THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP (Current outcomes in the management of acute coronary syndome)PGS. TS. Pham Nguyen VinhVien Tim TP. HCMBV. Tim Tam c Trung tam ao tao va Boi dng can bo Y teai hoc Y Dc TP. HCM

nh danh cac hoi chng ong mach vanh capTL: Braunwald E et al. J Am Coll Cardiol 2000; 36: 970THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

S o mo ta tien trien cua hoai t c tim sau nghen MVTL: Antman EM, Brauwald E. In Braunwalds Heart Disease. WB Saunders 2005, 7th ed, p 1144THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Tam quan trong cua hoi chng MV capMy : 529 659 t vong BMV/1999* 7 500 000 > 20 tuoi co tien s NMCT* (4 600 000 nam ; 2 900 000 n)

Chau Au : t vong HCMV cap 8,4%

Viet Nam : ngay cang tang

* American Heart Association. Heart and stroke statistical update 2002 (Dallas TX)THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Chuoi cac bien co: t mang x va khong on nh en t vongTL: Antman EM, Brauwald E. In Braunwalds Heart Disease. WB Saunders 2005, 7th ed, p 1153THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Cac tien bo t hai thap nien ve h/c MVCTieu chuan chan oan NMCT thay oiNong MV tien phat : nen tang cua tai ti mau NMCT ST chenh len NMCT ST khong chenh : can thiep sm ngay cang tangStent phu thuoc : thay oi ch nh ieu trThay oi quan iem ve dung thuoc : tieu si huyet, chong ket tap tieu cau, khang ong (heparinTTPT thap), m khong bao hoa va magnesiumMay chuyen nhp pha rung cay c (ICD)THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Tieu chuan chan oan NMCT cap, tien trien hoac mi (criteria for acute, evolving or recent MI)Mot trong 2 tieu chuan sau :Troponin tang va giam hoac tang nhanh roi giamKem theo 1 trong cac dau hieu sau :Trieu chng au that ngcXuat hien song Q tren ECGThay oi ECG kieu TMCB (ST chenh len roi sup)Can thiep MV (TD : nong MV)Dau hieu giai phau benh cua NMCT cap

TL : Alpert JS et al. J Am Coll Cardiol 2000 ; 36 : 959-969THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Tieu chuan NMCT a hnh thanh (Criteria for established MI)Mot trong 2 tieu chuan sau :Song Q mi xuat hien tren ECG o nhieu lan. Benh nhan co the khong trieu chng c nang. Ch iem sinh hoc hoai t c tim co the bnh thng

Dau hieu giai phau benh cua NMCT a thanh seo hoac ang thanh seoTL : Alpert JS et al. J Am Coll Cardiol 2000 ; 36 : 959-969THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Thay oi trong phan loai H/c MVC da tren li iem cua ieu tr THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Tng quan gia ECG luc khi benh va bien oi giai phau benh cung la chon ieu trTL : Brilalxin ES et al. Modern Management of Acute Myo cardial Infarction. Current Problem Cardiol 2003 ; 28 : 1-131THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP Khong NMCT

Cac trieu chng khong ac hieu cua NMCT ngi cao tuoiTL : Reeder GS et al. Acute myocardial infarction. In : Stein SH, editor. Steins internal medicine. St Louis (MO) : Mosby year Book 1994 ; p. 169-189THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP Trieu chng c nangBenh nhan (%)Tuoi 65-74Tuoi 75-84Tuoi > 85

au ngc786038Kho th414443Toat mo hoi342314Ngat31818Lan lon387

Tien trien ECG/NMCT capTL : Gau GT. Electrocardiography and vectocardiography. In : Brandenburg RO et al. editors. Cardiology : fundamentals and practice. Year Book Medical Publishers 1987, p. 268-309THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP Gi Giai oan toi cap

Chan oan NMCT/bn a co bloc nhanh trai t trcSong Q I, aVL, V5 hoac V6 (2 chuyen ao)R trc ngc giam danS co khac cham V1 en V4Thay oi ST cung hng vi phan chnh cua QRSTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Chan oan NMCT/bloc nhanh trai t trcST chenh len > 1mm trng hp QRS IIST chenh xuong > 1mm V2, V3ST chenh len > 5mm ngc chieu QRS DIII, aVF

TL : Sgarbossa EB et al. N. Engl J Med 1996, 334 : 481-48THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Cac chat anh dau trong huyet tng/MMCT cap(Serum biomarkers of MI)Thi iem xet nghiemLuc nhap vienGi th 6-9Gi 12-24 neu mau trc am va van nghi NMCT

