NGHIEN CLfU LAM SANG
Khao sat dac diem cua xa hinh tiidi mau cof tim pha tmh d benh nhan nhoi mau ctf tim cap
Iran Song loan, O^ng An Binh, Nguyin Phudc Minh Hi^p, Trin Thj Thiiy H^ng, Phgm Van Trieu, Bui Di^u Hang, L§ Thanh Liem.
Benh vien Cho Ray
TOMTAT
NMCT ll mot benh ly gly tfl vong hing dau trin toln ciu. C Viet Nam NMCT ciing ngly cang phat trien. tuy nhien khdng phai tat ca cac BN deu dtipc can thilp thi dau. Sau khi dn djnh NMCT, theo eae khuyin cao gin diy, benh nhan can dtide tiln hanh khao sat bang eae phticAig tien khdng xlm lin dl danh gii khin ning sdng edn eua vimg nhdi mlu vl phit hiin nhuiig vung cd nguy ed bi nhdi mlu. Xa hinh tim la m^t trong nhiing biln phap khdng xam Ian td ra hflu hieu trong vile dinh gia.
DAT VAN BE
Hien nay benh ly dpng mach vanh van la mdt trong nhting nguyin nhin chfl ylu dtia den tfl vong, thtidng tit vl tang phi tdn cfla qudc gia hcfn eic nhdm b§nh khlc^^'
Trong eae benh ly tim mach, nhdi mau ed tim (NMCT) cap vin edn la nguyin nhin gly tfl vong hang diu, Ii mpt vin de sflc khde cdng ddng quan trpng d cac ntidc phit trien, vl dang trd nen ngiy cang quan trpng d cac ntidc dang phat trien nhti VietNam.I«5
M|c du dl cd nhiing tiln bd trong chan doan vi dieu tri benh, NMCT cap vin dang la van d l sflc khde dfldc quan tam hang dau d nhting ntidc cdng nghiep phit trien va ngay cang tang d cIc ntidc dang phit trien.-^'
Tuy nhiln tfl vong liln quan den NMCT d p trong cdng ddng vin ll 15% - 20%, cd khoing 30%
benh nhin bi NMCT cap cd du dieu kien d l dilu tri tii tddi mlu nhting khdng dtide thtic hien va chi dtide dilu tri bao tdn'^-.
Nlu benh nhan NMCT nhip vien chtia can thi?p thi diu, theo cae htidng dan cua AHA, ACC va ESC, sau khi dn dinh trtidc khi xuat viin se dtide dinh gia bing cIc biln phip khdng xlm lin nham dinh gii tinh sdng cdn cfla vung NM vl sti hifn dien cua nhu&ig vung cdn nguy cd tii nhdi miu de can thiep nhim gdp phan trinh tai nhdi mau va giam thieu eic biln ehflng ve sau nhfl suy tim vi rdi loan nhip.
Xa hinh tfldi mau cd tim li m^t phflcftig phap tham dd khdng xam lin cho phip chan doan tinh sdng cdn, vung cdtim bi tdn thtidng^'''*'''"l
Hien nay t§i Viet Nam n g ^ l n ctiu ve linh vtie nay cdn rit haji che, nham khao sat, tim hiiu ve tinh trang ton ihticfng cd tim bang xa hinh tim trong theo ddi va dinh gia binh nhan NMCT. Do dd ehung tdi tien hinh de tai: "Khio sat die diem cfla X4 hinh ttidi miu ed tim pha tinh vdi bilu hien aia ST d binh nhan NMCT elp"
ISflTAP CHi TIM MACH HOC VIET NAM - SO68.2014
NGHIEN CLfU LAM SANG i
MUC TIEU NGHIEN Cdu Myc tilu nghiin cflu Mtfc tiiu chinh
Khio sat d|e diem hinh Inh cfla xa hinh tticW mau ed tim pha tinh ket hc^ vdi Nitrate tiiiyln tinh maeh d benh nhan NMCT elp.
Mqc tiiu chuyen biit
Danh gia tinh tr?ng tdn thtidng cd tim trong NMCTcap bang xa hinh ttidi miu ed tim.
Dinh gii tinh trang tdn thtidng ed tim d benh nhan NMCTclp khi ed them ele ylu td nguy ed (THA, DTD)bang xa hinh ttidi mau cd tim.
