TAP CHi Y DUOC L A M S A N G 108 Tap 6 - So 5/2011
r f
Bien doi do day lop noi trung mac thanh dong mach canh a
r r
benh nhan tang huyet ap nguyen phat co phi dai that trai
Studying the Intima - Media Thickness of the Carotid Artery in Hypertensive Patients with Left Ventricular Hypertrophy
vii Thi Nga - Nguyen Thj Kim Thuy Benh vien Trung uang Qudn doi 108
Tom tat
Muc dich: nghien cUu bien doi dp day Idp npi trung mac thanh dong mach, dudng kinh dong mach cinh chung d benh nhan tang huyet ap. Tim hieu moi lien quan giUa phi dai that trai vdi dp day ldp ngi mac dpng mach canh chung d benh nhan tang huyet ap. Doi tugng va phuong phap: nghien cUu dugc tien hanh tren 63 benh nhan tang huyet ap dp 1 va 2, den kham va dieu tri tai Benh vien TWQD 108 tU thang 4/2009- 9/2010, tuoi trung binh 45,9, dao dgng (35-65), cac benh nhan dugc chia thanh 2 nhom. Nhdm 1 gom 31 benh nhan tang huyet ap chUa co phi dai thait trai. Nhdm 2 gom 32 benh nhan tang huyet ap cd phi dai that trai. Phuong phap nghien cUu: tien cUu e l t ngang, cac benh nhan dugc do Idp noi trung mac dpng mach cinh 2 ben bang phuong phap sieu am B- mode. XU ly so lieu tren phan mem SPSS 15.0. Ket luan: ky thuat sieu am kieu 2 binh dien vdi dau do tan so cao (7,5 MHz) co the xac djnh dugc dp day Idp npi trung mac va dudng kinh dong mach canh chung. Nhom benh nhan tang huyet ap co phi dai that trai dudng kinh dong mach canh chung, dudng kinh cho phan chia cua dgng mach canh chung 2 ben giam hon so vdi nhom tang huyet ap chua phi dai that trai nhung sU khac biet chUa co y nghla thong ke vdi (p> 0,05). 6 nhom nay dp day Idp npi- trung mac dong mach canh chung va cho phan chia dong mach canh 2 ben tang ro ret so vdi nhom tang huyet ap chua CO phi dai that trai sU khac biet co y nghla (p<0,01). 0 6 day ldp ngi - trung mac cua dpng mach canh chung co moi tuong quan thuan, mUc dp chat vdi phi dai tam that trai (r = 0,895).
TUkhda: tang huyet ap, phi dai that trai.
Summary
Objective: To study the intima-media thickness (IMT) of carotid artery, the diameter of common carotid artery in hypertensive patients; to study the relationship between the carotid intima-media thickness (IMT) with left ventricular hypertrophy in hypertensive patients. Studying group: 36 patients of hypertension with degree 1, 2 were treated at Hospital 108 from 4/2009 to 9/2010, age (35-65), mean age (45.9). They were divided into two groups. Group 1 hypertensive patients without left ventricular hypertrophy (31 patients).
Group 2: hypertensive patients with left ventricular hypertrophy (32 patients). Methods: the cross-sectional study. Data processing statistics on SPSS 15.0 software. Results: the B mode ultrasound image with high resolution (7.5 MHz) was used to assess the thickness of the intima - media layer and diameter of the carotid artery. In the group of hypertensive patients with left ventricular hypertrophy, the results showed that the diameter of common carotid artery, the diameter of carotid arterybifurcation were less than that in the group of hypertenvive patients without left ventricular hypertrophy, but the difference was not statistically significant (p> 0.05), however in the former group, the intima - media thickness of the common carotid artery increased remarkably compared to the latter group (p <0.01). An Increase in intima media thickness of common carotid arterywas shown to be correlated to left ventricular hypertrophy (r = 0.895).
Keywords: left ventricular hypertrophy, hypertension.
