Nghien cuu Y hpc ^ Hoc TF. H o CW Minh * T^p 21 * So 6 * 2017
KHAO SAT N 5 N G D O TROPONIN I-hs, TROPONIN T-hs 6 BENH NHAN THAN NHAN TAO CHU KY KH6NG CO HOI CHL/NG MACH VANH CAP
Bm Le Thu Huang*, Nguyen Bach*
TOMTAT
Muc tiiw Tim hi^ ndng do cua Troponin I-hs vd Troponin T-hs & binh rdidn th&n rihdn tqo (TNT) chu k^
khdng cd hdi chung mqch vdnh (HCMV) cap vd Idido sdt moi tucmg quan ciia Troponin I-hs, Troponin T-hs wi cdc y&i td'tudi, phdn suai tdhg mdu (EF), chi sd'lgc mdu dii (kT/v), loai mdng loc.
Benh nMn vd phuong phdp nghien cdu: Benh nh&n: 67 bmh nh&n (BN) TNT chu ky khdng co HCMV ccq) tqi Khoa Ndi Than -Loc mdu Benh vien Thdng Nhdi, TP. HCM tii thdng 12/2016 deh thdng 04/2017. Tiiu chudn chon benh: (1) BN > 18 tiidi; (2). TNT chu ky ngoai tiii 3 lan/tmn > 3 thdng; (3). Khdng cdcandauthk nguc hoac khd th& vd ECG khdng cd co dau hiiu TMCT cap (thay ddi ST). Phuang phdp nghiin cieu: tieh deu, tat ngang, md td.Xd ly solieu thang ki: ph&n nOm SPSS.22.0 v&i cdc thudt todn thdng thu&ng.
Kei qua: Ndng do Troponin I- hs vd Troponin T- hs trung vi (Idwdng tu ph&n vi) Ian lugt Id 29,2 (15,6 - 46,3) vd 69,92 (43,87 - 107,2) ng/L. He sd tuang quan R giiea Troponin I- hs vd Troponin T- hs Id 0,567, p <
0,001. Nong dd Troponin I- hs vd Troponin T-hs& BN Igc mdu bang mdng loc high-flux so ziai low-flux Ian lugt Id 24,05 (10,35 - 41,25) so v&i 34,90 (21,55 - 60,85) ng/mL (p=0,019) vd 56,74 (37,65 - 91,74) so v&i 83,31 (47,43 -147,75) ng/mL (p=O,034).
Kei luqm Ndng dd cua Troponin Ths vd Troponin T-hs cao hem so zxn ngudng hinh ly cua d&n sd diung vd ldn lugt Id 29,2(15,6 - 46,3) ng/L vd 69,92 (43,87 -107,2) ng/L. Troponin I-hsva Troponin T-hsc6 heang quan thuan v&i nhau vd tuang quan nghich v&i chi sd'lgc mdu du, phdn suat tdng mdu ca tim. Ndng do Troponm I hs vd Troponin Ths& nhom binh nh&n Igc mdu bdng mdng Igc Law-flux cao hem co y nghia thmg ki so v&i a nhom BN Igc mdu bang mdng Igc high-flux.
Td khod: Troponin I-hs, Troponin T-hs, than nhdn tqo chu ky, hoi chieng mqch vdnh c^.
ABSTRACT
CONCENTRATION OF SERUM TROPONIN I-hs, TROPONIN T-hs IN CHRONIC HEMODIALYSIS WITHOUT ACUTE CORONARY SYNDROME
Bui Le Thu Huong, Nguyen Bach * Y Hoc TP. Ho Chi Minh * Vol. 21 - No 6 - 2017:104 -108 Objective: to investigate the concentrations of Troponin I- hs and Troponin T- hs in the chronic hemodialysis patients (CHD) zoithcmt Acute Coronary Syndrome (ACS) and ihe association betwem Troponin, l- hs. Troponin T- hs and age, ejedionfraction, kT/v and hemodialyzer.
Patimts and methods: Patimts: 67 C:HD patimts ivithout ACS were recruited in the study during the period 12/2016 to 4/2017 in the Departmmt of Nephrology and Dialysis, Thong Nhat hospital. Inclusion criteria:
(1). Age > 18 years old, (2). Chronic hemodialyzed 3 times/ioedc for more than 3 months, (3) Without chest pain syndrome, acute dyspnea, and change of ST-T segment on the electrocardiogram performed at the time (f sampling and analysed by a cardiologist Method: prospective, observational arui crassedional study. Stastidiad analysis: using SPSS version 22.0 with standard analysis.