D 6 | TU0NG VA PHimNG PHAP NGHIEN CUfU Ihiet ke n ^ l n cflu
Nghiin cflu md ti, cat ngang.
Ddi ttiang nghiin ctiu Tiiu chudn chon mdu
Tiiu chudn cht?n dcH tUOng nghiin cdu Tit ci benh nhin nhap khoa npi tim mach Benh vi?n Chd Riy va dtide chin doin NMCT d p lin dau tien.
Tiiu chudn loqi trii
Benh nhin cd tien eIn NMCT trtidc do.
B?nh nhan ed tiln can phau thuat tim, ehan thtidng tim, sdc di?n, NMCT thit (P).
Benh nhan tfl chdi khdng tham gia nghiin cflu.
Phtidng phap tiln hinh
Phtidng phap nghiin cflu: tien cflu, quan sit vl md ta.
Cie b | n h nhin dtide kham lim sing, do ECG, xlt nghiim men tim.
Chan doin NMCT d p dtia theo tilu chuan chin doin eua Td chtic Y te Thi gidi vdi du 2/3 tieu ehuan: dau thit ngfle kieu mach vanh hay trilu ehflng ttidng dtidng dau ngtic, thay ddi ECG die tning va dinh Itidng ele men tim tlng^'^'t^^'t*!.
Ngoai ra, cie benh nhan eung dtide lam mpt sd eae xet nghiem khic nhti: cdng thflc mau, dtidng miu, BUN, creatinin, ion dd. Lipid miu, XQ_ngtic thing v i sieu im tim.
Phtidng phap thfl nghiim Chup xa hinh hidi mau cd tim
Thdi diem chup xa hinh tfldi miu ed tim:
Trong khoang tfl ngay thfl 5 din ngly 14 sau NMCT d p .
Ngiy thflc hien xet nghi|m: BN khdng cin phii ngulig cie thudc dang sfl dyng, khdng dtide an sang hole chi an nhe.
Xet nghiem dfldc thtic hien theo quy trinh nghi tinh + Nitrate . Truyln Nitrate dtidng tinh maeh eho tit ci cac benh nhin cd huyet ip tam diu > 100 mmHg (khdng cd benh THA) va >
11 OmniHg (ddi vdi BN cd binh THA).
Lieu Itidng (Isoket, Glyceryl trinitrate): khdi dau 10-15^g/ph, tang lilu 5 - l O ^ p h mdi 3-5 phut.
Mue tilu: Truyln eho din khi tq sd HA tam thu giim dflde 20 mmHg so vdi tri so HA ban diu (hole ha huylt Ip tam thu eho den 90 mmHg ddi vdi ngtidi khdng cd benh THA, vi dat 110 mmHg ddi vdi BN bi b|nh THA).
Sau khi dat HA theo myc tilu thi tiem D CPX dtidng tinh maeh, lilu 30 mCi.
Sau tilm DCPX, BN dfldc htidng dan van ddng nhe (di bd vdi tdc dp binh thtidng) va udng ntidc liln h^clS - 30 phut trtidc khi ghi hinh: BN dtide cho udng 250 - 500 ml ntidc cd gas, sfla hole ntidc trii cay (de Iam tang dao thai ""Tc-sestamibi tfl gan, nham hpi chl viec gay nhieu khi xfl ly hinh inh cd tim cua SPECT ).
Ky titudt^i hinh vd xH ly thdng tin '^^
Thiet bj: may xa hinh eat Idp dien toan ( Gamma camera - SPECT ) Symbia T6 SPECT/
CT cua cty SIEMENS.
Sfl dung phin mim 4DM - SPECT cua trung tam y khoa Dai Hpe Michigan USA.
TAPCHiTIMMACH HOC VIET NAM-SO 68.20141131
: NGHIEN CCu LAM SANG
Tniyin Nitrate Tiem MIBI SOmCi
Quy trinh ghi hinh Tfl thi benh nhin: nam ngfla, tay trai dtia len dau.
Gated- SPECT: ky thuat SPECT kit ndi vdi cdng dien tim dd.
Phdn tich kit qud xq htnh tiidi mrfw cti tfmj'*!^'^'
That trai dtide chia thinh 17 vung tren 3 true: true ngan, true dai
17 1 6 — 15 . I I .
