CHUYEN Di B A O TAO LIEN TUC
CHUYEN flE flAO TAO LIEN TUC Viem ca tim
GS.TS. Nguyin Lan Viet; TS. Ph?m Manh Himg; ThS. Nguygn Hiiu Tuah;
Vien Tun Mach Viet Nam
TONG QUAN
Viem CO tim la mpt tinh trgng benh ly nhi^m trung co tim vdi benh canh lam sang rat phong phii, tu nhihig trudng hpp cd cac bieu hien kin dao cho tdi nhiing trudng hpp het siic nang ne. Viec chan doan dya vao cac tieu chuan md benh hoc, mien dich hoc va hoa miin dich. Viem co tim dupc md ta nhu "mdt tinh trang viem tham nhiem eua eo tim vdi nhung dam te'bao co tim hoai tii va/
hoae thoai hoa" (theo Phan logi Dallas, 1987) (Hinh 1). Benh tiiudng xuat Men tren nhiing ngudi cd co dia khoe manh, cd the dan de'n suy tim tie'n trien nhanh chdng (thudng gay tii vong) va cae rd'i logn nhip nguy hiem.
Lieberman da dua ra mpt phan logi mdi dua tren cac dae diem bpnh hpe lam sang, mge dii van ehua dupc cha'p nhgn mpt each rpng rai, theo eae tieu chi sau:
• Viem ea tim khdi phat nhanh:
thudng sau nhiing tripu chiing eiia nMem virus trudc do; de nhan thay khdi phat benh bao gdm eac trieu chiing tim mgch nang ne vdi roi loan chtic nang that tiai va viem CO tim the hogt dpng da o; hogc se tu btiih phyc hoae dan tdi hi vong.
• Viem eo tim cap: khdi phat kin dao hem, vdi rd'i logn chiic nang that tiai keo dai; ed the tien trien thanh benh eo tim gian.
• Viem CO tim mgn tinh the hogt dpng: khdi phat kin dao, vdi nhiing bieu Men lam sang va md benh hpe tai phat;
rdi loan chiic nang that trai tie'n trien ed lien quan deh nhiing bie'n doi kieu viem man tinh (vdi cac te'bao khdng 16).
• Viem CO tim mgn tinh dai dSng:
khdi phat am tham; cd tinh trgng tham nMem md benh hpe keo dai vdi nhiing o hogi tii te'bao co tim ma khong cd bieu hien rdi loan chiic nang that tiai, trir mpt vai trieu chiing nhu dau nguc, hdi hop danh trdng nguc.
Sinh ly benh:
Cd rat nhieu nguyen nhan nhiem khuan khac nhau cimg vdi nhiing rd'i loan do ttr mien, su tuang tac ve mat di truyen va cac ye'u to' ngoai sinh gay ra viem co tim. Hau het eae trudng hpp deu dupc cho la theo con dudng trung gian mien dich, eae ton thuang mang tinh chat tir mien, mgc dii cd ca tae ddng cua nhiing ye'u to' benh nguyen gay dpe tnrc tie'p va nhiing ton thuong do su xuat hipn cua cae cytokine tiong ca tim cd the ddng mdt
TAP CHi TIM MACH HQC VIET NAM - S6 52-2010
vai trd nhat dinh tiong benh sinh hoc eita viem ca tim. Cae thuong ton thudng theo CO che sau:
• Tac dung gay doe tnrc tiep ciia cac ye'u td'benh nguyen.
• Cac dap ling mien dich thti phat cd the do cac ye'u td'benh nguyen phat dpng.
• Su ed mat ciia cac cytokin tiong CO tim (vi du nhu ye'u td' gay hogi tir u TNF-alpha, eac en- zyme tdng hop NO).
• Tmh tigng chet theo chuong trinh dien ra mpt each bat thudng.
Qua trinh huy hoai ca tim trai qua 2 giai dogn nhu sau:
• Giai dogn cap (tiong 2 tuan dau tien): tinh tiang huy hogi eo tim la hau qua true tie'p cua cac ye'u td' gay benh, cae ye'u td' nay lam giai phdng cac cy- tokine va cac chat gay doc qua trung gian te'bao, gdp phan gay buy hogi va lam rd'i loan chiie nang te'bao co tim. Trong gian dogn nay thudng khdng phat hi?n dupe eac ye'u to gay benh.