Results: The median (interquartile range) concmtrations of Troponin I-hs and Troponin T-hs were
*Khoa Thiin- Lpc mau, Benh Vien Thong Nhat TP HCM
Tdcgid liin lac- TS Nguy&i Bach DT: 0918209808 E-mail: [email protected]
Y Hoc TP. m Chi M i n h * Tap 21 * S6 6 * 2017 NghiSn cuu Y hoc
29.2(15.6 - 46.3) and 69.92(^.87 - 107.2) ng/L, respectively; Correlation Coeffidmts Spearman betwem Troponin I- hs and Troponin T- hs was 0.567, p < 0.001. The concentrations of Troponin I- hs and Troponin T- hs in the patients dialyzed byHFvs those dialyzed by LF were 24.05 (10.35 - 41.25) vs 34.90 (21.55 - 60.85) ng/mL (p=0.019) and 56.74 (37.65 - 91.74), 83.31 (47.43 - 147.75) ng/mL (p=0.034), respectively
Conclusions: In the chronic hemodialysis patients xvithout Acute Coronary Syndrome, the concentrations of Troponin I- hs and Troponin T- hs were higher than range of normal people and 29.2 (15.6 ' 46 3) ng/L and 69.92 (43.87 - 107.2) ng/L), respectively. There was strong correlation between Troponin I- hs and Troponin T- hs. The concentrations of Troponin I- hs and Troponin T- hs in the patients dialyzed by LF were higher in those dialyzed by HF.
Key words: Troponin I-hs, Troponin T-hs, chronic hemodialysis patients. Acute Coronary Syndrome.
MO D A U
Benh ly tim mach rat thudng gap va la nguyen nhan gay tu vong hang dau d benh nhan than nhan tao (TNT) chu ky. Chan doan HCMV cap d benh nhan (BN) TNT chu ky trong mgt so trudng hpp thue su la mpt thach thiic cho cae nha Than hoc va Tim m^ch. Mac du men tim Troponin I va T la quan trpng c h ^ doan HCMV cap va la yeu to giup tien lupng sdng cdn nguy co tu vong do tim mgch d BN TNT chu ky(*). Tuy nhien, hien tai chua CO tri so tham chieu va chua rd ngudng gia tri chah doan men tim Troponin I va Troponin T o nhdm BN TNT chu ky. Ngoai ra, t^i Viet Nam, cae nghien cuu ve men tim Troponin I- hs va T-hs d BN TNT chu ky vSn cdn it.
Troponin I (Tni) vdi trpng krcmg phan tCc (TLFT) khoang 24.000 Dalton. Troponin tim T (cTnl^ ed TLFT ldn hem, 37.000 Dalton. Xet n g h i ^ Troponin sieu nhay ed chat lupng ky thugt tdt cd the phat hien dupe Troponin d nong dp rat thap. Troponin la dau &i sinh hpc giiip chah doan tdn ttiuong tim d BN suy ttian, bao gdm ca nhung BN TNT chu ky. 6 BN TNT chu ky khdng ed trieu ehiing mach vanh c%, TnT duong tinh khoang 30-70%. Tni ding tang trong suy than man nhung it horn TnT (<5%), cd the la do trpng lugng phan tu nhd hem. Tang troponin tim cdn cd ttie gap d cac BN khdng do NMCT cap nhu viem co tim, viem mang ngoai tun, suy tim sung huyet, tang huyet ap, ha huyet ap, phiu thuat tim, suy giap, BN dang hda tri ung thu, suy th$n, nhiim khuan nangC".
Chiing tdi xet nghiem Troponin I-hs va Troponin T-hs ngay trudc Igc mau d cac BN TNT chu ky ngoai tni khdng ed bieu hien lam sang va di|n tim cua HCMV cap, khdng mac cae benh ly kem theo gay tang Troponin nham tim hieu ndng dd ciia Troponin I-hs va Troponin T-hs va khao sat moi tuong quan ciia men Troponin vdi cac yeu to tudi, phan suat tdng mau (EF), chi sd Ipc mau du (kT/v) va loai mang Igc sii dung.
