dt nmct cap cn 2012

IU TR NHI MU C TIM CP: CP NHT 2012PGS. TS. Phm Nguyn Vinh i hc Y Khoa Phm Ngc Thch Bnh vin Tim Tm c Vin Tim Tp.HCM

iu tr NMCT cp: cn 2012

Cc nh ngha v sinh l bnh hi chng ng mch vnh cp (HCMVC)Hi chng ng mch vnh cp

Khng ST chnh ln NMCT KSTCau tht ngc khng n nh

ST chnh ln

NMCT khng Q

NMCT c Q

TL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-1351

2


nh ngha mi ca ESC/ ACC/ AHA/ WHF/ WHO v nhi mu c timTiu chun chn on NMCT cp

1. Tng v/hoc gim cht ch im sinh hc hoi t c tim*; km mt trong cc bin i sau:a. Triu chng TMCB b. Xut hin sng Q bnh l/ ECG c. ST chnh ln hay sp xung d. Ri lan vn ng vng/ chn on hnh nh 2. Gii phu bnh pht hin NMCT cp* Mt trong cc gi tr phi trn bch phn v 99 mc cao troponinTL: Alpert JS et al. Definition of myocardial infarction. ESC/ACC/AHA/WHF/WHO 20073


Dch t hc Tn sut mi mc HC MVC/KSTC > HC MVC/STC HC MVC/KSTC nhp vin: 3/1000 dn s T vong trong bnh vin HC MVC/STC > HC MVC/KSTC T vong vo thng th 6: tng ng gia 2 th bnh (12% so vi 13%) Vo nm th t, t vong HC MVC/KSTC > 2 HC MVC/STCTL: Bassand JP et al. ESC Guidelines for the diagnosis and treatment of non ST segment elevation acute coronary syndrome. June 14, 20074


Sinh l bnh Mng x va d tn thng (the vulnerable plaque) Huyt khi MV (coronary thrombosis) Bnh nhn d tn thng (the vulnerable patient): - multiple sites of plaque rupture - various systemic markers of inflammation - coagulation system activation Ri lon chc nng dn mch ca ni mc Cc c ch th cp lm tng nhu cu oxy c tim (td: st, cng gip, stress, tng hot giao cm)

5


Mng x va n nh so vi mng x va khng n nh



Tng quan gia YTNC, ri lon chc nng ni mc, vim vi hi chng MVC

NFKB= nuclear factor Kappa B ACE= angiotensin converting enzyme MCP1= monocyte chemoattractant protein -1 CNP= C- type natriceretic peptide UCAM= vascular cell adhesion nukcule PDGF= peatelet derived growth factor


7


Biu hin lm sng au tht ngc lc ngh ko di (> 20 pht): 80% au tht ngc nng (CCS III) mi khi pht au tht ngc n nh, nay nng hn (cn xut hin gia 20% tng), t nht CCS III au tht ngc sau NMCT

TL: Van Domburg RT et al. J Am Coll Cardiol 1998; 31: 1534 - 15398


Cc phng tin chn on Khm thc th ECG ECG gng sc Holter ECG Cc cht ch im sinh hc (Biomarkers) Siu m tim v phng tin hnh nh khng xm nhp khc (x k c tim, MRI) Chp MV c cn quang

9


Cc c im gip ngh au ngc l do nghn MV (1)Kh nng cao bit c BMV (c bit mi PCI) C cn au tht ngc in hnh t trc Thay i huyt ng hoc ECG/ lc au ngc ST chnh ln hay sp xung 1 mm T o, su, i xng trn nhiu C ngc Men tim tng hoc gimPCI: nong MVTL: De Lemos JA et al. Hurts The Heart, 13th ed 2011, McGraw-Hill. p. 1328-135110


Cc c im gip ngh au ngc l do nghn MV (2)Kh nng trung bnh Cn au tht ngc in hnh au tht ngc khng in hnh trn T hoc khng T nhng c 2 YTNC Nam Tui > 70 C bnh mch mu ngoi tim ST sp 0,5-1 mm hoc T o 1 mm Troponin tng nh, khng ln hay xung



Cc c im gip ngh au ngc l do nghn MV (3)Kh nng thp au vng ngc khi n T dt hoc o < 1 mm ECG bnh thng