P h i n bien khoa hoc: PGS. TS. T R A N V A N RIEP
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol6-N°5/2011
1. Oat van de
Tang huyet I p (THA) nguyen p h i t I I benh thudng gap va g l y ty le tU vong eao nhat. Tren the gidi ed ban 1 ty ngUdi mIe benh niy, ty le m i c benh d ngudi tren 20 tudi khoing 20%, d nhUng ngUdi tren 60 tudi ty le n i y tang gap 2,5 lan (50%- 60% ).
Neu khdng dugc theo ddi v l dieu trj cd he thdng thi THA la yeu td nguy co hang dau g l y tU vong do elc bien ehUng tim mach nhU benh mach m l u nao, benh ddng mach vanh, suy tim, suy than [2]... Nhieu nghien eUu tren the gidi da eho thi'y, t i n g do d l y eua ldp ndi trung mac (IMT) eua ddng mach cinh chung do THA g l y ra ed li^n quan vdi elc nguy co v l bien chUng tim mach, tUOng tU nhU cle yeu td tudi, t i n g cholesterol, triglycerid, glucose m l u v l phi dai CO that t r i i . Vi vly, muc dich eua ehung tdi n h i m :
Nghien eUu bien ddi do d l y Idp ndi trung mac v l dudng kinh ddng mach c i n h chung d benh n h i n t i n g huyet I p .
Tim hieu mdi lien quan giUa phi dai that t r i i va su tang do day Idp ndi mac ddng mach eInh ehung d benh nhan tang huyet I p .
2. Doi tugng va phUcmg phip nghien cufu 2.1. Doi tupng nghiin cdu
Nghien eUu dugc tien h l n h tren 63 benh nhan t i n g huyet ap do 1 v l 2, den k h i m va dieu trj tai Benh vien TWQO 108 tU t h i n g 4/2009- 9/2010, tudi trung binh (45,9), dao ddng (35-65), cle benh n h i n dugc chia thanh 2 nhdm. Nhdm 1: 31 benh n h i n t i n g huyet I p chua ed phi dai that t r i i . Nhdm 2: 32 benh n h i n t i n g huyet ap ed phi dai that trai.
Tieu chui'n loai trU nhUng trudng hgp BN ed dai t h i o dudng, md m l u eao, tai bien mach m l u nao, benh mach m l u ngoai bien, nghien thudc la va nghien rugu nang.
2.2. Phuong phip nghiin cufu
Tien cUu elt ngang.
+ Tieu chuan sCr dung nghien ctifu
Tieu chuan chan doan tang huyet I p (JNC VII) [1]
Phan do THA Binh thudng
Tien THA THA dp 1 THA dg 2
HHTTh (mmHg)
< 120 120-139 140-159
> 160
HATTr (mmHg)
<80 80-89 90-99 2 100 Tieu chan chan d o l n phi dai that trai:
Khdi lUdng co that t r i i dugc tinh theo cdng thu'c Devereux [4].
LVM (g)=1,04x [(Dd + IVSd -i-LpWd)^- Dd'] -13,6 Chi sd khdi lugng co that trai:
LVMI (g/m^) = LVM (g)/ BSA (m^)
Phi dai CO that t r i i dugc xlc djnh khi LVMI > 131 g/m^ vdi nam v l ^ 100 g/m^ vdi nU.
- Khim xet l l m sing va can l l m sing:
• BN dugc do HA chuan theo phuong phap Korotkoff trong 3 lan lien tuc: sd do HA phii lay trung binh cua 3 lan do, mdi lan elch nhau 2 phut.
• Soi day m i t , dien tim, X-quang tim phoi, xet nghiem md mau, Ure, Creatinin, Glueoza de loai tri/
nhUng trudng hgp khdng thudc dien nghien eUu.
-I- Sieu I m : he thdng sieu am Doppler mau SONOS 7500, dau dd sector da tan 2 - 4 MHz dat tai khoa chan doan ehUe n i n g Benh vien TWQD 108. Sif dung phuang phap sieu I m B- mode do Idp npi trung mac ddng mach c i n h 2 ben.