BENHNHAN-PHLfCaSfGPHAPNGHlgNajlJ B^nhnhSn
67 BN TNT chu ky khdng cd HCMV cap tai Khoa N0i Than - Loc mau, Benh vien Thdng Nhat, TP. Hd Chi Minh, tu ttiang 12/2016 d&i thang 04/2017. Tieu chuan ehpn benh: (1) BN > 18 tudi; (2). Lgc mau chu ky ngoai tni 3 lan/tuan > 3 thang; (3). Khdng cd ccm dau that nguc hoac khd thd va ECG khong cd cd dau hieu TMCT cap (thay doi ST). Tieu ehuah loai trir: BN cd cac benh c^p tinh kem theo nhu viem phoi, nhilm khu§h nang, xo gan, suy tim nang, viem mang ngoai tim cap, viem co tim cap, benh nhan cd b?nh tim bam sinh va benh van tim mac phai, tdn ttiuong dap co, co giat, COPD, thuyen tac phdi cap tinh, ung thu va cd sii dyng thudc lie che miin dich hoac dang dieu tri hoa tri, v^a ed b | n h mgch vanh cap trong 03 thang trudc ngay bat ^ u nghi&i ciiu va khdng dong y tham gia nghien cihi.
Fhuong phap ngJiien cim Ti&i ctiu, cat ngang, md ta.
Nghien cuu Y hpc Y Hpc TP. Ho Chi Minh * T$p 21 * So 6 * 2017
Tieu diuan chem dodn HCMV cap Cd 2 trong 3 tieu chuan sau day (1) ctm dau that nguc, khd ttid; (2). ECG cd dau hieu thieii mau CO tim dac trung dupe phSn tich bdi bac si
^ m sang va ttiam dd chiic nang; (3). Tang ddng hoc men tim Troponin I-hs va Troponin T-hs.
Troponin I-iis va Troponin T-hs djnh lupng theo phuong phap chuan b3ng may xet nghiem Cobas e411, hang Roche. Tri sd tham chieu cua Troponin I-hs va Troponin T-hs tgi khoa sinh hoa, benh vien Thdng Nhat lan lupt la < 15,6 ng/L va < 14 ng/L. Ngudng eh&i doan NMCI cap ciia Troponin I-hs va Troponin T-hs Ian lugt la > 160 ng/L va > 100 ng/LP-«.
Chan doan benh DTD, THA, benh tiian man theo tieu chuan y van.
Chi djnh TNT dinh ky
Suy than man dp 5 cd he so thanh thai creatinin huyg't thanh < 10 ml/phiit d BN khdng cd tieu dudng va < 15 ml/phiit d BN cd tieii dudng.
Chi sd lgc mau du tinh dua vao Cdng thiic Daugirdas:
kT/V=-ln(R - 0.008xt)+(4 - 3.5xR)x055xUF/V
Trong do: R = l- URR; T: Th&i gian loc (gia); UF: Lugng dich rut (kg); V: The tidi phan bo ure trong ca thidua theo con nSng, dtieu cao (lit).
KETQUA
Bdng 1. Ddc diem binh nhan TNT chu ky Idzdng cd HCM\rcdp (n=67)
Bic diim
Tuoi
Tmng blnh±09 I^ch chuan ThSp nhdt - cao n h ^
Tu6l>60, n(%) Nam, n (%) Nguygn nhan suy than man,
n(%)
Tang huyit ap E>d[ thdo d u ^ g
Khde DSy t h i t » t r § n ECG, n (%)
Thdn gian Ipc mSu (thdng);
Trung vi (khoang ti> phSn vl)
TrjsO 62,76±16,36
2 ^ 7 40 (59,70) 30 (44,78) 49 (73,13) 15 (22,39) 3(4,48) 22(32,84) 35(19-72,5)
D a c d i ^ Sir dyng m^ng Ipc HF, n (%) klW CTmng binh±E)0 l?ch chuin)
Phan suSttong mau (%), (Tmng binh ±0$ l|ch cihuan)
Tiisfl 38 (56,72) 1,45 ±0,44 63,89 ± 9,07 Bang 2. Ndng do Troponin I- hs vd Troponin T-hsb binh nh&n TNT chu ky khdng cd HCMV c^(n=67) ,
Troponin I-hs
N6ng dp Troponin (ng/L)
Troponi
Tmng vj (ithoing ti> ptiin vj) Troponin 1-hs >160. n (%) Troponin 1- hs> 15.6, n (%) Tmng vj Qchoang ti> phgn vj) Troponin T-hs>100ngfl.,n(%) Troponin T-hs >14 ngfl-,n(%)
