Nghien CLFU khoa hpc
VAI TRO CUA SIEU AM TIM GANG SlTC BANG XE DAP Ll/C KE TRONG CHAN DOAN BENH TIM THIEU MAU CUC BO
Trinh Viet Ha*, D6 Doan Loi*, Nguyin Thi Thu Hoai*
TOM TAT
Muc tieu.- ddnh gid gid tri ciia phuong phdp sieu dm tim gang sire bdng .xe dap luc ki trong chdn dodn binh tim thiiu mdu cue bd (BTTMCB). Ddi tuong va phuang phap.- 59 binh nhdn (BN) dau nguc trdi diin hinh hoac khdng dien hinh tudi trung binh 58 ± 7,3 (nam), ed yiu td nguy ea eiia binh dpng mgch vdnh (DMV) vd diin tdm do khdng diin hinh cua BTTMCB, sieu dm tim khi nghi khdng ed rdi logn van ddng viing, men tim binh thudng. Cdc BN nay dupe tiin hdnh ddng thdi siiu dm tim gang sire ddnh gid bdng rdi logn van dpng viing thanh tim vd biin ddi diin tdm do trong qud trinh gang sice. Sau do, cdc BN duac chup DMV ddi chiiu. Siiu dm tim gang sice dupe coi la diccmg tinh khi xudt hiin rdi logn van ddng viing mdi xudt hien. BN dupe siiu dm tim khi nghi, giai dogn gang sire 25W, tgi dinh gang sice vd giai dogn hdi phuc. Ket qua.- 19 BN cd hep DMV > 50%. Sieu dm tim gang sire duong tinh trong 17 trudng hap (TH) trong sd 19 ca hep DMV cd y nghTa (28,8%) vd dm tinh 52 TH (71,2%). Dp nhay, dp dac hiiu, gid tri chdn dodn duong tinh, gid tri chdn dodn dm tinh eua sieu dm tim gang sue dua vdo rdi logn van ddng viing tuang img la 84,2%, 97,5%, 94,1%, 92,8%. Khi phdi hap vdi bien ddi diin tdm dd, gid tri cua phuang phdp tuang img Id 94,7%, 82,5%, 72%, 97%,. Dp nhay dp ddc hieu trong chdn dodn DM liin thdt trude la 88,9%,, 97,5%,, DM md la 62,5%,, 100%,.
vd DMV phdi Id 50%, 100%. Ket luan.- sieu dm tim gang sice la mdt phuang phdp cd gid tri cao trong ehan dodn BTTMCB.
\. DAT VAN DE
Sieu am tim gang sire la mdt tham dd khdng xam nhap, giiip chan doan va phan tang nguy co BN BTTMCB. Tuy nhien, d Viet Nam chua cd nghien ciru nao danh gia day dii vai trd eiia phuong phap nay trong ehan doan BTTMCB. Vi vay, ebung tdi tien hanh sieu am rim gang sire bang xe dap lye ke d 59 BN dau ngyc trai nghi ngd BTTMCB rii thang 11 nam 2008 den thang 11 nam 2009 cd ddi chieu vdi ehup DMV d nhimg BN nay nham muc tieu: ddnh gid gid tri ciia phuong phdp sieu dm tim gang sice
bdng xe dgp luc ki trong chdn dodn BTTMCB.
* Vien Tim mgch Viet Nam
U. DOI TUONG VA PHUONG PHAP NGHIEN ClTU 1. Doi tu'Ong nghien ciru
Tieu chudn lua chpn BN
59 BN dau ngyc trai dien hinh hoac khdng dien hinh, ed dien tam do khdng dien hinh eua BTTMCB tai Vien Tim mach Qudc gia tir thang 11 /2008 den thang 11/2009.
Tieu chudn loai BN
- Dau that ngyc trong vdng 24 gid qua.
- Viem CO rim va viem mang ngoai tim cap.
- Loan nhip: NTT that nhieu d hoac chiim, nhjp nhanh nhT va that, rung cudng nhT.
- Bloc nhT that cap II va 111,
- Nhip tim cham < 45 chu ki/phiit liic nghi.
- Suy tim NYFL\ 4.