Phng thch cht ch im tn thng c tim HC MVC/KSTC

TL: Bassand JP et al. ESC Guidelines for the diagnosis and treatment of non ST segment elevation acute coronary syndrome. June 14, 2007 13


iu tr NMCT cp: thi gian; la chn ng phng tin iu tr

14


Giam au, kho th, lo langMorphine 2-4 mg TM Them 2 mg/ 5-15 phut

O2 (2 -4 l/h ) neu kho th hay suy timAn than (benh nhan lo lang)oo o

Chong oi ma(TD: metoclopamide 5-10 mg TM co the dung kem opoids) Atropine(0,5 1 mg TM, toi a 2 mg) ha HA, tim cham Oxygen (2-4 l/ph): th kem, suy tim, soc15


Tai lu thong MV: hang au/ NMCT cap ST chenh len

16


Tin trin ca hoi t c tim sau tc MV

TL: Antman E M, Braunwald. In Braunwalds Heart Disease, ed, by Libby, Bonow, Mann, Zipes.WB Saunders 2008, 8th ed, p .1210

17


Chien lc tai lu thong MVBenh vien co kha nang PCI PCI tien phat Tieu si huyet trc vao vien

Xe cap cu

Benh vien khong kha nang PCI

PCI cu van

That bai

Thanh Cong

Chup MV

PCI: Nong MV

TL: Van de Werf F et al. Eur. H. Journal 2008; 29: 2909-2945

18


ieu tr tai lu thong MVTai lu thong MV tat ca benh nhan NMCT/ STC < 12 giTai lu thong MV benh nhan NMCT > 12 gi, neu con TMCB Tai lu thong MV bang PCI benh nhan on nh > 12 24 giPCI MV tac hoan toan > 24 gi benh nhan on nh, khong con TMCB

Facilitated PCI: a bo Dau hieu TSH that bai: ST giam di 50% so vi mc ST cao nhat Rescue PCI: 12 gi sau khi phatTL: Van de Werf F et al. Eur. H. Journal 2008; 29: 2909-294519


iu tr ti lu thng MV/ can thip MV tin pht (1)Nong MV tien phat Can ekp co kinh nghiem, lam ngay T ca ti bong < 90 phut hoac < 2 gi PCI ngay/ benh nhan soc hoac benh nhan chong ch nh tieu si huyet ieu tr chong ket tap tieu cau Aspirin NSAID and COX-2 selective inhibitors Clopidogrel loading dose GPIIb/IIIa antagonist Abciximab Tirofiban Eptifbatide III: chng ch nh TL: Van de Werf F et al. Eur. H. Journal 2008; 29: 2909-2945 I: cn thc hin20

I I I

A B B

IIII I IIa IIb IIb

BB C A B C


iu tr ti lu thng MV/ can thip MV tin pht (2)iu tr chng thrombin Heparin Bivalirudin FondaparinuxDng c tr tht Thrombus aspiration PCI cu vn Tiu si huyt tht bi bnh nhn c vng nhi mu rng, thc hin trong vng 12 gi u I IIa II C B B

IIbIIa

BA



iu tr ti lu thng MV/ thuc tiu si huyt (1)ieu tr tieu si huyet Khi khong co chong ch nh va PCI khong thc hien ngay c I Nen dung thuoc chuyen biet tren fibrin ieu tr TSH trc khi en benh vien A I IIa I I IIa B A B B B

ieu tr chong tieu cau kem theoAspirine uong (tan trong nc hoac nhai) hoac tiem mach Lieu nap clopidogrel neu 75 tuoi > 75 tuoi : khi au bang lieu duy tr



iu tr ti lu thng MV/ thuc tiu si huyt (2)ieu tr chong thrombin ket hp Vi

Enoxaparin tiem mach bolus, sau o tiem di da Neu khong co enoxaparin, s dung heparin khong phan oan TM Vi Fondaparinux lieu nap TM, tiep theo tiem di da 24 gi sau

I I IIa

A A B B II a C

Enoxaparin lieu nap TM, 15 phut sau Tdd. Neu > 75 tuoi khong lieu nap IIa

tiem mach, lieu tiem di da can giamHeparin khong phan oan TM, co chnh lieu TL: Van de Werf F et al. Eur. H. Journal 2008; 29: 2909-294523