- Vj tri do:
• Odng mach canh chung 2 ben each cho phan chia cua OM c i n h chung 2 cm va tai ehd phin chia ddng mach cinh.
• Tai thanh xa cua ddng mach cinh so vdi dau do.
• Oudng kinh ddng mach la khoing elch giUa 2 Idp ndi mac mach thanh xa va thanh gan, tren mat elt dgc va ngang, tai vi tri do IMT.
Oe ket qua dugc chinh xac phai do 2 lan va ti le saisd 1%dcaclando.
+ XCf ly cac sd lieu nghien cUu: tat ca cac sd lieu dugc xCr ly tren phan mem SPSS 15.0.
TAP CHi Y DUOC LAM S A N G 108 Tgp 6 - So 5/2011
3. Ket q u i nghien ciiru
Bing 1. So sanh d i e diem lam sang giUa hai nhdm t i n g huyet I p ed v l ehUa cd phi dai that t r i i
Cac thong so Tuoi
Ty le nam/nQ HATThu(mmHg) HATTr (mmHg) Tan so tim
Dien tich be mat co the (BSA) m^
THA chua cd phi dai that trai(n=31)
43 ±13 20/11 149 ±13,21
92 ±12.30 78.6 ±11,2 1,72 ±0,18
THA CO phi dai that trai (n=32)
49 ±15 23/10 166± 14,10 108± 10,15 79±13,12 1,65 ±0,38
P
>0,05
>0,05
<0,01
<0,01
>0,05
>0,05
- HATTh, HATTr d nhdm benh n h i n ed phi dai that t r i i eao ban cd y nghTa thdng ke so vdi nhdm benh nhin chua cd phi dai that vdi p < 0,01.
Tudi, gidi, dien tieh be mat co the giUa hai nhdm khdng khic biet ed y nghla thdng ke.
Bing 2. So sanh cac thdng sd ve kich thude that t r i i giUa hai nhdm t i n g huyet I p ed v l chUa cd phi dai that t r i i
Cacthong so Dd (mm) Ds (mm) IVSd (mm) LPWd (mm)
Ao (mm) LA (mm) LVMI (g/m^)
THA chua cd phi dai that trai(n=31)
43 ± 3,5 25,8 ± 2,6
8,9 ± 0,9 9,2 ± 0,83 31,8 ±3,6 33,6 ± 2,9 97 ±13,1
THA CO phi dai that trai trai (n= 32)
45,2 ± 4,5 28,0 ± 5,2 11,9 ±3,4 12,0 ±2,3 35,2 ± 2,5 35,8 ±3,7 146 ±30,6
P
>0,05
>0.05
<0,01
<0,01
>0,05
>0,05
<0,01
- 6 nhdm THA cd phi dai that trai chieu day vIeh lien that, t h i n h sau that t r i i v l ehi sd khdi ea that t r i i Idn t i n g rd ret so vdi nhdm THA ehUa cd phi dai that t r i i vdi P < 0,01.
- Nguge lai khdng ed sU khic nhau cd y nghla thdng ke d cle thdng sd do dudng kinh t l m thu, dudng kinh tam trUong that trai, dudng kinh gdcOM ehu va kich thudc nhi t r i i giUa hai nhdm.
Bing 3. So sanh do day Idp ndi mac ddng mach d n h ehung giUa hai nhdm tang huyet I p ed va ehUa ed phi dai that t r i i
Cac thong so DMCC phai (mm) DMCC trai (mm)
Cho phan chia DMCC phai (mm) Cho phan chia DMCC t r i i (mm)
THA chua cd phi dai that trai (n=31)
0,63 ± 0,07 0,64 ± 0,06 0,69 ± 0,05 0,68 ± 0,02
THA cd phi dai that trai (n= 32) 0,86 ± 0,03 0,85 ± 0,02 0,90 ± 0,03 0,90 ± 0,05
P
<0,01
<0,01
<0,01
<0,01
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 6 - N°5/2011
- Od day Idp ndi trung mac ddng mach eInh ehung v l ehd phan chia eua ddng mach c i n h chung 2 ben eua nhdm THA ed phi dai that eao ban cd y nghla so vdi nhdm THA ehUa ed phi dai that vdi p< 0,01.