Tiis6 29.2 {15,6-46.^-
51 (76.12) 69,92 (43,87-07,g
20 g9,8S) 66 (98,51) Bang 3. Mm tucmg quan giiea Troponin I -hs v&i tiidi, dli sdlgc mdu dii kT/V, phan su^ tdhg mdu &
benh rihan TNT chu ky khdng co HCMV cap Y i u t a k h i o s d t
TuSi Ch!s6lQcmdu(Tu kT/V
EF(%)
H$ S6 timng quan R 0,209 -0,256 -0.291
P 0,09 0,03 0,018 Bang 4. Mm tuang quan gjua Troponin T-hs v&i tudi, chi sdlgc mdu du kT/V, phdn su&i tmg mdu a binh rdi&n TNT chu ky khdng co HCMV cap
Ydu ta khio sat Tu6i Chi so 19c mdu du kTA/
EF{%) 600.00- 500.00-
" ^ 400.0D- 1—
Toponi n
S 8100.DO- .00-
H$ sd tiMyng quan R 0,301 -0.249 -0,308
R=0,569,p<0,001
0
§ w
i i • ! ? . J J, J P 0,013 0,042 0,012
0
S S a S S S S T r o p o n i n I - h s Hirih 1. Mdi tuang quan gjda Troponin I-hsvdT-hs
& BN TNT chu ky khdng cd HCMVcqj
Y Hpc TP. m Chi M i n h » T^p 21 * So 6 * 2017 Nghien cuu Y hoc
Bdng 5: Ndng dd Troponin I- hs. Troponin T-hs a binh nh&n lgc mdu bdng mdng lgc high-flux zm low-flux (n=67)
Ygutd khao sdt Tuoi (Trung binh ± 06 lech chudn)
GI6I nam. n (%)
TTidl gian loc mdu (thdnq) Tmnq vj fkhoanq tii' phdn vi) kT/VfTmnq binh ± Do lech chudn) EF (%)(Tmna binh±Dd Idch chudn) Troponin 1 (no/Ll Tnjno vi fkhoanq ti> phdn vj) Troponin T hs fnq/L) Tmnq vj (khoang tij phdn vD
ManqlQCHF(n=3e) 62,16115.54
18(47,36) 33(14-64) 1,49 ±0.52 65,51 ±9,76 24,05(10,35-41,25) 66,74(37,65-91,74)
Mdngl9cLF(n=29) 63,55 ±15,36
12(41,38) 39(20,5-103,50)
1,41 ±0,29 61,83 ±7,80 34,90X21,55-60,85) 83,31 (47,43-147,75)
P 0,716 0,406 0.232 0.406 0,813 0,019 0,034 B A N L U A N
Ket qua nghien a i u nay cho thay nong do Troponin I- hs va Troponin T- hs d BN TNT chu ky khdng cd HCMV cap cao hon so vdi gia tri ngudng chan doan benh ly cua quan the chung.
Troponin I- hs va Troponin T- hs ed mdi tuong quan thu?n vdi nhau va ed moi tuong quan nghich d miie trung binh vdi cac yeii to Kt/v, phan suat tong mau co tim. Dac biet hong dp Troponin I- hs va Troponin T- hs d nhdm BN loc mau bang mang Ipc Low-flux (LF) cao hon ed y nghia ttidng ke so vdi d nhdm BN Ipe mau bang mang loc High-flux (HF) (p < 0,05).
Ddi vdi chi so Troponin I- hs: nong do Troponin I- hs la 29,2 (15,6 - 46,3) (ng/L). Tri so nay cao hon so vdi ngudng benh ly cua quan ttie chung la 15,6 ng/L. Cd den 76,12% benh nhan Ipc mau chu ky khdng ed HCMVC cd miic Troponin I -hs> 15,6 ng/L. Tuy vay, d ngudng chan doan NMCT cap (Troponin I- hs
>160 ng/L) chi cd 1 BN (1,49%). (bang 2).
Chiing tdi chua tim thay nghien cihi nao d Viet Nam ve men Troponin I-hs d BN TNT chu ky. Nong dp Ttroponin I-hs trong nghien cuu cua chung tdi tuong duong vdi tac gia Guiseppe Lippi'^). Theo tac gia nay, khi nghien Clhi tren 34 BN TNT chu ky ghi n h | n nong do Troponin I-hs la 0,03 (0,02 - 0,04) ng/mL tiie 30 (20 - 40) ng/L, cd 03 BN (9%) tang tren ngudng binh thudng Troponin I-hs < 0,06 ng/mL (60 ng/L).