Chng ch nh tiu si huyt: tuyt iChong ch nh tuyet oi ot qu xuat huyet hoac ot qu cha ro nguon goc, vao bat c thi iem nao ot qu TMCB trong vong 6 thang Bu hoac chan thng he than kinh trung ng Mi phau thuat hoac chan thng au (trong vong 3 tuan le) Xuat huyet tieu hoa trong vong 1 thang ang b xuat huyet Boc tach MC Ni choc do khong e ep c (TD: sinh thiet gan, choc do tuy song)TL: Van de Werf F et al. Eur. H. Journal 2008; 29: 2909-294524


Chng ch nh tiu si huyt: tng i- Cn thiu mu no thong qua trong vng 6 thng - ang iu tr khng ng ung - C thai hoc sau sanh trong 1 tun - THA nng (HATTh > 180 mmHg v/hoc HATTr > 110 mmHg) - Bnh gan tin trin - Vim ni tm mc nhim trng - Lot tiu ha ang hot ng - Khng vi hi sc (Refractory resuscitation)



ieu tr chong huyet khoi/ bnh nhan khong c tai thong MVieu tr chong tieu cau kem theoAspirin uong (hoa tan hoac nhai) hoac aspirin TM

Clopidogrel uongieu tr chong thrombin kem theo Fondaparinux lieu nap TM; 24 gi sau Tdd Fondaparinux: c che yeu to xa khong dung n oc (khong kem heparin)/ PCI N/C OASIS- 6: fondaparinux tot hn heparin

Enoxaparin lieu nap TM, 15 phut sau Tdd > 75 tuoi khong lieu nap Heparin khong phan oan tiem mach chnh lieu theo TCA sau 3 gi26



Hiu qu thuc chng kt tp tiu cu mi so vi clopidogrel

TL: Antman EM, Morrow D A. In Braunwalds Heart Disease, ed by Bonow, Mann, Zipes, Libby, Elsevier 2012, 9 th ed, p. 1111-1171


Thi gian la yeu to hang au trong tai thong MV


28


Ch nh chup MV trong thi gian nam vien sau ieu tr TSH hoac benh nhan khong c tai thong MV

Chng c TSH that bai hoac khong chac thanh cong : lam ngay

TMCB tai dien, tai nghen sau TSH thanh cong: lam ngayChng c TSH thanh cong : trong vong 3-24 gi cua THS Benh nhan khong on nh, cha c tai lu thong mach: lam ngay

Benh nhan on nh cha c tai lu thong mach: chup trc xuat hien


29


Tai cau truc that trai sau NMCTC/ STC



Tng quan gia t vong va mc TIMI TL: Antman E M, Braunwald. In Braunwalds Heart Disease, ed, by Libby, Bonow, Mann, Zipes.WB Saunders 2008, 8th ed, p .1210

31


Tng quan gia mc ti mau c tim va t vong


TMP: TiMi Myocardial Perfusion

32


Hng dan ve phong nga va ieu tr khong tai lu thong dong chay (noreflow)Phong nga Hut cuc mau ong

ieu tr

Verapamil



Ch nh phau thuat bac cau ong mach vanh (MV) PCI that bai Ton thng khong PCI c Trieu chng c nang nang mac du a PCI Soc tim Bien chng c hoc sau NMCT: v that, h 2 la cap, TLT

34


ieu tr phong nga thng qui/giai on cp NMCTC (1)X tr Loai MCC

Aspirin lieu duy tr 75-100 mg Clopidogrel 75 mg Khang viem khong steroid va chat chong COX-2 Chen beta TM Chen beta (uong) UCMC (uong) ngay ngay 1: Tat ca benh nhan neu khong chong ch nh Benh nhan nguy c cao

I I III IIb I IIa I

A A C A A A A

Loi III: chng ch nh TL: Van de Werf F et al. Eur. H. Journal 2008; 29: 2909-294535


ieu tr phong nga thng qui/giai on cp NMCTC (2)X trNitrates c che calci Magnesium Lidocaine Truyen Glucose- insulin - kali

LoaiIIb III III III III

MCCA B A B B



Qui trnh s dng chn beta/NMCT cp ST chnh ln

TL: Gheorghiade M, Coolstein S. Betablockers in post myocardial infarction patient. Criculation 2002; 106: 394 37


Hiu qu ca chn th th aldosterone chn lc trn NMCT cp (eplerenone)

