trng phn mn lin h. Chng ti cng xin lu vic sao chp mt phn hoc ton b tp bi ging ny ngoi mc ch hc tp cn c s ng ca n v ch qun hoc tc gi. Chn thnh cm n s quan tm v hp tc cng nh rt mong s gp ph bnh ca qu c gi . TM. Ban ch nhim B Mn Ni kim Ch bin PGS.TS. Hunh vn Minh hvminh@dng.vnn.vn hvminhdr@yahoo.com
3. 3. 1 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 thng hiu qu. 2. Dch t hc - Tui tr: 5 -15 tui. - Ma lnh m lm d vim hng. - Sinh hot vt cht: bnh thng gp cc nc chm pht trin, c iu kin sng thp. - Bnh xy ra sau vim hng do lin cu, hoc nhim lin cu nhng khng c triu chng, bnh d ti pht nht l bnh nhn thp tim c. 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 phn loi theo Protein M th c khong 60 type khc 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 1. Giai on u: Gy 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:
4. 4. 2 Ht Aschoff trong c tim: T bo c tim ln, nhiu nhn, c mt s t bo c nhiu ht nhn + 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 van hai l 40%. Van 2 l kt hp 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 50-200ml, 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, khi 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 khp in hnh, mt s trng hp khng c 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 t vong. C th gy vim c 3 lp cu to ca tim: - Vim mng ngoi tim + au vng trc tim. + C khi nghe c ting c mng ngoi tim. - Vim c tim + Ting tim m + Suy tim: nhp tim nhanh, ting nga phi, 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 do h van 2 l v hoc ting thi tm trng y tim do h van MC. 1.4. Nhng biu hin khc
5. 5. 3 - 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, du hiu vim thng xut hin mun. Hnh nh ht di da (hnh 1) v ban vng (hnh 2, 3) + 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 (alpha 2 v gamma Globulin). - Creactive Protein (CRP) dng tnh. 2.2. Biu hin nhim lin cu - Cy dch hng tm lin cu: Thng dng tnh, 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: Ngoi tm thu, bloc nh tht cc cp. 2.4. X quang: Bng tim c th bnh thng hoc ln hn bnh thng, nu vim c tim thy du tr tun hon phi, bng tim ln.
6. 6. 4 Hnh nh XQ tim ca bnh nhn 8 tui b vim c tim do thp tim (trc v sau iu tr) V. TIN TRIN V BIN CHNG 1.Th thng thng: Lm sng ci thin rt nhanh. - Triu chng khp gim sau 24-48h, PR cn ko di sau vi ngy, VS cn tng sau 2 - 3 tun. - Tt c cc triu chng thng mt sau 2 thng. 2. Th nng - Thp tim c tnh + Gp tr nh < 7 tui. + Vim tim ton b c bit l vim 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 (van tim). 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: rt him gp, thng kt hp vi cc van khc. 4. Vim mng trong tim nhim khun: bin chng nng, Osler hay gp h cc van hn l hp. 5. Ti pht: Hay gp bnh nhn khng d phng thp tim 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-CRP (+) - Tin s thp hay b bnh tim sau nhim lin cu. 1.3.Tiu chun mi b nhim liu cu
7. 7. 5 - 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. Siu m Doppler tim - Siu m 2 bnh din v M-Mode c th thy trn dch mng tim, cc bin i cc van tim, mc ri lon chc nng tim v tng p phi. - Siu m Doppler v Doppler mu: Pht hin h van 2 l, van MC, cho php nh gi mc h. H van 2 l trn Doppler mu, van 2 l dy ng khng kht trn 2D H van ng mch ch trn Doppler mu 2D v ph i tht tri trn siu m 2D Hp van 2 l trn Doppler mu 2D, trn Doppler lin tc (o din tch van 2 l-MVA=1,2cm2 ) v hp van 2 l trn siu m 2D 2. Chn on phn bit 2.1. Vim a khp dng thp: Vim nhiu khp nh, bin dng khp, teo c, cng khp bui sng, tin trin ko di. 2.2. Vim khp do lu cu: Vim thng mt khp, thng khp gi, dch khp c vi khun. 2.3. Lao khp: Thng trn 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 v nhiu c quan.