• Giai doan mgn: tinh trang
huy hogi te'bao co tim tiep tt^c xay ra theo CO ehe'ttr mien tu nMen, thudng lien quan de'n sir bieu hi^n cua cac khang the bgeh cau ngudi (HLA) tiong cac te'bao co tim (va tiong eae trudng hpp viem eo tim do virus, edn cd the tim tha'y bp gen ciia virus tiong te'bao co tim).
B*5*
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Hinh 1. Hinh anh Viem eo tim cap tren kinh high vi vdi svr tham nhilm ciia te'bao lympho (miii ten hinh A) va te'bao CDS (hinh B)
CHUYEN Bt €)A0 TAO Lt^N TUC
Trong viem co tim do virus, viec phan lap chinh xac tac nhan gay berth cdn phu thupc vao tinh hudng md va tinh Ian tian ctia virus. Vi du nhu, coxsackievirus A9 gay viem ca tim tij gidi han, tuy nMen coxsackievirus B3 lai gay ra nhiing tinh trgng viem eo tim het siie ngng ne vdi ty le tti vong kha eao. StJ bieu Men cac re- ceptor ciia coxsackie-adenovirus (CAR) va su tang san xuat cac yeu to tang cudng huy hogi cac protein sai lac (DAP, CD55) cd the cho phep xae dinh duoc bp gen ciia virus theo quy ude quo'c tehoa mot each hipu qua. Su nhan ban virus cd the gay ra nhiing rd'i logn ehuyen hoa nang ne hon va tinh tiang viem ding nhu cac dap ling viem them tiam tipng. Tmh tiang co mgch do virus xam nhgp vao cac te'bao ndi mgc ciing gdp phan lam cho cac ton thucmg eang ngng. Cac bang chiing mdi day cua bipn phap lam mat ai tinh ctia enterovirus do lie che'kha nang bieu hien ctia enzyme protease 2A cho tha'y khdng chi co mot co che'bpnh sinh duy nhat.
D|CH
TE HOC Tin suit cua benh:Mpt ngMen ctiu dich te do Karjalain- en va Heikkila tie'n hanh da cho tha'y tiong khoang 700.000 nam tan binh khoe mgnh tai Ha Lan cd 98 trudng hpp viem ca tim da bi chan doan nham vdi benh tim thie'u mau cue bp, trong dd ed mpt trudng hpp dot tir va 9 trudng hpp bieu hien bang benh co tim gian mdi xuat hien.
Tgi Nhat Ban, mpt nghien a i u keo dai tiong 20 nam bang sinh thiet hang
loat tieh hanh tren 377.841 benh nhan da cho tha'y nhiing trudng hpp viem ca tim vd can, khdng dae hieu, the ke hogc viem CO tim do virus ehi cMe'm 0,11% eae trudng hpp.
Nhiing ghi chep tgi Hoa Ky cho thay rat khd xae dinh tan suat tht^c te'mac beitii bdi tien lam sang, berth cartii viem eo tim bieu Men het stic da dgng. \Jac tinh ty le mac bpnh trong khoang tir 1/100.000 de'n 10/100.000. Ty le dupc chan doan xac dinh bang sinh thiet tim phai d nhiing benh nhan nghi ngd viem eo tim rat dao dpng (tir 0% den 80%). Theo udc tinh, khoang 1-5% so' benh nhan cd trieu chiing nhiem virus cap cd the cd cac bieu Men tgi tim.
Hau qua cua viem co" tim:
Hau het cac benh nhan vdi cac trieu chiing nhe deu hoi phtic hoan toan ma khdng de lai bat eii mdt di chiing rdi loan chiic nang tim nao nhung sau dd, 1/3 so' nay co the tie'n trien thanh benh eo tim gian.