TL: Pitt B et al. N Engl J Med 2003; 348: 14 38


Cc nghin cu GISSI trong NMCT cp Nghin cu GISSI: The Gruppo Italiano per lo Studio della Sopravvivenza nell In Miocardis GISSI 1, GISSI 2, GISSI 3 > 60 000 bnh nhn tham gia

39


Nghin cu GISSI 1 (1987) 11.712 bnh nhn NMCT cp Chng minh streptokinase gim t vong b/n NMCT cp (p = 0.008)

TL: GISSI Study Group. Lancet, Oct 17, 198740


Nghin cu GISSI 2 (1990) 12.490 bnh nhn NMCT cp So snh streptokinase, alteplase, SK + heparin, alteplase + heparin Chng minh li im tng ng ca TSH khi s dng sm (trong 6 gi u)

TL: GISSI Study Group. Lancet, 1990; 336: 65 - 6741


Nghin cu GISSI 3 (1994) Thit k: a trung tm, ngu nhin, m, c kim sot 18.895 bnh nhn/ 24 gi u NMCT cp Tiu ch chnh: t vong mi nguyn nhn 6 tun l Bn nhm: - Lisinopril 5mg, tng ti 10mg/ngy trong 48 gi - Glyceryl nitrate 5microg/pht TM tng 5-20 microgram/pht/5 pht trong 30 pht u hoc HA > 10%. Sau 24 gi u, thay bng thuc dn 10mg/ngy - Lisinopril + Glyceryl nitrate, nh trn - iu tr thng thng

TL: GISSI Study Group. Lancet, 1994; 343: 1115 - 1122

42


Kt qu ca GISSI 3

TL: GISSI. Lancet 1994; 343: 1115 - 22

43


Hieu qua giam t vong cua c che men chuyen/ NMCT cap: n/c ngan ngay

TL: Flather MD, Pfeffer MA. Angiotensin converting enzyme inhibitors. In Hennekens CH (ed): Clinical Trials in Cardiovascular Disease: a companion to Braunwalds Heart Disease. WB Saunders 1999, p 8444


Chm sc lu di sau ti lu thng MV (1)LoiX tr lu di da vo lng gi nguy c, bao gm: -Khm lm sng -ECG -TN cn lm sng khc -HbA1C -Mc vn ng th lc v TNGS -Siu m tim trc v sau BCMVSiu m tim trc v sau nong MV -Khuyn khch tp th dc 30-60 pht/ngy -Chng trnh tp th dc c kim sot/ b/n nguy c cao (TD: mi ti lu thng MV, suy tim) I I I I I I IIa I I

MCCC B B A B C C A B

-Gim cn, BMI < 25kg/m2, vng bng < 94 cm nam, < 80cm/n -Mi ln thm khm, cn kho st BMI v vng bng -Khuyn co s dng thc phm t tht, m

I I I

B B B45

TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555


Chm sc lu di sau ti lu thng MV (2)Loi-Thay i li sng -Mc tiu LDL-C < 100 mg/dL -Bnh nhn nguy c cao, mc tiu LDL-C < 70 mg/ngy S dng omega-3 di dng du c -Thay i li sng v s dng thuc huyt p < 130/80 mmHg - Chn beta v UCMC: thuc u tin Ngng thuc l nhc mi ln khm Bnh nhn T: -HbA1C < 6,5% -Gim ti a cc YTNC khc Kim tra tm l bnh nhn xem c trm cm I I I IIb I I I I I I I

MCCB A B B A A B B B C C

Chng nga cm mi nm

I

B

46 TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555


Cc nguyn nhn suy tim cp sau NMCT cp

-V vch tim: - Ti phnh tht - Ti phnh gi - H 2 l do t c tr - V vch lin tht


Khc bit gia ti phnh tht v ti phnh gi vch tht tri

TL: Antman EM, Morrow D A. In Braunwalds Heart Disease, ed by Bonow, Mann, Zipes, Libby, Elsevier 2012, 9 th ed, p. 1111-1171


iu tr bng thuc lu di sau ti ti mu c tim (1)Loi UCMC lin tc trn b/n c PXTM 40% v cho b/n c THA, T hoc bnh thn mn (tr phi c chng ch nh) UCMC cho tt c b/n, tr phi c chng ch nh Chn th th AG II/bnh nhn khng dung np UCMC v c suy tim hoc NMCT km PXTM 40% Chn th th AG II/tt c bnh nhn khng dung np UCMC I MCC A