Bing 4. So sinh dUdng kinh ddng mach d n h chung giUa hai nhdm THA ed v l chUa cd phi dai that trai
Cac thong s6 DMCC p h i i (mm)
DMCC trai (mm)
Cho phan chia DMCC ph^i (mm) Cho phan chia DMCC trai (mm)
THA chua c6 phi dai that trai (n=31)
6,55 + 0,20 6,54 ±0,21 6,54 ± 0,20 6,54 ±0,21
THA cd phi dai that trai (n=32)
6,19 ±0,37 6,23 ±0,35 6,23 ± 0,35 6,23 ±0,37
P
>0,05
>0,05
>0,05
>0,05
Oudng kinh ddng mach d n h ehung v l dUdng kinh ehd p h I n chia cua ddng mach d n h ehung 2 ben cua nhdm THA cd phi dai that trai nhd ban so vdi nhdm THA ehUa ed phi dai that, nhung sU khac biet chi/a cd y nghla thdng ke vdi p > 0,05.
Bing 5. Tuong quan giUa do d l y ldp ndi mac d n h ehung vdi chi sd khdi lugng co that trai Thong so
LVMI (g/m^)
0 6 day Idp ngi mac c i n h chung (mm) r
0,895
P
<0,001
Phuong trinh tUOng quan Y =1,88 +0,46 x LVMI
Od day Idp ndi trung mac ddng mach d n h chung tuong quan thuan mUc do manh vdi ehi sd khdi lugng CO that t r i i vdi (r=0,895; p<0,001).
1.2 -1
0.8 -
0.6
0.4
0.2
Dp day lop npi mac DMCC(mm)
r = 0,895
Chi so khoi CO that trai LVMI (g/m^)
50 100 150
— I —
200 250
Bieu d o ! . Oudng bieu dien tuong quan giUa do day Idp ndi mac trung OMCC va chi sd khdi ca that trai (LVMI)
TAP CHi Y DUOC LAM S A N G 108 T$p 6-So 5/2011
4. Ban luan
Qua nghien cUu 64 benh n h i n t i n g huyet I p giai doan 1,2 theo p h i n loai THA eua JNC VII, dUa tren tieu chui'n cd hay khdng ed phi dai that t r i i , benh nhin dugc chia thanh 2 p h i n nhdm, giUa d e phin nhdm khdng cd sU khic nhau ve tudi, gidi v l elc ehi sd nhin trie hge. Ket q u i nghien eUu eho thi'y nhdm benh nhan THA cd phi dai that t r i i HATTh v l HATTr t i n g ban so vdi nhdm chUa cd phi dai that trii, sU khic biet cd y nghia thdng ke (p<
0,01) (bing 1). So sinh kich thude cle budng nhi v l that giUa hai nhdm khdng thi'y sU khic biet ed y nghla thdng ke, nhUng nhdm t i n g huyet I p ed phi dai that chieu day vach lien that v l thanh sau that trii t i n g dan den ehi sd khdi lugng co that t r i i t i n g rd ret so vdi nhdm THA chUa ed phi dai that (146 ± 30,6 g/m^ so vdi 97 ± 13,1 g/m^• p< 0,01).
Oudng kinh ddng mach d n h ehung va dudng kinh ehd phin chia cua ddng mach d n h ehung 2 ben cua nhdm THA ed phi dai that nhd ban so vdi nhdm THA ehUa cd phi dai that, nhung sU khic biet ehUa ed y nghla thdng ke vdi p > 0,05 (bing 4).