Bang 2 cho thay nong dp Troponin T- hs la 69,92 (43,87 - 107,2) (ng/L). Tri so nay cao hon so vdi ngudng b^nh ly' ciia quan the chung la 14 ng/L. Cd den 98,51% BN TNT chu ky khong
cd HCMV cap ed miic Troponin T- hs > 14 ng/L. O ngudng chan doan NMCT cap (Troponin T-hs >100 ng/L) cd d&i 20 BN (29,85%). Cd 2 nghien euu ve nong dp Troponin T- hs d BN TNT chu ky. Ket qua ciia chiing tdi tuong tu tac gia Phan Anh va cs. va Huynh Trinh Tri. Phan Anh nghien cdu tren 48 BN TNT chu ky khdng ed HCMV cap nhan thay ndng dp Troponin T-hs trung binh la 70 ng/L va cd 43 BN (89,6%) tang Troponin T-hs tren miic binh thudng (> 0,01 fig/L), trong do cd 12 BN (25%) cd nong dp Troponin T- hs tang tren ngudng chan doan NMCT cap theo WHO (> 100 ng/L)ii). Nghien ciiu ciia Huynh Trinh Tri va cs tren 60 BN TNT chu ky khong cd HCMV cap tai Benh Vien An Giang ciing ghi nhan hdng dp Troponin T-hs la 0,155 + 0,158 ng/mL va cd 46% BN tang Troponin T-hs
>100 ng/L(3). Ndng dp Troponin T-hs trong nghien ciiu nay ciing tuong duong tac gia Guiseppe Lippi vdi miic Troponin T-hs la 0,07 (0,05 - 0,08) ng/mL va cd 30 BN (88%) tang tren ngudng binh thudng Troponin T < 0,01 ng/mL (10 ng/L)(5).
Nguyen nhan nong do Troponin I-hs va Troponin T-hs d BN TNT diu ky khong cd HCMV cap cao hon so vdi gia tri ngudng chan doan benh ly ciia quan flie chung cd the do yeu to suy than va hoae do chinh tinh trang suy tim d cac BN loc mau. O nhiing BN benh than man.
Troponin tim tang tren miic binh thudng cd lien quan true tiep d&i dp nang ciia benh. Nhieu tae gia eho rang cd the do ton thuang te bao co tim dudi lam sang, cac dap iing viem trong suy than va do qua tai the tich man tinh. Mot so nghien ciiu ghi nhan tang Troponin tim d BN TNT chu
107
Nghifin ciru Y hgc Y Hgc TP. Hb Chi Minh * Tap 21 * So 6 » 2017
ky ed gja tri tien lupng trong Hen trien benh va tu vongt*-^'.
Chung tdi ghi nhan cd moi tuong quan nghich miic dp trung binh giiia Troponin I- hs va Troponin T- hs va phan suat tong mau (bang 3, 4). Nghien ciiu ciia Phan Anh va cs dio thay cd mdi tuong quan n g ^ d i giua nong do Troponin T- hs va ptu dai that trai va dudng kinh that trai cuca tam truong*''. Bang 3 va 4 ghi nhan Troponin I- hs va Troponin T- hs cd moi tuong quan thuan d miic thap giiia Troponin I- hs va Troponin T- hs va yeii to tuoi. Tuy nhien, cd nhieu yeii to ed lien quan dSn yeu to tudi nhu fljih trang suy tim, thieii mau cue bd eo tim va tang huyet ap hon la yeii to tuoi don thuan. Do vay, can phan tich da bien tren mot mau ldn hem de xac dinh moi tuong quan nay. Bieu do 1 minh hpa nong dp Troponin I- hs va Troponin T- hs cd mdi tuong quan thuan miic dp chat. Do vay, de ban die chi phi xet nghiem d mdt so eo sd y te con kho khan, co the sir dung chi mdt trong 2 men tim nay.