Trong nghien ctiu Dieu tri viem co tim, d nhiing ngudi cd cac tri^u ehiing ctia suy tim va phan so' to'ng mau that tiai ban dau tiia'p hon 45%, ty le hi vong sau mdt nam la 20% va sau 4 nam ty le nay tang len 56%.
Vdi nhiing trudng hpp viem co tim te'bao khdng Id khdng dupe dieu tii, kha nang sd'ng sdt tiung binh ke tir kM bat dau cd trieu chiing chi la 5,5 thang, va ty le tii vong sau mpt nam la 80% (tinh ca so trudng hpp tii vong lan phai ghep tim).
Vdi nhiing trudng hpp viem eo tim
TAP CHi TIM MACH HOC VIET NAM - SO 52-2010
sau sinh, ty le tir vong van cdn cao, cd the tdi 50%.
Vin d l tudi, gio'i va chung toe:
Ngudi ta nhan tiiay khdng cd su khac biet ve ty le mac benh giiia cac chimg tpc, ngoai tru vdi viem co tim chu san la the dupc thdng bao cd ty le gap cao hon d nhiing ngudi gd'e PM.
Ty le mac bpnh gjiia hai gjdi tuong ducmg nhau, mac dii nam thanh men la ddi tupng dgc bipt de m^c.
Ve tudi bi benh, hau het cac benh nhan deu cdn kha tie. Dp tudi tnmg binh ctia cac benh nhan thudc the viem co tim tham nhiem te'bao lympho la khoang 42 tudi. Nhiing bpnh nhan thudc the viem CO tim te bao khd'ng 16 cd the gap d Iiia tudi cao hon (tudi tnmg binh la 58 tudi), nhung nhin chung ciing khdng ed su khac bipt rd ret ve tudi, gidi va cae trieu chiing bieu Mpn.
Nhiing ddi hrpng de mac benh khac bao gom nhung ngudi suy giam mien dich, phu nii cd thai va tie nhd, dge biet la tie so sinh.
LAM SANG Tneu chung cc nang:
Benh caitii lam sang thudng la tinh tiang suy tim mat bii cap d mpt ngudi khdng cd rdi loan chtic nang that tiai trudc dd hogc d nhiing ngudi cd nguy eo b^nh tim mach tha'p. Chan doan dting thudng cM can dua tien tinh tigng benh nhan va dien bieii lam sang (dgc biet vdi
nhiing trudng hpp tiJ hdi phuc sau thdi gian dupc dieu tri ti'ch ci^c).
• NMeu benh nhan cd the cM bieu Men nhiing trieu chiing nhe nhu dau ngue (tiong trudng hpp ed tian dich mang tim), sd't, va md hdi, ret run va khd thd.
• Trong viem ca tim do virus, ngudi benh cd the cd tien sti kieu hpi chiing aim trudc do (tiong vdng 1 - 2 tuan) vdi eae daii Meu nhu sd't, dau mdi cac khdp, m?t mdi hogc viem mui, hpng hay eae trieu chiing aia nMem khuan hd ha'p tien.
• Cac ngMen ctiu dich te da cho tha'y rang d ngudi trudng thanh, tiong viem CO tim, thudng gap cac trudng hpp tri^u chting ngheo nan hon la so ngudi cd tirih tigng nhiem dpe cap do so'c tim hoac suy tim ngng (viem eo tim khdi phat nhanh).
• Nhiing trieu chiing nhu hoi hop danh tiong nguc, ngat, tham cM la dpt tu ciing cd the gap, do cac rdi loan nhip that hogc do block nM that (dgc Met trong viem CO tim te'bao khong 16).
• d ngudi trudng thanh, b?nh cd the dan den hau qua suy tim nhi^u nam sau kM cd trieu chiing viem co tim dau tien (tiong nhieu bao cao, khoang 12,8% sd'benh nhan bi benh eo tim gian vd can dupe cho la da timg bi viem co tim trudc dd).