TL : Antman EM, Braunwald E. Braunwalds Heart Disease, NM Saunders, 7th ed 2005, p. 1159THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

ieu tr cap cu NMCT cap co ST chenh len Nam ngh ng TM ECG monitoringO2 ng mui (khi SaO2 < 90%)Giam au: morphine TMTTM Nitroglycerine (< 48 gi): NMCT + suy tim hoac NMCT + THA hoac con au ngc/ NMCT trc rongAspirin 160 325mg (nhai; pha vao nc)Heparin TLPT thap hoac heparin khong phan oanAtropine/ nhp xoang cham kem ha huyet apChen beta va c che men chuyenTai lu thong MV:- thuoc tieu si huyet- nong MV tien phat

* Khong dung magnesium thng qui trong NMCT cap ; tr phi thieu THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Tai lu thong ong mach vanh: bien phap hang au e giam t vong THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Tai lu thong MV: nong MV tien phat (PCI) hay thuoc tieu si huyet?THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

La chon phng phap tai lu thong MV: tuy thuoc phng tienTL: Antman EM, Brauwald E. In Braunwalds Heart Disease. WB Saunders 2005, 7th ed, p 1169THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

T vong 6 thang/ NMCT cap ieu tr bang PCI so vi thuoc tieu si huyet (n/c phan phoi ngau nhien)TL: Antman EM, Brauwald E. In Braunwalds Heart Disease. WB Saunders 2005, 7th ed, p 1229THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Thi gian: yeu to hang au trong tai lu thong MV/ thuoc tieu si huyet (d kien t 22 n/c)TL: Boersma E et al. Lancet 1996; 348: 771THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Cac yeu to thuan li cho PCIPhong PCI co kinh nghiem kem hau thuan ngoai khoa- BS lam PCI co kinh nghiem (> 75 trng hp nong tien phat/ nam)- Ca ti Bong < 90 phutNMCT cap ST chenh len co nguy c cao- Soc tim- Killip > 3Chong ch nh thuoc tieu si huyet: tang nguy c xuat huyet nao va chay mauen cham (> 3 gi)Chan oan NMCT cap ST chenh len con nghi ng

PCI : nong ong mach vanh

TL: Antman EM et al. ACC/AHA Guidelines for the Management of Patients with ST elevation Myocardial Infarction 2004THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

ieu tr noi khoa sau tai lu thong MV : can thiet cho tat ca ngi benhTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Hieu qua giam t vong cua chen beta tren b/n NMCT cap TL : Chac CV, Hennekens CH: Beta blockers. In Hennekens CH (ed): Clinical Trials in Cardiovascular Disease: a companion to Braunwalds Heart Disease. WB Saunders 1999, p 84

THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Hieu qua giam t vong cua c che men chuyen/ NMCT cap: n/c ngan ngayTL: 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 84

THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP OR : ty so chenh

Hieu qua giam t vong cua UCMC/ NMCT cap: n/c dai ngayTL: 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 84

THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP OR : ty so chenh

Hieu qua giam t vong cua chen thu the angiotensin II/ NMCT cap: n/c VALIANTTL: Pfeffer M et al. N Engl J Med 2003; 349: 1893

THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Nitrates trong ieu tr NMCT capNgam, TTM, uongNghien cu gop (10 n/c) trc thi ai tieu si huyet: giam t vong 35%Thi ai tieu si huyet:- cac nghien cu ln: GISSI 3, ISIS 4 -> nitrates khong giam t vong- nghien cu gop (22 n/c): nitrates giam t vong 3 4 b/n tren 1000 b/n ieu tr

TL: Antman EM, Braunwald E. In Braunwalds Heart Disease, WB Saunders 2005, 7th ed, p 1144

THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

S dung Nitrates/ NMCT capNitroglycerin TTM:- giam au that ngc- hieu qua dan mach/ NMCT suy that trai- ch s dung < 48 gi

Nitrates uong sau 48 gi: ch s dung khi cn au that ngc hoac co suy that trai

TL: Antman EM, Braunwald E. In Braunwalds Heart Disease, WB Saunders 2005, 7th ed, p 1144

THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Thuoc chong Thrombin va thuoc chong ket tap tieu cau : hieu qua ieu tr va hieu qua phong nga lau dai/ NMCT cap THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Thuoc chong ket tap tieu cau/ NMCT capAspirin: 162 325mg/ ngay 1 cua NMCT cap75 162mg/ cac ngay ke tiep. S dung lau daiClopidogrel: thay the khi khong dung c aspirin (d ng, loet tieu hoa)Ngng clopidogrel 5 7 ngay trc phau thuat bac cau MVBenh nhan co PCI:- aspirin + clopidogrel: toi thieu 1 thang/ stent thng; 6 thang oi vi stent phu thuoc- nghien cu CURE, CREDO: aspirin + clopidogrel trong 1 nam