DIEN D A N YHOC
Nghien ci^u khoa hoc
- Hep kbit \ an ddng mach chu (cd tien sir xiu ngat).
- Benh ca tim phi dai tac nghen.
- Tang huyet ap nang khi nghi: HA tam thu >
220mmHg va HA tam truong >1 lOmmHg.
- BN ed benh thue the nang: nhiem khuan, thieu mau, suy than nang. tieu dudng chua khdng ehe dupe, benh ac tinh. benh phdi tac nghen. ha kali mau.
- Ngd dpc Digitalis.
- BN khdng cd kha nang dap xe: benh mach mau ngoai bien, cyt chan. benh co xuong khdp.
- BN khdng hgp tac.
2. PhuQ-ng phap nghien cuu: md ta, tien cuii.
- Tat ea cae BN dupe hoi benh, khai thac trieu chimg lam sang va cac yeu td nguy co theo mau benh an.
- BN dupe iam sieu am tim gang sire bang xe dap lye ke theo mdt quy trinh chuan de phat hien rdi loan \ an ddng thanh tim. dy doan vi tri dpng mach
\ anh bi tdn thuang.
- Sieu am tim duge thyc hien trong eac giai doan: khi nghi. khi gang sire 25W, dinh gang sire va giai doan hdi phye. Sieu am tim gang sue tien hanh tren may Phillip iE33, vdi kT thuat ghi hinh sd hda \ a second harmonic giiip nhin rd van ddng viing thanh tim \ a tha\- rd \an ddng cua co tim \ a ndi mac.
- May dugc gan lien vdi mdt may ghi dien tam dd lien tiic trong qua trinh gang sire cd the lam ddng thdi DTD gang sire.
- Cac BN sau khi sieu am tim gang sire dugc chyp DMV de ddi chieu \di ket qua sieu am tim gang siic.
3. Xirli sd lieu:
Cac sd lieu thu dugc dugc xu li va phan tich tren may tinh theo chuong trinh SPSS 16.0 eua hiep hdi thdns ke Hoa Ki.
Danh gia dp nhay, dp dae hieu. gia frj am tinh, gia tri duong tinli eua phuong phap sieu am tim gang siic bang .xe dap lye ke theo cdng thiic.
HI. K E T Q U . \ NGHIEN CUU
1. Dac diem chung ciia ddi tuong nghien ciru 1.1. Tudi vd gi&i
Nam: 31 BN (chidm 52,5%); nir: 28 BN, chidm 47,5 %. Ti le nam/nir = 1.1.
Tudi trung binh la 58 ± 7,3 (nam), ldn nhat la 74 tudi va tudi thap nhat la 44 tudi.
1.2. Ddc diim vi yeu to nguy ca ciia doi tuang nghiin ciru
Tien su gia dinh cd ngudi mac benh DMV:
3,39%.
Dai thao dudng: 5,08%.
Hilt thude la: 40,67%.
Rdi loan Lipid mau: 44,06%.
Tang huyet ap: 66,12%.
1.3. Ddc diim dau nguc ciia doi tugng nghiin cuu Dau ngyc khdng dien hinh: 22 BN (chiem 62,70%).
Dau ngye khdng dien hinh: 37 BN (chiem 37.30%).
1.4. Ddc diim diin tdm do liie nghi Nhip xoang: 100%.
NTT that thua: 3 BN (5,08%).
Block nhanh phai: 5 BN (8,47%).
Block nhanh trai: 1 BN (1,69%).
ST chenh xudng <lmm: 6 BN (10,16%).
Ddy that trai: 9 BN (15,25%).
7.5. Kit qud diin tdm do gdng sire bdng xe dgp luc ki
Duong tinh: 16 BN.
Am tinh: 37 BN.
Khdng danh gia dupe: 6 BN.
/. 6. Kit qud sieu dm tim gdng sire bdng .xe dap lire ke Duong rinh: 17 BN (28,8 %).
Am tinh: 42 BN (chidm 71,2%).
Nghien CLPU khoa hpc
1.7. Kit qud chup dpng mgch vdnh cua doi tuang nghiin cim
Tdn thuang hep DMV ed y nghia la > 50%.
Hep cd y nghia: 19 BN (32,20%).
Hep khdng cd y nghTa: 40 BN (67,80%).