Trieu chipng thirc t h i :
Cac benh nhan viem co tim thudng cd cac trieu chiing ctia tinh tiang suy tim cap mat bii (nhu nhip nhanh, tie'ng ngya pM, hd van hai la, phii) va tie'ng cp mang
CHUYEN D E D A O TAO LIEN TUC
tim tiong nhiing trudng hpp cd tian dich mang tim kem theo. Nhiing trieu chiing dac hipu trong nhung trudng hpp dgc biet bao gdm:
• Viem CO tim the lien vdng: bgch to, thudng kem rd'i loan nhip, nhiing bieu hien cua to ehiie lien vong lien quan tgi cae CO quan khac (tdi tien 70%).
• Thap tim cap (thudng gap bieu Men tai tim d 50 - 90% tiudng hpp): cae da'u hieu kem theo nhu ban vdng, viem da khdp, miia giat, not dudi da (theo tieu ehuan Jones).
• Viem eo tim do qua man/ tham nMem bgeh cau ua add: ban san ngiia va tien sir diing thud'e tiudc dd.
• Viem CO tim te bao khong 16: nhip nhanh that ben bi va tinh trang suy tim tie'n tiien nhanh.
• Viem ea tim chu san: suy tun xay ra trong tiiang cudi oia thai ky hoge tiong vdng 5 thang sau sinh.
TAC NHAN GAY BENH:
Cho tdi nay, khoang 50% cae trudng hpp viem ea tim la vd can, mac dii virus thudng dupc cho la tac nhan gay benh nhung vin chua dupe chting minh, tham chi bing cac nghien eiiu hda mien dich va gen het siic tinh vi. Nhiing nghien ciiu gan day tren nhirng tiudng hop benh nhan cd benh eo tim gian vd can eho thay cd bang ehiing cua cae tieu the virus trong manh sinh thiet ndi mgc eo tim trong 2/3 sdbenh nhan.
• Virus: bao gom enterovirus, coxsackie
B, adenovirus, virus cum, cytomega- lovirus, virus gay bai liet, virus Ep- stein - Barr, virus HIV type I, cae virus viem gan, quai bi, rubeola, thuy dau, dau miia, arbovirus, virus hpp bao hd hap, virus herpes, virus gay benh sdt vang, virus dai.
• Rickettsial: sdt mo, bpnh sdt phat ban viing mii da, sdt Q.
• Vi khuan: bach hau, lao, lien cau, nao md cau, brucella, hogi thu sinh hcri, tu cau, melioidosis. Mycoplasma pneu- momae, vi khuan gay benh sdt vpt.
• Xoan khuan: giang mai, leptospirose/
b?nh Weil, sdt hdi quy/ Borreha, benh L3nne.
• Na'm: Candida, aspergillus, aspergil- losis, cryptococcosis, histoplasmosis, actinomycosis, blastomycosis, coedd- ioidomyeosis, mucormycosis (?).
• Ky sinh trimg: benh Chagas, benh do toxoplasmo, benh ngu, sdt ret, berth do leishmama, balantidiasis, sareospori- diosis. Cac loai giun TricMnosis, echi- nococcosis, schistosomiasis, hetero- phyiasis, cysticercosis, visceral larva migrans, filariasis.
• Do bi cin/ ddt: npc bp cap, npc ran, npc nhen den, npc ong bap cay, liet tick (?)
• Do thuo'c (thudng gay viem eo tim do qua man):
• Cac thudc dieu tii ung thu: doxorubicin and anthracyclmes, streptomycin(?), cyclophosphamide, interIeukin-2, anti- HER-2 receptor antibody/Hereeptin.
TAP CHi TIM MACH HOC VIET NAM - SO 52 - 2010
• Khang sinh: pemciUin, diloramphem- col, sulfonamides.
• Cac thud'e ha ap: mefhyldopa, spironolactone.
• Thudc chOTig dpng kinh: phenytoin, carbamazepine.
• Amphetamines, cocaine, cate- cholamines.
• Chemicals Hydrocarbons, carbon monoxide, arsenic, lead, phosphorus, mercury, cobalt
• Hoa chat: cac hydrocarbon, kM carbon monoxide, arsen, cM, phospho, thuy ngan, coban.
• Cac ye'u to vgt ly nhu tia xa, soc itiiiet, ha than nMet
• Sdt tha'p cap.