/ ? \
1. basal anterior 2. basal anteroseptal 3. basal inferciseptal 4. basal inferior 5. basal infcrolatcral 6. basal anic^ilatcral 7. raid anierior S. mid anteroseptal 9. mid infcroseptal
AD RCA dflng vl true dai ngang.
mid inferior mid inferolaieral mid anlcnilateral apical antericir apical septal apical inferior apical lateral apex
LCX
Mat eit true ngan (Short axis )
Mat eat dflng dpc true dai (Vertical long axis)
Mat d t dflng ngang (Horizontal long axis)
LAD: nhinh liln thit trtidc.
RCA: dpng mach vanh phai.
LCx: nhanh mu.
Ghi chd:
Apical: phan mdm. Anterior: thanh trtidc.
Mid: phan gifla. Apex: mdm.
Basal: phan day Inferior: thanh dtidi.
Septum: vach lien that.
Lateral: thanh bin.
Xfl ly thdng ke bang phan mem SPSS 22.0 ( Statistical Programs for Social Sciences). Cie phip kiem: T-test, Chi_square, Anova, Dunnett T3.
ISaTAP CHl'TIM MACH HOC VIET NAM - SO68.2014
NGHIEN CLt: LAM SANG t
K T QUA NGHEN Clkl
^^liCT cflti thtic hien tren 65 BN thupc Khoa Npi Tim mach Benh vien Chd Riy dtide xa hinh ttidi mau cd tim tfl thing 11/2013 d m 5/2014. Vdi ket qui thu dtide nhti sam
Dac dioD ve phai
Giff i tinh
Tiong 65 BN cd 46 Nam (70^%) va 19 Nti (29,2%).
Dac dian ve tDoi
r-r^\
7" / \
\
Tudi BN (nam)
<50 S ) - 5 9 S : ' - 6 9 >••
Phan phdi theo tu5l
Tudi trung binh (63,94 ± 11,27 tudi). Nhd nh&: 41 tudi, ldn nhat 84 tuoL
Nhan xet: Dac dion ve tuoi cd phan phdi ehiiab, troi^ do nhdm BN cao tuoi (>=70 tudi) c:hiem ti lecao nhat ( 3 5 , 4 M l h ^ nhat li nhdm bidi (<50 tudi) (n.S'^c).
Dac diem ve h ^ thn DCPX
Hinh anh giim h ^ thu DCPX cd 4 mflc dp va dtide cho diem nhti sau:
TAPCHiTIMMACH HOCVIETNAM-SO6820141133
i NGHIEN ClJu LAM SANG
0 = Binh thtidng, 1 = nhe, 2 = trung binh, 3 = nang, 4 = rit nang (khuyet xa).
Hinh dnh Mat bo (dUdc diia ra ldm 17 viing)
Dac diem ve kich thtidc 6 NMCT lien quan den yeu to ngny cd tim mach Y^u to nguy cd
Tang HA DTD Tang HA+DTB
Khac
SoBN 33 11 11 10
Trung binh kich Ihtftfc « NMCT (%) 38,94
42,82 42,55 44,2
Std 16,5 16,4 18,4 18,9 Nhdn xet: Khdng cd stikhacbilt ve kich thtidc d NMCT d p gitia eae nhdm yeu td nguy cd (p>0,05) phep kiem Anova.
10- b U "
• I t--- ^1
l«ie(<IS%) Tnmgljrti(15-Naig(:5.3&%) flatniig Phan loai mOc do NMCT
Nhqn xet: Nhdm BN bi NMCT cap ed ST chenh chilm da so phdi ehuan, EF trung binh d gidi han thap (39,15 ± 14,2%).
CO ST chenh khwig ST chenh
Phan loai NMCT I. Phin suit tdng miu (EF) cd phin
134JTAP CHI TIM MACH HOC VIET NAM - SO 68.2014
NGHIEN CL/U LAM SANG i^
0- r-
^ [ K ' l l / : J - \
0 20 40 60 80 Phan suittSng mau (%)
I 20 40 60 S
Kich tinroc o nhoi mau (S) Nhdn xet: Co sir khac biet v6 kich thuoc 6 NMCT cSp voi su thay d6i ST (chenh va k h o i ^ chenh) vdi ? = 0,033<O,O5, T-test.
Nhan xet: Co su khac biet vk phan suat tong mau (EF) giua cac nhom miic do 6 NMCT dp (p < 0,05) phep kiem Oneway-Anova.