Bang 5 cho Ihay mac du d 2 nhdm BN loc mau bang mang Ipc high-flux va low-flux khdng khac nhau ve tudi, gidi va chi so Ipc mau dii k^V nhung ndng dp Troponin I-hs, Troponin T- hs d nhom benh nhan Igc mau bang mang Ipc low- flux cao hon so vdi Ipc mau bang mang loc high- flux (p < 0,05). Cd 2 nguyen nhan giai thich su khac biet nay: thii nhat mang loc HF giup dao thai myoglobulin tot hon mang lgc LFP). Thii 2, cd the do cac BN Ipc mau bang mang Ipc LF cd tinh trang suy tim nang hon. EF cua nhdm LF la 61,83 ± 7,80 ttiap hon so vdi r*idm HF (65,51 ± 9,76) su khac biet nay chua eo y nghia thong ke do do can khao sat ky hon cae chi so danh gja suy tim khac tren mpt m l u ldn hon. Ket qua nciy tuong tyf Guiseppe Lippi(«). Tac gia nghien ciiu 16 BN TNT Ipc mau b5ng mang HF, nong dp Troponin I-hs: 0,04 (0,01 - 0,06) ng/mL, t^ le tang Troponin I-hs la 2 (13%). Ndng dp Troponin T-hs la 0,06 (0,04 - 0,07), ty Ie tang Troponin T-hs la 15 (94%). Ddi vdi nhdm BN Ipc mau bang mang LF, ndng dp Troponin I-hs va Troponin T-hs trudc
Ipe cao hon so vdi mang HF va Bn lupt la 0,03 (0,01 - 0,04) va 0,07 (0,04 - 0,11) ng/mL. Do v|y, trong thuc hanh can chii ^ phien dieh ket qua men tim d cae BN TNT sii dung cae losd mang Ipc khac nhau.
KETLUAN
O benh nhan TNT chu ky khdng cd bieu hioi benh 1^ madi vanh cap.
Ndng dp ciia Troponin I-hs va Troponin T-hs cao ban so vdi nguong benh Iy cua dan sd chiuig va Ian lupt la 29,2 (15,6 - 46,3) ng/L va 69,92 (43,87-107,2) ng/L.
Troponin I -hs va Troponin T- hs cd tuong quan thuan vdi nhau va tuong quan nghich voi dli so loc mau dii, phan suat tong mau co tim.
Ndng dp Troponin I- hs va Troponin T- hs 6 nhdm benh nhan loc mau bang mang Ipc Low- flux cao hon cd y nghia thdng ke so vdi d nhom BN loc mau bang mang loc high-flux.
TAI LIEU THAM KHAO
1 Brunei P, Oddoze C, PaganeUi F et al (2008), Cardiac Troponm T and Troponin I in Itemodialysis mthout acute coronary syndrome International Jouinal of Cardiology 129 (2008) 20S-209.
2 Diris JHC, Haekeng CM, Kooman ]P et al (20(H). Impaired reid clearance explains eleoated Troponin T fragments in hemodadysis patients. Circulation, 2004:109,23-25
3 H u y n h Trinh Tri, L u Cong Tning, Ma Lan Thanh, Tran Ngflc Giai (2011). Khao sdt r^g do Troponin T trong bftifi say Ih4n mm K^ yeii h ^ n g h | Khoa hpc b$nh V i ^ An Giang- So Ihang 10/2011 Tr 50-55
4. Khan NA, H e n u n d g a n BR et al (2005). Prognostic vidiu of Troponin T and Troponin I among asymptomatic patients -wilh end- stage Renal disease. A meta-analysis Circulation 112; 3088-3096.
5 Lippi G, Tessitore N , Monlagnana M, Salvagno GL, Lupo A, Gilldt GC (2008). bxfluence of sampling time and ultraBltradon Coffiaenl of flie Dialysis membrane on Cardiac Troponin I and T Arch Pathol Lab Med, 132:72-76
6 Phan Anh, Le Vigt I h S n g pOlO). Nghien dm sw Any dSiiibngi^
Troponin 1 huyH thanh suy than man tinh loc mau diu ky. Y hoc thyc hanh (712)-so 4/2010. "ftang 2 * ^
', Roongstitong C, Warraich L Bradley C (2004). Common causes of Troponin Elevations in Ihe Absence of Acute Myocardial infarctions. CHEST (2004). 125:1877-1884
8 Wayand D, Baum H, Schalzle G et al (2000). Cardiac Tti^miitt T and Troponin I in end-stage renal pilure. Clinical C3iemisfry 46; 9, 1345-1350.
Ngdy nh&n bdi bdo: 24/05/2027 Ngdy phdn biin nhan xet bdi bdo. 05/06/2017 Ngdy bdi bdo duac ddng: 30/10/2017