• Cac benh he thdhg: viem eo tim te'bao khdng Id, benh sarcoidose, bpnh Ka- wasaki, benh Crohn, lupus ban dd he thdng, viem rupt ke't, benh viem hat Wegener, nhiem ddc giap, hoai hi da, viem khdp dgng tha'p.
• Viem CO tim diu san.
• Tinh tiang dao thai manh ghep sau ghep tang.
CHAN BOAN PRAN BI|T:
Mpt sd'benh cd the de nham vdi Viem CO tim la:
- Ep tim cap.
-Sde tim.
- Benh co tim do rupu
- Benh CO tim do sti dui^ ma tuy (cocaine).
- B?nh co tim gian.
- Berth co tim pM dai.
- Benh co tim chu san.
- Benh co tim han che.
- Benh Chagas
- Bat thudng ddng mach vanh bam sinh.
- Benh ddng mgch vanh mgn tirih.
- Co that madi vanh.
- Nhoi mau ca tim.
- Phil phdi do tim.
- Phil phdi do dp cao.
- Phil phdi do nguyen rtiian than kinh.
- Xo phdi tien phat
- Dau that nguc khdng dn dinh.
- Nhip nhanh tha't.
- Cac nguyen nhan gay dot tii khac...
THAM BO CAN LAM SANG
• Cdng thtic mau: tang bach cau (cd the thay tang bach cau ua add).
• Tdc dp mau I5ng tang, protein C phan ting tang.
• Cac xet ngMem ve thap: phat Men cac benh he thd'ng.
• Tang men tim (creatine kinase hoac tioponin).
• Cho thay cd tinh tiang hoai tii te'bao CO tim. Dgc biet, tioponin tai tim (tio- ponin I hoac T) tang d it nhat 50% cac trudng hop viem co tim dupc chiing minh bang sinh tMet.
• Cac xet ngMem cd dp dac Mpu la 89%
va dp nhay la 34%, va thudng cd dp dgc hieu cao hem CK-MB (cM tang tiong 5,7% cac trudng hpp viem co tim dupc chiing minh bSng chup mach)
CHUYEN Oe DAO TAO LIEN TUC
C h i n doan hinh anh Sieu dm tim:
De logi trir cac nguy§n nhan gay suy tim khac (nhu benh van tim, berih amyloi- dose, benh tim bam sinh) va de danh gia miie dp rd'i logn ehiic nang tim (thudng thay hinh anh giam vgn dpng dong deu va rdi loan chiic nang tam truong). Sieu am tim cung eho phep danh gia so bp vi tri vimg ca tim bi viem (nhu rdi loan vgn dpng thanh, day thanh tim, tian dieh mang tim). Ngoai ra, sieu am tim cdn cho phep phan biet giiia viem co tim khdi phat nhanh va viem eo tim cap b§ng each xac dinh dudng kinh tam trucmg that tiai gan nhu binh thudng va tang dp day vach lien that tiong viem eo tim
khdi phat nhanh (so sanh vdi tang dudng kinh tam truong that tiai va dp day vaeh lien that binh thudng tiong viem CO tim cap) v<M su cai thien dang ke chtic nang tam thu theo thdi gian.
Chup nhap nhdy do CO tiem khdng the khdng myosin:
Phuang phap nay cd the xac djnh dupe tinh tigng viem eo tim vdi dp nhgy rat cao (91 -100%) va kha nang chan doan loai trir ding rat cao (93 -100%) nhung ed dp dgc Mpu thap (31 - 44%) va luc chan doan xac dinh ding tiiap(28-33%).
Chup cdt lap vai GalUunu Ky thuat nay thudng dupc dimg de danh gia tinh tiang tham nMlm co tim miic dp ngng va ed gia tri chan doan logi trir cao, tuy vay dp dac hieu ciing tuong dd'i thap.
Chup cong huang tie vai Gadolinium (hinh 2):
Ky thuat chijp nay ngay eang dupc ling dtmg rpng rai trong ehan doan logi trir eae trudng hpp nghi ngd; thudng dupc sir dung de danh gia miic dp Ian toa ctia tinh tigng viem, dinh khu va hudng dan eho sinh thiet eo tim. Tuy vay, phuong phap nay co dp dae hieu edn ban cai va can duoc nghien ctiu them.