Cd sti khic bi|t ve the tich cudi tim thu (ESV) gitia cac nhdm mflc dp 6 NMCT d p (p = 0,021 <
0,05) phep kiem Oneway-Anova.
Mdi tflcftig quan gifla EF vi ESV, b'ch thtidc d NMCT cap vi ESV.
•
^
> ^
• ^ \
•
•
T h i tich cu&l tam thu (ml) ^ j ^ j , t h u v c 5 n h d i m a u C%)
Nh4n xet: Cd mdi ttidng quan gifla phan suat tdng miu va ESV ( p<0,001).
R =-0,58 cho thay rang EF vl ESV ed mdi tticftig quan n ^ e h . Khi ESV cing tang thi EF cang giam.
|R| = 0,58 cho thay mdi quan h i khi gifla EF va ESV.
Cd mdi tticftig quan gifla Idch thtidc d nhdi mau va ESV (p<0,001).
R = 0,47 eho thiy rang vung nhdi miu vl ESV cd moi tfldng quan thuan. Khi vimg nhdi miu cang Idn dii ESV cIng ting.
|R| = 0,47 cho thay mdi quan he khi gifla vung nhdi mlu va ESV.
TAP CHI TIM MACH HOC VI ET NAM - SO 68.20141135
/. NGHIEN cCu LAM SANG
BANLUAN
Qua nghiin cflu eho thiy hau hit cae trtidng hdp BN bi NMCT din Benh vien Chd Ray diu ed tudi trung binh cao (64 tuoi), die biet la nhdm BN >70 hidi chiem ti 11 eao nhit (35,4%). Dilu nay do die diem cnia Benh vien Chd Ray 11 tuyen cuoi nhin da phan la benh nang va nhilu benh phdi hdp
Cac BN nhap vien dilu tn deu d tinh trpig nang, cy the la kich thtidc 6 NMCT trung binh cao (41%) vIEF trung binh thap (39%), da sd cIc trtidng hdp la NMCT d p ed ST chenh (80%). Do dd vin de theo ddi vl dieu tri tilp sau NMCT cho BN can dtide quan tam hdn vi trinh trang benh nang vl eie benh ly di kem.
Hiu hit cae BN den vdi chiing tdi diu cd d e benh ly khac di kem (cu thi la Tang HA vl DTD2) chiem vdi ti II cao (# 85%). Khdng cd sti khae biet vl kich thtidc d nhdi miu vdi d e nhdm ylu td nguyed.
Chiing tdi nh|n thiy cd mdi ttidng quan khi ch|it ([r| = 0,58) gifla phan suit tdng miu (EF) vl thi tieh cudi tam thu (ESV), diy 11 mdi ttidng quan nghich. Dilu dd cho thiy khi EF cang giim thi ESV d n g tang. VI mdi ttidng quan gifla ESV va kieh thflde d nhdi miu thi ehflng tdi thay ed mdi tfldng quan thuan (r=0,47). Nghiin cflu cnia ehiing tdi ed thap hcfti so vdi tie gia Raymond J. Gibbons (r=0,8) cd thi do mlu n ^ l n cniu ehflng tdi cdn thip va thdi diem do hdi khic nhau. Chung tdi se tiep tuc thu th|p them de cd sfl dinh gia them.
Qua nghien cflu, ehiing tdi nhin thiy cac trtidng hdp b; NMCT d p cd ST chenh len cd dien tich vflng giim bat xa va khuyet xa chiem ti
1^ eao, nhilu hdn so vdi nhdm NMCT d p khdng ST chinh. Kich thflde trung binh eua 6 NMCT d p cd ST chinh (43,2%) cao hdn so vcM khdng ST chenh (32,1%). Sti khae bi^t nay la cd y nghia thdngkl(p=0,033<0,05).
KETLUAN
Qua nghiin cflu tiren 63 BN b; NMCT cap dtide thtic hiin xa hinh ttidi mau cd tim (SPECT/
CT) ehung tdi nh|n thay:
Hau hit d e BN bi NMCT d p den Benh vien Chd RSy cd dp tudi trung binh eao (64 tudi), BN trin 75 tuoi chilm 35,4%. Va da sd diu ed it nhat mpt ylu td nguy ed tim mach (# 85%). BN co EF thip (39,1 ± 14,2%) va kich thtidc vung nhdi miu Idn, diy la nhitog ylu td anh htidng din hieu qui dilu tri vi tiln Iticftig eho BN. Nhdm BN bj NMCT d p cd ST chinh cd kieh thtidc 6 nhdi mlu ldn hdn so vdi nhdm BN khdng cd ST chenh, sfl khic biet nay la ed y ngliia thdng kl (p=0,033).