8. 8. 6 2.5. Vim mng ngoi tim, c tim do virus: Bnh tin trin rm r, cp tnh, st cao, c mng ngoi tim, ri lon nhp tim, ri lon dnc truyn c bit l blc nh tht hon ton, c th t vong, i vi th thng thng thng khi hon ton khng li di chng. VII. TIN LNG: Ph thuc vo tn thng tim. - Nu khng tn thng tim trong 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 x hi. 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 th tim b tn thng. - Din bin kh lng, d phng sut i ni ln tm quan trng ca thp tim tc ng ln tim c bit l bung tim tri.
9. 9. 7 BNH HP VAN HAI L Mc tiu 1. Nm vng cc triu chng lm sng v cn lm sng ca bnh hp van hai l. 2. Nm c cc th lm sng ca bnh hp van hai l. 3.Nm vng cc phng tin iu tr ni khoa bnh hp 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 van tim mc phi 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 v 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 vo nhng nm ny Cutter v Levine Phillipe (Hoa k) tm cch phu thut hp van hai l, ti Anh Souttar 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 v t vong. Bnh gp n nhiu hn nam (2/1) v nng thn mc nhiu hn thnh th. II. BNH NGUYN V C CH SINH BNH Tu theo tui, ch yu do thp tim (99%) i vi tui tr, mt s nguyn nhn khc nh bm sinh, Carcinoid c tnh, lupus ban h thng, vim khp dng thp c nhng 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 v gy tn thng tim. S d lin cu hng gy bnh thp tim m khng vo cc c quan khc l do i qua bch mch gia hng v tim. Cu trc bo thai hc cng 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 nhm A. C ch sinh bnh c th c ghi nhn 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 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 h van tim. 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 mc d 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 tri ln chn p vo thc qun nht l khi gng sc.
10. 10. 8 1.3. Du chng thc th: Nghe tim l ch yu, bnh nhn nm nghing tri, c th nghe khi nm nga, hoc c khi phi bnh nhn lm ng tc gng sc. Hp van hai l in hnh thng nghe c cc du chng sau tu theo tn thng van, bnh l phi hp hay bin chng ca hp van 2 l: - 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 rt kht, van v t chc di van dy, vi ha, dnh vi nhau. - T2 mnh y tim do tng p lc ng mch phi 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 mu cn li nh tri, nh tri bp y mu xung tht tri; nhng khi b rung nh hay nh tri gin 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 cc bin chng (suy tim phi, rung nh, tc mch) v nh cn lm sng nht l siu m tim 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 ln lt l 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 ng 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. - 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). Hnh nh XQ tim phi thng: Bn tri c hnh nh 4 cung, bn phi c hnh nh 3 cung; trn phim nghing c barit nh tri chn thc qun 1/3 gia 2.2. in tm
11. 11. 9 - 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. in tm hp van 2 l: Nhp xoang, trc hng phi, =850 , dy nh tri (D1, V1), tng gnh tht phi (V1, V3R, V4R) 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, nong van hay sa 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 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. - 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
12. 27. 25 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 ). + 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. X tr THA theo phn nguy c tim mch Nhng yu t nguy c, tn thng c quan v bnh cnh lm sng Bnh thng Bnh thng cao THA 1 THA 2 THA 3 Khng c yu t nguy c Khng iu tr HA Khng iu tr HA Thay i li sng vi thng ri dng thuc nu HA khng gim Thay i li sng vi tun ri dng thuc nu HA khng gim Thay i li sng+ dng thuc ngay C 1-2 yu t nguy c Thay i li sng Thay i li sng Thay i li sng vi tun ri dng thuc nu HA khng gim Thay i li sng vi tun ri dng thuc nu HA khng gim Thay i li sng+ dng thuc ngay
13. 28. 26 C 3 yu t nguy c, hi chng chuyn ho, tn thng c quan ch hoc i tho ng Thay i li sng Thay i li sng Thay i li sng+ dng thuc Thay i li sng +dng thuc Thay i li sng+ dng thuc ngay i tho ng Thay i li sng Thay i li sng+ xt dng thuc Thay i li sng+ dng thuc Thay i li sng+ dng thuc Thay i li sng+ dng thuc ngay C tnh trng lm sng i km hoc bnh thn Thay i li sng + dng thuc ngay Thay i li sng+ dng thuc ngay Thay i li sng+ dng thuc ngay Thay i li sng+ dng thuc ngay Thay i li sng+ dng thuc ngay * iu tr cn tng huyt p cp tnh Cn phi dng loi h huyt p bng ng tnh mch nh:
14. 29. 27 - 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 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.