Hinh 2: Hinh anh chup MRI trong viem eo tim (miii ten cM hinh anh viing eo tim bi viem)
TAP CHi TIM MACH HOC VIET NAM-S6 52-2010
Chup huang tim:
Thudng dupe cM dinh de logi trir nguyen nhan tMeu nang vanh gay suy tim ca'p, dac biet tiong nhiing trudng hop bieu Men lam sang tuong tu nhu trong nhdi mau co tim. Qua chup buong tim, cd the thay ap luc dd day tang len va cung lupng tim giam.
Cac phiivng phap chan doan idiac:
• Dien tam do: thudng khdng dgc hieu (nhu nhip nhanh xoang, bieh dd'i ST va T khdng dgc Meu).
• Ddi kM cd the cd block dan truyen tiong tim (block nM that hogc block tgi that), cac rdi logn nhip that, hoac hinh anh ton thucmg vdi nhiing bi&i doi dogn S T - T gan gidrtg vdi tiong tMeu mau eo tim hogc viem mang ngoai tim (hinh anh gia nhdi mau) thudng cho thay tien lupng kha toi.
• Cac rdi logn nhip thudng gap tiong benh Chagas, nhu block nhanh phai cd/
khdng kem block hai phan nhanh (50%), block nhl that hoan toan (7 - 8%), nmg nM (7 -10%) va cac rdi logn nhip that (39%).
Cac thu thuat co chay mau:
• Sinh tMet ndi mac that phai: day la tieu ehuain vang de chan doan viem eo tim, mac dii phucmg phap nay van ed han die'do dp nhgy va dp dac Meu khdng cao bdi tinh tiang viem cd die Ian toa hogc khu tni. Nhd MRI co tim cho phep dinh hudng vimg sinh tMet tot hon. Tuy nMen, sinh tMet ndi mgc that phai mpt each thudng quy tiong viec dua ra chain
doan viem ca tim thudng hiem khi cd ich tren lam sang, tuy nhien, vi chain doan md benh hoc khong phai ludn cd anh hudng de'n cMe'n lupc dieu tri trir tiong trudng hpp nghi ngd viem co tim te'bao khdng Id.
• Do phu thudc vao ky thuat la'y manh sinh thiet nen dp nhay ciia phuong phap cd the tang len kM lam lay nMeu manh benh pham (50% kM lay 1 manh, 90% khi lay tdi 7 manh khac nhau). Theo quy udc thudng lay it nhat 4 deri 5 manh, mac dil ty le am tinh gia van cdn kha cao, khoang 55%.
• Ty le duong tinh gja ciing kha cao, do cd mdt so nhd tiong dieu kien binh thudng ciing cd su xuat Men ctia cac te' bao lympho tiong co tim va cdn mdt khd khan niia tiong viec phan biet te'bao lym- pho vdi cac te'bao khac (nhu te'bao ua add tiong cac trudng hpp viem co tim do qua man hay tham nMem bach cau ua add).
• Sir phu thudc vao ngudi dpe ket qua md berih hoc ciing la mdt ye'u td' tac ddng nMeu de'n chari doan.
• Cac not khdng hoai hi gap tiong viem eo tim the md lien vdng ding cM thay tiong 5% cac trudng hop dupc sinh tMet eo tim, va cM 27% tiong cac trudng hpp giai phau tii tM hang logt.
• Su ton tai ciia mRNA aia virus cung cd the thay tiong 25 - 50% sd' benh nhan dupe chiing minh viem co tim bang sinh tMet, va su cd mat ciia mRNA vi- rus cung thudng dio tien lupng ngng ne. Nhung ket qua ve mat didi t l hpe tir
CHUYEN oe OAO TAO LIEN TUC
NgMen ctiu dich tl va dieu tri cac benh tim do viem nMdm 6 Chau Au gan day cho tha'y ehi 11,8% cae benh nhan cd ngM ngd viem ca tim cap hay mgn ttiih ed giam phan sd'tdiig mau that tiai dupc phat Men cd vat chat di truyen cua virus tiong mau benh phli'm sinh thiet.