NhUng khi so sinh do day Idp ndi - trung mac ddng mach d n h ehung chung tai 2 vj tri do eua OM d n h ehung 2 ben thi nhdm THA ed phi dai that eao ban ed y nghia so vdi nhdm THA chua ed phi dai that vdi p< 0,01 (bing 3). Od day Idp ndi trung mac OM d n h ehung tUOng quan thuan mUe do manh vdi ehi sd khdi lugng co that t r i i vdi (r = 0,895; p< 0,001) (bing 5). Ket q u i nghien eUu eua ehung tdi phu hgp vdi ket q u i nghien cUu cua d e t i e g i l tren the gidi.
Ohya Y v l CS tim hieu IMT tren 365 benh nhan THA, 16 benh nhin benh co tim phi dai, so sinh vdi 358 ngudi binh thudng cung lUa tudi, d l nhan thay, do dly IMT cua nhdm THA cd phi dai that trai t i n g ban nhdm THA khdng phi dai that t r i i , trong khi dd nhdm benh nhan benh ed tim phi dai, tuy ed day that trai nhUng IMT khdng tang va khdng khac biet so vdi nhdm ehijfng. Ngoai ra do day Idp ndi - trung mac cd lien quan chat che vdi chi sd khdi lugng cd that trai [8]. Ket luan nay phiJ hgp vdi ket qua nghien cUu cua chCing tdi.
Guarini P va CS danh gia mdi lien quan giUa THA vdi do day ndi trung mac ddng mach d n h chung va chi sd khdi lugng ea that t r i i d 89 benh nhin THA ed tudi dao ddng 35 - 80 (tudi trung binh 60,8) so sinh vdi 76 ngUdi huyet I p binh thUdng lam ehUng cung tudi, gidi. Ket q u i do day ndi - trung mac eua nhdm benh nhin THA eao ban so vdi nhdm ehUng sU khac biet cd y nghia (p<0,001), d e ddi tugng eao HA ed do day thanh sau that trai va vIeh lien that t i n g ban so vdi nhdm ehUng (p< 0,001), dieu n i y ndi len ring d nhUng benh nhin THA cd do d l y ldp ndi trung mac ddng mach d n h t i n g ed lien quan den phi dai t l m that t r i i [5].
Holaj R v l CS sieu I m OMC d 85 benh nhin THA tudi tU 42 72 trong dd 52 BN bj THA khdng dugc dung thude ha I p v l 33 BN THA dugc duy tri HA binh thudng bing thudc ha ap, ket q u i nhdm BN THA khdng dung thude ha I p ed do day Idp ndi trung mac OM d n h cao ban ed y nghia thdng ke so vdi nhdm THA dugc dieu trj bing thudc (0,987 4- / 0,152 mm so vdi 0,892 -)- / - 0,154 mm; p <0.001). Ldp ndi trung mac OM d n h cung t i n g hon cd y nghia giUa nhdm THA so vdi nhdm chUng (0,892 -i- / - 0,154 mm so vdi 0,812 -t- / - 0,124 mm; P <0,01) [7].
Oinh g i l mdi lien quan giUa do d l y ndi trung mac OM d n h vdi d e yeu td nguy co tim mach Hoffmann, K va CS nghien eUu 37 BN tre tudi dao ddng 21,2 ± 4,7, d e BN nay dUgc do d e ehi sd nhan trie, HA, ndng do cholesterol, triglycerid, glucose, do do day ndi trung mac OM d n h bing phuong p h i p sieu I m B-mode cd do p h i n gili cao, so sanh vdi 36 ngUdi lam ehUng cung tudi, gidi. Ket q u i : nhdm THA ed chi sd khdi lugng co the t i n g (BMI), ndng do cholesterol, triglycerid, glucose, do d l y Idp ndi mac OM d n h cung t i n g ed y nghia thdng ke so vdi nhdm chUng. Qua nghien eUu niy rut ra ket luan t i n g do d l y Idp ndi trung mac OM d n h thudng di cung vdi tang yeu td nguy cd tim mach d nhUng BN tr^. Viec xle djnh do day OM d n h eho phep d i n h g i l sUtien trien cua m i n g vUa xo [6].