15. 30. 28 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. 1. Tin gnh: l ko di ca cc si c tim sau tm trng, tin gnh ph thuc vo lng Sc co bp Hu gnh Tn s tim Cung lng timTin gnh
16. 31. 29 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. 5. C ch b tr trong suy tim 5.1. B tr ti tim Gin tm tht: L c ch thch ng u tin trnh qu tng p lc cui tm trng ca tm tht. Khi tm tht gin ra s lm ko di cc si c tim v theo nh lut Frank-Starling s lm tng sc co bp cc si c tim nu d tr co c vn cn. Ph i tm tht: Tim cng c th thch ng bng cch tng b dy cc thnh tim nht l trong cc trng hp tng p lc trong bung tim. Vic tng b dy cc thnh tim ch yu i ph vi tnh trng tng hu gnh v ci thin th tch tng mu b gim trong suy tim . Hnh : T bo c tht bnh c tim ph i v suy tim. S kch thch tng trng dn n s khc bit v hnh thi hc ca t bo c. 5.2. B tr ngoi tim
17. 32. 30 - Kch thch h thn kinh giao cm: Khi c suy tim h thn kinh giao cm c kch thch, lng catecholamine t cc u tn cng cc si giao cm hu hch c tit ra nhiu lm tng sc co bp ca c tim v tng tn s tim. Cng giao cm s co mch ngoi vi nh da, c, thn v cc tng bng u tin ti mu cho no v tim. - Kch thch h Renin-Angiotensin-Aldosteron: Tng hot ha giao cm v ti mu ti thn s kch thch b my cnh cu thn ch tit nhiu renin v lm tng nng renin trong mu. Renin s hot ha Angiotensinogen v cc phn ng tip theo tng tng hp Angiotensin II. Chnh Angiotensin II l cht co mch mnh, ng thi li tham gia kch thch tng hp Noradrenalin u tn cng cc si thn kinh giao cm hu hch v Adrenalin t ty thng thn. Cng chnh Angiotensin II cn kch thch v thng thn tit Aldosteron lm tng ti hp thu Natri v nc ng thn. - H Arginin-Vasopressin: suy tim giai on mun, vng di i- tuyn yn c kch thch tit ra Arginin-Vasopressin (ADH). ADH lm tng thm tc dng co mch ngoi vi ca Angiotensin II v lm gim bi tit nc ng thn. C 3 h thng co mch b tr ny nhm duy tr cung lng tim, nhng lu ngy chng li lm tng tin gnh v hu gnh, tng nc v Natri, tng cng v mc tiu th oxy c tim, to nn vng xon bnh l lm tim ngy cng suy thm. - Nhng yu t khc: Trong suy tim nhm c gng hn ch vic co mch khu tr hay ton thn qu mc, cc cht gin mch khc cng c gia tng sn xut nh: Bradykinin, Prostaglandin (PGI2,PGE2), Endothelin v c bit l yu t li niu nh ANP , m ngy nay ch yu l BNP c xem l yu t quan trng trong vic chng ri lon chc nng tht tri, lm ci thin tnh trng suy tim. IV. PHN LOI SUY TIM 4.1. Suy tim cp v suy tim mn Biu hin ca suy tim ty thuc vo tc din tin v thi gian hin tng tch t dch m k xy ra. Nhn chung nu bnh tim gc din tin chm, cc c ch b tr c thi gian hot ha, bnh nhn c kh nng iu chnh ph hp vi tnh trng thay i cung lng tim. Nu bnh l gc din tin nhanh hoc km yu t thc y suy tim, kt qu c th l ti mu c quan khng hoc sung huyt cp tnh. Ging tnh mch dn lu v tht b nh hng, gy ra mt b tim t ngt km theo gim cung lng tim v khi pht cp tnh cc triu chng.