BACBIEMMOBENHHVC:
Cac mau sinh thiet npi mac that phai thudng cho thay cd su tham nMlm ctia te bao bgch cau lympho va tinh tigng hogi tir ctia te'bao co tim.
Phan loai
Phan loai Dalas (1987) va phan loai Marburg ciia To chiic Y te'Thegidi (1996) dupc sti d i ^ g rpng rai nhat.
• PhSn typ te'bao: the bgch eau lym- pho, the bach cau ua add, the bgch cau trung tinh, the te' bao khdng 16, the hgt hogc tiie hdn hop.
• Lupng te bao hogi hi: khdng ed (dp 0), nhe (dp 1), trung binh (dp 2) hoac nang (dp 3).
• Su phan bo: khu tni (quanh mot mach mau), thanh dam, lan toa hoac tai phan bd (trong cac vimg to ehtie xo).
• Phan logi Dalas (1987):
• Sinh thiet tiudc dieu tri:
- Viem CO tim: cd hoai tir te' bao CO tim, thoai hoa hogc ca hai, khdng ed bieu hien cua td'n thuong ddng mgch vanh cd y nghia, ding vdi tinh trgng tham nhilm te'bao viem ed hogc khdng kem xo hoa.
• Nghi ngd viem co tim: tinh tigng
viem rai rac hoae te' bao eo tim bi ton thuang khdng rd rang.
• Khdng cd viem co tim.
• Sinh thiet sau dieu tri:
• Viem CO tim dai dang cd hoac khdng kem xo hoa.
• Viem ca tim dang thoai trien cd hogc khdng kem xa hoa.
• Viem eo tim da thoai tiieh cd hoac khong kem xo hoa.
• Ti^u chuan Marburg ciia To ehiie Y te'The'gidi (1996): ehan doan viem eo tim khi cd thkm nhiem td'i thieu 14 te'bao bgeh eau/mm^ dae biet la te' bao lympho T (CD45RO), hoac tuong duong khi cd 4 dgi thuc bao.
Dieu trj
Dieu tii viem eo tim bao gom cac bi^n phap dieu tii tiieu chiing suy tim cap, bao gdm Ipi tieu, nitrates hoge nitro- prusside va eac thuo'c lic che'men chuyeii.
Cac thudc tang co bop eo tim nhu Dob- utamine, Milrinone ed the can tiong cac trudng hpp suy tim nang mat bii, mac dii ehiing cung lam tang nguy co gay rd'i logn nhip. Dieu tri lau dai ding theo die dp thud'e tuong tu, vdi cae thud'e tic che'men chuyen, cac thud'e chen beta, cae thud'e khang Aldosterone. Tuy nhien, tiong mdt so' trudng hpp, mpt so thud'e tiong eae thudc tien cd the khdng the dimg ngay tir dau do tinh trgng huyet dpng.
• Ne'u ed the, can loai bd cac yeii td' lam ngng them benh (nhu cac thud'e ddc vdi tim, rupu). Dieu tri tinh trgng nhiem trimg kem theo hoae eae nguyen nhan gay nhilm trimg he thd'ng. Nen tranh dimg
TAP CHi TiM MACH HOC VIET NAM - S6 52 - 2010
cac thudc khang \'iem nonsteroid trong giai dogn cap bdi cac thuoc nay cd the lam chgm qua trinh phuc hoi ciia te' bao CO tim, lam qua trinh viem xay ra mgnh ban va lam tang ty le tii vong.
• Cac thudc didiig ddng cung nen dupc sti dimg vdi muc didi du phdng nhu ddi vdi rihiing nguyen nhan gay suy tim khac, mac dii van chua cd bang dning rd rang nao ve vai tio cua eac thudc nay tiong viem co tim.
• Cac thudc didrig loan nhip nen su dung het siic than tipng, bdi hau het cac thudc chdng logn nhip cd tiie lam gjam siic CO bdp CO tim do dd ed the lam tinh tigng suy tim nang them.