Trong dd, tdn thuang 1 nhanh: 12ca(cbiem63,16%)), 2 nhanh: 5 ca (26,32%), 3 nhanh: 2 ca (10,52%).
2. Vai tro ciia sieu am tim gang sire trong chan doan BTTMCB
Bdng 1. Moi lien quan giua bien doi dien tdm do trong qud trinh Idm siiu dm tim gdng siic vd tdn
thuang DMV
Bdng 3. Moi liin quan giira phoi hpp biin doi diin tdm do vd sieu dm dm gdng sire vd benh DMV
Ket qua DTDGS Duong rinh Am tinh Khdng danh gia dupe Tdng
Hep DMV
> 50%
9 8 2 19
Khong hep hoac hep <50%
7 29
4 40
Tdng 16 37 6 59 Nhdn xet: trong ddi tugng BN nghien cim. cd 6 BN dien tam dd khi nghi cd dang block nhanh.
Chiing tdi khdng danh gia tren dien tam dd gang sire ciia nhiing BN nay.
Dp nhay, dp dae hieu, gia tri chan doan duo-ng tinh, gia trj ehan doan am rinh ciia dien tam do gang sire tuong ung la 52,9%, 80,6%, 56,3%, 78,4%.
Bdng 2. Moi liin quan giua SA TGS vd benh DMV
Sieu am tim gang
siic Duong tinh Am rinh Tdng
Hep MV>50%
16 3 19
Khdng hep hoac hep
<50%
1 39 40
Tdng
17 42 59 Dp nhay, dp dac hieu, gia tri chan doan duong tinh, am tinh ciia sieu am tim gang siic tuong img la:
84,2%, 97,5%, 94,1%, 92,8%.
Phoi hgp DTDva SATGS Duong tinh Am tinh
Tdng
Hep MV>50%
18
• 1 19
Khdng hep hoac hep
<50%
7 33 40
Tdng
25 34 59 Dp nhay, dp dae hieu, gia tri chan doan duong tinh, am tinh ciia phdi hgp SATGS va DTDGS trong ciing mpt thdi diem tuong img la: 94,7%, 82,5%, 72%, 97%.
- Gia tri cua SATGS trong chan doan benh ly DMV theo gidi
Bdng 4. Kit qud ciia SA TGS trong chdn dodn BTTMCB a nam
Ket qua SATGS Duong tinh Am tinh Tdng
Hep DMV>
50%
9 2 11
Khong hep hoac hep
<50%
0 20 20
Tdng
9 22 31 Tir do, ta tinh dugc dp nhay, dp dac hieu, gia trj duong tinh va am tinh tuong irng la: 81,8%, 100%, 100%, 90,9%.
Bdng 5. Kit qud eiia SA TGS trong chdn dodn BTTMCB dnir
Ket qua SATGS Duong rinh Am tinh Tdng
Hep DMV>
50%
7 1 8
Khong hep hoac hep
<50%
1 19 20
Tong
8 20 28 Tu dd, ta tinh dugc dp nhay, dp dac hieu, gia tri duong tinh va am tinh frrong ung la: 87,5%, 95%, 87,5%, 95 %.
DIEN D A N YHOC
Nghien CLPU khoa hoc
Bdng 6. Gid trj ciia ede phuang phdp ti-ong chdn dodn binh li nhdnh DMV
Nhanh DMV DMLTT DM mil DMV phai
Duong Duong tinh that tinh gia
16 5
1 0
2 0 Am tinh
that 40 51 55
Am tinh gia
2 3 2
Do nhay '(%)'"
88,9 62.5 50
Do dac hieu (%)
97,5 100 100
Gia trj chan doan duQ-ng tinh (%)
94,1 100 100
Gia trj chan doan am tinh
(%) 95,2 94,4 96,5 Nhdn xet: dp nhay cua SATGS trong chan doan DMLTT la cao nhat nhung dp dac hieu lai thap hon trong chan doan DMV phai va DM mii.