IIa

A

I

A

IIa

A

TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555 49


iu tr bng thuc lu di sau ti ti mu c tim (2)Loi Chn beta cho tt c b/n sau NMCT hoc HCMVC hoc ri lon chc nng tht tri (tr phi c CC) Thuc gim lipid mu liu cao/tt c bnh nhn bt k mc lipid (tr phi c CC) Cn nhc s dng fibrates v omega-3 (1g/ngy)phi hp vi statin hoc b/n khng dung np c statin Cn nhc s dng niacin nhm tng HDL-C I I IIa MCC A A B

IIb

B


50


Chin lc theo di b/n khng triu chng c nng sau ti ti mu c timLoi TNGS hnh nh (siu m, x k) cn c thc hin thay v ECG gng sc Bnh nhn nguy c thp: ti u iu tr ni km thay i li sng Bnh nhn nguy c trung bnh hay cao: chp MV TNGS hnh nh cn c thc hin sm/nhm b/n c bit TNGS thng quy cn cn nhc sau nong MV 2 nm v sau BCMV 5 nmNguy c trung bnh hay cao: TMCB/gng sc cng thp; nhiu vng TMCBTL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-255551

MCC A C

I IIa

IIa IIb

C C

Nguy c thp: TMCB/ gng sc vi cng cao, khi u TMCB mun, 1 vng TMCB


Cc bnh nhn c bit cn kho st TNGS bng hnh nh sm-Tt c b/n ST chnh sau can thip hoc BCMV ti khn cn kho st trc ra vin hoc rt sm sau ra vin-Bnh nhn c ngh nghip cn an ton cao (TD: phi cng, ti x)hoc vn ng vin -S dng thuc c ch 5 phosphodiesterase (sildenafil, tadalafil) -Bnh nhn t t c cu sng -Bnh nhn ti lu thng MV khng hon ton -Bnh nhn c bin chng khi can thip (bc tch, NMCT chu phu, g b ni mc khi BCMV) -Bnh nhn T -Bnh nhiu nhnh MV km tn thng cn st li hoc TMCT yn lngTL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-255552


Chin lc theo di v x tr bnh nhn c triu chng c nng sau ti ti mu c timLoiTNGS hnh nh (siu m, x k) cn c s dng thay v TNGS/ECG Cn ti u iu tr ni km thay i li sng/TNGS nguy c thp Cn chp MV khi TNGS nguy c trung bnh n cao Chp MV khn cp/bnh nhn NMCTC-STC Chin lc can thip sm/NMCTC-KSTC nguy c cao I I I I I

MCCA B C A A

TL: Wijns W et al. ESC/ EACTS Guidelines on Myocardial revascularization. Eur. Heart J 2010; 31: 2501-2555 53


Qui trnh x tr tin phu bnh nhn ang s dng 2 kt tp tiu cu/cn phu thut tim hoc ngoi timPhu thut tim/hoc ngoi timTi khn Khn cp v bn cp Quyt nh theo tng trng hpChng trnh Ch ti khi ngng ch 2 kt np tiu cu

Phu thut

Nguy c huyt khi

Tip tc Aspirin + clopidogrel Tip tc aspirin ngng clopidogrel Ngng aspirin ngng clopidogrel54

Nguy c xut huyt



Ch nh t my ph rung cy c (ICD) trn b/n sau NMCTC/STC

TL: Antman EM, Morrow D A. In Braunwalds Heart Disease, ed by Bonow, Mann, Zipes, Libby, Elsevier 2012, 9th ed, p. 1111-1171

55


Qui trnh iu tr chng huyt khi khi xut vin b/n NMCTC/ STC


56


iu tr ca tng lai Cc bin php ci thin hin tng no-reflow Ti sinh t bo c tim


C ch bnh sinh hin tng noreflow v cc hng x tr



Ti sinh t bo c tim: ni sinh v ngoi sinh



Kt lun Chn on NMCTC: chun ha Tm quan trng ca ch im sinh hc

iu tr cp cu Thi gian l yu t hng u Tiu si huyt: khng s dng HCMVC/KSTC Cc thuc gim lon nhp v gim ti cu trc tht tri: UCMC chn beta

iu tr lu di sau NMCT: thit yu

dt nmct cap cn 2012

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