TL: Antman EM et al. ACC/AHA Guidelines for the Management of Patients with ST Elevation Myocardial Infarction 2004. ACC. www.acc.orgTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Thuoc khang Vitamine K (VKAs)Van e: AVKs n oc hoac AVKs + aspirin co li hn aspirin n oc / HC MV cap?THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Nghien cu WARIS 2 (Warfarin Aspirin Reinfarction Study)3630 b/n (< 75 tuoi), NMCT capWarfarin (INR 2,8 4,2): Aspirin 160mg/ngay; Warfarin (INR 2 2,5) + Aspirin (75mg/ngay)Theo doi: 4 namTieu ch chnh: t vong + NMCT khong t vong + ot qu thuyen tac

TL : Hurlen M et al. N Engl J Med 2002; 347: 969 - 974THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Ket qua n/c WARIS 2: Warfarin + aspirin chiem u theTL : Hurlen M et al. N Engl J Med 2002; 347: 969 - 974THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Sau can thiep cap cu, bien phap ieu tr lau dai sau NMCT cap giup giam t vong va tang chat lng cuoc song ngi benhTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

QUY TRNH LNG NH NGUY C SAU NMCTCan thiep MV tien phatThuoc tieu si huyetSieu am timChup TT luc can thiep (hoac SAT)Benh 1 nhanh MVBenh nhieu nhanh MVKhong trac nghiem themTNGS khi ra vien neu ch nhanh gay NMCT c can thiepTrieu chng TN trc ra vien? Hoac tm TNGS TMCBKq bnh thng (khong CTN, khong TMCBKet qua bat thngieu tr noiThong timTL : Textbook of cardiovascular Medicine Lippincott Williams & Wilkins 2nd ed 2002, p. 466THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP SAT : Sieu am tim

LNG NH HOAT TNH VIEMCRP cao (C-reactive protein)*

Bach cau cao**

=> Nguy c cao

TL : * Am J Cardiol 1999 ; 83 : 1595-1599 ** Circulation 2000 ; 102 : 2329-2334THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

BIEN CO TIM MACH SAU NMCT CAP THAY OI THEO NONG O CRPTL : Am J Cardiol 1999 ; 83 : 1595-1599THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

HIEN TNG VIEM/NMCTNhieu chng c : viem -> NMCT cap

Cac thuoc co hieu qua phan nao chong viem :* Statins* UCMC* Aspirin* ClopidogrelTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

THAY OI CAC YEU TO NGUY C BENH MVNgng thuoc la : giam 50% t vong

Van ong the lc :* Rat can thiet, ke ca benh nhan roi loan chc nang that T* T tuan le 6 sau NMCTTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

DINH DNG/NMCTRat can thiet

Vai tro cua chuyen gia dinh dngTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

KHA CANH TAM LY XA HOI/BENH NHAN NMCTBenh nhan a tot nghiep trung hoc tuan thu ieu tr > benh nhan cha tot nghiep

Suy sup tam ly : tang tai NMCT, t vong

Tram cam : * Tang tai phat NMCT* Co the s dung thuoc chong tram cam

Th gian chong stressTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

CAC THUOC S DUNG LAU DAI/BENH NMCTTL : Textbook of Cardiovascular Medicine, Lippincott Williams & Wilkins 2nd ed 2002 , p. 467THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Tom tat cac iem chnh trong thay oi loi songTL : Textbook of Cardiovascular Medicine, Lippincott Williams & Wilkins 2nd ed 2002, p. 470THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

May chuyen nhp pha rung cay c (ICD)Cai thien song con benh tim TBCB va benh c tim dan n

ICD : implantable cardiovertor defibrillatorTHANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP

Qui trnh lng nh benh nhan sau NMCT cap nham khao sat ien sinh ly hay at ICDTL : Antman EM et al. ACC (AHA Guidelines for the management of patients with ST elevation myocardial infarction. 2004 ; ACC. www.acc.org)THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP EPS : khao sat ien sinh ly

Ket luanThanh qua cua khoa hoc ; t vong NMCT cap t 30% giam con 6-8%

Ket hp ieu tr : noi khoa, thu thuat, ngoai khoa

Lam viec theo e-kp : rat can thiet THANH TU HIEN NAY VE IEU TR HOI CHNG ONG MACH VANH CAP