Bdng 7. Dp an todn ciia siiu dm gdng sue bdng .xe dgp luc ki
Tac dung phu Sd luong BN NTT T I 5 Cudng phe \ i
Choang vang Nhjp cham xoang Dau ngyc
1 3 1 4
Ti le (%) 8,47 1,69 5,08
1.69 6,77 Nhdn xet: khdng cd BN nao phai ngimg sieu am tim gang siic vi tai bien. tac dyng phy. Khdng cd tai bien nang NMCT hay tu \ ong.
IV. BAN LUAN
Qua tham dd sieu am tim gang sire va chyp DMV ddi chidu d 59 BN nghi ngd BTTMCB ed chyp DMV ddi chieu. chiing tdi tinh duge dp nhay.
dp dac hieu. gia fri chan doan duong tinh, gia tri chan doan am tinh cua sieu am tim gang siic ndu chi dua \ao rdi loan \an dpng \-iing tren sieu am frrong ling la 84,2%, 97,5%, 91,1%, 92,8%. Ndu phdi hgp ca dien tam do trong chan doan thi dp nhay tang len (94.7%). nhung do dac hieu giam di, edn 82,5%.
Ket qua cua chiing tdi ciing tuong ty nhu ket qua cua Ryan [9] va Tae Ho Park [10].
Badruddin [2].
Theo cac nghien eim ciia cae tae gia nude ngoai, SATGS bang xe dap lye ke cd dp nhay tir 71 % den 93% frong chan doan BTTMCB [2, 9, 10]. Dp nhay cao o nhirng BN cd tdn thuong DMV nang ne hay tdn thuong nhieu nhanh DMV.
Nhimg yeu td anh hudng lam giam dp nhay la nhung yeu td bao gdm hep nhe DMV hay miie gang sire khdng phii hgp va trong mdt sd TH benh lien quan den dpng maeh mii.[7, 8]
Cae ket qua nghien cim khac nhau ve dp nhay do sy khac nhau ve gidi, tudi, ti le nam/nir, sd lugng DMV tdn thuang khac nhau.
Mdt uu diem eiia phuong phap SATGS la cd the phat bien dugc -vung co tim thieu mau va dy doan dugc DMV tuong ung bj hep. Trong nghien ciiu cua chiing tdi, DMLTT hay gap nhat va cung cd dp nhay cao nhat (88,9%).
DM mu dp nhay 62,5%, dp dae hieu 100%, DMV phai cd dp nhay kem nhat, dp nhay 50%, dp dae hieu 100%.
Khi so sanh vdi tac gia Tae Ho Park [ 10] nghien ciiu tren 104 BN, danh gia gia tri ciia SATGS trong chan doan timg nhanh DMV, dp nhay va dp dac bieu frong chin doan tdn thuong DMLTT cua chiing tdi eao hon, cdn trong chan doan tdn thuang DM mil va DMV phai thi dp nhay trong nghien ciiu cua chiing tdi thap hon nhung dp dac hieu cao hem. Tuy nhien, trong nghien cuu cua chung tdi, sd
Nghien CLPU khoa hpc
lugng BN cd tdn thuong DMLTT la chu yeu va sd BN tdn thuong DM mu va DMV phai la qua it nen khi danh gia dp nhay va dp dae hieu ciia nghiem phap gang sire vdi cae nhanh DMV khac ed the khdng the hien day du.
Hon niia, theo each phan loai fren sieu am eiia hdi sieu am rim Hoa Ki, DMLTT cd sd vimg tudi mau nhieu hon (7/16 viing co tim), so vdi DM mii (4/16 viing) va DMV phai (3/16 viing). Ngoai ra, edn do dac diem giai phau he DMV, mdt sd viing co rim duge tudi mau dan xen bdi ca hai nhanh DMV nhu DMLTT va DM mii.
Sieu am tim gang siic la rat an toan. Theo tac gia Luciano [3], SATGS cd the thyc bien an toan vdi
ca nhirng BN ldn hon 75 tudi.
V. KET LUAN
SATGS bang xe dap lye ke ed dp nha}', dp dac hieu, gia tri ehan doan duong tinh va am tinh dya vao rdi loan van ddng viing thanh tim tuong ling la 84,2%, 97,5%, 94,1%, 92,8 %.
Ket hgp bien ddi dien tam dd va SATGS lam tang dp nhay eiia phuong phap len 94,7%, dp dac hieu, gia fri du bao duong tinh va am tinh tuong ling la 82,5%, 72%, 97%.