Cling ed sfl khac biet ve ve thi tieh cudi tim thu so vdi d e mtic dp 6 NMCT elp (p=0,02l). Xahinh ttidi miu ed tim vdi (^'^c-sestamibi) ngiy cang ed vai trd trong khao sat, danh gii tinh trang tdn thticftig, tinh sdng edn cd tim d BN NMCT d p .
ABSTRACT
Acute Ml is one ofthe primary causes of death in the world, so in VN. However, not all cases of AMI can be done primary PCI. All guidelines recommend that after stabilize MI, non invasive test to defined ischemia and viability is indicated.
Sress myocardial perfusion scintigraphy is one of non invasive test that ean be used.
1361TAP CHi TIM MACH HOC VIET NAM-SO 68.2014
NGHIEN CU'U LAM SANG ^
T A I U E U THAM K H A O
1. TnMng Quang Binh. 2012, Binh dong mtith vanh-Binh hoc ndi khoa, nha xuat banYHoc, taiban lan 2, tr 68-80.
2. Bui Dieu Hang. "Ong dtfngxa hinh tudi mdu aJ tim trong didn dodn benh tim thieu mdu cue bd man"
Luan van CKU 2002.
3. Ta Thi I h a n h Htitfng v4 Nguyen Huy. "Khio sat nong dp Troponin I trong nhoi mau cd tim cap"
Tap dii Tim modi Hoi Tim Modi Hgc TP, Ho ChiMinh, 2010.
4. Dang Van Phudc. "Benh dong mach vanh trong thuc hanh lam sang" rihd xudt bdn y hgc, 2006, pl07-146.
5. Vo Quang. "Benh dgng m^ch vanh tai Viet Nam" Dai hpi Tim miich hgc QuSc gia lin thiJ VIII, 2000, tr 444-446.
6. Antman EM, Braunwald E - et al" Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes" NEngl/Moi 1996 Oct 31i33S(18):1342-9.
7. Thomas A. Gaziano and J. Michael Gaziano "Global Burden of Cardiovascular Disease" B R A U N W A L D • S HEART DISEASE - A Textbook of Cardiovascular Medicine- VOLUME I - NINTH EDITION.
8. Kristian Ihygesen, Joseph S. Alpert - et al''Third Universal Definition of Myocardial Infarction"
BuropeanHeart/ouma; (2012)33,2551-2567.
9. Gibbons, MD and Todd D.Miller, MD " Troponin T levels and Iniiact size by SPECT myocardial perfusion imaging"//AC; Cflrdiovflscu/arfmaging, Vol4, N0.5,2011,p523-533.
10. Michael H.Crawford, MD " Current Diagnostic and Treatment Cardiology" Third Edition 2009, p 51-72.
11. James H-Thrall, MX) "Nuclear MedidneiThe Requisites In Radiology" third edition 2006 - p450- 507.
12. Pete Shackett "Nuclear Medicine Technology: Procedures and Quick Reference" - 2nd Edition, 2009, chapter 12-13.
13. Elliott M Antman, ST-Segment Elevation Myocardial Inferction: Pathology, Pathophysiology, and Clinical Features, B R A U N W A L D ' S HEART DISEASE - A Textbook of Cardiovascular Medicine - VOLUME I - 9* Edition, Chapter 54, p 1087 -1109.
14. Myron C. Gerson, MD, Cardiac Nuclear Medicine, Third Edition, 1997, Chapter 3 and 4, p 53-141.
15. E. Gordon Depuey, MD. Ernest V. Garcia - et al. Cardiac SPECT Imaging, Second Edition, 2001, Chapter l , p 3-15.
16. G. Sharat Lin, Horace H Hines, et al. Automated Quantification of Myocardial Ischemia and Wall Motion Defects by Use of Cardiac SPECT Polar Mapping and 4-Dimensional Surfice Rendering, J Nucl Med Tedinol 2006,34:3-17.
TAP CH i TIM MACH HOC VI ET NAM - SO 68.20141137