18. 33. 31 Trong suy tim mn, c ch thch nghi c hot ha mt cch t t v tim ph i dn. Nhng thay i ny cho php bnh nhn iu chnh v dung np hin tng gim cung lng d dng hn. Khi suy tim tri xy ra t t, tim phi to ra p lc cao hn p ng vi tnh trng khng lc mch mu phi cao; trng hp khng lc mch mu phi tng cp tnh ti mc tng t c th gy nn bnh cnh suy tim phi cp. Bnh nhn suy tim mn c th t c tnh trng b tr nhng sau c th mt b cp tnh nu c yu t thc y. 4.2. Suy tim phi v suy tim tri Suy tim thng ch b mt bn nu khi u t ngt (v d: Trong NMCT). Kh nng cha mu ca h tnh mch bn tri nh hn h tnh mch ton thn bn phi, v tng p lc tnh mch cng nh cc triu chng km theo ca suy tim tri xy ra khi c s tch t dch tng i t hn. Mc d qu trnh bnh ban u c th ch lin quan n mt tht, nhng v sau thng c hai tht u b suy, nht l khi tht tri b tn thng trc. C hai tht c chung vch lin tht v nhng thay i sinh ha khng ch gii hn bung tht b tn thng m nh hng n bung tht bn kia. Thm vo , do c bn bung tim nm trong khoang mng ngoi tim, khi kch thc ca bt k bung no tng ln t ngt, bung tim i din s b chn p v p lc y tht tng ln (iu ny c nh ngha nh l s ph thuc ln nhau gia cc bung tht). Suy tim tri thng gy suy tim phi, nhng suy tim phi n c (V d: Thng lin nh, tm ph mn) him khi gy suy tim tri nu khng c mt bnh l tim tri ring km theo (V d: Bnh mch vnh vi thiu mu cc b hoc NMCT). cc bnh nhn b suy tht tri, tim phi suy c th lm gim cc triu chng h hp (kh th khi gng sc, kh th khi nm, kh th v m) thng c trong suy tim tri . 4.3. Suy tim cung lng cao v suy tim cung lng thp Phn ln trng hp suy tim thng km theo tnh trng cung lng thp, gy ra nhng thay i tun hon ngoi bin (co mch), bao gm biu hin u chi lnh, m v xanh tm; thiu niu; p lc mch thp v chnh lch oxy gia mu trn tnh mch v mu ng mch thng ln. Suy tim cung lng cao, vn t gp hn, thng kt hp vi trng thi tng ng tun hon (thiu mu, nhim c tuyn gip, c thai, bnh xng Paget, d ng tnh mch). Cc tnh trng ny thng lm khi pht suy tim trn nn mt bnh l tim c sn. Khng ging nh tnh trng suy tim cung lng thp c tnh trng co mch, trong suy tim cung lng cao bnh nhn c tnh trng gin mch, da m, phng v mch ny mnh. chnh lch oxy gia mu ng mch v mu trn tnh mch bnh thng hay gim nhng thng cao hn mc ca bnh nhn suy tim cung lng thp. Mc d ch s tim thng cao
19. 34. 32 hn bnh thng (