SATGS cd dp nhay va dp dac hieu trong chan doan nhanh DMLTT tuong ling la 88,9%, 97,5%, DMV phai la 50%, 100%, DM mu la 62,5%, 100%.
TAI LIEU THAM KHAO
1. Nguyin Thupng NghTa (2009) "Mdi lien quan giica cdc phuang phdp chdn dodn kinh diin benh ddng mgch vdnh vdi chup dpng mgch vdnh edn quang", Chuyin de Tim mgch hpc Hpi Tim mgch TP Ho Chi Minh, NXB Y hpc 2009.
2. Baddrudin et al (1999), "Supine bicycle versus post treadmill exercise echo in the detection of myocardial Ischemia: a randomized single blind trial", J Am Coll Cardiol 1999. 34(2):613.
3. Luciano JanussI Vacanti, Luciano BH Sespedes (2004) "Exercise stress testing is useful, safe and efficient inpatients aged 75 years or older ", Arq Bras Cardiol, volume 82 (n"2) 151 - 4, 2004.
4. ManvlckTH, Anderson etal (199 5), "Exercise echocardiography Is an accurate and cost efficient technique for detection of eoronaiy arteiy disease in women ", J Am Coll Cardiol 26: 335-341.
5. Marwick TH, Shaw L, Case C et al (2003),
"Clinical and economic impact of exercise echocardiography In clinical practice", Eur Heart J 2003; 24: 1153-63.
6. Paramjit Jeetley Leah Burden, Ro.xy Senior
(2005) ' 'Stress echocardiography Is superior to exercise ECG in the risk sti-atifieation of patients presenting with acute chest pain with negative Troponin", Eur J Echocardiography (2006) 7, 155-164.
7. Patel MR, Spertiis JA, Brindis RG et al (2008), "Appropriateness Criteria for Stress Echocardiography", Journal of the American College of Cardiology.
8. Raymond J. Gibbons (2008) "Noninvasive Diagnosis and prognosis assessment in chronic coronary artery disease. Stress testing with and without Imaging perspective" , Cir Cardiovasc Imaging 2008; I; 257- 268.
9. Ryan T Segar DS, Sawada SG et al (1993)
"Detection of coronary artery disease using upright bicycle exercise echocardiography", J Am Soc Echocardiography 6: 186- 197.
10. Tae Ho Park (2007), "Supine bicycle stress echocardiography Improved diagnostic accuracy or physiologic assessment of coronary artery disease with
the incoiporatlon of intermediate stages of exercise ", J Am Cardiol, November 6, 2007; 50(19): 1857-6.
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DIEN D A N YHOC
Nghien CLPU khoa hoc
SUMMARY
ROLE OF SUPINE BICYCLE ERGOMETRY ECHOCARDIOGR.\PHY FOR THE Dl.AGNOSlS OF ISCHAEMIC HEART DISEASE
Objectives.- to assess the value of supine bicycle stress echocardiogi-aphy (SBSE) In diagnosis of chronic eoronaiy arteiy disease. Material and methods.- exercise echocardiography was performed
in 59patients (mean age: 58 ± 7.3 (years. 31 males).
The SBSE was started at 25 W with increments of 25W eveiy 3 minute stage. Images were digitalized at rest, 25W and peak and recoveiy stage. Significant eoronaiy arteiy disease was defined by quantitative coronary angiogi-aphy as a lesion with a diameter stenosis > 50%. A stress echocardiography was considered positive when new wall motion was
obsened. Resuhs.- the prevalence of eoronaiy arteiy disease was 32.2%,. SBSE was positive for ischemia In 17 patients, yielding a sensltivlp of 84.2%, a specificity of 97.5%o, PPVof94.1%. NPVof92.8%.
Ulien combined with ECG changing, the sensltlviti:
specificit}-, PPVandNPVwas 94.7%o. 82.5%, 72%, 97%. The sensitlvit}: specificit}- in diagnosis of LAD was 88.9% and 97.5%,, LCx 62.5%,. 100%,.
RCA 50%,, 100%,. Conclusion.- supine bicycle stress echocardiogi-aphy Is a valuable method in diagnosis of chronic eoronaiy arteiy disease.