Cung tuong tU nghien eUu eua Ones Pall va CS d 103 benh nhan tre THA so sinh vdi 58 thanh nien khde manh lam chUng, do day ndi mac OM dugc do d OM d n h ehung bang each sCr dung sieu I m B- mode, d c benh nhan nay eCing dugc xet nghiem
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 6 - N°5/2011
cholesterol, triglycerid, HDL-va LDL-eholesterols va glucose mau cung vai ehl sd khdi lugng ed that t r i i . Ket q u i dp day ldp ndi t r u n g mac O M d n h ehung eua n h d m t h a n h nien THA eao hdn so vdi ngUdi tr^ 2.
lam ehUng (0,55 ± 0,11 m m so vdi 0,48 ± 0,08 m m , p
<0,001), t u o n g t u ehl sd khdi lugng co that t r i i cua n h d m nay cung tang ban so vdi n h d m ehUng 103,2
± 30,6 g / m ' s o vdi 91,1 ± 25,2 g / m ^ p <0,001), nhin 3 ehung dp day ndi mach OM cd lien quan vdi tudi t i e , d n nang, ehi sd khdi lUgng co the, chi sd khdi lugng CO that t r i i , g i l tri t r u n g binh eua HATTh v l HATTr d u lieu n i y eho thay lien quan giUa do day cua Idp ndi t r u n g t d n t h u o n g co quan dich d nhUng BN n i y , vi v l y can ed nhUng bien phap chan d o l n sdm, dieu trj t h u d n g xuyen de phdng ngUa bien chUng do THA
gay ra [3]. "*•
5. Ket luan
Ky thuat sieu I m hinh I n h kieu B vdi dau dd ed
d o p h i n g i l i cao (7,5 MHz) ed the xac djnh dugc do 5.
day Idp ndi t r u n g mac va d u d n g kinh d d n g mach d n h ehung.
1. Nhdm benh n h i n tang huyet I p cd phi dai that trai d u d n g kinh d d n g mach d n h chung va d u d n g kinh ehd p h i n chia eua d d n g mach d n h ehung 2 ben g i i m hon so vdi n h d m t i n g huyet I p chua ed phi dai that t r i i n h u n g su k h i c biet chua ed y nghia t h d n g ke vdi p > 0,05. 6 n h d m nay d o d l y Idp ndi- t r u n g mac d d n g mach d n h ehung va ehd p h i n chia d d n g mach d n h 2 ben t i n g rd ret so vdi
n h d m t i n g huyet I p ehUa day that trai su k h i c biet ^' c d y nghia (p<0,01).
2. O d day Idp ndi t r u n g mac eua d d n g mach d n h ehung cd mdi t u a n g quan thuan, mUe do chat vdi phi dai t l m that trai (r = 0,895).
8.
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Common Carotid Artery Intima media Thickness in Adolescent Hypertension Results from the Debrecen Hypertension Study" Cerebrovascular disease, 15:167-172.
Devereux R.B. (1987), "Detection of left ventricular hypertrophy by M- mode echocardiography. Anatonnic validation, standardization and comparison to other methods". Hypertension, 9:1119-1126.
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Hypertension, 9: 19-26.
Hoffmann, K; Bryl, W; Strazynska, A; Rzesos, A;
Poplawski, D; Pupek-Musialik. D (2010), "Common Carotid Artery Intima-Media Thickness and Metabolic Profile of Young Patients With Primary Arterial Hypertension"Journal of Hypertension, Volume 28:
e72-e73.
Holaj R, Zelinka T, Wichterie D, Petrok O, Strauch B, Widimsky J Jr(2008). "Increased intima-media thickness of the common carotid artery in primary aldosteronism in comparison with essential hypertension", J Hypertens. 26(7): 1499-500.
Ohya Y, Abe I, Fujii K, Kobayashi K, Onaka U, Fujishima M (1997). "Intima-media thickness of the carotid artery in hypertensive subjects and hypertrophic cardiomyopathy patients"
Hypertension, 29: 361-5.