• Vdi nhung trudng hpp nhip nhanh tien that, cd the sd'e dipn chuy&i nhip.
• Vdi nhiing ngoai tam thu that dp cao va cac loai nhip nhanh that, can het siic than tipng kM dimg chen beta va cac thudc chdng loan nhip.
• Cac benh nhan viem ca tim thudng kha nhay cam vdi digoxin, do dd nen dimg than tipng va vdi lieu tha'p (Digoxin OD the lam tang sir xuat Men aia eac cy- tokine tien x-iem va lam tang ty le tti vong d ddng vat tM ngMem).
• CM dinh dgt may tgo nhip tgm thdi neu cd block nM that cap HI.
• Cay may pha nmg tu ddng Me'm khi dupc cM dinh tiong cae tnrdng hpp viem CO tim the tham nMem te'bao lym- pho, trir ikM cd tinh tiang xo hoa Ian toa.
• Trong viem co tim, nen xem xet sdm cM dinh thdng kM' nhan tao va dimg
cac bien phap hd tip tuan hoan (nhu bom bdng ngupc ddng trong dpng mach chu) bdi benh cd the dien bioi rat nhanh dua doi tinh tiang mat bii ciing nhu kha nang hoi phuc tdt oia ngudi benh.
• Cac thuoc lie che mien dich diua du<?c ehiing minh cd kha nang lam tiiay ddi dien bieh tu nMen aia cac te'bao co tim bi viem. Ba ngMen ciiu tieh ctiu quy md Idn ve vai tid cua cac thudc tie che' mien dich dupe sii dung cho cac benh nhan viem CO tim da dupe tie'n hanh, nhung chua cd ngMen ctiu nao cho thay thudc cd Ipi ich rd rang. Dd la cac ngMen oiu Su dimg prednisone aia Vien stic khoe Qud'c gja Hoa Ky, NgMen cirii dieu tri viem co tim, va ngMen oiu Dieu tri tiong viem co tim va berth ca tim cap. Dieu tri du phdng bang cac thuoc tic die' mien dich tiong cac benh tu mien he thdhg, dgc biet trong viem eo tim the te'bao khong 16 va ^ m CO tim the lien vdng thudng dua tren bang chiing tir mdt so' ngMen oiu nhd trudc day.
• Chua tha'y cd bang chung rd rang nao ve vai tid oia cac thud'e khang virus, mac dil ding da cd mot so'ngMen ctiu nhd chiing minh hieu qua ciia chting (Meu qua oia interferon-anpha se dupc danh gia tiong ngMen oiu ESETCID dang tieh hanh)
Phlu thuat:
• Cay tMet bi hd tip that va mang tiao ddi oxy cd the d u dinh de hd tip tuan hoan tgm thdi neu can tiong tnrdng hpp cd soc tim.
• Ghep tim:
CHUYEN OE DAO TAO LIEN TUC
+ O cae benh nhan viem co tim cap, ngudi ta tha'y rang ty le tii vong khdng tang Ien, mac dxi eae ngMen ciiu hdi ctiu da cho tha'y cd the cd tinh tigng dao thai manh ghep cap hoge eae benh ly mgeh sau ghep tim xay ra nMeu hon d nhiing ngudi nay.
+ Ghep tim td ra dae biet ed ieh vdi nhung ngudi cd ehan doan viem co tim the te bao khong 16 qua sinh tiiie't; ty le sdng sau 5 nam sau ghep tim la 71%, mac du 25% ed bieu hien cua tinh tgng sau
ghep tang (9/34 benh nhan trong Nghien oiu da tiung tam ve viem eo tim te' bao khdng Id).
C h i do dinh dird'ng va sinh hoat:
• Ap dung ehe' dp an giam mudi nhu tiong dieu tri suy tim tiidng thudng.
• Che dp sinh hoat: ngM ngoi tgi giudng va tianh cae hogt ddng vdi cudng dp mgnh la nhirng khuyai cao theo kinh ngMem (giam ty le xuat M ^ rdi logn nhip).
TAI LIEU THAM KHAO
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